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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2700
} | Medical Text: Admission Date: [**2128-10-29**] Discharge Date: [**2128-11-17**]
Date of Birth: [**2070-9-2**] Sex: M
Service: [**Location (un) **]/INTERNAL MEDICINE
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname **] was a 50-year-old
gentleman with a history of hepatopulmonary syndrome,
hypoxemia, end-stage liver disease, and DIC who was
transferred from an outside hospital after being found down
and apneic.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit at the [**Hospital6 2018**] and aggressive measures were made to support the
patient's respiratory status. Unfortunately, however, the
patient succumbed to his hepatopulmonary syndrome and
continued active bleeding to his lungs and gastrointestinal
tract from fistulae in his lungs and from his DIC. He
expired on [**2128-11-17**] after being made comfort
measures only by his family, specifically his brother.
DISCHARGE DIAGNOSIS:
1. Hepatopulmonary syndrome.
2. Disseminated intravascular coagulation.
3. Hypoxemia.
4. Gastrointestinal bleed.
5. Panhypopituitarism.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2129-1-13**] 02:00
T: [**2129-1-13**] 16:03
JOB#: [**Job Number **]
ICD9 Codes: 5715, 5119, 2875, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2701
} | Medical Text: Admission Date: [**2191-1-10**] Discharge Date: [**2191-1-13**]
Date of Birth: [**2143-2-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
shortness of breath, difficulty sleeping
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
47 yo M hx CAD s/p MI, DM II, who presented to OSH c/o
difficulty sleeping for the last 2-3 weeks, associated with some
difficulty breathing. The pt notes he has been having difficulty
staying asleep, wakes up at night and has to sit at the side of
the bed. He notes difficulty with lying flat, but denies actual
SOB. In addition, he has been getting SOB with minimal activity,
and recently has PFTs done by his PCP. [**Name10 (NameIs) **] notes increased cough
and some increased sputum production over the last few days, no
fever or chills. He denies any episodes of chest pain, although
did have some L jaw pain 3days ago, relieved with NTG x1, lasted
several minutes. His MI in '[**83**] was associated with severe CP, L
arm pain and L jaw pain.
The pt initially presented to [**Hospital 1474**] Hospital where an ABG was
7.19/96/83. He was also noted to be hypoxemic to 80's on RA. He
was placed on BiPAP. In addition, cardiac enzymes were drawn and
troponin T noted to be 0.7. He was given ASA, lovenox SC,
solumedrol, lasix 40mg IV and transferred to [**Hospital1 18**]. No ECG
changes were noted.
On arrival to [**Hospital1 18**] ED, repeat ABG was 7.24/78/64 with HCO3 of
32. He was continued on BiPAP, CXR was felt to show CHF, given
additional lasix 20mg IV with total response of 700cc urine out,
and transferred to MICU
Past Medical History:
CAD s/p STEMI '[**83**] treated with stent to LCx
DM II
Hypercholesterolemia
PVD: ABI 0.89 in 10/99 mod R tibial dz,
s/p R common iliac stenting [**7-/2183**]
Social History:
The patient is single, has one daughter. [**Name (NI) 25835**] unemployed,
worked as machinist. 50 pck year smoker, 1ppd, denies EtOH or
recreational drug use.
Family History:
Mother died in her 70's of an myocardial infarction. Father died
in his 50's of an myocardial infarction. Sister had a
cerebrovascular accident in her 30's.
Physical Exam:
VS: 97.7, HR 96, BP 124/84, RR 18, O2 sat 94% on BiPAP 5/9, 50%
FiO2
Gen: very obese middle aged male, awake, alert, tolerating
BiPAP, no accessory muscle use, does not appear dyspneic.
HEENT: anicteric, OP clear
Neck: unable to see JVP 2/2 beard
Resp: good air movement, decreased BS L base, mild crackles b/l,
no wheezes
CV: RRR nl s1, s2, no m/r/g
Abd: obese, soft, NT, ND, no HSM
Extr: 1+ pittin edema b/l, 1+ distal pulses
Neuro: [**6-11**] motor strenth, no focal abnormalities
Pertinent Results:
Admission Labs:
[**2191-1-10**]
11:28p
pH
7.35 pCO2
68 pO2
78 HCO3
39 BaseXS
8
Comments: No Calls Made - Same Abnormality Previously Noted
Today
Type:Art; Not Intubated; Temp:36.2
Other Blood Gas:
O2-Flow: 3
[**2191-1-10**]
8:35p
CK: 47 MB: Notdone Trop-*T*: 0.04
Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
[**2191-1-10**]
2:42p
5.2 34
CK: 48 MB: Notdone Trop-*T*: 0.04
Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Mg: 1.8
PT: 12.7 PTT: 21.9 INR: 1.1
Other Hematology
D-Dimer: 3458
[**2191-1-10**]
10:16a
pH
7.29 pCO2
70 pO2
91 HCO3
35 BaseXS
4
Comments: Verified
Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art
[**2191-1-10**]
08:32a
pH
7.31 pCO2
66 pO2
165 HCO3
35 BaseXS
4
Comments: Verified
No Calls Made - Same Abnormality Previously Noted Today
Type:Art; Bipap
Na:140 K:5.0 Cl:95 Glu:155 freeCa:1.17 Lactate:1.2
[**2191-1-10**]
06:22a
pH
7.24 pCO2
78 pO2
64 HCO3
35 BaseXS
2
Comments: Qns To Verify
Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:Art; Not Intubated
[**2191-1-10**]
06:16a
139 98 24 146 AGap=14
5.0 32 0.8
estGFR: >75 (click for details)
CK: 70 MB: Notdone Trop-*T*: 0.05
Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Other Blood Chemistry:
proBNP: 1755
Reference Values Vary With Age, Sex, And Renal Function;At 35%
Prevalence, Ntprobnp Values; < 450 Have 99% Neg Pred Value;
>1000 Have 78% Pos Pred Value;See Online Lab Manual For More
Detailed Information
94 D
15.7 18.6 221
58.8 D
N:89.2 Band:0 L:5.5 M:4.4 E:0.2 Bas:0.6
Anisocy: 1+
Plt-Est: Normal
DD ADDED 11:45AM
PT: 15.8 PTT: 32.1 INR: 1.4
.
ECG: NSR, right axis, nl intervals, small Q in III, aVF, no ST
or T wave changes
.
CXR: mild CHF, elevated L diaphragm.
.
Echo [**5-/2183**]: Preserved left ventricular systolic function. Normal
valvular function.
.
Exercise MIBI [**5-/2184**]:
IMPRESSION: Exercise myocardial perfusion scan is performed and
read without comparison and demonstrates an ejection fraction of
57% with normal wall motion. There is normal perfusion during
rest and stress imaging.
.
Cath [**5-/2183**]:
1. Coronary arteriography of this right dominant system reveals
two vessel disease. The left main is normal. The LAD has mild
luminal irregularities. The left circumflex has a long 90%
stenosis in its mid portion, with thrombus and appearance of
plaque rupture. The flow was TIMI 2. The OM1 is tiny and
diffusely diseased. The OM2 has a distal 60% stenosis. The OM3
has a proximal 30% stenosis. The RCA is dominant and diffusely
diseased up to 60% in its mid portion.
2. Hemodynamic measurements reveal elevated filling pressures,
with mean RA of 15 mmHg, mean PCWP of 26 mmHg, PA 42/26 mmHg.
The cardiac index, SVR, and PVR are within normal limits.
3. The right iliac was subtottally occluded just proximal to the
bifurcation of the femoral artery and could not be crossed with
[**Last Name (un) 25836**]
wire. Therefore, the left femoral artery approach was used.
4. Successful acute PTCA and Stenting of Mid Circumflex.
.
CXR [**2191-1-10**]: Mild congestive heart failure, elevated L
diaphragm.
.
CXR [**2191-1-11**]: Left hemidiaphragm is elevated and could be
paralyzed or eventrated. Mild pulmonary edema and small left
pleural effusion are present. Heart size is top normal. Fullness
in the right lower paratracheal region is probably due to
distended mediastinal veins.
.
Echo [**2191-1-10**]: The left atrium is mildly elongated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. The
right ventricular cavity is mildly dilated. Free wall motion is
depressed (?mild). The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve is grossly normal. No
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Right ventricular cavity enlargement with free wall
hypokineiss. Pulmonary artery systolic hypertension. Preserved
global left ventricular systolic function. Is there a history to
suggest a primary pulmonary process (e.g., pulmonary embolism,
COPD, bronchospasm, etc.)
.
CTA [**2191-1-10**]: 1. Study limited by motion and bolus timing with no
definite evidence of segmental or main pulmonary artery
embolism.
2. Opacity in the left lower lobe with shift in the major
fissure posteriorly consistent with near total
collapse/atelectasis.
3. Opacities in the inferior lingula and right lower lobe also
suggestive of atelectasis.
Brief Hospital Course:
A&P: 47 yo M hx CAD, DM p/w mild dyspnea, orthopnea x [**3-12**]
weeks, with hypercarbia, hypoxia and new Aa gradient and right
heart failure.
.
1 Hypercarbia - appears to be acute on chronic based on his ABG
and bicarbonate. Likely his pCO2 baseline elevated (mid 60's).
This may be [**3-11**] chronic COPD with concominant OSA/obesity
hypoventialaion that may have been acutely exacerbated by left
hemidiaphragm paresis or acute bronchitis. He was seen by sleep
medicine and set up for outpatient sleep study. Additionally he
was started on BIPAP in house with settings of 9/5cm H2O, that
he was minimally compliant with while here. He was set up to
have home BIPAP on discharge. He was also started on albuterol
and iprtropium. He was started on azithromycin to complete a 5
day course which seemed to improve his productive cough.
Supplemental oxygen was used to maintain a goal o2 sat >88% but
<92%. He will follow-up in sleep disorders clinic and
additionally was set-up to have primary care at [**Company 191**].
.
2 Hypoxia - pt may have obesity hypoventilation syndrome, also
may have an element of CHF and COPD, CTA negative for PE.
Polycythemia suggests chronic hypoxia. O2 sat on room air
without ambulation was 84%, with 3-4 L by nasal canula he
maintained goal O2 sat of 88%-92%. He was discharged with home
O2 to wear at all times and advised of the dangers of smoking on
oxygen.
.
3 conjunctivitis-per pt at baseline, suspect [**3-11**] BIPAP causing
OP inflammation, increased lacrimal obstruction. Will encourage
saline nasal spray, to decrease inflammation, no other
signs/symptoms of viral URI.
.
4 CAD - elevated troponin may be explained by pulmonary process.
No evidence of ACS based on lack of symptoms, no EKG changes, CE
flat x3. Continue ASA, statin, B-blocker at low dose. Lipid
panel WNL.
.
5 DM - restart glipizide, use sliding scale insulin, hgb A1C
6.0.
.
6 Ppx - heparin sc, bowel regimen, no GI ppx indicated
currently.
.
7 Code: Full.
Medications on Admission:
ASA, glipizide, lopressor, atorvastatin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*QS 1 unit* Refills:*2*
4. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Capsule(s)* Refills:*0*
5. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO DAILY (Daily).
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal TID (3 times a day) as needed.
Disp:*QS 1 bottle* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. home oxygen
Mr. [**Known lastname 174**] will require home oxygen therapy by nasal canula at
all times at a rate of [**4-11**] liters per minute to maintain oxygen
saturation >88% but <92%.
9. home BIPAP therapy
Mr. [**Known lastname 174**] will need home BIPAP therapy with set at 9cm H2O over
5cm of H2O, with 3 liters per minute of oxygen, to be worn at
night while sleeping for obstructive sleep apnea.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypercarbia, hypoxia
.
Obstructive sleep apnea, chronic obstructive pulmonary disease,
obesity hyperventilation.
Discharge Condition:
Stable.
Discharge Instructions:
Please keep all follow-up appointments. Please take all
medications as prescribed. Please call your primary care doctor,
Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 25837**] ([**Telephone/Fax (1) 25838**] if you experience any
chest pain, shortness of breath, worsened cough, fevers, chills,
nausea, vomitting, night sweats, or any symptoms that are
concerning to you.
Followup Instructions:
Please also follow-up with sleep disorders clinic on [**1-19**], [**2190**] at 10:30am-[**Location (un) **] (neurology) of the [**Hospital Ward Name 23**]
building, please call ([**Telephone/Fax (1) 513**] if you need to change this
appointment or if you have questions.
.
Please also follow-up with your new primary care doctor here,
Dr. [**Known firstname **] [**Last Name (NamePattern1) **] on the [**Location (un) **] of the [**Hospital Ward Name 23**] building on
[**2191-1-19**], at 2:00pm.
.
You should recieve a phone call tomorrow by Sleep Health Center
to schedule you for sleep study.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
ICD9 Codes: 4280, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2702
} | Medical Text: Admission Date: [**2130-3-1**] Discharge Date: [**2130-3-7**]
Date of Birth: [**2081-7-16**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
PICC line placement
Upper endoscopy [**2130-3-1**]
History of Present Illness:
Ms. [**Name13 (STitle) 805**] is a 48-year-old F PMhx chronic HCV w Stage I
fibrosis, hypertension, Crohn's disease, rheumatoid arthritis,
and bipolar disorder who presented with with 3 days of
nausea/vomitting, and new onset hematemesis. Patient reports 10
episodes of about a cup full of vomiting dark, coffee ground
emesis following a binge on 40 ounces of malt liquor and a half
a fifth of Captain [**Doctor Last Name **] original spiced rum. Patient
reports that she often vomits after drinking (up to 3 times a
week). She denies taking any cocaine during this time. Patient
states that she has been having fevers (unmeasured) but no other
localizing symptoms. She states that she has been drinking
water, but not taking any of her home medications and not eating
due to the vomiting. She states that she may not have urinated
for the past 2 days and that she did pass a dark, oily stool
yesterday. Patient denies recent travel, strange foods, or
sick contacts. On the morning of admission, patient had 1
episode of hematemesis and called 911.
On initial presentation to the ED vital signs were not checked.
Patient was sitting up in bed and able to discuss her history.
Exam was significant for good mentation, nontender abdomen.
Initial labs were significant for Hct 34 (previously 29-36), WBC
18 (N67), Cr 6.4 (normal 1.4-1.7), ALT/AST 33/43 (previously
27/26), lactate 5.8. CXR demonstrated an elevated right
hemidiaphragm and no consolidation or pleural effusion seen on
the lateral view. She was bolused with IV NS (total 5L) with
blood pressure responsive and resolving to SBP 115-130s with HR
80bpm. Had clear NG lavage. Digital rectal exam showed dark
brown guaiac positive stool. Repeat labs showed lactate 3.8,
Hct 29. She received 1 dose zosyn and vancoymcin given concern
for infection, and 1 dose IV protonix given concern for GI
bleed. She was admitted to [**Hospital1 18**]
On arrival to the ICU patient had an initial blood pressure of
60s/20s, although this was in the context of her wiggling around
and not sitting still when the cuff was measuring. I checked
the pressure myself and got 120/50 on a manual cuff. Patient
did report some recent dizziness with standing, but denies frank
syncope. Bladder scan was done with 750cc in the bladder. A
foley was inserted.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies diarrhea, constipation, abdominal pain. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
1) Cardiomyopathy most likely secondary to hypertensive heart
disease and polysubstance abuse, LV systolic dysfunction,
EF 35-40%, NYHA class I-II.
2) Hypertension
3) Polysubstance abuse (cocaine, etoh)
4.) Crohn's disease since [**2099**] vs. ulcerative colitis (Chronic
active colitis with ulceration seen on biopsy in [**8-18**] and [**2-/2114**])
5.) hx abnormal mammogram with L breast biopsy in [**10-19**] -
sclerosing adenosis, Pseudoangiomatous stromal hyperplasia.
6.) Bipolar/Schizophrenia (per patient)
7.) Depression (per patient)
8.) Fibromyalgia (per patient)
9.) Brain aneurysm s/p surgery at [**Hospital1 112**] (per patient)
10.) Nicotine abuse
Social History:
Patient lives on SSI/disability and lives alone in an apartment
above her 25 year old daughter. + h/o cocaine and alcohol
abuse; + tobacco [**7-23**] cigarrettes a day since age 35
Family History:
Non contributory
Physical Exam:
Admission:
Vitals: T:98.9 BP:75/43 P:111 R: 18 O2: 100%
General: Alert, oriented, moving around alot/ psychomotor
agitation.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP unable to see, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic flow
murmur over precordium not on carotids, not radiating to left
axilla. No rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-18.6*# RBC-3.64* Hgb-10.5* Hct-31.6* MCV-87 RDW-13.9 Plt
Ct-427
---Neuts-67.5 Lymphs-26.1 Monos-5.1 Eos-0.7 Baso-0.6
Glucose-168* UreaN-72* Creat-6.4*# Na-136 K-3.4 Cl-86* HCO3-28
ALT-33 AST-43* AlkPhos-57 TotBili-0.6
Albumin-3.7 Calcium-9.2 Phos-6.1*# Mg-1.7
BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
Lactate-5.8*
UA: Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 Blood-SM Nitrite-NEG
Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG
pH-5.5 Leuks-NEG
RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 UreaN-447 Creat-99
Na-74 K-26 Cl-48 TotProt-23 Prot/Cr-0.2 bnzodzp-NEG barbitr-NEG
opiates-NEG cocaine-POS amphetm-NEG mthdone-NEG
==============
OTHER STUDIES
==============
ECG [**2130-3-1**]:
Sinus tachycardia. It is difficult to determine the Q-T interval
secondary to underlying artifact and non-specific ST-T wave
changes. However, the Q-T interval may be slightly prolonged.
Compared to the previous tracing of [**2127-4-21**] artifact is not seen
on the current tracing and the Q-T interval may be prolonged.
Clinical correlation is suggested.
.
Chest Radiograph PA and Lateral [**2130-3-1**]:
IMPRESSION:
1. Elevated right hemidiaphragm.
2. Left base not well evaluated on the frontal view, although no
consolidation or pleural effusion seen on the lateral view.
.
EGD [**2130-3-1**]:
Impression: Severe esophagitis in the gastroesophageal junction
and lower third of the esophagus
Ulcer in the gastroesophageal junction
No blood was seen throughout the procedure
Otherwise normal EGD to third part of the duodenum
Recommendations: Continue PPI 40mg [**Hospital1 **].
Restart ranitidine when renal function improves, if possible.
Consider sucralfate slurry 1gram QID.
Alcohol cessation counselling.
Antireflux regimen: Avoid chocolate, peppermint, alcohol,
caffeine, onions, aspirin. Elevate the head of the bed 3 inches.
Go to bed with an empty stomach.
Repeat endoscopy in [**8-27**] weeks to evaluate esophageal ulcer and
esophagitis for healing.
.
Renal U/S [**2130-3-2**]:
IMPRESSION:
No obstructing stones, masses or hydronephrosis.
[**2130-3-7**] 05:48AM BLOOD WBC-8.5 RBC-3.69* Hgb-11.1* Hct-32.7*
MCV-89 MCH-30.1 MCHC-34.0 RDW-13.9 Plt Ct-291
[**2130-3-5**] 06:30AM BLOOD WBC-8.5 RBC-3.48* Hgb-10.1* Hct-30.4*
MCV-88 MCH-29.1 MCHC-33.3 RDW-14.6 Plt Ct-231
[**2130-3-4**] 06:00AM BLOOD WBC-7.1 RBC-3.34* Hgb-10.1* Hct-29.4*
MCV-88 MCH-30.4 MCHC-34.5 RDW-13.9 Plt Ct-224
[**2130-3-3**] 05:02AM BLOOD WBC-7.6 RBC-3.33* Hgb-10.3* Hct-29.1*
MCV-88 MCH-30.9 MCHC-35.4* RDW-14.0 Plt Ct-247
[**2130-3-2**] 09:49PM BLOOD WBC-7.5 RBC-3.25*# Hgb-9.4*# Hct-27.8*
MCV-86 MCH-29.1 MCHC-33.9 RDW-14.0 Plt Ct-231
[**2130-3-2**] 05:18AM BLOOD WBC-6.8 RBC-2.59* Hgb-7.4* Hct-22.8*
MCV-88 MCH-28.7 MCHC-32.6 RDW-13.7 Plt Ct-260
[**2130-3-1**] 01:20PM BLOOD WBC-13.2* RBC-2.86* Hgb-8.4* Hct-25.4*
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.8 Plt Ct-322
[**2130-3-1**] 08:40AM BLOOD WBC-18.6*# RBC-3.64* Hgb-10.5* Hct-31.6*
MCV-87 MCH-28.9 MCHC-33.4 RDW-13.9 Plt Ct-427
[**2130-3-4**] 06:00AM BLOOD Neuts-46.4* Lymphs-39.9 Monos-8.5
Eos-4.8* Baso-0.4
[**2130-3-1**] 08:40AM BLOOD Neuts-67.5 Lymphs-26.1 Monos-5.1 Eos-0.7
Baso-0.6
[**2130-3-1**] 09:30AM BLOOD PT-12.2 PTT-23.3* INR(PT)-1.1
[**2130-3-7**] 12:47PM BLOOD Creat-1.7*
[**2130-3-7**] 05:48AM BLOOD Glucose-140* UreaN-21* Creat-1.8* Na-141
K-4.2 Cl-108 HCO3-26 AnGap-11
[**2130-3-6**] 06:30AM BLOOD Glucose-103* UreaN-15 Creat-1.6* Na-142
K-4.3 Cl-110* HCO3-29 AnGap-7*
[**2130-3-5**] 06:30AM BLOOD Glucose-152* UreaN-15 Creat-1.7* Na-141
K-3.9 Cl-108 HCO3-27 AnGap-10
[**2130-3-4**] 06:00AM BLOOD UreaN-18 Creat-1.8* Na-142 K-4.0 Cl-107
HCO3-29 AnGap-10
[**2130-3-3**] 05:02AM BLOOD Glucose-142* UreaN-18 Creat-1.9*# Na-142
K-3.9 Cl-106 HCO3-28 AnGap-12
[**2130-3-2**] 05:18AM BLOOD Glucose-94 UreaN-38* Creat-3.1*# Na-145
K-3.4 Cl-108 HCO3-31 AnGap-9
[**2130-3-1**] 01:20PM BLOOD Glucose-95 UreaN-55* Creat-4.7*# Na-139
K-3.7 Cl-104 HCO3-25 AnGap-14
[**2130-3-1**] 08:40AM BLOOD Glucose-168* UreaN-72* Creat-6.4*# Na-136
K-3.4 Cl-86* HCO3-28 AnGap-25*
[**2130-3-4**] 06:00AM BLOOD ALT-34 AST-36 LD(LDH)-239 AlkPhos-50
TotBili-0.2
[**2130-3-1**] 08:40AM BLOOD ALT-33 AST-43* AlkPhos-57 TotBili-0.6
[**2130-3-1**] 08:40AM BLOOD Lipase-21
[**2130-3-7**] 05:48AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.7
[**2130-3-4**] 06:00AM BLOOD Mg-2.2
[**2130-3-3**] 05:02AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.4
[**2130-3-2**] 05:18AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.7
[**2130-3-1**] 01:20PM BLOOD TotProt-5.8* Calcium-7.9* Phos-3.6#
Mg-1.7
[**2130-3-1**] 08:40AM BLOOD Albumin-3.7 Calcium-9.2 Phos-6.1*# Mg-1.7
[**2130-3-2**] 02:00PM BLOOD Cryoglb-NO CRYOGLO
[**2130-3-1**] 01:20PM BLOOD PEP-POLYCLONAL
[**2130-3-2**] 02:00PM BLOOD HIV Ab-NEGATIVE
[**2130-3-1**] 01:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2130-3-1**] 10:44AM BLOOD Lactate-3.8*
[**2130-3-1**] 08:53AM BLOOD Lactate-5.8*
.
Microbiology:
[**2130-3-1**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2130-3-1**] URINE URINE CULTURE-FINAL INPATIENT
[**2130-3-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2130-3-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
Brief Hospital Course:
48-year-old F PMhx chronic HCV w Stage I fibrosis, hypertension,
Crohn's disease, rheumatoid arthritis, and bipolar disorder who
presented with several days of nausea/vomiting, and new onset
hematemesis.
#Severe esophagitis causing hematemesis and acute blood loss
anemia in the context of alcohol abuse and history of candidal
esophagitis. Patient is on Protonix and ranitidine at home but
has questionable compliance. EGD [**2130-3-2**] demonstrated severe
esophagitis as well as an ulcer at the GE junction. We
initially started IV pantoprazole 40mg [**Hospital1 **], but switched to PO
after the first day. We also started sucralfate slurry 1gram
QID and recommended/ encouraged alcohol cessation counseling.
Per GI we also instituted an antireflux regimen: Avoid
chocolate, peppermint, alcohol, caffeine, onions, aspirin.
Elevate the head of the bed 3 inches. Go to bed with an empty
stomach. While in the ICU, we held patient's antihypertensive
regimen. Patient's hematocrit also decreased the day after
admission down to 22.8 and patient was transfused 2 units of
PRBCs. Hct was stable thereafter around 29. Pt was discharged
on sucralfate, pantoprazole [**Hospital1 **], and ranitidine. HCT was 32.7
upon discharge. She was discharged with an appointment with GI
for repeat evaluation and discussion of repeat endoscopy to
ensure ulcer healing. Pt can retrial ASA therapy upon discharge
if clinically indicated.
#Acute renal failure with anion gap acidosis: Question prerenal
from hypotension/ poor PO intake versus toxic injury/ cocaine
(positive u tox). Initial lactate 5.85, trended down to 3.8.
Also possible is retention as patient had 750cc in her bladder
when a foley was placed, perhaps from opioid use. Anion gap
closed rapidly, possibly starvation/EtOH due to poor PO and
alcohol use. Patient received 5L crystalloid in the ED. FeNa
2.53 and FeUrea 39 consistent with intrinsic renal disease.
Nephrology was consulted but Cr began to dramatically fall prior
to completion of work up ( showed no obstruction). HIV was
rechecked and was negative. Once Cr back down to 1.7 (near
baseline of 1.3-1.5) ranitidine was restarted first. Attempted
to restart HCTZ and lisinopril and creatinine bumped to 1.8.
Thus these were stopped and pt was advised not to restart these
medications upon discharge until further evaluation and repeat
labs by PCP. [**Name10 (NameIs) 17781**] negative. Pt's new baseline Cr may be
1.6-1.8. Follow up labs will help with determination. Creatinine
was 1.7 upon discharge.
#Leukocytosis: Unclear etiology: patient given vancomycin and
Zosyn in the ED but then stopped as no clear source. All
cultures remained negative and trended down without other
intervention. Likely leukemoid reaction due to vomiting and
acute GI bleeding.
#Tachycardia: Patient tachycardic during admission in the ICU.
Likely multifactorial including poor PO intake/ volume down
versus manic episode versus drug use. Patient was given 2 units
of blood. Tachycardia resolved by first night out of the ICU
and tele stopped.
.
#Chronic systolic CHF: Most recent TTE with marginally low EF of
50% (though previously as low as 35%). Pt appeared euvolemic
during admission and without lower extremity edema or pulmonary
edema. BB continued. Attempted to restart ACEI, however, pt had
a slight Cr bump and requested discharge. Lasix was also not
restarted given above. Pt did not report any SOB and was not
hypoxic.
#Psychomotor agitation and recent alcohol abuse/cocaine use-
Patient reported binge drinking up 3 times a week. Last drink
was 2/12 per report. Question side effects from benzotropine as
well. Cocaine + per urine. Patient was started on CIWA with
Ativan 1-2 mg PO q 2h CIWA>10 (initially IV). She did not
require any Ativan on [**3-2**]. On regular medical floor patient
without clear psychomotor retardation and received no further
BZD without signs of withdrawal.
#Nicotine abuse: Patient has been smoking up to a pack a day
for the past 10-20 years. We counseled on quitting and
continued a NICOTINE patch.
#Hypertension: Initially all anti-hypertensives were held in
setting of GI bleed. Labetalol was restarted prior to leaving
MICU as BPs trending high. Attempted to restart Lisinopril and
HCTZ on [**3-6**], however, pt had a slight Cr bump on [**3-7**] and these
medications were discontinued. Labetalol was increased to 600mg
[**Hospital1 **]. SHE WAS STRONGLY URGED NOT TO USE LABETALOL WHILE USING
COCAINE. Lasix was not restarted given recent GI bleeding and
[**Last Name (un) **].
#Crohn's disease since [**2099**] vs. ulcerative colitis: Pt on
sulfasalazine at baseline but this was held given acute renal
failure. This was restarted upon discharge as [**Last Name (un) **] resolved.
.
#Fibromyalgia (per patient): On chronic tramadol. This was
restarted at discharge.
.
#Depression/ Bipolar/Schizophrenia (per patient)/social issues:
She was continued on her quetiapine and ziprasidone at home
doses with pleasant (if odd) somewhat hypomanic behavior.
Continued benzotropine as well. Psychiatry was consulted and did
not feel as though pt had any psychiatric contraindications to
discharge. Pt was offered resources by SW and psychiatry for
assistance with stopping ETOH and drug use. However, she
declined. She was advised to follow up with her psychiatrist
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], [**Location (un) 669**] Comprehensive (per old records: cell
[**Telephone/Fax (1) 93299**], office [**Telephone/Fax (2) 93300**]). Pt told the psychiatry
team prior to discharge that she woiuld call to make an
appointment. Per report, SW attempted to file a 51A given pt's
reports of possible abuse involving her boyfriend and her
grandson's-reported to social work [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7839**]. However, pt
would not give her daugther's/grandson's address-stated she did
not know it and therefore report, per report, was unable to be
filed. Pt did not report this information to her attending. She
reported this to SW who attempted to file a 51A unsuccessfully
as the address could not be reportedly found.
-WOULD STRONGLY CONSIDER NEUROPSYCHIATRIC TESTING TO HELP IN
DETERMINING IF UNDERLYING COGNITIVE VS. PSYCHIATRIC STATE
IMPAIRING DECISION MAKING. PT UNABLE TO RECEIVE VNA SERVICES FOR
HOME SAFETY EVALUATION AS SHE IS AMBULATORY.
#COPD w/o exacerbation: Pt continued on chronic bronchodilators
#Transitional:
-Repeat endoscopy in [**8-27**] weeks ([**2130-4-20**]) to evaluate esophageal
ulcer and esophagitis for healing. Appointment made with GI
-BP check to determine if labetalol dosing should be changed
-chemistry panel check to determine if lasix, lisinopril, HCTZ
can be/should be restarted
-neuropsychiatric testing.
Medications on Admission:
BENZTROPINE 1mg qAM, 2mg qPM
Lasix 20mg daily prn lower extremity edema
HCTZ - 25mg daily
COMBIVENT 2 puffs QID
LABETALOL 400mg [**Hospital1 **]
LISINOPRIL 40mg daily
PANTOPRAZOLE 40mg Tablet [**Hospital1 **]
PREDNISOLONE ACETATE 1%Drops QID to R eye
QUETIAPINE 700mg qHS
RANITIDINE 300mg [**Hospital1 **]
SULFASALAZINE 1000mg [**Hospital1 **]
TRAMADOL 50mg [**1-16**] Tablet qid prn
ZIPRASIDONE 80mg [**Hospital1 **]
ASPIRIN 81mg daily
NICOTINE patch
Discharge Medications:
1. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. quetiapine 400 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO QHS (once a day (at bedtime)):
700mg total.
4. quetiapine 300 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO at bedtime: 700mg total.
5. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
6. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO twice a
day.
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
14. benztropine 1 mg Tablet Sig: 1-2 Tablets PO twice a day:
take 1mg (1 tablet) in the morning and 2mg (2 tablets) in the
evening.
15. labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*0*
16. pantoprazole 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:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 249**]
Discharge Diagnosis:
Primary Diagnosis:
Hematemesis due to esophagitis
gastro-esophageal ulcer
Acute renal failure
Secondary Diagnoses:
Chronic systolic CHF
Hypertension
Bipolar affective disorder/shizophrenia
Crohn's Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to bleeding from your gastrointestinal
tract including your stomach. You were initially admitted to the
ICU and underwent an endoscopy that showed an ulcer and severe
irritation in your esophagus (the tube connecting your mouth to
your stomach). You were started on some new medications for
this. You will need to follow up with a gastroenterologist after
discharge to ensure that your ulcer is healing.
.
Please avoid alcohol as this will worsen your ulcer and
esophagitis. You have been seen by social work to help provide
you with resources.
.
Please stop using cocaine. If you take labetalol (medication for
blood pressure) with cocaine you could suffer a significant
heart attack and die. Please use the resources that were
provided to you by social work to stop using cocaine. If you
continue to use cocaine, please do not take your labetalol.
.
Your medications have been changed
1.Sucralfate has been started to help heal your esophagus
2.omeprazole has been started to help with ulcer healing
3.Hydrochlorothiazide, lasix, and lisinopril have been stopped
at this time due to your kidney function.
4.your labetalol was increased because your other blood pressure
medications were changed.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
.
We strongly recommend you stop using alcohol to excess and other
drugs to help protect your health.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2130-3-10**] at 1:45 PM
With:DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ( who works on Dr. [**Last Name (STitle) 93301**] team)
Phone:[**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**], south
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: MONDAY [**2130-4-3**] at 4:30 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2163**], MD
Phone:[**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 5845, 2762, 2851, 4280, 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2703
} | Medical Text: Admission Date: [**2128-2-13**] Discharge Date: [**2128-2-19**]
Date of Birth: [**2054-3-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
s/p fall with right hip pain and fracture
Major Surgical or Invasive Procedure:
Open reduction internal fixation right valgus impacted femoral
neck fracture with 7.3 mm screws x3.
History of Present Illness:
73 year old woman with past medical history of IDDM, seizure
disorder and breast cancer who lives alone presenting with
right-sided hip, leg and low back pain after slipping off her
toilet this morning. Patient does not remember any other details
at this time. There were no witnesses, and it is not clear how
long she was down for.
.
In the ED, the intitial VS t 96.6 hr 109 bp 138/83 rr 15 and
pain was [**9-19**]. Physical exam showed pain with active and
passive R hip rotation. She was given 1g tylenol, 2mg IV
morphine and 2L NS. Evaluated by ortho. Imaging showed
subcapital femoral neck fx. Guaiac negative, cr 1.8 from b/l of
1.3. K+ 5.8->5.6, EKG notable for new T wave inversions in
V1-V4. A CT abdomen and pelvis showed urinary retention and a
foley catheter was placed. Perceived to have a somewhat altered
mental status although unclear baseline.
Past Medical History:
Seizure disorder (developed [**1-13**] DKA in [**2095**])
breast CA s/p mastectomy with prosthetic reconstruction ([**2107**])
IDDM
RA
HTN
glaucoma
bilat TKRs
.
Of note, neuropsych evaluation in [**2125**] commented that "her
marked attentional impairments raises concerns around her
safety, medication compliance, and other areas of functional
vulnerability."
Social History:
Social History: Lives alone. Ambulatory at baseline.
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
Family History: mother died at 47 in surgery (possibly during a
hysterectomy). No information was available to her regarding her
birth father. She has several step siblings. Her daughter is
healthy.
Physical Exam:
PE on Admission to MICU:
Vitals: T 96.8 BP 111/50 P 84 RR 16 O2 99ra
General: Alert, oriented to place, year and ethnicity but not
name of the current president; calm but in visible pain
HEENT: Sclera anicteric, dry MM
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
Chest: right prosthetic breast
GU: foley
Ext: cold and pale bilaterally with weak but palpable distal
pulses bilaterally
Pertinent Results:
ADMISSION LABS:
[**2128-2-14**] 12:40PM BLOOD WBC-3.1* RBC-3.70* Hgb-11.5* Hct-32.8*
MCV-88 MCH-31.1 MCHC-35.2* RDW-19.1* Plt Ct-66*
[**2128-2-13**] 06:45PM BLOOD Neuts-72.0* Lymphs-20.1 Monos-6.4 Eos-0.9
Baso-0.7
[**2128-2-14**] 01:50AM BLOOD PT-12.9 PTT-25.7 INR(PT)-1.1
[**2128-2-14**] 12:40PM BLOOD Glucose-90 UreaN-47* Creat-1.8* Na-143
K-4.6 Cl-112* HCO3-22 AnGap-14
.
DISCHARGE LABS:
[**2128-2-18**] 06:50AM BLOOD WBC-5.5# RBC-4.50 Hgb-14.1 Hct-41.6
MCV-93 MCH-31.3 MCHC-33.8 RDW-18.7* Plt Ct-222
[**2128-2-18**] 06:50AM BLOOD Glucose-155* UreaN-37* Creat-1.3* Na-138
K-4.9 Cl-108 HCO3-21* AnGap-14
[**2128-2-18**] 06:50AM BLOOD ALT-30 AST-31 LD(LDH)-597* AlkPhos-147*
TotBili-0.5
.
CARDIAC ENZYME TREND:
[**2128-2-13**] 12:00PM BLOOD CK 108 CK-MB-10 MB Indx-9.3*
cTropnT-0.16*
[**2128-2-13**] 06:45PM BLOOD CK 147 CK-MB-13* MB Indx-8.8*
cTropnT-0.22*
[**2128-2-14**] 01:50AM BLOOD CK 119 CK-MB-10 MB Indx-8.4*
cTropnT-0.22*
[**2128-2-16**] 06:37PM BLOOD CK 72 CK-MB-NotDone cTropnT-0.18*
[**2128-2-16**] 11:45PM BLOOD CK 49 CK-MB-NotDone cTropnT-0.16*
.
RADIOLOGY:
R Hip Films: [**2128-2-13**]
FINDINGS: There is a nondisplaced, slightly impacted right
subcapital hip
fracture. No other fractures are identified. Mild degenerative
changes
involving the SI joints and lumbar spine are noted. There is a
normal bowel
gas pattern.
IMPRESSION: Right subcapital hip fracture as described above.
.
CT ABD/PELVIS [**2128-2-13**]
IMPRESSION:
1. Right subcapital hip fracture.
2. Fibroid uterus.
3. Distended bladder with mild left pelvic fullness.
4. Bilateral adrenal gland thickening, left greater than right.
.
CT HEAD [**2128-2-13**]
IMPRESSION: No acute intracranial hemorrhage.
.
CT C-SPINE [**2128-2-13**]
IMPRESSION:
1. No evidence of acute fracture.
2. Multilevel degenerative changes as described above.
3. Lung apices suggestive of edema, inflammatory, or small
airways disease, vs infectious process.
4. 6mm peripherally calcified right thyroid nodule for which
further
evaluation with ultrasound.
.
EKG [**2128-2-13**]
Sinus rhythm. The P-R interval is prolonged. There is a late
transition with Q waves and ST-T wave changes in the anterior
leads consistent with probable prior anterior myocardial
infarction. There are tiny R waves in the inferior leads
consistent with possible prior inferior myocardial infarction.
Compared to the previous tracing ST segment changes are new.
.
CXR [**2128-2-13**]
IMPRESSION: No acute cardiopulmonary process.
.
R HIP FILMS [**2128-2-16**]
FINDINGS: In comparison with study of [**2-13**], views from the
operating suite show placement of three metallic screws across
the previously described fracture of the femur.
.
[**2128-2-16**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is unusually
small. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is markedly dilated with severe global free wall
hypokinesis. There is abnormal diastolic septal motion/position
consistent with right ventricular volume overload. The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Markedly dilated right ventricle with severe global
hypokinesis. At least moderate pulmonary hypertension. Small
left ventricular cavity size with preserved systolic function.
.
[**2038-2-16**] CAROTID ULTRASOUNDS
IMPRESSION: There is less than 40% stenosis within the internal
carotid
arteries bilaterally.
.
[**2128-2-17**] CXR
FINDINGS: In comparison with the study of [**2-16**], there has been a
substantial decrease in the bilateral opacification, which had
been more prominent on the left and could have represented
either asymmetric pulmonary edema or diffuse aspiration. Some
residual areas of opacification are seen at the right base
laterally and at the left base. These most likely represent
residual aspiration or possible atelectasis.
.
[**2128-2-18**] EKG
Normal sinus rhythm with Q waves in the right precordial leads
consistent with anterior wall myocardial infarction. Q waves in
the inferior leads consistent with inferior myocardial
infarction. Compared to tracing #2 there is no change.
Brief Hospital Course:
73F PMHx of DM, seizure disorder and breast cancer, found down
on her floor with R hip fx s/p fall, admitted to the ICU with
hip fx, ARF, NSTEMI, and hypoxia. Hospital course by problem:
# Elevated Cardiac Enzymes and EKG Changes: Had elevated
troponins in the setting of [**Last Name (un) **] and new TWI both in the setting
of anemia. [**Hospital **] medical regimen included ASA 81mg, statin
80mg daily, and beta blocker. ACE-I was held given recent acute
on chronic renal failure and preserved EF as seen on echo (see
below).
.
# Right Hip Fracture s/p Fall. Pt was evaluated by orthopedics
who planned for
minimally invasive pinning procedure pending medical clearance,
which was provided by daughter, [**Name (NI) 1785**], as pt was delirious.
Went to OR on [**2128-2-16**], no complications intra-op, but did go back
ot the ICU for overnight monitoring as she had some hypoxia
postoperatively (had received a larga amount of morphine). She
commenced PT POD#1, and was significantly limited by pain, but
this improved by POD#3 (ay of d/c). She did receive narcotics
around the time of PT to aid in progress. Pain was also managed
with tylenol. She was discharged on lovenox 40mg sQ daily for
DVT ppx, and with orthopedic followup.
# Pancyopenia: Presented with acute on chronic anemia with
baseline in low 30s, as well as thrombocytopenia with nadir
platelets in the 40s, and leukopenia to a nadir of 2.1 Felt
likely [**1-13**] methotrexate use with questionable use of folate
(marrow suppressive process). She was transfused 3 units in the
ICU and on HD#2 had a stable Hct to 32.8. DDAVP was given for
low platelets. Her methotrexate was held, she received
supplemental folic acid, and all cell lines recovered to normal
by discharge. She will followup with erh rheumatologist for ?
resumption of methotrexate.
# Acute Kidney Injury: Baseline creatinine = 1.3, but she
presented with creatinine 1.8 -> max of 2.2 in setting of fall.
Normal CKs made rhabdo unlikely. Felt likely [**1-13**] hypoperfusion
and prerenal state. Pt. was given IVF boluses and Cr decreased
to 1.3 by discharge.
# Transaminitis: Had elevations of ALT, AST and Alk Phos without
elevation in bilis. Unclear etiology, felt [**1-13**] mild ischemic
liver in setting of hypotension. Her methotrexate was also held.
LFTs had entirely normalized by discharge.
# IDDM: well-controlled by A1c. FS were checked every 4 hours
and she was placed on an insuling sliding scale. Her lisinopril
was held. On discharge,her metformin was continued, but
lisinopril was still held in setting of recent acute renal
failure.
# Fall: unclear etiology in pt with h/o seizure d/o and multiple
CAD risk factors.
Her cardiac enzymes were followed and Trop was trended from
0.16-->0.22-->0.22, so an MI could be the etiology but this
could also have been a conseqeunce of her fall. Further syncope
workup included monitoring on telemetry without significant
arryhtmia, sending a tegretol level (normal), repeating EKGs
(developed signs of MI), and carotid ultrasounds which were
normal. Head CT and Cspine Ct in ED were negative.
# Hypoxia - pt still had minimal O2 requirement on d/c. Has
known OSA per prior sleep evaluations. Also received many liters
of IVF and 3 units of blood during her hospital course, so ?
some element of hypervolemia, but phsical exam did not support
this. Echo performed this admission revealed preserved EF of
60-65% but markedly dilated RV with severe global free wall
hypokinesis. There was abnormal diastolic septal motion/position
consistent with right ventricular volume overload. There was
moderate pulmonary artery systolic hypertension. This was
thought to possible represent sequelae from her MI. Pulmonary
embolism was on the differential but given her acute on chronic
renal failure, a CT-A was deferred, and the patient was allowed
to autodiurese and recover from the imediate postoperative
period and wean off of narcotics. If persistent, this could be
further worked up as an outpatient.
# RA: methotrexate was held during admission given pancytopenia
above.
# Depression: dx with mild depression - Effexor therapy was
continued
# Dementia/Delerium: unclear circumstances of diagnosis, per
record patient reporting forgetfulness, psych testing showing
mild attention deficits. She was continued on Aricept. She did
experience significant delirium during her hospitalization which
had improved by her discharge, but was still present in a waxing
and [**Doctor Last Name 688**] nature but easily treated with reorientation and
discontinuation of foley catheter, telemetry, and hydration. She
does have followup scheduled with her cognitive neurologist.
# FEN:
pt was seen by speech and swallow who recommended:
1. Continue current diet of thin liquids and puree.
2. Pills whole or crushed with puree.
3. 1:1 supervision for all POs.
4. Give POs ONLY when patient is most awake and alert.
5. Nutrition consult.
6. Recommend repeat swallowing evaluation at rehab prior to
upgrading diet.
# Prophylaxis: will be on lovenox 40mg sQ daily until ealry
[**Month (only) 547**] for DVT ppx, also d/c'ed on bowel regimen
# Communication: with patient and daughter [**Name (NI) **] HCP
[**Name (NI) 1785**] [**Name (NI) 1356**]
[**PO Box 103136**]
[**Location (un) 2268**], [**Numeric Identifier 103137**]
Home: [**Telephone/Fax (1) 103138**]
Cell: [**Telephone/Fax (1) 103139**]
Work: [**Telephone/Fax (1) 103140**]
# Code: Full
# Dispo:
To [**Hospital3 **]
Medications on Admission:
Lipitor 20 mg daily
Tegretol 200 mg TID
Aricept 10 mg daily
Lisinopril 5 mg daily
Meloxicam 15 mg daily
Metformin 500 mg daily
Methotrexate 12.5 mg weekly
Effexor 150 mg Daily
Discharge Medications:
1. Senna 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. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily) for 25 days: LAST DAY OF THERAPY IS
[**2128-3-14**].
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Vitamin D 400 unit Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
14. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every [**5-18**]
hours as needed for pain: HOLD for any CNS or respiratory
depression (RR <12). Can be given prior to physical therapy
sessions.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary:
- Right valgus impacted femoral neck fracture.
- NSTEMI vs. demand ischemia
- shock liver
- Pancytopenia likely due to methotrexate
- Right heart failure
Secondary:
- Rheumatoid arthritis
- Hypertension
- Depression
- Seizure disorder
- Diabetes mellitus type II
- Obstructive sleep apnea
- Dementia
- H/O breast cancer
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital after falling at home. You
were found after being down on the floor for a prolonged time.
As a result of the fall, you suffered a fractured right hip, as
well as low blood pressure which caused major stress to your
heart and liver. Your hip fracture was surgically repaired, and
as you were given IV fluids, the damage to your heart and liver
improved substantially. You will need a course of rehabilitation
and aggressive physical therapy to regain your previous level of
function.
.
We also discovered that the right side of your heart is not
working well, which will need to be worked up further by your
PCP. [**Name10 (NameIs) **] the meantime we did discharge you with some supplemental
oxygen to keep your oxygen levels at a healthy level.
.
Some changes were made to your medications, as follows:
1) Your methotrexate was STOPPED, since it might have been
lowering your blood cell counts when you came to the hospital.
The blood counts revcovered nicely when you were taken off
methotrexate. You can determine when to restart this when you
see Dr. [**Last Name (STitle) 6426**] in followup.
2) Your lipitor was increased to 80mg daily
3) You will be receiving daily injections of lovenox, a blood
thinner, to prevent blood clots after your hip surgery, for the
next 25 days
4) START calcium and vitamin D supplements to help with bone
healing
5) START metoprolol 12.5mg [**Hospital1 **] to protect the heart
6) START a baby aspirin every day to protect the heart
Followup Instructions:
Orthopedics:
Tuesday [**3-2**] at 11:20 with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Location (un) 8661**]
Building, [**Location (un) **])
.
Cognitive Neurology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. Phone:[**Telephone/Fax (1) 1682**]
Date/Time:[**2128-3-2**] 10:30
.
Primary Care:
Thursday, [**2130-4-9**]:20 with Dr. [**First Name (STitle) **]
.
Rheumatology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2128-3-4**] 11:30
ICD9 Codes: 5849, 5859, 4280, 2767, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2704
} | Medical Text: Admission Date: [**2105-9-3**] Discharge Date: [**2105-9-11**]
Date of Birth: [**2026-6-15**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
fall from standing at home
Major Surgical or Invasive Procedure:
embolisation of L5 lumbar artery
History of Present Illness:
This is a 76 year old woman who trip and fell at home. She was
initially brought to [**Hospital 1474**] hospital and subsequently
transferred to the [**Hospital1 18**] for treatment of a retroperitoneal
bleed and a pubic rami fracture.
Past Medical History:
A fib (on coumadin)
Coronary Artery Disease
Cerebrovascular accident
Osteoporosis
Social History:
lives at home alone, has VNA to check on coumadin levels
Family History:
non-contributory
Physical Exam:
Physical Exam:
Vitals - T: 98.5 BP:146/66 HR: 98.2 RR: 20 02-Sat: 99%/2L
GENERAL: Pleasant woman in NAD, appears to be
somewhat labored breathing.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: irregular rhythm, tachycardic. No murmurs,
rubs or [**Last Name (un) 549**]. no JVP
LUNGS: Crackles to basis bilaterally
ABDOMEN: NABS. Soft, NT, ND.
EXTREMITIES: Trace of edema
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate.
Pertinent Results:
[**2105-9-3**] 09:07PM GLUCOSE-184* UREA N-35* CREAT-2.2* SODIUM-140
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-21* ANION GAP-19
[**2105-9-3**] 09:07PM CK(CPK)-234*
[**2105-9-3**] 09:07PM CK-MB-11* MB INDX-4.7 cTropnT-0.14*
[**2105-9-3**] 09:07PM CALCIUM-8.1* PHOSPHATE-5.2* MAGNESIUM-2.7*
[**2105-9-3**] 09:07PM WBC-13.2* RBC-3.06* HGB-9.3* HCT-29.3* MCV-96
MCH-30.4 MCHC-31.8 RDW-15.3
[**2105-9-3**] 09:07PM PLT COUNT-159
[**2105-9-3**] 09:07PM PT-21.3* PTT-31.8 INR(PT)-2.0*
[**2105-9-3**] 09:07PM FIBRINOGE-286
[**2105-9-3**] 06:16PM GLUCOSE-173* LACTATE-3.2* NA+-138 K+-4.9
CL--104 TCO2-21
[**2105-9-3**] 05:50PM UREA N-33* CREAT-2.2*
[**2105-9-7**] 05:45AM BLOOD Plt Ct-129*
[**2105-9-5**] 06:00PM BLOOD PT-11.4 PTT-25.8 INR(PT)-0.9
[**2105-9-8**] 07:35PM BLOOD Glucose-131* UreaN-43* Creat-2.2* Na-134
K-4.3 Cl-96 HCO3-28 AnGap-14
CT ABDOMEN W/CONTRAST Study Date of [**2105-9-3**] 6:26 PM
Findings
1. Left large retroperitoneal hematoma with active extravazation
has only
mildly increased in size since the prior exam from 3.5 hours
prior making
large arterial bleed an unlikely possibility. Source of active
extravazation
is likely venous or small arterial lumbar branch. Additionally,
there is
likely a tamponade efffect of the retroperitoneum.
2. Small right retroperitoneal hematoma.
3. right sup/inf pubic rami fx, right sacral fracture.
Bilateral L5 and left L4 transverse process fractures.
4. Probable grade 1 laceration of the spleen.
5. Simple small pericardial and bilateral pleural effusions.
Brief Hospital Course:
The patient was admitted to trauma service on 09//[**4-9**] after a
fall at home.
She has a history of chronic atrial fibrillation treated with
Coumadin. Upon admission her INR was 6.0. CT scans from
[**Hospital 1474**] hospital as well as our institution showed a large left
retroperitoneal hematoma and a contrast study showing acute
extravasation. The patient had been generally hemodynamically
stable but has required pressors and several units of packed red
blood cells after admission. She underwent embolization on the
[**2105-9-5**] after arteriography showed a acute contrast
extravasation consistent with bleeding from the left L5 lumbar
artery. This branch was successfully Gelfoam embolized. Her
lateral compression pelvic fracture was complicated by bleeding
but did not require surgical orthopedic management for
stability. Mrs [**Known lastname 24397**] is encouraged to weight bearing as
tolerated and when able with a walker. Orthopedics will follow
her course and see her as an outpatient 4 weeks after discharge.
We diuresed her with several doses of IV furosemide. Her
breathing and clinical
exam greatly improved. The patient was not able to ambulate in
the hospital yet, but remained stable.
During her hospital stay she was not anticoagulated with
coumadin, given her recent episode of bleeding. She is receiving
5000 units sq heparin twice daily and is instructed to get in
touch with her PCP as soon as possible to resume her coumadin
therapy. We increased her beta-blocker dose to 50 mg QID.
Her most current hematocrit is 27.9%.
Medications on Admission:
Acetaminophen, Insulin, Famotidine, Simvastatin, Dilaudid,
Heparin, Hydralazine, Metoprolol, Nitro, Aspirin, Lisinopril
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
14. Oxycodone 5 mg/5 mL Solution Sig: One (1) ml PO Q4H (every 4
hours) as needed for pain for 2 weeks.
Disp:*400 ml* Refills:*0*
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) for 2 weeks.
Disp:*30 Capsule(s)* Refills:*0*
17. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
units per sliding scale Injection ASDIR (AS DIRECTED): Sliding
scale:
Glucose
0-60mg/dL 1/2ampD50
61-160mg/dL 0 Units
161-180mg/dL 2 Units
181-200mg/dL 3 Units
201-220mg/dL 4 Units
221-240mg/dL 5 Units
241-260mg/dL 6 Units
261-280mg/dL 7 Units
> 280 notify MD.
18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
-ight LC1 pelvic ring injury
-right L5 TP fx
-left L4/L5 TP fx
-left retroperitoneal bleed
Discharge Condition:
good, hemodynamically stable
Discharge Instructions:
You have been admitted because because of pelvic fracture and
an inner bleeding sustained after a fall.
Please call your doctor or return to the ED if you experience
any of the following
any signs and symptoms of infection, including fevers, chills
any chest pain or shortness of breath
or any other symptoms that may be of concern.
You are weight bearing as tollerated on your lower extremities.
It is of importance that you follow up with your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 17887**] as soon as possible for further guidance on your
coumadin therapy. Please schedule this appointment as soon as
possible (refer to follow up instructions)
Followup Instructions:
Please follow up with Orthopedics in 4 weeks. Call [**Telephone/Fax (1) 1228**]
to make an appointment.
Follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17887**] for resuming your coumadin
therapy. Call [**Telephone/Fax (1) 45878**] to make an appointment.
Follow up with Dr [**Last Name (STitle) 519**] (Trauma service) in 2 weeks. Call [**Telephone/Fax (1) 108664**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2105-9-10**]
ICD9 Codes: 2851, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2705
} | Medical Text: Admission Date: [**2111-1-17**] Discharge Date: [**2111-1-27**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Fell down; transferred to medicine for CHF mgmt.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Sister [**Name (NI) 106556**] is an 80-yo W w/hx. of CAD s/p CABG x4, AFib, HTN,
AS, AI s/p mechanical fall this past weekend outside her
[**Hospital3 **] facility w/o LOC and GCS 15. Sustained contusion
and lac over L. temporal area and L periorbital/zygomatic region
w/nondisplaced zygomatic fx. - not surgically treated. Also had
intraparenchymal bleed. Was admitted to OSH then transferred to
[**Hospital1 18**] ICU. While there developed NSTEMI and CHF. She was
transferred to Med floor today for ongoing mgmt. of her CHF. Per
pt., she has been in pain since her hospital admisson mainly in
her l. lateral rib cage. Otherwise she denies current SOB, PND
(sleeps on one pillow), or lightheadedness, although had
complained of SOB earlier today. Reports that while in ICU, had
experienced some nausea w/o V. Also denied F/C/other pain.
Past Medical History:
- CAD s/p CABG x4 in [**2101**]
- AFib
- AS, AI
- HTN
- Dyslipidemia
- MI in [**2094**]; tx. by PCTA
- Lumbar discectomy x2
- Bladder polypectomy
- Gout
- cataract surgery
Social History:
Retired nun. No T/A/D
Family History:
Noncontributory
Physical Exam:
Gen: Sister [**Name (NI) 106556**] was resting in bed in NAD. Ecchymosis is
present in L. periorbital area along w/contusing over l. temple.
some bruising also visible in L hand and L knee
HEENT: PERRLA, No lymphadenopathy, vision intact.
CVS: 2-3/6 systolic murmur best heard at L and R parasternal
borders; peripheral pulses intact; slightly elevated JVP; no
signs of peripheral edema
Pulm: Prominent rales bilaterally [**1-12**] way up lung fields; nl
tympany to percussion
Abd: soft, ND/NT, +BS
Neuro: AOx3; sensation intact in all dermatomes; [**5-14**] muscle
strength throughout UE's and LE's; 2+ reflexes bilaterally in
all extremities; normal finger-to-nose testing and rapid
alternating movements; gait not assessed
Pertinent Results:
[**2111-1-16**] 06:45PM WBC-14.7* RBC-3.79* HGB-10.8* HCT-34.1*
MCV-90 MCH-28.5 MCHC-31.6 RDW-16.9*
[**2111-1-16**] 06:45PM PLT SMR-NORMAL PLT COUNT-260
[**2111-1-16**] 06:45PM NEUTS-91.4* BANDS-0 LYMPHS-6.0* MONOS-1.8*
EOS-0.5 BASOS-0.4
[**2111-1-17**] 06:10AM GLUCOSE-197* UREA N-49* CREAT-1.5* SODIUM-142
POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-28 ANION GAP-16
[**2111-1-17**] 06:10AM CALCIUM-9.8 PHOSPHATE-4.7* MAGNESIUM-2.0
[**2111-1-17**] 06:10AM CK(CPK)-114
[**2111-1-17**] 06:10AM CK-MB-9 cTropnT-0.04*
[**2111-1-17**] 09:19PM CK(CPK)-269*
[**2111-1-17**] 09:19PM CK-MB-28* MB INDX-10.4* cTropnT-0.50*
CT Sinus- ? fractures of the left zygomatic arch of left
zygomatic arch and left squamus temporal bone of undetermined
age. Clinical correlation with point tenderness recommended.
CT Head-Stable left subtle contusion and minimally displaced
zygomatic arch fracture.
ECHO-Conclusions:The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with near
akinesis of the basal 2/3rds of the septum. The remaining
segments contract well. The aortic valve leaflets are moderately
thickened. There is mild 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. Mild to moderate ([**1-11**]+) mitral regurgitation is
seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD. Mild
aortic valve stenosis. Mild aortic regurgitation. Mild-moderate
mitral
regurgitation. Pulmonary artery systolic hypertension.
Brief Hospital Course:
CHF
Pt. transferred to [**Hospital1 18**] from outside hospital s/p fall at home
and was judged to have zygoma fx. not needing intervention. Pt.
was transferred to SICU for two days. Serial CXR's showed
evidence of CHF, and EKG showed changes suggestive of NSTEMI.
TpnT trended up from 0.04 to 0.50 as did CK. On Mon [**1-19**] pt.
was transferred to med floor from SICU for further mgmt. and was
continued on beta-blocker and lasix. Echo and CXR were obtained
for further evaluation, confirming low EF and some akinesis but
signs of improvement. Pt. was put on ACE inhibitor and started
on nesiritide and monitored throughout week. She showed
progressive clinical improvement on this medical regimen along
with low Na diet and goal of minus 1L net fluid intake daily and
incentive spirometry.TpnT, however, continued to trend upward
after a brief drop, reaching 2.02. CK trended down and remained
flat and pt. showed no signs of new MI after repeat EKGs.
Cardiology consulted and agreed with regimen focusing on
diuresis with ACEI. It was decided there was no need to
continually monitor Tpn in absence of clinically concerning
sx's. Pt. continued to improve and was able to increase
activity, and ceased to experience SOB. Spironolactone was added
to regimen. Expectation is that she will remain stable and be
able to return to acute rehab center after discharge.
CAD/Dyslipidemia
Pt. had known athersclerosis and was kept on atorvastatin for
duration of her hospital stay. NSTEMI/demand ischemia that
occurred in SICU was likely exacerbated or caused by coronary
occlusion and cardiology consult addressed this during pt.'s
course. Pt. will need to continue on statin with plan to have
assessment for eventual cardiac catheterization. when she is
fully recovered post-discharge, she should obtain MIBI
scan/stress test.
AFib
Pt. had longstanding hx of AF prior to transfer to our ED and
SICU. On med floor, pt. was continued on beta blocker for rate
control and digoxin to help rhythym. Digoxin levels were
monitored and pt. was found to have therapeutic level which
trended upward, prompting dose reduction. Level increased again
and digoxin was d/c'ed but bb continued. Throughout her course
pt. was frequently tachycardic and in non-sinus rhythym. SC
heparin was used for prophylaxis, and AF continued to stay under
reasonable control during her stay. Following discharge, she
can, at her physician's discretion, return to a regular Coumadin
regimen with possible aim for cardioversion vs. rate control
medical mgmt.
Neurological
Pt. was evaluated by neurosurgical and orthopedic consult in ED
and had head CT as well. There was agreement that injury was
nondisplaced zygomatic fx. not requiring invasive repair.
However, Coumadin that pt. had been on prior to arrival was
d/c'ed for fear of bleeding risk. While on medical service, pt.
was prophylaxed with SC heparin and low dose aspirin and
remained stable for rest of her stay. She will be instructed to
follow up with ophthalmologist and/or orthopedist as needed
after discharge.
UTI
Pt. developed a UTI shown to be Klebsiella pneumonia with
pansensitivity. She was treated with a 7 dd course of
antibiotic, first with 3 dd.levo. This was suspected to
contribute to daily nausea she experienced, and was thus
switched to ceftriaxone. Pt. did well throughout week with
improvement in nausea sx's. She remained afebrile and Foley was
eventually d/c'ed.
Pain
Pt. was given acetaminophen during her stay and a lidocaine
patch as well. SHe mainly experience LUQ/L lower chest pain that
resolved upon relief of her constipation via lactulose and
enema. Lateral axillary pain was present which was thought to be
due to fall and responded well to morphine while in ED then to
PO pain meds and lidocaine patch whle on med floor.
Hypernatremia
Pt. initially presented with upward trend in serum Na. This was
addressed by instituting a low Na diet and encouraging free
water intake. She responded well, normalized, and remained
stable for the duration of her stay.
Following discharge, Sr. [**Known lastname 106556**] should return to acute rehab and
follow up with her cardiologist to decide on the following
issues: 1) how best to address pump function and CAD and 2) how
to treat Afib. Per the recommendations of cardiology at [**Hospital1 18**],
she would benefit from MIBI stress testing within the following
weeks with subsequent catheterization if feasible. As for the
arrhythmia, it will be her doctor's discretion whether to focus
on rate controlling her, or on returning to a Coumadin regimen
with the aim of cardioversion. Her zygomatic and conjunctival
injury should also be addressed by follow up in [**2-13**] weeks with
optho and/or ortho services.
Medications on Admission:
norvasc 10', lasix 60', allopurinol 300', atenolol 75', lipitor
40', tramadol 50', lisinopril 40', KCL 40', Colace 100", motrin
800''' prn, amoxicillin 2gm prn proph, coumadin 5', asa 81', SL
nitro 0.4'
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
7. 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:*5*
8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Bumetanide 2 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
12. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
14. Imdur 30 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:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Left Frontal Lobe Contusion
CHF
CAD
Hyperlipidemia
A.fib
Discharge Condition:
Stable, no SOB, ambulating without dyspnea, no neuro deficits
Discharge Instructions:
Please take all medications as instructed. Please do not restart
your digoxin and follow up with your doctors regarding
controlling your heart rate with other medications.
Do not start taking your coumadin until told to do so by your
doctors,this should be restarted about [**2111-2-8**] but check with
your doctors [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**].
If you experience any chest pain, shortness of breath, lower
extremity swelling, weight gain, lightheadedness you should seek
medical attention.
Followup Instructions:
1. Follow-up with Dr. [**Last Name (STitle) 739**] in [**1-11**] wks. Call
[**Telephone/Fax (1) 1669**] for an appointment. Please inform the office that
you need a Head CT scan prior to your appointment.
2. Follow-up with your outpatient ophthalmologist in 4 wks.
3. Follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to
evaluate a L thyroid calcification noted on the CT scan. Also
you need to follow up with Dr. [**Last Name (STitle) **] in regards to your heart
failure and atrial fibrillation. It has been recommended that
your coumadin be held for 3 weeks until [**2-8**].
4. You should follow up with your cardiologist about CHF and
a.fib management.
ICD9 Codes: 4280, 5990, 2760, 5849, 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2706
} | Medical Text: Admission Date: [**2157-1-1**] Discharge Date: [**2157-1-5**]
Date of Birth: [**2080-1-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
This is a 76 year-old male with a history of sarcoid and recent
admission who presents with altered mental status.
.
In the ED, the patient had initial vitals of 100.1 with BP
137/100 HR 80s rr 100% RA. While in the ED the patient was
treated empirically for pneumonia with levofloxacin and
vancomycin. O2 sats ranged from 90-100% eventually being placed
on 100% NRB. He was given 0.5 mg ativan at 23:40. Due to hypoxia
to 74% and increased work of breathing the patient was intubated
at 1AM. He was sedated on propofol. The ED attempted to contact
the nursing home without success to address code status.
There is mention in the ED note that the patient may have taken
oxycodone prior to presentation.
.
Upon discussion with the family the patient has not been feeling
well for the last 1 week. He was not specific about his
discomfort, but has been increasing his pain medications. The
family is concerned that he has been increasing his intake of
oxycodone and has become more confused as a result. The reason
for his increased intake of oxycodone (i.e. the location of
increased pain) is unclear. The family reports that he took at
least 8 percocets in the last 36 hours. The do not recall any
localizing symptoms including no fever, chills, chest pain,
shortness of breath, diarrhea. The family was concerned about
his general health such that they took him to his PCP on
thursday and he saw his nurse practitioner [**First Name (Titles) **] [**Last Name (Titles) **]. Both
health care practitioners were not concerned for any acute
change in his health and are well known to the patient.
.
ROS: unable to be obtained as the patient is intubated and
sedated.
Past Medical History:
1) Sarcoidosis
2) GERD
3) Paroxysmal atrial fibrillation
4) CVA with resulting memory difficulty
5) Hypertension
6) Anemia
7) Chronic Back Pain (post-herpetic neuralgia)on chronic
prednisone
Social History:
Retired physician, [**Name Initial (NameIs) **], 2 grandchildren. Son-in-law [**Name (NI) **]
very supportive. Divorced from wife, who recently died. Patient
has never smoked. Patient rarely consumes alcohol. Patient lives
alone at [**Hospital1 100**] Senior Life. His meals are provided for him, he
does go shopping on his own and is quite active. He ambulates
with a walker since fracturing his acetabulum recently.
Family History:
NC, no family history of sarcoid
Physical Exam:
Vitals: Afebrile, normotensive, satting well on room air, at
times requires 1-2L NC.
General Appearance: Thin
Eyes / Conjunctiva: constricted pupils approx , mildly reactive
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub
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, Bowel sounds present
Extremities: Right: Absent edema , Left: Absent edema
Skin: small faruncle on left leg, no surrounding erythema
Musculoskeletal:
Skin: Warm
Neurologic: Sedated, Tone: Not assessed, down going plantar
reflexes, withdraws all extremities to pain
Pertinent Results:
LABS ON ADMISSION:
.
HEMATOLOGY:
[**2156-12-31**] 07:30PM BLOOD WBC-10.7 RBC-4.69 Hgb-13.7* Hct-39.5*
MCV-84 MCH-29.3 MCHC-34.8 RDW-15.5 Plt Ct-233
[**2156-12-31**] 07:30PM BLOOD Neuts-87.8* Lymphs-5.9* Monos-5.2 Eos-0.8
Baso-0.4
[**2157-1-1**] 05:54AM BLOOD PT-35.2* PTT-36.2* INR(PT)-3.7*
.
CHEMISTRY:
[**2156-12-31**] 07:30PM BLOOD Glucose-107* UreaN-18 Creat-1.2 Na-141
K-4.1 Cl-99 HCO3-33* AnGap-13
[**2156-12-31**] 07:30PM BLOOD ALT-27 AST-32 CK(CPK)-222* AlkPhos-96
TotBili-1.1
[**2156-12-31**] 07:30PM BLOOD Lipase-33
[**2156-12-31**] 07:30PM BLOOD CK-MB-10 MB Indx-4.5 cTropnT-0.10*
[**2157-1-1**] 05:54AM BLOOD CK-MB-7 cTropnT-0.06*
[**2156-12-31**] 07:30PM BLOOD Calcium-9.2 Phos-2.2*# Mg-2.3
.
TOX:
[**2156-12-31**] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
URINE:
[**2156-12-31**] 08:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG
[**2156-12-31**] 08:10PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
.
MICROBIO:
blood, urine, sputum - no growth to date
.
.
RADIOLOGY:
CT HEAD ([**12-31**])
FINDINGS: Exam is moderately limited by motion, although there
is no gross
intracranial abnormality. There is no evidence of shift of
normally midline structures, large hemorrhage or fracture. The
paranasal sinuses and mastoid air cells are grossly clear except
to note persistent mucosal retention cyst in the right anterior
ethmoid sinus.
IMPRESSION: Moderately limited exam without large intracranial
hemorrhage or fracture.
.
MRI HEAD (Prelim [**1-1**])
No evidence of acute ischemia or infarction. Moderate degree of
chronic small vessel ischemia again seen. No gross vascular
abnormalities. Major vessels patent and well perfused.
.
CTA CHEST ([**12-31**]) prelim
sl. limited by resp motion. no central/segmental PE
similar chronic lung changes related to sarcoidosis, possibly
worse at L
hilum.
small bilateral pleural effusions.
MRI L-SPINE:
IMPRESSION:
1. Multilevel spondylosis of the lumbar spine which is most
severe at level of L4-L5.
2. Grade 1 anterolisthesis of L4 over L5 is associated with mild
canal
narrowing and bilateral moderate neural foraminal narrowing.
Brief Hospital Course:
76 year-old male with a history of sarcoidosis and atrial
fibrillation who presents with 1 week of malaise and worsening
respiratory status.
.
# Altered mental status: unclear etiology though increased pain
meds (fentanyl patch, percocet, pregabalin) seem at least partly
the cause. It seems that the patient took 8 percocets in one
day when he normally takes 2. Resolved after intubation. Per
outpatient PCP patient is on a strict narcotics regemin and
usually keeps to this.
.
# Respiratory failure: brief period of hypoxemia followed by
persistent O2 requirement. Patient was found to be aspirating.
It is thought that the altered mental status may have worsened
his aspiration events and caused him to become hypoxic. After
extubation his persistent O2 requirement improved with regular
PT and chest PT. Patient had difficulty understanding and
complying with the incentive spirometry.
.
# Hip pain: New pain seems to be refered from his L-spine. He
has been seen by ortho as an outpatient. A repeat MRI showed
L4-L5 disease. The pain team was consulted and his pain
medications were adjusted. Pain did not limit his movement with
PT. A lidocaine patch was started, his fentanyl patch was
decreased and his home dose of percocer and pregabalin was
continued upon discharge.
.
# Sarcoidosis: Not currently treated (except for inhalers as
prednisone is not for sarcoid per pulmonologist). Continued
inhalers.
.
# Atrial fibrillation: Currently rate controlled and
anticaogulated. INR initially therapeutic and so was held. He
was discharged on coumadin.
.
# History CVA: Head CT no acute hemorrhagic event.
.
# GERD: continued pantoprazole
Medications on Admission:
Discharge meds as of 11.24, family believes them to be correct
1. Percocet 2.5-325 mg up to 8/day per family
2. Lidocaine 5 %(700 mg/patch)
3. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
4. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO QPM (once
a day (in the evening)).
5. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q48H (every 48 hours).
6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q48H (every 48 hours).
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
8. Warfarin 5 mg
9. Docusate Sodium 100 mg
10. Senna 8.6 mg .
11. Omeprazole 20 mg Capsule, [**Hospital1 **]
12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO qhs
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID
14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
15. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
16. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation Inhalation [**Hospital1 **]
17. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol
18. Calcitrate-Vitamin D 315-200 mg-unit Tablet Sig: Two (2)
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for wheezing.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed for wheezing.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-17**]
Drops Ophthalmic PRN (as needed).
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
15. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
16. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for pain: No more than 2 per day - preferably 1.5 .
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for Hip pain.
18. Pregabalin 75 mg Capsule Sig: Three (3) Capsule PO QPM (once
a day (in the evening)).
19. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
Hypoxic respiratory failure
Aspiration
Discharge Condition:
Stable, At times requires 1L O2 via NC.
Discharge Instructions:
You were admitted to the hospital because of confusion. In the
ED you had low oxygen level which required you to be intubated
and sent to the ICU. You did well and the tube was removed the
next day and you were transfered to a medical floor. On the
floor you required oxygen to keep your oxygen levels up. This
improved with the chest PT and walking around with PT. You were
evaluated by the speech and swallow team who recomended a
special diet for you to help you swallow safely. We think that
you may have aspirated some food into your lungs which caused
your oxygen level to go low. You will need to be very careful
when you eat.
Medication changes:
Fentanyl patch to 100
Lidocaine patch for back
Please continue the rest of your medications as presiously
directed. You should not take more than 2 percocets per day per
your primary care doctor.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 5351**] at [**Telephone/Fax (1) 608**] after rehab to set up a
follow up appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11642**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2157-3-1**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 5068**]
Date/Time:[**2157-5-19**] 2:00
ICD9 Codes: 2930, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2707
} | Medical Text: Admission Date: [**2157-3-20**] Discharge Date: [**2157-3-31**]
Service: MEDICINE
Allergies:
Penicillins / Warfarin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 F presented to ED w/ complaints of bilateral lower extremity
pain and weakness over the lsat 9-10 days. She lives alone in
her own apartment and is now having trouble ambulating because
"my legs just won't work well, and I have pain from hips to my
feet". She was recently admitted and treated with Azith +
Cefpox for presumed URI. At that time, it was recommended by PT
consult that she go to rehab, but she refused. Her daughter
stayed with her at home until today when she went back to NY.
Patient then came here. She states she wanted to come into ED
on Friday, but daughter [**Name (NI) 36665**]'t let her.
.
ROS: No HA, falls, fever, SOB, CP, abd pain, cough, chills,
flank pain, numbness, change speech, diarrhea, vomiting,
dysuria, rash or syncope. Other 10 pt detail is negative
.
In the ED vital signs wer 98.6, 168/82, 85, 18, 99%RA. They
noted her abdomen to be tender. Urinalysis was concerning for
urinary tract infection so she was given Ciprofloxacin for
presumed UTI. (Prior UAs have shown WBCs, leuk est, without
doucmented UTI). She denies dysuria, fever, flank pain. Other
labs were normal. She received xrays of pelvis, hips, L-S spine
and these were reportedly normal (final read pending). A 5 x
2.5cm AAA was noted on CT aortogram, and felt to be unchanged
from prior evaluations (final read pending). She has stable
mild hip flexor weakness but no other neurologic symptoms.
.
She has no elected HCP in her chart. A daughter is listed as
her emergency contact.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Coronary Artery Disease s/p CABG in2006
4. Paroxysmal atrial fibrillation
5. Right common iliac stenosis with retrograde dissection
6. Abdominal aortic aneurysm (4.5 x 4.7 cm)
7. h/o hyperthyroidism
8. Cataracts
9. Vitamin B12 deficiency
10. history of Gallstone pancreatitis
11. Hearing Loss
12. s/p appendectomy
13. Uterine prolapse s/p pessary placement (none now)
14. s/p Spinal infarct 10 yrs ago. Patient now has partial
numbness in both leg, vagina and perineum.
15. Recent antibiotic treatment: Azithromycin/Cefpodoxime [**2-26**]
Social History:
Home: lives alone; widowed; has a daughter in [**Name (NI) 531**]
([**Female First Name (un) **])
and son [**Doctor First Name 4884**] in [**State 4565**]
EtOH: Denies
Drugs: Denies
Tobacco: 60-80 PPY history, quit > 10 years ago
Family History:
Father - died at age 77 with bleeding PUD
Mother - died in 90s with history of HTN
Sister - died at age 59 with colon cancer
Physical Exam:
VS: 98.2, 65, 173/81, 98% RA
GEN: Well in NAD
ENT:Anicteric, OP clear w/o lesions, no [**Doctor First Name **], nl thyroid, no
bruits
LUNGS: CTA bilat
COR: Regular w/ occasional premature beat, nl S1/S2, no audible
MRG
ABD: soft, non-tender, palpable pulsatile mass, no HSM, active
b.s.
EXT: no C/C, no edema
SKIN: no rash or lesions
NEURO: A&O x 3, moves all extremities, strength grossly intact
except 4+/5 left hip flexor vs R, all else is symmetric, no
sensory deficits, patient walks with me in the hallway taking my
arm. Initially states she can't get beyond the bed, but when
distracted seems to walk well and does so down the hallway with
me. Stands to side of bed and gets in bed on her own without
difficulty.
Pertinent Results:
[**2157-3-20**] 02:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2157-3-20**] 02:25PM URINE RBC-0-2 WBC-[**4-28**]* BACTERIA-FEW
YEAST-NONE EPI-0-2 TRANS EPI-0-2 RENAL EPI-0-2
[**2157-3-20**] 10:40AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5
LEUK-SM
[**2157-3-20**] 10:40AM URINE RBC-0 WBC-21-50* BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2157-3-20**] 10:38AM LACTATE-1.4
[**2157-3-20**] 10:30AM GLUCOSE-100 UREA N-15 CREAT-0.9 SODIUM-141
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14
[**2157-3-20**] 10:30AM LIPASE-33
[**2157-3-20**] 10:30AM CALCIUM-8.6 PHOSPHATE-2.9
[**2157-3-20**] 10:30AM WBC-5.9 RBC-4.20 HGB-11.0* HCT-33.3* MCV-79*
MCH-26.2* MCHC-33.0 RDW-15.1
[**2157-3-20**] 10:30AM PLT COUNT-418
[**2157-3-20**]
Pelvic xray
Hip xray
L-S xray
CT aortogram
Brief Hospital Course:
87 yo female admitted with self-reported functional decline.
This coincides with her daughter having left to return to
out-of-state home after being with her for several weeks after
last admission. Patient has reportedly declined home VNA and
home PT, and she states they weren't giving me what I needed,
though is vague about the latter. Soon after admission she
developed AF with RVR.
.
Atrial fibrillation with rapid ventricular response: The
patient has a long h/o AF wiht RVR. An IV amio load was started
and soon afterward she cardioverted back to SR. Unfortunately
she refused to take the PO amio as she developed the same side
effects that she previously had on this drug. She was put back
on her Toprol XL and the dose was titrated to 100 mg [**Hospital1 **]. Her
resting HR's are in the 50-60's at this dose and she ambulates
without symptoms. If she failed this BB dose, may consider
dronedarone. At this higher dose of BB she does occasionally go
into AF, but the rates stay in the 100-120 range rather than
200+ as she had on admission. Should have a high threshold for
holding BB. Would avoid adding HCTZ as electrolyte abnormalities
propigate her AF.
Coronary Artery Disease: s/p CABG in [**2154**]. She has a known
reversible LAD defect on stress testing with ST changes with
rapid rates which have now resolved. We continued ASA 325.
Cellulitis: The patient got an infection at an IV site. This was
treated with ancef/keflex and it improved rapidly. She will
complete a 5 day course.
Anemia: Hematocrit at baseline. Continue B12 supplements
Deconditioning:The patient is quite deconditioned from her
multiple hospital stays and needs physical therapy. This was not
working well at home and we have arranged inpatient rehab for
her.
Dirty UA: Repeat UA's were not significant for infection. Would
not treat w/o symptoms.
Code: confirmed DNR/DNI
Communication: Patient . Patient requests that her family not be
contact[**Name (NI) **]. [**Telephone/Fax (1) 36659**] ([**Name2 (NI) **]TER)
Medications on Admission:
Regular Daily meds
1.Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2.Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3.Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
.
Non-regular meds
4.Pyridoxine 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5.Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6.Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation for 3 doses.
Discharge Medications:
1. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis: 427.31 ATRIAL FIBRILLATION
Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN
Secondary Diagnosis: 414.05 CAD, BYPASS GRAFT
Secondary Diagnosis: 285.9 ANEMIA, UNSPECIFIED
Secondary Diagnosis: 682.3 CELLULITIS, ARM
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:
Patient being transferred to a facility.
Followup Instructions:
(if patient no longer in rehab)
Department: [**Hospital3 249**]
When: TUESDAY [**2157-4-12**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2157-4-19**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 0389, 5845, 2762, 2761, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2708
} | Medical Text: Admission Date: [**2143-7-18**] Discharge Date: [**2143-7-26**]
Date of Birth: [**2098-12-27**] Sex: M
Service: SURGERY
Allergies:
Ciprofloxacin / Hydralazine
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Hypertensive urgency
Major Surgical or Invasive Procedure:
[**2143-7-21**]: renal transplant nephrectomy
History of Present Illness:
This is a 42 year old M with past medical history significant
for ESRD s/p LRRT in [**2134**] c/b rejection now on HD with malignant
hypertension and likely PRES who presents with hypertensive
urgency. The patient reports that he had been feeling well since
his discharge from [**Hospital1 18**] in [**Month (only) 205**] of this year, though he notes
that his blood pressure has been persistently elevated to around
150s-160s/90s-100s. He presented to see his transplant
nephrologist this morning and developed acute onset of posterior
headache with visual changes which consisted of floaters in his
peripheral vision and the visualization of streaks of color. He
also notes that he felt tremulous at the time and as if he might
pass out, but this quickly passed. He therefore presented to the
ED for further evaluation.
.
The patient has a history of malignant hypertension and was
admitted in [**Month (only) 116**] of this year with a hypertensive emergency at
which time he had a seizure and a small SAH. He was then
admitted again in [**Month (only) 205**] with headaches and vision changes and a
SBP up to 200s. At that time, his antihypertensive regiemen was
increased and he has tolerated this regimen.
.
In the ED, initial VS: T 98.8 HR 69 BP 167/106 16 99% on RA. He
received 1L NS, morphine 4mg IV x1 and tylenol 650 mg PO x1 with
modest improvement in symptoms.
.
At this time, patient feels much improved. Denies any visual
changes, states headache is less than a [**1-20**] and does not want
further medication at this time. Otherwise, ROS negative for
fevers, chills, nightsweats, chest pain, shortness of breath,
cough, abdominal pain, nausea, vomiting, diarrhea, melena,
hematochezia, hematemesis, dysuria. No paresthesias or weakness.
Pertinent positives as above.
Past Medical History:
- ESRD secondary to chronic ureterovesical junction obstruction
leading to bilateral hydronephrosis, on hemodialysis
- S/p living-related renal transplant [**2134**] ([**Name (NI) 106515**] brother),
failed, now on hemodialysis since [**12-18**]
- Malignant hypertension
- PRES
- s/p SAH
- Gout
- Peptic Ulcer disease
- Bladder neck stricture
- Atypical chest pain
Social History:
40py, quit 2 yrs ago. No EtOH or other drugs. Lives in apartment
building with his wheelchair-bound wife where he works as
superintendent.
Family History:
Father had MI mid 50s. No DM. Brother had cancer of jaw which
was resected.
Physical Exam:
VS: T 98.5 BP 158/98 P 77 RR 22 98% RA
GEN: Well-appearing, comfortable in bed, talkative and in NAD
HEENT: NCAT, EOMI, PERRL, oropharynx clear and without erythema
or exudate
NECK: Supple, no appreciable JVD
CV: RRR, normal S1S2, no murmurs, rubs or gallops
PULM: CTAB, no w/r/r, good air movement bilaterally
ABD: Soft, NTND, normoactive bowel sounds, no organomegaly,
multiple well-healed incisions
EXT: Warm and well perfused, full and symmetric distal pulses,
no pedal edema, two hyperpigmented papules on plantar surface of
left foot
NEURO: AAOx3, responds appropriately to questions, CN 2-12
grossly intact, full strength in bilateral upper extremity
extensors, wrists, fingers, and lower extremities, downgoing
toes bilaterally
Pertinent Results:
On Admission: .
IMAGING:
.
CT HEAD W/O CONTRAST
Interval resolution of subarachnoid hemorrhage seen within the
parieto-occipital lobes in [**2143-5-5**]. No acute intracranial
hemorrhage.
Aerosolized secretions within the sphenoid sinus.
.
CXR [**2143-7-20**] -
PA and lateral views of the chest are obtained. A right IJ
dialysis catheter is noted with its tip at the cavoatrial
junction. Lungs are clear bilaterally without evidence of
pneumonia or CHF. Cardiomediastinal silhouette is normal. There
is no pleural effusion or pneumothorax. Osseous structures
appear intact.
.
On Admission: [**2143-7-18**]
WBC-5.0 RBC-4.52* Hgb-13.3* Hct-42.1 MCV-93 MCH-29.3 MCHC-31.5
RDW-14.3 Plt Ct-153
PT-13.7* PTT-41.3* INR(PT)-1.2*
Glucose-83 UreaN-37* Creat-6.9*# Na-140 K-5.6* Cl-101 HCO3-26
AnGap-19
ALT-6 AST-18 CK(CPK)-217* AlkPhos-53 TotBili-0.4
Calcium-9.2 Phos-6.9* Mg-2.3
.
On Discharge [**2143-7-26**]
WBC-5.0 RBC-3.55* Hgb-10.4* Hct-32.1* MCV-90 MCH-29.3 MCHC-32.4
RDW-14.5 Plt Ct-224
Glucose-91 UreaN-26* Creat-10.3* Na-141 K-4.0 Cl-101 HCO3-26
AnGap-18
Calcium-9.8 Phos-5.7*# Mg-2.1
[**2143-7-23**] TSH-0.79
[**2143-7-23**] T4-8.0
[**2143-7-26**] 05:20AM BLOOD
Brief Hospital Course:
44 year old M with history of ESRD s/p failed transplant on HD
who presents with headache and hypertension.
.
# Headache: Per the patient, it is similar to the headache he
had from his prior SAH in [**Month (only) 116**]. This, however, resolved much more
quickly and he currently has no other symptoms. Has been
improved with tylenol and one dose of morphine in the ED. No
other focal neurologic findings. Most likely due to
hypertension. As no focal neurologic deficits, no clear
indication for MRI or further imaging as no evidence of bleed on
CT non-contrast.
# Malignant hypertension/h/o PRES: Has been admitted in the past
with hypertensive emergency and seizures. Concern for PRES
syndrome based on MRI done in [**Month (only) 116**] (was also on
tacrolimus/cyclosporine in the past). Also concern that patient
may have malignant hypertension as a result of failed renal
transplant. Previous work up for renal transplant artery
stenosis which was negative. Renin/[**Male First Name (un) 2083**] levels drawn in [**Month (only) 205**]
showed low renin and aldosteron within normal range.
#Patient underwent transplant nephrectomy on [**7-21**] with Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The transplant kidney was satisfactorily removed
and he was extubated and transferred to the PACU in stable
condition.
.
# ESRD on HD s/p failed transplant: Patient underwent HD on
[**2143-7-19**], and then per M-W-F outpatient schedule.
In the post op period he progressed nicely. He was maintained on
many different classes of antihypertensives with reasonable
control. When he missed some doses due to HD on [**7-24**] he remained
with elevated BP requiring IV Lopressor.
He is being discharged on a new BP med regimen
.
Medications on Admission:
Lisinopril 40 [**Hospital1 **]
Valsartan 160 [**Hospital1 **]
Bactrim 80-400 mg qday
Cellcept 1 gram [**Hospital1 **]
Sevelamer 800 mg tid
Clonidine patch 0.3 mg/24 hours - 1 patch q week
Carvedilol 50 mg [**Hospital1 **]
Protonix 20 mg q day
Hydralazine 50 mg q 6 hours
Nifedipine 30 mg q day
Nephrocaps 1 mg q day
Discharge Medications:
1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for pruritis, dryness, pain.
5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
6. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
9. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
11. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
13. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
(1) Posterior reversible encephalopathy syndrome (PRES)
(2) End stage renal disease, on hemodialysis
(3) S/p renal transplant now s/p transplant nephrectomy
Secondary Diagnoses:
(1) Malignant hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with headache and vision
changes that were likely related to your prior diagnosis of PRES
syndrome. Please continue to monitor your blood pressure at
home as you have been doing, keep a copy and bring to clinic
visits.
Call your doctor at [**Telephone/Fax (1) 673**] if BP routinely goes high
(above 180 for the systolic pressure), if you have dizziness or
headaches.
Please continue your normal dialysis schedule.
Continue food, fluid and medication recomendations per your
kidney doctors [**First Name (Titles) 7219**]
[**Last Name (Titles) **] heavy lifting, nothing more than a gallon of milk
Do not drive if taking narcotic pain medication
Monitor incision for redness, drainage or bleeding
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2143-8-1**] 8:00
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2143-8-6**] 2:40
Completed by:[**2143-7-26**]
ICD9 Codes: 5856, 2767, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2709
} | Medical Text: Admission Date: [**2155-5-10**] Discharge Date: [**2155-5-28**]
Date of Birth: [**2074-11-9**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Cefazolin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
fever x 2 days, chest congestion x 1 week
Major Surgical or Invasive Procedure:
PICC placement
PEG placement
History of Present Illness:
History obtained from son and daughter. 80 yo F with severe
alzheimer's dementia (non-verbal at baseline) who presents with
1 week of increased respiratory secretions, cough, SOB and
lethargy. One week ago, pt was started on levofloxacin by her
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**]. Yesterday, pt developed a fever >100. Of note
pt has multiple areas of skin breakdown as well.
.
In ED, found to be febrile to 102, tachy to 130s with
leukocytosis, elevated lactate consistent with sepsis. Pt's code
status was discussed with daughter and who confirmed that pt is
DNR/DNI. Given IVF, acetaminophen with some improvement in
tachycardia. Started on Vanco, Levo, Flagyl empirically for
PNA, cellulitis, ? osteo.
.
ROS: no N/V/abd pain, diarrhea. no HA. per family, no coughing
or choking after eating. Family reports pt has PCN allergy-
unclear whether this is documented allergy to cefazolin or other
allergy.
Past Medical History:
Severe Alzheimer's dementia x 10 years
aspiration
HTN
GERD
decubitus ulcers
h/o GI bleeding secondary to aspirin
chronic L lateral malleolus ulcer
AF
Social History:
Lives with daugher in [**Location (un) 538**], non-verbal and
non-ambulatory at baseline. Has 2 PCAs who help care for her.
per family, sometimes seems to be able to understand commands
but not consistently. h/o tobacco (quit 25 yrs ago, only few
cigarettes/day before that), no EtOH. DNR/DNI
Family History:
N/C
Physical Exam:
98.7 138/86 102 22 95% (3L)
Gen: lying in bed, non-verbal, eyes closed, groans with passive
movement, gurgling noises from back of throat
HEENT: dry mm, OP clear, no stridor
CV: Reg, S1, S2, no M/R/G
lungs: limited exam, rales at bases bilaterally
Abd: soft, NT/ND, +BS
Ext: warm, area of edema over R hip without erythema, fluctuance
Skin: 6 x 4 cm area of skin breakdown with central and
surrounding necrosis over L lateral malleolus. 5 x 3 cm deep
ulcer over L elbow with surrounding necrosis. Skin tear on R
deltoid. Healed ulcerations over R hip/buttocks.
Neuro: non-responsive, groans with passive movement
Pertinent Results:
EKG: Sinus tach @ 120, L axis, RBBB, inf q waves (old), TWI
V1-V3 (old), no acute ischemic changes c/w [**2154-11-19**].
[**2155-5-10**] 03:15PM WBC-16.2*# RBC-5.51*# HGB-13.9# HCT-42.9#
MCV-78* MCH-25.3* MCHC-32.5 RDW-17.1*
[**2155-5-10**] 03:15PM NEUTS-84.2* LYMPHS-9.5* MONOS-5.4 EOS-0.3
BASOS-0.6
[**2155-5-10**] 03:15PM PLT COUNT-464*
[**2155-5-10**] 03:15PM PT-13.8* PTT-24.9 INR(PT)-1.2*
[**2155-5-10**] 03:15PM GLUCOSE-264* UREA N-42* CREAT-1.3*
SODIUM-150* POTASSIUM-4.5 CHLORIDE-117* TOTAL CO2-22 ANION
GAP-16
[**2155-5-10**] 03:15PM ALT(SGPT)-41* AST(SGOT)-66* CK(CPK)-3182* ALK
PHOS-121* AMYLASE-29 TOT BILI-0.4
[**2155-5-10**] 03:15PM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-2.4
[**2155-5-10**] 03:23PM LACTATE-4.2*
[**2155-5-10**] 05:53PM LACTATE-2.3*
[**2155-5-10**] 03:15PM CK-MB-3
[**2155-5-10**] 03:15PM cTropnT-0.03*
[**2155-5-10**] 03:26PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2155-5-10**] 03:26PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2155-5-10**] 03:26PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
CXR [**5-10**]: No acute cardiopulmonary abnormality. Mild
cardiomegaly.
L ankle X-ray [**5-10**]: Soft tissue defect adjacent to left lateral
malleolus. Indistinct lateral malleolus cortex is worrisome for
osteomyelitis. Further evaluation with three-phase bone
scintigraphy or MRI can be performed.
,
MRI LLE [**5-12**]: 1. Edema and enhancement in the distal fibula.
Although this is a nonspecific finding, it lies immediately
deep to the patient's soft tissue ulcer and is therefore
concerning for osteomyelitis. No interosseous or deep soft
tissue abscess is identified.
2. Degenerative splits of peroneus brevis and longus tendons,
with minimal associated edema enhancement, which is most likely
reactive.
3. PTT tendon degenerative changes.
4. Extensive muscle atrophy.
.
MRI LUE [**5-15**]: 1. Edema and associated enhancement in the
subcutaneous fat overlying the olecranon and lateral epicondyle
and in the anconeus muscle. Differential diagnosis includes
both edema and cellulitis/muscle infection. 2. No abscess
collection, joint effusion, or abnormal marrow signal to
indicate osteomyelitis is identified. 3. Patient unable to
extend arm, arm imaged in flexed position.
.
CXR [**5-18**]: Moderate cardiomegaly is longstanding. Small opacity
just above the eventrated right hemidiaphragm developed between
[**5-10**] and [**5-11**] consistent with pneumonia. When feasible routine
radiographs should be performed to exclude the possibility that
this is, instead, a longstanding nodular abnormality seen in the
lower lungs on an abdomen CT [**2154-11-15**]. No appreciable
pleural effusion or pneumothorax. Tip of the left PICC line
projects over the junction of the brachiocephalic veins.
.
CXR [**5-19**]: Left PICC line remains in place. New focal right
basilar opacity is without change allowing for patient rotation.
There is also a questionable new area of opacity in the left
retrocardiac region, which could be due to aspiration or
atelectasis.
.
TTE [**5-19**]: 1. The left atrium is normal in size.
2. There is mild symmetric LVH. The left ventricular cavity size
is normal. Left ventricular systolic function is hyperdynamic
(EF>75%).
3. Right ventricular chamber size is normal. Right ventricular
systolic function is normal.
4. The ascending aorta is mildly dilated.
5. The aortic valve leaflets are mildly thickened. There is mild
aortic valve stenosis. No aortic regurgitation present.
6. The mitral valve leaflets are mildly thickenedl. Mild (1+)
mitral
regurgitation is seen.
7. There is moderate pulmonary artery systolic hypertension.
8. There is a trivial/physiologic pericardial effusion. There
are no
echocardiographic signs of tamponade.
.
CXR [**5-21**]: 1. Left lower lobe atelectasis-infiltrate, which is
recurrent and might be related to aspiration.
2. There is no evidence of congestive heart failure.
.
CT Abd [**5-21**]: 1. No evidence of abscess or bowel perforation.
2. Improvement in right lower lobe opacities.
3. Stable hypoattenuating lesion in the right lobe of the liver
most likely representing a cyst.
4. Cholelithiasis without evidence of cholecystitis.
5. Diverticulosis without evidence of diverticulitis.
6. Moderate sized hiatal hernia.
7. Soft tissue density opacities in both breasts. Correlation
with mammography is again recommended.
8. Umbilical hernia containing small bowel loops without
evidence of incarceration.
.
Discharge Labs: WBC 13 Hct 28.9 Plt 568 BUN 13 Cr 1.0
ALT/AST [**10-1**] AP 85 TBili 0.2
[**5-24**]: ESR 113 CRP 120
Brief Hospital Course:
80 yo F with severe alzheimers dementia, multiple areas of skin
breakdown presents with fever, cough, lethargy and found to have
sepsis. Hospital course by problem as below:
.
# SEPSIS: She was thought to have aspirated, and was started on
vancomycin/ levofloxacin/ flagyl. Her family refused central
line at this time and the patient was admitted to the floor,
rather than the ICU. She was also noted to have a large ulcer
on her left lateral maleolus (decubitus) and left elbow. MRI of
the left ankle revealed possible osteomyelitis. ID was
consulted to help with antibiotic regimen. MRI of the elbow
showed soft tissue changes, but no definitive osteo. ID
recommended 6 week-course of vanco/levo empirically, since she
was not a good candidate for bone biopsy. A PEG tube was
placed, with family understanding the continued risk of
aspiration.
.
Her course was complicated when she developed fever to 103 with
transient hypotension and respiratory distress on [**5-19**]. Blood
cultures drawn from PICC line grew E. coli (resistant to levo),
so she was broadened to zosyn. Her fevers and hypotension
resolved on this regimen. Her PICC line was changed over a wire
(IR was unable to resite it since she has difficult access).
Abdominal CT scan did not reveal another source for the
bacteremia. She had recurrnt fever and respiratory distress
overnight [**5-21**], possibly due to re-aspiration. The likely
source of the E. coli bacteremia was aspiration event. Her PEG
tube feeds were stopped. The patient was then changed from
zosyn to ceftriaxone once culture data returned. She tolerated
the ceftriaxone well and remained afebrile. She was given a 2
week total course of gram negative coverage for bacteremia. She
will need a total of 6 weeks coverage for osteomyelitis with
vancomycin and ceftriazone/levofloxacin. She will need weekly
labs for monitoring.
.
# ANEMIA: Patient had a questionable episode of coffee ground
emesis [**Hospital **] transfer to the ICU. She also intermittently had
guaiac positive stools, in the setting pf PEG placement. Her
Hct fluctuated but overall was stable. Iron studies were
consistent with anemia of chronic disease. There was thought to
be no role of colonoscopy for cancer work-up, as patient is not
a treatment candidate. She received one unit of blood during
her stay.
.
# ARF: She initially had a bump in her Cr, but it improved to a
Cr of 1.0 on discharge. Vanco troughs were checked and she did
well with daily dosing.
.
# FEN: The patient had a PEG placed on [**5-14**] to help with her
nutritional status. Risks of aspiration were discussed with the
family. She was kept NPO while in-house. Speech and Swallow
consultants recommended honey-thickened liquids and pureed diet
as outpatient, if the family chooses to feed her. Her family
was trained in PEG care.
.
# WOUND CARE: The wound care consultants evaluated her while she
was here and made many recommendations management of her ulcers.
She was treated with Zinc and Vitamin C while in house to
facilitate wound healing.
.
# Code/Communication: She was maintained as DNR/DNI during her
admission. Her contacts are as follows:
-Granddaughter [**Name (NI) 101579**] [**Name (NI) 101580**]; bilingual): [**Telephone/Fax (1) 101581**]
-Daughter ([**First Name8 (NamePattern2) **] [**Known lastname 76050**]) (HCP): [**Telephone/Fax (1) 101582**]
-Son [**Doctor Last Name **]: [**Telephone/Fax (1) 101583**]
-Son [**First Name8 (NamePattern2) **] [**Name (NI) 76050**]) [**Telephone/Fax (1) 101584**] (cell); [**Telephone/Fax (1) 101585**]
Medications on Admission:
MVI
Levoflox x 7 days
Tylenol
Prilosec
Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 5 weeks.
Disp:*qs 35 days worth* Refills:*0*
2. Nutrition
Tubefeeding: Promote w/ fiber (or equivalent) Full strength at
45 ml/hr
q4h Hold feeding for residual >= 100 ml
Flush w/ 200 ml water q8h
# quanitity sufficient for life
3. Nutrition
Kangaroo 324 pump
(for tube feeds)
#1
4. Normal Saline Flush 0.9 % Syringe Sig: One (1) Injection as
directed: flush PICC line 5cc NS pre and post vancomycin
infusion per PICC protocol.
Disp:*100 syringes* Refills:*2*
5. Heparin Flush 100 unit/mL Kit Sig: One (1) Intravenous as
directed below: flush PICC with 3cc after antibiotic infusion.
Disp:*50 synringes* Refills:*2*
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) mL PO
BID (2 times a day) as needed for constipation.
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO BID (2 times a day).
9. Ascorbic Acid 90 mg/mL Drops Sig: Five (5) mL PO DAILY
(Daily).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
12. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q24H (every 24 hours) for 7 days.
Disp:*7 grams* Refills:*0*
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 4 weeks: Please start on [**6-3**]. Administer via PEG tube.
Disp:*28 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
Please draw weekly vancomycin trough, CBC, ESR, CRP, LFTs, BUN,
Cr starting on Thursday, [**5-29**]. Fax results to Dr [**Last Name (STitle) 1789**] at
[**Telephone/Fax (3) 101586**] (phone)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
osteomyelitis, left ankle
aspiration pneumonia
E. coli bacteremia
advanced dementia
..
DM
HTN
Discharge Condition:
medically stable, baseline mental status
Discharge Instructions:
Contact MD if patient develops fever/chills, difficulty
breathing, or other concerning symptoms.
.
Please take all medications as directed. You have been
prescribed 2 antibiotics to take for the next 5 weeks.
Followup Instructions:
Please follow-up with Dr [**Last Name (STitle) 1789**] within one week at [**Telephone/Fax (1) **].
ICD9 Codes: 5070, 5849, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2710
} | Medical Text: Admission Date: [**2198-12-26**] Discharge Date: [**2198-12-28**]
Date of Birth: [**2143-11-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
thoracentesis
History of Present Illness:
55 year old female with history of metastatic breast cancer with
mets to cervical spine, right hip and history of malignant
pericardial and pleural effusions. Pt underwent pericardial
window on [**7-30**] for pericardial effusion with improvement in
symptoms of dyspnea. Subsequently developed a left > right
pleural effusion, which was managed with thoracentesis and
placement of a pleurex catheter in [**9-29**]. Since that time pt has
noted persistent weakness and dyspnea on exertion, now worsened
to the point where the patient has difficulty with dressing,
transfer and is unable to walk between rooms. She reports having
worsening right hip pain recently, was found on MRI to have
evidence of bony mets and earlier today had cycle [**2-24**] of
radiation to this area with her radiation oncologist Dr. [**Last Name (STitle) **].
She noted that whereas she us usually able to walk from her car
to the lobby for these appointments she was unable to do so
today and required a wheelchair. Called EMS, was noted to by
hypoxic to 87% on RA.
.
Otherwise on notable history pt notes chronic cough x years,
mildly worse lately with clear to yellow sputum production.
Weight loss (was 200lbs, now 128) with decreased appetite,
weakness. Had one episode of n/v over the weekend with low grade
temp to 100.3. Has since resolved.
.
On ROS denies headache, vision changes, neck pain/stiffness,
nausea, vomiting. Has mild chest discomfort with coughing and
dyspnea as above. No palpitations, abd pain. No diarrhea. +
Occasional constipation. No LE edema. No rashes.
.
In the ED, 02 sat increased from 88% on RA to 93% on 2L. Had CXR
which showed bibasilar pleural effusions L>R and LLL infiltrate.
Bedside TTE showed suggestion of pericardial effusion. F/u
formal TTE showed LVEF 35-40% with increased echo-dense
loculated pericardial effusion and some evidence of increased
pericardial pressure.
Inital VS: 97.4 123 161/92 24 93% 2L (88% RA). She was given 1L
NS, vanc and cefepime for the pneumonia. Had an elevated WBC
with left shift. Admitted to the CCU for monitoring of
pericardial effusion with concern for evolving tamponade. Upon
arrival to CCU pt underwent thoracentesis with interventional
pulmonology, with removal of 200cc cloudy fluid, pt reported
interval symptom improvement.
Past Medical History:
1) Metastatic breast adenocarcinoma: Breast cancer diagnosis in
[**2185**] s/p mastectomy and CA chemotherapy. Recurrence in neck in
[**2189**] with XRT. In [**2192**] known metastatic disease to spine,
supraclavicular node, and right hip. She has tried and failed
multiple chemotherapy regimens, now cycle 1, day 16 of
Herceptin/Xeloda
2) Anxiety
3) Hypertension (has been on lisinopril but stopped on own)
4) s/p appendectomy
5) Hypothyroidism
.
Social History:
Social history is significant for no tobacco since [**2165**]. The
patient drinks socially and quite infrequently with no history
of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her father died of a AAA rupture. There is a
history of cancer in multiple family members.
Physical Exam:
VS: HR 115 BP 139/82 93% 2L 18
GENERAL: Middle aged - elderly woman, older than stated aged.
Tachypneic, anxious.
HEENT: Alopecia, multiple scabs.
NECK: Extensive radiation changes, difficult to appreciate neck
veins, no distention noted.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR. Nl S1/S2. Tachycardic. Unable to take pulsus (s/p
axillary LN dissection on R and PICC on L) Evidence of venous
distention of L superfical thoracic wall veins.
LUNGS: s/p R mastectomy and LN dissection, swelling R breast,
chronic. s/p L thoracentesis. Decreased BS R>L, poor air
movement.
ABDOMEN: Soft, NTND. + BS
EXTREMITIES: Slight pitting edema L breast, b/l elbows. s/p left
PICC line placement. S/p removal of L port-a-cath. Some
surrounding erythema, nothing expressible, not warm.
SKIN: Multiple scabs on shins, hands, scalp, per pt self
inflicted.
Pertinent Results:
[**2198-12-26**] 10:00AM BLOOD WBC-16.0*# RBC-4.27 Hgb-10.7* Hct-33.8*
MCV-79* MCH-25.0* MCHC-31.6 RDW-20.5* Plt Ct-451*
[**2198-12-26**] 10:00AM BLOOD Neuts-87.0* Lymphs-3.2* Monos-9.4 Eos-0.3
Baso-0.1
[**2198-12-26**] 10:00AM BLOOD PT-16.9* PTT-32.2 INR(PT)-1.5*
[**2198-12-26**] 10:00AM BLOOD Glucose-149* UreaN-13 Creat-0.5 Na-138
K-4.2 Cl-95* HCO3-33* AnGap-14
[**2198-12-28**] 05:18AM BLOOD ALT-9 AST-19 LD(LDH)-245 CK(CPK)-17*
AlkPhos-92 TotBili-0.4
[**2198-12-26**] 10:00AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2198-12-27**] 05:33AM BLOOD Albumin-3.7 Calcium-9.2 Phos-4.0 Mg-2.1
[**2198-12-27**] 05:33AM BLOOD TSH-3.6
[**2198-12-27**] 07:26AM BLOOD Type-ART pO2-98 pCO2-109* pH-7.12*
calTCO2-38* Base XS-2
[**2198-12-26**] 10:14AM BLOOD Lactate-1.8
[**2198-12-27**] 07:26AM BLOOD O2 Sat-95
.
EKG - Sinus tachycardia. Left atrial abnormality. Low limb lead
voltage. Probable prior anterior myocardial infarction. Compared
to the previous tracing of [**2198-11-6**] the rate has increased.
Otherwise, no diagnostic interim change.
.
Echo - Left ventricular wall thicknesses and cavity size are
normal. There is moderate global left ventricular hypokinesis
(LVEF = 35-40 %). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. There is a moderate sized partially echo filled
loculated pericardial effusion most prominent anterior to the
right ventricle (1.8cm) and anterolateral to the left ventricle
(1.8) with minimal (1.1cm) inferior to the left ventricle and
minimal around the lateral left ventricle and apex. The effusion
is echo dense, consistent with blood, inflammation or other
cellular elements. There is mild intermittent right ventricular
diastolic collapse but no exacerbation of transmitral Doppler
inflow.
.
Compared with the prior study (images reviewed) of [**2198-9-13**],
the effusion is larger and increased pericardial pressure is
suggested. A prominent pleural effusion is also now present.
Left ventricular systolic dysfunction is also now present.
Brief Hospital Course:
Patient was admitted to the CCU in respiratory distress. Patient
was placed on BiPAP. Family and patient decided that patient was
to be DNR/DNI and only wanted nasal cannula for oyxgen withoute
bipap. The following day patient and family decided to make
patiet comfort measures only. Patient expired with husband
present.
Medications on Admission:
Clonazepam 0.5mg prn
Compazine 10mg PO Q6 prn nausea
Fentanyl patch 25mcg Q 72 hours
Levothyroxine 150mcg daily
Metoprolol tartrate 25mg [**Hospital1 **]
Oxycodone 5mg PO Q4 prn
Vitamin D 400 units daily
Zometa 4mg IV Q 3 months
Herceptin Q 3 weeks
Adriamycin
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic breast cancer
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2198-12-31**]
ICD9 Codes: 486, 4019, 2449, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2711
} | Medical Text: Admission Date: [**2108-12-12**] Discharge Date: [**2108-12-18**]
Date of Birth: [**2031-12-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ceclor
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2108-12-12**]: AVR ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] 21mm tissue), replacement ascending
aorta [**12-12**]
History of Present Illness:
77 year old woman with known progressive aortic stenosis has
been followed by serial echocardiograms through the years. Her
most recent echo has shown
severe aortic stenosis with a valve area of 0.7cm2 and normal LV
function. She describes a progressive decline in activity
tolerance with dyspnea with minimal exertion. This can occur
with as little as getting up quickly to cross the room and
answer the phone. She denies PND, orthopnea or palpitations but
does admit
to one episode of syncope last year when rushing to get into the
bathroom.
Past Medical History:
Hyperlipidemia
Hypertension
Severe aortic stenosis
Osteoarthritis
Left shoulder fracture s/p replacement in [**2084**]
Varicose vein ligation right leg
Lower back pain with intermittent pinched nerves (sees a
chiropractor every two weeks)
s/p Left shoulder repair
Hysterectomy
Melanoma excision to right arm
bilateral cataract
Social History:
Race:Caucasian
Last Dental Exam:5 months ago, she will call dentist to have
clearance faxed to office
Lives with:wife
Contact: [**Name (NI) **] (daughter) Phone #[**Telephone/Fax (1) 91963**]
Occupation:retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [] [**1-1**] drinks/week [x] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Brother died of MI at 45
years old. Mother died at age 64 from an MI
Physical Exam:
Pulse:64 Resp:13 O2 sat:97/RA
B/P Right:168/70 Left:164/69
Height:5'5" Weight:143 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade II/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema 1+
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit radiating murmur
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 37561**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 91964**]Portable TTE
(Complete) Done [**2108-12-14**] at 10:14:06 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2031-12-3**]
Age (years): 77 F Hgt (in): 65
BP (mm Hg): 96/56 Wgt (lb): 145
HR (bpm): 102 BSA (m2): 1.73 m2
Indication: Pericardial effusion.
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: West CCU
Contrast: None Tech Quality: Adequate
Tape #: [**2108**]-:00 Machine: E9-1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.5 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: *3.1 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *2.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 17 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 9 mm Hg
TR Gradient (+ RA = PASP): <= 20 mm Hg <= 25 mm Hg
Pericardium - Effusion Size: 0.6 cm
Findings
This study was compared to the prior study of [**2108-12-6**].
LEFT ATRIUM: Normal LA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta tube graft.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR gradient.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
(2+) MR.
TRICUSPID VALVE: Mild [1+] TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. The
appearance of the ascending aorta is consistent with a normal
tube graft. A bioprosthetic aortic valve prosthesis is present.
The transaortic gradient is normal for this prosthesis. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a very small pericardial effusion.
IMPRESSION: Tiny pericardial effusion. Symmetric LVH with normal
global and regional biventricular systolic function.
Normally-functioning bioprosthetic AVR and ascending aortic tube
graft. Moderate mitral regugitation.
[**2108-12-14**] 06:00AM BLOOD WBC-8.4 RBC-2.82* Hgb-8.9* Hct-25.3*
MCV-90 MCH-31.5 MCHC-35.0 RDW-15.9* Plt Ct-120*
[**2108-12-14**] 06:00AM BLOOD Glucose-111* UreaN-22* Creat-0.8 Na-138
K-4.8 Cl-106 HCO3-21* AnGap-16
[**2108-12-16**] 04:28AM BLOOD WBC-10.5 RBC-2.80* Hgb-8.8* Hct-25.2*
MCV-90 MCH-31.6 MCHC-35.0 RDW-15.3 Plt Ct-182
[**2108-12-15**] 01:00PM BLOOD Hct-28.9*
[**2108-12-15**] 01:00AM BLOOD WBC-11.3* RBC-2.99* Hgb-9.2* Hct-26.4*
MCV-88 MCH-30.7 MCHC-34.8 RDW-15.9* Plt Ct-134*
[**2108-12-16**] 04:28AM BLOOD Glucose-109* UreaN-27* Creat-0.7 Na-136
K-4.2 Cl-101 HCO3-28 AnGap-11
[**2108-12-15**] 01:00AM BLOOD Glucose-122* UreaN-23* Creat-0.7 Na-136
K-3.7 Cl-101 HCO3-29 AnGap-10
[**2108-12-17**] 05:35AM BLOOD WBC-10.0 RBC-2.99* Hgb-9.0* Hct-27.2*
MCV-91 MCH-30.1 MCHC-33.1 RDW-15.2 Plt Ct-190
[**2108-12-16**] 04:28AM BLOOD WBC-10.5 RBC-2.80* Hgb-8.8* Hct-25.2*
MCV-90 MCH-31.6 MCHC-35.0 RDW-15.3 Plt Ct-182
[**2108-12-17**] 05:35AM BLOOD Glucose-93 UreaN-24* Creat-0.7 Na-137
K-4.2 Cl-99 HCO3-29 AnGap-13
[**2108-12-16**] 04:28AM BLOOD Glucose-109* UreaN-27* Creat-0.7 Na-136
K-4.2 Cl-101 HCO3-28 AnGap-11
[**2108-12-17**] 04:18PM BLOOD PT-14.0* INR(PT)-1.3*
[**2108-12-16**] 04:28AM BLOOD PT-13.4* INR(PT)-1.2*
Brief Hospital Course:
On [**2108-12-12**], the patient underwent elective aortic valve
replacement([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] 21mm tissue) and replacement of ascending
aorta. The surgery was performed by Dr. [**Last Name (STitle) **]. Please
see the operative note for details. She tolerated the procedure
well and was admitted post-operatively to the surgical intensive
care unit on the cardiac surgery service. Initially after
transfer to the unit she had high chest tube drainage, but it
lessened overnight. She had oliguria on her first postoperative
night which was treated with Lasix and Albumin and her
creatinine remained stable at baseline. By the following day she
was extubated and transferred to the step down floor. She
underwent an echocardiogram which revealed a trivial pericardial
effusion. Her chest tubes were removed. On POD2 overnight she
went into a rapid atrial fibrillation and was started on an
Amiodarone drip. She converted to sinus rhythm several hours
later. She remained in sinus rhythm in the 80's for the rest of
her hospital stay and her beta blocker was titrated up for
better heart rate and blood pressure control. On the following
day her epicardial wires were removed. She was seen in
consultation by the physical therapy service. On POD 4 she went
into a rapid atrial fibrillation and was given additional
Lopressor and converted into sinus rhythm. She was started on
Coumadin as this was her third episode. She was in sinus rhythm
x 24 hours prior to discharge. By post-operative day #6 she was
ambulating with assistance, her incisions were healing well and
she was tolerating a full oral diet. She was discharged to home.
All follow-up appointments were advised.
Medications on Admission:
ATENOLOL 50 mg daily
[**Last Name (un) 91965**] VITALIZER GOLD Dosage uncertain
SIMVASTATIN 10 mg daily
ADVIL 200 mg every morning
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg daily for 7 days then decrease to 200mg daily starting
[**2108-12-26**].
Disp:*90 Tablet(s)* Refills:*2*
9. Coumadin 2.5 mg Tablet Sig: dose per INR Tablet PO once a
day: indication afib
Goal INR 2.0-2.5.
Disp:*90 Tablet(s)* Refills:*2*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
11. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 10 days.
Disp:*20 Tablet Extended Release(s)* Refills:*0*
12. Outpatient Lab Work
INR check on [**2108-12-19**] then every other day
Call results [**Telephone/Fax (1) 91966**] [**Doctor First Name 16883**] at Dr.[**Last Name (STitle) **],[**First Name3 (LF) 251**] T.
[**Telephone/Fax (1) 4475**]
***on amiodarone***
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
aortic valve stenosis
post-op afib
secondary diagnosis
Hyperlipidemia, Hypertension, Severe aortic stenosis,
Osteoarthritis, Left shoulder fracture s/p replacement/[**2084**],
Varicose vein ligation right leg, Lower back pain with
intermittent pinched nerves (sees chiropractor every 2 weeks),
s/p Left shoulder repair, Hysterectomy, Melanoma excision to
right arm, bilateral cataract
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
[**11-26**]+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw [**2108-12-19**]
Results to phone [**Doctor First Name 16883**] ([**Telephone/Fax (1) 91966**]at Dr.[**Last Name (STitle) **],[**First Name3 (LF) 251**] T.
[**Telephone/Fax (1) 4475**]
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**1-15**] at 1:00pm in the [**Hospital **]
medical office building [**Doctor First Name **] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**1-7**] at 3:40pm
Wound check on [**2108-12-27**] at 10am in the [**Hospital **] medical office
building [**Doctor First Name **] [**Hospital Unit Name **]
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) 251**] T. [**Telephone/Fax (1) 4475**] in [**2-28**] weeks
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw [**2108-12-19**]
Results to phone [**Doctor First Name 16883**] ([**Telephone/Fax (1) 91966**]at Dr.[**Last Name (STitle) **],[**First Name3 (LF) 251**] T.
[**Telephone/Fax (1) 4475**]
**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:[**2108-12-23**]
ICD9 Codes: 4241, 9971, 2859, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2712
} | Medical Text: Admission Date: [**2159-8-27**] Discharge Date: [**2159-9-8**]
Date of Birth: [**2088-4-20**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Infrarenal abdominal aortic aneurysm.
Major Surgical or Invasive Procedure:
[**2159-8-27**]: Abdominal aortic aneurysm repair with 14 mm
Dacron graft.
History of Present Illness:
The patient is a 71-year-old female with a 5 cm infrarenal
abdominal aortic aneurysm. The patient was scheduled for
elective open abdominal aortic aneurysm repair.
Past Medical History:
HTN, depression, ?DM, LLL small emphysematous bullae, SOB with
activity, 60 year smoker
hernia repair X2
Social History:
1 [**1-30**] ppd X 60 years
3 ETOH drinks/month
Family History:
Mother dies of HF at [**Age over 90 **] years old
Father died of lung cancer at 62 years old
Brother had CABG
Physical Exam:
VSS: 98.7, 132/60 18 92%RA
Pain: none
Neuro: A&OX3
CV: RRR
RESP: B/L wheeze
ABD: soft, NT
Ext: B/L dop PT/DP
Incision C/D/I, no infection
Pertinent Results:
[**2159-9-6**] 04:01AM BLOOD WBC-14.2* RBC-3.41* Hgb-10.3* Hct-30.7*
MCV-90 MCH-30.1 MCHC-33.4 RDW-14.5 Plt Ct-321
[**2159-9-6**] 04:01AM BLOOD Plt Ct-321
[**2159-9-6**] 04:01AM BLOOD Glucose-123* UreaN-15 Creat-0.5 Na-139
K-4.3 Cl-107 HCO3-23 AnGap-13
[**2159-9-5**] 05:08AM BLOOD Glucose-108* UreaN-16 Creat-0.5 Na-136
K-3.9 Cl-107 HCO3-20* AnGap-13
[**2159-8-29**] 07:32AM BLOOD CK-MB-13* MB Indx-0.4 cTropnT-<0.01
[**2159-8-29**] 12:28AM BLOOD CK-MB-17* MB Indx-0.5 cTropnT-<0.01
[**2159-9-6**] 04:01AM BLOOD Calcium-7.9* Phos-3.3 Mg-2.3
[**2159-9-3**] 02:24AM BLOOD O2 Sat-98
[**2159-9-2**] 08:18PM BLOOD O2 Sat-95
[**2159-9-2**] 03:25AM BLOOD O2 Sat-95
[**2159-9-4**] ECHO: IMPRESSION: Preserved regional and global left
ventricular systolic function. Mild diastolic dysfunction.
Moderate pulmonary hypertension. Mildly dilated aortic root.
[**2159-8-31**] CHEST CTA
INDICATION: 71-year-old female post-op day 4 from open AAA
repair with persistent tachypnea, tachycardia and respiratory
difficulty. Please evaluate for pulmonary embolism.
IMPRESSION:
1. No pulmonary embolism.
2. Moderate-to-severe apical predominant centrilobular
emphysema, with likely superimposed moderate pulmonary edema.
ARDS is considered less likely, as there is no patchy
distribution of ground-glass opacity. Other causes of
pneumonitis are also less likely given rapid radiographic
change.
3. Small bilateral pleural effusions, right greater than left.
4. Cholelithiasis.
[**2159-9-2**] Chest XRAY INDICATION: AAA repair, with increasing WBC,
shortness of breath. Evaluate for infiltrate/ARDS.
FINDINGS: There is interval improvement in aeration of the
lungs, suggesting improvement of pulmonary edema. However, there
are persistent changes consistent with pulmonary edema atop
background emphysema. Cardiac and mediastinal silhouettes are
unchanged. Right-sided IJ introducer sheath again extends to the
lower SVC. Right-convex scoliosis of the lumbar spine is again
noted with surgical skin staples seen over the mid abdomen. No
evidence of pneumothorax.
IMPRESSION: Improved aeration of the lungs, suggesting
improvement of CHF/pulmonary edema atop emphysema.
Brief Hospital Course:
[**2159-8-27**] Underwent Abdominal aortic aneurysm repair with 14 mm
Dacron graft for
Infrarenal abdominal aortic aneurysm with chronic contained
rupture.
Mrs. [**Known lastname 73821**],[**Known firstname 4092**] was admitted on [**8-27**] with AAA. SHe agreed
to have an elective surgery. Pre-operatively, she was consented.
A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all
other preperations were made.
It was decided that she would undergo a Infrarenal abdominal
aortic aneurysm with chronic contained rupture.
.
She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She tolerated the procedure
well without any difficulty or complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring.
She was then transferred to the VICU for further recovery. While
in the VICU she recieved monitered care. When stable she was
delined. Her diet was advanced. A PT consult was obtained. When
she was stabalized from the acute setting of post operative
care, she was transfered to floor status.
Pt had episodes of hypoxia. She required lasix for diuresis. Pt
was still hypoxic. Ruled out foe PE. Pt received a pulmonary
consult, her hypoxia was multifactoral / CHF / emphzema / Pt
rled out for MI.
Pt did get transfered to the CSRU because of the hypoxia. There
she required more lasix. Pt did have a Echocardiagram
On DC she is requiring O2. She will probably have to have O2
requirements at home.
To note pt has an appointment for PFT and a pulmonary follow -
up as a outpt.
On the floor, she remained hemodynamically stable with his pain
controlled. She progressed with physical therapy to improve her
strength and mobility. She continues to make steady progress
without any other incidents. She was discharged to a
rehabilitation facility in stable condition.
Medications on Admission:
HCTZ, Effexor, Zyprexa, Geodon
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Ziprasidone HCl 40 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): until fully ambulatory.
6. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) Inhalation [**Hospital1 **] (2 times a day): Beclomethasone Dipropionate
80 mcg/Actuation Inhalation [**Hospital1 **] .
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
14. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
16. Regular Insulin Sliding Scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner
Regular
Glucose Insulin Dose
0-65 mg/dL 4 oz. Juice
and 15 gm crackers
66-149 mg/dL 0 Units 0 Units 0 Units
150-199 mg/dL 2 Units 2 Units 2 Units
200-249 mg/dL 4 Units 4 Units 4 Units
250-299 mg/dL 6 Units 6 Units 6 Units
> 300 mg/dL Notify M.D.
17. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Academy Manor of [**Location (un) 7658**]
Discharge Diagnosis:
71 F s/p open AAA repair, postop hypoxia (CTA-no PE, r/o MI, no
PNA)
PMH: HTN, depression, ?DM
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**7-6**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**3-3**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1241**]
Date/Time:[**2159-9-18**] 2:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2159-9-27**] 1:00 Shariro [**Location (un) **] ([**Hospital Ward Name 516**])
Pulmonary Follow up- Dr. [**First Name (STitle) **]/Dr. [**Last Name (STitle) 73822**] [**Hospital Ward Name 23**] 7th floow ([**Hospital Ward Name 5074**])
[**Telephone/Fax (1) 612**]
Completed by:[**2159-9-7**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2713
} | Medical Text: Admission Date: [**2137-12-29**] Discharge Date: [**2137-12-30**]
Date of Birth: [**2060-10-12**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The pt is a 77 y/o woman who presents with Headache and
Comatose. Pt has history of respiratory failure, A-fib on
Coumadin, HTN, Parkinson's. P/W Headache of abrupt onset around
4:30 pm. Was with daughter [**Name (NI) 8368**] who said she held her left
hand
to the left side of the head. Her daughter then stepped out for
a
bit and when she came back she was unresponsive. She called EMS
after unable to get her to respond. Headache was sudden onset.
no
symptoms before 4:30 per daughters report.
- came to ED and found to have extensive Left sided ICH. was
intubated in ED for airway protection. placed on propofol.
Neurosurgery consulted and no intervention on there side.
- Talked with HCP ([**Doctor First Name **]) and other daughter ([**Doctor First Name **]) who want
everything done at this moment. [**Name2 (NI) **] intubated and sedated
currently.
Past Medical History:
SLE, Parkinson's disease
Atrial fibrillation/aflutter
Paralysis agitans
Episodic hypertension during previous hospitalizations
H/O respiratory failure requiring tracheostomy placement
Tracheal and subglottic stenosis
Glaucoma, blind in R eye
Social History:
Patient lives at [**Hospital **] Rehabilitation and Nursing Center.
Denies any history of tobacco, alcohol, or illit drug use. She
is originally from [**Country **] and worked at [**Company 22916**] Corporation in
[**Location (un) 86**]. Daughters [**Name (NI) **] lives in [**Location 686**] and [**Doctor First Name **] in
[**Location (un) 101401**], FL.
Family History:
non-contributory
Physical Exam:
Vitals: T: P:70 R: 14 BP:129/90 (on Nicardipine gtt)
SaO2:100
intubated. BG 130's
General: sedated/ Intubated
PUlm: CTA b/l frontal fields
CV: Murmur at LUSB grade II
Abd: Soft.
Ext 1+ edema b/l with LE contracture at the ankles
Neuro: Intubated/ sedated on propofol. Not responding to sternal
rub or pinch at all 4 ext. Pupils Left is fixed at 4.5mm Right
is
4mm with hazy sclera. No movement noted. Reflexes not
appreciated
in lower upper extremities. No cough, no gag, no corneal, no
dolls eyes. toes mute
EXAM
T 98 P absent BP absent R 0
Brain death protocol was initiated and cranial nerves were
absent
and apnea test showed CO2 elevation. Test was performed by both
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD attending of record and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**], MD,
SICU attending.
Pupils 8mm b/l and non-reactive
No eye movement w/ cold calorics
Absent corneals
Gag absent
Cough absent
Pertinent Results:
[**2137-12-29**] 07:04PM TYPE-ART RATES-/14 TIDAL VOL-400 O2-100
PO2-196* PCO2-31* PH-7.49* TOTAL CO2-24 BASE XS-2 AADO2-495 REQ
O2-82 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-RECTAL TEM
[**2137-12-29**] 07:04PM GLUCOSE-160* LACTATE-1.5 NA+-140 K+-3.8
CL--105
[**2137-12-29**] 06:50PM GLUCOSE-164* UREA N-16 CREAT-0.8 SODIUM-143
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-23 ANION GAP-16
[**2137-12-29**] 06:50PM estGFR-Using this
[**2137-12-29**] 06:50PM LIPASE-34
[**2137-12-29**] 06:50PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.8
[**2137-12-29**] 06:50PM WBC-10.7 RBC-3.57* HGB-9.9* HCT-29.4* MCV-82
MCH-27.6 MCHC-33.6 RDW-14.5
[**2137-12-29**] 06:50PM NEUTS-85.7* LYMPHS-10.8* MONOS-2.3 EOS-0.9
BASOS-0.2
[**2137-12-29**] 06:50PM PT-25.9* PTT-32.2 INR(PT)-2.5*
[**2137-12-29**] 06:50PM PLT COUNT-215
[**2137-12-29**] 06:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2137-12-29**] 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-150
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2137-12-29**] 06:15PM URINE RBC-0-2 WBC-[**2-22**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2137-12-29**] 06:15PM URINE HYALINE-<1
[**2137-12-29**] 06:15PM URINE MUCOUS-FEW
Brief Hospital Course:
Patient was admitted with large left frontal intracerebral
hemorrhage with interventricular extension. She was intubated
and admitted to the neuro-ICU. By the following morning it was
noted that brainstem reflexes were absent. A brain death
protocol was performed and completed at 14:30 pm. Family were
present and the patient had ventilator stopped.
Patient expired at 14:30 on [**2137-12-30**].
Medications on Admission:
1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q 8H (Every 8 Hours).
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for Constipation.
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for Constipation.
12. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
Thirty (30) ML PO QID (4 times a day) as needed for GI upset.
13. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q8H (every 8 hours).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
16. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
17. Pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO Q6 ().
18. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID
(twice daily).
19. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day:
Follow INR with [**Hospital **] clinic.
20. Acetylcystein Neb 1-2mL PRN mucous plugging
21> Duoneb Q2HR:PRN SOB
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerebral hemorrhage - expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2138-1-1**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2714
} | Medical Text: Admission Date: [**2118-11-22**] Discharge Date: [**2118-12-9**]
Date of Birth: [**2052-12-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Ceftriaxone / Crestor / Bee
Pollens
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
prothetic mitral regurgitation, rapid atrial fibrillation
Major Surgical or Invasive Procedure:
[**2118-11-25**] Redo mitral valve replacement(33mm On-X), coronary
artery bypass graft x 1 (LIMA-LAD), esophagogastroscopy
Implantation of permanent transvenous pacemaker/defibrillator
[**2118-12-5**]
Redosternotomy, removal Right pleural chest tube [**2118-12-2**]
History of Present Illness:
This 65 year old white male underwent tissue mitral valve
replacement here in [**2112**] for endocarditis after a bout with a
septic prosthetic knee. This was done via a right thoracotomy.
He did well until recently when heart failure symptoms
developed. He was found to have significant mitral
regurgitation with left ventricular dysfunction. He was
scheduled for rooperation and was admitted now with rapid atrial
fibrillation and acute heart failure.
Past Medical History:
Coronary Artery Disease
History of Streptococcal Endocarditis [**2112**]
chronic Atrial Fibrillation
s/p Ablation
Hypertension
Pulmonary Hypertension
Rheumatoid Arthritis
s/p Minimally Invasive mitral valve replacement
s/p Left total knee replacement
s/p Redo Left total knee replacement
s/p right rotator cuff repair
s/p cervical mediastinoscopy/bronchoscopy [**11-14**]
Schatzki Ring
Social History:
Occupation: dentist
Last Dental Exam:
Lives with wife
[**Name (NI) **]:Caucasian
Tobacco:[**1-7**] mini-cigars per yr.
ETOH:1 beer/night
Family History:
noncontributory
Physical Exam:
Admission:
Pulse:110s Resp: O2 sat: 100%
B/P Right: 89/63 Left:
Height: 71" Weight:88.6kg
General:fatigued easily
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Heart: irregularly irregular, SEM III/VI
Lungs: bibasilar crackles
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
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:n Left:n
Pertinent Results:
[**2118-12-5**] Echocardiogram
Suboptimal image quality. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
severe global left ventricular hypokinesis (LVEF = 20%) with
inferior/infero-lateral akinesis. No masses or thrombi are seen
in the left ventricle. The right ventricular cavity is dilated
with depressed free wall contractility. There is no aortic valve
stenosis. A bileaflet mechanical mitral valve prosthesis is
present. The transmitral gradient is normal for this prosthesis.
Mitral regurgitation is present (probably mild?) but cannot be
quantified. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2118-12-8**] 05:02AM BLOOD WBC-12.2* RBC-3.29* Hgb-9.7* Hct-29.1*
MCV-88 MCH-29.6 MCHC-33.5 RDW-14.7 Plt Ct-497*
[**2118-12-8**] 05:02AM BLOOD PT-27.2* INR(PT)-2.7*
[**2118-12-7**] 11:09PM BLOOD PT-27.2* PTT-61.8* INR(PT)-2.7*
[**2118-12-7**] 03:49PM BLOOD PT-24.0* PTT-50.7* INR(PT)-2.3*
[**2118-12-7**] 06:17AM BLOOD PT-23.1* PTT-44.1* INR(PT)-2.2*
[**2118-12-6**] 11:24PM BLOOD PT-23.7* PTT-48.0* INR(PT)-2.2*
[**2118-12-6**] 03:13PM BLOOD PT-21.0* PTT-37.7* INR(PT)-1.9*
[**2118-12-8**] 05:02AM BLOOD UreaN-20 Creat-0.8 K-4.6
[**2118-12-7**] 06:17AM BLOOD Glucose-100 UreaN-17 Creat-0.7 Na-138
K-4.0 Cl-103 HCO3-28 AnGap-11
[**2118-12-9**] 08:19AM BLOOD PT-30.6* INR(PT)-3.1*
Brief Hospital Course:
Following admission he was stabilized, diuresed and his heart
failure cleared. His creatinine rose to 1.6 and stabilized. On
[**11-25**] he was taken to the Operating Room where redo mitral valve
replacement was accomplished via a median sternotomy. See
operative note for details. He weaned from bypass on Milrinone,
Levophed and Propofol in stable condition. His coagulopathy was
corrected and he was extubated the following morning. The
Milrinone was turned off and Lisinopril begun. The Levophed was
also weaned off and his hemodynamics were good with PA pressures
in the low 50s and a cardiac index of greater than 2.5.
He remained well and invasive lines were removed, diuresis were
begun and he was mobilized. Slow ventricular response to atrial
fibrillation led to ventricular pacing. Anticoagulation was
started for the mechanical valve and fibrillation on POD 1 and
intravenous Heparin on POD 2.
Mr. [**Known lastname **] right pleural chest tube was unable to be removed
and the patient was taken to the Operating Room on [**12-2**] for
removal of trapped chest tube and exploration of inferior pole
of sternotomy incision. The inferior pole of the incision was
opened and it was discovered that the tube had been caught on
the Vicryl midline fascial closure suture. That suture was cut,
and the tube was pulled back from under the drapes. The wound
was irrigated with copious amounts of antibiotic irrigation. A
small fluid collection at the inferior aspect of the wound
substernally was noted and the patient was started on
ciprofloxacin and vancomycin for a 7 day course empirically.
There were no positive cultures.
Electrophysiology was consulted due to conduction issues
perieoperatively. Due to prolonged AV conduction, dilated
cardiomyopathy and prolonged QRS, it was determined that he
needed an ICD placed. Coumadin was held and Heparin drip was
started. On [**2118-12-5**] the INR was 1.8 and he was taken to the EP
lab for ICD implantation. Lopreesor was titrated up for rate
control after ICD implantation. Heparin and Coumadin were
resumed post procedure.
He progressed well and Heparin was discontinued once the INR
rose above 2.0. His antibiotics were continued for a seven day
course. Arrangements for Coumadin follow up at the [**Hospital **]
[**Hospital 197**] clinic were made, as this was his routine before this
surgery. He was ambulatory, wounds were clean and healing well.
Discharge medications and restrictions were discussed with him
prior to leaving the hospital. He was neurologically intact. He
was discharged on 5mgm of Coumadin 12/4,5 and 6 to have an INR
checked on [**12-12**].
Medications on Admission:
Lipitor 40 mg(1), Aspirin 81 (1), Plaquenil 200 (1),
Leflunomide 20 (1), lisinopril 5 mg daily, Clindamycin prn
dental
proc., lasix 20 mg daily, KCl 20 mEq daily
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
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. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Leflunomide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Vicodin ES 7.5-750 mg Tablet Sig: 1-2 Tablets PO every [**4-11**]
hours as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
daily as directed. INR [**2-8**] goal.
Disp:*100 Tablet(s)* Refills:*2*
13. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Bioprosthetic mitral regurgitation
s/p mitral valve replacement
s/p redo mitral valve replacement
s/p Coronary Artery Disease s/p coronary artery bypass graft x 1
chronic atrial fibrillation
s/p Ablation
Streptococcal Endocarditis [**2112**]
hypertension
gastroesophageal reflux disease
hyperlipidemia
rheumatoid arthritis
Schatzki Ring
s/p Left total knee replacement
s/p Redo Left total knee replacement
s/p Esophogeal Dilatation
s/p right rotator cuff repair
s/p mediastinoscopy/bronchoscopy [**11-14**]
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Dr. [**First Name (STitle) **] [**Name (STitle) 48633**] in 2 weeks ([**Telephone/Fax (1) 35142**])
Please call for appointments
Coumadin management by [**Hospital1 **] Heart Center [**Hospital 197**] Clinic
Completed by:[**2118-12-9**]
ICD9 Codes: 2762, 4254, 4240, 4168, 4280, 3051, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2715
} | Medical Text: Admission Date: [**2194-6-1**] Discharge Date: [**2194-6-7**]
Date of Birth: [**2128-6-13**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
Caucasian gentleman who presented to the [**Hospital1 346**] Emergency Department from an outside
hospital for three episodes of spiking fevers, significant
chills, and rigors, dyspnea, and tachypnea, and episodes of
delirium. The patient states this started Thursday at around
3:00 p.m. when he was driving home for work, but he did not
measure his temperature. After one hour of feeling very hot,
having chills, and extreme rigors the patient stated the
episode went away. Again, he had this same episode with
diaphoresis, chills, rigors, tachypnea, and a fever to 104
degrees Fahrenheit on Friday. The patient was admitted to an
outside hospital - which was [**Hospital6 6640**].
The patient had another episode on the morning of admission
to [**Hospital1 69**]. While at the
outside hospital, he was worked up for fever of unknown
origin with an unknown infectious site. The patient had two
episodes of rigors at the outside hospital with fevers to
105. Per the patient, he had a lumbar puncture under
fluoroscopy and a negative head computer tomography. He had
a negative KUB, and blood cultures that were drawn. The
patient's vital signs other than fever were stable except for
a desaturation to the low 80s during his rigorous episodes.
The rigorous episodes needed Tylenol; although, this did not
shorten the course of the episode but did bring the fever
down.
He denies any recent travel history, visits or exposures to
forests or [**Last Name (LF) 6641**], [**First Name3 (LF) 691**] ingestion of recent raw or undercooked
food. All other review of systems were essentially negative.
The patient has no trauma and no obvious signs of puncture.
No obvious infectious exposures. The patient denies any
chest pain, palpitations, nausea, vomiting, diarrhea,
constipation, or abdominal pain - but does state some
dysuria, hesitancy, and urgency, and the feeling of being
dehydrated. The patient denies a cough, headache, neck pain,
photophobia, recent trauma, blood in the urine, blood from
any other orifice, cold symptoms, myalgias, arthralgias, or
any recent symptoms of this kind.
The patient's daughter states that during these rigorous
episodes the patient gets delirious and misnames common
objects that are around the room. An example, was he called
a person an envelope. He had been anxious since Thursday,
especially during these rigorous episodes; and, per the
daughter, he was agitated and not himself.
The patient's past medical history is significant for
multiple uric acid stones, which the patient feels may be
leading to this presentation. The patient states about one
year ago he was diagnosed with urate stone at the outside
hospital, but nothing was done for it, and he does feel he
has passed the stone either.
PAST MEDICAL HISTORY: Hypertension.
Gastroesophageal reflux disease.
Coronary artery disease; status post myocardial infarction in
[**2182**].
Status post angioplasty.
Degenerative joint disease.
History of recurrent urate stones.
PAST SURGICAL HISTORY: Status post angioplasty in [**2172**].
MEDICATIONS ON ADMISSION: Aspirin, Zantac, and he denies any
herbal medications.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He denies any alcohol or intravenous drug
abuse. He states a smoking history of one and a half packs
of cigarettes times 50 years.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
his temperature was 98.4, his blood pressure was 134/80, his
pulse was 92, his respiratory rate was 24, and he was
saturating 99 percent on 3 liters. General physical
examination revealed he was anxious appearing and appropriate
for age. He was in no acute distress. He was alert and
oriented times three. Head, eyes, ears, nose, and throat
examination revealed the pupils were equal, round, and
reactive to light and accommodation. The extraocular muscles
were intact. The mucous membranes were dry. Cardiovascular
examination revealed distant heart sounds. A regular rate
and rhythm. There were no murmurs. First heart sounds and
second heart sounds. On pulmonary examination, he had
prolonged expirations and mild rales in the left middle lobe,
and left lower lobe, and the right lower lobe. The abdomen
was distended. The abdomen was soft. There were positive
bowel sounds. The abdomen was nontender. There was no
hepatosplenomegaly. He was passing flatus. Extremity
examination revealed no clubbing, cyanosis, or edema. No
visibile puncture wounds. There was no costovertebral angle
tenderness. There was no flank tenderness. Neurologic
examination revealed cranial nerves II through XII were
grossly intact. There was presence of high cortical
function. No focal deficits. No changes in sensation. Mini-
Mental Status Examination was greater than 28.
PERTINENT LABORATORY VALUES FROM THE OUTSIDE HOSPITAL: The
lumbar puncture under fluoroscopy showed no organisms. Gram
stain, there was 1 white blood cell, 7 red blood cells,
clear, with a pending culture. Blood cultures from the
outside hospital showed gram-negatives growing in anaerobic
bottles [**1-13**].
RADIOLOGY: As stated before, a head computer tomography and
KUB - per outside hospital - were also negative.
A chest x-ray showed no acute process.
PERTINENT LABORATORY VALUES IN HOUSE: Negative urinalysis in
house, showed 2 plus protein, large blood, 20 to 30
epithelials, and leukocyte esterase negative. White blood
cell count was 3.1, his hematocrit was 44, and his platelets
were 100. Polymorphonuclear neutrophils of 77 percent.
Erythrocyte sedimentation rate was 8. Sodium was 140,
potassium was 3.4, chloride was 108, bicarbonate was 26,
blood urea nitrogen was 7, creatinine was 0.5, and his blood
glucose was 128. His troponin was less than 0.02. His
albumin was 3.6. His INR was 1.5.
SUMMARY OF HOSPITAL COURSE: The patient is a 65-year-old
gentleman with a 3-day history of fever of unknown origin
with rigors, chills, tachypnea, and episodes of tachycardia
with delirium who was admitted from an outside hospital. The
patient was initially worked up because of the rales found on
his physical examination as well as some signs suggestive of
either congestive heart failure or pneumonia found on chest x-
ray. He was initially diagnosed with pneumonia and was
started on Levaquin and Flagyl for a possible aspiration
pneumonia.
The patient continued to have these rigor episodes while on
Levaquin and Flagyl, and other etiologies were also pursued.
As the only imaging not done at the outside hospital -
including his abdomen and with a history of uric acid stones
and questionable picture of urosepsis, the patient received a
computer tomography of the abdomen which showed a left portal
vein septic thrombus.
During the first day of his admission, the patient had one
episode of rigors and chills which lasted for one hour with a
temperature to 105 - per axillary [**Location (un) 1131**]- as well as
tachycardia into the 140s (which was normal sinus). The
patient had to be put on 10 liters of nonrebreather to keep
his oxygen saturations above 90 percent. The patient was
given Tylenol. The patient was normalized within one hour
with a normal temperature, a normal heart rate, and not
having any oxygen requirement at all.
After the left portal vein septic thrombus was found on the
computed tomography scan, the patient was immediately moved
to the Surgical Intensive Care Unit for further observation.
Blood cultures were again drawn, and the patient was changed
to ceftriaxone and azithromycin. While in the Intensive Care
Unit the patient was seen by Surgery who did not feel that
the patient had any acute surgical needs. Discussion, per
the surgeons with the Interventional radiologists - all
agreed that the thrombus was stable at present (as confirmed
by a follow-up magnetic resonance imaging) that no surgical
intervention was necessary for removal of this clot.
The patient was started on Zosyn and then gentamicin was
later added. He continued to spike fevers to 101 while in
the Surgical Intensive Care Unit; although, he did not have
any of his rigorous episodes. The patient continued to have
crackles at bibasilar base. Because of the correlation with
chest x-ray it was later assumed to be congestive heart
failure either from diastolic dysfunction from his
tachycardia or an underlying congestive heart failure
picture; that was also given to using gentamicin, Flagyl, and
ampicillin. It was discussed whether or not the patient
should be anticoagulated. It was later decreased that
anticoagulation would most likely be necessary at a weight-
based protocol dose for a clot and was started on the day
prior to discharge.
Throughout his hospital course, the patient - after being in
the [**Hospital Ward Name 332**] Intensive Care Unit for 24 hours being afebrile -
was sent back up to the floor. While upon the floor, the
patient was afebrile for at least 48 hours. He never
complained of abdominal pain. Of note, the patient never did
complain of abdominal pain on admission or while in the
[**Hospital Ward Name 332**] Intensive Care Unit. The patient's white blood cell
count had normalized, and the patient did not have any
rigorous episodes his initial presentation.
On the day of discharge, the patient is on Zosyn and
gentamicin - which are per Infectious Disease recommendations
is being changed to Levaquin and Flagyl for four weeks.
Because a left portal vein thrombus is not very common
occurrence, and because the literature is very sparse in
terms of the most efficacious treatment, the patient is going
to be on Levaquin and Flagyl for coverage for anaerobes and
gastrointestinal flora and will be given Lovenox and Coumadin
for anticoagulation to dissolve the clot.
The patient has follow-up appointments with the Infectious
Disease Clinic in four weeks. The patient has an appointment
for an outpatient computer tomography of his abdomen to see
if there are any interval changes in the size of the clot
and/or the location of the clot in his left portal vein for
three and a half weeks. The patient was also to meet with a
hematologist - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6160**] - in five weeks for
a workup of hypercoagulable state; as normally an underlying
hypercoagulable state is necessary before a left portal vein
thrombus is produced.
Computer tomography findings were also suggestive of a
resolving diverticulitis that may have led to this left
portal vein thrombus. The patient stated he had recently had
a colonoscopy which showed a diverticulosis and was unaware
of what the correct diet for a patient with diverticulosis
should be. The patient was seen by the Nutrition Service and
was started on a low-residue diet for three weeks, to be
slowly advanced as tolerated. The patient notes that he
frequent servings of nuts and popcorn before admission, but
he did not recall any acute diverticulitis type symptoms
before presentation of the rigors to the outside hospital.
Blood cultures from the outside hospital confirmed anaerobic
bottles grew out Prevotella melaninogenica and Bacteroides
fragilis, but no blood cultures or urine cultures from in
house have grown any organisms. Because of being started on
Lovenox and Coumadin, the patient was to have his INR checked
in three days at his [**Hospital 6642**] Hospital. He is having liver
function tests checked in two weeks. The workup for any
liver manifestations of his diverticulitis and left portal
vein thrombus were also worked up; although, his liver
function tests at the highest were in the 60s, and upon
discharge were in the 50s and 30s. The patient did not show
any laboratory values of an obstructive bile pathology as his
bilirubin and alkaline phosphatase were normal throughout his
admission.
Three days prior to discharge, the patient noted have some
loose stools - about two to three per day - which were green
in color; although not watery in consistency. A Clostridium
difficile toxin times two were negative before discharge, and
the patient did not have any diarrhea on the day of
discharge. The patient was given Lovenox teaching prior to
discharge and understood that he had to continue both Lovenox
and Coumadin until his INR is therapeutic. The patient also
understood to take his Levaquin and Flagyl for at least four
weeks until he sees the Infectious Disease physicians - whom
it will be up to regarding make a decision regarding
discontinuance of the antibiotics in four weeks. The patient
also understood that he was to have his INR and liver
function tests checked and have a computer tomography of the
abdomen in the future. The patient also understood to see
the hematologist regarding when to discontinue his Coumadin
and when to not be anticoagulated any longer as well as for a
workup of hypercoagulability. The patient was also given a
prescription for hypercoagulability laboratories which are to
be drawn at the [**Location (un) 448**] of the [**Hospital 469**] Clinic Laboratory
before he presents to the hematologist.
DISCHARGE DIAGNOSES: Pylephlebitis in the left portal vein.
Status post diverticulitis; continuous diverticulosis.
Coronary artery disease.
Congestive heart failure.
Degenerative joint disease.
History of recurrent urate stones.
Hypertension.
MEDICATIONS ON DISCHARGE:
1. Levaquin 500 mg once per day (times 30 days).
2. Flagyl 500 mg three times per day (times 30 days).
3. Lisinopril 5-mg tablets take one-half tablet by mouth once
per day.
4. Zantac 150-mg tablets one tablet by mouth twice per day.
DISCHARGE INSTRUCTIONS: Prescription to have blood draw for
prothrombin time and INR on [**6-10**] and [**6-13**] and to have
the results faxed or called to the patient's primary care
physician [**Name Initial (PRE) **] [**Name10 (NameIs) 6643**] is Dr. [**First Name4 (NamePattern1) 6644**] [**Last Name (NamePattern1) **] (fax number [**Telephone/Fax (1) 6645**]). The patient to be on both Lovenox and Coumadin. The
patient may stop Lovenox injections upon advice of his
primary care physician when his INR is normalized.
The patient was instructed to have to have blood drawn for
aspartate aminotransferase and alanine-aminotransferase in
two weeks; and then in four weeks at Adelboro Laboratory and
have the results telephoned or faxed to his primary care
physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 6644**] [**Last Name (NamePattern1) **] - (fax number [**Telephone/Fax (1) 6646**]).
The patient was instructed to follow the advice of his
primary care physician regarding medication changes if
necessary, as the patient is on Lovenox, Coumadin, and
chronic antibiotics.
The patient was instructed to have his blood drawn at the
[**Hospital 469**] Clinic - [**Location (un) 448**] laboratory - at least three
days prior to his [**7-14**] appointment with the hematologist,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6160**]. These laboratories should include
C protein, S protein, antithrombin III lupus anticoagulant,
homocystine, and factor V Leiden.
DISCHARGE FOLLOWUP: The patient was instructed to follow up
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6160**] - the hematologist - in five weeks,
on [**7-14**] at 10:00 a.m. on the ninth floor of the [**Hospital 469**]
Clinic. The patient to have his blood drawn for C protein, S
protein, lupus anticoagulant, homocystine, factor V Leiden at
least three days prior to his appointment; for which a
prescription was given.
The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) 6647**] [**Last Name (NamePattern1) **]-
[**Doctor Last Name **] in the [**Last Name (un) 2577**] Building - Infectious Disease Clinic -
(telephone number [**Telephone/Fax (1) 457**]) on [**2194-7-1**] at 1:00 p.m.
The patient was scheduled for an outpatient computed
tomography scan of the abdomen which is scheduled for [**2194-7-10**].
The patient was instructed to contact his primary care
physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 6644**] [**Last Name (NamePattern1) **] - regarding his admission to the
[**Hospital1 69**]. The patient was to
have his Discharge Summary faxed to his primary care
physician regarding this admission and regarding followup on
INR and liver function tests.
The patient was given very explicit instructions to continue
the Lovenox and Coumadin until told to stop by his primary
care physician.
The patient was also reminded to complete his full - at least
4-week - course of antibiotics. All questions about his
diagnosis, his condition, followup, and medications were
answered satisfactorily for the patient.
The patient understood his diagnosis, and need for followup,
and the parameters for returning to the Emergency Department
to [**Hospital6 6640**] or for calling his primary care
physician in the future.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with multiple follow-up
instructions.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 6648**]
Dictated By:[**Doctor First Name 6649**]
MEDQUIST36
D: [**2194-6-7**] 10:39:43
T: [**2194-6-7**] 12:26:30
Job#: [**Job Number 6650**]
cc:[**Telephone/Fax (1) 6651**]
ICD9 Codes: 7907, 4280, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2716
} | Medical Text: Admission Date: [**2124-6-28**] Discharge Date: [**2124-7-12**]
Date of Birth: [**2073-9-5**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
visual disturbance, left sided numbness, left sided weakness
Major Surgical or Invasive Procedure:
[**2124-7-4**] Cerebral angiogram with mechanical thrombectomy
History of Present Illness:
50-year-old man with history of HTN, HLD, MI with vfib arrest
and RCA stent, prior stroke, transferred from OSH with new
left-sided weakness and numbness starting at 13:30 today.
He reports over the past three weeks he has "not felt right."
He awoke one day three weeks ago with numbness in his head, jaw,
and tongue which was non-lateralizing. He has been mildly
fatigued and has had two episodes of left-sided vision loss
(binocular) lasting hours at a time, described as everything
suddenly going black and then becoming [**Doctor Last Name 352**] and blurry after
that. This last occurred on Thursday and still reports some
blurry vision in his left visual field.
He has had some slurred speech and occasional difficulty finding
words during this time which he describes as mild.
Today at 1:30 PM after carrying a television down stairs he sat
down and had sudden onset of numbness and weakness of his left
arm and leg and numbness in his left side of his face. He
describes his limbs on the left as feeling heavy and had
difficulty lifting them antigravity. Onset was sudden, possibly
with some slurring of speech, and has been gradually improving
over the past few hours but not back to baseline.
Notes from [**Hospital3 13313**] also report episodes of right
facial numbness, tingling in his left fingertips. He was
admitted to [**Hospital3 13313**] overnight and discharged [**2124-6-23**]
after his episode of left visual field loss. Discharge
paperwork stated CT head and carotid ultrasound were negative,
and was discharged home without change in medications. Upon
return to ED today, CT head showed right PCA and bilateral
cerebellar subacute strokes and small hemorrhage in right PCA
infarct and was transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
- CAD, RCA stent, vfib arrest
-HTN
-HLD
Social History:
Divorced and lives with two kids. Remote tobacco hx, no etoh or
drug hx.
Family History:
No history of strokes or MI.
Physical Exam:
Physical Examination on Admission
Gen; lying in bed, NAD
HEENT; NC/AT, MMM, oropharynx clear
Neck; no bruits
CV; RRR, no murmurs
Pulm; CTA b/l
Abd; soft, nt, nd
Extr; no edema
Neuro;
MS; A&Ox3, speech fluent. Naming, repetition, comprehension
intact. Misses left side of sentence when trying to read.
Follows midline and appendicular commands. No apraxia or
neglect.
CN; PERRL 4mm-->3mm, EOMI, no nystagmus. Left homonymous
hemianopia. Face sensation intact V1-V3. Left nasolabial fold
flattening and mild left facial droop. Hearing intact to
finger-rub b/l. Palate elevate symmetrically. SCM and trap
strong and symmetric. Tongue midline.
Motor; normal bulk and tone, left pronator drift. Strength is
(R/L) delt [**2-22**], bicep [**3-23**], tricep [**2-22**], WrE 4+/5, FE [**2-22**], FF [**3-23**],
IP [**3-23**], ham [**3-23**], quad [**3-23**], TA [**3-23**], gastroc [**3-23**].
Sensory; intact to light touch, no extinction to DSS. Decreased
to pinprick in left leg > arm, intact in face.
Reflexes; 1+ and symmetric, toes upgoing.
Coordination; No dysmetria on FNF. RAMs intact.
Gait; deferred.
Pertinent Results:
Labs on Admission:
[**2124-6-28**] 05:05PM BLOOD WBC-10.7 RBC-5.43 Hgb-16.9 Hct-46.8
MCV-86 MCH-31.0 MCHC-36.0* RDW-13.2 Plt Ct-232
[**2124-6-28**] 05:05PM BLOOD Neuts-74.4* Lymphs-19.9 Monos-4.3 Eos-0.5
Baso-0.9
[**2124-6-28**] 05:05PM BLOOD PT-13.5* PTT-23.8 INR(PT)-1.2*
[**2124-6-28**] 05:05PM BLOOD Glucose-116* UreaN-24* Creat-1.4* Na-140
K-3.7 Cl-103 HCO3-24 AnGap-17
[**2124-6-28**] 05:05PM BLOOD CK(CPK)-64
[**2124-6-28**] 05:05PM BLOOD cTropnT-<0.01
[**2124-6-29**] 05:21AM BLOOD CK-MB-2 cTropnT-<0.01
[**2124-6-29**] 05:21AM BLOOD Albumin-4.3 Calcium-9.6 Phos-2.8 Mg-1.7
Cholest-135
[**2124-6-28**] 05:05PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2124-7-4**] 08:16PM BLOOD Type-ART pO2-115* pCO2-28* pH-7.58*
calTCO2-27 Base XS-5
[**2124-6-29**] 01:46PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2124-7-6**] 09:00AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.028
[**2124-6-29**] 01:46PM URINE Hours-RANDOM Creat-194 Na-92 K-GREATER TH
Cl-136 TotProt-17 Prot/Cr-0.1
[**6-28**] CT/A Head/Neck IMPRESSION:
1. Extensive, partly hemorrhagic infarct of the right posterior
cerebral artery territory which in conjunction with further
infarcts in the cerebellar hemispheres and occlusion of the
proximal right vertebral artery is likely embolic in nature.
2. Complete occlusion of the proximal right vertbral artery with
retrograde or collateral refilling of the vessel down to C6.
There is atherosclerotic disease of the intracranial vertebral
arteries bilaterally.
3. Occlusion of the right posterior cerebral artery at the level
of the P3-P4 segment.
[**6-29**] TTE
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic arch is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: No atrial septal defect identified.
[**6-29**] NCHCT
IMPRESSION: Unchanged interval appearance of infarcts at the
left MCA-PCA
junction, left cerebellar hemisphere, and right PCA
distribution, the latter with hemorrhagic transformation. The
distribution is suggestive of shower emboli, superimposed on
posterior circulation insufficiency (as demonstrated on CTA).
The hyperdensity in right PCA region likely represents petechial
hemorrhage.
[**6-30**] MR [**Name13 (STitle) 430**]
IMPRESSION: Acute right posterior cerebral infarct, left
cerebellar infarct and punctate foci of acute infarcts in the
left occipital lobe. Acute infarcts are also seen in the right
thalamus. Blood products are seen in the right posterior
cerebral artery infarct.
[**6-30**] MRA Neck
IMPRESSION: MRA and the fat-suppressed images demonstrate
absence of flow
signal in the proximal right vertebral artery indicating
occlusion or slow
flow. There is also appearance of slow flow seen in the distal
right
vertebral artery in the distal V2, V3 and V4 segments.
Irregularity of the
flow in the distal vertebral arteries in V4 segment indicates
atherosclerotic disease.
[**6-30**] EEG
IMPRESSION: This is an abnormal EEG during wakefulness due to
intermittent generalized theta occasionally intermixed with
delta
slowing of background during wakefulness. This finding may
represent an
underlying mild encephalopathy or diffuse vascular pathology. No
epileptiform activity or electrographic seizures were present.
[**7-4**] CTA Head/Neck IMPRESSION:
1. The right PCA territory infarction with hemorrhagic
transformation, the
right superior cerebellar infarction, and the left inferior
cerebellar
hemisphere infarction are grossly unchanged.
2. Increased effacement of the right lateral aspect of the
fourth ventricle, without dilatation of the third and lateral
ventricles. Persistent compression of the temporal and occipital
horns, as well as the body, of the right lateral ventricle.
3. Persistent occlusion of the right vertebral artery origin,
with increased extent of occlusion in the V2, increased
narrowing of the V3 segments, and new occlusion of the V4
segment. New filling defects in the basilar artery with an
approximately 50% stenosis in its midportion. New right AICA
narrowing.
4. Persistent right distal PCA occlusion. Persistent right PICA
nonvisualization.
5. Approximately 40% stenosis of the proximal cervical right
internal carotid artery due to noncalcified plaque.
[**7-5**] MR [**First Name (Titles) 430**] [**Last Name (Titles) **]
IMPRESSION:
1. Acute infarcts in bilateral posterior cerebral artery
territories, bilateral cerebellar hemispheres, bilateral thalami
and midbrain. New infarcts are noted in bilateral thalamus and
left posterior cerebral artery territory and in the midbrain.
Consider dedicated MRA if necessary.
2. Increased hemorrhage in right posterior cerebral artery
territory infarct and blood products are also noted in the
midbrain infarct.
3. Mucosal thickening and fluid are noted in all the paranasal
sinuses and mastoid air cells.
[**7-7**] Sputum Culture - Coagulase positive staphylococcus aureus
(pan-sensitive)
[**7-8**] Blood Culture - Coagulase negative staphylococcus (one
bottle)
Brief Hospital Course:
See above for a more extensive history of present illness.
Briefly, Mr. [**Known lastname 91128**] initially presented with left-sided
weakness, left-sided numbness, and dysarthria to an outside
hospital. He was transferred to [**Hospital1 18**] for further care and was
outside the window for intravenous tPA. He was additionally on
exam found to have a dense left homonymous hemianopia. The
investigation at the OSH was negative, but at [**Hospital1 18**] he was found
to have a R PCA infarction with an associated R vertebral artery
occlusion. Although not having a known history of AF, he did
experienced AF with RVR early during this hospitalization. He
was started on a heparin infusion to prevent further propagation
of the clot. While on heparin, he was doing well. He passed a
speech/swallow evaluation, and was eating well except for
intermittent nausea. His strength significantly improved and was
only left with some slight depressed mood and left field cut.
On the morning of [**7-4**], he was noted to have a new right facial
droop, fixed and dilated pupils bilaterally, and depressed LOC
with subsequent obtundation. A noncontrast head CT showed no
evidence of bleed. He was transferred to the Neuro ICU for
further management with the Interventional team notified and
activated. He was intubated in the Neuro ICU as he showed signs
of extensor posturing in all extremities and myoclonic jerks. He
was brought to the angiography suite where he was found to have
a basilar artery occlusion which was removed via mechanical clot
retrieval. He was brought back to the Neuro ICU for further
management. His exam improved with regards to his motor
function, but several of his brainstem reflexes were lost
(pupillary reaction, oculocephalic reflexes) and he did not
follow commands or demonstrate awareness. Multiple discussions
were held with his father [**Name (NI) 892**] and his sister [**Name (NI) 5627**] who together
opted to deescalate care. He was made CMO on [**2124-7-11**]: he was
extubated and placed on a morphine infusion for control of pain
and air hunger. At this time, he was transferred to the
neurology floor for formal CMO level care and was switched to
sublingual morphine. His PICC line was discontinued prior to
discharge.
Note that after being intubated, the patient was noted to have
thick secretions which were sent for culture in the setting of
low-grade fevers. He was started on empiric antibiotic treatment
with Vancomycin, Cefepime, and Tobramycin. These returned from
[**7-7**] as coagulase-positive staphylococcus aureus. Following the
switch to CMO status, his antibiotics were discontinued.
Medications on Admission:
-aspirin 325 mg daily
-plavix 75 mg daily
-atenolol 50 mg [**Hospital1 **]
-fish oil 1g tid
-HCTZ 25 mg daily
-zestril 10 mg daily
-zocor 40 mg qhs
Discharge Medications:
1. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
15mg PO Q4H (every 4 hours).
2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
10mg PO Q2H (every 2 hours) as needed for tachypnea RR>25.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 44563**] Nursing and Rehabilitation Center - [**Hospital1 10478**]
Discharge Diagnosis:
Coma secondary to Ischemic Stroke
Paroxysmal Atrial fibrillation
Pneumonia
History of Hypertension
History of Hypercholesterolemia
History of Coronary Artery Disease s/p MI and PCI
Discharge Condition:
Discharge Condition: Eyes closed at baseline, breathing
approximately 20 breaths/min, left hemiplegia, some intermittent
spontaneous movements on the left that are not purposeful. He
does not arouse to painless or painful central or peripheral
stimulation. Brainstem examination is significant for no
pupillary response, no gag, positive corneal reflex and he does
breathe on his own.
Discharge Instructions:
Mr. [**Known lastname 91128**] was admitted to the neurology wards of the [**Hospital1 18**]
on [**2124-6-28**] for an acute stroke that left him with new
left sided weakness and a left sided visual field deficit. He
was started on IV heparin and initially did well, until
approximately five-six days later when his neurological
examination deteriorated and required the mechanical retrieval
of an expanding intracranial clot. He was intubated at that time
and transferred to the ICU where he remained in a comatose state
with poor brainstem reflexes and mechanically ventilated. On
[**2124-7-11**] he was made CMO [comfort measures only] by his
father [**Name (NI) 382**] and subsequently transferred back to the floor. He
was placed on an IV morphine drip initially and transitioned to
scheduled doses of sublingual morphine for comfort. He can
receive additional . He remains comfortable with these
medications, breathing regularly. At this time, he is without IV
fluids or PEG/NG/OG source of nutrition.
Followup Instructions:
None
Completed by:[**2124-7-12**]
ICD9 Codes: 431, 5849, 412, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2717
} | Medical Text: Admission Date: [**2138-8-1**] Discharge Date: [**2138-8-7**]
Date of Birth: [**2065-10-30**] Sex: F
Service: GSURG-GOLD
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 33749**] is a 72 -year-old
woman who is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the UMG who was
admitted to Dr. [**Last Name (STitle) 519**] on [**8-2**] in the early morning with a
probable gallstone pancreatitis. Mrs. [**Known lastname 33749**] underwent a
left carotid endarterectomy by Dr. [**Last Name (STitle) 1476**] on [**7-31**]. At
home, on [**2138-8-1**], Mrs. [**Known lastname 33749**] experienced sudden
onset of an upper abdominal pain with limited emesis.
REVIEW OF SYSTEMS: She had nausea, vomiting, fever or
chills, and sweats. She complains of diarrhea, but denies
any melena, hematochezia, or bright red blood per rectum.
She has not had any prior history of a right upper quadrant
pain or indigestion. There were no relieving factors;
however, the pain was exacerbated by food ingestion. There
were no urinary symptoms described by the patient.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial
infarction, congestive heart failure, and on [**2138-2-20**],
percutaneous transluminal coronary angioplasty with stent.
2. History of Helicobacter pylori positive upper
gastrointestinal bleed.
3. Cerebrovascular accident with right sided hemiparesis.
4. Chronic obstructive pulmonary disease and 30 pack year
smoking history.
5. A question of chronic renal failure.
PAST SURGICAL HISTORY:
1. Left carotid endarterectomy.
2. Appendectomy.
3. Right ankle open reduction and internal fixation.
ADMITTING MEDICATIONS: Lasix, Prevacid, lisinopril,
Albuterol, Atrovent, Flovent, aspirin, Paxil, and Diltiazem.
ALLERGIES: She has allergies to Levaquin and penicillin
which cause a rash.
PHYSICAL EXAMINATION: On admission, her temperature was 98.1
F and she was afebrile without chills. Her blood pressure
was 168/77, heart rate was 106, respiratory rate was 23, and
saturations were 95% on four liters. She was alert and
oriented times three. Her lung examination was clear to
auscultation bilaterally. Heart examination was regular rate
and rhythm. The abdominal examination showed a soft, obese
abdomen with positive right upper quadrant tenderness,
including a positive [**Doctor Last Name 515**] sign. She also had percussion
tenderness. There was a question of a palpable gallbladder
in the right upper quadrant. The rectal examination was heme
positive with good rectal tone. The pulses were palpable
bilaterally equally.
PERTINENT LABORATORY VALUES: On admission, the CBC showed an
elevated white count of 20.2 with a hematocrit of 35.8 and
platelets of 33.8. She had 71% neutrophils and a bandemia of
14%. Sodium was 137, potassium 5.5, chloride 102,
bicarbonate 19, BUN of 32, and creatinine was elevated to
1.7, with a baseline of 1.0 to 1.4. Her glucose at the time
was 143. Liver function tests showed an ALT of 13, AST of
29, and alkaline phosphatase of 79, and a total bilirubin of
0.5. Amylase was elevated significantly to 571 and lipase
was 1,365. A urinalysis showed 3 to 5 white blood cells with
moderate bacteria, and less than 1.0 epithelial cells per
high power field.
CT scan as per Dr.[**Name (NI) 1745**] review with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] showed
moderately dilated gallbladder with a vascule over the liver,
mild diffusely intrahepatic ductal dilation, generous common
bile duct at 6.0 mm. The pancreatic head looked questionably
enlarged with atrophy otherwise. The ducts were normal. The
colon was probably normal with or without focal thickening.
There was nothing to suggest cholecystitis.
HOSPITAL COURSE: The patient was admitted to the General
Surgery team into the Intensive Care Unit for IV hydration,
antibiotics, and for a decision as to whether or not the
gallbladder would receive a percutaneous drain, versus an
endoscopic retrograde cholangiopancreatography
sphincterotomy, versus a laparoscopic cholecystectomy. In
addition, Dr. [**Last Name (STitle) 1476**] and the Vascular service team will be
following the patient in house as well.
Overnight in the Unit, the patient was stable, but was
continued with tender, right upper quadrant pain. She had
one episode of nausea. By hospital day two, her white count
had decreased to 14 and her lipase had significantly
decreased to 28. The liver function tests were still normal
when repeated, as per the previous day, and amylase was down
to 45 as well. Mrs.[**Known lastname 33756**] urine output on postoperative
day two was approximately 30-70 cc/hr and she had two bowel
movements. She continued to be NPO. She was started at
Flagyl and ceftriaxone at the time because of her Levaquin
allergy, as prophylaxis and treatment for a potential
gallstone pancreatitis.
Because the patient was felt to still be somewhat unstable,
the decision to perform an interventional procedure was
delayed until postoperative day three. On [**8-4**], an
ultrasound was performed to reevaluate the gallbladder which
showed a mildly distended gallbladder with sludge. However,
there were no gallbladder stones or thickening, and there was
no pericholecystic fluid. Mrs.[**Last Name (un) 33756**] vital signs
continued to be stable and her white count continued to fall
from 14.3 to 13 by hospital day four. The panel 7 continued
to be normal and the amylase and lipase continued to be also
within normal limits at 51. Stool was sent for Clostridium
difficile that was negative and a urinalysis was also
negative at this time.
Because of the recent carotid endarterectomy, there was much
discussion as to the appropriate management of her condition.
Because she had become stable in the Intensive Care Unit on
[**8-5**], she was transferred to the floor. There was a
coughing spell on transfer and respiratory therapy helped.
In addition, Mrs. [**Known lastname 33749**] was to have a laparoscopic
cholecystectomy on [**8-5**]. Her laparoscopic
cholecystectomy occurred at approximately 03:00 PM on [**8-5**] and was uneventful.
Mrs. [**Known lastname 33749**] remained on perioperative antibiotics and had a
postoperative hematocrit of 29.5. By hospital day six, her
hematocrit had returned to 35.3 and she was recovering bowel
function, such that her diet was advanced. Case manager had
screened her for rehabilitation and on hospital day seven,
her antibiotics were discontinued and she was advanced to a
full diet. She will be discharged to home with a home
nursing care for taking care of her today, on [**2138-8-7**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home with nursing care.
FOLLOW-UP: She will follow-up with Dr. [**Last Name (STitle) 519**] in two weeks and
with Dr. [**Last Name (STitle) 1476**] from Vascular in approximately three weeks.
DISCHARGE MEDICATIONS: Percocet one to two tablets po q four
to six hours prn, Colace 100 mg po bid, Serevent two puffs po
bid, Combivent two puffs po tid, Flovent two puffs po bid,
Lasix 40 mg po q day, Ativan 0.5 mg q six hours po prn
nausea, metoprolol 50 mg po bid, Protonix 40 mg po q 24
hours, Paxil 20 mg po q day, and Flomax 0.4 mg po bid.
DISCHARGE DIAGNOSES:
1. Status post right carotid endarterectomy.
2. Status post laparoscopic cholecystectomy for treatment of
a presumed gallstone pancreatitis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 9800**]
MEDQUIST36
D: [**2138-8-7**] 09:27
T: [**2138-8-11**] 11:10
JOB#: [**Job Number 33757**]
ICD9 Codes: 496, 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2718
} | Medical Text: Admission Date: [**2159-9-17**] Discharge Date: [**2159-9-25**]
Date of Birth: [**2093-9-29**] Sex: M
Service: CARDIAC SURGERY
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 65 year-old gentelman
who is status post coronary artery bypass graft in [**2138**] and
status post re-do coronary artery bypass graft in [**2149**] who
presented with continued angina and had a positive exercise
treadmill test. Cardiac catheterization showed an ejection
fraction of 70%. The left internal mammary coronary artery
to left anterior descending coronary artery graft was patent.
Previous vein grafts were occluded. The patient was
scheduled for coronary artery bypass graft by Dr. [**Last Name (Prefixes) 411**].
PAST MEDICAL HISTORY: 1. Status post coronary artery bypass
graft in [**2138**]. 2. Status post re-do coronary artery bypass
graft in [**2149**]. 3. Hypercholesterolemia. 4. Hypoglycemia.
5. Status post ear surgery.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS: 1. Isordil 120 mg po q day. 2.
Prevacid 15 mg po q day. 3. Atenolol 50 mg po q day. 4.
Altace 10 mg po q day. 5. Aspirin 325 mg po q day. 6.
Lipitor 20 mg po q day.
PHYSICAL EXAMINATION: Vital signs, pulse 74 regular rate and
rhythm. Blood pressure 128/68. Respiratory rate 22. Room
air oxygen saturation 98%. Weight 170 pounds. This is a
well appearing 65 year-old male in no acute distress. Skin
without lesions or rashes. HEENT is unremarkable. Neck is
supple. Chest lungs are clear to auscultation bilaterally.
Heart S1 and S2 regular rate and rhythm. Abdomen is soft,
nontender, nondistended. Extremities are warm and well
profuse with trace pedal edema.
LABORATORY DATA: White blood cell count 7.7, hematocrit
42.6, platelet count 159, sodium 143, potassium 4.5, chloride
106, bicarb 27, BUN 13, creatinine 1.1. Electrocardiogram
showed normal sinus rhythm with borderline IZCD.
HO[**Last Name (STitle) **] COURSE: The patient was taken to the Operating Room
by Dr. [**Last Name (Prefixes) **] on [**2159-9-17**] for a coronary artery bypass
graft times three, radial artery to obtuse marginal,
saphenous vein graft to diagonal and saphenous vein graft to
posterior descending coronary artery. The patient was
transferred to the Intensive Care Unit in stable condition.
The patient was weaned from mechanical ventilation and
extubated on postoperative day number one. The patient
required neosinephrine and fusion to maintain adequate blood
pressure. The patient was also maintained on a nitroglycerin
drip for the radial artery graft. Neosinephrine was weaned
to off by postoperative day number three. The patient was
able to maintain adequate blood pressure. The patient
remained in the Intensive Care Unit requiring aggressive
pulmonary toilet for what was thought to be an upper
respiratory infection or bronchitis. Sputum cultures from
[**9-19**] showed only oropharyngeal flora. Chest x-ray showed
right lower lobe atelectasis and small left effusion. No
identifiable infiltrate. The patient was started on Levaquin
for presumed bronchitis. The patient had reported being on
antibiotics for bronchitis prior to entering the hospital.
The patient was requiring around the clock nebulizer
treatments with Albuterol and Atrovent as well as humidified
O2 and aggressive chest physical therapy. The patient's
coughing and sputum production gradually subsided as O2
requirement decreased and the patient was transferred out of
the Intensive Care Unit on postoperative day number four.
The patient continued to require aggressive pulmonary toilet
with around the clock nebulizer treatments. The patient
remained afebrile during this time. The patient's white
blood cell count rose to high of 14.7 on postoperative number
two, but quickly returned to [**Location 213**] by postoperative number
four. By postoperative number seven the patient was weaned
from nasal cannula. The patient was ambulating 500 feet and
climbing stairs with physical therapy on room air tolerating
activity well. On postoperative day number eight the patient
was cleared for discharge.
CONDITION ON DISCHARGE: Temperature max 98.2. Pulse 80
sinus rhythm with frequent premature atrial contractions.
Blood pressure 116/60. Respiratory rate 20. Room air oxygen
saturation 98%. Weight 78.4 kilograms. Neurological intact.
Cardiovascular regular rate and rhythm without rub or murmur.
Respiratory breath sounds clear bilaterally, moderately
productive cough for yellow sputum. Gastrointestinal,
positive bowel sounds, soft, nontender, nondistended,
tolerating a regular diet although with decreased appetite.
Sternal incision is clean and dry without drainage or
erythema. Sternum is stable. Left radial artery graft
harvest site is clean and dry with minimal erythema. No
drainage. Saphenectomy sites are clean and dry without
erythema. Electrocardiogram on [**2159-9-25**] showed sinus
arrhythmia with a right bundle branch block. Chest x-ray
from [**2159-9-21**] showed small bilateral effusions with right
lower lobe atelectasis.
LABORATORY ON DISCHARGE: White blood cell count 10.6,
hematocrit 31.5, platelet count 244, sodium 136, potassium
4.8, chloride 99, bicarb 29, BUN 26, creatinine 0.9.
The patient is to be discharged to home in stable condition.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft second re-do.
2. Status post coronary artery bypass graft [**2138**].
3. Status post coronary artery bypass graft [**2149**].
4. Hypercholesterolemia.
5. Hyperglycemia.
6. Status post ear surgery.
DISCHARGE MEDICATIONS: 1. Lopressor 25 mg po b.i.d. 2.
Lasix 20 mg po q day times seven days. 3. K-Ciel 20
milliequivalents po q day times seven days. 4. Guaifenesin
400 mg po q.i.d. times seven days. 5. Levaquin 500 mg po q
day times six days. 6. Aspirin 81 mg po q day. 7. Lipitor
20 mg po q.h.s. 7. Percocet 5/325 one to two tabs po q 4 to
6 hours prn. 8. Ibuprofen 400 mg po q 4 to 6 hours prn. 9.
Combivent MDI with spacer two puffs q.i.d. times one week and
then prn. 10. Imdur 30 mg po q day times three months.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2159-9-25**] 12:28
T: [**2159-9-25**] 12:33
JOB#: [**Job Number 35688**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2719
} | Medical Text: Admission Date: [**2103-9-24**] Discharge Date: [**2103-10-4**]
Date of Birth: [**2019-8-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
worsening shortness of breath
Major Surgical or Invasive Procedure:
[**2103-9-25**]
1. Right mini thoracotomy.
2. Transaortic placement of a 29-mm core valve aortic valve
bioprosthesis. The valve data is the following: Model
number MCS-P3-943, serial number [**Serial Number 90597**].
3. Thoracic aortography.
4. Balloon aortic valvuloplasty.
5. Right and left heart catheterization.
History of Present Illness:
Patient is an 83yo caucasian male with known AS, CAD - s/p
CABGx4([**2084**]), PVD, and significant pulmonary disease
(restrictive
and obstructive, asbestosis) on home oxygen. He presents with
c/o
worsening shortness of breath. He reports prior activity of
walking to the senior center twice a week, now is visibly pale
and unsteady after observed walking 50 feet. Admits to
lightheadedness, denies chest pain. He was evaluated at [**Hospital1 2025**] and
was deemed to be prohibitively high risk for surgical AVR, and
not a candidate for TAVI there due to significant peripheral
vascular disease. He is referred here for evaluation for
treatment options for his symptomatic severe AS.
NYHA Class: III/IV
Past Medical History:
Aortic Stenosis
s/p CoreValve Aortic Valve Replacement
PMH:
CABG x 4 ([**Hospital3 **] - early [**2081**]'s)
Severe aortic stenosis
Pulmonary hypertension
Restrictive and Obstructive Lung disease (home O2)
Pulmonary asbestosis
Extensive pleural plaques
right cerebellar infarct
peripheral vascular disease
hypertension
dyslipidemia
left nephrectomy secondary to renal carcinoma
gastritis
herpes zoster
depression
right carotid endartectomy ([**2091**])
cholecystectomy ([**2090**])
Social History:
Usually stays with his girlfriend. [**Name (NI) **] has three
children (daughter, 2 sons). [**Name2 (NI) **] is a retired shoe repairman
where
he worked in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 20181**] environment with glues and solvents. He
also
had some asbestos exposure when working in a shipyard for a
year.
He never smoked. He rarely drinks alcohol.
Average Daily Living:
Live independently Yes [x] No [ ]
Bathing [x] Independent [ ] Dependent
Dressing [x] Independent [ ] Dependent
Toileting [x] Independent [ ] Dependent
Transferring [x] Independent [ ] Dependent
Continence [x] Independent [ ] Dependent
Feeding [x] Independent [ ] Dependent
Family History:
non-contributory
Physical Exam:
Pulse: 57
B/P: 118/57
Resp:20
O2 Sat: 93 (O2 - 2L nc)
Temp: 98.3
Height: Weight:
General: Alert pleasant elderly male with oxygen in use
Skin: color pale, skin warm and dry
HEENT: normocephalic, anicteric, EOMI's. Oropharynx moist. Nasal
prongs in place, no decubiti.
Neck: Supple, trachea midline, bilateral bruits vs. murmer,
carotid upstroke.
Chest: Well healed sternal incision, mild kyphosis
Heart: murmer throughout
Abdomen: soft, nontender, nondistended, (+) BS
Extremities: 2+ lower extremity edema.
Neuro: Alert and oriented. Gross FROM. Unsteady gait.
Pulses: palpable peripheral pulses
Pertinent Results:
[**2103-10-4**] 08:40AM BLOOD WBC-10.6 RBC-4.40* Hgb-13.5* Hct-41.2
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.0 Plt Ct-313
[**2103-10-3**] 03:32AM BLOOD WBC-9.1 RBC-3.87* Hgb-12.1* Hct-36.3*
MCV-94 MCH-31.2 MCHC-33.4 RDW-14.1 Plt Ct-252
[**2103-10-1**] 01:39AM BLOOD PT-12.7 PTT-25.0 INR(PT)-1.1
[**2103-10-4**] 08:40AM BLOOD UreaN-32* Creat-1.5* Na-138 K-4.3 Cl-98
[**2103-10-3**] 03:32AM BLOOD Glucose-102* UreaN-29* Creat-1.4* Na-138
K-4.1 Cl-98 HCO3-31 AnGap-13
[**2103-10-2**] 05:25AM BLOOD UreaN-24* Creat-1.2 Na-137 K-4.0 Cl-98
HCO3-33* AnGap-10
[**2103-10-2**], Intra-op Echo
Conclusions
The left atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is 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 transaortic gradient is normal for this prosthesis.
Trace/mild paravalvular aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2103-9-27**],
trace/mild paravalvular aortic regurgitation is now visualized
but prior study is suboptimal for comparison.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2103-9-25**] where
the patient underwent Transcatheter Aortic Valve Implantation
with Dr. [**Last Name (STitle) 914**] in conjunction with cardiology. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. He developed acidosis with rising lactate
immediately post-operatively. He was given fluid boluses and
hemodynamics remained stable on low dose phenylephrine. He was
chemically paralyzed and ventilation improved. Echo showed good
LV function with no pericardial effusion and no evidence of
aortic valve malfunction. Transplant surgery was consulted for
rising lactate. Suspicion was low for mesenteric ischemia and
labs were followed. KUB did not reveal any free air. Lactate
trended down. Vasopressor support was weaned. The patient was
weaned from the ventilator and extubated on POD 4. He did
exhibit some post-op delerium. Geriatrics was consulted and
recommended improved sleep/wake cycles. Mental status returned
to baseline and the patient as oriented and appropriate prior to
discharge. Beta blocker was initiated and the patient was
gently diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility.
By the time of discharge on POD# 9 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to [**Hospital 4470**] Health Care
Center Rehab in good condition with appropriate follow up
instructions.
Medications on Admission:
Atenolol 50mcg daily
Aspirin 81mg daily
Aggrenox 200/25 mg daily
Imdur 30mg dialy
Lasix 40mg daily
Zocor 40mg daily
Advair 250/25mg one puff twice daily
Celexa 20mg daily
Flonase 50mctg to each nostril daily
Prilosec 20mg daily
Trazodone 50mg before bedtime
Vitamin B12 1000mcg daily
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet [**Hospital **]: One (1) Tablet PO TID
(3 times a day).
2. citalopram 20 mg Tablet [**Hospital **]: One (1) Tablet PO DAILY (Daily).
3. trazodone 75 mg Tablet [**Hospital **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital **]: One (1) Inhalation Q6H (every 6 hours).
5. ipratropium bromide 0.02 % Solution [**Hospital **]: One (1) Inhalation
Q6H (every 6 hours).
6. clopidogrel 75 mg Tablet [**Hospital **]: One (1) Tablet PO DAILY
(Daily).
7. heparin (porcine) 5,000 unit/mL Solution [**Hospital **]: One (1)
Injection TID (3 times a day).
8. simvastatin 40 mg Tablet [**Hospital **]: One (1) Tablet PO DAILY
(Daily).
9. cyanocobalamin (vitamin B-12) 100 mcg Tablet [**Hospital **]: One (1)
Tablet PO DAILY (Daily).
10. fluticasone 110 mcg/Actuation Aerosol [**Hospital **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. magnesium hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
(2 times a day).
14. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
15. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. lisinopril 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
18. hydralazine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours).
19. furosemide 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day) for 1 weeks: please re-evaluate need for ongoing diuresis
following 1 week course.
20. potassium chloride 10 mEq Tablet Extended Release [**Last Name (STitle) **]: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 1
weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4470**] HealthCare Center at [**Location (un) 38**]
Discharge Diagnosis:
Aortic Stenosis
s/p CoreValve Aortic Valve Replacement
PMH:
CABG x 4 ([**Hospital3 **] - early [**2081**]'s)
Severe aortic stenosis
Pulmonary hypertension
Restrictive and Obstructive Lung disease (home O2)
Pulmonary asbestosis
Extensive pleural plaques
right cerebellar infarct
peripheral vascular disease
hypertension
dyslipidemia
left nephrectomy secondary to renal carcinoma
gastritis
herpes zoster
depression
right carotid endartectomy ([**2091**])
cholecystectomy ([**2090**])
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Thoracotomy Incision - healing well, no erythema or drainage
Edema: 1+
Discharge Instructions:
**See attached TAVI 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 2 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:
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2103-11-5**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2103-11-16**] 9:20
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2103-10-29**]
9:00
Please schedule follow-up with your primary care physician [**Last Name (NamePattern4) **]
[**3-6**] weeks:
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 17503**]
Completed by:[**2103-10-4**]
ICD9 Codes: 4241, 2762, 496, 4439, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2720
} | Medical Text: Admission Date: [**2129-1-7**] Discharge Date: [**2129-1-14**]
Date of Birth: [**2058-10-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History: From Daughter, served as interpreter
PCP: [**Name Initial (NameIs) 65249**]
70 y.o. female with COPD on 4L home O2 and BiPAP, CHF (s/p ICD),
CAD s/p CABG, HTN, presents with dyspnea and hypercarbic
respiratory distress. She was in her USOH (sleeping in a
reclining chair, with DOE at 10 feet) until 1 week ago when she
stopped wearing her BiPAP. Her daughter notes that she became
gradually fatigued over the past week. Three days prior to
admission her daughter noted that she was more short of breath
and called her in the middle of the night complaining of dyspnea
on each of the nights prior to admission. On the morning of
admission the patient was even more dyspneic and called her
daughter, who was out of the house. The patient then pressed
her life alert button and activated EMS.
In the ER she was found to be hypercarbic with 7.27/93/76.
SBP:140s, HR:70s. CXR with pulmonary Edema. She was given 80
mg IV lasix, neb treatment, Solumedrol 125 x 1 and Levofloxacin
500 mg IV x 1. She was admitted to the MICU with hypercarbic
respiratory failure and CHF.
ROS:
POSITIVE: non-compliant with low Na diet, +PND over the last 3
days, DOE with walking 10 feet, mild wheezing.
NEGATIVE: fevers, wt change, CP, Palp, Edema, ABD pain,
weakness, numbness, change in urination, dysuria.
Past Medical History:
1) CAD s/p 4-vessel CABG in [**2119**]
2) CHF with EF 40% by echo at [**Hospital3 **] on [**2128-8-25**] with
mild TR, mild Pulm HTN (38mm Hg)
3) DM Type 2
4) HTN
5) COPD on home O2, BIPAP with multiple past admissions for
non-compliance with BiPAP and pCO2 in the 70-80 range
6) Schizophrenia
7) L3 fracture in [**2127**]
8) Runs of symptomatic VT s/p ICD in [**1-2**]
Social History:
Do not Intubate. Lives in an [**Hospital3 **] facility.
Persian-speaking only. Former home maker. 70 pack year
history, quit in [**2098**]. No EtOH. Uses a walker or cane to
ambulate. Can only take 10 steps prior to having severe
dyspnea. Her daughter cooks her meals for her.
Family History:
Mother with CHF
Physical Exam:
Temp:98.0 BP: 127/43 HR: 80 RR:10 O2: 95%
Gen: Fatigued, some accessory muscle use. CPAP mask on without
leak. Pt opens eyes to voice. A/O x 3. GCS 15.
HEENT: PEARLA. EOMI. No JVD. Dry mm
CV: RR. Non-displaced PMI. No murmurs
Pulm: Rales at bases b/l
ABD: Soft NT/ND. Mild hepatic pulsatility
Ext: Trace edema b/l
Neuro: Motor [**6-3**] at all flex/ex. [**Last Name (un) **]: GI to LT. CN II-XII GI.
Pertinent Results:
Imaging:
[**2129-1-7**] CXR - Congestive heart failure with perihilar and
interstitial edema as well as small pleural effusions
[**2129-1-9**] CXR - Again seen is an ICD with lead terminating in the
right ventricle. There continues to be a hazy bilateral
vasculature with pulmonary vascular redistribution consistent
with fluid overload/CHF. Compared to the film from the prior
day, there has been no significant change
[**2129-1-10**] ECHO - The left atrium is moderately dilated. The left
ventricular cavity size is top normal/borderline dilated. There
is mild regional left ventricular systolic dysfunction. Overall
left ventricular systolic function is mildly depressed. Resting
regional wall motion abnormalities include mid to distal
anteroseptal and apical hypokinesis. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a fat pad, though a
loculated anterior pericardial effusion cannot be excluded.
[**2129-1-11**] CXR - Improved opacity within the right lung base,
likely due to resolving atelectasis. Otherwise unchanged since
[**2129-1-9**]
Cultures:
[**2129-1-7**] Urine - no growth
[**2129-1-7**] Blood - pending
Labs:
[**2129-1-7**] 11:40AM BLOOD WBC-9.9 RBC-3.51* Hgb-9.9* Hct-30.8*
MCV-88 MCH-28.1 MCHC-32.1 RDW-15.5 Plt Ct-192
[**2129-1-8**] 04:57AM BLOOD WBC-7.9 RBC-2.95* Hgb-8.2* Hct-25.6*
MCV-87 MCH-27.7 MCHC-31.9 RDW-15.8* Plt Ct-198
[**2129-1-8**] 06:35AM BLOOD Hct-25.6*
[**2129-1-12**] 04:16AM BLOOD WBC-7.4 RBC-3.38* Hgb-9.4* Hct-30.1*
MCV-89 MCH-27.9 MCHC-31.4 RDW-15.2 Plt Ct-182
[**2129-1-13**] 05:27AM BLOOD WBC-8.3 RBC-3.58* Hgb-10.1* Hct-31.2*
MCV-87 MCH-28.3 MCHC-32.5 RDW-15.2 Plt Ct-166
[**2129-1-7**] 11:40AM BLOOD PT-12.4 PTT-21.7* INR(PT)-1.0
[**2129-1-7**] 11:40AM BLOOD Plt Smr-NORMAL Plt Ct-192
[**2129-1-8**] 04:57AM BLOOD PT-13.3 PTT-21.8* INR(PT)-1.2
[**2129-1-8**] 04:57AM BLOOD Plt Ct-198
[**2129-1-13**] 05:27AM BLOOD PT-12.7 PTT-21.2* INR(PT)-1.1
[**2129-1-13**] 05:27AM BLOOD Plt Ct-166
[**2129-1-7**] 11:40AM BLOOD Glucose-146* UreaN-30* Creat-0.9 Na-141
K-5.1 Cl-97 HCO3-38* AnGap-11
[**2129-1-7**] 07:46PM BLOOD Glucose-151* UreaN-33* Creat-0.8 Na-143
K-4.6 Cl-96 HCO3-39* AnGap-13
[**2129-1-11**] 02:28AM BLOOD Glucose-295* UreaN-48* Creat-1.0 Na-142
K-4.9 Cl-99 HCO3-37* AnGap-11
[**2129-1-12**] 04:16AM BLOOD Glucose-170* UreaN-47* Creat-0.9 Na-145
K-4.5 Cl-101 HCO3-40* AnGap-9
[**2129-1-13**] 05:27AM BLOOD Glucose-163* UreaN-31* Creat-0.9 Na-141
K-4.2 Cl-96 HCO3-38* AnGap-11
[**2129-1-7**] 11:40AM BLOOD ALT-11 AST-16 CK(CPK)-44
[**2129-1-7**] 07:46PM BLOOD CK(CPK)-23*
[**2129-1-8**] 04:57AM BLOOD CK(CPK)-24*
[**2129-1-7**] 11:40AM BLOOD CK-MB-NotDone
[**2129-1-7**] 11:40AM BLOOD cTropnT-<0.01 proBNP-2233*
[**2129-1-8**] 04:57AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2129-1-7**] 11:40AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.1
[**2129-1-7**] 07:46PM BLOOD Calcium-9.1 Phos-5.2* Mg-1.7
[**2129-1-12**] 04:16AM BLOOD Calcium-9.0 Phos-3.6# Mg-2.7*
[**2129-1-13**] 05:27AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.0
[**2129-1-8**] 04:57AM BLOOD calTIBC-384 Ferritn-33 TRF-295
[**2129-1-7**] 11:40AM BLOOD Digoxin-0.6*
[**2129-1-11**] 08:00AM BLOOD Digoxin-0.7*
[**2129-1-13**] 05:27AM BLOOD Digoxin-0.4*
[**2129-1-7**] 11:40AM BLOOD Valproa-14*
[**2129-1-11**] 01:00PM BLOOD Valproa-10*
[**2129-1-7**] BLOOD Type-ART pO2-76* pCO2-93* pH-7.27* calHCO3-45*
Base XS-11
[**2129-1-8**] BLOOD Type-ART pO2-76* pCO2-80* pH-7.33* calHCO3-44*
Base XS-11
[**2129-1-8**] BLOOD Type-ART pO2-108* pCO2-94* pH-7.30* calHCO3-48*
Base XS-15
[**2129-1-8**] BLOOD Type-ART pO2-63* pCO2-77* pH-7.36 calHCO3-45*
Base XS-13
[**2129-1-8**] BLOOD Type-ART pO2-76* pCO2-75* pH-7.35 calHCO3-43*
Base XS-11
[**2129-1-9**] BLOOD Type-ART pO2-74* pCO2-73* pH-7.36 calHCO3-43*
Base XS-11
[**2129-1-9**] BLOOD Type-ART pO2-60* pCO2-72* pH-7.39 calHCO3-45*
Base XS-14
[**2129-1-9**] BLOOD Type-ART pO2-66* pCO2-78* pH-7.36 calHCO3-46*
Base XS-13
[**2129-1-9**] BLOOD Type-ART pO2-74* pCO2-76* pH-7.36 calHCO3-45*
Base XS-12
[**2129-1-10**] BLOOD Type-ART pO2-64* pCO2-62* pH-7.36 calHCO3-36*
Base XS-6
[**2129-1-10**] BLOOD Type-ART pO2-65* pCO2-69* pH-7.39 calHCO3-43*
Base XS-12
[**2129-1-10**] BLOOD Type-ART pO2-75* pCO2-84* pH-7.35 calHCO3-48*
Base XS-16
[**2129-1-10**] BLOOD Type-ART pO2-68* pCO2-74* pH-7.36 calHCO3-44*
Base XS-11
[**2129-1-10**] BLOOD Type-ART pO2-83* pCO2-78* pH-7.34* calHCO3-44*
Base XS-11
[**2129-1-10**] BLOOD Type-ART pO2-80* pCO2-84* pH-7.34* calHCO3-47*
Base XS-15 Intubat-NOT INTUBA
[**2129-1-11**] BLOOD Type-ART pO2-81* pCO2-82* pH-7.26* calHCO3-39*
Base XS-6
[**2129-1-11**] BLOOD Type-ART pO2-88 pCO2-84* pH-7.29* calHCO3-42*
Base XS-10
[**2129-1-11**] BLOOD Type-ART pO2-104 pCO2-84* pH-7.30* calHCO3-43*
Base XS-11
[**2129-1-12**] BLOOD Type-ART pO2-92 pCO2-72* pH-7.35 calHCO3-41* Base
XS-10
[**2129-1-7**] BLOOD Lactate-1.0
Brief Hospital Course:
70 y.o. female with OSA/COPD (on home O2 with BIPAP at night),
schizophrenia, CAD s/p CABG, CHF with EF 40% presents with
dyspnea and hypercarbic respiratory distress > CHF flare.
1) Hypercarbic Respiratory Distress: She has severe COPD and
sleep apnea on 3L home O2 and 14/8 nasal BIPAP. According to
her primary physician and her daughter, she has been extremely
non-compliant with BIPAP and home medications. Baseline CO2
elevated (~70s-80s) per records from [**Hospital3 **]. On
admission here her ABG was 7.27, PCO2 93, PO2: 105. According
to her daughter, she had not worn her BiPAP for 1 week prior to
admission likely accounting for her hypercarbia. He bicarbonate
level of 38 suggests that she had been compensating for a
chronic respiratory acidosis for some time. She was initially
placed on a CPAP mask with bimodal settings in the ER, but upon
arrival to the MICU she was unresponsive to deep sternal rub
and as she was Do-not-intubate code status, she was placed on AC
setting through the CPAP full face mask. After ~4-6 hours she
became more responsive and pH rose above 7.3. She was able to
wean to nasal cannula after ~14 hours with pCO2 in the high 70s.
On the 3 night of hospitalization she was somewhat agitated and
was given 15 mg temazepam (7.5 x 2) which she takes at home to
sleep. Subsequently she became more lethargic and an ABG was
7.11/132/134. She was then placed on Pressure Control
Ventilation (PCV) mode through the CPAP mask with pressures of
18 and had tidal volumes of ~450 with a rate set at 22. She
gradually improved with subsequent ABG of 7.26/82/81. Over the
next 2 days she was able to be weaned to BiPAP at night only
(using her home nasal BIPAP mask) and it was decided that we
would not check blood gases unless she had a change in mental
status and would not prematurely start BiPAP (prior to the
evening) unless her pH was <7.3. She was transferred to the
floor with nighttime Bipap settings of 14/8 and did well. She
continued to oxygenate well on the floor with NC 4L and nightly
BIPAP.
2) COPD Flare. She was initially given duonebs q1 hour, then q2
hours, then weaned to q4 hours. She was also empirically
treated with 125 solumedrol x 2 days, then prednisone taper.
She was also treated empirically with levaquin 500 x 7 days.
3) CHF with EF 40%. She was diuresed 2 liters per day for a
length of stay (-) 6 L with IV lasix boluses. As she was
initially hypertensive, she was started on a Nitro drip with
good blood pressure control. This was weaned off on HD #2.
Toprol 50, digoxin, ACE-I were restarted but limited at times by
bradycardia.
Strict I/O, 1 liter fluid restriction, daily weights, Low Na
diet were maintained.
Positive pressure to reduce afterload was used at night (as
above).
4) H/O VT with ICD. 1 7-beat run of NSVT on hospital day 5,
asymptomatic. We maintained K>4, Mg>2
5) CAD s/p CABG. No evidence of ischemia by signs or symptoms.
ECG unchanged. ASA , BB, ACE-I, statin continued.
6) DM: Glucose well controlled on ISS, then glyburide and
metformin. Creatinine was 0.9-1.1 throughout admission. Her
blood sugars became more elevated after initiation of the
steroid taper. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was called and the patients
glyburide was increased to [**Hospital1 **].
The patient and family agreed to placement in rehab. She was
discharged to rehab on [**2129-1-14**].
Medications on Admission:
Metformin 1000 [**Hospital1 **]
Lasix 60 daily
Digoxin 0.25 daily
Glyburide 5 daily
Lisinopril 5 daily
Toprol 50 daily
ASA 81 daily
L-thyrox 125 daily
Medroxyprogesterone 10 qAM
Lipitor 10 daily
Zoloft 75 qAM
Abilify 20 QHS
Risperdal 2 QHS
Depakote 125 daily
Duo Neb qid
Flovent 4 puffs [**Hospital1 **]
Flonase 2 puffs Nasal [**Hospital1 **]
Restoril 7.5 QHS
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Risperidone 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: Two
(2) Spray Nasal [**Hospital1 **] (2 times a day).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4 ().
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
12. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
13. Medroxyprogesterone 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed: do not give more than 4 g in 24
hours.
15. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
18. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
21. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-1**] Sprays Nasal
QID (4 times a day) as needed.
22. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
24. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
25. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
26. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
27. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
28. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: from [**2129-1-16**] to [**2129-1-18**].
29. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 days: thru [**2129-1-15**].
30. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
31. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
32. GlyBURIDE 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
33. GlyBURIDE 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)): can stop after patient off steroids.
34. Insulin Regular Human 100 unit/mL Solution Sig: 1-20 units
Injection four times a day: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
COPD
CHF
Discharge Condition:
Fair; oxygenating in the mid 90's on 4L NC, getting BIPAP at
night. Mentating AAOx3.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
--Please continue to take all medications as prescribed
--Return to hospital for any change in breathing, SOB, coughing,
fevers, chills, chest pain.
Followup Instructions:
--Please make an appointment with your primary care doctor (Dr.
[**Last Name (STitle) 4922**] in the next 1-2 weeks.
ICD9 Codes: 4280, 496, 4271, 5990, 4019, 2859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2721
} | Medical Text: Admission Date: [**2137-9-19**] Discharge Date: [**2137-10-12**]
Date of Birth: [**2075-12-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
s/p CABGx5(LIMA->LAD, SVG-.pLAD, Ramus, PDA, LCX) [**2137-9-19**]
Reexploration for bleeding.
Cardiac catherization
History of Present Illness:
61 year old male with angina over last year relieved with rest.
Presented to OSH when angina did not relieve with rest and ruled
in for NSTEMI. Transferred for cardiac catherization
Past Medical History:
Hypertension
Angina
Heart Failure
Atrial Fibrillation
Skin Cancer
Social History:
Works at [**Company **] globe, is married
Tobacco - denies
ETOH - [**2-16**]/day
Family History:
Non contributory
Physical Exam:
Discharge
Neuro: alert, oriented x3, strength R=L [**3-20**], no vision left eye,
normal vision right eye
Pulmonary: lungs clear to auscultation bilaterally
Cardiac: RRR +murmur 2/6 SEM, no rub/gallop
Sternal incision: healing no erythema, no drainage, sternum
stable
Abdomen: soft, nontender, nondistended, +bowel sounds last BM
[**10-12**]
Extremeties: warm, edema +1 nonpitting, pulses palpable
Leg incision: endovascular harvest, healing, no drainage, no
erythema
Pertinent Results:
RENAL U.S.; DUPLEX DOP ABD/PEL LIMITED
Reason: r/o RAS
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p CABGx5 with acutely increased creatinine
REASON FOR THIS EXAMINATION:
r/o RAS
INDICATION: Status post CABG with acutely increased creatinine.
Rule out renal artery stenosis.
RENAL ULTRASOUND: No prior examinations. The kidneys are normal
in size and appearance. The right kidney measures 13.6 cm and
left kidney measures 13.2 cm. There are normal arterial
waveforms in the parenchyma bilaterally. The maximum RI on the
right is 0.76 and on the left is 0.8 (both of which are
minimally elevated). There is no evidence of renal artery
stenosis. No hydronephrosis, stone, or mass. The bladder is
filled with fluid and shows no wall thickening or focal masses.
IMPRESSION: Minimally elevated resistive indices in both
kidneys, with no evidence of renal artery stenosis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 18394**] [**Name (STitle) 18395**]
CHEST (PA & LAT) [**2137-10-11**] 6:30 PM
CHEST (PA & LAT)
Reason: evaluate pleural effusion
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p CABG
REASON FOR THIS EXAMINATION:
evaluate pleural effusion
INDICATION: Status post CABG, evaluate pleural effusion.
PA AND LATERAL CHEST: Compared to [**2137-10-10**]. Left-sided PICC line
is unchanged in position with its tip in the distal SVC. There
is no pneumothorax. There remains a small left pleural effusion
not significantly changed and a small amount of linear
atelectasis at the left mid lung base. Calcified left hilar
adenopathy again seen. Heart remains upper limits of normal in
size. No significant short interval change.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size. Overall left ventricular
systolic
function is moderately depressed (EF 35-40%). Due to the
suboptimal image
quality, a regional wall motion abnormality cannot be excluded.
Right
ventricular chamber size is normal. There is mild global right
ventricular
free wall hypokinesis. The ascending aorta is mildly dilated.
The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly
thickened. There is a small pericardial effusion. The effusion
is echo dense,
consistent with blood, inflammation or other cellular elements.
There are no
echocardiographic signs of tamponade.
IMPRESSION: Small echodense pericardial effusion without
echocardiographic
signs of tamponade. Moderate left ventricular systolic
dysfunction. Mild
aortic regurgitation.
Compared with the prior study (images reviewed) of [**2137-10-3**],
the pericardial
effusion is smaller. The other findings are similar.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD on [**2137-10-10**] 14:51.
MRA head
IMPRESSION:
1. No evidence of orbital abnormality on limited sections
through the orbits.
2. Evidence of atherosclerotic disease, but without marked
stenoses or occlusion among the major arteries of the circle of
[**Location (un) 431**]. Because of the limitations of the study, the ophthalmic
arteries are not well visualized on either side.
3. Multiple small foci of T2 hyperintensity suggestive of prior
tiny infarcts in the cerebral white matte bilaterally. A few of
these demonstrate faintly increased signal also on
diffusion-weighted imaging, suggesting that they may be either
subacute or chronic.
Brief Hospital Course:
Transferred in from OSH and underwent cardiac catherization that
resulted in intra aortic balloon pump placement and transferred
to operating room emergently [**9-19**]. Please see catherization
report for further details. He underwent coronary artery bypass
graft x5, please see operative report for further details. He
was transferred to the CSRU on Neo and propofol with IABP. He
received FFP, protamine, and platlets for post operative
bleeding, and then returned to operating room for reexploration,
please see operative report for further details. He was
transferred to CSRU for continued management. He continued with
tachycardia not responsive to esmolol was changed to cardizem
with better control, required vasopressors for hypotension. On
postoperative day [**1-16**] the IABP was weaned and removed, he
continued on vasopressors, cardizem was discontinued and he was
started on beta blockers. He remained intubated due to
hemodynamics and agitation. Agitation continued with weaning of
sedation, diuresed, and betablocker increased. Postoperative
day [**4-18**] tolerated CPAP and was extubated but was confused moving
all extremeties. Blood pressure and heart rate labile, labetolol
started. Postoperative [**6-20**] he went into atrial fibrillation and
treated with Amiodarone and beta blockers. He remained in the
CSRU due to agitation on CIWA d/t ETOH withdrawal, hemodynamic,
and respiratory management. Psychiatry consulted due to
continued delirium and medications adjusted. Anticoagulation
was started for atrial fibrillation with coumadin on POD [**11-25**].
On postoperative 14/13 he was ready for transfer to [**Hospital Ward Name **] 2 with
a sitter, he continued with confusion at times, in/out atrial
fibrillation. He continued to progress and physical activity
increased, he became more oriented, and was able to wean off
ativan and sitter. On posterative day 20/19 he complained of
not being able to see out of left eye - opthamology evaluated
with question of posterior ischemic optic neuropathy which is
diagnosis by exclusion and he underwent MRI. Plan for follow up
with opthamology in clinic no medical intervention at this time.
On postoperative day 21/20 creatinine elevated with decreased
sodium. Fluid intake was increased, renal consulted,
echocardiogram (EF 35-40%). All diuretics, ACE inhibitors, and
NSAID discontinued. Creatinine decreased on Postoperative day
23/22 but sodium remained decreased and placed on free water
restriction with plan for chemistry to be rechecked [**10-14**] at
rehab. He was ready for discharge to rehab with plan for lab
checks.
Medications on Admission:
lopressor, lipitor, ASA, pepcid, Solumedrol, Plavix,
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
14. Haloperidol 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
15. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Outpatient Lab Work
please check SMA 7 and HCT [**10-14**]
17. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
please give 0.5mg [**10-13**] and check INR [**10-14**] .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Coronary artery disease.
HTN
Delirium.
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, powders, or creams on wounds.
Call our office for sternal drainage, temp>101.5.
Please have SMA 7, HCT, INR checked [**10-14**]
Free water restriction for hyponatremia
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 131**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 4469**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks.
Make an appointment to see your local opthamologist after
discharge.
Make an appointment to see Dr. [**Last Name (STitle) 22897**] with Neuro-opthamology
after discharge. Phone #[**Telephone/Fax (1) 253**].
Please have SMA 7, HCT, and INR drawn [**10-14**]
Completed by:[**2137-10-12**]
ICD9 Codes: 5849, 9971, 2875, 4280, 4168, 311, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2722
} | Medical Text: Admission Date: [**2191-1-16**] Discharge Date: [**2191-2-3**]
Date of Birth: [**2112-8-1**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Motor Vehicle Collision
Major Surgical or Invasive Procedure:
ORIF R patella
Tracheostomy
G-tube
History of Present Illness:
78f s/p head-on MVC, restrained passenger,+EtOH,30 mph with
extensive front end damage & deployment of airbag, GCS 15,
complain of chest pain/back pain. L chest tube placed at OSH for
decreased breath sounds on Left. Transfer to [**Hospital1 18**] intubated,
hypotensive ontransfer, respond to fluid bolus, repeat
hypotension, DPL neg, FAST neg, Right chest tube placed with min
output, then 2nd Left chest tube placed with gush of air,also
noted L patellar fx on eval.
Past Medical History:
breast ca,L mastectomy, asbestos, COPD,neck tumor s/p excision
and radiation, hypothyroid,mitral stenosis,Rheumatic heart
disease,scarlet fever, prior fall w sternal fx, back fx, rib fx,
also compression back fx 2 mo prior to admit
Social History:
N/A
Family History:
non-contributory
Physical Exam:
96.6/133/146/77,15,91 AC 500/16/5/0/100
intub sedated
Bilat pupils sluggish
tachycardic
chest coarse bilaterally, with chest tubes
abd soft, non distended,stable pelvis
+fem/DP bilateral,
R knee deformity, L ant. tib lac
nl tone guaiac neg
back no step-off, deformity
Pertinent Results:
[**2191-2-2**] 02:56AM BLOOD WBC-12.0* RBC-3.42* Hgb-10.0* Hct-31.4*
MCV-92 MCH-29.3 MCHC-31.9 RDW-15.6* Plt Ct-389
[**2191-2-1**] 02:31AM BLOOD WBC-11.7* RBC-3.75* Hgb-11.1* Hct-33.6*
MCV-90 MCH-29.6 MCHC-33.1 RDW-15.6* Plt Ct-370
[**2191-1-31**] 04:28AM BLOOD WBC-13.4* RBC-3.94* Hgb-11.5* Hct-35.9*
MCV-91 MCH-29.2 MCHC-32.0 RDW-15.9* Plt Ct-394
[**2191-1-30**] 02:10AM BLOOD WBC-11.2* RBC-3.93* Hgb-11.9* Hct-34.6*
MCV-88 MCH-30.4 MCHC-34.4 RDW-16.1* Plt Ct-322
[**2191-1-29**] 02:49AM BLOOD WBC-9.9 RBC-3.74* Hgb-10.9* Hct-33.1*
MCV-88 MCH-29.1 MCHC-32.9 RDW-16.1* Plt Ct-276
[**2191-1-28**] 01:18AM BLOOD WBC-12.1* RBC-3.63* Hgb-10.8* Hct-32.9*
MCV-91 MCH-29.7 MCHC-32.8 RDW-15.8* Plt Ct-246
[**2191-1-27**] 04:00AM BLOOD WBC-10.8 RBC-3.80* Hgb-11.1* Hct-34.1*
MCV-90 MCH-29.3 MCHC-32.7 RDW-15.8* Plt Ct-228
[**2191-1-26**] 02:40AM BLOOD WBC-10.6 RBC-3.46* Hgb-10.2* Hct-31.5*
MCV-91 MCH-29.4 MCHC-32.4 RDW-15.7* Plt Ct-190
[**2191-1-25**] 01:48AM BLOOD WBC-11.4* RBC-3.66*# Hgb-10.7*# Hct-32.3*
MCV-88 MCH-29.3 MCHC-33.2 RDW-16.1* Plt Ct-164
[**2191-1-24**] 05:21PM BLOOD Hct-30.3*
[**2191-1-23**] 10:15PM BLOOD WBC-11.8*# RBC-2.81* Hgb-8.3* Hct-24.8*
MCV-88 MCH-29.7 MCHC-33.6 RDW-15.8* Plt Ct-168
[**2191-1-23**] 02:24PM BLOOD Hct-24.2*
[**2191-1-23**] 01:35AM BLOOD WBC-7.7 RBC-2.95* Hgb-8.8* Hct-26.1*
MCV-88 MCH-29.8 MCHC-33.8 RDW-15.8* Plt Ct-142*
[**2191-1-22**] 03:11PM BLOOD Hct-26.1*
[**2191-1-22**] 07:46AM BLOOD Hct-27.7*
[**2191-1-22**] 02:15AM BLOOD WBC-5.9 RBC-2.89* Hgb-8.6* Hct-26.1*
MCV-90 MCH-29.8 MCHC-33.0 RDW-15.8* Plt Ct-126*
[**2191-1-21**] 08:24PM BLOOD Hct-26.4*
[**2191-1-21**] 02:41PM BLOOD Hct-25.7*
[**2191-1-21**] 02:14AM BLOOD WBC-6.9 RBC-3.04* Hgb-9.0* Hct-26.8*
MCV-88 MCH-29.6 MCHC-33.6 RDW-15.6* Plt Ct-122*
[**2191-1-20**] 02:08AM BLOOD WBC-6.2 RBC-3.20* Hgb-9.6* Hct-28.2*
MCV-88 MCH-30.0 MCHC-34.0 RDW-15.6* Plt Ct-104*
[**2191-1-19**] 02:13AM BLOOD WBC-6.1 RBC-3.14* Hgb-9.4* Hct-27.6*
MCV-88 MCH-29.8 MCHC-34.0 RDW-15.5 Plt Ct-109*
[**2191-1-18**] 05:31PM BLOOD WBC-6.5 RBC-3.18* Hgb-9.5* Hct-27.7*
MCV-87 MCH-29.8 MCHC-34.2 RDW-15.7* Plt Ct-108*
[**2191-1-18**] 01:30PM BLOOD Hct-26.0* Plt Ct-114*
[**2191-1-18**] 02:09AM BLOOD WBC-6.8 RBC-3.23* Hgb-9.6* Hct-27.7*
MCV-86 MCH-29.7 MCHC-34.6 RDW-15.8* Plt Ct-92*
[**2191-1-17**] 05:48PM BLOOD Hct-30.2* Plt Ct-102*
[**2191-1-17**] 09:02AM BLOOD Hct-32.4*
[**2191-1-17**] 01:22AM BLOOD WBC-7.6 RBC-3.80*# Hgb-11.5*# Hct-32.4*
MCV-85 MCH-30.4 MCHC-35.7* RDW-15.4 Plt Ct-72*
[**2191-1-16**] 05:53PM BLOOD Hct-32.5*#
[**2191-1-16**] 12:31PM BLOOD WBC-6.7 RBC-3.03* Hgb-8.9* Hct-25.8*
MCV-85 MCH-29.5 MCHC-34.6 RDW-13.7 Plt Ct-110*
[**2191-1-16**] 11:43AM BLOOD Hct-26.9*
[**2191-1-16**] 05:49AM BLOOD WBC-11.9* RBC-2.73* Hgb-7.9* Hct-23.7*
MCV-87 MCH-28.8 MCHC-33.2 RDW-14.0 Plt Ct-86*
[**2191-1-16**] 04:16AM BLOOD WBC-9.5# RBC-2.39*# Hgb-7.2*# Hct-20.7*#
MCV-87 MCH-30.0 MCHC-34.5 RDW-13.8 Plt Ct-72*#
[**2191-1-16**] 01:00AM BLOOD WBC-21.7* RBC-4.81# Hgb-14.7# Hct-42.7#
MCV-89 MCH-30.5 MCHC-34.4 RDW-13.5 Plt Ct-149*
[**2191-1-15**] 11:20PM BLOOD WBC-19.3* RBC-3.68* Hgb-11.2* Hct-33.2*
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.6 Plt Ct-158
[**2191-1-26**] 02:40AM BLOOD Neuts-93.9* Bands-0 Lymphs-3.3* Monos-2.1
Eos-0.7 Baso-0.1
[**2191-2-2**] 02:56AM BLOOD Plt Ct-389
[**2191-1-15**] 11:20PM BLOOD Plt Ct-158
[**2191-1-25**] 12:07PM BLOOD PT-13.6 PTT-25.4 INR(PT)-1.2
[**2191-1-15**] 11:20PM BLOOD PT-17.5* PTT-40.9* INR(PT)-1.9
[**2191-1-15**] 11:20PM BLOOD Fibrino-136*
[**2191-1-16**] 04:16AM BLOOD Fibrino-211#
[**2191-2-2**] 02:56AM BLOOD Glucose-116* UreaN-24* Creat-0.4 Na-141
K-4.0 Cl-104 HCO3-32* AnGap-9
[**2191-1-16**] 01:00AM BLOOD Glucose-295* UreaN-19 Creat-0.6 Na-142
K-3.2* Cl-112* HCO3-21* AnGap-12
[**2191-1-29**] 02:49AM BLOOD ALT-20 AST-29 AlkPhos-236* Amylase-50
TotBili-1.9*
[**2191-1-16**] 01:00AM BLOOD ALT-133* AST-286* LD(LDH)-680*
CK(CPK)-236* AlkPhos-106 Amylase-54 TotBili-0.5
[**2191-1-16**] 01:00AM BLOOD Lipase-23
[**2191-1-16**] 01:00AM BLOOD CK-MB-10 MB Indx-4.2 cTropnT-0.02*
[**2191-2-1**] 02:31AM BLOOD Calcium-7.7* Phos-3.1 Mg-2.0
[**2191-1-16**] 04:16AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.2
[**2191-1-29**] 02:49AM BLOOD TSH-2.4
[**2191-1-15**] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2191-2-2**] 02:33PM BLOOD Type-ART pO2-84* pCO2-52* pH-7.42
calHCO3-35* Base XS-7
[**2191-1-16**] 12:55AM BLOOD Type-ART pO2-65* pCO2-52* pH-7.19*
calHCO3-21 Base XS--8
[**2191-2-2**] 02:33PM BLOOD Glucose-135*
[**2191-1-16**] 12:04AM BLOOD Glucose-295* Lactate-4.9* Na-139 K-3.4*
Cl-112 calHCO3-20*
[**2191-2-2**] 02:33PM BLOOD freeCa-1.08*
[**2191-1-16**] 12:55AM BLOOD freeCa-1.03*
Brief Hospital Course:
78F s/p MVC (see HPI for list of injuries). Pt admitted to
Trauma ICU, remaned intubated. Neurosurgery consulted regarding
multiple vertebral fractures, TLSO brace and C-collar
recommended. Due to increased risk, IVC filter placed by
interventional radiology [**1-19**]. ORIF Right patellar fracture,
Trach and PEG [**1-21**]. Pt advanced on tube feeds to goal. Pt with
increased stool output, c diff positive, PO flagyl then PO
Vancomycin instituted. Pt. had prolonged vent wean, chest tubes
removed Right on [**1-24**], Left [**1-26**]. Sputum culture grew Staph Aureus
coag positive, GNR, Blood Cultures grew Staph Coag negative and
gram +cocci, with appropriate antibiotics added. Pt continued to
Improve, following commands and interacting, still requiring
rehabilitation services and vent weaning expected to be
prolonged therefore pt screened for vented rehab, felt to be
ready for discherge to such on [**2190-2-2**].
Medications on Admission:
lasix, prevacid,nicoderm,synthroid, prinivil
Discharge Medications:
1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
2. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two
(2) Packet PO BID (2 times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Acetaminophen 160 mg/5 mL Elixir Sig: [**1-23**] PO Q4-6H (every 4
to 6 hours) as needed for temp spike.
6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
12. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H ()
as needed.
13. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
14. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*30 Tablet(s)* Refills:*2*
16. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
17. Piperacillin-Tazobactam 4-0.5 g Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours).
18. Vancomycin HCl 10 g Recon Soln Sig: One (1) gm Intravenous
Q12H (every 12 hours).
19. Hydromorphone HCl 2 mg/mL Syringe Sig: One (1) Injection
Q2-4 PRN ().
20. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
once a day.
21. Vancomycin HCl 250 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 14 days: start [**2190-1-25**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
s/p Motor Vehicle Collision
C7 fracture, c spine ligamentous injury,
T 10, L2, L4, Coccyx fractures,
bilateral rib fractures with Left tension pneumothorax,
manubrium fracture,
anterior chest wall hematoma,
epidural hematoma T4-10 with cord compression at T10,
spinal stenosis at L4-L5,
Right patella fracture,
bilateral pulmonary contusion,
ARDS, Congestive Heart Failure, splenic laceration.
Discharge Condition:
stable
Discharge Instructions:
d/c to vented-rehab facility for prolonged wean. TLSO brace at
alltimes, C-collar on at all times. Please call with questions,
follow up as indicated
Followup Instructions:
Trauma Clinic 1-2 weeks after d/c (call for appointment)
Orthopedic surgery 1-2 weeks after d/c (call for appointment)
ICD9 Codes: 496, 486, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2723
} | Medical Text: Admission Date: [**2131-5-7**] Discharge Date: [**2131-5-28**]
Date of Birth: [**2090-9-16**] Sex: M
Service: MEDICAL INTENSIVE CARE UNIT
HISTORY OF PRESENT ILLNESS: This is a 40-year-old male with
no significant past medical history who presented to an
outside hospital on [**5-6**] with complaints of two to three
days of fever, cough productive of yellow sputum and
shortness of breath. Oxygen saturations were 79% on room air
and the patient's vitals were blood pressure 152/72,
respiratory rate 24 to 30, heart rate 133, temperature of
96.3??????. An arterial blood gas was performed which showed pH
7.46, PCO2 32, PO2 40. Chest x-ray showed bilateral
infiltrates. The patient was given intravenous levofloxacin,
ceftriaxone, Bactrim and Solu-Medrol. The patient was
placed on 100% nonrebreather. Approximately eight hours
later he was noted to have increased labored breathing and
his saturations were 87% to 88% on the 100% nonrebreather.
The patient was intubated at that time. The patient's
admission labs at the outside hospital were noted for a
positive urine and serum toxicology screen for cocaine and
opiates, as well as a white count of 15.8 with 14% bands.
A PA line was placed at the outside hospital showing RA
pressure of 18, RV pressure of 42/15, PA pressure of 42/30
and a pulmonary capillary wedge pressure of 30. Cardiology
was consulted and the patient was diuresed. Repeat values
showed PA pressure 43/25 and a pulmonary capillary wedge
pressure of 14. According to reports, the patient became
agitated and required sedation which caused a drop in his
blood pressure. The patient was started on Neo-Synephrine at
that time. The patient also underwent bilateral lower
extremity ultrasounds which were negative for deep venous
thrombosis at the outside hospital.
On arrival, the patient's vent settings were AC of 18 with a
tidal volume of 700 and PEEP of 12. The patient had received
fentanyl and had been paralyzed with vecuronium in transit.
His oxygen saturations were in the mid 90s on 100% FIO2.
Arterial blood gases on arrival showed pH of 7.29, PCO2 of 55
and PO2 of 82. The Neo-Synephrine was weaned off quickly
without difficulty on presentation here.
PAST MEDICAL HISTORY: None known.
HOME MEDICATIONS: None known.
ALLERGIES: No known drug allergies.
TRANSFER MEDICATIONS:
1. Bactrim
2. Solu-Medrol
3. Levaquin
4. Rocephin
5. Propofol
6. Heparin subcutaneous
7. Carafate
8. Neo-Synephrine
9. Prevacid
SOCIAL HISTORY: The patient is single and unemployed. He
smokes one pack per day and denies drug use. (This was
obtained from outside records).
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Temperature 100.0??????, pulse 117, blood pressure
155/69, respiratory rate 18, oxygen 94% on FIO2 100%.
GENERAL: He was intubated and sedated, as well as paralyzed.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light.
CARDIOVASCULAR: Regular rhythm, tachycardic, no murmurs
appreciated.
LUNGS: Coarse breath sounds bilaterally.
ABDOMEN: Soft, obese, decreased bowel sounds.
EXTREMITIES: Trace edema bilaterally, warm.
LABS AT PRESENTATION TO OUTSIDE HOSPITAL: Chem-7 132, 4.1,
93, 26, 8, 0.9, 155. Calcium 8.8, phos 5.0, magnesium 1.6,
AST 49, ALT 44, alkaline phosphatase 118, LDH 231, CK 242, MB
index negative, troponin negative. Hemoglobin A1C of 6.5.
PT 13.7, PTT 26, INR 1.3, D-dimer less than 250. CBC showed
white count of 15.8 with 14% bands, hematocrit of 49.7,
platelets of 254. Alcohol level less than 10. Aspirin level
less than 2.8. Amylase 22, lipase 5. The following day, the
patient's white count was up to 18.1 with 34% bands.
ADMISSION LABS HERE: White count 13.3 with 8% bands,
hematocrit 43, platelets 201. Chem-7: Sodium 130, potassium
3.4, chloride 93, bicarbonate 24, BUN 23, creatinine 1.5,
glucose 408.
HOSPITAL COURSE BY SYSTEM:
1. PULMONARY: The patient had bilateral pulmonary
infiltrates and hypoxic and hypercapnic respiratory failure
with very low PO2 to FIO2 ratio. This was consistent with a
diagnosis of ARDS. This is thought to be likely secondary to
pneumonia (although all sputum cultures have been negative)
or due to pneumonitis (the patient has a history of drug
use). On presentation, the patient was paralyzed and
maintained on AC. On [**5-8**], the ventilator mode was changed
to pressure control with a driving pressure of 25 and PEEP of
15. A bronchoscopy was done that day in which BAL samples
were taken. The airways showed minimal secretion and some
inflammation. BAL studies are all negative at the time of
this dictation. Due to elevated total pressures to
approximately 40, an esophageal balloon was placed on [**5-10**]. This showed a transpulmonary pressure of only 15,
indicating that the patient's elevated total pressures are
likely due to non pulmonary causes such as his marked
obesity.
Due to this finding, the patient's peak was elevated to 20.
On [**5-11**], the paralytics were discontinued and in the
following days a slow wean of the patient's driving pressure
was done. This went well and on [**5-16**], the patient was
switched to pressure support ventilation and was able to
maintain excellent tidal volumes with a pressure support of
only 5. By this time, his FIO2 had been weaned down to 40%
to 50%. Over the following days, a slow wean of the patient's
PEEP was done. At the time of this dictation, the patient's
vent settings are a pressure support of 5, PEEP of 15 and
FIO2 of 50%.
2. INFECTIOUS DISEASE: The patient was initially started on
empiric treatment for pneumocystis carinii pneumonia at the
outside hospital with Bactrim and steroids. This was
continued here until the BAL samples were negative on [**5-8**]. The patient was initially treated with vancomycin and
levofloxacin to cover a pneumonia. The vancomycin was
discontinued on [**5-11**] after five days when all cultures
were returning negative. The patient completed a 10 day
course of levofloxacin on [**5-16**] as empiric coverage for
community acquired pneumonia. On [**5-17**], the patient again
spiked temperatures to 101?????? to 102??????. He was again pan
cultured. All of this data is pending at the time of this
dictation.
3. CARDIOVASCULAR: The patient is reported to have had a
wedge of 30 at the outside hospital. This corrected with
diuresis and the patient's wedge pressures continued to be
normal here. The Swan-Ganz catheter was discontinued on [**5-10**]. An echocardiogram was done on [**5-8**] which was a
suboptimal study due to body habitus positioning, but
indicated a normal ejection fraction.
4. RENAL: The patient had a mild creatinine bump to 1.5 at
presentation. This is likely prerenal secondary to the brief
episode of hypotension at the outside hospital. This quickly
resolved and there were no further renal issues.
5. ENDOCRINE: The patient is not known to be a diabetic.
However, the patient had a hemoglobin A1C of 6.5 at the
outside hospital. The patient was placed on an insulin drip
and continued on this for 10 days for aggressive blood sugar
control. During this time, the patient required 4 units of
insulin an hour to maintain blood sugars in the 80 to 130
range. On [**5-18**] (due to access issues) the insulin drip
was discontinued and the patient was placed on NPH with a
regular insulin sliding scale.
6. GASTROINTESTINAL: Initially, the patient was poorly
tolerating his tube feeds. This resolved with the initiation
of standing Reglan.
NOTE: This discharge summary covers the dates of [**5-7**] to
[**2131-5-18**]. Subsequent hospital course and discharge
information will be dictated by the intern taking over this
patient's care.
DR.[**First Name (STitle) **],[**Known firstname **] 11-575
Dictated By:[**Last Name (NamePattern1) 15468**]
MEDQUIST36
D: [**2131-5-18**] 13:49
T: [**2131-5-18**] 14:01
JOB#: [**Job Number 41650**]
ICD9 Codes: 5185, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2724
} | Medical Text: Admission Date: [**2128-10-6**] Discharge Date: [**2128-10-11**]
Date of Birth: [**2068-7-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Oxycodone / Zanaflex
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left lower lobe nodule.
Major Surgical or Invasive Procedure:
[**2128-10-6**]: Video-assisted thoracic surgery left lower lobe
wedge resection.
History of Present Illness:
Admitted for scheduled VATS and left lower lobe resection.
Past Medical History:
Coronary Artery Disease s/p 1v CABG in [**2111**] (SVG -> RCA),
occluded RCA and SVG->RCA graft on Cath in [**1-20**] and RCA fills w/
collaterals; PCI to LAD(3.0x23 Cypher) in [**8-20**] and OM1(2.5x15
Vision-BMS) in [**5-/2127**]
Supraventricular tachycardia s/p ablation
Peripheral [**Year (4 digits) 1106**] disease s/p Right femoral to dorsalis pedis
vein graft, L. femoral-peroneal bypass, right femoral-DP vein
graft bypass, and left BKA, Excision of vein graft and aneurysm
of the right common femoral artery with proximal vein bypass
with interposition segment of nonreversed right basilic vein.
Cath [**8-20**] showed LSFA stents were totally occluded with
collaterals
Emphysema: Home Oxygen 2-4 Liters
Pulmonary Embolism: on coumadin [**11-20**]
Hypercholesterolemia
Total thyroidectomy for thyroid CA->Hypothyroidism
Bilateral inguinal hernia repair
CVA [**2116**] with left-sided weakness
Carotid Stenosis: Right Total occulsion
Seizure disorder
Ischemic neuropathy
Social History:
He denies alcohol use. He smoked 1 ppd for 20 years but quit in
[**2126**]. Lives alone with multiple family members living nearby.
Formerly worked as a computer systems engineer but had to retire
in [**2109**] due to multiple surgeries and medical problems.
Currently on disability. Reports asbestos exposure for 7 years
at a building he worked at.
Family History:
Noncontributory, sister with history of ruptured cerebral
aneurysm at age 48.
Physical Exam:
VS: T 97.6 HR: 87 SR BP 90/50 Sats: 88-91% 4L NC Wt 210
lbs
General: sitting up in bed no apparent distress
Neck: supple
Card: RRR
Resp: decreased breath sounds Right i/4 up, Left 1/3 up no
crackles or wheezes
GI: obese benign
Extr: warm L BKA
Incision: left VATs clean/dry intact, site ecchymotic
Neuro: non-focal
Pertinent Results:
[**2128-10-9**] 07:00AM BLOOD WBC-8.6 RBC-4.13* Hgb-13.8* Hct-40.5
MCV-98 MCH-33.5* MCHC-34.2 RDW-15.2 Plt Ct-141*
[**2128-10-7**] 03:37AM BLOOD WBC-11.2*# RBC-4.45* Hgb-15.2 Hct-43.3
MCV-97 MCH-34.1* MCHC-35.0 RDW-15.3 Plt Ct-134*
[**2128-10-9**] 07:00AM BLOOD Glucose-115* UreaN-8 Creat-0.8 Na-139
K-4.6 Cl-100 HCO3-31 AnGap-13
[**2128-10-7**] 03:37AM BLOOD Glucose-117* UreaN-9 Creat-0.8 Na-138
K-4.1 Cl-100 HCO3-32 AnGap-10
[**2128-10-6**] TISSUE Site: LOBE LEFT LOWER LOBE NODULE.
GRAM STAIN (Final [**2128-10-6**]): No Growth
TISSUE (Final [**2128-10-9**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2128-10-7**]): NO ACID FAST BACILLI SEEN ON
DIRECT
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2128-10-7**]): NO FUNGAL
ELEMENTS
PA AND LATERAL CHEST ON [**2128-10-9**]
FINDINGS: Left IJ central catheter in stable satisfactory
position. Left-
sided chest tube remains as before, there is small amount of
subcutaneous
emphysema on the left. Focal opacity of the left base appears
improved when compared with the previous film of [**2128-10-8**]. There
is no specific evidence of CHF. [**Date Range **] margins are sharp.
Heart remains normal in size. Osseous structures are intact.
CXR: [**2128-10-8**]
FINDINGS: There is improvement in fluid status versus prior
study. Chest
tubes remain in place, subcutaneous emphysema again noted, and
there is slight decrease in the blunting seen at the left CP
angle. No new consolidations.
CHEST RADIOGRAPH [**2128-10-6**].
FINDINGS: As compared to the previous radiograph, the left-sided
chest tube and left-sided central venous access line are in
unchanged position. A minimal left-sided pneumothorax is
minimally better seen than on the previous examination.
Unchanged retrocardiac atelectasis, soft tissue air collection
in the left lateral chest wall.
Brief Hospital Course:
Mr. [**Known lastname 16807**] was admitted on [**2128-10-6**] for Video-assisted
thoracic surgery left lower lobe wedge resection. He was
extubated in the operating room and monitored in the PACU prior
to transfer to the floor. His [**Doctor Last Name **] drain was converted to bulb
suction. He tolerated a regular diet. His pain was managed
with a Dilaudid PCA.
On [**10-7**] the patient was found somnolent with a SP02 of 75% and
[**Doctor Last Name **] drain with air. He was administered narcan with no result.
His [**Doctor Last Name 406**] drain was converted to pleuravac to low wall suction
with a notable airleak. He was transferred to the SICU where he
spontaneously woke. A chest-x-ray showed a small pneumothorax.
He was placed on nocturnal BiPap On [**2128-10-8**] the chest tube
drained > 400cc of serosanguinous fluid. It was placed to water
seal with minimal air leak. Good pulmonary toilet continued. He
was restarted on his home medications. On [**2128-10-9**] he
transferred to the floor. He was seen by cardiology who agreed
with restarting lasix. His chest x-ray revealed no pneumothorax
and was converted to [**Doctor Last Name 406**] bulb without airleak. Physically
therapy saw the patient and cleared him for home with PT.
Medical Oncology saw the patient who deemed him not a candidate
for adjunctive therapy secondary to co-morbidity. They will
continue to follow his pathology. On [**10-10**] the [**Doctor Last Name 406**] drain was
removed and follow-up chest x-ray showed no pneumothorax. The
foley was removed and failed to void. A bladder scan showed 400
urine. On [**2128-10-11**] the foley was removed and he voided. He
continued to make steady progress and was discharged to home
with VNA and PT. He will follow-up with Dr. [**Last Name (STitle) **] as an
outpatient.
Medications on Admission:
Atorvastatin 20mg qd Clonazepam 1mg TID Clopidogrel 75mg daily
ASA 325mg daily
Fluticasone-Salmeterol 250/50 1 inh [**Hospital1 **] Furosemide 20mg qAM
Gabapentin 800mg TID Hydroxyzine 25mg q4-6H PRN itch
Levetiracetam 1500mg [**Hospital1 **] Levothyroxine 150mcg daily
Metoprolol tartrate 25mg TID Nitroglycerin 0.3 mg tab SL PRN
Tiotropium 18 mcg capsule, 1 cap inh daily
Calcium carbonate 500 mg (1250mg) tablet, chewable, 1 tab daily
Cholecalciferol 400 U tablet daily Pyridoxine 50mg daily
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. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
4. Levetiracetam 750 mg Tablet Sig: Two (2) Tablet PO every
twelve (12) hours.
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
[**Hospital1 **]:*90 Tablet(s)* Refills:*0*
15. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times
a day.
16. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
[**Hospital1 **]:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left lower lobe nodule.
Discharge Condition:
stable
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**10-26**] at 3:30pm on the [**Hospital Ward Name 5074**] Sharpiro Clinical Center [**Location (un) 24**].
Report to the [**Location (un) **] Radiology Department for a Chest X-Ray
45 minutes before your appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16800**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2128-10-19**] 4:00
Completed by:[**2128-10-12**]
ICD9 Codes: 4439, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2725
} | Medical Text: Admission Date: [**2157-10-3**] Discharge Date: [**2157-10-7**]
Date of Birth: [**2111-10-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Fexofenadine
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
RCA dissection
Major Surgical or Invasive Procedure:
Intra Aortic Balloon Pump- placed in OSH, removed here at [**Hospital1 18**]
History of Present Illness:
45yo Spanish-speaking woman w/ HTN, DM2, anxiety and seizure
disorder who presented to her PCP w/ chest pain. An EKG was doen
in clinic and was concerning for TW inversions in V5-V6 and she
was transferred to the ED for possible MI. Her chest pain was
relieved by nitro and she was admitted for r/o MI. She has
already had multiple negative stress tests, so the decision was
to go to cath to definitively rule-out coronary artery disease.
.
Catheterization revealed no left main disease or LAD disease.
LCX seperate ostium adjacent to RCA ostium, RCA non-obstructive
proximal plaque. Following Cath she developed chest pain and
reported ST elevations. Repeat cath revealed spiral dissection
to distal vessels with proximal occlusion. She reportedly became
bradycardic to the 30's and received 0.75 mg atropine. A stent
was deployed across the distention with likely jailing off of
the acute marginal branch. An IABP was placed to improve
myocardial oxygenation and she was transfferred to [**Hospital1 18**] for
managemetn of IABP.
.
On arrival she complained of chest pain with radiation to the
back.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Type 2 DM w/ A1c of 9
- Depression/anxiety
- Hyponatremia, attributed to polydipsia and diuretic use
- Seizure disorder - on Depakote and Keppra?
- s/p hysterectomy
Social History:
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Lives with her husband and daughter. [**Name (NI) **] by a VNA daily.
Family History:
Aunt with unknown cancer
Physical Exam:
Admission Exam:
VS: T=97.6 BP=100/70 in both arms HR=95 RR= O2 sat= 93%RA
GENERAL: Moderatly obese spanish speaking woman diaphoretic in
moderate distress. Oriented x3.
HEENT: NCAT. Sclera anicteric. Pupils pin point but reactive.
NECK: Supple with JVP of 11 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft nontender
EXTREMITIES: No femoral bruits.
SKIN: Stasis dermatitis. No ulcers or scars.
Right: R 2+ DP 2+
Left: R: not palpable [**12-21**] pressure dressing in place. DP 2+
Pertinent Results:
Echo:
Suboptimal image quality.The left atrium is normal in size. No
atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is no ventricular septal defect.
The RV free wall appears hypokinetic (the apex is hyperdynamic).
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is a minimally increased gradient
consistent with trivial mitral stenosis. There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: RV infarction? If indicated, a repeat study with
echo contrast may better assess basl to mid RV free wall
function
Repeat Echo few days later:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with depressed free wall contractility. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The tricuspid valve leaflets are
mildly thickened. There is borderline pulmonary artery systolic
hypertension. There is a small pericardial effusion. The
effusion appears circumferential. There are no echocardiographic
signs of tamponade. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional left ventricular systolic
function. Dilated RV with free wall hypokinesis. The apex of the
right ventricle has preserved function. There is pressure/volume
overload of the right ventricle. The estimated pulmonary artery
pressures are only mildly elevated - may be UNDERestimated.
Small pericardial effusion located mostly posterior to the left
ventricle without tamponade physiology.
Brief Hospital Course:
48 YO woman with multiple cardiac risk factors s/p cardiac cath
to R/O CAD complicated by RCA dissection and likely jailing of
acute marginal branch in setting of placement of 3 stents,
transfered to [**Hospital1 18**] CCU with clinical picture concerning for
acute MI of the RV.
.
# Coronaries/Chest pain: Symptoms and EKG findings (STE in
Inferior leads III>II with STE in RV leads is consistent)
consistent with RV infarct likely proximal RCA. Pt's RCA
dissection was secondary iatrogenic causes which temporarily
disrutped flow through RCA. Three stents were placed which
jailed off some of the braching arteries resulting in
post-procedure troponin bump. Troponin peaked at 1.28 and
trended down. Pt transfered here on IABP and heparin drip. IABP
was weaned. Pt given plavix 75mg daily, ASA 325mg daily,
lovastatin 20mg daily for medical management of her CAD. Will
follow with cardiologist outpatient.
.
# PUMP: Initially on IABP which was weaned. Pt's EF is >55%.
Echo showed dilated RV with free wall hypokinesis. Apex has
preserved function.
.
# RHYTHM: Initially had Junctional escape rhythm and then atrial
escape rhythm likely secondary to ischemia of sinus node from
jailing off of proximal RCA branches. Asymptomatic and stable
hemodynamically.
.
# Hyperkalemia: Initially had hyperkalemia on transfer with some
T-wave elevations. Was given kayexelate and insulin with
stabalization of potassium. No further hyperkalemia.
.
# Seizure disorder: Spoke with outpatient neurologist and
patient was given her outpatient seizure regimen.
.
# DM: ISS and held metformin
.
# Dyslipidemia: Continued statin
.
# Anemia: Likely chronic in nature since pt is on ferrous
sulfate at home. It was stable at 28 range. Asymptomatic.
Medications on Admission:
Lantus 80u HS
Lisinopril (Patient has two prescriptions 40mg once a day and
40mg [**Hospital1 **])
Novolog 15u TID
Ativan 0.5mg QHS
Magnesium Oxide 400mg QD
Metformin 1000 MG [**Hospital1 **]
Ranitidine 150mg [**Hospital1 **]
Ferrous sulfate 325mg daily
Vitamin D 400U daily
Lovastatin 20mg QD
Asprin 81mg QD
Lasix 20mg Daily
Naprosyn 500mg [**Hospital1 **]
Depaktoe ER 1000mg [**Hospital1 **] (confirmed with Neurologist)
Risperdal 2mg QHS
Keppra 1000mg [**Hospital1 **] (confirmed with Neurologist)
Detrol 2mg Daily
Primidone 100mg [**Hospital1 **] (confirmed with Neurologist)
Albuterol MDI 2 puffs PRN wheezing
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
2. Lantus 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous at bedtime.
3. Novolog 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous three times a day: Before meals.
4. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
6. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
7. ferrous sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
8. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Outpatient Lab Work
Please check Chem-7 on Monday [**2157-10-10**] with results to Dr.
[**Last Name (STitle) **],KIAME J [**Telephone/Fax (1) 63099**]
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. divalproex 500 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO BID (2 times a day).
15. risperidone 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
16. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. primidone 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
18. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
19. tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Home With Service
Facility:
Multicultural Home Care
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Seizure disorder
Hypertension
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a cardiac catheterization at [**Hospital6 3105**]
and one of your heart arteries was damaged and needed to be
fixed with a bare etal stent. You had some damage to the right
side of your heart that should get better over time. You will be
on a new medicine called Clopidogrel or Plavix and your will
need to increase your aspirin to 325 mg daily from 81 mg daily.
It is extremely important to take Aspirin and Plavix every day,
no not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix and aspirin unless
Dr. [**Last Name (STitle) **] tells you it is OK. You will need to see Dr.
[**Last Name (STitle) 66153**] in 1 week and Dr. [**Last Name (STitle) **] in 1 month. No lifting more
than 10 pounds for one week. Please watch the right groin area
for any increasing pain or bruising or any bleeding. Call Dr.
[**Last Name (STitle) **] if you notice any of these changes.
Medication changes:
1. Start Plavix to keep the stent in your heart artery from
clotting off
2. Increase Aspirin to 325 mg daily
3. Start taking Norvasc to control your blood pressure
4. Do not take your Lisinopril or naprosyn until Dr. [**Last Name (STitle) 66153**]
tells you it is ok to start.
5. You will need to have some blood drawn on Monday to check
your kidney function.
.
Make sure to follow up outpatient with Dr. [**Last Name (STitle) 66153**] to get a
sleep study for possible sleep apnea.
Followup Instructions:
Name: [**Last Name (STitle) **],KIAME J
Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 63099**]
*Please call your PCP to book an appointment within 1 week.
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital 46644**] MEDICAL ASSOCIATES,LLC
Phone: [**Telephone/Fax (1) 63259**]
When: Wednesday, [**11-9**], 1PM
ICD9 Codes: 2761, 5849, 4019, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2726
} | Medical Text: Admission Date: [**2169-6-8**] Discharge Date: [**2169-6-14**]
Date of Birth: [**2105-6-4**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Darvon
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
Femoral CVL
PICC
History of Present Illness:
64 y.o. female with Hep C/etoh cirrhosis, history of GIBs and
monoclonal gammopathy who presented to the ED after suffering a
fall at home. Patient ambulates with a walker at home and per
daughter and HCP, is not fully independent with her ADLs. She
reportedly was trying to maneuver her walker and fell backwards
hitting her head and it is unclear if she loss consciousness.
Per the patient's daughter who does not live with her and did
not witness the fall, the patient was reportedly sleepy after
her fall and slept through the night. Once the fall was learned
of this morning, the patient was brought to the ER for further
evaluation. Upon arrival in the [**Hospital1 18**] ER, vitals were stable and
the patient was complaining of back pain and right wrist and
shoulder pain. CT head, c-spine and torso as well as plain films
of the hips, right wrist and shoulder revealed a T3 burst
fracture without spinal cord involvement, but otherwise showed
chronic, insignificant injuries. Patient was seen by trauma
surgery and neurosurgery, both of whom felt that surgery was not
indicated. Incidentally, patient was found to have a Hct of 17,
down from 24 a month prior. She denied any melena, hematochezia
or hematemesis. She was given 2 units of FFP and 10 of vitamin K
for an INR of 2.9 and then written for 2 units of PRBCs, one of
which she received prior to coming to the unit for further
management.
.
In the ICU, patient was hemodynamically stable and lying in bed
comfortably, denying chest pain, SOB, palpitations,
lightheadedness/dizziness.
Past Medical History:
- ?Etoh/ HCV cirrhosis with recurrent hepatic encephalopathy
- Iron deficiency anemia
- GI bleed - hemorrhoids, s/p TIPS; also w/ known portal
gastropathy
- Sigmoid diverticulosis
- Schatzki's ring
- Duodenal polyps and duodenitis
- Monoclonal gammopathy of undetermined significance
- Psychotic disorder on olanzapine
- Polysubstance abuse - etoh, cocaine, marijuana
- COPD
- Temporal lobe epilepsy (per daughter no seizure in 30 yrs)
- Subcutaneous variceal rupture s/p hematoma exploration in LLQ
- Chronic kidney disease (baseline Cr ~1.4)
- Fractures: clavicle and pubic rami
Social History:
Lived in nursing home but recently discharged home with hospice
(1/[**2169**]). History of tobacco, EtOH and drug abuse. She is
originally from [**State 3908**]. She worked as an administrative
assistant when she was younger, but is now on SSDI (for
?schizophrenia and seizure disorder). Patient's daughter,
[**Name (NI) 4850**], is heavily involved in care.
Family History:
Mother: asthma, grandmother with diabetes, HTN. No family
history of liver disease or bleeding disorders. Great aunt with
epilepsy.
Physical Exam:
Vitals: T: 96.4, BP: 92/52, P: 89, R: 17, O2: 100% 2L
General: Awake, alert, NAD, resting in a hard neck collar
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB
CV: S1, S2 nl, no m/r/g appreciated
Abdomen: Soft, NT, ND, + BS; multiple surgical incisions noted
on abdomen
Ext: No c/c; 2+ pitting edema b/l in LEs
Pertinent Results:
[**2169-6-8**] 06:00PM BLOOD WBC-3.9*# RBC-1.83* Hgb-5.8* Hct-17.9*#
MCV-98# MCH-31.6 MCHC-32.4 RDW-16.7* Plt Ct-90*
[**2169-6-8**] 04:25PM BLOOD PT-28.8* PTT-92.2* INR(PT)-2.9*
[**2169-6-8**] 04:25PM BLOOD Glucose-65* UreaN-10 Creat-1.4* Na-127*
K-4.9 Cl-96 HCO3-23 AnGap-13
[**2169-6-8**] 04:25PM BLOOD ALT-21 AST-36 CK(CPK)-73 AlkPhos-119*
TotBili-2.5*
[**2169-6-8**] 04:25PM BLOOD Albumin-1.7* Calcium-8.4 Iron-33
[**2169-6-8**] 04:25PM BLOOD calTIBC-26* Ferritn-925* TRF-20*
[**2169-6-11**] 03:54AM BLOOD Hapto-<20*
[**2169-6-8**] 04:33PM BLOOD Lactate-2.1*
[**2169-6-11**] 08:48AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.023
[**2169-6-11**] 08:48AM URINE Blood-LG Nitrite-POS Protein-TR
Glucose-NEG Ketone-TR Bilirub-MOD Urobiln-4* pH-6.5 Leuks-SM
[**2169-6-11**] 08:48AM URINE RBC->50 WBC->50 Bacteri-MANY Yeast-NONE
Epi-0-2
Images:
CT C-Spine
IMPRESSION:
1. Possible acute compression fracture of T3 involving anterior
and posterior
columns with posterior retropulsion of the fragmented vertebral
body. The
thecal sac is indented. Evaluation of cord injury, posterior
longitudinal
ligament complex, and possible extra-axial hematoma at this site
is incomplete
with CT and would recommend MRI for better evaluation.
2. Chronic fracture of the spinous processes of C7, T1, and T2.
In addition,
there is anterior widening between the vertebral bodies of C6
and C7. All
these findings may represent sequela of a prior hyperextension
injury;
however, acute injury of the anterior longitudinal ligament at
C6/C7 cannot be
fully excluded. MRI would be better for evaluation.
3. Degenerative changes in the cervical spine, most notably at
C4/C5, C5/6
with loss of intervertebral disc space height and posterior disc
osteophyte
complexes.
4. As the T3 vertebral body fractures incompletely assessed on
this study,
one cannot exclude additional vertebral body injuries below this
level and
would recommend further imaging to better evaluate.
CT Head:
IMPRESSION: No acute pathology.
.
CXR:
IMPRESSION: Feeding tube in place.
.
CT Chest/Abdomen/Pelvis
IMPRESSION:
1. Age-indeterminate compression fractures at T3 and T8. Chronic
compression
fracture at T11. Old spinous process fractures at T3 and T4.
Chronic
posterior right eleventh and twelfth rib fractures. Likely
chronic sacral
insufficiency fracture. A bone scan may be useful for further
evaluation.
2. Cirrhotic-appearing liver with stable TIPS catheter. Slightly
increased
volume of abdominal and pelvic ascites.
3. Enlarged ptotic gallbladder without wall thickening or
gallstones to
suggest cholecystitis.
4. No retroperitoneal collections to suggest hematoma.
5. Marked biapical emphysema.
6. Dense atherosclerotic calcifications, however, the abdominal
vasculature
appears patent.
7. Secretions within the thoracic trachea put the patient at
increased risk
for aspiration.
.
Lower ext U/S
IMPRESSION: No DVT. Right groin hematoma without vascular flow.
No AV
fistula.
Brief Hospital Course:
64 y.o. female with Hep C/etoh cirrhosis, history of GIBs and
monoclonal gammopathy who presented to the ED after suffering a
mechanical fall at home.
Hospitalization was complicated by GI bleeding, aspiration event
with progressive hypoxia and hypotension in spite of agressive
antibiotic and supportive therapy. Given lack of improvement
patient was made CMO on [**2169-6-14**]. She expired later that
afternoon. Below is a problem based summary leading to her
death.
# T3 Burst Fracture: She hit her head on fall, but denied LOC.
In the ED the patient's vitals were stable. CT head, c-spine and
torso as well as plain films of the hips, right wrist and
shoulder revealed a T3 burst fracture without spinal cord
involvement, but otherwise showed chronic, insignificant
injuries. Patient was seen by trauma surgery and neurosurgery,
both of whom felt that surgery was not indicated.
# Anemia/Hct Drop: Patient has a history of GIB and now presents
with a Hct of 17, down from 24.5 one month ago. Last EGD in
2/'[**68**] without varices. Patient was found to have a Hct of 17 on
admission, down from 24 a month prior. She was transfused 2U
([**6-8**]), 4U ([**6-9**]) and 2U ([**6-10**]). The patient had a right femoral
line that was pulled and showed hematoma on U/S. No evidence of
fistula or aneurysm. She was evaluated by vascular surgery and
recommended supportive care. Her Hct increased to 28 on [**6-11**],
but then again dropped to 21 the evening of [**6-11**]. The patient
underwent CT-scan of her abd/pelvis that did not show evidence
of RP bleed. She had guaiac positive brown stool. On [**2169-6-14**]
frank blood was aspirated from oropharynx.
.
#. Aspiration pneumonia: Pt with likely aspiration on [**6-11**] and
CXR showed questionable RML pneumonia. The patient was started
on Vanco/Unasyn and maintained on broad spectrum antibiotics,
later changing to Vanc/ Meropenem, although with progressive
decline.
#UTI: The patient had a postive UA that eventually grew E. coli
which was treated Unasyn given her aspiration pneumonia.
# Cirrhosis: Her liver disease is secondary to EtOH and HCV.
Patient is followed at liver center by Dr. [**Last Name (STitle) 497**]. She was
continued on lactulose, rifaxamin, and ursodiol, and still felt
not to be a transplant candidate.
.
# CKD: On admission the patient's Cr was 1.4, which was near her
baseline. Her creatinine trended down to 1.3.
.
# Goals of care: Pt made DNR/DNI. Discussed goals of care with
daughter and patient, with ongoing deterioration patient was
made CMO
.
Prophylaxis: SCDS, PPI, lactulose
Access: PICC
Code: DNR/DNI
Communication: Patient and her daughter, [**Name (NI) 4850**] [**Name (NI) 99446**] (HCP):
[**Telephone/Fax (1) 99373**]
Medications on Admission:
1. Rifaximin 400 mg PO TID
2. Ursodiol 300 mg PO BID
3. Camphor-Menthol 0.5-0.5 % Lotion QID PRN
4. Olanzapine 5 mg PO BID
5. Lactulose 30 ML PO Q6H
6. Keppra 750 mg PO BID
7. Tramadol 50 mg PO Q4H
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
T3 Fracture
Anemia
Right thigh hematoma
Aspiration Pneumonia
UTI
Secondary:
Etoh/ HCV cirrhosis
MGUS
COPD
Chronic kidney disease
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 5070, 5990, 2851, 5849, 5789, 2875, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2727
} | Medical Text: Admission Date: [**2194-1-21**] Discharge Date: [**2194-3-7**]
Date of Birth: [**2164-5-10**] Sex: M
Service:
DISCHARGE SUMMARY ADDENDUM:
He did well after transfer to the Medical Floor from the
Intensive Care Unit. His Haldol was tapered to 5 mg po
t.i.d. with the eventual plan to taper off as per Psychiatry.
The Valium was also tapered to 5 mg po b.i.d. The eventual
goal is to discontinue both medications over the next one to
two weeks. He otherwise remains stable, increasing mobility
and strength as per physical therapy. His sinus pain
secondary to feeding tube placements, however, resolved with
no fever or worsening pain. He continues to have a Foley
secondary to poor mobility. This can probably be
discontinued as his mobility improves. He continues to
tolerate his tube feeds at a goal rate of 70 cc an hour. His
subcutaneous heparin can be discontinued with improved
mobility as well. Likely, it should be monitored while on
tube feeds.
DISCHARGE STATUS: Stable vital signs. Still improving
strength and mobility.
DISCHARGE MEDICATIONS: Please disregard discharge
medications list on previous summary. Current discharge
medications will be:
1. Heparin 5000 units subcutaneous b.i.d.
2. Topamax 100 mg po q.h.s.
3. Fentanyl patch 75 mcg td q. 72 hours.
4. Haldol 5 mg po t.i.d.
5. Valium 5 mg po b.i.d.
6. Motrin 200 mg q. 6.
7. Tylenol 650 mg po q. 8.
8. Dulcolax 10 mg po q.d. prn.
9. Tube feeds, Peptamen at 70 cc an hour.
FOLLOW-UP: Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**] from
Gastroenterology regarding pancreatitis.
[**First Name8 (NamePattern2) 312**] [**Name8 (MD) 313**] M.D. [**MD Number(1) **]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2194-3-9**] 11:29
T: [**2194-3-9**] 11:29
JOB#: [**Job Number 19405**]
ICD9 Codes: 5185, 486, 2760, 4589, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2728
} | Medical Text: Admission Date: [**2167-4-9**] Discharge Date: [**2167-5-3**]
Date of Birth: [**2086-6-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
trauma transfer from OSH, s/p unwitness fall, right rib
fractures, right pneumothorax, spinal compression fractures
Major Surgical or Invasive Procedure:
placement of right chest tubes done at bedside (x3)
pleurodesis right lung done at bedside
History of Present Illness:
Patient is an 80 year old patient who experienced a witnessed
fall onto concrete. She had no recollections of the events. She
craweled into the house and was found by her son. At that time
she was in respiratory distress and complained of right chest
pain. She was brought to the [**Hospital3 628**] and was
subsequently transferred here. She was found to have a
pneumothorax on the right and chest tubes were placed at OSH.
Patient had small abrasions on the right forearm and right knee.
She was hemodynamically stable on arrival.
Patient was also found to have compression fractures of L4, L5,
T6, T7, T9, T12.
Patient has no prior history of trauma.
Past Medical History:
PMH:
COPD on O2 at home ranges from 2-2.5 LNC
hypertension
hyperlipedemia
Dementia
Depression
Osteoporosis
PSH:
surgical excision of [**Last Name (un) 5902**] neuroma
Social History:
- patient lives with son
- is retired
- smokes 1 pack of cigarettes a day
- denies etoh and drug use
Family History:
non-contributory
Physical Exam:
PE:
VS: Tm 98.8, HR 78, BP 132/76, RR 20, O2 sat 98% on 2L/min NC
gen: WA/WD, NAD
CV: RRR, no m/r/g
pulm: CTA b/l
abdomen: +BS, ND/NT, soft
extremities: no edema
right chest: site of chest tube insertion is clean and dry,
there is no discharge, no edema or erythema, dressing is in
place
Pertinent Results:
CBC:
[**2167-4-9**] 04:50AM BLOOD WBC-14.4* RBC-4.48 Hgb-12.3 Hct-37.6
MCV-84 MCH-27.4 MCHC-32.7 RDW-13.3 Plt Ct-309
[**2167-4-10**] 01:12AM BLOOD WBC-9.0 RBC-3.36* Hgb-9.5* Hct-29.9*
MCV-89 MCH-28.3 MCHC-31.8 RDW-13.9 Plt Ct-208
[**2167-4-10**] 02:07AM BLOOD WBC-9.4 RBC-3.78* Hgb-10.4* Hct-32.0*
MCV-85 MCH-27.6 MCHC-32.6 RDW-13.5 Plt Ct-201
[**2167-4-11**] 01:34AM BLOOD WBC-6.6 RBC-3.47* Hgb-9.5* Hct-29.0*
MCV-84 MCH-27.4 MCHC-32.8 RDW-13.6 Plt Ct-170
[**2167-4-12**] 01:57AM BLOOD WBC-5.4 RBC-3.87* Hgb-10.5* Hct-32.7*
MCV-85 MCH-27.1 MCHC-32.1 RDW-14.0 Plt Ct-216
[**2167-4-13**] 02:29AM BLOOD WBC-5.1 RBC-3.80* Hgb-10.5* Hct-31.8*
MCV-84 MCH-27.6 MCHC-33.0 RDW-14.0 Plt Ct-258
[**2167-4-14**] 02:00AM BLOOD WBC-6.1 RBC-3.66* Hgb-9.9* Hct-30.3*
MCV-83 MCH-27.1 MCHC-32.8 RDW-14.1 Plt Ct-252
[**2167-4-15**] 06:40AM BLOOD WBC-9.5# RBC-3.83* Hgb-10.8* Hct-32.8*
MCV-86 MCH-28.1 MCHC-32.8 RDW-14.7 Plt Ct-388#
[**2167-4-16**] 06:45AM BLOOD WBC-15.9*# RBC-4.22 Hgb-11.6* Hct-35.3*
MCV-84 MCH-27.6 MCHC-32.9 RDW-15.2 Plt Ct-493*
[**2167-4-16**] 07:07AM BLOOD WBC-18.1*# RBC-4.25 Hgb-12.1 Hct-36.4
MCV-86 MCH-28.4 MCHC-33.1 RDW-15.0 Plt Ct-571*
[**2167-4-17**] 01:44AM BLOOD WBC-8.6# RBC-3.10*# Hgb-8.9*# Hct-26.2*#
MCV-84 MCH-28.5 MCHC-33.8 RDW-15.3 Plt Ct-346
[**2167-4-17**] 07:41AM BLOOD Hct-25.5*
[**2167-4-17**] 02:06PM BLOOD Hct-26.1*
[**2167-4-18**] 02:02AM BLOOD WBC-10.8 RBC-3.15* Hgb-8.7* Hct-26.9*
MCV-85 MCH-27.6 MCHC-32.4 RDW-15.9* Plt Ct-349
[**2167-4-19**] 02:37AM BLOOD WBC-11.0 RBC-3.25* Hgb-9.2* Hct-28.3*
MCV-87 MCH-28.2 MCHC-32.4 RDW-15.5 Plt Ct-397
[**2167-4-20**] 01:51AM BLOOD WBC-11.2* RBC-3.29* Hgb-9.0* Hct-28.0*
MCV-85 MCH-27.5 MCHC-32.3 RDW-15.5 Plt Ct-374
[**2167-4-21**] 06:45AM BLOOD WBC-10.5 RBC-3.52* Hgb-9.8* Hct-30.7*
MCV-87 MCH-27.7 MCHC-31.7 RDW-15.8* Plt Ct-469*
[**2167-4-23**] 06:30AM BLOOD WBC-15.1* RBC-2.84* Hgb-8.0* Hct-25.1*
MCV-88 MCH-28.2 MCHC-31.9 RDW-16.8* Plt Ct-625*
[**2167-4-24**] 07:30PM BLOOD Hct-25.5*
[**2167-4-25**] 07:05AM BLOOD WBC-13.2* RBC-2.59* Hgb-7.3* Hct-23.6*
MCV-91 MCH-28.2 MCHC-31.0 RDW-17.6* Plt Ct-596*
[**2167-4-26**] 07:32AM BLOOD Hct-21.3*
[**2167-4-26**] 09:30PM BLOOD Hct-26.7*#
[**2167-4-26**] 09:30PM BLOOD Hct-26.7*#
[**2167-4-28**] 06:50AM BLOOD WBC-11.0 RBC-3.36*# Hgb-9.5*# Hct-30.0*
MCV-89 MCH-28.3 MCHC-31.7 RDW-17.0* Plt Ct-697*
[**2167-4-29**] 07:25AM BLOOD Hct-27.4*
electrolytes:
[**2167-4-9**] 04:50AM BLOOD Glucose-138* UreaN-18 Creat-0.7 Na-140
K-3.8 Cl-101 HCO3-29 AnGap-14
[**2167-4-10**] 01:12AM BLOOD Glucose-488* UreaN-21* Creat-0.7 Na-140
K-6.0* Cl-114* HCO3-25 AnGap-7*
[**2167-4-10**] 02:07AM BLOOD Glucose-121* UreaN-23* Creat-0.8 Na-142
K-4.3 Cl-109* HCO3-28 AnGap-9
[**2167-4-11**] 01:34AM BLOOD Glucose-137* UreaN-23* Creat-0.6 Na-142
K-4.3 Cl-111* HCO3-24 AnGap-11
[**2167-4-12**] 01:57AM BLOOD Glucose-103* UreaN-28* Creat-0.7 Na-142
K-4.5 Cl-109* HCO3-23 AnGap-15
[**2167-4-13**] 02:29AM BLOOD Glucose-97 UreaN-27* Creat-0.6 Na-140
K-4.5 Cl-106 HCO3-27 AnGap-12
[**2167-4-13**] 04:05PM BLOOD Glucose-92 UreaN-22* Creat-0.6 Na-141
K-3.9 Cl-102 HCO3-31 AnGap-12
[**2167-4-14**] 02:00AM BLOOD Glucose-104* UreaN-23* Creat-0.5 Na-140
K-3.7 Cl-102 HCO3-30 AnGap-12
[**2167-4-15**] 06:40AM BLOOD Glucose-85 UreaN-23* Creat-0.5 Na-141
K-3.9 Cl-101 HCO3-29 AnGap-15
[**2167-4-16**] 06:45AM BLOOD Glucose-137* UreaN-25* Creat-0.6 Na-143
K-3.9 Cl-99 HCO3-32 AnGap-16
[**2167-4-16**] 07:07AM BLOOD Glucose-137* UreaN-25* Creat-0.6 Na-144
K-4.4 Cl-100 HCO3-34* AnGap-14
[**2167-4-16**] 05:55PM BLOOD Glucose-140* UreaN-30* Creat-0.7 Na-142
K-3.6 Cl-100 HCO3-31 AnGap-15
[**2167-4-17**] 01:44AM BLOOD Glucose-138* UreaN-29* Creat-0.6 Na-140
K-3.4 Cl-100 HCO3-33* AnGap-10
[**2167-4-18**] 02:02AM BLOOD Glucose-155* UreaN-32* Creat-0.5 Na-141
K-3.9 Cl-104 HCO3-33* AnGap-8
[**2167-4-19**] 02:37AM BLOOD Glucose-105* UreaN-27* Creat-0.5 Na-139
K-3.6 Cl-101 HCO3-33* AnGap-9
[**2167-4-20**] 01:51AM BLOOD Glucose-94 UreaN-22* Creat-0.6 Na-138
K-3.9 Cl-97 HCO3-34* AnGap-11
[**2167-4-21**] 06:45AM BLOOD Glucose-87 UreaN-15 Creat-0.6 Na-139
K-3.6 Cl-98 HCO3-34* AnGap-11
[**2167-4-23**] 06:30AM BLOOD Glucose-108* UreaN-42* Creat-0.6 Na-139
K-4.2 Cl-100 HCO3-28 AnGap-15
[**2167-4-24**] 09:10AM BLOOD Glucose-88 UreaN-29* Creat-0.7 Na-137
K-3.1* Cl-102 HCO3-26 AnGap-12
[**2167-4-25**] 07:05AM BLOOD Glucose-88 UreaN-30* Creat-0.5 Na-140
K-3.8 Cl-108 HCO3-25 AnGap-11
[**2167-4-27**] 06:20AM BLOOD Glucose-91 UreaN-19 Creat-0.5 Na-138
K-3.6 Cl-104 HCO3-27 AnGap-11
[**2167-4-28**] 06:50AM BLOOD Glucose-86 UreaN-18 Creat-0.5 Na-141
K-4.0 Cl-104 HCO3-29 AnGap-12
[**2167-4-9**] 01:45PM BLOOD CK(CPK)-1193*
[**2167-4-9**] 08:55PM BLOOD CK(CPK)-1530*
cardiac enzymes:
[**2167-4-9**] 04:50AM BLOOD cTropnT-0.20*
[**2167-4-9**] 04:50AM BLOOD CK-MB-22*
[**2167-4-9**] 01:45PM BLOOD CK-MB-33* MB Indx-2.8 cTropnT-0.14*
[**2167-4-9**] 08:55PM BLOOD CK-MB-32* MB Indx-2.1 cTropnT-0.22*
[**2167-4-22**] 12:45PM BLOOD CK-MB-7 cTropnT-0.01
electrolytes:
[**2167-4-10**] 01:12AM BLOOD Calcium-6.7* Phos-2.7 Mg-2.2
[**2167-4-10**] 02:07AM BLOOD Calcium-7.7* Phos-3.1 Mg-2.5
[**2167-4-27**] 06:20AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.4
[**2167-4-28**] 06:50AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.4
imaging:
[**2167-4-9**]
CT c-spine:
1. No acute fracture of the cervical spine.
2. Grade 1 anterolisthesis of C2 on C3 and C3 on C4 which may be
degenerative, although this cannot be confirmed without prior
studies. Grade 1 retrolisthesis of C4 over C5 with mild kyphosis
and moderate canal stenosis.
3. Moderate spinal canal stenosis at C4-5 and C5-C6, which could
predispose the patient to cord injury in the setting of minor
trauma. MRI is recommended for further assessment of cord or
ligamentous injury, provided the patient has no
contraindications to MRI.
[**2167-4-9**]
CT Head:
No acute intracranial hemorrhage or edema. No acute skull
fracture, within the limitations of slight motion.
[**2167-4-9**]
CT abdomen/pelvis/chest:
1. Moderate to large right pneumothorax with a small component
of
hydropneumothorax.
2. Large hiatal hernia containing fluid. Fluid in the entire
esophagus,
placing the patient at risk for aspiration.
3. Emphysema.
4. Posterior right rib fractures 5 through 11.
5. Multiple compression deformities of the thoracic and lumbar
spine as
detailed above, age indeterminate.
6. Extensive subcutaneous gas of the neck, abdomen, pelvis and
right arm.
Pneumomediastinum.
7. Diverticulosis, no evidence of diverticulitis.
[**2167-4-13**] EKG:
Sinus rhythm. Low QRS voltage. Consider prior inferior
myocardial infarction. Prior anterior myocardial infarction.
Since the previous tracing of [**2167-4-9**] delayed R wave progression
is more prominent but there may be no significant change.
[**2167-4-14**] echocardiogram:
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. There is
a mid-cavitary LV systolic gradient, which increases with the
Valsalva maneuver. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a promient fat pad.
IMPRESSION: Small, hypertrophied and hyperdynamic left ventricle
with a mid-cavitary gradient. Moderate pulmonary hypertension
[**2167-5-3**] CXR
No pneumothoraces are seen on either side. There is again seen a
very large hiatal hernia which is less air-filled. There are
bilateral pleural
effusions, right side worse than left, which are unchanged from
prior. There are no signs for overt pulmonary edema. There is
demineralization of the thoracic spine with some compression
deformities.
microbiology:
[**2167-4-30**] Stool Clostridium difficile culture - negative
Brief Hospital Course:
The patient was admitted to the Trauma Surgical Service after
transfer from the OSH. She was s/p fall with multiple right rib
fractures and right pneumothorax. The chest tubes were placed to
suction. She also had lumbar and thoracic spinal compression
fractures which were non-operative; neurosurgery was consulted.
She was initially admitted to the surgical trauma ICU for
monitoring of her respiratory status. The patient was
hemodynamically stable.
Neuro: Initially pain service was consulted regarding epidural
anasthesia. However, that was not done, and instead the patient
received IV morphine with good effect and adequate pain control.
She also recieved a transdermal lidocaine patch to the chest.
She recieved Tylenol and Toradol. On [**4-12**], she was strated on
PCA dilaudid. When tolerating oral intake, the patient was
transitioned to oral pain medications, namely in liquid form and
that was easier for her to tolerate. Pain service was involved
to manage pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Cardiac
anzymes were monitored multiple times and were negative. The EKG
was performed on [**2167-4-13**], which was not suspicious for acute
ischemia. The echo was done on [**2167-4-14**], the results are detailed
in the previous section.
Pulmonary: Patient was admitted with the right pneumothorax and
subcutaneous emphasema along the right lateral chest wall and
flank extending inferiorly to about right anterior superior
iliac spine. At the time of admission she had one chest tube
placed and later on the same day she had a second chest tube
placed to suction. Good pulmonary toilet, early ambulation and
incentive spirrometry were encouraged throughout
hospitalization. She recieved albuterol and ipratropium as
needed for shortness of breath. Both of the two chest tube were
removed on [**4-12**].Subsequetly, patient experienced some
respiratory distress on [**4-13**]; she had small apical pneumothorax
on CXR. The respiratory distress was treated with nebulizers,
cpap and diuresis. Her repiratory status was monitored in the
trauma ICU until [**4-14**], when she was transferred to the floor.
Two days later she experienced respiratory distress and was
transferred back to the ICU on [**4-16**]. Subsequntly, patient was
intubated in the ICU and chest tube was placed on the right
side. She continued to have an air leak, the chest tube stayed
to suction. Treatment with vancomycin and cefepime were started
for presumed pneumonia. Patient's respiratory status improved
and she was extubated on [**4-20**] and transferred to the floor.
She did well on the floor, even though she had a persistent air
leak. Attempts were made to clamp the chest tube, she initially
did not tolerate it. The pleurodesis was done by thoracic
surgery service at bedside. Patient tolerated it well. Several
days later, the air leak largely disappeared, patient eventually
tolerated clamping and chest tube to water seal for almost 48
hours. The chest tube was then removed and patient remained in
good respiratory status with no residual pneumothorax on chest
x-ray. Patient recieved daily chest x-rays to monitor her right
sided pneumothorax.
By the time of discharge patient was on her home dose on
supplemental oxygen, sating well over 92%.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
Patient was kept NPO initially secondary to large hiatal hernia
and concern for aspiration risk. She had a speech and swallow
evaluation on [**2167-4-10**]. The recommendations were diet of thin
liquids and pureed consistency solids, medications to be crushed
with the liquids, one on one supervision and nutrition consult
was recommended. Recommended diet was started following this
evaluation.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. She remained afebrile.
The sputum cultures were sent once, but contained only
respiratory flora. Patient was treated with vancomycin and
cefepime for presumed pneumonia.
Stool was sent on [**5-10**] for Clostridium difficile analysis. There
was no growth.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required. Her anemia was at
baseline.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible with physical therapy.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet with supplements, ambulating with assisstance, voiding, and
pain was well controlled. Her respiratory status was much
improved and stable, at her baseline. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
simvastatin 10 mg once daily
albuterol
flovent
Celexa 20 mg once daily
lisinopril
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed
for constipation.
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 1 weeks.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO daily PRN as needed for
constipation.
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: stop the taper on [**5-6**] after the last dose .
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for Wheezing.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
10. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) ml PO
TID PRN .
11. Oxycodone 5 mg/5 mL Solution Sig: [**1-24**] ml PO every 4 hours
PRN as needed for pain for 1 weeks.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO BID (2
times a day).
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
multiple right rib fractures
right pneumothorax
lumbar and thoracic spinal compression fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized because of the fall that resulted in your
rib fractures and lead to the right lung pneumothorax.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
* Call or return immediately if you experience pain which is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) **] in [**2-25**] weeks. His
office phone number is ([**Telephone/Fax (1) 2537**].
Please make an appointment with your primary care physician [**Last Name (NamePattern4) **]
[**1-24**] weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2167-5-3**]
ICD9 Codes: 486, 5185, 4168, 4019, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2729
} | Medical Text: Admission Date: [**2182-4-12**] Discharge Date: [**2182-4-19**]
Date of Birth: [**2100-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
ARF/ Unsteady gait
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 82 year old patient of Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who presented
to [**Company 191**] episodically with 3 days of unsteady gait per his wife.
She provides the majority of the history today as she states his
dementia is quite severe. She reports that for the last 3 days,
he has been shaking on his feet and has actually fallen twice.
Once, it appeared that his knees gave out and another time he
fell to the left side. She denies any head injury or LOC. She
states that he had almost fallen multiple other times but was
either steadied by his wife or fell into a wall which prevented
his fall.
She reports multiple problems with his legs in the past. He
reports he had rickets as a child and had surgery to bilateral
knees. Additionally, his statin was stopped in the past due to
myalgias. She states he had an episode like this three years ago
that improved with physical therapy, but she is not sure if it
was quite this bad. Both patient and wife deny dizziness, leg
pain, urinary symptoms, though frequency of urination is old,
decreased urine output,
urinary odor, constipation, diarrhea, headaches, chest pain,
shortness of breath, fevers, cough or other symptoms. He has not
had any blood in his urine or his stool She does report he has
seemed "groggier" than usual over the last few days but is not
able to further characterize. Given his CKD, she ensures that he
drinks 1 quart of water daily to stay hydrated and does not feel
that he has had decreased or increased PO intake recently. He
did have a prostate biopsy for surveillance of his prostate ca
on [**4-4**] which came back negative on pathology. Both deny any
symptoms after the biopsy.
In the ED, initial vs were: T97.8 P74 BP 156/74 RR 16 O2 sat
100%. Patient was given amp of calcium, insulin 10u IV, amp of
dextrose and kayexelate for hyperkalemia. CT head was negative
for acute intracranial process, and CXR was unremarkable. Labs
were remarkable for hyperkalemia and acute renal failure.
On the floor, vitals are 141/72, HR 75, RR 16 O2 sat 100% RA. He
is comfortable and has no complaints, he is accompanied by his
wife who provides most of the history.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Per OMR:
* hypertension
* dementia
* mild chronic renal insufficiency: Cr 1.4-1.6 at baseline
* MGUS with detailed evaluation in [**2178**]
* remote history of testicular cancer
* prostate cancer, more recently evaluation is negative for
prostate cancer
* chronic leg pain, EMG suggesting radiculopathy, degenerative
lumbar changes seen on skeletal survey
* regular debridement of toenails/foot lesions by podiatry
* psoriasis
Social History:
Former smoker, quit 15 years ago; EtOH: drinks one drink a night
most nights, sometimes two drinks when out with friends
(1x/2weeks). [**Name2 (NI) **]d; wife accompanying him here.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 97 BP: 141/72 P: 75 R: 18 O2: 100 RA
General: Alert, oriented to [**Hospital **] Hospital, not oriented to year or
month, no acute distress, comfortable.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur heard throughout the precordium, no rubs, gallops
Abdomen: soft, non-tender, moderately distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. No
CVA or flank tenderness
GU: penile prosthesis. 0.25 mm well circumscribed superficial
erosion on glans. Prostate exam non-tender, without nodules,
within normal limits. Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact. Strength 5/5 in all extremities. Gait
not assessed. + Dysmetria on finger to nose test. Slow and
somewhat uncoordinated movements for RAMS (hand turning).
Pertinent Results:
LABS ON ADMISSION:
[**2182-4-12**] 06:20PM BLOOD WBC-7.0 RBC-3.71* Hgb-10.6* Hct-32.2*
MCV-87 MCH-28.7 MCHC-33.0 RDW-15.2 Plt Ct-294
[**2182-4-12**] 06:20PM BLOOD Neuts-75.8* Lymphs-16.9* Monos-5.1
Eos-1.9 Baso-0.3
[**2182-4-12**] 06:20PM BLOOD PT-11.2 PTT-24.1 INR(PT)-0.9
[**2182-4-12**] 06:20PM BLOOD Glucose-78 UreaN-116* Creat-11.8*#
Na-131* K-6.1* Cl-101 HCO3-16* AnGap-20
[**2182-4-13**] 01:44PM BLOOD ALT-19 AST-37 LD(LDH)-344* AlkPhos-36*
TotBili-0.2
[**2182-4-12**] 06:20PM BLOOD TotProt-6.3* Albumin-4.0 Globuln-2.3
Calcium-9.5 Phos-5.9*# Mg-3.1*
[**2182-4-13**] 01:44PM BLOOD calTIBC-263 Ferritn-210 TRF-202
[**2182-4-12**] 06:20PM BLOOD Osmolal-328*
[**2182-4-12**] 06:20PM BLOOD PEP-PND
[**2182-4-13**] 07:23AM BLOOD Type-ART pO2-89 pCO2-33* pH-7.36
calTCO2-19* Base XS--5
[**2182-4-12**] 06:40PM BLOOD Glucose-67* K-6.3*
[**2182-4-12**] 06:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2182-4-12**] 06:20PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2182-4-12**] 06:20PM URINE RBC-0 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2182-4-12**] 06:20PM URINE Eos-NEGATIVE
[**2182-4-12**] 10:04PM URINE Hours-RANDOM Creat-43 Na-69 K-11
TotProt-73 Prot/Cr-1.7*
[**2182-4-12**] 10:04PM URINE U-PEP-PND Osmolal-284
Labs on discharge:
[**2182-4-19**] 08:20AM BLOOD WBC-5.8 RBC-3.42* Hgb-9.2* Hct-29.2*
MCV-85 MCH-26.8* MCHC-31.4 RDW-14.9 Plt Ct-343
[**2182-4-19**] 08:20AM BLOOD Plt Ct-343
[**2182-4-19**] 08:20AM BLOOD Glucose-78 UreaN-54* Creat-2.8* Na-147*
K-4.0 Cl-112* HCO3-24 AnGap-15
[**2182-4-13**] 01:44PM BLOOD calTIBC-263 Ferritn-210 TRF-202
[**2182-4-12**] 06:20PM BLOOD Osmolal-328*
[**2182-4-12**] 06:20PM BLOOD PEP-TWO TRACE IgG-580* IgA-198 IgM-53
IFE-MULTIPLE T
[**2182-4-13**] 01:44PM BLOOD C3-106 C4-19
IMAGING:
Renal U/S: No hydronephrosis.
CXR: No acute cardiopulmonary abnormality.
CT Head: 1. No acute intracranial abnormality. 2.
Age-appropriate cortical and cerebellar atrophy, with chronic
small vessel ischemic change.
TEE: The left atrium is normal in size. No atrial septal defect
is seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal for the patient's body size. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is a mild resting left ventricular outflow tract obstruction. A
mid-cavitary gradient is identified. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is no
systolic anterior motion of the mitral valve leaflets. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Skeletal Survey: No focal lytic bony lesion is seen.
Brief Hospital Course:
82 yo M with h/o prostate, testicular cancer, MGUS, and dementia
presents with worsening ataxia, found to have renal failure and
hyperkalemia.
.
# Acute kidney injury: Pt's creatinine was increased ten-fold on
admission (baseline 1.5 to 11). Did not appear volume overloaded
and urine lytes revealed FeNa of 13%. Urine eosinophils
negative. There was concern for AIN or possible cast nephropathy
given MGUS. His complement levels were normal, but SPEP and UPEP
were positive and remaining clinical picture was suggestive of
multiple myeloma. His creatinine improved to 2.8 on discharge,
and he required IV fluid hydration while hospitalized, though
his creatinine continued to trend down even while drinking PO
fluids alone. He did develop hypernatremia to 147 on the day of
discharge (at which point he was hydrating with only PO fluids),
but renal was comfortable discharging as long as patient had
close follow-up. His wife was instructed several times to be
sure to encourage PO fluids at home, and he will have his
chemistries recheck as an outpatient on Monday, [**2182-4-22**]. He has
renal follow up and close PCP [**Name9 (PRE) 702**] as well. Lisinopril,
gabapentin, and citalopram were all held on discharge, given the
fact that his renal function had not completely normalized.
Lisinopril should likely not be restarted given his higher risk
of volume depletion and cast nephropathy.
# Multiple Myeloma: Given patient's history of MGUS, acute renal
failure, and increase in light chains, heme-onc was consulted
for evaluation of progression to multiple myeloma. Bone marrow
biopsy was performed, and showed >20% plasma cells
(preliminarily, close to 60% plasma cells). He had a negative
skeletal survey. He will follow-up with oncology as an
outpatient for possible initiation of chemotherapy. Before any
chemotherapy is started, the positive PPD found on this
admission should be addressed. It is unclear if he has ever had
treatment for his positive PPD in the past.
.
# Bradycardia: In the MICU, patient was noted to be unresponsive
for 90 seconds. Monitoring showed bradycardia to 30s. Was
eventually aroused, with blood sugar of 100, EKG within normal
limits (rate of 60), and unremarkable ABG. Telemetry strip
showed possible junctional escape rhythm, and cardiology was
consulted for possible pacer placement. Cardiology felt likely
junctional escape with sick sinus syndrome, deferred pacing and
recommended avoiding AV nodal agents. He was monitored on
telemetry throughout his stay and had no other arrhythmias.
.
# Ataxia: Patient's initial complaint. [**Month (only) 116**] have been due to
weakness and electrolyte abnormalities (hyperkalemia known to
cause lower extremity weakness). Head CT negative for acute
intracranial process and has had a negative RPR in past. There
were no acute changes in his neurological status, and he was
cleared by PT to go home with services.
.
# Agitation/Sundowning: Patient was noted to have episodes of
sundowning while on the general medical floors. While inhouse,
he was maintained on zyprexa 5mg, which was very effective for
him.
.
# Murmur: Systolic murmur on exam had not been documented in
recent outpatient notes. He had an echocardiogram to evaluate
for structural heart disease, but the echo showed only mild
LVOT, which likely accounts for the murmur..
.
# Anemia: Pt had stable hemoglobin of 9. Unclear baseline,
likely acute on chronic secondary to his multiple myeloma. Guiac
positive in ED which is consistent w/ recent prostate biopsy.
Denied melena, hematemesis. Anemia studies consistent with
anemia of chronic disease, likely secondary to multiple myeloma.
.
# Hypertension: Home lisinopril held in setting of renal failure
as documented above. SBPs in 130s, 140s, sometimes to 160s/170s.
Continued on home amlodipine 10mg QD. Hydralazine could be
started in the short term as an outpatient. AV nodal blocking
agents and ACE inhibitors should be avoided.
OUTPATIENT TO DO'S:
1. Follow-up BMP drawn on [**2182-4-22**] (with particular attention to
sodium and BUN/Cr)
2. Ensure that heme-onc is aware of positive PPD before
initiating chemotherapy
3. Blood pressure check, consider starting hydralazine if not
well controlled (avoid AV nodal blocking agents and ACE-i)
4. Assess the need to restart citalopram, gabapentin as an
outpatient after renal function has normalized.
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
CITALOPRAM - 20 mg Tablet - 0.5 Tablet(s) by mouth once a day
for
1 week; then increase to 1 qd
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times
a
day
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth once a day.
Increased from 5 mg 1 month ago.
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth twice a day
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply daily as needed
for for 7 to 10 days only
.
Medications - OTC
ASPIRIN [ENTERIC COATED ASPIRIN] - (OTC) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- Dosage uncertain
Discharge Medications:
1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
6. Outpatient Lab Work
Please check Basic Metabolic Panel on Monday, [**2182-4-22**]
before your appointment at [**Company 191**]. Also fax results to DR. [**First Name (STitle) **]
[**Name (STitle) **]. Fax #: [**Telephone/Fax (1) 9420**] (Ph# [**Telephone/Fax (1) 721**]).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
* Acute on chronic renal insufficiency
* Symptomatic bradycardia due to junctional escape rhythm
* Multiple Myeloma
SECONDARY DIAGNOSES:
* vascular dementia
* MGUS
* remote history of testicular cancer
* prostate cancer
* hypertension
* carotid aneurysm
* obstructive sleep apnea
* chronic leg pain, possibly secondary to radiculopathy
* psoriasis
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2182-4-12**] after you were having
falls. We found that you were in kidney failure and you went to
the ICU temporarily. This may have been due to the antibiotics
you took earlier this month. Your kidney function was improving
nicely at the time of discharge. You will need to follow up as
an outpatient with the kidney doctors when [**Name5 (PTitle) **] leave the
hospital.
During your work up for kidney failure, there was a concern that
your MGUS may be progressing further. A bone marrow biopsy was
performed and suggest you have multiple myeloma. You are to
follow up with Dr. [**Last Name (STitle) **], your hematologist/oncologist, for
further management of this.
While you were in the ICU, you also had an episode where your
heart was beating very slowly and you were unresponsive. This
did not occur again while you were in the hospital. You will
need to follow up with the heart doctors as [**Name5 (PTitle) **] outpatient.
The following changes were made to your medications:
1. STOP taking lisinopril (broken down by kidney)
2. STOP taking citalopram (broken down by kidney)
3. STOP taking gabapentin (broken down by kidney)
PLEASE ENSURE YOU HAVE BLOODWORK CHECKED ON [**2182-4-22**]. AS WE
DISCUSSED WITH YOUR WIFE, YOU SHOULD BE DRINKING AT LEAST [**1-26**]
LITERS PER DAY!!!
Followup Instructions:
The following appointments are already scheduled for you:
Department: [**Hospital3 249**]
When: MONDAY [**2182-4-22**] at 9:30 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
YOU WILL HAVE LABWORK DRAWN ON THIS DAY AND MAKE SURE YOUR
DOCTOR FOLLOWS IT UP WITH YOU. RESULTS SHOULD ALSO BE FAXED TO
DR. [**Last Name (STitle) **] (YOUR KIDNEY DOCTOR)
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2182-4-25**] at 3:30 PM
With: DR. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 721**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2182-5-2**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2182-5-6**] at 3:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2182-5-6**] at 10:20 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) 1243**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 **] [**Location (un) 2352**] SUITE B
When: MONDAY [**2182-6-3**] at 10:30 AM
With: DR. [**First Name (STitle) **] [**Doctor Last Name **] [**Telephone/Fax (1) 1142**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2182-6-11**] at 10:45 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5845, 2762, 2760, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2730
} | Medical Text: Admission Date: [**2172-7-6**] Discharge Date: [**2172-7-10**]
Date of Birth: [**2096-4-25**] Sex: M
Service: Cardiothoracic Surgery Service
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
gentleman who is a patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47696**] who was
transferred in from [**Hospital3 3583**] status post a myocardial
infarction for cardiac catheterization. He was seen by
Cardiology on admission.
He was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] and was seen on [**7-6**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Myocardial infarction.
3. Hypercholesterolemia.
4. Myocardial infarction in [**2158**].
5. Status post cancer and radiation therapy to the mouth.
6. Grave's disease with right eye diplopia.
7. Transient ischemic attack in [**2156**].
8. Syncope.
9. Glaucoma.
10. Left carotid endarterectomy in [**2170**].
11. Transurethral resection of prostate.
MEDICATIONS ON ADMISSION: (Medications on admission were as
follows)
1. Plavix 75 mg p.o. once per day
2. Aspirin 325 mg p.o. once per day.
3. Lopressor 25 mg p.o. twice per day.
4. Lisinopril 5 mg p.o. once per day.
6. Synthroid 0.025 mg p.o. once per day
7. Lipitor 10 mg p.o. once per day.
8. Flonase 2 puffs as needed.
9. Xalatan eyedrops once per day.
10. Trusopt one drop three times per day to both eyes.
PERTINENT RADIOLOGY/IMAGING: Cardiac catheterization showed
left vein and 3-vessel disease with an ejection fraction of
45%.
Cardiac catheterization today just showed left vein 60% left
anterior descending artery, 60% to 80% first diagonal, 100%
left circumflex, and 90% ostial right coronary artery.
His preoperative chest x-ray showed no acute cardiopulmonary
disease.
On [**7-7**], he had ultrasounds done which showed a right
internal carotid stenosis of 60% to 69%, a left internal
carotid stenosis of less than 40%. Please refer to the final
dictated report.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, blood
pressure was 166/77, oxygen saturation was 100% on room air,
respiratory rate was 18, and heart rate was 55. His left eye
pupil appeared larger but both were reactive. Sclerae were
anicteric. He had well-healed scars bilaterally on his neck.
His lungs were clear. His heart was regular in rate and
rhythm. Normal first heart sounds and second heart sounds.
No murmurs. His abdominal examination was benign with good
bowel sounds and no hepatosplenomegaly. His extremities were
warm and well perfused with no cyanosis, clubbing, or edema,
or varicosities. He had good peripheral pulses throughout.
PERTINENT LABORATORY VALUES ON PRESENTATION: His creatine
kinase peaked at [**Hospital3 3583**] at 384 with a troponin of
8.35. He had Q waves in his inferior leads. His
preoperative laboratories were as follows; white blood cell
count was 5.8, hematocrit was 36.5, and platelet count was
162,000. Prothrombin time was 13.1, partial thromboplastin
time was 40.9, and INR was 1.1. Sodium was 134, potassium
was 3.9, chloride was 104, bicarbonate was 22, blood urea
nitrogen was 22, creatinine was 0.9, and blood glucose was
87. ALT was 22, AST was 28, alkaline phosphatase was 64,
total bilirubin was 0.5, and albumin was 3.7. Creatine
kinase was 270 followed by 320. Troponin was 8.3.
HOSPITAL COURSE: Plavix was placed on hold. On [**8-3**], he
underwent coronary artery bypass graft times four with a left
internal mammary artery to the left anterior descending
artery, saphenous vein graft to posterior descending artery,
saphenous vein graft from obtuse marginal to diagonal.
Coming off bypass, the patient experienced right ventricular
failure and went back on bypass with drug manipulations.
Additional echocardiography showed an ejection fraction still
approximately 35% to 40% with moderate mitral regurgitation,
moderate aortic insufficiency, and moderate tricuspid
regurgitation and aortic regurgitation. Intra-aortic balloon
pump was still in good position which had been placed.
The patient went back on bypass a third time for increased
right ventricular failure and increasingly unstable vital
signs. The patient was placed on right heart bypass with
cannulas in the right atrium and pulmonary artery going into
the left pulmonary artery. This was confirmed by an
echocardiogram.
The patient was brought to the Cardiothoracic Intensive Care
Unit with a right heart bypass cannulation in place. The
patient was profoundly hypoxic and acidotic. He was
unresponsive on examination and was successfully sedated. He
was on the following drips: Amiodarone at 1, dobutamine at
2.5, epinephrine at 0.3, and Levophed at 0.8, lidocaine at 2,
and pitressin at 0.2. His heart rate was 98. He was
atrially paced with a blood pressure of 93/41. Intra-aortic
balloon pump was at 1:1. He was fully supported by the
ventilator with a blood gas of 7.27/35/41/17/-9. Temperature
maximum was 93.9. Hematocrit was 20.8. He was on an insulin
drip also. He remained fully on Swan-Ganz catheter and
monitored with maximum pressors and inotropic support. He
was critically hypoxic with instructions to do no
cardiopulmonary resuscitation but to defibrillate only.
The patient was seen by a Renal fellow on [**7-8**]. Please
note to refer to the patient's Operative Note. In the
operating room, the patient coded and was asystolic on the
way out of the operating room and then went back to the
operating room on bypass times three. That was when the
intra-aortic balloon pump was placed and the right
ventricular assist device was placed, as the right
ventricular wall was not moving. In addition, to the
saphenous vein graft to the right coronary artery. Please
refer to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15933**] Operative Report.
It was the impression of the Renal consultation that the
patient's urine output had slowly resumed. His blood
pressure had increased to a mean arterial pressure of greater
than 70, but the prognosis was very poor. They recommended
continuous venovenous hemofiltration for fluid removal and
oxygenation to help improve it, but the patient was clearly
hypoxic and had cardiogenic shock. He also had lactic
acidosis and congestive heart failure. The hypernatremia was
likely secondary to multiple ampules of bicarbonate given
during the operation. The left femoral venous dialysis was
placed under sterile conditions in the Intensive Care Unit on
[**7-8**] in preparation for continuous venovenous
hemofiltration.
The patient was seen again the next morning by the Renal
Service with the right ventricular assist device still in
place and massive volume overload after DOR noted on maximal
ventilatory support with acute renal failure secondary to the
prolong hypertension. The right ventricular assist device
remained in place at that time. Blood pressure dropped with
the fluid removal.
On postoperative day two, the pressors were slowly weaned.
The patient received two units of packed red blood cells, and
his positive end-expiratory pressure was increased. The
patient was unresponsive with no movement. The patient was
on a Levophed drip, amiodarone drip, epinephrine drip, and
Milrinone, as well as dobutamine drip, lidocaine drip, as
well as pitressin drip. Heart rate was 76, A-paced. Blood
pressure was 118/48. Blood gas that morning was
7.47/26/63/19/-2 with a temperature maximum of 99.5. White
blood cell count was 16.7. Hematocrit was 45. Platelet
count was 121. Sodium was 132, potassium was 4.6, blood urea
nitrogen was 22, creatinine was 2.3, chloride was 97,
bicarbonate was 18, and blood glucose was 104. The patient
was continued on propofol sedation. Lidocaine was decreased
to 1. The patient was continued on perioperative vancomycin.
Levofloxacin was also added in. The patient remained
critically ill in the Intensive Care Unit. The patient
continued to have low-flows and low blood pressures on his
right ventricular assist device with coarse breath sounds.
He was sedated and intubated with massive anasarca. His
extremities appeared to have anasarca emboli and were warm.
His blood urea nitrogen was 27 with a creatinine of 2.6. His
hematocrit dropped from 48 to 32.2. He remained on
amiodarone drip at 0.5, lidocaine drip at 1, dobutamine drip
at 2.5, epinephrine drip at 0.3, Levophed drip at 0.27, and
Milrinone drip at 0.25, vasopressin drip at 0.08,
Neo-Synephrine drip at 1.4, propofol drip at 20, insulin drip
at 1, as well as perioperative antibiotics. He was continued
on his right ventricular assist device and his intra-aortic
balloon pump with acute tubular necrosis and was requiring
vasopressors and on inotropic support. He had a poor
potassium clearance, by Renal Service, suggesting
extreme/extensive recirculation of fluid. He continued with
continuous venovenous hemofiltration. The TE showed some
right ventricular function remaining. A pericardial clot was
evacuated at the bedside, and his pressure dropped slightly.
He remained on all of his inotropic and vasopressor support.
He was fully sedated, intubated, and paralyzed. He was
continued on perioperative antibiotics. The plan was to try
and wean his sedation, and try weaning his right ventricular
assist device, and transfuse him as needed, with orders to
defibrillate only.
He was seen by clinical Nutrition Service for a discussion of
starting some parenteral nutrition, but the patient continued
to decline and stopped responding to his drugs with any full
measure.
On [**7-10**], at approximately 7:30 p.m., the family had made
the decision to stop all pressors and withdraw support. At 7
p.m., all infusions were stopped. The patient developed
profound hypotension, his rhythm deteriorated to asystole.
At 7:25 p.m., the pupils were fixed and dilated. There was
no cardiac activity or spontaneous respirations. The patient
was pronounced dead. The family was present. Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1537**] was notified. Postmortem was declined by the family.
Please refer to the death note by Dr. [**First Name4 (NamePattern1) 6644**] [**Last Name (NamePattern1) 47697**].
The patient expired in the Cardiothoracic Intensive Care Unit
on [**7-10**] at 7:30 p.m. Please refer to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15933**]
Operative Report.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2172-7-29**] 14:46
T: [**2172-8-5**] 08:30
JOB#: [**Job Number 47698**]
ICD9 Codes: 9971, 4271, 4280, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2731
} | Medical Text: Admission Date: [**2158-2-15**] Discharge Date: [**2158-2-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Shortness of breath x 1 month
Major Surgical or Invasive Procedure:
Cypher stent to left main coronary artery, Taxus stent to
proximal LAD with 2 overlapping bare metal stents to mid and
proximal LAD on [**2158-2-15**]
History of Present Illness:
The patient is an 84 year old ex-smoker (2 ppd x 40 years) with
a history of CAD s/p CABG (SVG->RCA, LAD) in [**2144**], CHF EF 20%,
hypertension post AAA repair, and CRI who presented to [**Hospital **]
Hospital on [**2158-2-13**] with the chief complaint of shortness of
breath and dyspnea on exertion x 1 month. The patient complained
of no chest pain, nausea, vomiting, or diaphoresis. Nor did he
complain of any jaw pain, left arm, epigastric or back pain. He
had noted increased lower extremity edema x 5 weeks and a 10
pound weight gain in the past 1 month but denied any orthopnea.
He noted decreased exercise tolerance with difficulty climbing
one flight of stairs in his house which is different than his
baseline where he has no difficulty with one flight.
At home, he states he had been compliant with his home
medications. He was taking lasix x 3 days alternating with HCTZ
for 4 days. He states he has adhered to a low salt diet at home.
At [**Location (un) **], he was found to have a BNP of 3280, CK-MB 18 and a
troponin of 9.18 with pulmonary edema on CXR and TWVI in I, II,
III and V3-V6. His SBP was 119/61 with a pulse of 73. He had an
echo which showed an EF of 20% with mild MR [**First Name (Titles) **] [**Last Name (Titles) **] with moderate
PAH. His apex and mid-distal septal wall and mid-distal inferior
walls were akinetic and the anterior wall was akinetic. Trace AR
with mild dilatation of the ascending aorta. PAP 45 mm Hg with
dilated, hypocontractile RV. He also underwent a VQ scan with
low probability for PE and a negative LENI of the RLE.
The patient was transferred for cath on [**2158-2-15**] on heparin gtt,
atenolol 50 mg QD, aspirin 81 mg, KCL 20 meq [**Hospital1 **] and lasix 40 mg
IV BID.
His cath was significant for:
[**2158-2-15**]:
LMCA 80% ostial
LAD 80% ostial, 95% proximal, 70% mid occlusion
LCX one major OM patent
RCA 100% ostial
SVG single proximal aortic anastomosis [**1-18**] aortic calcification
with bifurcating graft to RCA occluded and limb to LAD with two
serial "ugly" thrombotic lesions
LIMA - not utilized during surgery [**1-18**] small vessel
LVEDP 44 mm Hg
PA 52/22
CO 4.59
CI 2.20
RA 10
RVEDP 15
In the cath lab, the patient received Integrillin, 40 mg IV
lasix, plavix, and 1/2NS.
Past Medical History:
CAD s/p CABG [**2144**] at NEDH (SVG->distal RCA, LAD)
HTN
AAA repair
HL
CRI (baseline creatinine unknown; 1.5 at [**Location (un) **])
Bilateral total hip replacement (left twice, right once)
s/p cholecystectomy
Social History:
Quit smoking 28 years ago, smoked 2 ppd x 44 years. Denies EtOH.
Multiple tattoos. He is married and lives with his wife. [**Name (NI) **] has
4 children.
Family History:
Noncontributory.
Physical Exam:
Tc=98.2 P=59 BP=112/74 RR=25 99%O2 on RA
Gen- NAD, AOX3, mildly obese male
HEENT - 10 cm JVD, PERLA, EOMI, MMM
Heart - Grade soft II/VI holosystolic murmur best heard at apex,
regular rate and rhythm
Lungs - CTAB anteriorly
Abdomen - Soft, NT, ND + BS, no hepatosplenomegaly/bruits
Ext - Right groin no hematoma, +1 femoral pulse with no bruit,
+1 d. pedis, +1 pitting edema to knees bilaterally
Pertinent Results:
[**2158-2-15**] 08:38PM GLUCOSE-183* UREA N-45* CREAT-1.6* SODIUM-136
POTASSIUM-3.8 CHLORIDE-89* TOTAL CO2-39* ANION GAP-12
[**2158-2-15**] 08:38PM CK(CPK)-115
[**2158-2-15**] 08:38PM CK-MB-5 cTropnT-3.06*
[**2158-2-15**] 08:38PM CALCIUM-7.7* PHOSPHATE-4.6* MAGNESIUM-1.7
[**2158-2-15**] 08:38PM WBC-11.1* RBC-4.00* HGB-12.1* HCT-35.6*
MCV-89 MCH-30.1 MCHC-33.9 RDW-14.7
[**2158-2-15**] 08:38PM PLT COUNT-192
[**2158-2-15**] 08:38PM PT-14.0* PTT-30.9 INR(PT)-1.2
[**2158-2-15**] 04:16PM CK(CPK)-102
[**2158-2-15**] 04:16PM CK-MB-5 cTropnT-2.95*
[**2158-2-15**] 03:44PM TYPE-ART O2 FLOW-2 PO2-62* PCO2-60* PH-7.45
TOTAL CO2-43* BASE XS-14 INTUBATED-NOT INTUBA COMMENTS-NASAL
[**Last Name (un) 154**]
[**2158-2-15**] 03:44PM GLUCOSE-133* K+-3.5
[**2158-2-15**] 03:44PM O2 SAT-92
Brief Hospital Course:
The patient is an 84 year old male with a history of CAD s/p
CABG (SVG->RCA, LAD), CHF EF 20%, HTN s/p AAA repair,
significant tobacco history and HL, and chronic renal
insufficiency (baseline Cr unknown) who presented on [**2158-2-13**]
with NSTEMI with peak troponin of 9.18 now s/p cath with DES to
LAD and LMCA
The patient was continued on aspirin, plavix 75 mg x 9 months
post PCI, Integrillin 18 hours post cath, and simvastatin 40 mg.
His Atenolol 50 mg QD was changed to Lopressor 50 mg TID with
good effect. The patient's BP remained well-controlled on
Lopressor 50 mg TID. An ACE would be beneficial for cardiac
remodeling, however, given his rising creatinine, an ACE was not
initiated at this time.
Patient has history of CHF with EF of 20%.The patient appeared
overloaded on presentation. He is not on an ACE. We gave him
another 40 mg IV lasix x 1 on transfer to the CCU, he received
40 mg IV lasix in the cath lab and was transferred from [**Location (un) **]
on Lasix 40 mg IV BID. He takes lasix 40 mg QD x 3 days (per
patient) and HCTZ 50 mg x 4 days (per patient) at home for the
past 2 weeks. He diuresed well to Lasix 80 mg IV and then
stablized on lasix 40 mg QD.
His baseline creatinine is unknown, it was 1.6 (1.5 at OSH)on
presentation. It rose to 2.2 with aggressive diuresis.
He was doing well post cardiac catheterization until the early
morning of [**2158-2-20**]. He suddenly went into ventricular
fibrillation. Code was called and was fully ran. He was
defibrillated 10 times with no restoration of regular pulse.
Patient was intubated. He also recieved epinephrine, atropine,
magnesium and calcium when central access was established.
Echocardiogram was performed at the bedside and no pericardial
effusion was found. The code was ran for about 30 minutes.
Family member and the attending were called. Family member
denied post mortem.
Discharge Disposition:
Home
Discharge Diagnosis:
Non-ST elevation myocardial infarction
Congestive heart failure
Chronic renal insufficiency
Discharge Condition:
passed away
Completed by:[**2158-2-20**]
ICD9 Codes: 4280, 4275, 5849, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2732
} | Medical Text: Admission Date: [**2122-10-3**] Discharge Date: [**2122-10-10**]
Date of Birth: [**2051-8-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lasix / Penicillins / Gentamicin / Lipitor / Vancomycin /
Tetracycline / Levaquin / Warfarin / Shellfish Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2122-10-5**] Redo sternotomy mitral valve replacement (27 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
tissue)
History of Present Illness:
70 year-old female with history of mitral stenosis s/p mitral
valve commissurotomy [**2094**], chronic atrial fibrillation admitted
for pre-operative IV heparin.
Past Medical History:
Rheumatic Fever
Mitral Stenosis
Atrial Fibrillation
Hyperlipidemia
Left Breast CA
GERD
Gastric polyps
[**Doctor Last Name 9376**] Disease
Right ankle fracture
Hypothyroid
S/P Mitral valve commissurotomy [**2094**] at [**Hospital1 **] with Dr. [**First Name (STitle) **]
s/p lumpectomy and XRT for L breast CA [**2108**]
Cholecystectomy
Uterine Suspension with lysis of colon adhesions
Appendectomy
Tonsillectomy
R eye cataract surgery
Social History:
Occupation:Retired
Lives with: Husband
[**Name (NI) 1139**]:quit 45 years ago, smoked for 5 yrs
Family History:
Father with [**Name2 (NI) **] age 63, mother with angina, brother with CAD
Physical Exam:
Pulse: 64 irregular Resp: O2 sat: 98% RA
B/P Right: 143/83 Left: 156/90
Height: 5'5" Weight:146 lbs 66.4 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [**3-13**]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [] Edema
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:N Left:N
Pertinent Results:
[**2122-10-8**] 09:30AM BLOOD WBC-15.0* RBC-3.53* Hgb-9.7* Hct-30.7*
MCV-87 MCH-27.4 MCHC-31.5 RDW-14.9 Plt Ct-128*
[**2122-10-3**] 01:35PM BLOOD WBC-7.9 RBC-4.60 Hgb-13.0 Hct-40.5 MCV-88
MCH-28.3 MCHC-32.2 RDW-14.1 Plt Ct-238
[**2122-10-5**] 01:46PM BLOOD Neuts-78.7* Lymphs-19.2 Monos-1.2*
Eos-0.6 Baso-0.3
[**2122-10-8**] 09:30AM BLOOD Plt Ct-128*
[**2122-10-8**] 09:30AM BLOOD PT-15.7* INR(PT)-1.4*
[**2122-10-3**] 01:35PM BLOOD Glucose-92 UreaN-15 Creat-0.8 Na-141
K-4.1 Cl-101 HCO3-32 AnGap-12
[**2122-10-8**] 09:30AM BLOOD Glucose-197* UreaN-11 Creat-0.7 Na-137
K-3.8 Cl-98 HCO3-30 AnGap-13
[**2122-10-3**] 01:35PM BLOOD ALT-29 AST-24 LD(LDH)-232 AlkPhos-70
Amylase-48
[**2122-10-3**] 01:35PM BLOOD Lipase-36
[**2122-10-3**] 01:35PM BLOOD Albumin-4.6 Calcium-9.6 Phos-3.6 Mg-2.2
[**Known lastname **], [**Known firstname 26**] [**Hospital1 18**] [**Numeric Identifier 99893**] (Complete) Done
[**2122-10-5**] at 12:26:49 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2051-8-15**]
Age (years): 71 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for MVR
ICD-9 Codes: 427.31, 440.0, 394.2, 424.2
Test Information
Date/Time: [**2122-10-5**] at 12:26 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW4-: Machine: IE33
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *7.9 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% >= 55%
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.7 cm <= 2.5 cm
Mitral Valve - Peak Velocity: 1.4 m/sec
Mitral Valve - Mean Gradient: 3 mm Hg
Mitral Valve - MVA (P [**2-6**] T): 2.1 cm2
Findings
LEFT ATRIUM: Marked LA enlargement. Elongated LA. No spontaneous
echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Cannot exclude LAA
thrombus. All four pulmonary veins identified and enter the left
atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler. Prominent Eustachian valve (normal
variant).
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Normal regional LV systolic function. Low normal LVEF.
[Intrinsic LV systolic function likely depressed given the
severity of valvular regurgitation.]
RIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV
systolic function.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Characteristic rheumatic deformity of the mitral valve leaflets
with fused commissures and tethering of leaflet motion. Moderate
mitral annular calcification. Moderate thickening of mitral
valve chordae. Mild valvular MS (MVA 1.5-2.0cm2). Eccentric MR
jet. Severe (4+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. Results were personally reviewed with
the MD caring for the patient.
Conclusions
PRE BYPASS The left atrium is markedly dilated. The left atrium
is elongated. No spontaneous echo contrast is seen in the body
of the left atrium or left atrial appendage. Due to image
quality, a left atrial appendage thrombus cannot be completely
excluded. The right atrium is dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is dilated with borderline normal free wall function.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are severely thickened/deformed. The mitral valve shows
characteristic rheumatic deformity. There is moderate thickening
of the mitral valve chordae. There is mild valvular mitral
stenosis (area 2.0cm2). An eccentric, posteriorly directed jet
of severe (4+) mitral regurgitation is seen originating between
the A1 and P1 mitral valve scallops. The tricuspid valve
leaflets are mildly thickened. 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 being AV paced. Epinephrine was used
initially when separating from bypass but then quickly weaned.
The right ventricle displays normal systolic function, though
the amount of tricuspid regurgitation is now moderate and so
intrinsic right ventricular function may be somewhat less than
normal. The left ventricle displayed severe lateral wall
hypokinesis during initial separation from bypass but this
quickly resolved. Left ventricular systolic function was then
normal (> 55%). There is a bioprosthesis in the mitral position.
It is well seated and displays normal leaflet function. The
maximum pressure gradient across the valve was 12 mmHg and the
mean gradient was 4 mmHg at a cardiac output of 4 liters/minute.
There is trace valvular mitral regurgitation. The thoracic aorta
appears intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2122-10-5**] 15:00
Brief Hospital Course:
Admitted for preoperative workup and heparin bridge from
coumadin. On [**10-5**] was brought to the operating room and
underwent mitral valve replacement. See operative report for
further details. She received vancomycin for perioperative
antibiotics because she was in the hospital preoperatively.
Post operatively she was transferred to the intensive care unit
for hemodynamic management. In the first twenty four hours she
was weaned from sedation, awoke neurologically intact, and was
extubated without complications. She was transferred to the
floor on postoperative day one and her coumadin was resumed for
atrial fibrillation. Her INR was 1.6 on day of discharge and
was rec'ing 4 mg coumadin. Physical therapy worked with her on
strength and mobility. She continued to do well and was ready
for discharge home with services on postoperative day five.
Medications on Admission:
Zetia 10mg daily/qam
Coumadin 3mg tablet daily/qpm Last Dose [**2122-9-29**] ([**Hospital1 18**] coumadin
clinic)
Edecrin 25mg daily/qam
Digoxin 0.125mg daily/qam
Levoxyl 50mcg daily/qam
Clindamycin 600mg [**Hospital1 **]/PRN prophylactic for invasive/dental
procedures
Discharge Medications:
1. Outpatient [**Name (NI) **] Work
Pt/INR for atrial fibrillation with goal INR 2.0-2.5. Results
to Dr [**Last Name (STitle) 17887**] office [**Telephone/Fax (1) 99894**] First draw sunday [**2122-10-11**]
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Digoxin 125 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. Levoxyl 50 mcg Tablet Sig: One (1) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ethacrynic Acid 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): take 2 times per day for 10 dasy then decrease to
once daily ongoing.
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
11. Coumadin 1 mg Tablet Sig: as directed Tablet PO once a day:
take as directed by Dr. [**Last Name (STitle) 17887**] based on INR goal 2-2.5
.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Mitral Stenosis s/p MVR
Rheumatic Fever
Atrial Fibrillation
Hyperlipidemia
Left Breast CA
GERD
Gastric polyps
[**Doctor Last Name 9376**] Disease
Right ankle fracture
Hypothyroid-new
S/P Mitral valve commissurotomy [**2094**] at [**Hospital1 **] with Dr. [**First Name (STitle) **]
s/p lumpectomy and XRT for L breast CA [**2108**]
Cholecystectomy
Uterine Suspension with lysis of colon adhesions
Appendectomy
Tonsillectomy
R eye cataract surgery
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming
Monitor wounds for infection and report any redness, warmth,
swelling, tenderness or drainage
Please take temperature each evening and Report any fever 100.5
or greater
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month 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 wear bra to reduce pulling on incision, avoid rubbing on
lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr [**Last Name (STitle) 17887**] in [**2-6**] weeks [**Telephone/Fax (1) 6699**]
Cardiologist Dr [**Last Name (STitle) **] in [**2-6**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Pt/INR for atrial fibrillation with goal INR 2.0-2.5. Results
to Dr [**Last Name (STitle) 17887**] office [**Telephone/Fax (1) 99894**] First draw sunday [**2122-10-11**]
Completed by:[**2122-10-10**]
ICD9 Codes: 4168, 2859, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2733
} | Medical Text: Admission Date: [**2168-3-4**] Discharge Date: [**2168-3-15**]
Date of Birth: [**2125-7-23**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Gentamicin
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Metastatic ocular melanoma to the liver
Major Surgical or Invasive Procedure:
[**2168-3-4**]: Extended right hepatic lobectomy, cholecystectomy,
anastomosis of left portal vein to main portal vein, portal vein
thrombectomy, Roux-en-Y hepaticojejunostomy to the left hepatic
duct and intraoperative ultrasound.
History of Present Illness:
42-year-old female who underwent a proton beam therapy for an
ocular
melanoma in [**2158**]. She had recurrence in [**2163**] and again received
proton beam irradiation. She has been followed by Dr.[**Last Name (STitle) **]
[**Name (STitle) 81582**] and on [**2167-11-17**] she was noted to have an
elevated alkaline phosphatase of 189. A CT scan on [**2167-12-31**] demonstrated a 4 cm mass in the dome of the liver in the
right lobe (segment 7, 8) and a second 5 cm lesion in segment 4b
(medial segment of the left lobe). The lesion in the medial
segment is sitting close to the confluence of the right and left
portal vein but there is no involvement of the portal vein
itself. Pre-op MRI of brain was negative, and chest CT
demonstrated no evidence of pulmonary metastases. She underwent
preoperative right portal vein embolization in anticipation of
performing a right hepatic trisegmentectomy. She had significant
hypertrophy of the left lateral segment by CT scan.
Past Medical History:
HTN, metastatic ocular melanoma
PSH: C-section '[**49**], L cataract, phtoablation x 2 melnoma eye,
s/p portal vein embolization [**2-1**], right hepatic lobectomy, CCY,
Roux-n-Y hepaticojejunostomy, portal vein thrombectomy [**2168-3-4**]
Social History:
Married. Lives in Northern [**State 1727**] with husband and one son
Family History:
Mother age 77: HTN, Father age 79: HTN,stroke.
maternal grandmother died in her 90s and her paternal
grandmother also died in her 90s. Paternal grandfather died in
his 60s or 70s of an MI. Maternal grandfather died of unknown
causes.
Physical Exam:
VS: 98.2, 115/50
NCAT, EOMI, moist mucous membranes
Neck supple without anterior or posterior LAD
Tachycardia, normal S1 and S2, no M/R/G
Decreased BS at R. base markedly different from the L. base
where
she is quite clear to auscultation
soft, distended, appropriately tender along the R. upper flank.
Wound C/D/I 2 JP drains in place
No CVAT
2+ peripheral edema, warm and well perfused.
Pertinent Results:
On Admission: [**2168-3-4**]
WBC-11.8*# RBC-3.32* Hgb-10.4* Hct-29.7* MCV-90 MCH-31.4
MCHC-35.1* RDW-14.9 Plt Ct-164
PT-18.3* PTT-99.9* INR(PT)-1.7*
Glucose-153* UreaN-10 Creat-0.9 Na-139 K-5.3* Cl-104 HCO3-17*
AnGap-23*
ALT-880* AST-912* AlkPhos-30* TotBili-3.6*
Albumin-2.6* Calcium-9.0 Phos-5.1* Mg-1.9
On Discharge [**2168-3-15**]
WBC-12.8* RBC-3.18* Hgb-9.6* Hct-29.9* MCV-94 MCH-30.2 MCHC-32.1
RDW-16.3* Plt Ct-322
Glucose-109* UreaN-9 Creat-0.6 Na-136 K-3.4 Cl-101 HCO3-27
AnGap-11
ALT-111* AST-43* AlkPhos-140* TotBili-0.9
Albumin-2.2* Calcium-7.3* Phos-2.6* Mg-2.1
Brief Hospital Course:
42 y/o female with metastatic ocular melanoma who was taken to
the OR with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Extended right hepatic
lobectomy, cholecystectomy, anastomosis of left portal vein to
main portal vein, portal vein thrombectomy, Roux-en-Y
hepaticojejunostomy to the left hepatic duct and intraoperative
ultrasound. Per Dr [**Last Name (STitle) 37914**] note, at the time of exploration, she
had a large mass in the dome of the liver that was adherent and
superficially growing into the right hemidiaphragm. This
lesion was easily separated from the diaphragm and a small
portion of the fibrous portion of the diaphragm removed without
entering the right chest. There was a large amount of necrotic
tumor in the segment VIII mass. Ultrasound also
demonstrated the lesion in the medial segment of the left lobe.
No other lesions were seen in the left lateral segment.
This was a complicated surgery, she received 9000 mL of
crystalloid, 9 units of packed red cells, 1250 mL of albumin,
1000 mL of Hespan, 1 unit fresh frozen and made 1100 mL of
urine. Estimated blood loss was 5000 mL. She was transferred to
the SICU for initial post op management. Please see the op note
for surgical detail.
She received an additional 5 units of RBCs while in the SICU,
and the her Hct remained stable for the rest of the
hospitalization.
On POD 1 an ultrasound was obtained as liver enzymes bumped
significantly to the 3000-4000 range. The ultrasound showed
appropriate waveforms in the left portal
vein, which is patent. Limited waveforms of the left hepatic
artery appear
normal. There is no fluid collection or ascites. IMPRESSION:
Expected post-trisegmentectomy appearance of the left lobe of
the liver.
The liver enzymes started to trend down by POD 2 and continued
to do so throughout the hospitalization. Although not normal
they were much improved by day of discharge.
She was transferred to the regular surgical floor on POD 3.
Morphine dosing was backed down for oversedation. She was then
able to start working with PT, start taking POs with good
tolerance and having return of bowel function.
JP medial drain had around 400 cc output, lateral drain was
always less than 100.
A T tube cholangio was done on POD 10 showing contrast filling
the jejunostomy loop. The tip of the T-tube is directed away
from the biliary system and has likely been dislodged. No
extravasation of contrast was seen. The drain was capped.
The lateral drain was removed, the medial drain was left to JP
bulb drainage.
Of note, the biopsy revealed:
Liver, right lobe: Metastatic melanoma, extending to within 1 mm
of posterior resection margin.
Diaphragmatic nodule: Metastatic melanoma.
The patient was discharged to a local hotel with VNA coverage as
they live in northern [**State 1727**].
Medications on Admission:
Lisinopril 20QD, Cyclopentolate 1 drop OS QWK, Brimonidine 1
drop OS [**Hospital1 **]
Lasix 40QD, Potassium 2meq QD, CaCO3 1000BID, Tylenol 325prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Limit to 7 tablets daily.
2. Cyclopentolate 1 % Drops Sig: One (1) Drop Ophthalmic 1X/WEEK
(SA).
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed).
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-25**]
Drops Ophthalmic PRN (as needed).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO every 4-6 hours as needed for pain: Hold
for sedation.
Disp:*25 Tablet Sustained Release(s)* Refills:*0*
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO twice a day as needed for take away from
mealtime.
9. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
8 days.
Disp:*8 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Metastatic ocular melanoma to the liver.
Discharge Condition:
Good/Stable
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever > 101,
chills, nausea, vomiting, increased abdominal pain, yellowing of
skin or eyes, inability to take or keep down food, fluids or
medications
Drink enough fluids to keep urine light yellow in color
Use nutritional supplements such as Ensure if you are not taking
enough calories
Monitor for sedation if taking pain meds
You may use up to two grams of Tylenol daily for pain control
No heavy lifting
Monitor incision for redness, drainage or bleeding. Call if the
incision starts putting out more drainage. You may keep a
dressing on to be changed at least once daily
Drain and record the JP drain output. Twice daily and more often
as needed. Report to Dr [**Last Name (STitle) 4727**] office if it gets more green in
color, develops a foul odor or gets cloudy. Bring a record of
drain output with you to your clinic visit next week.
Keep the Roux tube coiled and under a dressing to prevent
pulling
[**Month (only) 116**] shower. Change dressings post. Do not allow drains to hang
without support
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2168-3-23**]
2:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2168-3-24**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2734
} | Medical Text: Admission Date: [**2167-8-18**] Discharge Date: [**2167-8-24**]
Date of Birth: [**2113-6-6**] Sex: F
Service: NEUROLOGY
Allergies:
Aspirin / Penicillin G / Shellfish Derived
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
initially N/V, vertigo; transferred from [**Hospital1 3278**] for management fo
HTN
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The pt is a 54 year-old right handed woman with a past
medical history significant for HTN and recent admission to
[**Hospital1 3278**]
with a right cerebellar hemorrhage who presents with difficult
to
control blood pressure. The patient was in town for a business
convention on [**2167-8-4**] when she had sudden onset of nausea,
vomiting and vertigo. She presented to [**Hospital 3278**] Medical Center
where
she was found to have a right cerebellar hemorrhage. The
etiology
of the hemorrhage was felt to be hypertensive as vascular
malformation or neoplastic disease was visualized on MRI/A or
CTA
imaging. On admission to [**Hospital1 3278**] she was already taking HCTZ and
diovan. After discharged metoprolol XL 200mg daily was added.
The hospitalization was complicated by a UTI for which she is
still being treated with ciprofloxacin 500mg [**Hospital1 **] until [**2167-8-23**].
She also had an NSTEMI with peak enzymes on [**2167-8-6**] of CK - 155
MB - 10.1 TpI 2.3. An EKG demonstrated LAE, LVH, and possible
anterior ST-segment elevation, but this too may have been LVH.
An
ECHO only showed concentric LVH and mild AV thickening. A CXR
was
suspicious for vascular congestion and another was read as
possibly showing a LLL PNA.
Since discharge the patient has felt "disoriented" by which she
means that she knows what she is doing, but has a poor memory of
recent events. She feels apathetica and somewhat detached. She
is
also feeling anxious, which she attributes to her quiting
tobacco
as part of this recent illness.
Recently the patient was visited by her cousin, Dr. [**First Name (STitle) **] who was
a
fellow of Dr.[**Name (NI) 5255**], in the neurology department. Dr. [**First Name (STitle) **]
actually faciliated a clinic visit with Dr. [**Last Name (STitle) 1693**] today who
detected elevated blood pressure and sent the patient here for
admission to facilitate blood pressure management prior to [**Last Name (un) 1292**]
return to the West Coast. Of note the patient's blood pressure
as
measured at home by another cousin was 180/90.
ROS
Besides what is noted above the patient endorsed dysuria
The patient denied HA, visual difficulty, hearing changes,
difficulty speaking, language problems, difficulty swallowing,
dizziness, lightheadedness or vertigo, unsteady gait,
paresthesias, sensory loss, weakness, or falls.
The patient denied fever, wt loss, appetite changes, cp,
palpitations, DOE, sob, cough, wheeze, nausea, vomiting,
diarrhea, constipation, abd pain, fecal incont, dysuria,
nocturia, urinary incontinence, muscle or joint pain, hot/cold
intolerance, polyuria, polydipsia, easy bruising, depression,
anxiety, stress, or psychotic sx.
Past Medical History:
HTN
Social History:
Married. Lives in [**Location 79411**], CA.
Smoked 1 ppd prior to recent presentation to [**Hospital1 3278**].
NO ETOH, NO Drugs.
Family History:
Maternal aunt - aneurysm.
[**Name2 (NI) **] hx of stroke or seizure
Physical Exam:
Vitals: T:98.6 P:64 R:15 BP:238/93 SaO2:97% RA
General: Somewhat slow to answer questions. She is somewhat
lethargic. NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Somewhat slow to answer questions. Oriented to
ED, [**University/College **], [**8-16**] (incorrect). Didn't know that this was
[**Hospital1 18**]. Unable to relate history without difficulty. Inattentive,
unable to name [**Doctor Last Name 1841**] backward without difficulty. Language is
fluent with intact repetition and comprehension. Normal prosody.
There were no paraphasic errors. Pt. had some difficulty naming
high and low frequency objects - she names a stethoscope,
fingers, knuckles, and a pen. She could not name a pen cap or a
watch. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall [**2-12**] at 5
minutes. The pt. had good knowledge of current events. There was
no evidence of apraxia or neglect.
-Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and brisk.
VFF to confrontation. There is no ptosis bilaterally.
Funduscopic
exam revealed no papilledema, exudates, or hemorrhages. EOMI
without nystagmus. Normal saccades. Facial sensation intact to
pinprick. No facial droop, facial musculature symmetric. Hearing
intact to finger-rub bilaterally. Palate elevates symmetrically.
5/5 strength in trapezii and SCM bilaterally. Tongue protrudes
in
midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
C5 C6 C7 C8/T1 L2 L3 L4/S1 L4 L5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
C5 C7 C6 L4 S1
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
[**2167-8-22**] 07:00AM BLOOD WBC-6.5 RBC-4.48 Hgb-13.1 Hct-38.4 MCV-86
MCH-29.2 MCHC-34.0 RDW-13.5 Plt Ct-388
[**2167-8-21**] 04:58AM BLOOD WBC-7.0 RBC-4.36 Hgb-12.6 Hct-37.5 MCV-86
MCH-28.9 MCHC-33.6 RDW-13.5 Plt Ct-376
[**2167-8-20**] 05:20AM BLOOD WBC-8.1 RBC-4.22 Hgb-12.8 Hct-36.2 MCV-86
MCH-30.3 MCHC-35.4* RDW-13.5 Plt Ct-359
[**2167-8-19**] 04:50AM BLOOD WBC-7.6 RBC-4.26 Hgb-12.7 Hct-36.0 MCV-85
MCH-29.8 MCHC-35.2* RDW-13.3 Plt Ct-380
[**2167-8-17**] 07:20PM BLOOD WBC-8.3 RBC-4.64 Hgb-14.0 Hct-39.3 MCV-85
MCH-30.2 MCHC-35.6* RDW-13.5 Plt Ct-350
[**2167-8-17**] 07:20PM BLOOD Neuts-60.2 Lymphs-31.7 Monos-5.5 Eos-1.9
Baso-0.6
[**2167-8-22**] 07:00AM BLOOD Plt Ct-388
[**2167-8-21**] 04:58AM BLOOD Plt Ct-376
[**2167-8-20**] 05:20AM BLOOD Plt Ct-359
[**2167-8-19**] 04:50AM BLOOD Plt Ct-380
[**2167-8-17**] 07:20PM BLOOD Plt Ct-350
[**2167-8-17**] 01:24AM BLOOD PT-12.3 PTT-29.5 INR(PT)-1.0
[**2167-8-22**] 07:00AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-144
K-3.9 Cl-108 HCO3-26 AnGap-14
[**2167-8-21**] 04:58AM BLOOD Glucose-97 UreaN-9 Creat-0.7 Na-144 K-4.1
Cl-110* HCO3-26 AnGap-12
[**2167-8-20**] 05:20AM BLOOD Glucose-127* UreaN-11 Creat-0.7 Na-143
K-4.0 Cl-110* HCO3-26 AnGap-11
[**2167-8-19**] 04:50AM BLOOD Glucose-97 UreaN-11 Creat-0.7 Na-142
K-4.1 Cl-109* HCO3-27 AnGap-10
[**2167-8-17**] 07:20PM BLOOD Glucose-118* UreaN-11 Creat-0.6 Na-144
K-4.2 Cl-105 HCO3-30 AnGap-13
[**2167-8-18**] 06:37AM BLOOD CK(CPK)-48
[**2167-8-17**] 07:20PM BLOOD CK(CPK)-48
[**2167-8-18**] 06:37AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2167-8-17**] 07:20PM BLOOD cTropnT-0.01
[**2167-8-22**] 07:00AM BLOOD Calcium-9.4 Phos-4.7* Mg-2.0
[**2167-8-21**] 04:58AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.9
[**2167-8-20**] 05:20AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.9
[**2167-8-19**] 04:50AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.1
[**2167-8-17**] 07:20PM BLOOD Calcium-9.3 Phos-3.8 Mg-2.3
Brief Hospital Course:
This 54 yo F initially presented with nausea, vomiting, and
vertigo to [**Hospital1 3278**] meidcal Center and was found to have a right
cerebellar hemorrrhage. Prior to admission to [**Hospital1 3278**] she was
already taking HCTZ and diovan. After discharge metoprolol XL
200mg daily was added.
That hospitalization was complicated by a UTI for which she
was treated with ciprofloxacin 500mg [**Hospital1 **] until [**2167-8-23**].
She also had an NSTEMI with peak enzymes on [**2167-8-6**] of CK - 155
MB - 10.1 TpI 2.3. An EKG demonstrated LAE, LVH, and possible
anterior ST-segment elevation, but this too may have been LVH.
An
ECHO only showed concentric LVH and mild AV thickening. A CXR
was
suspicious for vascular congestion and another was read as
possibly showing a LLL PNA.
Here at [**Hospital1 18**], pt was initially admitted to the neuro ICU
and placed on a labetalol gtt to control her pressures, which
were as high as the 200's systolically. Over the course of days,
an oral regimen was initiated that included adding oral
Labetalol which was titrated up as required. When her systolic
blood pressures were maintained on an oral regimen under SPB
160, she was transferred to the stroke floor. There, her BP
regimen was refined further, and we found that adding
Hydralazine 37.5 mg Q6hrs kept her systolic blood pressure
generally in a range of 110-140. On exam, she continues to have
some mild dysmetria on FNF b/l, but worse on right. She has no
headaches and is able to ambulate. She was discharged to a hotel
on [**2167-8-24**] with a plan for one checkup of her BP with Dr. [**Last Name (STitle) 1693**]
before returning to CA.
Medications on Admission:
Simvastatin 40 daily
Diovan 320 daily
HCTZ 25 daily
Toprol XL 200 daily
Percocet 5/325 1-2tab q4h PRN pain
Cipro 500mg [**Hospital1 **] to stop on [**2167-8-23**]
Discharge Medications:
1. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
Disp:*60 Capsule(s)* Refills:*2*
3. Labetalol 100 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
Disp:*450 Tablet(s)* Refills:*2*
4. Hydralazine 25 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Right cerebellar hemorrhage.
Discharge Condition:
stable
Discharge Instructions:
You have had a right cerebellar hemorrage, likley secondary to
significant uncontrolled hypertension.
Please call Dr [**Last Name (STitle) 1693**] before you return to [**State 4565**] # ([**Telephone/Fax (1) 79412**]. He will have you get your blood pressure checked
either at [**Hospital 4415**] or here at [**Hospital1 18**] before you
fly home.
Followup Instructions:
Please call Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 79413**] office to schedule a Neurology
Appointment: ([**Telephone/Fax (1) 79414**]
Please call Dr [**Last Name (STitle) 1693**] before you return to [**State 4565**] # ([**Telephone/Fax (1) 79412**].
Call your PCP Dr [**First Name (STitle) **] #[**Telephone/Fax (1) 79415**] to schedule a follow up appt.
Completed by:[**2167-8-24**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2735
} | Medical Text: Admission Date: [**2200-9-23**] Discharge Date: [**2200-9-28**]
Date of Birth: [**2141-2-13**] Sex: F
Service: CCU
CHIEF COMPLAINT: Chest pain with nausea and vomiting.
HISTORY OF PRESENT ILLNESS: This is a 59 year old woman with
a history of hypertension and borderline hypercholesterolemia
who presents complaining of shoulder and arm pain that
nausea and vomiting. She was noted to awake from sleep with
ten out of ten substernal chest pain described as heavy
pressure with shortness of breath radiating to her left
shoulder and arm and she went to [**Hospital3 **], given two
sublingual Nitroglycerin and started on Aspirin, Aggrestat,
Heparin and oxygen with a decrease in her symptoms with her
pain rated as a two out of ten. She was noted to be
[**Hospital1 69**] for emergent
catheterization.
She was noted to have similar symptoms of left sided chest
pain and shortness of breath, nausea and vomiting
approximately one week ago rated two to three out of ten
while at work. She felt better after vomiting and left work
while feeling fatigued. These episodes of chest pain are now
new for her and seemingly unrelated to exertion. She is
currently chest pain free, denies shortness of breath or
palpitations, but continues with nausea.
Initial cardiac catheterization revealed cardiac output of
6.14, cardiac index of 3.77, wedge of 17, right atrial
pressure of seven, right ventricular pressure of 29/4,
pulmonary artery pressure of 26/15. Left ventriculogram
revealed mitral regurgitation with low normal ejection
fraction with inferobasal hypokinesis. Right dominant
system, 85% proximal lesion in the left anterior descending,
40% lesion in the left circumflex at the origin. The right
common artery was tortuous with a distal occlusion and distal
vessel comprised of two small diffuse diseased vessels that
were unable to stent.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypothyroidism.
3. Increased lipids.
MEDICATIONS ON ADMISSION:
1. Avapro 150 mg p.o. once daily.
2. Synthroid 112 mcg p.o. once daily.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient smokes approximately for twenty
plus pack years, currently smoking one pack every other day.
She denies any alcohol or intravenous drug abuse. She is
divorced and has five kids and lives in [**Location 43901**] and works at
[**Company 39532**].
FAMILY HISTORY: Significant for colon cancer and Alzheimer's
disease. No coronary artery disease.
REVIEW OF SYSTEMS: She denies currently fever, chills,
headaches, eye pain, ear pain, dysphagia and abdominal pain,
melena, hematochezia or myalgias.
PHYSICAL EXAMINATION: On admission, temperature was 98.4,
blood pressure 99/42, heart rate 67, respiratory rate 20, 98%
oxygen saturation on two liters nasal cannula. In general,
she appears comfortable, sleeping on the stretcher. Head,
eyes, ears, nose and throat - The pupils are equal, round,
and reactive to light and accommodation. Extraocular
movements are intact. Normocephalic and atraumatic. Mucous
membranes are moist. She has dentures. Her oropharynx is
pink and moist. The neck revealed no lymphadenopathy, flat
neck veins, no carotid bruits and 2+ carotid pulses
bilaterally. The lung examination was clear to auscultation
bilaterally, no wheezes, rales or rhonchi. Cardiovascular
examination reveals S1 and S2, regular rate, II/VI systolic
murmur at the right upper sternal border which is
nonradiating, no rubs or gallops. Abdominal examination -
bowel sounds present, soft, nontender, nondistended, no
guarding, tenderness or rebound, no masses palpated, no
hepatosplenomegaly. Groin revealed no hematoma and no
femoral bruit. Extremity examination revealed warm
extremities, no cyanosis, clubbing or edema, 2+ dorsalis
pedis pulses bilaterally.
LABORATORY DATA: White blood cell count 7.2, hematocrit
32.5, platelets 298,000. Sodium 138, potassium 4.3, chloride
104, CO2 22, blood urea nitrogen 21, creatinine 0.7, glucose
185. CPK at outside hospital was 348; at 8:00 p.m. on
arrival to hospital was 386 with a MB fraction of 36.
Electrocardiogram on admission revealed normal sinus rhythm,
rate 54 beats per minute, normal QRS axis, borderline left
ventricular hypertrophy, good R wave progression, PR interval
of 0.15, QRS 0.09, Q waves found in leads II, III and aVF,
flipped T waves in II, III, aVF, V5 and V6, approximately 1.[**Street Address(2) 27948**] elevations in II and aVF.
HOSPITAL COURSE:
1. Cardiovascular - The patient was taken to emergent
cardiac catheterization but was unable to stent the right
coronary artery. The proximal lesion found in the left
anterior descending was initially left alone. She was
started on an Aspirin and Lipitor as well as a low dose ace
inhibitor and beta blocker. However, the patient continued
to experience mild to moderate episodes of nausea and
vomiting as well as recurrent chest and shoulder pain. She
was brought back to the cardiac catheterization laboratory
and the proximal left anterior descending lesion was stented
and her symptoms of nausea and shoulder pain resolved. An
echocardiogram after her second catheterization revealed an
ejection fraction of 55%, mildly dilated left atrium, mild
regional left ventricular systolic dysfunction with focal
akinesis of the basal third of the inferior wall, mild aortic
regurgitation, trivial mitral regurgitation and no
pericardial effusion was present. Her ace inhibitor and beta
blocker were titrated upwards. She did continue to experience
mild left shoulder pain usually present in the morning that
was alleviated with a combination of Tylenol and sublingual
Nitroglycerin. Imdur 30 mg was started for long acting
anginal control. Her ace inhibitor and beta blocker were
changed to once daily dosing. These episodes of shoulder
pain and mild nausea were not accompanied by
electrocardiographic changes. Her CPK peaked at 633 with a
MB fraction of 55 and a troponin greater than 50. These
cardiac enzymes down trended throughout the remainder of her
hospital admission and she appeared stable for discharge on
hospital day number five. She is to follow-up with her
primary care physician in regards to choosing a cardiologist
as well as pursuing an outpatient cardiac rehabilitation
program.
2. Hematology - The patient was noted to have a baseline
hematocrit of 32.0 which down trended after her cardiac
catheterization. She was transfused two units throughout her
hospital admission and her hematocrit remained stable
thereafter and she had no transfusion complications.
3. Pulmonary/Infectious Disease - The patient was noted to
have low grade temperature after her second cardiac
catheterization. Blood cultures, urine cultures, chest x-ray
were sent in regards to finding a possible infectious
etiology of her temperatures. Her blood cultures were no
growth to date at the time of this dictation. Her urine
cultures were no growth to date at the time of dictation.
Her urinalysis was normal with slight leukocyte esterase, [**3-25**]
white blood cells and occasional bacteria. She was not
complaining of dysuria at this time. Chest x-ray revealed no
infiltrates. It was felt that this low grade temperature was
secondary to atelectasis, and her fever grade remained low
grade and incentive spirometry was encouraged. She will be
afebrile for approximately 24 hours prior to discharge.
CONDITION ON DISCHARGE: Deceased.
DISCHARGE STATUS: Deceased.
Addendum: The patient on the day prior to discharge became
unresponsive with code called. The patient was attempted to be
resuscitated but all attempts failed. Initial rhythm was
pulseless electrical activity and despite maximal measures
including temporary ventricular pacing, ACLS protocols and urgent
echocardiography (to rule out pericardial effusion) the patient
could not be resuscitated.
MEDICATIONS ON DISCHARGE:
1. Atenolol 12.5 mg p.o. once daily.
2. Lisinopril 20 mg p.o. once daily.
3. Atorvastatin 20 mg p.o. once daily.
4. Levoxyl 112 mcg p.o. once daily.
5. Plavix 75 mg p.o. once daily for thirty days.
6. Aspirin 325 mg p.o. once daily.
7. Imdur 30 mg p.o. once daily.
DISCHARGE DIAGNOSES:
1. Acute inferior myocardial infarction, status post left
anterior descending stent. s/p cardiac arrest without ability
to resuscitate.
2. Anemia requiring transfusion.
3. Atelectasis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2200-9-27**] 10:53
T: [**2200-10-5**] 10:19
JOB#: [**Job Number 43902**]
ICD9 Codes: 4275, 5180, 3051, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2736
} | Medical Text: Admission Date: [**2106-11-4**] Discharge Date: [**2106-11-9**]
Date of Birth: [**2023-2-21**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
Colonoscopy
Blood transfusions
History of Present Illness:
Ms. [**Known lastname **] is an 83 y/o woman with PMH notable for type 2 DM,
hypertension, and recent NSTEMI who presented to the ER after
several episodes of bright red blood per rectum starting last
evening. The patient states that she went to move her bowels and
noted bright blood in the toilet; she has a history of
hemorrhoids but this typically presents as red blood on toilet
tissue. She noted several more stools filling the toilet bowl
with bright red blood. She also noted some clots. She noted
dizziness per ED notes but denies this to me. She also reports
fatigue.
.
On arrival to the ED, the patient's initial VS were T 98.8, HR
84, BP 156/79, RR 16, 100% on RA. On exam, there was no evidence
of obvious bleeding hemorrhoid but there was bright red blood on
rectal exam. Two 18 g PIVs were placed. Hematocrit was found to
decrease from recent 31 --> 26 and 23. GI was contact[**Name (NI) **] and
their recommendations are pending. He is now admitted to the
MICU for further workup.
.
On arrival to the MICU, the patient's first unit of PRBCs is
hanging. She denies any abdominal pain, chest pain, difficulty
breathing, or dizziness. She endorses some rectal pain,
especially when moving her bowels last night.
Past Medical History:
NSTEMI (diagnosed during admission [**9-1**])
* DM type II (recent admit for hypoglycemia, glipizide stopped)
* Mild-moderate diabetic retinopathy
* HTN
* Arthritis
* Cataracts
Social History:
Patient was born in [**Country **]. Moved to the United States in [**2075**].
Currently living with her daughter. Previously worked as a
housekeeper at [**Hospital 13128**]. Denies tobacco/EtOH.
Family History:
Son in good health.
Physical Exam:
PE: T: 98.5 BP: 172/70 HR: 83 RR: 18 O2 98% RA
Gen: Pleasant elderly female in no distress, lying in bed
HEENT: no scleral icterus, L pupil large but reactive, R pupil
reactive
NECK: supple, JVP at 7 cm, no lymphadenopathy
CV: rrr, 2/6 systolic murmur at LUSB
LUNGS: clear bilaterally, no wheezing or rhonchi
ABD: soft, hypoactive bowel sounds, nontender throughout
EXT: warm, trace pitting edema bilateral LE, dp pulses 1+
bilaterally
SKIN: no rashes
NEURO: alert & oriented to self, place not oriented to time,
speech somewhat difficult to understand given dentures out &
accent, face symmetric, moving all extremities
.
Pertinent Results:
[**2106-11-4**] 08:30AM CALCIUM-8.9 PHOSPHATE-2.9# MAGNESIUM-1.8
[**2106-11-4**] 08:30AM CK-MB-NotDone cTropnT-<0.01
[**2106-11-4**] 08:30AM CK(CPK)-44
[**2106-11-4**] 08:30AM estGFR-Using this
[**2106-11-4**] 08:30AM GLUCOSE-297* UREA N-38* CREAT-1.0 SODIUM-136
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11
[**2106-11-4**] 08:55AM freeCa-1.07*
[**2106-11-4**] 08:55AM HGB-8.8* calcHCT-26
[**2106-11-4**] 08:55AM GLUCOSE-277* LACTATE-1.5 NA+-137 K+-5.4*
CL--101
[**2106-11-4**] 08:55AM PH-7.47* COMMENTS-GREEN TOP
[**2106-11-4**] 09:15AM PT-12.7 PTT-23.0 INR(PT)-1.1
[**2106-11-4**] 09:15AM PLT COUNT-240
[**2106-11-4**] 09:15AM NEUTS-63.6 LYMPHS-29.2 MONOS-4.3 EOS-2.9
BASOS-0.1
[**2106-11-4**] 09:15AM WBC-4.1 RBC-2.61*# HGB-7.7*# HCT-22.3*#
MCV-85 MCH-29.5 MCHC-34.7 RDW-13.2
[**2106-11-4**] 09:15AM cTropnT-<0.01
.
.
Colonoscopy [**2106-11-8**]:
Diverticulosis of the whole colon
Polyp in the proximal ascending colon (polypectomy)
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
Ms. [**Known lastname **] is an 83 year old woman with a history of diabetes,
hypertension, and recent NSTEMI in setting of hypoglycemia who
was admitted with multiple episodes of bloody stools.
.
During this hospitalization the following issues were addressed.
.
# GI bleeding: The pt was admitted to the MICU initially with
bright red blood per rectum. In the MICU, the patient received 5
units of packed red blood cells. She was unable to tolerate a
Golytely prep and was unable to have colonoscopy on [**11-5**]. She
had an incomplete tagged RBC scan that was unable to be
completed as the pt was unable to tolerate the duration of the
exam. On [**11-7**] the pt was able to complete a Golytely prep and
underwent colonoscopy on [**11-8**]. Colonoscopy revealed diffuse
diverticulosis and one benign-appearing polyp. There was no
active bleeding during the colonoscopy. The pt's hematocrit
remained stable for 24 hours following colonscopy and the pt was
discharged with instructions to return to the ED if she
experience any additional bleeding per rectum.
.
# Recent NSTEMI: On the pt's recent [**9-1**] admission for
hypoglycemia the patient had a cardiac enzyme elevation. On this
admission the pt's EKG was unchanged and she had no overt
symptoms of ischemia. Because of the pt's heart disease the pt
was transfused with goal hematocrit of 28. The pt had negative
cardiac enzymes and the pt's aspirin was discontinued due to GI
bleeding. The pt was instructed not to take aspirin for 10 days
following colonoscopy.
.
# Type 2 diabetes: The pt was monitored on sliding scale insulin
during this admission. She was discharged on her home dose of
metformin.
.
# Hypertension: The pt's beta-blocker was discontinued during
this admission in order to not mask tachycardia. The pt's
losartan was continued and the pt was discharged on her home
dose of losartan and metoprolol.
.
Medications on Admission:
aspirin 325 mg daily
* colace 100 [**Hospital1 **] prn
* ibuprofen prn
* losartan 100 mg daily
* metformin 500 mg [**Hospital1 **]
* toprol XL 25 mg daily
* pravastatin 40 mg daily
* tylenol prn
* timolol 0.5% eye gtt twice daily to left eye
* isopto hyoscine eye drops to left eye
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain.
2. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Glucophage XR 500 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO twice a day.
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis: Diverticulosis, gastrointestinal bleeding
.
Secondary diagnosis: Hypertension, diabetes
Discharge Condition:
Stable, able to breathe comfortably on room air, able to
ambulate with walker.
Discharge Instructions:
You were admitted with gastrointestinal bleeding and you were
found to have anemia because of blood loss. During this
admission you received 5 blood transfusions and you had a
colonoscopy that showed multiple diverticuli that may have
caused the bleeding. You also had a small polyp that was
benign-appearing that was removed. During the remainder of this
admission you did not experience any more bleeding.
.
.
All of your home medications have been continued except for
aspirin. Please do not take aspirin for the next 10 days. Please
take all of you other medications as directed. We have added a
medication called omeprazole for stomach acid. Please take this
medication every day.
.
.
Below are your follow up appointments. Please make sure that you
attend your follow up appointments as they are very important
for your long-term health.
.
Please go to the emergency room or call your primary care doctor
if you develop headaches, nausea, vomiting, weakness or
numbness, are
unable to tolerate food or liquids, fever > 100.4, chills,
shortness of breath, chest pain, or experience any other
bleeding in your bowel movements or any other concerning
symptoms.
Followup Instructions:
Gerontology follow up:
Provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2983**] Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2106-11-11**]
9:00
Primary care follow up:
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2106-12-1**] 2:00
ICD9 Codes: 2851, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2737
} | Medical Text: Admission Date: [**2165-7-28**] Discharge Date: [**2165-7-31**]
Date of Birth: [**2137-12-12**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
PT s/p single car MVC rollover
Major Surgical or Invasive Procedure:
L index finger partial amputation
Bedside debridement & irrigation of wound
History of Present Illness:
Pt was driving with EtOH on board and rolled her vehicle over,
suffered injuries to left digits and left shoulder and c spine
Social History:
EtOH
Physical Exam:
Pt was found to have L degloving injury at PIP of finger, neck
pain, and a left posterior shoulder laceration/abrasion
Pertinent Results:
[**2165-7-28**] 07:28AM WBC-13.6* RBC-3.66* HGB-11.4*# HCT-32.9*
MCV-90 MCH-31.1 MCHC-34.6 RDW-13.5
[**2165-7-28**] 02:05AM BLOOD ASA-NEG Ethanol-320* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2165-7-29**] 05:40AM BLOOD WBC-8.2 RBC-3.97* Hgb-12.2 Hct-35.3*
MCV-89 MCH-30.7 MCHC-34.5 RDW-13.3 Plt Ct-141*
[**2165-7-29**] 05:40AM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-136 K-4.0
Cl-101 HCO3-24 AnGap-15
[**2165-7-28**] 02:11AM BLOOD Hgb-14.7 calcHCT-44 O2 Sat-68 COHgb-4
MetHgb-0
Brief Hospital Course:
Patient was seen by plastics in ED, eval of finger suggested
that eventual amputation will be necessary C spine films showeda
R posterior lamina fracture with assoc transvers foramina
compression, pt was placed in a hard collar, Left shoulder films
were negative but Left shoulder was with large abrasion which
was treated with wet to dry and xeroform dressings.
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
2. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
4. Dressing supplies
Normal saline, sterile gauzes & kerlex dressing
Discharge Disposition:
Home With Service
Facility:
Community VNA of [**Location (un) 6981**]
Discharge Diagnosis:
s/p motor vehicle accident
L index finger amputation
L shoulder laceration
C5 vertebral fracture (R posterior lamina)
Discharge Condition:
Stable
Discharge Instructions:
Take medications as perscribed, wear cervical collar at all
times, follow up with orthopaedics and trauma surgery as
indicated below. Return to the Emergency Department if you have
high fevers, pain that is uncontrollable on your pain
medications. Follow Physical therapy recommendations as
indicated
Followup Instructions:
follow up with:
Plastic surgery clinic for your ultimate finger repair:
[**Telephone/Fax (1) 274**]
Orthopaedics: Dr. [**Last Name (STitle) 363**] in 2 weeks call ([**Telephone/Fax (1) 61627**] to
discuss your neck fracture
Trauma Clinic: call ([**Telephone/Fax (1) 29931**] for an appointment in 2 weeks
ICD9 Codes: 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2738
} | Medical Text: Admission Date: [**2112-5-7**] Discharge Date: [**2112-7-7**]
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old man
with a history of coronary artery disease status post
coronary artery bypass graft times three in [**2104-2-26**], hypertension, aortic insufficiency, and hiatal hernia,
who presented with postprandial epigastric pain followed by
nausea and vomiting. The patient denied any shortness of
breath, diaphoresis, palpitations. He states that this pain
is different from the pain that he had when he had his
myocardial infarction. When seen in the Emergency Room, the
patient was given aspirin, morphine, heparin, and he was
admitted to rule out myocardial infarction. The patient's
amylase and lipase were found to be elevated consistent with
pancreatitis.
PAST MEDICAL HISTORY:
1. Coronary artery bypass graft in [**2104**].
2. Hypertension.
3. Aortic insufficiency.
4. Hiatal hernia.
5. Echocardiogram with an ejection fraction of 44 to 48%.
MEDICATIONS:
1. Lopressor.
2. Aspirin.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was admitted to the Medical
Service in which care I did not partake in during that time.
The patient was seen by General Surgery for a consultation of
abdominal pain. The rest of his labs included ALT 15, AST
21, alkaline phosphatase 99, total bilirubin 0.7, amylase
111, lipase 164, albumin 3.
The patient underwent an extensive work-up which eventually
revealed that he had an obstructing lesion at the fourth part
of the duodenum and proximal jejunum at the area of the
ligament of Treitz, and therefore was taken for an
exploratory laparotomy on [**2112-5-20**]. The patient had a
exploratory laparotomy and lysis of adhesions, takedown of
splenic flexures, biopsy of peritoneal metastases,
duodenal-jejunal bypass, placement of feeding jejunostomy
tube. Please see Operative Note for further detail.
Postoperatively, the patient was admitted to the Surgical
Intensive Care Unit for a week for close cardiac monitoring.
The patient, afterwards, continued to have nausea and
vomiting. The patient had a prolonged ileus and gastroparesis
which became evident postop and likely stemmed from
longstanding duodenal obstruction as well as his age, and
physical status, which required TPN use. The patient
tolerated tube feeds well. Once TPN was discontinued the
[**Hospital 228**] hospital stay was thus characterized as slowly
progressing nutrition, p.o. and then there would be episodes
of nausea and vomiting, then the patient would start over with
tube feeds, p.o. and his feedings were slowly advanced.
UGI study showed that the contrast passed through the native
duodenum as well as the bypasss loop and upper endoscopy
showed that the duodenojejunostomy was widely patent. Thus
he was treated with reglan and erythromycin for gastroparesis
with slow improvement clinically.
His cultures while in the hospital: He had transient episode
of urinary sepsis and urine cultures at that time showed
Pseudomonas treated with IV antibiotics and then
Ciprofloxacin; a swab on [**5-30**] of a small separation and
wound infection in the upper portion of his abdominal wound
was growing out Methicillin resistant Staphylococcus aureus
and he was treated with vancomycin. The recent KUB on [**7-4**] showed no obstruction. There was plenty of stool in the
rectum. The patient's diet was slowly advanced and tolerated
a regular diet, also tolerating tube feeds well in hospital,
with Physical Therapy. The patient and his family were told of
his diagnosis and oncology consult and evaluation was
recommended. However, the patient adamantly refused. His
daughter will therefore make arrangements for follow-up by his
PCP.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcutaneously twice a day.
2. Megace 600 mg p.o. q. day for appetite.
3. Protonix 40 mg p.o. q. day.
4. Reglan 5 mg p.o. q. six.
5. Erythromycin 250 mg p.o. q. six.
6. Colace 100 mg p.o. twice a day.
7. Ciprofloxacin 500 mg p.o. q. day times five more days.
8. Flagyl 500 mg p.o. three times a day times five more
days.
9. Tube feeds, ProMod with fiber, 90 cc for 18 hours.
DISPOSITION: The patient is being sent to rehabilitation
for Physical Therapy, caloric counts, p.o. monitoring.
The patient will follow-up with Dr. [**Last Name (STitle) **] in 1 week and will
follow-up with his PCP as well.
[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**]
Dictated By:[**Name8 (MD) 6908**]
MEDQUIST36
D: [**2112-7-7**] 08:28
T: [**2112-7-7**] 09:36
JOB#: [**Job Number 6909**]
ICD9 Codes: 5990, 4241, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2739
} | Medical Text: Admission Date: [**2154-3-10**] Discharge Date: [**2154-3-18**]
Date of Birth: [**2087-8-9**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66yo PMHx COPD (on 3L home O2), morbid obesity, dCHF who
presents w fever and cough. Patient reports that 1 wk prior to
presentation, she developed malaise and decreased appetite
without associated symptoms. 5d prior to presentation, she
developed fever/chills (tmax 102.6), productive cough (reports
"peanut butter" like sputum) and SOB. Patient reports
associated HA, malaise, myalgias. Denies associated N/V, chest
pain, BRBPR/melena/diarrhea/constipation. Denies recent travel,
but lives in [**Hospital3 **] and reports many sick contacts.
.
In ED, initial vital signs were 100.5 108 136/76 20 92% 10Lneb.
Exam signficant for diffuse crackles, absence of LE edema. Labs
were significant for WBC 8.7 (N77, 3Bands), Na134, K4.4, Cl86,
HCO3 36, Cr0.9, BUN19, ALT 40, AST 46. UA with many bacteria,
8WBCs, 5 epi's. CXR demonstrated bilateral pleural effusions w
atelectasis. EKG unchanged from prior. Patient placed on
Bipap, given levofloxacin and 40mg IV lasix with improved O2
requirement to 5L. Patient initially planned for floor
admission, but concerns regarding high O2 requirement. On
re-evaluation, patient reporting increased shortness of breath
with abdominal discomfort. CTA torso demonstrated no PE,
multifocal PNA (lingula, LUL, and RLL), R ventral hernia, no
acute process in the abd/pelvis. Patient was given CTX +
vancomycin and planned for admission to ICU.
.
Prior to transfer, most recent vitals were 102.7 98 106/62 28
93%6L
.
On arrival to the ICU initial vital signs were 99.4 88 102/60 18
91%6L, pleasant and breathing comfortably. She confirmed above
history and reported review of systems as below.
.
Review of systems:
(+) Per HPI
(-) Denied night sweats, recent weight loss or gain, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies rashes or skin changes.
Past Medical History:
- COPD (2LNC @ baseline)
- Obstructive sleep apnea on home CPAP
- dCHF (EF75%)
- Mild aortic stenosis
- HTN
- HLD
- DMII
- Psoriasis
- h/o GI bleed of uncertain etiology ([**2-/2153**])
Social History:
Lives in Listen Towers, [**Hospital3 **] facility; she is
unemployed and on disability. Prior to this she worked in
freight airline business. She quit smoking 10 yrs ago but prior
to that she smoked 2ppd for last 2 yrs and prior to that 1ppd
for 30 yrs. She denies Etoh and illicit drug use and abuse.
Family History:
She is an adopted child
Physical Exam:
Admission Physical Exam:
Vitals: 99.4 88 102/60 18 91%6L
General: AOx3, no acute distress
HEENT: MMM, oropharynx clear, supple, no lymphadenopathy
Neck: Supple, JVP not elevated, no LAD
Lungs: Ronchi at bases bilaterally, no wheezes/rales, no use of
accessory muscles
CV: Regular rate and rhythm, II/VI systolic murmur loudest at
RUSB
Abdomen: naBSx4, +obese, +mild tenderness in LUQ, large RLQ
hernia +reducible, no rebound/guarding
GU: +foley
Ext: 1+ edema at hips and upper thighs, WWP 2+ DP/PT/radial
pulses, no clubbing/cyanosis
Derm: Scaly patch over L knee
.
Discharge Exam:
98..0 134/78 85 18 94 on 3L
Lungs: No appreciate rales
Extr: No edema
Pertinent Results:
Admission Labs:
[**2154-3-10**] 09:10PM BLOOD WBC-8.7# RBC-3.87* Hgb-10.9* Hct-33.6*
MCV-87# MCH-28.1 MCHC-32.4 RDW-14.2 Plt Ct-180
[**2154-3-10**] 09:10PM BLOOD Neuts-77* Bands-3 Lymphs-9* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-1*
[**2154-3-10**] 09:10PM BLOOD Glucose-150* UreaN-19 Creat-0.9 Na-134
K-4.4 Cl-86* HCO3-36* AnGap-16
[**2154-3-10**] 09:10PM BLOOD ALT-40 AST-46* AlkPhos-64 TotBili-0.5
[**2154-3-10**] 09:10PM BLOOD Lipase-16
[**2154-3-10**] 09:10PM BLOOD cTropnT-<0.01
[**2154-3-10**] 09:10PM BLOOD proBNP-181
[**2154-3-10**] 09:10PM BLOOD Albumin-3.6
[**2154-3-10**] 09:34PM BLOOD Lactate-2.0
URINE:
[**2154-3-11**] 10:36AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.043*
[**2154-3-11**] 10:36AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2154-3-11**] 10:36AM URINE RBC-97* WBC-12* Bacteri-NONE Yeast-OCC
Epi-2
MICRO:
Blood cultures ([**3-10**]): pending
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
urine legionella: negative
[**2154-3-11**] 10:36 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2154-3-11**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
[**2154-3-12**] 12:25 pm Influenza A/B by DFA
Source: Nasopharyngeal swab.
**FINAL REPORT [**2154-3-12**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2154-3-12**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2154-3-12**]):
Negative for Influenza B.
Respiratory Viral Culture (Pending):
IMAGING:
CXR ([**2154-3-10**]):
FINDINGS: Single semi-erect AP portable view of the chest was
obtained.
There are low lung volumes. Previously seen right PICC is no
longer
identified. There is also removal of a previously seen
nasogastric tube.
There are likely bilateral pleural effusions, left greater than
right, with overlying atelectasis, there is also perihilar
vascular prominence, more so on the left than the right, raising
concern for asymmetric pulmonary edema. The cardiac silhouette
is difficult to assess due to the bibasilar opacities.
Mediastinal contours are slightly less prominent as compared to
the prior study.
CT Torso w/ Contrast:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Multifocal pneumonia predominating the lingula, also
involving the left
upper lobe and right lower lobe, with likely reactive
prevascular
lymphadenopathy.
3. Fatty liver.
4. Stable elevation of the right hemidiaphragm.
5. Right ventral hernia containing nondilated bowel loops.
However, the
extreme anterior portion of the hernia sac is incompletely
imaged.
.
Discharge Labs:
[**2154-3-18**] 06:10AM BLOOD WBC-6.8 RBC-3.96* Hgb-10.8* Hct-33.8*
MCV-85 MCH-27.1 MCHC-31.8 RDW-14.7 Plt Ct-353
[**2154-3-18**] 06:10AM BLOOD Glucose-95 UreaN-29* Creat-1.1 Na-140
K-4.2 Cl-92* HCO3-42* AnGap-10
[**2154-3-18**] 06:10AM BLOOD Mg-2.2
Brief Hospital Course:
66F with COPD (on 3L home O2), morbid obesity, dCHF p/w fever,
cough, imaging and exam consistent with multifocal PNA, admitted
to ICU with elevated O2 requirement, was treated for multifocal
PNA and an acute diastolic CHF exacerbation.
.
# Multifocal Bacterial PNA - Pt presented with several days
productive cough and fever, increased O2 requirement to 6L
(baseline 2L), exam with bilateral ronchi, CT demonstrating
bilateral pnuemonia; most concerning aspect of presentation is
hypoxia, initially requiring bipap in ED, but improved with IV
lasix and nebs, sugggesting component of volume overload and
COPD as well. Covered broadly with
vancomycin+cefepime+levofloxacin given [**Hospital3 **], but then
narrowed to PO levofloxacin. Transferred to the floor when O2
requirement improved.
.
# Chronic dCHF - EF75%, currently appearing euvolemic on exam.
Pt was diuresed ~10L down to weight of ~316lbs. Cr bumped from
0.8 to 1.1. Bicarb 42 on discharge. Breathing comfortably 94% on
3L (her home 02).
- Will d/c pt on her home dose of Lasix 40mg PO, pt likely has
more fluid to diurese but would monitor weights, 02 requirement
and Cr closely.
.
# DMII - reports on metformin at home, although PCP records
demonstrate it was discontinued several months ago. Continued on
sliding scale humalog while in house.
# Depression: continued duloxetine
.
# GERD: Continued omeprazole
TRANSITIONAL ISSUES
- Pt to go to [**Hospital **] Rehab in [**Location (un) 3146**]. Direct verbal signout
provided to facility over phone prior to discharge.
- Pt will be discharged this evening and attempt to have someone
at home bring in her CPAP machine. If unable to get it this
evening, pt is ok to not have it this evening with the
understanding that it should be brought from home to rehab as
soon as possible.
Medications on Admission:
- Duloxetine 60mg daily
- Fluticasone-Salmeterol 250-50 [**Hospital1 **]
- Lasix 40mg daily
- Hydrocodone-Acetaminophen 5mg-500mg TID prn pain
- Ipratropium 17mcg/Actuation 2 puffs QID prn
- Omeprazole 20mg daily
- Verapamil XR 120mg daily
- Ferrous Sulfate
- Miralax prn
- Reports metformin (although OMR shows inactivated by PCP
[**4-/2153**])
Discharge Medications:
1. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q24H (every 24 hours).
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Atrovent HFA 17 mcg/actuation HFA Aerosol Inhaler Sig: [**1-21**]
Inhalation four times a day.
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
Pneumonia, bacterial
Acute on chronic diastolic heart failure
Moderate aortic stenosis
Chronic obstructive pulmonary disease without exacerbation
Obstructive sleep apnea
Diabetes Mellitus, type 2
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:
Ms. [**Known lastname 75400**],
You were admitted to the hospital with difficulty breathing.
This was likely due to the combined effects of a pneumonia and
excess fluid (heart failure). You received 5 days of
antibiotics which effectively treated the pneumonia. You
received diuretics and we effectively removed over 2 gallons (10
liters) of fluid from you. Your dry weight at the time of
discharge is 316lb. You should remember this number and weigh
yourself daily. If you notice that your weight is increasing or
that you again develop swelling, you should call Dr.[**Name (NI) 11689**]
office to receive instructions on increasing the frequency of
your diuretics for a few days.
Please talk to Dr. [**Last Name (STitle) **] about starting daily aspirin therapy
as you are a diabetic.
Followup Instructions:
Please follow up with your primary care physician and
cardiologist following discharge from rehabilation.
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: FRIDAY [**2154-5-17**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2154-5-28**] at 3:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: TUESDAY [**2154-5-28**] at 3:30 PM
ICD9 Codes: 4280, 496, 2724, 4019, 4241, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2740
} | Medical Text: Admission Date: [**2163-4-28**] Discharge Date: [**2163-5-5**]
Date of Birth: [**2120-9-25**] Sex: F
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 104077**] is a 41-year-old
woman with diabetes mellitus Type 1, end stage renal disease,
and multiple recent admissions for diabetic ketoacidosis as
well as sepsis. The patient has a history of living related
renal transplantation in [**2150**], which was complicated by
chronic rejection, and is again on hemodialysis with a recent
[**2163-4-13**] creation of a left arteriovenous fistula, brachial
artery to basilic vein. The patient also had a right
tunneled Perma-Cath placed, and had been doing well on
hemodialysis, and had initially been on cyclosporin and
Imuran, although the Imuran was recently discontinued. The
patient was started on Rapamune, and cyclosporin was
discontinued after some overlap.
The patient, however, had ceased making urine the weekend
prior to admission, and had been placed on a short course of
prednisone for question of rejection. On [**2163-4-26**], the patient
was noted to have drainage from the exit site of her
right-sided Perma-Cath, however, the patient was afebrile at
that time, with no rigors. Blood cultures were obtained, and
the patient was given vancomycin as well as gentamicin. When
blood cultures subsequently grew gram-positive cocci in
clusters, resistant to oxacillin (i.e., methicillin resistant
staphylococcus aureus), the patient was sent for admission,
and Surgery was consulted.
Prior to arriving on the Medical floor, the patient did have
her Perma-Cath pulled out by Surgery, given the presence of
bacteremia.
PAST MEDICAL HISTORY: Diabetes mellitus Type 1 for 33
years, end stage renal disease secondary to diabetes
mellitus, status post living related renal transplantation in
[**2150**] complicated by chronic rejection, hypertension, negative
ETT Thallium in [**6-20**], steroid-induced osteoporosis,
hydradenitis suppurativa, recurrent urinary tract infections,
eating disorder, neuropathy, personality disorder.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Rapamycin 2 mg by mouth once
daily, Procrit 4000 per week, aspirin 325 by mouth once
daily, Lantus 10 units daily at bedtime, sliding scale
insulin, Lopressor 50 mg by mouth twice a day, lasix 80 mg by
mouth twice a day, Neurontin 100 mg by mouth twice a day,
Urecholine 25 mg by mouth three times a day, Zocor 20 mg by
mouth once daily.
PHYSICAL EXAMINATION: At the time of admission, temperature
was 103.2, blood pressure 154/80, pulse 108, respirations 20.
In general, the patient appeared anxious and fatigued, and
she was curled up in the fetal position. The eyes were
anicteric. The right Perma-Cath site was noted to have some
erythema, and an intact dressing. There was no jugular
venous distention. The patient was tachycardic, with a
regular rhythm. No murmurs were noted. The chest was clear
to auscultation anteriorly. The abdomen was soft, nontender,
nondistended. The extremities demonstrated no edema. The
left arteriovenous fistula site had a bruit with no erythema
present. The patient was alert and oriented at the time of
initial examination. (Please note that the patient did
refuse examination of some examiners, and this examination
was a composite therefore.)
DATA: CBC at the time of admission revealed a white count of
9.1, hematocrit of 33.9, with 77% neutrophils, 5% bands, 7%
lymphocytes, 11% monocytes, no eosinophils. Platelet count
was 235. PT was 14.9, with an INR of 1.5, PTT 103.0, which
later decreased. Chem 7 at the time of admission revealed a
sodium of 135, potassium 5.6, chloride 94, bicarbonate 12,
BUN 20, creatinine 3.9, glucose 471, with an anion gap of 35.
Calcium was 8.4, phosphate 5.5, magnesium 1.7. There was
moderate acetone measured at 1 o'clock A.M. on [**2163-4-29**]. A
rapamycin level from [**2163-4-29**] was 7.2, with a reference range
of 3 to 20 nanograms/ml. Acetone was measured on [**4-29**] and
found to be moderate. On [**5-2**], it was negative. Please see
record for levels of vancomycin, however, the most recent
vancomycin level was 24.9 on [**5-5**]. A blood culture from
[**2163-5-3**] showed one out of four bottles positive for
gram-positive rods, speciation is pending at this time. A
blood culture from [**2163-4-28**] demonstrated no growth. A blood
culture from [**2163-4-26**] showed coag-positive staphylococcus
aureus, resistant to oxacillin, sensitive to clindamycin,
erythromycin and vancomycin. A blood culture from [**2163-4-21**] had
demonstrated no growth. Catheter tip culture from [**2163-4-28**]
demonstrated again staphylococcus aureus coag-positive, with
the same sensitivities. A swab taken from the right
Perma-Cath site likewise demonstrated staphylococcus aureus.
A chest x-ray was performed on [**2163-5-3**], showing no evidence
for pneumonia. An Indium scan is pending at the time of this
dictation.
HOSPITAL COURSE: The patient was admitted with the above
complaint of bacteremia, likely secondary to Perma-Cath line
infection, this line having been discontinued the day of
admission. The patient was initially placed on gentamicin
and vancomycin for coverage of resistant staphylococcus
aureus, however, sensitivities ultimately returned resistant
to gentamicin, and this drug was discontinued on or about
[**2163-5-4**], at which time Rifampin 300 mg by mouth twice a day
was started.
The patient was febrile at the time of admission, however,
rapidly defervesced and, for much of the rest of this
interval dictation, was afebrile, though complaining of
chills and profuse diaphoresis, which soaked the bed sheets.
The patient again had a fever of 101.5 on [**2163-5-3**], with blood
cultures as noted above, and has not had a fever since
[**2163-5-3**] at this time.
The patient was followed by the [**Last Name (un) **] Diabetes service, with
whom decision was made regarding the patient's Glargine as
well as Humalog sliding scale dosing (please see below and
page one for current dosing). The patient was dialyzed with
a temporary line on [**2163-4-30**], with a right femoral Quinton,
which was then discontinued after dialysis. The patient was
refusing to allow phlebotomy on several days during this
admission, despite our best efforts at convincing her
otherwise. The patient appeared to understand the risks of
refusing testing, including laboratory testing, and was also
noted on several occasions to refuse examination or to fail
to comply with the instructions of house staff, including
instruction to keep the right leg stable after placement of a
second right groin catheter.
On [**2163-5-2**], the patient was noted to have a critically high
finger stick at 2 A.M., and received Humalog, with again an
elevated finger stick in the critical range at 3:30 A.M.
This apparent diabetic ketoacidosis resolved during the day
without the use of an insulin drip, however, recurred on
[**2163-5-3**], and the patient was noted to be febrile to 101.5,
with worsening diaphoresis, and blood cultures were sent as
described above.
On [**2163-5-3**], as noted above, the patient was changed from
gentamicin to Rocephin, and continued on vancomycin for
coverage of presumed continued staphylococcal bacteremia, and
a right groin line was placed for hemodialysis access.
The patient remained tearful through much of the course of
this hospital course to date, claiming that "I just can't
take it anymore," however, refusing psychiatric consultation
or other evaluation or intervention. The patient did deny
any intent to hurt herself at this time.
On [**2163-5-5**], the patient was injected with nuclear medicine
tracer to assess for uptake in the rejected right lower
quadrant kidney, as well as to search for signs of occult
infection possibly contributing to the patient's ongoing
labile blood sugars as well as sweats. The results of this
study are pending at the time of this dictation.
This report will be addended at a later date with discharge
medications as well as additional discharge diagnoses by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
NEW DIAGNOSES AT THE TIME OF THIS DICTATION:
1. Recurrent diabetic ketoacidosis
2. Staphylococcal bacteremia, probably secondary to line
infection
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7576**]
Dictated By:[**Name8 (MD) 2058**]
MEDQUIST36
D: [**2163-5-5**] 22:46
T: [**2163-5-6**] 00:49
JOB#: [**Job Number 104078**]
ICD9 Codes: 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2741
} | Medical Text: Admission Date: [**2151-4-2**] Discharge Date: [**2151-4-8**]
Date of Birth: [**2090-10-4**] Sex: M
Service: SURGERY
Allergies:
Penicillins / pollen / Pineapple
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
ARF
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 yo M with PMH of insulin dependent DM and
Chronic Kidney Disease. Patient underwent to peritoneal catheter
placement on [**2151-3-25**], surgical procedure was uneventfully, there
were no complications. According with patient and patient's
wife,
he did well the first couple of days after his surgery, pain was
well managed with oxycodone. Then patient started having fever,
chills and rigors, alterated mental status with somnolence and
lethargica and decreased urinary output.
Patient was taken to the [**Hospital3 417**] Medical Center, at the
emergency room he was found to be hypotensive and lethargic. SBP
in the 60's. s/p IVF resuscitation, Hydrocortisone, 2U RBC, 1
amp
HCo3. Patient was started Levophed gtt.
On arrival to the ED on OSH his labs were as followed:
124 86 133
------------< 151 10 > 7.2 < 170k ptT 41 / inr 1.4
5.9 9 12
Phosphorus 17
Mag 3.7
Cal 5.6
LFT's ALT 13 AST 14 Aphos Tbili 1.1
CT scan showed bilateral pleural effusion and atelectasis.
Gallbladder wall edema and trace of pericholecystic fluid.
RUQ US no cholelithiasis, mod gall bladder wall thickening and
small amount of pericholecystic fluid. Equivocal for
cholecystitis.
In settings of severe metabolic acidosis and ARF double lumen
RIJ
was placed HD was started.
Pressors were weaned off. Patient was found to have new onset
afib, HR under control with IV metoprolol.
Past Medical History:
DM II c/b neuropathy, retinopathy (followed by outside
endocrinologist)
HTN
CHF (TTE [**4-4**] EF > 55%, LVH)
Asthma
OSA on CPAP (unknown settings)
Gout (last flare in [**2118**]'s)
PD catheter placement [**2151-3-23**]
Thrombocytopenia [**2151-3-30**]
Social History:
Denies tobacco. Reports drinking 3-4 times per year for
holidays. + MJ, last use last pm. No IVDA.
Family History:
father and mother with HTN. Denies family h/o CAD, diabetes,
cancers.
Physical Exam:
Patient alert and oriented
Vitals:
97.9 HR: 83 BP 188/78 RR 20 O2Sat 99% 3 L NC
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Afib
PULM: Bilateral wheezing. Decreased respiratory sounds at the
bases bilaterally
ABD: Prominent, soft, nondistended, nontender, no rebound or
guarding. Peritoneal catheter in place. No erythema or purulent
discharge
Ext: No LE edema, LE warm and well perfused
Labs:
pH 7.36 pCO2 42 pO2 70 HCO3 25 BaseXS -1
Type:Art Lactate:0.9
Source: Catheter
Color Yellow Appear Hazy SpecGr 1.009 pH 5.5 Urobil Neg
Bili Neg Leuk Lg Bld Lg Nitr Neg Prot 100 Glu 100 Ket 40
RBC >182 WBC >182 Bact Many Yeast None Epi 3 Other Urine
Counts Mucous: Occ
Ucx : Pending
135 91 48
-----------<165 AGap=28
3.6 20 5.1
estGFR: [**11-12**]
Ca: 6.3 Mg: 2.2 P: 6.0 ∆
ALT: 22 AP: 155 Tbili: 0.4 Alb: 3.4
AST: 24 Lip: 17
8.9
7.4 >--< 18 ∆
26.5
N:89.5 L:4.9 M:4.6 E:0.8 Bas:0.2
PT: 14.7 PTT: 30.6 INR: 1.4
IMAGING:
EKG : Afib HR under control 99 bpm
CXR: RLL opacities / vascular congestion
MICRO:
Ucx : P
Blood Cx: P
Pertinent Results:
[**2151-4-8**] 05:55AM BLOOD WBC-10.3 RBC-3.28* Hgb-9.2* Hct-29.2*
MCV-89 MCH-28.2 MCHC-31.6 RDW-14.8 Plt Ct-17*
[**2151-4-2**] 07:14PM BLOOD Plt Smr-RARE Plt Ct-18*#
[**2151-4-4**] 03:20PM BLOOD Plt Ct-23*#
[**2151-4-6**] 06:00AM BLOOD Plt Ct-27*
[**2151-4-7**] 05:45AM BLOOD Plt Ct-16*
[**2151-4-8**] 05:55AM BLOOD Plt Ct-17*
[**2151-4-2**] 07:14PM BLOOD Glucose-165* UreaN-48* Creat-5.1* Na-135
K-3.6 Cl-91* HCO3-20* AnGap-28*
[**2151-4-8**] 05:55AM BLOOD Glucose-152* UreaN-74* Creat-5.7* Na-135
K-3.1* Cl-92* HCO3-27 AnGap-19
[**2151-4-2**] 07:14PM BLOOD ALT-22 AST-24 AlkPhos-155* TotBili-0.4
[**2151-4-3**] 01:55AM BLOOD ALT-18 AST-21 LD(LDH)-314* AlkPhos-134*
TotBili-0.3
[**2151-4-8**] 05:55AM BLOOD Calcium-6.7* Phos-4.1 Mg-1.9
[**2151-4-2**] 21:02
HEPARIN DEPENDENT ANTIBODIES
TEST RESULT
---- ------
HEPARIN DEPENDENT ANTIBODIES Negative
COMMENT: Negative for Heparin PF4 Antibody Test by [**Doctor First Name **]
Complete report on file in the laboratory.
Brief Hospital Course:
60 yo M with PMH of DM and CKD p/w Septic shock for unknown
origin, likely sources were Pneumonia, Peritoneal Cath
infection, Acute Cholecystitis, UTI. ARF requiring dialysis, now
stable off pressures. He was transferred from [**Hospital3 417**]
Hospital directly to SICU. He was alert and oriented upon
admission. New onset Afib was treated initially with IV
Metoprolol for rate control. Ceftriaxone and Zithromax were
continued for RLL pneumonia and positive UA.
RUQ US was done to evaluate for cholecystitis. Sludge in the
gallbladder without son[**Name (NI) 493**] evidence for acute cholecystitis
was noted.
Creatinine increased indicating acute on chronic renal failure
likely from hypotension. HD was performed via temporary HD line
for volume overload for a couple treatments. Nephrology
recommended continuing Lasix and increasing dose to 80mg [**Hospital1 **].
Foley was initially placed. Urine culture was negative. Urine
output averaged [**Telephone/Fax (1) 92973**] liter per day. Daily serum potassium
was low in the 2.8-3.1 range.
Once stable, he was transferred out of the SICU. The PD catheter
was hand flushed noting bloody effluent. Catheter was then
flushed with 500 ml of dialysate with bloody effluent. No
leaking occurred. Repeat flushing was done with one liter dwell
and drainage. Fluid was clearer. Cell count and culture were
negative for peritonitis. Dry gauze dressing was applied to
catheter insertion site that appeared dry and without redness.
UA and Blood cultures were negative to date.
He was also noted to have thrombocytopenia on admission with
level of 18. Hematology was consulted and w/u ensued. HIT was
negative and it was felt that thrombocytopenia was most likely
due to sepsis and exposure to new drugs including vancomycin,
aztreonam, Levaquin, famotidine, heparin and new HD. Levaquin
was likely drug culpert. Platelet count increased to 27, however
this level decreased to 17 again. He was hemodynamically stable.
Notation was made of bloody effluent from PD rapid exchange to
assess PD catheter on [**4-6**] and [**4-7**]. HCT remained stable during
admission (26 on admit/29 on day of discharge). Temporary HD
line was removed without incident.
Hematology recommended f/u PLT count as an outpatient on [**4-12**].
Recommendations were to f/u with Hematology if PLT count
remained less than 20,000.
Amlodipine was added to Toprol for SBP that was elevated in the
161/79 range. BP responded with SBP decreasing to 140s.
PT was consulted as he was unsteady and required a walker. After
a couple PT sessions of 2 days, he was declared safe for home
with VNA/PT. [**Hospital1 1474**] VNA services were arranged.
The plan was to discharge to home with f/u at [**Last Name (un) **] Dialysis
Unit with [**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], RN. PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was contact[**Name (NI) **]
to review hospital course and discuss management/follow up of
PLT count and PD. Labs will be drawn on [**4-12**] at [**Last Name (un) **] with fax
to Dr. [**Last Name (STitle) **].
Medications on Admission:
ALLOPURINOL 100 mg '
- CALCIUM ACETATE 667 mg '''
- DARBEPOETIN ALFA IN POLYSORBAT 60 mcg/0.3 mL SC 1x month
- DOXAZOSIN 2 mg ''
- FLUTICASONE-SALMETEROL 100 mcg-50 mcg 2 pf'
- FUROSEMIDE 80' am / 40' pm
- LANTUS 12 units in am, 4-10 units in pm
- QUINAPRIL 40 mg''
- SIMVASTATIN
- ZAFIRLUKAST 20 mg Tablet'
- CHOLECALCIFEROL (VITAMIN D3) 1,000'
- FERROUS SULFATE 325 mg 65mg'
- MULTIVITAMIN
- OMEGA-3 FATTY ACIDS-VITAMIN E 1,000 mg
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
8. amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
11. zafirlukast 20 mg Tablet Sig: One (1) Tablet PO daily ().
12. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
13. Outpatient Lab Work
[**4-12**] stat labs: CBC, chem 10
Fax to PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 34311**]
14. Medications on hold
Quinapril
15. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation: stool softner to avoid straining. Stop
if diarrhea.
17. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous once a day.
Disp:*1 Bottle* Refills:*2*
18. Lantus 100 unit/mL Solution Sig: 4-10 units Subcutaneous at
bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
ESRD
PD catheter obstruction
thrombocytopenia
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if you experience
any of the following:
temperature of 101 or greater, shaking chills, nausea, vomiting,
abdominal pain, malfunctioning PD catheter.
-call your pcp if you have any dizziness/easy bruising or any
bleeding ie., blood in urine/stool or any vomiting
-You need to have blood drawn on Monday [**4-12**] for platelet
monitoring. These labs can be drawn at [**Last Name (un) **] in dialysis unit.
-Visiting nurse services have been arranged with [**Hospital1 1474**] VNA to
include physical therapy
-Be extra careful with anything that is sharp. Do not use a
razor. [**Month (only) 116**] use an electric razor.
-If you fall or bump yourself, you need to go to emergency room
to get checked for any bleeding.
Followup Instructions:
-please schedule follow up appointment as soon as possible with
your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 10813**]
-Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2151-7-15**] 10:30
-follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Last Name (un) **] Dialysis tomorrow [**4-9**]
Completed by:[**2151-4-8**]
ICD9 Codes: 0389, 5856, 486, 5849, 2762, 4280, 2749, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2742
} | Medical Text: Admission Date: [**2148-6-12**] Discharge Date: [**2148-7-5**]
Date of Birth: [**2091-2-25**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Biaxin / Ciprofloxacin
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
fever, chills
Major Surgical or Invasive Procedure:
Mechanical Ventilation
Arterial Line Placement
Hemodialysis Line Placement
Internal Jugular Central Line Placement
History of Present Illness:
57m with HIV (last CD4 525 with VL undetectable ~2 months ago)
presents with acute onset of fever, chills, and extreme weakness
several hours prior to presentation. He was at his office
working feeling in his usual state of health until about 9pm
last night. At that time, he developed abrupt onset of fever,
chills, hot flashes. +Nausea. No vomiting. No cough, SOB, chest
pain. No urinary symptoms. No sick contacts. [**Name (NI) 4084**] had episode
like this before. No recent travel.
.
In the [**Hospital1 18**] ED, initial vitals were T 102.5, BP 118/65, HR 116,
RR 20, 94% RA. His BP dropped to 70/30s at one point but
improved with IVF. BP then dropped again. R IJ was placed.
Levophed was started. He remained persistently tachy to
120-130s. Labs notable for lactate of 2.5, no leukocytosis, hct
49. UA neg. CXR unremarkable. Admitted to MICU for closer
monitoring.
.
On arrival to the MICU, the patient's main complaint is feeling
very thirsty. He also has severe back and knee discomfort [**3-18**]
chronic arthritis pain and lying flat on his back. SBP dropped
again to as low as 60s. Vasopressin and neosynephrine were added
to bring up BP.
.
ROS: As above. Otherwise negative in detail.
Past Medical History:
HIV
Hep B, never been treated
Obesity
Hypercholesterolemia
Asthma
R medial meniscal tear
DM type 2
Hx splenic abscess s/p splenectomy in [**2135**]
Social History:
In long term relationship w/ partner. [**Name (NI) **] smoking. No alcohol. No
drugs.
Family History:
Noncontributory
Physical Exam:
VS - T 100.9; BP 90/44; HR 120; RR 12; O2sat 92% on 4L
Gen: anxious appearing, obese male, diaphoretic, alert and
interacting appropriately
HEENT: PERRL, EOMI, dry MM, OP clear
CV: distant HS,
Chest: face tent, CTAB, no w/r/r
Abd: obese, soft, nondistended, mild tenderness at
RUQ/mid-epigastrium
Ext: no LE edema
Skin: no rash
Neuro: A+O x 3
Pertinent Results:
[**2148-6-11**] 10:30PM BLOOD WBC-9.4 RBC-5.26# Hgb-16.2# Hct-49.1
MCV-93# MCH-30.8# MCHC-33.0 RDW-14.3 Plt Ct-432
[**2148-6-12**] 03:42PM BLOOD WBC-24.9* RBC-4.68 Hgb-14.3 Hct-43.9
MCV-94 MCH-30.5 MCHC-32.6 RDW-14.6 Plt Ct-247
[**2148-6-14**] 04:03AM BLOOD WBC-48.3* RBC-4.06* Hgb-12.4* Hct-37.1*
MCV-91 MCH-30.7 MCHC-33.5 RDW-15.1 Plt Ct-23*
[**2148-6-18**] 03:53PM BLOOD WBC-45.6* RBC-3.29* Hgb-10.4* Hct-30.0*
MCV-91 MCH-31.6 MCHC-34.6 RDW-16.4* Plt Ct-72*
[**2148-6-23**] 04:10AM BLOOD WBC-17.4* RBC-2.59* Hgb-8.2* Hct-24.4*
MCV-94 MCH-31.6 MCHC-33.5 RDW-17.1* Plt Ct-355#
[**2148-7-2**] 06:30AM BLOOD WBC-8.2 RBC-2.53* Hgb-8.0* Hct-26.0*
MCV-103* MCH-31.6 MCHC-30.8* RDW-19.2* Plt Ct-811*
[**2148-7-5**] 06:00AM BLOOD WBC-9.5 RBC-3.04* Hgb-9.6* Hct-29.7*
MCV-98 MCH-31.5 MCHC-32.3 RDW-19.5* Plt Ct-738*
[**2148-7-2**] 06:30AM BLOOD WBC-8.2 Lymph-20 Abs [**Last Name (un) **]-1640 CD3%-81
Abs CD3-1333 CD4%-23 Abs CD4-373 CD8%-58 Abs CD8-953*
CD4/CD8-0.4*
[**2148-6-11**] 10:30PM BLOOD Glucose-133* UreaN-27* Creat-1.0 Na-137
K-4.4 Cl-99 HCO3-25 AnGap-17
[**2148-6-28**] 03:00AM BLOOD Glucose-79 UreaN-80* Creat-6.6* Na-147*
K-5.1 Cl-109* HCO3-19* AnGap-24*
[**2148-6-29**] 03:12AM BLOOD Glucose-89 UreaN-73* Creat-6.1* Na-150*
K-4.7 Cl-110* HCO3-18* AnGap-27*
[**2148-7-4**] 06:40AM BLOOD Glucose-86 UreaN-39* Creat-3.1* Na-145
K-4.1 Cl-107 HCO3-24 AnGap-18
[**2148-6-11**] 10:45PM BLOOD Lactate-2.5*
[**2148-6-12**] 12:17PM BLOOD Lactate-6.1*
[**2148-6-15**] 10:21AM BLOOD Lactate-2.0
[**2148-6-29**] 03:53PM BLOOD Lactate-0.8
ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2148-6-12**] 8:29 AM
IMPRESSION:
1. Limited examination shows no gross intrahepatic biliary
dilatation.
2. Markedly edematous gallbladder, without stones or distension.
The
appearance of the wall can be seen in patients with underlying
liver disease
or hypoproteinemia.
3. Fluid within the left upper quadrant, of uncertain etiology
or location.
Differential considerations include a fluid-filled, distended
stomach, vs.
post- operative fluid within the splenectomy bed.
4. Small amount of ascites.
Portable TTE (Complete) Done [**2148-6-14**] at 11:43:53 AM:
Left Ventricle - Ejection Fraction: >= 55%
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve,
but cannot be fully excluded due to suboptimal image quality.
Trace aortic regurgitation is seen. No masses or vegetations are
seen on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. There is no pericardial effusion.
IMPRESSION: No vegetations seen (suboptimal-quality study).
Normal global and regional biventricular systolic function. In
presence of high clinical suspicion, absence of vegetations on
transthoracic echocardiogram does not exclude endocarditis.
Brief Hospital Course:
Mr [**Known lastname **] is a 57 year old man with history of HIV,
splenectomy, presented with acute onset of fever, chills and
nausea. Patient was evaluated in the ED where he spiked fever to
102.5 and developed acute hypotension requiring rapid escalation
of care with 3 pressors and large volume resusitation for septic
shock.
.
Patient was in MICU from [**6-12**] where his course included Xigris
administration, CVVH for massive volume overload and treated
with broad spectrum antibiotics. Eventually the patient was
weaned off of pressors, received one dose of IVIG, and
subsequently placed on PCN G for strep viridans culture but had
one episode of hypotension and fever during which time 1 time
doses of vanc/zosyn were given. Today is day 18/28 as per ID of
PCN G course. In addition, the patient had unexplained
transaminitis during his stay, history of HBV infection and HBV
core antigen positive, negative HCV Ab. Transaminitis resolved
as patient was weaned from ventilation and pressures stabilized
-- on transfer AST/ALT have normalized and Alk Phos trending
down. Amylase and Lipase elevated on [**6-18**], continues to be
elevated -- there was an initial concern for pancreatitis and
abd. CT done showing mild pancreatitis; however lipase now
trending down and no signs of infection (fever, leukocytosis) is
present at transfer. Pt. also suffering from ARF likely ATN from
septic shock, received several rounds of CVVH after massive
fluid resuscitation, now auto-diuresing with up to 3L UOP/day,
though Cr still above 5 on transfer. In addition, pt. had a
transient drop in plt's to a nadir of 10 requiring plt
transfusion -- heme/onc consulted, reviewed smear, and believed
pathogenesis to be bone marrow suppression in light of
overwhelming sepsis, and not DIC. Plt levels have since returned
to normal.
.
On transfer to the floor, pt. was alert and talkative. Was seen
by physical therapy and was able to transfer from bed to chair
and back with assistance. Continued to have good urine output,
so renal concluded no need to place HD line. Cr trended
downward to 3.1 the day prior to discharge, and patient was
tolerating adequate PO's. Will be discharged on day 23 of 28 of
his PCN G as per ID. In addition, was having diarrhea, C.diff
negative x 2.
.
Follow Up:
---------
- Please follow up MICROSPORIDIA STAIN, CYCLOSPORA STAIN, and
Cryptosporidium/Giardia DFA stool samples
- When Cr is under 1.5, please resume original HAART medications
MICU COURSE
===============
Events [**6-12**]:
- BCx [**3-18**] GPCs in pairs
- Zosyn changed to ceftriaxone and clindamycin
- Given IVIG
- RUQ u/s showed edematous gallbladder
[**6-13**]
-Climbing WBC
-Renal put in HD cath
-f/u CXR shows decreased pulm edema, effusions, but ?aspiration,
L retrocardiac opacity
-standing tylenol
-started IV hydrocortisone
- 25g albumin x2
- IVFs w/ bicarb
[**6-14**]
-Platelets to 10K, 1 bag of platelets given, increased to 39
-D/C'ed ceftriaxone per ID given interaction with calcium
gluconate on CVVH
-DIC labs
-Heme/Onc does not believe plt drop is DIC, believes it is
suppression of marrow due to sepsis
-Dopamine weaned off, on CVVH
.
[**6-15**] Events:
-PEEP decreased to 16
-cultures growing strep viridans
[**6-16**] events:
d/c-ed vanc, clinda. Started PCN with one dose of [**Last Name (LF) **], [**First Name3 (LF) **] ID
recs
-weaned off levophed and vasopressin!
-please bring up with nephrology whether patient can get
dialysis now that pressures are stable.
[**6-17**] Events
-Patient with labored breathing, PEEP was increased to 20, pt.
placed back on midazolam sedation.
-IP, saw free flowing fluid with no loculations, performed
diagnostic thoracentesis, transudative pleural fluid
-TEE to be done tomorrow, tube feeds restarted, NPO past
midnight
-RUQ ultrasound being done- prelim read -> interval decrease in
gb wall edema, gb not distended, no gstones, no cholecystitis,
small amount of free fluid adj to liver
-[**Month/Day (4) **] level 0.7, given [**Month/Day (4) **] per ID recs
-HIT Ab negative
-Bronch done, demonstrated esophageal balloon in lung, extracted
-PLT increasing
.
[**6-18**] Events:
-TEE showed no vegetations
-labs show pancreatitis, plan to obtain CT abd after off CVVH
-hypotensive to 70s with 500 ccs negative per hour, given 1000
cc bolus, changed CVVH to run at even, held versed
-hepatitis panel sent
-amylase level of pleural fluid added on
-started acyclovir
-need to ask ID in am about IV vs topical acyclovir, need for
[**Month/Day (1) **], and when to restart HAART
[**6-19**] events:
d/c-ed [**Month/Day (4) **] per ID recs
-wanted to continue po acyclovir for now
-considering starting HAART soon, not quite yet
-they did not comment on whether or not to start broader abx
coverage for pna. So we started Levofloxacin for pna.
I/Os: -4.2L
[**6-20**] events:
-two episodes of hypotension with SBP below 100, given two 500cc
boluses of fluid
-temp to 101, pan cultured, given 1x dose of zosyn and
vancomycin
-PEEP @ 12
-HCV and HBV negative
-Increased Cr to 2.1
-EBV IgG positive
.
[**6-21**] events:
-HD
-HD line removed, tip for culture
-ABx d/c'd
-CT abd completed- no abscess or fluid collection, mild
pancreatitis, b/l pleural effusions c/ atelectasis, L opacity
.
[**6-22**] events:
patient more arousable
+2L
.
[**6-23**] Events
- Renal recs to make patient NPO for tomorrow for possible
tunneled cath HD line placement; however, if patient's urine
output is picking up (last UOP decidedly more than prev. at
100-110 every 2 hours)
- Holding heparin
- Patient sitting up, responsive to questions
- ABG pristine on PS ventilation (7.42/40/90)
===================================
Medications on Admission:
Metformin 500mg PO BID
Atripla 1 tab PO daily
Lisinopril 5mg PO daily
Lipitor 10mg PO daily
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Month/Year (2) **]: One
(1) Appl Ophthalmic PRN (as needed).
2. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Miconazole Nitrate 2 % Powder [**Month/Year (2) **]: One (1) Appl Topical PRN
(as needed) as needed for pannus fungal infection.
4. Lactulose 10 gram/15 mL Syrup [**Month/Year (2) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: Six (6)
Puff Inhalation Q6H (every 6 hours) as needed for wheezing.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for aggitation.
8. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing,
SOB.
11. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback
[**Last Name (STitle) **]: 3,000,000 units Intravenous Q4H (every 4 hours) for 6 days:
Please stop on [**2148-7-10**].
12. Insulin Glargine 100 unit/mL Solution [**Date Range **]: Eight (8) units
Subcutaneous QAM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Septic Shock
Acute Renal Failure
Secondary:
HIV on therapy
Hepatitis B, untreated
Obesity
Hypercholesterolemia
Asthma
Diabetes Mellitus Type 2
History of splenic abscess status post splenectomy in [**2135**]
Discharge Condition:
Stable, eating, drinking, voiding, and having bowel movements,
conversant, can get from chair to bed with assistance.
Discharge Instructions:
You were admitted initially for a severe infection and severe
inflammation. Upon arrival you were promptly taken to the
intensive care unit where you were given antibiotics and
resucitated with fluids. After you stabilized in the ICU, you
were transferred to the floor where you were recovering very
well. You are being sent to a rehabilitation facility where you
will work with physical therapy to recover your strength. You
will also complete your course of antibiotics there. Upon
discharge from the rehab facility, please set up an appointment
with your primary care physician [**Name Initial (PRE) 176**] 1 to 2 weeks of
discharge.
Please take all medications as prescribed. The most notable
medication that we are continuing you on is your penicillin, for
which you have 1 more week to complete.
If you experience any sudden chest pain, shortness of breath,
nausea, vomiting, diarrhea, constipation, lightheadedness, or
loss of consciousness, please contact your primary care provider
[**Name Initial (PRE) 2227**].
Followup Instructions:
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2148-11-13**]
1:00
Completed by:[**2148-7-5**]
ICD9 Codes: 5849, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2743
} | Medical Text: Admission Date: [**2107-4-30**] Discharge Date: [**2107-4-30**]
Date of Birth: [**2050-12-17**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Cerebral angiogram
History of Present Illness:
56M who was in his usual state of health today and reports while
working he experienced the worse headache he has felt. This
occurred at about 4pm. He works as a dishwasher for a hotel. He
describes the headache as very strong and intense, originating
in the occipital region then radiating down his neck and down
the left side of his body. He reports blurry vision during the
headache and nausea. Denies vomiting. Denies any fevers. He was
seen at an OSH where a head CT was negative, per ER reports an
LP was performed which was positive. He was transferred to [**Hospital1 18**]
for further management.
PMHx:
-Diabetes
-HTN in past / currently off meds
-? Head trauma in [**2099**] in the [**Country 13622**] Republic- MVA that left
large laceration but denies any intracranial surgery.
-Left knee surgery for cyst removal
All: NKDA
Medications prior to admission:
Metformin twice daily
Ibuprofen prn
Social Hx:
Spanish speaking only. Married, lives with wife, works as a
dishwasher in a hotel. Denies tobacco, ETOH, and recreational
drug use.
Family Hx:
Colon cancer, denies cardiac or neurological history. No known
familial hx of aneurysms
ROS: pain 6/10 l neck
PHYSICAL EXAM:
O: T: 98.0 BP: 118/79 HR: 85 R 16 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, no visible sign of trauma
Neck: no nuchal rigidity
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: R pupil 3-2mm, L pupil slightly smaller 2.5-2mm. Visual
fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-21**] throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Handedness: Right
CTA Head/Neck:
Question of 1 mm left supraclinoid ICA aneurysm vs. outpouching
(Recons pending)
Labs: LP results from OSH
CSF Tube 4: WBC 44, RBC 6667, Gluc 122, Prot 50
Positive xanthochromia per ER to ER report
Assessment/Plan:
56M who reports experiencing the WHOL at 4pm, was taken to an
OSH
where a head CT was negative, LP positive, and transferred to
[**Hospital1 18**]. A CTA head/neck performed at [**Hospital1 18**] showed a question of a
tiny L supraclinoid ICA aneurysm. Given that this possible tiny
aneurysm correlates to patient's symptoms, ICU admission is
recommended
Past Medical History:
-Diabetes
-HTN in past / currently off meds
-? Head trauma in [**2099**] in the [**Country 13622**] Republic- MVA that left
large laceration but denies any intracranial surgery.
-Left knee surgery for cyst removal
Social History:
Spanish speaking only. Married, lives with wife, works as a
dishwasher in a hotel. Denies tobacco, ETOH, and recreational
drug use.
Family History:
Colon cancer, denies cardiac or neurological history. No known
familial hx of aneurysms
Physical Exam:
O: T: 98.0 BP: 118/79 HR: 85 R 16 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, no visible sign of trauma
Neck: no nuchal rigidity
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: R pupil 3-2mm, L pupil slightly smaller 2.5-2mm. Visual
fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-21**] throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Handedness: Right
Pertinent Results:
CTA Head/Neck:
Question of 1 mm left supraclinoid ICA aneurysm vs. outpouching
Labs: LP results from OSH
CSF Tube 4: WBC 44, RBC 6667, Gluc 122, Prot 50
Positive xanthochromia per ER to ER report
[**2107-4-30**] Angiogram: small infundibulm anterior choridal, no
aneurysm
Brief Hospital Course:
Pt was admitted to neurosurgery and monitored closely in the
ICU. He remained neurologically intact throughout his hospital
stay. He underwent angigram on [**2107-4-30**] AM which showed no
aneursym. His headache lessened. He was stable post-angiogram.
His metformin was held secondary to dye-load from angiogram. He
was kept flat for 6 hours post-angio and then diet and activity
advanced. He was discharged to home with followup with PCP [**Last Name (NamePattern4) **] 2
days to check renal function.
Medications on Admission:
Metformin twice daily
Ibuprofen prn
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/ fever.
2. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): do not take and [**Male First Name (un) **] not resume until blood work done by
PCP and kidney function is confirmed normal.
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
take while on pain med.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
traumatic lumbar puncture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
No heavy lifting for one week.
Remain out of work for one week.
Do not take your metformin until bloodwork done by your PCP.
Followup Instructions:
Please follow up with your PCP on [**Name9 (PRE) 766**] for bloodwork - check
glucose and renal function s/p angiogram.
Follow up with Dr. [**First Name (STitle) **] in neurosurgery in 4 weeks - please
call [**Telephone/Fax (1) 1669**] to schedule appt.
Completed by:[**2107-4-30**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2744
} | Medical Text: Admission Date: [**2105-5-2**] Discharge Date: [**2105-5-27**]
Date of Birth: [**2029-5-17**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
found unresponsive by family
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
External ventricular drain placed [**2105-5-5**]
Cerebral angiography [**2105-5-7**]
History of Present Illness:
75 year old man with a history of hypertension was transferred
to [**Hospital1 18**] after being found unresponsive by wife.
Per family, patient had been shopping throughout the morning
with his wife. They currently live in an apartment and are
selling their house. They stopped by the house ~11am to check on
it, and pt went around to back deck to make sure back door was
locked. Wife waited in the car. She reports that he got out of
the car slowly and with difficulty and then seemed to walk fine.
3-4 minutes later when he had not returned, she drove car around
and saw him laying face up on the back deck. She reports that
his eyes were open and at midline gaze, but he was unresponsive.
EMS was immediately activated and found the patient with "agonal
breathing and no gag reflex." He was subsequently sedated with
versed and intubated in the field and brought to [**Hospital3 60734**]. There a head CT uncovered a subarachnoid hemorrhage
and he was noted to be in atrial fibrillation on EKG (no
previous history of afib). He was then transferred emergently
to [**Hospital1 18**] ER for neurosurgical evaluation. He arrived here at
2:20 pm. He was treated with flagyl, levaquin, dilantin, and
tylenol (febrile to 101.8). The neurosurgery service did not
feel an intervention was warranted and requested evaluation by
neurology at 5 pm.
According to family, he has history of gait difficulties and
moving "slowly." About 3 months ago, pt was evaluated for ?NPH
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10132**] in Neurology at [**Hospital3 **] with lumbar
puncture. Family reports some improvement in gait after tap.
Repeat LP was planned for early [**Month (only) **] to re-evaluate and
determine if diagnosis of NPH was correct. Family reports that
for the last ~3 weeks his gait had again started to worsen, with
him moving more slowly, especially getting in and out of car.
Review of systems largely unobtainable since pt intubated and
unresponsive. Family does reports that pt complained of
"dizziness" last week. He had not told them of any other
problems.
He had been moving about "slow" all morning, and in fact for the
last few weeks per his son.
Past Medical History:
1. Hypertension
2. Anxiety
3. H/o gait disorder, ?NPH (see HPI)
Social History:
Lives with wife. [**Name (NI) **] recent alcohol or tobacco use
Family History:
Son with afib s/p ablation.
Physical Exam:
Vitals: 101.8 80 150/96 16 100% intubated
General: older man lying still on bed
Neck: supple
Lungs: decreased breath sounds at the bases
CV: Regular rate and rhythm
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema
Neurologic Examination:
no response to loud voice; left fist clenching to sternal rub;
pupil 1mm b/l and minimally reactive; unable to test dolls as
pt. still in hard collar; weak corneal reflex b/l, weak gag
reflex b/l; face symmetric; some spontaneous mvt. in left arm
and leg; withdraws slightly to pain on left extremities, minimal
flexor posturing to pain on right, dtr's brisk 2+ throughout,
toes upgoing b/l
Pertinent Results:
WBC-11.4* (89N, 7L, 3M) HCT-42.6 PLT-113*
PT-12.0 PTT-29.3 INR(PT)-1.0
Na-141 K-4.1 Cl-105 HCO3-25 BUN-23* CREAT-1.5* Gluc-89
ALBUMIN-3.8 CALCIUM-9.2 PHOSPHATE-2.4* MAGNESIUM-1.8
ALT-20 AST-32 ALK PHOS-92 TOT BILI-0.8 Lipase-27 AMYLASE-109*
CK(CPK)-67 CK-MB-NotDone cTropnT-<0.01
UA: BLOOD-LGE NITRITE-NEG LEUK-NEG RBC->50 WBC-0 BACT-NONE
Head CT/CTA ([**5-2**]): Extensive subarachnoid hemorrhage in the
quadrigeminal cistern, right sylvian fissure, right occipital
[**Doctor Last Name 534**], right frontal horns, bilateral posterior parietal regions,
around the posterior interhemispheric fissure and along the
falx. These findings are suspicious for traumatic subarachnoid
hemorrhage. Hemorrhagic dural metastasis is a possibility but
considered very less likely. Bifrontal subdural hygroma is noted
of uncertain clinical significance. Punctate hemorrhage in the
pons, which may represent a tiny shear injury. Hemorrhage is
also noted adjacent to the interhemispheric fissure in the right
lateral ventricle. CT angiogram demonstrates good flow in the
anterior and posterior circulation. No definite aneurysms or
vascular malformation.
Brief Hospital Course:
75M h/o HTN found unresponsive by wife and neurological exam
with comatose mental status, and few lateralizing focal
deficits. Head CT with multiple intraparenchymal and
subarachnoid hemorrhages. Pt was admitted to the neurology ICU
for further management.
1. Neuro: Etiology of subarachnoid bleeds is unclear, though
most likely related to trauma as pt was found down, lying on his
back. Alternative possibilities included aneurysm or vascular
malformation in the brainstem that bled, resulting in fall which
then caused traumatic SAH. The somewhat nodular appearance on CT
of the bleeds also suggested possible dural metastases as
etiology. MRI with contrast showed no evidence of dural
metastases or other enhancing lesions. CSF cytology was negative
for malignant cells. Neither MRA nor CTA showed aneurysm, but
MRI with contrast did have some enhancement in the brainstem
near the intraparenchymal bleed, so vascular malformation was
still possible. On [**2105-5-7**] (day #5 since SAH) a cerebral
angiogram was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Interventional
Neuroradiology. Angiogram showed no evidence of aneurysm,
vascular malformation or vasospasm. Thus, most likely etiology
of bleed is traumatic as result of fall backwards onto deck.
Etiology of fall is somewhat unclear. Two most likely
possibilities are secondary to patient's gait disorder, or could
be due to sinus pauses on conversion from afib back to sinus
rhythm (see below for more details).
Patient remained minimally responsive for the first 14 days in
the hospital. He was started on dilantin for seizure prophylaxis
given the likely closed-head injury and the subarachnoid blood.
An EEG was performed to ensure that he was not having
subclinical, nonconvulsive seizures as the cause of his
decreased alertness. It showed rare blunt and sharp waves over
the right posterior quandrant, no epileptiform activity, and
generalized delta frequency slowing suggesting a moderate to
severe encephalopathy.
--still with minimal resposiveness
--nimodipine 60 q4h and dilantin for SAH
--EEG prelim read with no epileptiform and mod-severe
encephalopathy
--Repeat CT [**5-5**] with more blood around midbrain/pons and
worsening hydrocephalus, so neurosurg put vent drain in
--MRI and CT of C-spine with no injury-->d/c'd hard collar
--neurosurg following
--angio [**5-7**]--no aneurysm, no AVM seen, no vasospasm either. All
looked good. Will keep SBP 110-140s where its been
-nimodipine and dilantin/keppra eventually discontinued as
patient showed no evidence of seizure activity or vasospasm
2. Pulm: Intubated, vented. Had been doing well on FiO2 0.30
with PO2 ~100 but on [**5-5**] had PO2 ~60 and had to increase FiO2
to 0.40. Has PNA--see ID below
3. ID: Has been persistently febrile (101-102), unclear
[**Name2 (NI) **]--SAH vs infection. WBC still normal, but on [**5-5**] had
incr'd O2 requirement and thick yellow sputum. Sputum from [**5-4**]
with Serratia. Started CTX on [**5-5**]. CXR [**5-6**] with RLL opacity and
right effusion. Changed abx to levoflox on [**5-7**] as Serratia tends
to become resistant to cephalosporins per lab, on [**5-21**] found to
be cipro resistant, so then switched to meropenum
.
4. CV:
a) Afib with RVR: on night of [**5-3**] starting having afib/RVR (no
history of such, though ?found by EMS in afib per son) and
started on amio IV load AM [**5-4**]. Then while amio going in, had
multiple sinus pauses, up to ~8 sec!, mostly when flipping out
of afib back to sinus. EP consulted, and since they can't be
sure that he wasn't doing this without the amio (he has had
dizziness in past few weeks) and since can't be sure that fall
wasn't symptomatic sinus pause, they will put in temporary pacer
(has to be temporary given PNA currently) on [**5-6**].
--so new attndg on EP and plan changed--will just watch on tele
in ICU until afeb/PNA over and then put in permament pacer
--currently on dilt gtt for rate control. avoid amio if can per
EP
--no heparin/coumadin for PAF for now given ICH
b) BP: nimodipine for SAH, goal BP<130
FEN: TFs
PPx: PPI, ISS, boots. Start hep sc [**5-8**] (24hrs after angio)
Full code
Comm: with wife and dtr
Medications on Admission:
Aricept, metoprolol, zoloft, trazodone, ativan
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
7. Metoclopramide 5 mg/mL Solution Sig: Ten (10) mg Injection
Q6H (every 6 hours) as needed.
8. Metoprolol Tartrate 5 mg/5 mL Solution Sig: Five (5) mg
Intravenous Q6H (every 6 hours).
9. Meropenem 1 g Recon Soln Sig: 1000 (1000) mg Intravenous Q8H
(every 8 hours) for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. stroke
2. afib
3. subarachnoid hemorrhage
Discharge Condition:
Stable neurologic exam
Discharge Instructions:
Please return to nearest ER if symptoms worsen. Please take all
medications as prescribed. Keep all follow-up appointments.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **]/[**Doctor Last Name **] in 4 months, call
[**Telephone/Fax (1) 44**] to schedule a convenient time.
Completed by:[**2105-5-27**]
ICD9 Codes: 0389, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2745
} | Medical Text: Admission Date: [**2122-9-3**] Discharge Date: [**2122-9-18**]
Service: MEDICINE
Allergies:
Trazodone
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Placement of tunneled hemodialysis line
Placement of PICC line
History of Present Illness:
Ms. [**Known lastname **] is a 87 yo F PMHx sig for HTN, HL, AAA, s/p b/l renal
artery stents and R CEA presented to the ED last night ([**9-3**])
with back pain x 1-2 months w/ acute worsening x 1-2 days. [**1-18**]
days ago, she had acute worsening of pain with difficulty with
bowel/bladder control and episodes of incontinence. In the ED,
she denied fevers. Cr was found to be 7 from mid-1s in 9/[**2121**].
CT AP showed increase in size of known AAA without evidence of
rupture. She was admitted to vascular surgery. renal was
consulted for ARF and anuria. The evening of admission, she
spiked a temp to 102. Blood Cx were done, and CXR was without
any obvious PNA. This morning, she became hypotensive to 80/34
and got 2L fluids with improvement in BP to the 90s. She became
hypoxic to 84%, and is now on 3L O2. She was started in
vanc/Zosyn and a medicine consult was called given concern for
early sepsis.
.
Her AAA was first noted in [**2118**], 3.9x3.9. On CT last night, it
was measured 5.3cm but not felt to be emergent by the vascular
team. There was no evidence for dissection blocking renal
arteries, Of note, B/L renal artery stents placed in [**2121**] by Dr.
[**Last Name (STitle) 14533**] which appearred patent on US. Renal was consulted
who felt that there was no indication for HD at this time and
recommnedded a number of studies for further workup with
supportive management and trending Cr for now.
.
On the floor, when evaluated by the MICU, the patient was
mentating and asymptomatic, but did endorse feeling overwhelmed
with all the information and not thinking well. She had recently
defervesced, with VS T99.3, Tm 102.3, HR 61-76, BP 91/32 in
trendelenburg (baseline 120/80s), RR17-20, 94% on 3L nasal
cannula.
Past Medical History:
* Chronic kidney disease, stage III/IV
* Coronary artery disease and NSTEMI in [**2116**] (s/p DES/LCx,
BMS/RCA [**5-/2118**], refused CABG)
* Atrial fibrillation, not on coumadin but was on amiodarone
* Congestive heart failure (EF 70% [**2121-8-8**])
* Aortic stenosis ([**Location (un) 109**] 1.2-1.8, mild in [**7-/2121**])
* Anemia
* Hyperlipidemia
* Hypertension
* Infrarenal AAA last measured 4.4 cm [**5-/2121**]
* Rheumatic heart disease as child
* Left breast cancer (stage 1 infiltrating ductal carcinoma) s/p
hormonal therapy with arimidex [**2118**], T1b, N0, M0; ER positive,
PR negative and HER-2/neu negative
* Bilateral renal artery stent [**2119-4-27**]
* Right carotid endarterectomy [**2116**]
Social History:
(per OMR) - Lives with her husband whom she cares for (he has
COPD, on home oxygen)
- Tobacco: Quit smoking >20 years ago
- Alcohol: Denies
- Illicits: Denies
The patient is married and lives with her 80-year-old husband
who is a home O2 dependent. She cares for him. They have two
children, a son 55 who lives here in the area and a single
granddaughter. She has one daughter who is 54 and lives in
[**State 4565**]. She smoked cigarettes from age 20-50 : approx [**1-18**]
ppd. ETOH rare.
significant for the absence of current tobacco use - does have a
previous 15 pack year smoking history. There is no history of
alcohol abuse.
Family History:
Renal disease in her brother
Negative for cancer except for one nephew with melanoma at age
60. Mother-CVA at 77. Father died in an accident
young age. She has one brother 82 who has had a history of an
abdominal aortic aneurysm and one sister 80 with heart disease.
Physical Exam:
On arrival to the MICU
Vitals: T: 96.2 BP: 95/39 P:51 R:15 18 O2:96% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: sinus bradycardia, 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 with no urine visible
Ext: warm, well perfused, no clubbing, cyanosis or edema
Discharge exam:
PHYSICAL EXAM:
VS - Temp 97.9F, BP 180/52, HR 57, R 18, O2-sat 94% on RA
GENERAL - well-appearing elderly woman in NAD, comfortable,
appropriate.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no carotid bruits. JVD to 1.5cm
above
clavicle with bed reclined to 30 degrees.
LUNGS ?????? Mild expiratory crackles at lung bases bilaterally, no
rh/wh,
good air movement, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR. Blowing systolic
crescendo/decrescendo
murmur heard at LLSB. No rubs or gallops, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses. Liver palpable to 4cm
below
costal margin; no splenomegaly. No rebound/guarding. No CVA or
flank
tenderness.
EXTREMITIES - WWP, no c/c, 1+ pitting edema of lower extremities
bilaterally with [**Male First Name (un) **] support stockings on; 2+ radial pulses; 1+
DP and
posterior tibialis pulses
SKIN ?????? Scattered 0.5-2cm ovoid purple ecchymoses across stomach,
arms
and legs.
LYMPH - no cervical, axillary, or supraclavicular LAD
NEURO - awake, A&Ox3. CNs II-XII intact with exception of
right-sided
facial droop consistent with baseline per MICU, with forehead
sparing.
Moves all extremities, sensation grossly intact throughout.
Pertinent Results:
Admission labs:
[**2122-9-3**] 10:30AM BLOOD WBC-8.2# RBC-2.92* Hgb-9.9* Hct-27.4*
MCV-94 MCH-33.9* MCHC-36.1* RDW-13.1 Plt Ct-82*
[**2122-9-3**] 10:30AM BLOOD Neuts-90.8* Bands-0 Lymphs-4.6* Monos-4.4
Eos-0.1 Baso-0.1
[**2122-9-4**] 07:50AM BLOOD PT-13.2 PTT-24.9 INR(PT)-1.1
[**2122-9-3**] 10:30AM BLOOD Glucose-103* UreaN-86* Creat-7.0*#
Na-132* K-3.5 Cl-93* HCO3-19* AnGap-24*
[**2122-9-3**] 09:00PM BLOOD Calcium-6.7* Phos-6.2*# Mg-2.2
[**2122-9-3**] 11:04AM BLOOD Lactate-1.5
[**2122-9-4**] 07:50AM BLOOD WBC-6.0 RBC-2.93* Hgb-10.1* Hct-27.8*
MCV-95 MCH-34.5* MCHC-36.3* RDW-13.2 Plt Ct-79*
[**2122-9-5**] 05:53AM BLOOD WBC-7.5 RBC-2.86* Hgb-9.9* Hct-27.8*
MCV-97 MCH-34.7* MCHC-35.8* RDW-13.4 Plt Ct-87*
[**2122-9-6**] 02:40AM BLOOD WBC-8.3 RBC-3.23* Hgb-10.9* Hct-31.7*
MCV-98 MCH-33.9* MCHC-34.5 RDW-13.6 Plt Ct-112*
[**2122-9-7**] 02:45AM BLOOD WBC-5.9 RBC-2.88* Hgb-9.8* Hct-27.8*
MCV-97 MCH-34.0* MCHC-35.2* RDW-13.3 Plt Ct-114*
[**2122-9-8**] 02:27AM BLOOD WBC-5.4 RBC-2.81* Hgb-9.2* Hct-26.5*
MCV-95 MCH-32.7* MCHC-34.6 RDW-13.2 Plt Ct-107*
[**2122-9-10**] 05:04AM BLOOD WBC-4.9 RBC-2.69* Hgb-9.0* Hct-26.5*
MCV-98 MCH-33.5* MCHC-34.0 RDW-13.3 Plt Ct-94*
[**2122-9-11**] 05:31AM BLOOD WBC-5.5 RBC-2.61* Hgb-8.7* Hct-25.5*
MCV-98 MCH-33.4* MCHC-34.2 RDW-13.2 Plt Ct-100*
[**2122-9-12**] 06:11AM BLOOD WBC-6.0 RBC-2.43* Hgb-8.1* Hct-23.8*
MCV-98 MCH-33.6* MCHC-34.2 RDW-13.1 Plt Ct-98*
[**2122-9-13**] 06:45AM BLOOD WBC-7.2 RBC-2.54* Hgb-8.7* Hct-25.0*
MCV-98 MCH-34.2* MCHC-34.8 RDW-13.5 Plt Ct-81*
[**2122-9-14**] 06:29AM BLOOD WBC-8.1 RBC-2.51* Hgb-8.7* Hct-24.9*
MCV-99* MCH-34.9* MCHC-35.2* RDW-14.0 Plt Ct-106*
[**2122-9-4**] 07:50AM BLOOD Neuts-89.2* Lymphs-5.8* Monos-4.4 Eos-0.3
Baso-0.3
[**2122-9-12**] 06:11AM BLOOD Neuts-86.6* Lymphs-9.4* Monos-1.8*
Eos-2.0 Baso-0.2
[**2122-9-13**] 06:45AM BLOOD Neuts-85.4* Lymphs-10.6* Monos-1.7*
Eos-2.0 Baso-0.3
[**2122-9-5**] 05:53AM BLOOD Plt Ct-87*
[**2122-9-6**] 02:40AM BLOOD PT-13.0 PTT-35.0 INR(PT)-1.1
[**2122-9-6**] 02:40AM BLOOD Plt Ct-112*
[**2122-9-7**] 02:45AM BLOOD PT-13.0 PTT-34.9 INR(PT)-1.1
[**2122-9-7**] 02:45AM BLOOD Plt Ct-114*
[**2122-9-8**] 02:27AM BLOOD PT-13.6* PTT-34.3 INR(PT)-1.2*
[**2122-9-8**] 02:27AM BLOOD Plt Ct-107*
[**2122-9-9**] 06:07AM BLOOD Plt Ct-103*
[**2122-9-10**] 05:04AM BLOOD Plt Ct-94*
[**2122-9-11**] 05:31AM BLOOD Plt Ct-100*
[**2122-9-12**] 06:11AM BLOOD Plt Ct-98*
[**2122-9-13**] 06:45AM BLOOD Plt Ct-81*
[**2122-9-14**] 06:29AM BLOOD Plt Ct-106*
[**2122-9-5**] 05:53AM BLOOD Glucose-89 UreaN-111* Creat-8.3* Na-135
K-4.3 Cl-101 HCO3-13* AnGap-25*
[**2122-9-5**] 08:00PM BLOOD Glucose-111* UreaN-114* Creat-8.8*
Na-131* K-5.5* Cl-97 HCO3-13* AnGap-27*
[**2122-9-6**] 02:40AM BLOOD Glucose-107* UreaN-118* Creat-9.0* Na-134
K-5.4* Cl-100 HCO3-15* AnGap-24*
[**2122-9-6**] 06:00AM BLOOD UreaN-123* Creat-9.4* Na-136 K-4.3 Cl-99
[**2122-9-6**] 03:28PM BLOOD Glucose-121* UreaN-130* Creat-9.4* Na-135
K-4.1 Cl-98 HCO3-14* AnGap-27*
[**2122-9-7**] 02:45AM BLOOD Glucose-102* UreaN-139* Creat-9.8* Na-133
K-4.1 Cl-96 HCO3-13* AnGap-28*
[**2122-9-8**] 02:27AM BLOOD Glucose-108* UreaN-88* Creat-6.9*# Na-136
K-3.7 Cl-99 HCO3-22 AnGap-19
[**2122-9-10**] 05:04AM BLOOD Glucose-102* UreaN-92* Creat-7.3* Na-135
K-3.7 Cl-99 HCO3-21* AnGap-19
[**2122-9-11**] 05:31AM BLOOD Glucose-100 UreaN-54* Creat-5.0*# Na-137
K-3.7 Cl-100 HCO3-27 AnGap-14
[**2122-9-12**] 06:11AM BLOOD Glucose-96 UreaN-29* Creat-3.5*# Na-138
K-3.7 Cl-102 HCO3-33* AnGap-7*
[**2122-9-13**] 06:45AM BLOOD Glucose-100 UreaN-44* Creat-4.7*# Na-136
K-4.0 Cl-99 HCO3-31 AnGap-10
[**2122-9-14**] 06:29AM BLOOD Glucose-119* UreaN-56* Creat-5.5* Na-136
K-3.9 Cl-98 HCO3-30 AnGap-12
[**2122-9-6**] 02:40AM BLOOD ALT-172* AST-372* AlkPhos-112*
TotBili-0.3
[**2122-9-8**] 02:27AM BLOOD ALT-97* AST-71* AlkPhos-94 TotBili-0.3
[**2122-9-9**] 06:07AM BLOOD ALT-72* AST-54* AlkPhos-108* TotBili-0.2
[**2122-9-10**] 05:04AM BLOOD ALT-65* AST-52* AlkPhos-108* TotBili-0.2
[**2122-9-11**] 05:31AM BLOOD ALT-60* AST-59* LD(LDH)-183 AlkPhos-97
TotBili-0.2
[**2122-9-6**] 02:40AM BLOOD Calcium-8.8 Phos-8.9* Mg-2.5
[**2122-9-6**] 03:28PM BLOOD Calcium-8.3* Phos-8.8* Mg-2.4
[**2122-9-7**] 02:45AM BLOOD Calcium-8.1* Phos-9.0* Mg-2.5
[**2122-9-8**] 02:27AM BLOOD Calcium-8.2* Phos-5.6*# Mg-2.1 Iron-110
[**2122-9-9**] 06:07AM BLOOD Calcium-7.7* Phos-5.0* Mg-2.1
[**2122-9-10**] 05:04AM BLOOD Calcium-7.9* Phos-5.1* Mg-2.1
[**2122-9-11**] 05:31AM BLOOD Albumin-2.5* Calcium-7.9* Phos-3.7 Mg-2.1
[**2122-9-14**] 06:29AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2
[**2122-9-8**] 02:27AM BLOOD calTIBC-137* Ferritn-430* TRF-105*
[**2122-9-7**] 04:53PM BLOOD TSH-2.4
[**2122-9-9**] 06:07AM BLOOD Cortsol-28.4*
[**2122-9-4**] 07:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2122-9-6**] 06:00AM BLOOD Vanco-15.3
[**2122-9-6**] 02:46AM BLOOD Type-[**Last Name (un) **] Temp-36.8 pH-7.20* Comment-GREEN
TOP
[**2122-9-7**] 02:49AM BLOOD Type-[**Last Name (un) **] Temp-35.7 pH-7.25* Comment-GREEN
TOP
[**2122-9-7**] 02:49AM BLOOD freeCa-1.07*
[**2122-9-14**] 06:29AM BLOOD WBC-8.1 RBC-2.51* Hgb-8.7* Hct-24.9*
MCV-99* MCH-34.9* MCHC-35.2* RDW-14.0 Plt Ct-106*
[**2122-9-15**] 07:30AM BLOOD WBC-6.4 RBC-2.35* Hgb-7.9* Hct-23.6*
MCV-100* MCH-33.7* MCHC-33.6 RDW-13.8 Plt Ct-114*
[**2122-9-13**] 06:45AM BLOOD Neuts-85.4* Lymphs-10.6* Monos-1.7*
Eos-2.0 Baso-0.3
[**2122-9-15**] 07:30AM BLOOD Neuts-82.6* Lymphs-12.1* Monos-2.6
Eos-2.2 Baso-0.4
[**2122-9-14**] 06:29AM BLOOD Plt Ct-106*
[**2122-9-15**] 07:30AM BLOOD Plt Ct-114*
[**2122-9-4**] 07:50AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2122-9-14**] 06:29AM BLOOD Glucose-119* UreaN-56* Creat-5.5* Na-136
K-3.9 Cl-98 HCO3-30 AnGap-12
[**2122-9-15**] 07:30AM BLOOD Glucose-90 UreaN-33* Creat-3.7*# Na-137
K-3.9 Cl-100 HCO3-29 AnGap-12
[**2122-9-14**] 06:29AM BLOOD proBNP-[**Numeric Identifier **]*
[**2122-9-14**] 06:29AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2
[**2122-9-15**] 07:30AM BLOOD Calcium-8.2* Phos-1.9*# Mg-2.0
[**2122-9-16**] 06:32AM BLOOD WBC-7.3 RBC-2.51* Hgb-8.5* Hct-25.2*
MCV-101* MCH-33.9* MCHC-33.7 RDW-14.0 Plt Ct-129*
[**2122-9-16**] 06:32AM BLOOD Plt Ct-129*
[**2122-9-16**] 06:32AM BLOOD Glucose-98 UreaN-43* Creat-4.2* Na-139
K-3.9 Cl-100 HCO3-30 AnGap-13
[**2122-9-16**] 06:32AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.0
.
CXR [**2122-9-3**]: No acute cardiopulmonary process.
.
CT AP [**2122-9-3**]:
1. Infrarenal abdominal aortic aneurysm has increased in size in
comparison to prior study from [**2118**] now measuring up to 5.3 cm
without evidence of rupture. A curvilinear hyperdense focus in
the periphery of the aortic aneurysm sac may represent
calcification within the thrombotic portion of the aneurysm
which is favored, or alternatively, could represent focal
hemorrhage into the thrombus. Assessment for dissection is
limited on this study. Further evaluation with MRI is
recommended.
2. Extensive atherosclerotic disease with bilateral renal
stents, the patency of which cannot be assessed on this exam.
3. Likely hemorrhagic cyst in the left kidney.
.
Rneal US with Doppler [**2122-9-3**]:
1. Well-vascularized symmetric-appearing kidneys bilaterally,
with moderately elevated RIs. Both renal arteries are patent.
2. 1.4-cm complex cyst within the upper pole of the right kidney
for which a followup ultrasound in one year is recommended. 3.
9-mm simple cyst of the upper pole of the left kidney.
.
Echo [**2033-9-4**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is unusually
small. Overall left ventricular systolic function is normal
(LVEF 65%). However, mechanical dyssynchrony is present. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area 0.9
cm2). Mild to moderate ([**1-18**]+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**1-18**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2121-8-8**], the aortic valve effective orifice area is
further reduced.
.
Abdominal US with Doppler [**2122-9-5**]
1. Cholelithiasis without specific evidence of cholecystitis.
2. Patent hepatic vasculature as described above
**FINAL REPORT [**2122-9-6**]**
URINE CULTURE (Final [**2122-9-6**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2122-9-4**] 7:31 pm URINE Source: Catheter.
**FINAL REPORT [**2122-9-6**]**
URINE CULTURE (Final [**2122-9-6**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Time Taken Not Noted Log-In Date/Time: [**2122-9-4**] 9:10 pm
URINE CHM S# [**Serial Number 103590**]M ADDED [**9-4**].
**FINAL REPORT [**2122-9-5**]**
Legionella Urinary Antigen (Final [**2122-9-5**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**2122-9-5**] 3:59 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2122-9-6**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2122-9-6**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2122-9-9**]- Blood Cultures-negative.
[**2122-9-15**] Vein Mapping Study for placement of AVF.
[**2122-9-11**] Negative blood culture
[**2122-9-18**] 07:47AM BLOOD WBC-6.4 RBC-2.87* Hgb-9.7* Hct-28.2*
MCV-98 MCH-33.8* MCHC-34.4 RDW-15.0 Plt Ct-91*
[**2122-9-18**] 07:47AM BLOOD Plt Smr-LOW Plt Ct-91*
Brief Hospital Course:
87yo F with known CKD s/p B/L renal artery stents who was
admitted with back pain, concerning for growth of her AAA. She
was initially admitted to vascular surgery, but transfered to
the MICU for hypotension, new O2 requirement, and urosepsis.
#UTI complicated by sepsis/bactermia: 1 of 2 blood cultures grew
pan-sensitive E. coli. Urine culture also grew pan-sensitive E.
Coli. She was initally on ceftriaxone and levofloxacin for
community aquired organisms, but this was narrowed to
ceftriaxone based on Cx data. C. diff negative, RUQ u/s negative
for acute cholecystitis. After transfer to the general medicine
floor, she was transitioned to ceftazidime on [**9-13**] to allow for
simultaneous hemodialysis administration. Ceftazidime was
switched to PO cefpodoxime starting on [**2122-9-16**]. Continue
cefpodoxime for 14 days after first negative blood cultures.
First negative blood cultures were drawn on [**9-9**]. [**9-11**] blood
cultures were also negative.
# Acute on chronic renal failure: FeNa 11% on admission. Initial
urinalysis showed many white cells and some muddy brown casts.
Her acidosis (likely secondary to uremia) was worsening, so HD
was initiated [**2122-9-7**]. Worsening renal failure (high of Cr was
9.8) was thought to be due to acute ischemic damage from sepsis.
UPEP revealed significant polyclonal bands but no monoclonal
predominance and no Bence-[**Doctor Last Name **] proteins. She remained with low
urine output (~100smL/24 hrs) through her stay on the general
medicine floor. She responded well to hemodialysis with
appropriate reductions in BUN/Cr and normalization of
electrolytes.
# Hypoxia: Felt to be due to volume overload in setting of
worsening renal failure. She was maintained on 2L O2 nasal
cannula with O2 sats in the 98-100% range. She was tried on room
air on [**9-14**] and desaturated to 86%; her O2 sat recovered
immediately after replacement of nasal cannula. On [**9-16**], at HD
were able to successfully remove 1.5L. Pt has been on RA since
[**9-16**]. She had another 1.5L removed on [**9-17**] and 1L on [**2122-9-18**].
# Atrial Fibrillation: During a session of HD, she went into
a-fib, and became hypotensive. She dropped her pressures into
systolics of 70s, and she was fluid responsive to 250cc boluses.
She was amiodarone loaded and she converted into sinus rhythm.
She was continued on amiodarone 400mg PO BID from [**Date range (1) 103591**]. She
is to switch to amiodarone 200mg PO daily afterward.
# Severe aortic stenosis: She showed clinical signs of
congestive heart failure consistent with aortic stenosis during
hospitalization, including bilateral 1+ pitting edema of lower
extremities, pulmonary edema, 3/6 systolic crescendo-decrescendo
murmur at LLSB, and widened pulse pressure. Her echocardiogram
from [**2122-9-5**] showed severe aortic stenosis with a
cross-sectional area of 0.9cm. She was evaluated by the
cardiothoracic surgery team for possible aortic valve
replacement but was thought to be a poor candidate for either
surgical or catheter-based valve replacement given her age and
dialysis.
# Hypocalcemia: Likely related to progressive renal failure.
Corrected calcium of 7.4. Follow ionized calcium and repleted
PRN. PTH 497, vit D 44ng/ml. Patient is on Calcitriol.
# Transaminitis: No EtOH Hx. Hypotension unlikely profound
enough for shock liver. Followed labs and they trended down. RUQ
US as noted above with no acute cholecystitis. Statin held in
the setting of LFT abnormalities.
# CAD: Held ASA in the setting of thrombocytopenia.
# HLD: Held anti-hypertensives given transient hypotension and
renal failure.
# Breast CA: Hold letrozole in setting of low CrCl
# Code: Full (confirmed with patient)
Pending Issues
Blood culture [**9-11**] pending
We held patient's letrozole 2.5 mg daily as has low CrCl
We held her BP meds: Olmesartan-HCTZ 20mg-12.5mg daily,
Amlodipine 10mg daily - Nitroglycerin 0.4mg SL PRN because of
low BP here.
her ASA was switched from 325mg to 81mg because of
thrombocytopenia
We held Rosuvastatin 20mg daily because of transaminitis
We held her Ergocalciferol 50,000 units every other week and are
giving her Calcitriol 0.25 mcg PO EVERY OTHER DAY
These medications may be restarted/titrated in conjunction with
her PCP and [**Name9 (PRE) 62587**] physicians.
-
Medications on Admission:
* Amlodipine 10mg daily
* Ergocalciferol 50,000 units every other week
* Letrozole 2.5mg daily
* Olmesartan-HCTZ 20mg-12.5mg daily
*Rosuvastatin 20mg daily
* Aspirin 325mg daily
* Ferrous sulfate 325mg daily
* Nitroglycerin 0.4mg SL PRN
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-18**] Sprays Nasal
QID (4 times a day) as needed for nasal dryness.
6. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO QMONWEDFRI
(): Last day is [**2122-9-23**]. Please give after each
dialysis session, Monday,Wednesday Friday.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3137**] Care Center - [**Location (un) 1468**]
Discharge Diagnosis:
Urosepsis
Acute Kidney Injury
End Stage Renal Disease
Severe Aortic Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to care for you during your hospitalization at
[**Hospital1 69**]. You were admitted to the
hospital for back pain. During your admission, we performed
laboratory tests and determined that you had renal failure and a
urinary tract infection, which then infected your blood stream.
You were treated in the intensive care unit (ICU), and given IV
fluids and antibiotics. You were given hemodialysis to replace
the kidneys' function in cleaning your blood. You were also
given physical therapy to rebuild your strength after your stay
in the ICU.
.
You also had signs of heart failure related to your aortic valve
stenosis, including leg swelling, changes in your blood
pressure, and fluid in your lungs. Our cardiothoracic surgeons
evaluated you and currently believe that surgical replacement of
your aortic valve while on dialysis poses more risks than
benefits. You may wish to ask your primary care provider about
this issue at a future date.
.
Please make sure to attend your hemodialysis appointments three
times a week as scheduled. Upon arrival to rehab facility,
please see the facility's physician. [**Name10 (NameIs) **] discharge from rehab
facility, please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7726**],[**First Name3 (LF) 177**] A. at
[**Telephone/Fax (1) 7728**] to schedule a follow up appointment concerning your
hospitalization.
.
You were evaluated by the nephrologists and the attending
internal medicine physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) **], who feel that
it is safe for you to be transferred to the rehabilitation
hospital now.
.
We made several changes to your medications. You should STOP
taking the following medication until your primary care doctor
says otherwise:
-amlodipine
-letrozole
-nitroglycerin
-olmesartan-hydrochlorothiazide (Benicar)
-rosuvastatin
-Ergocalciferol
.
You should START taking:
-Cefpodoxime 200mg on MWF (with dialysis)- (last day is [**2122-9-23**])
-Metoprolol succinate 12.5mg ONCE daily
-Amiodarone- 200mg once daily
-Tylenol as needed for pain
-Calcitriol
-B complex-vitamin C-folic acid
Followup Instructions:
Department: TRANSPLANT CENTER
When: THURSDAY [**2122-10-15**] at 1:20 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: FRIDAY [**2122-12-11**] at 10:10 AM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2122-9-18**]
ICD9 Codes: 5845, 2762, 2761, 2875, 4280, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2746
} | Medical Text: Admission Date: [**2170-10-9**] Discharge Date: [**2170-10-18**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
female with coronary artery disease. The patient is status
post cardiac catheterization during [**2170-8-31**] admission
for right femoral-popliteal bypass when the patient developed
an episode of chest pain while at dialysis. She went to
catheterization during which a cypher stent was placed in her
right coronary artery.
The patient had no further cardiac symptoms following this
until four days prior to her current admission when she
developed an episode of chest pain. The patient was at
dialysis and was briefly hypotensive, requiring cessation of
dialysis. Several hours following this she developed chest
pain which was accompanied by weakness and lethargy. Her
weakness continued over the next few days. She also noted
dyspnea with walking and presented to the Emergency
Department for further evaluation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Depression.
3. End-stage renal disease (on hemodialysis).
4. Hypercholesterolemia.
5. Type 2 diabetes mellitus.
6. History of transient ischemic attack.
7. Coronary artery disease; status post myocardial
infarction.
8. Glaucoma.
9. Cataracts.
10. Peripheral vascular disease; status post right
femoral-popliteal bypass; status post left femoral-tibial
bypass graft; status post right coronary artery stent.
MEDICATIONS ON ADMISSION: Home medications included aspirin,
Plavix, Pravastatin, captopril, Prilosec, Lopressor, Renagel,
Vicodin, insulin, and eyedrops.
ALLERGIES:
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
the patient's temperature was 96.7 degrees Fahrenheit, her
blood pressure was 142/38, her heart rate was 84, and her
respiratory rate was 23. In general, the patient was a pale
elderly female in no acute distress. Head, eyes, ears, nose,
and throat examination revealed surgical pupils. Left pupil
was dilated and nonreactive. The right pupil was minimally
reactive; thought from surgical. Extraocular movements were
intact. The oropharynx was clear. The mucous membranes were
dry. Cardiovascular examination revealed a regular rate.
Normal first heart sounds and second heart sounds. There was
a holosystolic murmur heard loudest at the apex. The lungs
were clear to auscultation anteriorly. The abdominal
examination revealed positive bowel sounds. The abdomen was
soft, nontender, and nondistended. Extremity examination
revealed pulses were dopplerable. The right was bandaged.
No edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed the patient's white blood cell count was 11.6, her
hematocrit was 28.6, and her platelets were 245. Her sodium
was 142, potassium was 3.9, chloride was 102, bicarbonate was
28, blood urea nitrogen was 41, creatinine was 4.6, and blood
glucose was 100. Creatine kinase was 179, CK/MB was 20, MB
index was 11.2, and troponin was 5.95.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a
normal sinus rhythm at a rate of 70, left ventricular
hypertrophy. There were 1-mm to 2-mm ST elevations in leads
II, III, and aVF.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR ISSUES: (a) Coronaries: Given
electrocardiogram changes and cardiac history, the patient
went to the Catheterization Laboratory upon arrival to the
Emergency Department.
Cardiac catheterization showed a thrombus in her proximal
right coronary artery stent. During catheterization, this
was successfully re-stented with a 3.5-mm X 23-mm Hepacoat
stent. The catheterization also showed elevated filling
pressures with an elevated wedge pressure.
The patient was transiently hypotensive during cardiac
catheterization and briefly required a dopamine drip, but her
procedure was otherwise uncomplicated.
The patient was then transferred to the Coronary Care Unit
for close monitoring. She was loaded on Plavix and received
Integrilin for 18 hours. She was continued on a daily
regimen of aspirin, Plavix, and statin. She was heparinized
until an echocardiogram was obtained. She was started back
on a beta blocker and ACE inhibitor which were titrated up
throughout her hospitalization. The patient developed a
cough with the ACE inhibitor and was instead switched to an
angiotensin receptor blocker.
(b) Pump: The patient had a post myocardial infarction
echocardiogram which showed an ejection fraction of 40%. She
was put back on an ACE inhibitor for afterload reduction
which was then changed over to an angiotensin receptor
blocker as she developed a cough. She received regular
hemodialysis for management of her volume status.
(c) Rhythm: The patient was monitored on telemetry
throughout her hospitalization. She did not have any
arrhythmia complications.
(d) Valves: The patient was admitted with a history of
mitral regurgitation. Her post myocardial infarction
echocardiogram showed 2+ mitral regurgitation. She was
continued on an ACE inhibitor.
2. PULMONARY ISSUES: No active issues. The patient
saturated well on room air throughout her hospitalization.
3. RENAL ISSUES: The patient with end-stage renal disease
(on hemodialysis). She was followed by the Renal Service
throughout her hospitalization and continued to receive
dialysis three times per week (per her regular schedule).
She was also continued on Renagel for her elevated phosphate.
4. ENDOCRINE ISSUES: The patient with a history a type 2
diabetes mellitus. She was continued on NPH insulin with
regular insulin supplementation at meals (per her home
regimen).
5. PERIPHERAL VASCULAR DISEASE ISSUES: The patient was
status post a right femoral-popliteal bypass. He wound was
monitored and dressed throughout her hospitalization. Her
surgical followup was verified.
6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
placed on a cardiac, diabetic, American Diabetes Association
diet which she tolerated well. Her electrolytes were
monitored.
7. OPHTHALMOLOGIC ISSUES: The patient with a history of
glaucoma and cataracts. The patient was continued on her
glaucoma eyedrops (per her home regimen).
8. NEUROLOGIC ISSUES: The patient was admitted with
complaints of fatigue and somnolence. These symptoms quickly
resolved following cardiac catheterization and were thought
to be due to her cardiac problems. She had a
thyroid-stimulating hormone sent which was normal. She did
not have any further episodes of lethargy or other
neurological issues during her hospitalization.
9. INFECTIOUS DISEASE ISSUES: The patient with urinalysis
showing asymptomatic bacteruria. Her Foley catheter was
removed, and she remained asymptomatic. Per consultation
with the Renal Service, the patient was not treated for her
asymptomatic bacteruria.
10. PROPHYLAXIS ISSUES: Proton pump inhibitor for
gastrointestinal prophylaxis and subcutaneous heparin for
deep venous thrombosis prophylaxis. Colace and Senna were
given for a bowel regimen.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to rehabilitation.
DISCHARGE DIAGNOSES:
1. Right coronary artery stent thrombosis with successful
restenting of thrombosed stent.
2. End-stage renal disease (on hemodialysis).
3. Non-ST-elevation myocardial infarction.
4. Urinary tract infection.
MEDICATIONS ON DISCHARGE:
1. Losartan 25 mg by mouth once per day.
2. Heparin 5000 units subcutaneously q.12h.
3. Metoprolol 50 mg by mouth twice per day.
4. Renagel 800 mg by mouth three times per day.
5. Pantoprazole 40 mg by mouth q.24h.
6. Nephrocaps one tablet by mouth once per day.
7. Pramipexole 0.25 mg by mouth at hour of sleep.
8. Timolol 0.5% ophthalmologic eyedrops one drop both eyes
twice per day.
9. Prednisolone 1% ophthalmologic suspension one drop both
eyes twice per day.
10. Pilocarpine 2% one drop both eyes at hour of sleep.
11. Levobunolol 0.5% one drop both eyes at hour of sleep.
12. Dorzolamide 2%/Timolol 0.5% one drop twice per day (to
right eye only).
13. Brimonidine tartrate 0.15% ophthalmologic eyedrops q.8h.
14. Quinine sulfate 325 mg by mouth every Monday, Wednesday,
and Friday.
15. Pravastatin 10 mg by mouth at hour of sleep.
16. Senna one tablet by mouth twice per day as needed.
17. Colace 100 mg by mouth twice per day.
18. Plavix 75 mg by mouth once per day.
19. Aspirin 325 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Surgery on
[**10-23**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as previously scheduled.
2. The patient was instructed to follow up with her primary
care physician in one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Last Name (NamePattern1) 5212**]
MEDQUIST36
D: [**2170-10-18**] 16:16
T: [**2170-10-18**] 16:37
JOB#: [**Job Number 101053**]
ICD9 Codes: 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2747
} | Medical Text: Admission Date: [**2152-8-27**] Discharge Date: [**2152-9-4**]
Date of Birth: [**2119-2-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 33 year old Brazilian
man who was painting his house at 05:00 p.m. on [**8-26**].
At around 09:00 p.m. he developed right facial droop,
slurred speech and altered mental status. He was taken to an
outside hospital by EMS where a CT scan showed a 2 centimeter
by 4 centimeter by 3 centimeter bleed in the right basal
ganglion. He was then transferred to the Neurosurgery Service
at [**Hospital1 69**]. He was started on
Nipride and Decadron. Medicine was consulted regarding the
question of malignant hypertension. They declined the
secondary hypertension work-up because they felt that normal
renal function along with long-standing hypertension was less
likely. The patient did have a diagnosis of essential
hypertension but was not taking his medications, possibly
Hydrochlorothiazide, for one to two years.
An angiogram was done which was negative for malformation.
It was thought that the patient had this bleed due to his
history of essential hypertension.
The patient also had a fever and increased white blood cell
count that was noticed after he was intubated. His sputum
was positive for Streptococcus pneumoniae and Hemophilus and
he was started on Levaquin. He was extubated on [**8-31**]
and did well.
He was weaned off Nitroprusside and that was stopped on
[**9-1**], and he was then started on Lopressor 100 mg
p.o. q. six, Enalapril 20 mg q. day and Clonidine patch for
blood pressure control. He was transferred to the Neurology
Service at this time.
PHYSICAL EXAMINATION: On mental status, he was alert,
oriented to person and place, not date or year. There was
some language barrier due to his speaking mainly Portugese.
His speech was dysarthric. He can repeat but difficult to
assess secondary to language. No apraxia. He is able to
follow commands appropriately. Difficult to understand at
times. Cranial nerves were right facial droop, extraocular
movements intact. Pupils are equal, round and reactive to
light. There was right sided tongue deviation. Sensation
was normal. Shrug was normal. Strength was five out of five
on the left; on the right deltoids are three plus; biceps
were four minus, triceps were three plus, wrist flexors were
three plus, wrist extensors four minus. Finger flexors were
three plus, finger extensors four minus. Interosseous four
minus, hip flexors four plus. Hip extensors five. Knee
flexors five minus, knee extensors five. Toe extensors five,
toe flexors five. Sensory was intact to light touch for both
temperature and proprioception. Deep tendon reflex were two
out of four plus bilateral upper extremities and lower
extremities. Right patella was three out of four plus, and
left was two out of four. Gait was not assessed. The patient
refused to walk. Coordination was normal,
finger-to-nose-finger, rapid alternating movements on the
left as well. There was slight ataxia on the right likely
secondary to weakness. There was slow repetitive knee
movements.
HOSPITAL COURSE: On admission to the Neurology Service, the
patient was doing well and continued to do well with Physical
Therapy, Occupational Therapy and Speech. It was deemed that
the patient should continue these three modalities of
rehabilitation on discharge.
In regards to his blood pressure he was on the medicines as
stated above. On the day prior to discharge, his pressures
were extremely well controlled. His pressures ranged from
100 to 130 systolic over 68 to 80 diastolic. Multiple doses
of his Lopressor were held in the two days prior to discharge
for a total of four doses held over two days, secondary to
the low blood pressure parameters. His other vital signs
were stable and the patient and his wife were excited to go
home.
He was sent home on [**9-4**], and was doing well
neurologically. We decreased his Metoprolol to 100 mg twice
a day as his blood pressure was well controlled and continued
the rest of his medicines as stated below.
DISCHARGE INSTRUCTIONS:
1. He is to follow-up with Dr. [**Last Name (STitle) **] in the [**Hospital 878**]
Clinic in four weeks.
2. He is also to follow-up with Dr. [**Last Name (STitle) **] at 02:00 p.m. on
the [**Hospital Ward Name 23**] 6 floor building and I called and made an
appointment for him. This is on Tuesday, [**9-12**]. His
phone number is [**Telephone/Fax (1) 250**].
3. He will continue on Levaquin for four more days for his
pneumonia to complete a ten day course.
CONDITION ON DISCHARGE: Otherwise, the patient was stable
and doing well.
DISCHARGE MEDICATIONS:
1. Lopressor 100 mg twice a day.
2. Enalapril 20 mg q. day.
3. Protonix 40 mg q. day.
4. Clonidine TTS patch q. Thursday.
5. Levaquin 500 mg p.o. q. day times four more days.
DISCHARGE STATUS: To home with Home Health Services.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2152-9-4**] 18:56
T: [**2152-9-11**] 05:27
JOB#: [**Job Number 8149**]
ICD9 Codes: 431, 486, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2748
} | Medical Text: Admission Date: [**2137-12-27**] Discharge Date: [**2138-1-17**]
Date of Birth: [**2074-12-26**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides) / Tomato / Fish Product Derivatives / Peach
/ Citrus Derived / Egg
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Consulted for subdural empyema
Major Surgical or Invasive Procedure:
1. Bilateral frontal sinus trephine.
2. Left external ethmoidectomy.
3. Left endoscopic maxillary antrostomy.
History of Present Illness:
HPI: 63yM with HTN who was transfered from [**Location (un) 620**] after being
found down at 5am at his office bathroom. He was intially
thought to have a stroke based on [**Location (un) 620**] CT and left sided
hemiparesis. MRI done here shows a frontal sinusitis with
resulting empyema along the falx cerebri and along the lateral
right frontal lobe.
Past Medical History:
PMHx: HTN
Social History:
Social Hx: no tobacco, EtOH, drug use, single, lives with sister
Family History:
Family Hx: father died age 85yo, mother died 85yo w/ CHF,
grandfather died of brain tumor
Physical Exam:
PHYSICAL EXAM:
O:
T: 101.7 BP: 138/63 HR: 92 R16 O2Sats 97RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs Intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Asleep, easily aroused, somnolent, mostly
cooperative with exam, blunted affect.
Orientation: Oriented to person, place, and date.
Language: Speaks in short sentences with good comprehension and
repetition. Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 2
mm bilaterally. Visual fields are full to confrontation. No
anopsia or neglect was noted
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone in bilateral upper extremities.
Increased tone in RLE and normal tone LLE. No abnormal
movements,
tremors. Strength full power [**6-1**] throughout bilateral upper
extremities. RLE with full strength thoughout. LLE with IP
[**6-1**];
Q [**5-2**]; H [**5-2**]; G, [**Last Name (un) 938**], AT 0/5. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes equivocal left and downgoing on right
No Clonus
Coordination: normal on finger-nose-finger, rapid alternating
movements
Pertinent Results:
Labs:
Coags 14.1/27.4/1.2
CBC 22.4>39.8<401 Diff 88.2/5.5/6/0.1/0.2
Lactate 2.6
Chem 132/3.5/92/23/41/2.0/142 CMP 9.1/2.7/3.3
UA Many bacteria, nitr neg, leuk tr, wbc 21-50, epi 0-2
[**12-27**]:
HEAD CT: Again seen are hypodensities involving the bilateral
frontal lobe, along the margins of the falx, with the right
frontal lobe more severe than the left. There is also suggestion
of a right subdural collection along the anterior right frontal
lobe convexity. The ifferential diagnostic considerations
includes an acute infarct or cerebritis. The ventricles and
sulci are normal in caliber and configuration. There is
complete opacification of the left maxillary sinus, with
opacification of the left ethmoidal sinuses and frontal sinus.
CTA: The carotid and vertebral arteries and their major
branches are patent with no evidence of stenoses. CT perfusion
images reveal slight delayed time to peak involving the right
frontal lobe. However, no definite vascular territory
abnormality is identified.
IMPRESSION:
1) Hypodensity involving bilateral frontal lobes along the falx
and the right inferior frontal lobe, with some suggestion of a
small subdural fluid collection anterior to the right frontal
lobe. Although these findings do not correspond to a major
vascular territory and the CTA images do not reveal any vascular
abnormalities, the differential diagnostic considerations still
includes an acute infarct or may represent cerebritis.
2) Opacification of the left maxillary, ethmoidal, and frontal
sinuses.
[**12-27**]:
MRA Head
FINDINGS: There is a small extra-axial fluid collection along
the
interhemispheric fissure as well as along the anterior right
frontal lobe.
There is corresponding restricted diffusion involving this fluid
collection. Given the restricted diffusion, this is suggestive
that this fluid collection may be an empyema. Additionally,
there is slight T2 hyperintensity of the frontal lobes
bilaterally along the falx, which also exhibit restricted
diffusion. These signal abnormalities are not in the expected
location of a vascular territory, suggesting that these findings
may represent cerebritis rather than an acute infarct.
MRA images reveal that the intracranial vertebral and internal
carotid
arteries and their major branches are normal without evidence of
stenosis,
occlusion, or aneurysm formation.
There is opacification of the left maxillary, ethmoid, and
frontal sinuses. On T2- weighted images, there appears to be a
linear structure that communicates with the opacified frontal
sinus and the fluid collection anterior to the right frontal
lobe. This may represent a site of abnormal communication
leading to underlying empyema.
IMPRESSION:
1. Abnormal small extra-axial fluid collection along the
interhemispheric
fissure as well as along the anterior right frontal lobe, with
associated
restricted diffusion. This is concerning for an empyema.
2. Slight T2 hyperintense signal of bilateral frontal lobes
adjacent to the falx and inferior frontal lobes bilaterally.
These lesions also exhibit restricted diffusion, and may
represent cerebritis associated with the overlying empyema
rather than an acute infarction.
3. Left maxillary, ethmoidal, frontal sinus opacification with
abnormal
linear structure connecting the frontal sinus with the abnormal
fluid
collection, suggestive of a possible source of communication.
[**12-27**]
SINUS CT: There is complete opacification of the left maxillary
sinus with opacification of the left ostiomeatal unit, left
anterior ethmoidal air cells as well as left frontal sinus. As
seen on prior MR, there appears to be a site of potential
abnormal communication involving the posterior aspect of the
left frontal sinus with the extra-axial space (series 2, image
52).
Additionally, there is mild mucosal thickening of the left
sphenoid sinus as well as the right maxillary and anterior
ethmoidal air cells. There is also mild mucosal thickening of
the right frontal sinus. The right ostiomeatal unit appears to
be patent.
The cribriform plates are intact. The anterior clinoid
processes are not
pneumatized.
Again seen is hypodensity of the frontal lobes bilaterally,
along the margins of the falx as well as a hypodensity involving
the inferior frontal lobes. However, this is better appreciated
on MRI of the brain on the same day.
IMPRESSION:
1. Opacification of the left maxillary sinus, left anterior
ethmoidal air
cells, as well as left frontal sinus, consistent with an
obstructive
sinusitis. There appears to be a potential site of
communication involving the posterior left frontal sinus with
the extra-axial space.
2. Mild mucosal thickening of the right frontal, right anterior
ethmoidal,
and right maxillary sinus.
3. Hypodensity involving bilateral frontal lobes along the
margins of the
falx seen on prior MRI, without significant change from earlier
in the
morning.
[**12-28**]
CT OF THE HEAD WITHOUT CONTRAST: Motion artifact limits the
study. Since
prior exam, there has been interval craniotomy. Pneumocephalus
is seen,
likely related to recent procedure. 4 mm leftward midline shift
is noted and unchanged. The right subdural empyema has
resolved. Hyperdense subdural collection in the right frontal
convexity measuring up to 6 mm in (2 A, I 24) is new and likely
represents small subdural hematoma. There is effacement of the
right frontal sulci, which is unchanged. Hyperdense material
along the falx is noted consistent with subdural hematoma.
Unchanged appearance of the paranasal sinuses.
IMPRESSION:
1. Interval craniotomy and drainage of right subdural empyema.
2. Hyperdense material along the falx cerebri and right frontal
convexity
consistent with subdural hematoma.
3. Small pneumocephalus likely related to recent procedure.
Unchanged minimal leftward midline shift and effacement of the
frontal sulci.
[**12-29**]
CT OF THE HEAD WITH AND WITHOUT IV CONTRAST:
There is no significant change compared to one day prior. Right
frontal craniotomy is again seen with a small amount of residual
pneumocephalus. Small right subdural hemorrhage layering along
the right frontal convexity and falx is unchanged. A 4-mm of
midline shift is also unchanged. The ventricles are normal in
size and configuration. Hypodensity along the parafalcine
frontal cortex may represent subdural fluid and necrosis related
to the patient's empyema. The paranasal sinuses again
demonstrate diffuse opacification of the left maxillary sinus
and the ethmoid air cells, as well as the frontal sinuses, which
both contain drainage catheters. Contrast-enhanced imaging does
not demonstrate any
evidence of dural venous thrombosis. However, this is not a CT
venogram,
simply a routine post contrast CT scan. If there is concern of
sinus
thrombosis, an MR venogram, or a CT venogram are suggested.
There is again
mild hyperenhancement of the right frontal cortex, suggesting
persistent
cerebritis.
IMPRESSION:
1. Relatively unchanged appearance of right subdural
hemorrhage/fluid
collection. Unchanged hypodensities in the right frontal
parafalcine cortex related to the patient's cerebritis.
2. No evidence of dural venous thrombosis on routine post
contrast CT. A CT venogram was not performed.
3. Bilateral frontal sinus drainage catheters in situ.
[**1-4**]
Non-contrast head CT.
FINDINGS: Complex hypodensities within the frontal lobes
bilaterally are
again noted and appear larger in size compared to the previous
examination. A large area of hypodensity tracking along the
anterior falx measuring approximately 10 x 1.7 cm appears
significantly larger compared to the previous examination.
Low-attenuation material is seen to extend along the right
cerebral convexity into the right middle cranial fossa. There
is significant associated mass effect with shift of normally
midline structures to the left by approximately 12 mm which is
dramatically worse compared to the previous examination. There
is significant mass effect on the right lateral ventricle with
near-complete compression of the occipital [**Doctor Last Name 534**]. Subfalcine
herniation is noted. A component of right uncal herniation is
also probably present. Compared to the previous examination,
there has been interval removal of bifrontal drains. The
frontal sinuses appear nearly completely opacified with just a
few areas pneumocephalus. Dense material is again noted within
the left maxillary sinus, extending into the left ethmoid air
cells. Mucosal thickening is also noted within the sphenoid
sinus. Numerous staples overlie the right frontal bone and
there is evidence of a right frontal craniotomy. There is also
evidence of a right parietal craniotomy.
IMPRESSION: Significant interval progression of right cerebral
subdural
collections, now extending along the anterior falx and into the
middle cranial fossa. Significant associated mass effect
including leftward shift of normally midline structures as well
as subfalcine and uncal herniation.
[**1-4**]
MRI of the brain and MRV of the head.
BRAIN MRI:
There is increase in the interhemispheric collection identified,
which extends to frontal to the occipital region, also extending
along the posterior interhemispheric fissure and along the right
side of the tentorium. The previously noted subdural collection
along the right side frontoparietal region laterally has also
slightly increased. There is now an extensive increased T2
signal seen in both frontal lobes adjacent to the
interhemispheric fissure. These signal changes are new.
However, previously noted slow diffusion in the brain parenchyma
has resolved. This finding indicates development of vasogenic
edema. Following gadolinium, extensive enhancement of the
meninges is identified along the collections. The collection
itself demonstrated an area of low signal in the
interhemispheric region on T2 and FLAIR images. The persistent
soft tissue changes seen in both frontal sinuses. There is mass
effect on the right lateral ventricle, which is partially
obliterated. There is also mass effect with partial
obliteration of the basal cisterns. Soft tissue changes are
seen in bilateral mastoid air cells.
IMPRESSION: Increase in size of interhemispheric and convexity
subdural
collections with extensive enhancement along the margins
indicative of
empyema. There is persistent slow diffusion seen within these
collections. However, presence of low signal intensity areas
within the collection also indicatea an associated hemorrhagic
component. The mass effect on the right lateral ventricle and
obliteration of the right hemispheric sulci has increased since
the previous study. There is now extensive vasogenic edema seen
in both frontal lobes.
MRV OF THE HEAD:
The MRV of the head demonstrates slightly narrowed but patent
superior
sagittal sinus. The right transverse sinus, also demonstrate
normal flow
signal. The left transverse sinus is not well visualized on the
projection images, but on the source images it is partially
visualized and could be congenitally small.
IMPRESSION: No definite evidence of superior sagittal sinus
thrombosis.
[**1-8**]
CT of the head.
FINDINGS: Again identified is an interhemispheric subdural
collection along the right side of the falx with high density
posteriorly indicative of blood products. Since the previous
study the air within the collection has resolved. The
collection is now better defined and visualized. Bifrontal
hypodensity secondary to brain edema are again noted. A small
right-sided frontal parietal convexity collection is also again
identified. Compared to the prior study the mass effect has
decreased with slight decrease in the midline shift. There is
also decreased distortion of the brainstem indicative of
improvement in uncal herniation. There is no hydrocephalus
identified. There is no new area of hemorrhage seen.
IMPRESSION: Decrease in mass effect compared to the prior CT of
[**2138-1-5**] with improvement in uncal and subfalcine herniations.
There is persistent
interhemispheric collection identified better visualized on the
current study, possibly secondary to resolution of edema in this
right cerebral hemisphere. Convexity, small subdural collection
is again identified as before. No new area of hemorrhage seen.
[**1-9**]
UPPER EXTREMITY ULTRASOUND WITH DOPPLER:
Real-time ultrasound evaluation of the left upper extremity deep
venous system using grayscale, color, and pulse wave Doppler
demonstrates a clot in the cephalic vein extending more
peripherally toward the elbow. No flow is identified in the
cephalic vein, and the vein is not compressible. The basilic
vein, brachial vein, and left internal jugular vein demonstrate
normal flow and compressibility.
IMPRESSION: Superficial venous clot in the cephalic vein. No
evidence of
deep venous thrombosis.
[**1-10**]
BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND:
Grayscale Doppler and pulse wave son[**Name (NI) 1417**] of the bilateral
lower extremities demonstrate non-compressibility, lack of flow
and echogenic thrombus in the right lesser saphenous vein. The
bilateral common femoral, superficial femoral, and popliteal
veins demonstrate normal compressibility, augmentation, and
flow.
IMPRESSION:
1. Occlusive thrombus in the right lesser saphenous vein.
2. No evidence of thrombosis in the deep venous structures of
bilateral lower extremities.
[**1-11**]
CT Head without Contrast:
FINDINGS: Again identified is an interhemispheric subdural
collection along the right side of the falx high-density
posteriorly consistent with blood products, unchanged appearance
from the prior study allowing for subtle differences in patient
positioning. Interval resolution of the postoperative
pneumocephalus. Bifrontal hypodensities secondary to edema
without interval change. Small right-sided frontoparietal
temporal extra-axial collection, not significantly changed.
There is persistent 5-mm rightward shift of normally midline
structures. Basal cisterns are not effaced. No new foci of
hemorrhage. Persistent moderate paranasal sinuses
opacification. Calcification of the mastoid air cells persists.
The patient is status post right frontal and right posterior
parietal craniotomies. Skin staples are in place.
IMPRESSION:
1. No significant short interval change in persistent posterior
interhemispheric collection and extra-axial collection overlying
the right
cerebral convexity.
2. Stable bifrontal edema with persistent 5 mm subfalcine
herniation.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the ICU for a right frontal
subdural empyema. On [**12-27**], he underwent a bilateral frontal
sinus trephine, left external ethmoidectomy and a left
endoscopic maxillary antrostomy by Dr. [**Last Name (STitle) 1837**] on the ENT
service. On [**12-28**], Mr. [**Known lastname **] had three right-sided
craniotomies for subdural empyema drainage. He was taken to the
ICU postoperatively and was intubated. On [**12-28**] the patient was
extubated and put on a face mask with an oral airway. the
preliminary cultures on the brain abscess fluid from the
drainage revealed streptococcus milleri growing in the sinus
tissue samples. On [**12-29**] he started having problems with
hypertension requiring a labetolol drip. On [**12-30**], a Dobhoff tube
was placed for enteric nutrition. On [**12-31**] a PICC line was placed
and the patient opened his eyes spontaneously for the first time
after his surgery. On [**1-3**], the infectious diseases team
recommended keeping the patient on at least 4 weeks of
antibiotics.
Mr. [**Known lastname **] became tachypneic to the 40s on [**1-3**] and was
reintubated for airway protection. He also had a spike in his
temperature at that time to a max of 102 degrees farenheit. On
[**1-4**], a repeat CT of the head was worse. An MRI was performed
which showed an empyema. An MRV showed no evidence of a venous
thrombus in the brain. On [**1-5**], Mr. [**Known lastname **] was taken back to
the OR for a sterotactic drainage of the abscess. 40cc of
purulent material was drained at that time. On [**1-6**], Mr.
[**Known lastname **] was started on Keppra for seizure prophylaxis.
On [**1-8**], the patient was taken back to the OR for evacuation of
the remaining abscess fluid. The preliminary results of the
abscess fluid revealed no growth of any micro organisms. Mr.
[**Known lastname **] also had another PICC line placed at this time for
antibiotic access. On [**1-9**] a left upper extremity ultrasound
revealed a superficial venous clot in the cephalic vein without
evidence of deep venous thrombosis. On this same day, Dr. [**Last Name (STitle) **]
arranged for a family meeting but the family was not available
to meet due to inclement weather. On [**1-11**], purulent material
was noted to be coming out from his penis, around the foley
catheter. The catheter was removed and a new one was put in
place. Also on [**1-11**], Mr. [**Known lastname **] had a bilateral lower
extremity ultrasound which revealed an occlusive thrombus in the
right lesser saphenous vein but no evidence of thrombosis in the
deep venous structures of bilateral lower extremities. The
patient was extubated on this day and did well off of the
ventilator.
Mr. [**Known lastname **] was deemed appropriate to transfer to the floor on
[**1-13**]. He was given a bedside swallow study which determined
that he could have a thin pureed diet with 1:1 supervision at
all times. Subsequent S/S evaluation determined that he was
safe to tolerate regular diet, which he tolerated for several
days prior to discharge. On [**1-13**] the ID team recommended
starting IV flagyl for positive c-diff infection. He will be on
the IV form for 14 days and then will be switched back to the PO
form of flagyl. The patient's staples were removed on [**1-13**] as
well. To date all of the cultures are negative except for the
positive clostridium difficile for which the patient is being
treated.
Pt with slightly elevated BPs upon arrival to floor - lisinopril
added, with inmprovement in readings. Family and patient are
aware and agree with the transfer to [**Hospital3 **].
Medications on Admission:
All: Sulfa
Medications prior to admission:
Atenolol, ASA
Discharge Medications:
1. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours): stop on [**1-26**] then
change dose to PO.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-29**]
Drops Ophthalmic PRN (as needed).
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
8. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): 1 Q6 hour through [**2138-2-6**] then change to Q8 then stop
on [**2138-2-19**].
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: [**1-29**]
MLs Intravenous DAILY (Daily) as needed.
12. Ceftriaxone 2 gram Piggyback Sig: One (1) Intravenous twice
a day: STOP on [**2138-2-22**].
13. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q
12H (Every 12 Hours): Titrate to trough of 20 will continue to
[**2138-2-22**].
14. Outpatient Lab Work
Weekly CBC, BUN, Creatinine, AST,ALT,Alk phos, LDH
please fax results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 432**]
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Subdural Empyema
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Follow up in the [**Hospital **] clinic: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2138-2-24**] 9:00
Need head CT on [**1-29**] and [**2-12**] call radiology
[**Telephone/Fax (1) 11**] to confirm time
Follow up with Dr [**Last Name (STitle) **] in 4 weeks call [**Telephone/Fax (1) 2731**] for an
appointment
YOU WILL Need a CT with contrast at that time
Antibiotic Instructions:
vancomycin 1g IV q8h through at least [**2138-2-22**]; goal trough 15-20
ceftriaxone 2g IV q12h through at least [**2138-2-22**]
Flagyl 500 mg PO q8h through at least [**2138-2-22**]
PO vancomycin 125 mg PO q6h through [**2138-2-6**], then 125 mg PO q8h
through [**2138-2-19**], then 125 mg PO q12h through [**2138-2-26**], then stop.
Laboratory Monitoring Required
weekly safety labs (CBC, BUN/Cr, LFTs) and vanco trough to be
drawn and results faxed to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 432**].
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**]. All questions regarding outpatient
antibiotics should be directed to the infectious disease R.Ns.
at
Completed by:[**2138-1-17**]
ICD9 Codes: 5849, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2749
} | Medical Text: Admission Date: [**2144-10-14**] Discharge Date: [**2144-10-29**]
Date of Birth: [**2072-12-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p PEA arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
71F with hx of COPD (on home O2 with cor pulmonale), DM2,
history of NSTEMI, diabetes, hyperlipidemia, diastolic
dysfunction, and pulmonary hypertension presents s/p PEA arrest
during hip fracture surgery. 2 weeks prior to admission,
patient had 2 falls, daughter spoke with witness of fall who
reported patient "blacked out". On [**10-8**], patient had MVA, hit a
tree but refused to go to the ER, no major injuries. On [**10-11**],
she had to lower herself to the floor to become comfortable
because of "swollen legs", but lost balance and fell on her
buttocks, causing a left hip fracture, which brought her to the
hospital the day after falling. Minimal PO intake in days prior
to admission.
Upon admission to OSH ED, found to have K+ 6.7, given calcium
gluconate, D50 with insulin, repeat K was 5.2. CK 66, Trop
0.04. CXR showed hyperinflation and left costophrenic angle
blunting. ECG in complete heart block with peaked T waves.
Dual chamber atrial sensing pacer placed [**2144-10-13**], then had hip
fracture surgery [**2144-10-14**]. Also received 1 unit PRBC transfusion
for dropping Hct ? GI bleed per family, they were told she would
need outpt colonscopy.
Towards closing of surgery, her BP suddenly dropped, she went
into PEA arrest, was given epi and atropine and CPR was
completed for 2-3 minutes with restoration of pulse. Echo was
completed that showed ? new anterior wall motion abnormality,
but hard to assess because she was paced. [**Hospital 56108**]
transferred to [**Hospital1 18**] for cath and CCU management.
Update before arriving to floor: Clean coronaries found during
catheterization, fighting tube, mean PCWP 38, biventricular
failure, mean RA 20, RV 55/20, PA mean 47, CI 4.2, latest ABG
7.19/67/349/27 Vent 420mL, 26, 100% FiO2, 5 PEEP, K 3.6, Lactate
1.0, H/H 9.8/29, no central line access, on 5mcg dopamine
peripherally, urine cloudy 100cc, received 300mL NS bolus, on
heparin for possible PE
On review of systems, she is intubated and sedated, not
responding to stimuli. Upon arrival to the floor patient no
longer on dopamine drip, BP dropped to 50s/30s with MAPs 40s, HR
120s ventricular paced regular p waves, faint carotid pulses
felt, started phenylephrine drip with rapid increase in MAPs to
70s and greater palpable pulses.
Per family, cardiac review of systems is notable for absence
TIA, stroke, palpitations, dysphagia, odynophagia, moves bowels
1/day, occasionally BRBPR [**3-17**] hemorrhoids, no melena, has
diarrhea occasionally, + ankle edema, no orthopnea, no PND, no
chest pain, baseline is 0.5-1 flight of stairs then needs to
stop secondary to SOB no CP.
Past Medical History:
severe COPD, on home O2 1.5L (per family), [**2138**] PFTS: FEV1 0.42,
FEVI/FVC 31, low DLCO,
DM2 - non-insulin dependent, no
retinopathy/neuropathy/nephropathy
HTN since [**2139**]
CAD s/p NSTEMI in [**2138**] - @[**Hospital1 18**] cath EF 55% normal coronaries
hypercholesterolemia
pulmonary hypertension
PAST SURGICAL/GYN HISTORY
G5P5
s/p tonsillectomy
s/p hysterectomy
Social History:
Has supportive family; one son and four daughters. Previously
worked as a bookkeeper, currently volunteers in an office.
-Tobacco history: reportedly 100+ pk-years, continues to smoke
1ppd, had bad dreams on nicotine patch in past, would not want
nicotine patch to be placed (per family)
-ETOH: 1 drink/year
-Illicit drugs: none
- caffeine use: [**7-22**] cups caffeine/day
Baseline - completes all IADLs and ADLs, drives, ambulates
independently, active volunteer
Family History:
father with liver CA died at 76, brother died of liver CA as
well, mother died at 80 had osteoporosis, 2 sisters with HTN, 1
son with HTN, 4 healthy daughters, no history of sudden death or
known arrythmias
Physical Exam:
Admission Exam:
T 95 HR 125 BP 118/57 (off dopa) sats 100% on AC Tv 400ml RR 28
FiO2 50%, PEEP 5, elevated Peak pressures
GENERAL: Intubated, not sedated, not agitated, not responding to
stimuli; withraws to nailbed pressure on toes but not on fingers
HEENT: NCAT. Sclera anicteric. PERRL. 1+ carotid pulses
CARDIAC: 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. + diffuse wheezing
anterior and posteriorly, no crackles or rhonchi.
ABDOMEN: Soft, NT, mildly distended, does not grimace to
palpation. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES: 2+ LE pitting edema, 1+ chest wall edeam, no
cyanosis, feet slightly cool, unappreciable PT/DP and radial
pulses, no femoral bruits, femoral venous and arterial lines
c/d/i.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Discharge Exam:
Pertinent Results:
(from OSH)
UA small leuk esterase, neg nitrates, 2-5WBCs.
BUN/Cr 42/0.8
Na 142
K 6.7 repeat after intervention 5.2
Ca 8.4
albumin 3.2
alk po4 98
AST 32
ALT 74
CK 66
trop 0.04
INR 1.0
PTT 27.5
WBC 8.6
Hct 27.9
Plt 216
ABG 7.33/50/62/26.2 89% (unknown settings)
.
[**2144-10-14**] 11:20PM BLOOD WBC-12.0* RBC-3.69* Hgb-11.2* Hct-35.3*
MCV-96 MCH-30.3 MCHC-31.7 RDW-16.4* Plt Ct-234#
[**2144-10-16**] 03:13PM BLOOD WBC-8.5 RBC-2.65* Hgb-8.2* Hct-23.2*
MCV-88 MCH-30.8 MCHC-35.1* RDW-17.5* Plt Ct-135*
[**2144-10-18**] 03:56AM BLOOD WBC-10.7 RBC-3.24*# Hgb-9.4* Hct-27.8*
MCV-86 MCH-29.1 MCHC-33.8 RDW-18.8* Plt Ct-175
[**2144-10-14**] 11:20PM BLOOD Neuts-92.1* Lymphs-3.6* Monos-3.9 Eos-0.2
Baso-0.3
[**2144-10-15**] 10:13PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-3+ Polychr-2+ Ovalocy-OCCASIONAL Target-1+
Burr-1+ Stipple-1+
[**2144-10-14**] 11:20PM BLOOD PT-12.1 PTT-30.2 INR(PT)-1.0
[**2144-10-14**] 11:20PM BLOOD Glucose-232* UreaN-12 Creat-0.6 Na-137
K-3.8 Cl-108 HCO3-23 AnGap-10
[**2144-10-18**] 03:56AM BLOOD Glucose-160* UreaN-23* Creat-0.8 Na-141
K-4.5 Cl-102 HCO3-32 AnGap-12
[**2144-10-14**] 11:20PM BLOOD ALT-52* AST-41* LD(LDH)-440* AlkPhos-123*
TotBili-0.4
[**2144-10-15**] 06:11PM BLOOD Hapto-148
[**2144-10-15**] 01:57AM BLOOD TSH-1.3
[**2144-10-17**] 09:00AM BLOOD Vanco-31.9*
[**2144-10-18**] 10:48AM BLOOD Vanco-20.1*
[**2144-10-14**] 09:48PM BLOOD Type-ART pO2-349* pCO2-67* pH-7.19*
calTCO2-27 Base XS--3
[**2144-10-18**] 11:33AM BLOOD Type-ART pO2-110* pCO2-47* pH-7.49*
calTCO2-37* Base XS-10
[**2144-10-14**] 09:48PM BLOOD Glucose-216* Lactate-1.0 Na-135 K-3.6
Cl-105
[**2144-10-15**] 01:17AM BLOOD freeCa-0.77*
[**2144-10-16**] 04:19AM BLOOD freeCa-1.12
.
Cardiac Cath Study Date of [**2144-10-14**]
COMMENTS:
1. Selective coronary angiography in this left dominant system
revealed
no angiographically significant disease.
2. Limited resting hemodynamics revealed elevated right
(RVEDP=20mmHg)
and left (PCW=38mmHg) sided filling pressures. There was
moderate
pulmonary arterial hypertension (SBP=56mmHg). Systemic pressures
were
normal while on 5mcg/kg/min of dopamine. The cardiac index was
normal
(CI=3.1l/min/m2).
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal ventricular function.
3. Moderate pulmonary hypertension.
4. Elevated right and left sided filling pressures
.
ECG Study Date of [**2144-10-14**]
The patient is atrial sensed and ventricular paced at a rate of
111. There is an intraventricular conduction delay with
secondary ST-T wave changes. On the prior tracing of [**2138-8-12**],
the patient was in normal sinus rhythm. Therefore, comparisons
are not valid.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
111 0 158 358/447 0 -85 95
.
CHEST (PORTABLE AP) Study Date of [**2144-10-14**]
FINDINGS: No pneumothorax. The patient is newly intubated, the
tip of the
ETT projects 4.5 cm above the carina. Expected course of the
nasogastric
tube. Newly inserted right pectoral pacemaker with expected
course of the
leads. Slight costophrenic angle blunting due to old pleural
scar, no
evidence of recent pleural effusions. Moderate interstitial
edema could be
present. Viral pneumonia would be an alternative explanation for
the slight increase in visibility of the interstitial
structures. Normal size of the cardiac silhouette.
.
Portable TTE (Focused views) Done [**2144-10-15**]
Conclusions
There is moderate regional left ventricular systolic dysfunction
with mid to apical severe hypokinesis. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %). The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The aortic valve leaflets are mildly thickened (?#).
Mitral regurgitation is present but cannot be quantified. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is
trivial/physiologic pericardial effusion.
IMPRESSION: Limited views in an emergency study. Regional left
ventricular systolic dysfunction is consistent with stress
cardiomyopathy (Takotsubo) or coronary artery disease. Right
ventricular dilation, hypokinesis, and moderate pulmonary artery
systolic hypertension are consistent with pulmonary emobli or
other chronic lung diseases.
.
ECG Study Date of [**2144-10-15**]
Marked baseline artifact. Patient remains in an atrial sensed,
ventricular
paced rhythm at a rate of 126. Otherwise, compared to tracing #1
there is no diagnostic interval change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
126 0 152 340/455 0 -85 92
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2144-10-15**]
IMPRESSION:
1. No pulmonary embolism. Mild pulmonary edema.
2. Severe centrilobular and paraseptal emphysema.
3. Extensive anasarca.
4. Left upper lobe spiculated lesion, malignancy cannot be
excluded, if
clinically appropriate, a short interval followup CT is
suggested in three
months' time.
.
BILAT LOWER EXT VEINS Study Date of [**2144-10-15**]
IMPRESSION: No evidence of right or left lower extremity DVT.
.
CAROTID SERIES COMPLETE PORT Study Date of [**2144-10-15**]
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On the right there is moderate heterogeneous plaque in
the ICA. On the left there is mild heterogeneous plaque in the
ICA, ECA and CCA. On the right systolic/end diastolic velocities
of the ICA proximal, mid and
distal respectively are 110/35, 133/36, 108/23 cm/sec. CCA peak
systolic
velocity is 52 cm/sec. ECA peak systolic velocity is 66 cm/sec.
The ICA/CCA ratio is 2.3. These findings are consistent with
40-59% stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 68/26, 85/28, 97/32, cm/sec. CCA peak
systolic
velocity is 52 cm/sec. ECA peak systolic velocity is 66 cm/sec.
The ICA/CCA ratio is 2.3. These findings are consistent with
<40% stenosis.
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Impression: Right ICA stenosis 40-59%.
Left ICA stenosis <40% .
.
HIP 1 VIEW Study Date of [**2144-10-15**]
FINDINGS: No previous images. Hemiarthroplasty is seen on the
left without
evidence of hardware-related complication. Soft tissue changes
of recent
surgery are noted.
.
CT HEAD W/O CONTRAST Study Date of [**2144-10-17**]
FINDINGS: There is no acute intracranial hemorrhage, major
vascular
territorial infarction, mass effect or edema. [**Doctor Last Name **]-white matter
differentiation is preserved. There is periventricular and
subcortical white matter hypodensity which is similar to prior
and most likely related to chronic small vessel ischemic
disease. Age-appropriate prominence of
ventricles and sulci is consistent with diffuse parenchymal
volume loss. Basal cisterns are preserved. Globes and lenses are
intact. Visualized paranasal sinuses and mastoid air cells are
well aerated. No osseous abnormality is identified.
IMPRESSION:
1. No acute intracranial abnormality. If there is concern for
acute
ischemia, MRI is recommended for further evaluation if not
contraindicated.
2. Findings compatible with chronic small vessel ischemic
disease.
.
CT PELVIS W/O CONTRAST Study Date of [**2144-10-17**]
CT ABDOMEN WITHOUT IV CONTRAST: There is septal thickening and
small bilateral pleural effusions at the lung bases, compatible
with mild edema, but slightly improved compared to the prior
study. Emphysematous changes are again noted. Enteric tube is
noted in situ.
Evaluation of the abdominal organs is limited without IV
contrast. Within
this limitation, the liver, gallbladder, pancreas, spleen, and
bilateral
adrenal glands are normal. There is delayed nephrogram of the
bilateral
kidneys suggestive of impaired renal function. No evidence of
hydronephrosis or hydroureter. There is mild intra-abdominal
ascites. The stomach and intra-abdominal loops of small and
large bowel are unremarkable. No free air in the abdomen. There
is dense atherosclerotic calcification of the abdominal aorta
through its bifurcation. Evaluation for mesenteric and
retroperitoneal lymphadenopathy is limited; however, no large
lymphadenopathy is noted.
CT PELVIS WITHOUT IV CONTRAST: Evaluation is limited by streak
artifact from the hip prosthesis. Within this limitation, the
urinary bladder is collapsed around a Foley catheter. The distal
ureters and rectum are unremarkable. There is sigmoid
diverticulosis without evidence of acute diverticulitis. Small
amount of simple free fluid in the dependent portion of the
pelvis. No pelvic or inguinal lymphadenopathy is noted.
BONE WINDOWS: The patient is status post left THR. T12
compression deformity is again noted. Multilevel degenerative
change in the lumbar spine is present with endplate osteophyte
formation. In addition, there is vacuum disc phenomenon with
loss of disc height at L5-S1.
IMPRESSION:
1. Within limitations above, no evidence of intra-abdominal or
pelvic
hematoma.
2. Small intra-abdominal ascites and free fluid in the dependent
portion of the pelvis.
3. Delayed persistent nephrogram suggestive of impaired renal
function.
4. Mild pulmonary edema, slightly improved from prior.
5. Sigmoid diverticulosis without evidence of acute
diverticulitis.
.
Brief Hospital Course:
71F with history of severe COPD, DM2, HLD, HTN, pulmonary HTN,
presents with recent diagnosis of complete heart block, s/p
pacer, followed by hip fracture repair during which time she
became acutely hypotensive and had PEA arrest, CPR and ACLS
protocol achieved restoration of pulse, now s/p cath clean
coronaries, biventricular failure and persistent tachycardia.
.
# s/p PEA arrest: Etiology unclear, initial differential
included hypotension, PE, sepsis, or given recent hip fracture
repair, bone cemement implantation syndrome. Pt required
levophed for pressor support. Empiric antibiotics for possible
sepsis (most likely source was pneumonia) were begun (cefepime
and vancomycin). Pancultures were sent which showed sputum with
gram positive rods and cocci and gram neg rods and sputum
cultures grew ACINETOBACTER BAUMANNII COMPLEX sensitive to
cipro. Pt was placed initially started on cefepime then placed
on 8 day course of Cipro. Urine cultures and blood cultures
showed no growth.
.
Cardiac catheterization was completed to evaluate for possible
ischemic causes of her PEA arrest, however catheterization
showed normal coronary arteries. It also showed moderate
pulmonary hypertension and markedly elevated right and left
sided filling pressures. Due to elevated filling pressures and
initially high suspicion for a PE, a CT-A chest was completed
which excluded PE, but showed mild pulmonary edema, severe
centrilobular and paraseptal emphysema, extensive anasarca and a
left upper lobe spiculated lesion, (malignancy could not be
excluded). She was actively diuresed with improvement of her
oxygenation and was able to be successfully extubated. An ECHO
was also completed that showed LV basal hyperkinesis and
relative apical [**Name2 (NI) 56109**], RV not adequately visualized.
.
#. Respiratory failure: Pt was known to have severe COPD, on
home O2, with pulmonary hypertension, biventricular failure and
possible fluid overload. She had significant anasarca and was
agressively diuresed as her blood pressure would allow. High
peak pressures on vent were likely secondary to COPD, retaining
CO2 on gas. Combivent q4hr, flovent [**Hospital1 **] and empiric antibiotics
(cefepime and vancomycin) as above were initiated; pt vanco and
cefepime d/c'ed and pt placed on cipro for sensitive
acinetobacter. Attempts to wean oxygen saturation and monitor
ventilation status towards goal of extubation were challenging
given pt's neurologic status. However, gradually respiratory
status improved. Pt was able to be extubated but mental status
did not improve significantly.
.
#. Mental Status/non-responsive: Pt remained relatively
non-responsive. She was not on sedation. Neurology was consulted
as patient was no longer requiring sedation and was not
responding to stimuli. EEG was performed which showed limited
brain activity at that time. CT of head showed no acute
abnormality only chronic vessel ischemic disease. MRI of the
head could not be performed due to pacemaker. Pt's mental status
marginally improved but waxed and waned. At times responded to
questions w/simple [**2-15**] word answers and could follow simple
commands but at other times was lethargic. Initially it was
hoped that temporary NG tube for tube feeds during the pt's
early recovery would help aid improved mental status and
recovery; however, it became clear that improvement in
neurologic function and clinical status was unlikely. After
several family meetings and discussions with the team and
neurology, the decision was made to make the patient CMO in
[**Location (un) **] with what her family believed to be her previously stated
wishes (she did not want to live in a debilitated state in a
nursing home).
.
#. Biventricular diastolic dysfunction (normal CI). CXR did not
show impressive pulmonary edema. Diastolic dysfunction was
likely due to combination of COPD, pulmonary hypertension and
HTN.
.
#. Tachycardia: Pt had dual chamber atrial sensed pacemaker,
regular tachycardic p waves. Etiology for sinus tachycardia
included PE, verses sepsis. It was felt that it was unlikely
re-entrant pacer tachycardia as pacer adequately firing at
120bpm and we can see regular p waves. Some of tachcardia was
attributed to possible pain as tachycardia would improve when
patient was repositioned off of hip but would increase with
manipulation. Fentanyl was started to treat possible pain and
pt's tachycardia improved. Fentanyl was switched to tramadol to
decrease any possible sedation. Pain appeared well managed;
tachycardia improved. When pt was made CMO, morphine was
provided to ease any discomfort on the part of the pt.
.
#. Elevated Trop 0.04: Pt had h/o NSTEMI [**2141**] but clean
coronaries on cath. Concern for stress induced cardiomyopathy.
Aspirin was condinued and CE trended down.
.
# L Hip Fracture. Ortho was consulted; hip films showed no
misalignment or acute process related to fixation. One proposed
hypothesis for pt's condition given lack of evidence for PE was
the possiblilty of bone cement implantation syndrome which
procudes similar symptoms.
.
#. Metabolic acidosis: new development of metabolic acidosis a
few hours after being on floor was of unclear etiology.
Possibilities included lactic acidosis (patient was on metformin
at home) although lactate normal 1.0, DKA although BS 200s, RTA
less likely considering normal renal function. No toxins
suspected. Blood glucose was monitored. With eventual addition
of tube feeds, blood glucose levels where moderately challenging
to control so basal insulin of 4 units glargine was started in
addition to ISS.
.
#DM2: ISS was started. Home metformin was held given risk of
lactic acidosis.
.
#Hyperlipidemia: statin was continued
.
# CODE: Initial pt was full but after several lenghty
conversations w/team and neuro, family felt the pt would not
want to be reintubated or want any extreme measures. Family
members also felt that pt would not want to have a feeding
tube/PEG or live incapacitated in a nursing home. Pt was made
DNR/DNI/CMO w/ no feeding tube. All unnecessary medications were
stopped with the exception of medications deemed necessary for
comfort. This decision was confirmed with the patients children
and family members. [**Name (NI) **]: [**Name (NI) 41417**] [**Telephone/Fax (1) 56110**] ([**Name2 (NI) **]er),
[**Name (NI) **] [**Telephone/Fax (1) 56111**] (daughter), [**Name (NI) **] [**Name (NI) **] (son and primary
health proxy lives in NJ) [**Telephone/Fax (1) 56112**] h [**Telephone/Fax (1) 56113**] c).
.
Pt was discharged to inpatient skilled nursing facility and
needs hospice evaluation immediately upon arrival to skilled
nursing facility.
Medications on Admission:
pravastatin 80mg qHS
diltiazem 120mg daily
imdur 15mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
asa 325mg daily
spirivia 18mg qAM
symbicort inh [**Hospital1 **]
calcium with vit D
lisinopril 2.5mg qPM
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing or increased work of breathing.
2. Morphine Concentrate 20 mg/mL Solution Sig: [**2-15**] PO Q2H
(every 2 hours) as needed for pain, respiratory distress.
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety or respiratory distress.
4. Haloperidol Lactate 5 mg/mL Solution Sig: [**2-15**] Injection Q4H
(every 4 hours) as needed for agitation.
5. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Transdermal
once a day as needed for excessive secretions.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
PEA arrest
.
Secondary:
COPD
pulmonary hypertension
hip fracture s/p surgical repair
Diabetes Type 2
CAD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mrs. [**Known firstname 8368**] [**Last Name (NamePattern1) **] was admitted to the hospital after her heart
stopped while having her fractured hip repaired. It was unclear
why this happened given that the surgery had gone well up until
that point. Unfortunately, the lack of blood to her brain
resulted in what will likely be long standing neurologic
deficits and disability. Due to the significant decline
physcial/mental functioning and the unlikilood of recovery, the
decision was made to make the patient "comfort measures only" in
[**Location (un) **] with previously stated wishes by Mrs. [**Last Name (STitle) **] that she
would not want to live in a debilitated state. In accordance
with these wishes, Mrs. [**Last Name (STitle) **] was transferred to inpatient
hospice services where she could receive appropriate care in
line with her wishes.
.
All unnecessary medications were stopped and only those
medications which maintained the patient's optimal level of
comfort where continued.
Start taking Morphine sublingual, Haldol, Ativan, Scopalamine,
Albuterol and Dulcolax as needed for comfort.
.
Thank you for letting us be a part of your care.
Followup Instructions:
No recommended follow-up is scheduled
Completed by:[**2144-10-29**]
ICD9 Codes: 9971, 0389, 4275, 2762, 4168, 412, 2724, 2859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2750
} | Medical Text: Admission Date: [**2118-10-30**] Discharge Date: [**2118-11-25**]
Date of Birth: [**2072-7-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Fever, pancytopenia, RUQ pain.
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy
ERCP with CBD stent placement
Central Line/HD Line placement
Intubation
Lumbar Puncture
Bronchoscopy
History of Present Illness:
HPI: 46 yo M with h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2905**] [**Last Name (un) **] s/p thymectomy on Imuran
who initially presented to his PCP [**Name Initial (PRE) 151**] T103 and dry cough
treated with Amoxicillin and Augmentin without improvement. He
was then admitted to an OSH on [**2118-10-25**] for pancytopenia (WBC
2.6, 18% bands, plt 104) and elevated LFTS c/w cholestasis. He
was treated with Azythromycin and Atovaquone for suspected tick
borne illness. He had a positive monospot test. Hepatitis
serologies were negative.
.
Patient was admitted to the surgical service at [**Hospital1 18**] on
[**2118-10-30**] for persisitent fever and an elevated direct Tbili
thought to be secondary to cholangitis. He was started on
Unasyn. He underwent an ERCP on [**10-31**] which did not show
biliary tract obstruction, however, a CBD stent was placed. He
was transfused 1 Unit of PRBC's, 3 bags of FFP, and 3 bags of
plts.
.
Prior to the ERCP he developed repsiratory distress and was
intubated. CXR revealed bilateral patchy pulmonary infiltrates.
He became hemodynamically unstable and he was started on Norepi
gtt. ID was consulted and Ceftriaxone/ Doxycyclin were added;
Zosyn was d/c'ed. He spiked a temp to 105.3. He was transfered
to the MICU on [**10-31**] for further managament.
Past Medical History:
- Myasthenia [**Last Name (un) 2902**] for 19 years s/p thymectomy [**2103**]
- Migraines
- Prednisone induced osteoporosis
- Low back Pain
Social History:
Has a girlfriend. [**Name (NI) **] a 14 yo son who recently had a cold.
Lives with girlfirend and step children. Smokes and drinks EtOH
occassionally. No hx of IVDU. Lives in [**Location 4310**] near a swamp.
Breakheart reservation is 2 miles away. No hx of tick bites.
Family History:
Mother has HTN.
Physical Exam:
Upon transfer to [**Hospital Unit Name 153**]:
Tm 102.2 Tc 97.6 BP 175/92 (108-175/52-92) HR 89 (71-111)
PS 5/0 FiO2 35% Vt 850 (700-850) RR 16; ABG 7.44/33/173/23
Fentanyl 125; Off Midaz since [**11-6**]
Gen: Sedated/intubated, appears comfortable on ventilator,
occasional hiccups
HEENT: ET tube in place, Eyes with lubricant, PERRL, pupils
pinpoint
CV: distant heart sounds. No murmurs appreciated.
Resp: anteriorly - crackles throughout
Abd: Soft, distended, decreased BM, unable to appreciate HSM
Skin: Warm. Well Perfused.
Ext: hyperreflexic, Spastic, 5 beats of myoclonus, Toes
upgoing, strong DP/PT pulses
Access: Right IJ triple lumen placed [**11-6**], Left IJ temp
dialysis cath placed [**11-3**] by IR
Pertinent Results:
Liver US [**10-30**]:
1. Marked gallbladder wall edema with an effaced, non-distended
gallbladder lumen is noted, without intrahepatic biliary ductal
dilatation. There is minimal pericholecystic fluid.
2. Dilatation of the proximal CBD.
3. Prominent periportal lymphadenopathy, nonspecific.
.
CxR [**10-31**]: New perihilar pulmonary edema and bilateral pleural
effusions.
.
ERCP [**10-31**]:
Ccannulation of the common bile duct. Cholangiogram
demonstrates a normal caliber of the common bile duct and
intrahepatic ducts. The cystic duct is also filled with
contrast, partially opacifying the gallbladder. No strictures
or filling defects are identified. Following cholangiogram,
there is placement of a plastic stent within the common bile
duct.
.
CT Chest/Abd/Pelvis [**10-31**]:
1. Multifocal pulmonary opacities, which could represent an
infectious process.
2. Bilateral axillary and right hilar lymphadenopathy, all
could be related to the underlying infectious process.
3. Moderate bilateral pleural effusions.
4. Although there is ascites, fluid within the lesser sac and
adjacent to the pancreatic head raises the suspicion of
pancreatitis.
5. Splenomegaly.
6. Periportal lymphadenopathy.
.
Echo [**11-1**]: No evidence of endocarditis. Normal global and
regional
biventricular systolic function. Mild mitral regurgitation.
.
Immunophenotyping [**11-2**]: Pending
.
Bronchial washings [**11-2**]: NEGATIVE FOR MALIGNANT CELLS.
Pulmonary macrophages. No viral cytopathic changes or
microorganisms seen.
.
R LENI [**11-6**]: No evidence of right lower extremity DVT.
.
CXR [**11-7**]: Pulmonary edema, now mild, has improved
substantially since [**11-5**]. A relatively rapid onset
between [**10-30**] and 16 and pace of improvement suggests the
diagnosis is cardiogenic rather than noncardiac edema. Heart is
normal size. There is no mediastinal or pulmonary vascular
engorgement. Lungs are clear aside from bands of atelectasis.
Other pleural surfaces are normal except for mild thickening
associated with fractures of left ribs at least the fifth, which
may have developed between [**11-2**] and 21. Tip of the right
jugular line projects over the junction of the brachiocephalic
veins and a left internal jugular line ends in the upper SVC.
.
CT abd/pelvis [**11-7**]:
1. Slightly increased amount of intraabdominal simple free
fluid.
2. Interval placement of CBD stent with collapsed, edematous
gallbladder.
3. Pancreas appears similar to previous exam.
.
CT Head [**11-7**]:
1. No acute intracranial hemorrhage or mass effect.
2. Interval opacification of multiple mastoid air cells.
.
[**2118-10-30**] 09:46PM BLOOD HCV Ab-NEGATIVE
[**2118-10-31**] 10:21PM BLOOD HIV Ab-NEGATIVE
[**2118-10-30**] 09:46PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HAV-NEGATIVE
[**2118-11-21**] 06:30AM BLOOD TSH-2.9
[**2118-10-31**] 10:21PM BLOOD calTIBC-156* VitB12-1420* Folate-14.4
Hapto-65 Ferritn-6065* TRF-120*
[**2118-11-5**] 02:36AM BLOOD Lipase-760*
[**2118-11-23**] 06:25AM BLOOD Lipase-242*
[**2118-10-30**] 01:20PM BLOOD ALT-81* AST-240* AlkPhos-294*
Amylase-147* TotBili-8.9* DirBili-7.4* IndBili-1.5
[**2118-11-1**] 11:35PM BLOOD ALT-90* AST-361* LD(LDH)-665*
CK(CPK)-725* AlkPhos-217* Amylase-203* TotBili-7.5*
[**2118-11-24**] 06:20AM BLOOD ALT-85* AST-21 AlkPhos-136* TotBili-1.7*
[**2118-10-30**] 01:20PM BLOOD UreaN-16 Creat-1.0 Na-131* K-4.1 Cl-98
HCO3-24 AnGap-13
[**2118-11-4**] 06:30PM BLOOD Glucose-111* UreaN-88* Creat-7.1* Na-130*
K-4.9 Cl-98 HCO3-18* AnGap-19
[**2118-11-25**] 07:40AM BLOOD Glucose-87 UreaN-30* Creat-1.1 Na-138
K-3.8 Cl-105 HCO3-25 AnGap-12
[**2118-11-2**] 03:23AM BLOOD WBC-3.5* Lymph-17* Abs [**Last Name (un) **]-595 CD3%-97
Abs CD3-580 CD4%-89 Abs CD4-532 CD8%-8.5 Abs CD8-51*
CD4/CD8-9.9*
[**2118-11-25**] 07:40AM BLOOD Gran Ct-70*
[**2118-10-30**] 01:20PM BLOOD WBC-2.0* RBC-3.50* Hgb-11.5* Hct-33.5*
MCV-96 MCH-32.8* MCHC-34.3 RDW-15.6*
[**2118-11-25**] 07:40AM BLOOD WBC-0.4* RBC-2.72* Hgb-8.1* Hct-22.6*
MCV-83 MCH-29.9 MCHC-35.9* RDW-14.7 Plt Ct-81*#
[**2118-11-17**] 02:14PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-0
Lymphs-87 Monos-13
[**2118-11-1**] 11:34PM CEREBROSPINAL FLUID (CSF) WBC-13 RBC-3* Polys-0
Lymphs-95 Monos-0 Macroph-5
[**2118-11-1**] 11:34PM CEREBROSPINAL FLUID (CSF) WBC-13 RBC-32*
Polys-0 Lymphs-67 Monos-0 Macroph-33
[**2118-11-17**] 02:13PM CEREBROSPINAL FLUID (CSF) TotProt-34 Glucose-61
[**2118-11-1**] 11:34PM CEREBROSPINAL FLUID (CSF) TotProt-19 Glucose-63
.
BM Bx
ERYTHROID-DOMINANT MARROW WITH INCREASED HEMOPHAGOCYTIC
HISTIOCYTES, DECREASED CELLULAR DENSITY, AND INCREASED
BACKGROUND EOSINOPHILIC CELL DEBRIS, CONSISTENT WITH
HEMOPHAGOCYTIC SYNDROME (HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS
Brief Hospital Course:
Hospital Course:
.
# Fever/Pancytopenia/ID/Hemophagocytic Lymphohistiocytosis: Pt
had been afebrile since [**11-4**] and all ABX d/c'ed on [**11-6**],
however, Vanco/Ceftaz were restarted on [**11-7**] for Tm of 102.2.
Concern was for VAP given increased respiratory secretions vs
recurrent pancreatitis with pseudocyst as pancreas enzymes were
rising after recently having restarted TF. CT Abd/pelvis was
without evidence of worsening radiographic pancreatitis. Other
sources considered included line infections (Right IJ recently
replaced in same site) or C. diff given prolonged ABX course.
.
Extensive prior infectious workup had revealed a positive EBV
IgM, EBV PCR, and EBV PCR in CSF. Given pancyotpenia,
splenomegaly, and EBV infection Heme/Onc and ID were considered
the diagnosis of Hemophagocytic Lymphohistiocytosis, which was
confirmed by repeat bone marrow biopsy (first biopsy
unremarkable). Pt was begun on etoposode, IVIG and decadron on
~[**11-7**]. His pancytopenia was also treated with epogen and
neupogen.
.
Per HEME, HLH likely triggered by underlying EBV infection.
While there was evidence of EBV in the CSF; because of normal
Protein no need for IT-MTX. The patient was started on a
steroid taper (currently on 10 mg Decadron) and will need 8
weeks total of Etoposide. Renal failure, pancreatic
abnormalities, and elevated LFTs all thought to be d/t
underlying HLH. In addition, ID consults did not recommend
treating EBV viremia with anti-virals.
.
On [**11-9**], pt was noted to have EBSL klebsiella in a sputum and
BAL sample, and was begun on meropenem for 14 day course. He
continued to develop low grade temperature (100.0-100.6), which
were attributed to his HLH, IVIG, and CVVHD.
.
# Respiratory Failure: Pt intubated on [**2118-10-30**] for impending
respiratory distress at time of his ERCP. Upon admission to the
[**Hospital Unit Name 153**] on [**11-7**], his respiratory mechanics had improved
considerably, and he was oxygenating and ventilating well on PS
5/0. Initially unable to extubate secondary to altered mental
status and increased secretions. Pt was often desyncrhonous on
vent secondary to hiccups when sedation weaned. As mental
status improved gradually, pt was extubated on [**11-10**]. His
respiratory status continued to improve slowly, despite +BAL for
EBSL klebsiella and total body fluid overload, and on [**11-14**] pt
was sat'ing >95% on RA.
.
# Mental Status - pt presented to [**Hospital1 18**] alert & oriented,
however his mental status subsequently declined. After
intubation on [**10-30**], pt remained largely sedated until just
prior to admission to the [**Hospital Unit Name 153**] on [**11-7**]. Attempts to wean
sedation were limited by hiccups which resulted in dysynchrony
the mechanical ventilation, breif neuro exam at time of [**Hospital Unit Name 153**]
admission with sedation weaned revealed pt responsive only to
deep painful stimulus (sternal rub), pupils minimally reactive
to light bilaterally, gag was present, with slow corneal reflex.
+hyperreflexia, though tone was flacid, and 5-10 beat clonus of
both feet was noted which initially worsened to 20 beat clonus
on [**11-11**] before slowly improving.
.
Was seen by the neurology/psychiatry services given his new
neurological findings and h/o myasthenia [**Last Name (un) 2902**] (which
predominantly was ocular per pt's family). EEG was obtained
which showed diffuse slowing, but no focus of seizure activity.
CT head on [**11-7**] unremarkable. Over the course of his first week
in the [**Name (NI) 153**], pt's mental status improved dramatically,
presumably with chemotherapy. By [**11-14**] pt was alert, pleasantly
conversive, and following all commands. His imuran for
myasthenia [**Last Name (un) 2902**] has been held since admission. Neuro also
noted proximal weakness of his arms, which improved during his
hospital course. Per Neruo, he should hold Imuran until he
follows up with Neuro as an outpatient.
.
# Renal - pt without h/o CRI, developed ARF likely secondary to
ATN from hypotension and underlying HLH on [**11-1**]. Pt was
started on CVVHD at that time for volume overload [**2-17**] anuria,
however, UOP gradually improved, and on [**11-15**] pt was
discontinued from HD. Creatinine normal on discharge.
.
# Cholestasis/hepatitis/pancreatitis - pt presented to [**Hospital1 18**]
from OSH with RUQ pain, fever, and elevated LFTs (Tbil 7's), for
which he underwent ERCP with CBD stent on [**11-2**]. LFTs have
since trended down, though amylase/lipase (peak in 1000s) were
starting to plateau at 500s on [**11-14**]. CT abdomen showed
pancreatic fluid collection, but not psuedocyst or necrosis. On
[**11-13**] pt denied abdominal pain, and was hungry, thus was
transitioned from TPN to TF cautiously, as prior attempt to
restart tube feeds was limited by bump in amylase/lipase. On
[**11-14**], pt was tolerating TF without difficulty, in addition to
sips of clear liquids, thus he was advanced to a regular diet
after a speech & consult was obtained. On the floor, he
tolerated his diet without other clinical s/sx of pancreatitis.
.
Psych: thought the patient had a mild encephalopathy that was
slowly resolving. Recommeded Haldol/Seroquel for sleep;
however, this made the patient feel strage. Given resolution of
MS changes, ok for patient to receive ambien at rehab prn.
.
HTN: kept on Lopressor 100 mg TID with excellent results.
Medications on Admission:
Imuran, Imitrex, Amoxicillin, Augmentin, Atovaquone, Azithromax
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous every eight (8) hours: please continue until ANC
>500.
Disp:*qs mg* Refills:*2*
3. Dexamethasone 4 mg Tablet Sig: 2.5 Tablets PO once a day:
Please give 10 mg PO daily until [**12-5**]; then begin 5 mg po
daily.
Disp:*qs Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
Disp:*qs Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: while on
steroids.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*qs qs* Refills:*0*
7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*qs qs* Refills:*2*
8. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
9. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Please continue until ANC >500.
.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Hemophagocytic lymphohistiocytosis
2. Acute Renal Failure, resolved
3. Elevated LFTs secondary to Obstruction/HLH
4. Elevated amylase/lipase, likely secondary to HLH
5. Myasthenia [**Last Name (un) **], stable
6. Hospital Acquired PNA (Klebsiella)
7. Pancytopenia/Febrile Neutropenia
8. Sepsis
9. Respiratory Failure
10. Hypertension
Discharge Condition:
stable
Discharge Instructions:
Please contact Dr.[**Name (NI) 3588**] office or your PCP should you
develop any fevers, chills, sweats, abodminal pain, nausea,
vomiting, or any other complaints.
Please make an appointment to see your outpatient Neurologist as
soon as possible.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2118-11-30**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2118-11-30**] 11:00
Someone from the Gastroenterology Team will be calling you at
Rehab regarding pulling the stent from your liver.
Please f/u with your neurologist as an outpt.
ICD9 Codes: 5845, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2751
} | Medical Text: Admission Date: [**2127-7-30**] Discharge Date: [**2127-8-6**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Erythromycin Base / Naprosyn
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
CABGx4 (LIMA>LAD, SVG>RAMUS, SVG>OM, SVG>PDA) [**2127-8-1**]
History of Present Illness:
84M with CAD s/p PTCA in [**2115**], positive stress test in [**Month (only) 956**]
at OSH, cath showing 3VD in [**Month (only) 116**], who was scheduled to undergo
CABG next week, presented to OSH Tuesday evening with substernal
chest pain. He was sitting in his living room, watching the
Celtics game, when he experienced onset of crushing substernal
pain, similar to previous episodes of angina, that was not
relieved by NTG.
At OSH, received NTG SL and then IV, and morphine, and was then
chest pain free. He was transferred here on heparin and NTG gtt.
NTG was d/c'd in [**Hospital1 18**] ED to change over lines/pumps, and not
restarted because pt remained CP free. Additionally given
aspirin, metoprolol, and admitted for further management. CT
surgery was notified of his admission
Past Medical History:
acute on chronic diastolic heart failure
HTN, DJD of knees b/l, AF, PVD, hyperlipidemia, PE, CAD, R
popliteal artery aneurism s/p bypass grafting with saphenous
vein, hemerhoids, hernia
Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension
Social History:
He is divorced and lives with his daughter who is also his
primary caregiver. [**Name (NI) **] does not smoke and drinks minimally.
Family History:
N/C
Physical Exam:
VS - 96.0 162/85 68 18 100% 2L
Gen: thin elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of [**10-22**] cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. II/VI midsystolic murmur at LLSB. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. Palpable cord on L antecubital
vein, non erythematous, nontender
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Numerous SKs esp around neck
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2127-8-5**] 05:50AM BLOOD WBC-9.0 RBC-3.38* Hgb-9.7* Hct-29.0*
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.6* Plt Ct-158
[**2127-8-6**] 05:50AM BLOOD PT-13.2 INR(PT)-1.1
[**2127-8-5**] 05:50AM BLOOD PT-14.9* INR(PT)-1.3*
[**2127-8-1**] 01:40PM BLOOD PT-13.7* PTT-62.5* INR(PT)-1.2*
[**2127-8-6**] 05:50AM BLOOD Glucose-101 UreaN-23* Creat-1.1 Na-131*
K-4.1 Cl-95* HCO3-28 AnGap-12
Radiology Report CHEST (PA & LAT) Study Date of [**2127-8-6**] 9:32 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2127-8-6**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 76925**]
Reason: ? effusion
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? effusion
Final Report
HISTORY: Status post CABG.
FINDINGS: In comparison with the study of [**8-4**], there is
evidence of
bilateral pleural effusions, more marked on the left. Streaks of
atelectasis
are seen in the left mid and lower lung zones. Intact sternal
sutures
persist.
IMPRESSION: Bilateral pleural effusions, more prominent on the
left.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 76926**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76927**] (Complete)
Done [**2127-8-1**] at 11:28:14 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2043-2-14**]
Age (years): 84 M Hgt (in): 68
BP (mm Hg): 137/87 Wgt (lb): 78
HR (bpm): 72 BSA (m2): 1.37 m2
Indication: Intra-op TEE for CABG
ICD-9 Codes: 427.31, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2127-8-1**] at 11:28 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 35981**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Focal calcifications in
aortic root. Mildly dilated ascending aorta. Normal aortic arch
diameter. Simple atheroma in aortic arch. Mildly dilated
descending aorta. Complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. No MS. Moderate (2+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. Results were personally reviewed with
the MD caring for the patient. See Conclusions for post-bypass
data The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The left atrium is moderately dilated. No atrial septal
defect is seen by 2D or color Doppler.
2. Aymmetric hypertrophy of the Septum near the LVOT is seen.
However no gradient across the LVOT is seen.The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. There are simple atheroma in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. Mild (1+) aortic regurgitation is
seen. Aortic sclerosis is seen with a valve area of about 2.2
cm2
6. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. Two jets are seen, one extremely
anterior directed and a second smaller central jet. Prolapse of
the P3 scallop is seen. Mild [**Male First Name (un) **] is seen with no gradient across
the LVOT and valve.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being V paced.
1. Biventricular function is preserved.
2. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**].
3. Aorta is intact post decannulation.
4. Other findings are [**Last Name (Titles) 1506**]
Brief Hospital Course:
He ruled out for MI with CEs and had No ECG changes. His
surgery was moved up because of his symptoms and on [**8-1**] he was
taken to the operating room where he underwent a CABG x 4. He
was transferred to the ICU in stable condition. He was extubated
later that same day. He was started on vasopressin for ? of
SIRS. He was weaned from his vasoactive drips on POD#2. He was
transferred to the floor on POD #3. He required aggressive
diuresis. He was restarted on coumadin with a lovenox bridge for
his recent history of PE. He was ready for discharge to rehab on
POD #5,
Medications on Admission:
Aspirin 81mg
metoprolol succinate 50mg daily
atorvastatin 80mg daily
lisinopril 5mg daily
MVI
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
9. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1
doses: then check INR daily and continue lovenox until INR > 2,
then check PRN. Dose coumadin accordingly.
10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): until INR > 2.0.
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1
weeks: then please reassess need for diuresis.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours): while on lasix.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]
Discharge Diagnosis:
CAD s/p CABG
acute on chronic diastolic heart failure
PMH: HTN, hyperlipidemia, PVD, postop PE (coumadin), L popliteal
aneurysm, AF/flutter, arthritis, DJD, ? old MI, wide complex
tachycardia
PSH: s/p R fem-tib bypass [**3-/2127**], appendectomy, R hernia repair,
umbilical hernia repair, hemorrhoidectomy + rectal polyp
removed, L cataract surgery
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon
Followup Instructions:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-8-21**]
1:45
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2127-8-21**] 2:15
Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 6699**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 2 weeks
Completed by:[**2127-8-6**]
ICD9 Codes: 4111, 4280, 4019, 4439, 2724, 4240, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2752
} | Medical Text: Admission Date: [**2143-1-29**] Discharge Date: [**2143-2-4**]
Date of Birth: [**2074-5-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 174**] is a 68 year-old man with IgA meyloma s/p Velcade
(last treatment [**2143-1-4**]), DM2, CKD, and schizophrenia who
presents from his [**Hospital3 **] with confusion and is admitted
to the MICU for sepsis/hypotension.
.
He was in his USOH until three days ago when nursing staff
noticed that he was more confused. Today, he was noted by staff
to have high finger sticks (glucose > 500), urinary
incontinence, and to be more confused, with waxing and [**Doctor Last Name 688**]
mental status. He was given 22 units insulin and had a BP of
86/51. Per report, he had no fever, cough, headache, nausea, or
emesis.
.
-------
Upon Transfer to the Floors:
For full HPI, please refer to MICU H and P. Briefly, the patient
is a 68 YO M with IgA MM, IDDM, CKD and schizophrenia admitted
to the MICU on [**1-29**] for hypotension in the setting of altered
mental status. He was found to have high-grade GNR bacteremia. A
R IJ was placed and he was fluid resucitated. Her initially
required norepinephrine for pressure support but was weaned off
of presssors on [**2143-1-30**]. He was started on vanc and cefepime
pending culture results. Vanc was stopped on [**1-31**] and he remains
on cefepime. Sensitivities have just returned and the GNR
appears to be sensitive to cipro.
.
The patient's ICU stay was complicated by rising creatinine,
currently 4.4, from a baseline of 1.5. He has been seen by
renal. Urine sediment revealed muddy [**Known lastname **] casts consistent with
ATN. As of the day of transfer, his urine output has increased
to almost 4L in the past 24 hours. He has gotten 1L of fluids
with bicarb as per renal suggestion due to low bicarb in the
setting of ATN.
.
He has also been hyperglycemic requiring close glucose
monitoring.
.
He reports feeling much improved and has no specific complaints
at this time. He denies pain. His voice is difficult to
understand and he reports being tired of everyone repeatedly
examining him, making the interview somewhat limited.
.
Review of systems:
(+) Per HPI; unable to obtain a full ROS. As above, he denies
pain including dysuria prior to presentation. He does state he
knew he was sick but is not able to elaborate on his specific
symptoms. He says he's "all fixed up down there now."
In the ED, vital signs were initially: 100.3 99 93/51 16 99. A
CXR was negative for pna and a head CT was limited by motion but
prelim negative. A UA was grossly positive and he was given
vanc/ceftriaxone. SBPs drop to the 80s and he was given 5L IVF.
A RIJ was placed with a CVP of 8, and he was also started on
levophed and an insulin drip. He was then admitted to the MICU
for further management.
.
On arrival to the floor, he is comfortable, A/O x 3, and
requesting to return to his [**Hospital3 **] center.
Past Medical History:
1. IgA multiple myeloma. He is status post multiple cycles of
Velcade. His course has been complicated by renal failure.
2. Chronic Renal Failure. Likely related to his MM.
3. Type 2 diabetes
3. Schizophrenia, managed by psychiatry, seen by Dr. [**Last Name (STitle) 4366**] and
receives Haldol Depo every month.
4. Hyperlipidemia
Social History:
Lives at [**Location 4367**] [**Hospital3 400**]. Smokes [**4-29**] cigs/day; formerly
1 ppd. Denies alcohol or drug use. He is a former high school
football coach and worked in construction, when he moved to [**Location (un) 4368**].
Family History:
Denies history of diabetes, renal disease, or hematologic
malignancies.
Physical Exam:
Vitals: T: 99.2 BP: 118/65 P: 95 R: 15 O2: 97% RA
General: Alert, oriented, no acute distress; difficult to
understand but interactive and appropriate, following commands
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: patient refused lung exam
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: very dry and cracked
Lines and tubes: R IJ in place, C/D/I; foley draining voluminous
light, clear yellow urine
Pertinent Results:
Labs on admission:
[**2143-1-29**] 04:20PM GLUCOSE-758* UREA N-57* CREAT-3.6*#
SODIUM-125* POTASSIUM-5.4* CHLORIDE-94* TOTAL CO2-19* ANION
GAP-17
[**2143-1-29**] 04:20PM WBC-6.8# RBC-3.20* HGB-9.5* HCT-32.6*
MCV-102* MCH-29.5 MCHC-29.0* RDW-14.5
[**2143-1-29**] 04:20PM NEUTS-70 BANDS-1 LYMPHS-12* MONOS-17* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2143-1-29**] 04:37PM LACTATE-1.7
[**2143-1-29**] 05:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE->1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.5
LEUK-SM
Micro:
[**2143-2-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-2-2**] URINE URINE CULTURE-PENDING INPATIENT
[**2143-2-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-2-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-2-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-1-31**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-1-31**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-1-31**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-1-30**] URINE URINE CULTURE-FINAL INPATIENT
[**2143-1-30**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-1-29**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2143-1-29**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
EMERGENCY [**Hospital1 **]
[**2143-1-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic
Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2143-1-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic
Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2143-1-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic
Bottle Gram Stain-FINAL
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging:
CXR [**1-29**]
FINDINGS: Lung volumes are mildly diminished. Similar to the
prior exam,
there is slight accentuation of the interstitial markings.
Bibasilar
atelectasis is evident. The mediastinum is unremarkable. The
cardiac
silhouette is within normal limits for size. No effusion or
pneumothorax is noted. Please note the patient's chin obscures
the extreme right apex. The osseous structures again reveal
vertebral body height loss in multiple
thoracic vertebral body segments.
IMPRESSION: Relatively stable examination with bibasilar
atelectasis. No
definite consolidation noted.
CT head
IMPRESSION:
1. Markedly limited study due to patient motion. No gross
interval change
from prior without evidence of large intracranial hemorrhage.
Evaluation for infarction is limited on this motion-limited
study, and MRI is more sensitive for detection of acute ischemia
(for which the patient would require sedation in order to
obtain).
2. Mild mucosal thickening in the left maxillary sinus.
Renal U/S
IMPRESSION: No renal abscess or perinephric collection. Please
note that
pyelonephritis cannot be diagnosed on ultrasound.
CXR [**2-1**]:
New opacification in both lower lungs could be pneumonia.
Pleural effusions if any are small. Upper lungs clear. Heart
size is normal. Right jugular line ends at the superior
cavoatrial junction. [**First Name4 (NamePattern1) 3095**] [**Last Name (NamePattern1) 4369**] was paged
Brief Hospital Course:
68 YO M with IgA MM, IDDM2, CKD, and schizophrenia admitted to
the MICU with AMS and hypotension found to have urosepsis and
ATN.
.
# Urosepsis: Pt found to have high-grade E.coli bacteremia. A R
IJ was placed and he was fluid resucitated. He initially
required norepinephrine for pressure support but was weaned off
of presssors on [**2143-1-30**]. He was started on vanc and cefepime
pending culture results. Vanc was stopped on [**1-31**] and he remained
on cefepime until [**2-1**]. When sensitivities returned, found that
e. coli sensitive to ciprofloxacin, and patient switched to
Cipro. He had no other complications, no evidence of abscess on
renal U/S. Prostate exam benign (no tenderness on exam),
scheduled for urology follow-up as outpatient.
He was last febrile on [**2-2**] and levaquin was started for possible
b/l PNA on CXR (though no hypoxia or respiratory complaints).
No aspiration on S&S. Possible he aspirated when he was altered
and came in. R IJ removed, but contaminated and could not be
sent for cx. Switched cipro to levaquin on [**2-2**] for treatment of
PNA in addition to urosepsis. Will need total of two week course
for treatment of urosepsis (will end on [**2143-2-12**]). Currently
dosed at levaquin 250mg Q48 in light of renal failure. Final
blood and urine cultures must be followed up after discharge
(last positive blood cx on [**1-29**]).
.
# Acute kidney injury [**2-26**] ATN. The patient's ICU stay was
complicated by rising creatinine, which peaked to 4.6, from a
baseline of 1.5. He was seen by renal. Urine sediment revealed
muddy [**Known lastname **] casts consistent with ATN. He was maintained on IVF
but made excellent urine output of 4L for each of the 3 days
prior to discharge, illustrating post-ATN diuresis. His
creatinine trended down to 3.9 on the day of discharge. Has
follow-up with Dr. [**First Name (STitle) 805**] as outpatient.
.
# Hyperglycemia/Diabetes. History of poorly controlled finger
sticks now exacerbated in setting of infection. No urine
ketones. Lantus increased from 36units to 40 units and sliding
scale added. He only has VNA twice a day (patient refused to go
to rehab), so will only get BS check twice a day. Glipizide
titrated down to [**Hospital1 **] dosing instead of TID dosing, adjusted for
renal failure.
.
# IgA multiple myeloma. Status post multiple cycles of Velcade
with last treatment on [**2143-1-4**]. Patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. NP
notified that patient being discharged and will call patient for
appointment in late [**Month (only) 404**]. Continued acyclovir 400 [**Hospital1 **].
.
# Anemia. Slightly down from baseline of 31-34. Likely related
to acute inflammation in the setting of chronic iron def anemia
as well as myeloma. Guaiac positive and scheduled for GI
follow-up w/ Dr. [**First Name (STitle) 4370**] [**Name (STitle) 4371**] as outpatient.
.
# Thrombocytopenia. Platelets trended down but stable throughout
hospitalization. Platelets of 134 on discharge and were trending
up at that point. CBC should be checked as outpatient, and
further management as per heme-onc team.
.
# Schizophrenia: Managed by psychiatry, seen by Dr. [**Last Name (STitle) 4366**] and
receives Haldol Depo every month.
.
STRONGLY RECOMMENDED TO PATIENT THAT HE GO TO REHABILITATION
FACILITY FOR PHYSICAL THERAPY. PATIENT REFUSED, AND WILL HAVE
HOME PT.
Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 (One) Tablet(s) by mouth twice a
day
GLIPIZIDE - 5 mg Tablet - 1 (One) Tablet(s) TID
HALOPERIDOL LACTATE [HALDOL] 5 mg/mL Solution - Inject 1 ml IM q
monthly
INSULIN GLARGINE [LANTUS] 100 unit/mL Solution - 36 units in AM
INSULIN LISPRO [HUMALOG] 100 unit/mL Solution - 1-15 units twice
a day to be given by VNA according to his sliding scale
LENALIDOMIDE [REVLIMID] 15 mg Capsule - 1 (One) Capsule(s) by
mouth once a day for 21 days
SIMVASTATIN - 40 mg Tablet - 1 (One) Tablet(s) by mouth at
bedtime
UREA - 40 % Lotion - Apply to feet as directed as needed
ACETAMINOPHEN - 325 mg Tablet - [**1-26**] Tablet(s) by mouth every
four hours as needed for pain, fever
ASPIRIN - 81 mg Tablet - 1 (One) Tablet(s) by mouth once a day
COLACE - 100MG Capsule - ONE BY MOUTH EVERY DAY
FERROUS SULFATE - 325 mg [**Hospital1 **]
MULTI-VITAMIN - Tablet - 1 Tablet(s) by mouth once per day
Discharge Medications:
1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO once a day.
2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 8 days: Next dose should be tonight, then on [**2-27**], [**2-10**], [**2-12**].
Disp:*5 Tablet(s)* Refills:*0*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous QAM.
Disp:*1 month supply* Refills:*0*
9. Humalog 100 unit/mL Solution Sig: 1-16 units Subcutaneous as
directed: please dose according to sliding scale.
10. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Haldol
Please continue to get your regularly scheduled monthly
injections of haldol,
5 mg/mL Solution
Inject 1 ml IM q monthly
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Urosepsis
2. Acute Tubular Necrosis
SECONDARY DIAGNOSIS:
1. IgA multiple myeloma.
2. Chronic Renal Failure.
3. Type 2 diabetes mellitus
3. Schizophrenia
4. Hyperlipidemia
Discharge Condition:
Mental Status:Confused - sometimes (schizophrenia)
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to the hospital on [**2143-1-29**] because you were
confused. We found that you had a severe infection of your
bladder and your blood. You were in the intensive care unit for
this and you had kidney failure as a result of your infection.
Your kidney failure is improving. You were started on
antibiotics and you will need to continue levaquin until [**2143-2-12**]
for your infection.
Since it is unusual for men to have urinary tract infections,
please follow up with urology as listed below.
You MUST DRINK PLENTY OF FLUIDS for your kidney failure. Drink
at least 8 glasses of water a day.
The following changes have been made to your medications:
1. Increase lantus from 36 units to 40 units in the morning
2. Start the humalog sliding scale attached
3. Decrease glipizide from 5mg three times a day to 5mg twice a
day.
It was our recommendation that you go to a rehabilitation
facility to get your muscle strength up, but you refused.
Therefore you will have home physical therapy only.
Followup Instructions:
Provider: [**Name10 (NameIs) 2483**],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 191**] MEDICAL UNIT (SB)
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2143-2-5**] 10:40. This is your new
PCP.
[**Doctor First Name **], your NP at heme/onc will call your facility in late
[**Month (only) 404**] to set up an appointment.
Please follow up with Dr. [**First Name (STitle) 805**] (your kidney doctor [**First Name8 (NamePattern2) **] [**Last Name (un) 4372**]) Thurs [**2-7**], at 4:30pm.
Since it is unusual for men to develop infections of the
bladder, we would like you to follow-up with a urologist. The
following appointment has been made for you, but they will call
you if there are any cancellations and an earlier appointment
can be made.
UROLOGY: Dr. [**Last Name (STitle) **], appointment on [**4-8**] at 3pm in [**Hospital Ward Name 23**]
[**Location (un) 470**] at [**Hospital1 18**] [**Hospital Ward Name 516**].
ICD9 Codes: 5845, 5990, 5859, 2875, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2753
} | Medical Text: Admission Date: [**2108-8-27**] Discharge Date: [**2108-8-31**]
Date of Birth: [**2057-8-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting times three (left interior
mammary artery to left anterior descending, saphenous vein graft
to diagonal, saphenous vein graft to PLV), placement of synthes
sternal plates [**8-27**]
History of Present Illness:
Mr. [**Known lastname 3265**] is a 51 year male who has had a one year history of
exertional chest tightness. He had a pulmonary workup and used
an inhaler and prednisone, which did not relieve symptoms. He
was referred for a stress test on [**2108-8-13**] by his primary care
physician which elicited [**4-3**] chest tightness with exercise and
ST changes. Echo images revealed a moderately hypokinetic apex
and severely hypokinetic inferior apex with consistent with
likely apical ischemia. Ejection fraction was 55-60%. After his
stress echo on [**2108-8-13**] he was started on baby aspirin and
metoprolol. He was referred for left heart catheterization. He
was found to have two vessel coronary artery disease upon
cardiac catheterization and is now being referred to cardiac
surgery for revascularization.
Past Medical History:
Hypercholesterolemia
Cystic hygroma removed from abdomen age 6
Right knee surgery
Tonsillectomy
Social History:
He lives with his wife and 8 children. He is an unemployed
carpenter.
He denies smoking or alcohol use. He reports drinking more than
8 alcoholic beverages per week.
Family History:
His father was diagnosed with heart disease at age 71
Physical Exam:
Pulse:87 Resp:16 O2 sat:97/RA
B/P Right:137/91 Left:134/89
Height:5'[**07**]" Weight:204 lbs
General:
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _None____
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right:+1 Left:+1
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: cath site Left:+2
Carotid Bruit Right:None Left:None
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 91661**] (Complete)
Done [**2108-8-27**] at 9:49:35 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2057-8-11**]
Age (years): 51 M Hgt (in): 71
BP (mm Hg): 112/62 Wgt (lb): 204
HR (bpm): 68 BSA (m2): 2.13 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 745.5, 424.0
Test Information
Date/Time: [**2108-8-27**] at 09:49 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW-:1 Machine: us2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 3 < 15
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Arch: 2.3 cm <= 3.0 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.3 cm
Mitral Valve - E Wave: 0.4 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 0.80
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All
four pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right
shunt across the interatrial septum at rest.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Normal LV cavity
size. Normal regional LV systolic function. Overall normal LVEF
(>55%). Doppler parameters are most consistent with Grade I
(mild) LV diastolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Normal aortic arch diameter. Simple atheroma in
aortic arch. Normal descending aorta diameter. Simple atheroma
in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild to moderate ([**11-27**]+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. A patent foramen ovale
is present, confirmed by bubble study. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Doppler parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the ascending aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**11-27**]+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results at
time of surgery.
POST-BYPASS: The patient is on no inotropes. Biventricular
function is unchanged. Mitral regurgitation is unchanged. The
aorta is intact post-decannulation.
[**2108-8-31**] 05:47AM BLOOD WBC-7.6 RBC-3.64* Hgb-11.2* Hct-32.4*
MCV-89 MCH-30.8 MCHC-34.5 RDW-12.9 Plt Ct-209#
[**2108-8-27**] 12:53PM BLOOD WBC-11.5*# RBC-4.11* Hgb-12.5* Hct-36.5*
MCV-89 MCH-30.5 MCHC-34.3 RDW-12.7 Plt Ct-174
[**2108-8-28**] 12:36AM BLOOD PT-13.9* PTT-32.7 INR(PT)-1.2*
[**2108-8-27**] 07:58AM BLOOD PT-12.0 INR(PT)-1.0
[**2108-8-31**] 05:47AM BLOOD UreaN-16 Creat-0.8 Na-140 K-4.1 Cl-101
[**2108-8-27**] 12:53PM BLOOD UreaN-15 Creat-0.8 Na-143 K-4.1 Cl-111*
HCO3-25 AnGap-11
Brief Hospital Course:
On [**8-27**], Mr. [**Known lastname 3265**] [**Last Name (Titles) 1834**] a coronary artery bypass grafting
times three (left interior mammary artery to left anterior
descending, saphenous vein graft to diagonal, saphenous vein
graft to PLV), placement of synthes sternal plates performed by
Dr. [**Last Name (STitle) 914**]. CARDIOPULMONARY BYPASS TIME:71 minutes.CROSS-CLAMP
TIME: 57 minutes. Please see the operative note for details.
He tolerated the procedure well and was transferred in critical
but stable condition to the surgical intensive care unit on a
levophed infusion. He extubated but then post-operatively he
had high chest tube output and returned to the operating room
for re-exploration. He returned again to the intensive care
unit and was extubated again on the following evening after
diuresis. He was started on Beta-Blocker/Statin/Aspirin and
diuresis. On post-operative day two his chest tubes were removed
and he was transferred to the step down floor. Physical therapy
was consulted for evaluation of strength and mobility. He was
started on an ACE-I for more aggressive blood pressure control,
beta-blocker optimized. The remainder of his hospital course was
essentially uneventful. He continued to progress and on POD#4 he
was dicharged to home with VNA. All follow up appointments were
advised.
Medications on Admission:
DESIPRAMINE 10 mg Tablet one Tablet by mouth once a day
METOPROLOL SUCCINATE 25 mg Tablet Extended Release 24 hr - one
Tablet by mouth once a day
SIMVASTATIN 20 mg Tablet 1 Tablet by mouth once a day
ASPIRIN 81 mg Tablet, Delayed Release one Tablet by mouth once a
day
MV-MIN-FOLIC ACID-LUTEIN [CENTRUM SILVER] Dosage uncertain
OMEGA-3 FATTY ACIDS-FISH OIL [OMEGA 3 FISH OIL] Dosage uncertain
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:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. desipramine 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. 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*
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
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**]
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) 914**] [**Telephone/Fax (1) 170**] on [**10-2**] at 3:15pm
Cardiologist: Dr.[**First Name (STitle) **] [**Name (STitle) 2257**], on [**9-19**] at 10:30am
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 59223**],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 6803**] in [**2-28**] 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:[**2108-8-31**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2754
} | Medical Text: Admission Date: [**2131-3-16**] Discharge Date: [**2131-3-25**]
Date of Birth: [**2093-10-20**] Sex: F
Service: Medical Intensive Care Unit Team, [**Location (un) **]
CHIEF COMPLAINT: Near syncope, shortness of breath,
hyperkalemia.
HISTORY OF PRESENT ILLNESS: The patient is a 37 year old
female with a complex respiratory and cardiac history
including nonHodgkin's lymphoma, status post CHOP and
radiation resulting in pulmonary fibrosis, pulmonary
hypertension, status post left pneumonectomy for
aspergillosis infection. Also the patient has a
cardiomyopathy with an ejection fraction of 20%. He is
status post tracheostomy. On the day of admission while in
pulmonary rehabilitation the patient experienced a transient
near syncopal event lasting for 2 to 5 minutes with
concomitant shortness of breath. The symptoms resolved
spontaneously. Upon arrival to the [**Hospital6 649**] Emergency Department the patient was found to
be hyperkalemic with a potassium of 7.8 and an increased
blood urea nitrogen level of 43, up from a baseline of 20.
In the Emergency Department the patient was treated with
calcium, insulin and Kayexalate. Since arrival to the [**Hospital6 1760**] Emergency Department the
patient had been asymptomatic.
PAST MEDICAL HISTORY: NonHodgkin's lymphoma, pulmonary
histoplasmosis and pulmonary aspergillosis, pulmonary
fibrosis with the following pulmonary function tests, FVC .6,
FEV 1/FEC 68%, tuberculosis in [**2121**], status post splenectomy,
status post left pneumonectomy, cardiomyopathy with an
ejection fraction of 20%, anxiety and depression.
MEDICATIONS ON ADMISSION: Trazodone, Captopril, Lasix 40
b.i.d., Atrovent, Serevent, Protonix, tube feeds, Ativan
subcutaneous Heparin, Digoxin, Haldol, Risperdal, inhaled
Tobramycin, Lopressor and Remeron.
ALLERGIES: The patient has allergies to sulfa, oxacillin and
Verapamil.
SOCIAL HISTORY: The patient has a distant smoking and
drinking history. The patient lives with her mother but has
recently required prolonged hospital care for tracheostomy
and ventilator support.
PHYSICAL EXAMINATION: Vital signs, 100.7, heartrate 110,
blood pressure 76/30, respiratory rate 19, oxygen saturation
97% on pressor support ventilation of 5 with a positive
end-expiratory pressure of 5, and FIO2 of .4. In general the
patient is awake and alert in no distress. Pupils are equal
and reactive and anicteric. The patient has dry mucous
membranes. Neck, no jugulovenous distension is noted.
Tracheostomy tube is in place with minimal secretions.
Respiratory examination, the patient has diffuse expiratory
wheezes on the right with no breath sounds on the left.
Cardiac, the patient is tachycardiac with a summation gallop
palpable on the chest wall, II/VI systolic murmur is
auscultated best at the apex. Abdominal examination, soft,
nontender, gastrostomy tube in place with significant
drainage at the bandage and erythema surrounding the
gastrostomy tube site. Extremities, the patient has 1+
peripheral edema with 2+ peripheral pulses. Neurological
examination, the patient is alert and oriented times three,
moving all extremities. Nonfocal examination.
LABORATORY DATA: Laboratory data on admission revealed
sodium 133, potassium 7.8, chloride 88, bicarbonate 37, BUN
43, creatinine .5, glucose 138, white blood cell count 15.6,
81 neutrophils, 11 lymphocytes. Hematocrit was 35.7 and
platelets 467,000. PT is 12.7, PTT 26.6, INR 1.1, calcium
8.3, magnesium 2.0, albumin 2.6, Digoxin level 1.5, CK of 15,
troponin of less than .3. Urinalysis is significant for 20
hyaline casts. Chest x-ray on admission revealed congestive
heart failure, however, improved from previous x-rays during
previous admission.
HOSPITAL COURSE: The [**Hospital 228**] hospital course by systems is
summarized below:
Fluids, electrolytes and nutrition - The patient was admitted
with hyperkalemia with an initial potassium of 7.8. The
patient responded well to insulin, Kayexalate and calcium
given in the Emergency Room and repeat potassium was 5.6. On
hospital day #2 the patient's potassium was down to 4.3 and
remained in the normal range for three days. With the
initiation of aggressive Lasix diuresis, the patient became
hypokalemic for the rest of her hospital course with values
ranging between 3 and 3.6. The patient was placed on a
standing dose of 40 of [**Doctor First Name 233**]-Ciel by gastrostomy tube once a
day and additionally the patient required frequent
intravenous doses of [**Doctor First Name 233**]-Ciel. At the time of discharge, the
patient will likely require an increase in the dose of
[**Doctor First Name 233**]-Ciel for maintenance.
Respiratory - The patient was having difficulty weaning off
of ventilator support via tracheostomy during her previous
admission and throughout her current hospital stay. The
patient was initially on pressor controlled ventilation in
the Intensive Care Unit with inspiratory pressures of 35,
FIO2 of .4 and positive end-expiratory pressure of 5. The
patient was soon changed over the pressor support ventilation
initially at 20/5 with an FIO2 of .40. The patient was
clinically volume-overloaded and it was felt that the
patient's ventilator dependence would improve with aggressive
diuresis. Throughout the remainder of the [**Hospital 228**] hospital
course through [**2131-3-26**], the patient was switched over
the pressor support ventilation, initially 20/5 and
eventually weaned down to 8/5. The patient had a successful
tracheostomy masked trial lasting two and a half hours on
tracheostomy mask on [**2131-3-25**]. The patient was rested
during the evening of [**2131-3-25**] on pressor support of
[**7-23**]. Throughout, the criteria used for pressor support
weaning throughout the patient's Intensive Care Unit stay was
based on the title volumes the patient was taking as well as
the patient's subjective feelings of shortness of breath and
anxiety. At baseline the patient's title volumes are between
200 and 250.
Cardiovascular - The patient was felt to be volume overloaded
upon admission and was felt that she would benefit from
aggressive Lasix diuresis. Initially diuresis was difficult
as the patient's blood pressures were consistently low with
systolic pressures in the 70s and 80s. The decision was made
to discontinue the patient's Lopressor and Captopril and
after this change the patient's blood pressures were much
more appropriate and Lasix diuresis was instituted
successfully. The goal of the diuresis was to bring the
patient down from an admission weight of approximately 59 kg
to her calculated dry weight of approximately 51 kg. The
patient was initially on an intravenous Lasix b.i.d. regimen,
however, diuresis was not successful with this, therefore on
hospital day #4 the patient was placed on a Lasix drip. The
initial dose was 3 mg/hr, however, the patient was soon moved
up to a Lasix drip of 7 mg/hr for successful diuresis. The
patient remained on a Lasix drip of 7 mg per hour through
hospital day #10 ([**2131-3-25**]) with daily diuresis between
1 and 1.5 liters. The patient's blood pressure remained
stable with systolic pressures in the 80s during this time.
On [**2131-3-25**], the patient was taken off of Lasix drip and
was placed on a Lasix dose of 80 mg intravenously b.i.d.
The patient's Digoxin dose was also increased on hospital day
#4 after a Digoxin level came back subtherapeutic at .7. The
patient's Digoxin dose was increased from .125 q.d. to .125
q.o.d. alternating with .250 mg q.o.d. Follow up Digoxin
level on hospital day #9 was 1.2 within the therapeutic
range.
Gastrointestinal - The patient presented with a percutaneous
gastrostomy tube in place, however, there was a significant
amount of drainage from the site in addition to some skin
erythema and excoriation. The Surgical Service was consulted
and made multiple attempts at bedside revision of the
gastrostomy tube, however, none of these were successful and
the patient continued to have drainage from the site. At the
time of this dictation the patient is planned for laparotomy
with gastrostomy tube resiting on [**Last Name (LF) 766**], [**2131-3-26**] or
Tuesday [**2131-3-27**].
Hematology - The patient was initially admitted with a
hematocrit of 35.4, however, this coursed down throughout
hospital days 1 through 4. On hospital day #4 the patient's
hematocrit was 24.6. Anemia laboratory data were notable for
a low iron level of 24 and the patient was started on iron
supplementation, 325 mg p.o. q.d. Hemolysis laboratory data
was negative. On hospital day #4 the patient was transfused
1 unit of packed red blood cells and on hospital day #5 the
patient's hematocrit had gone up to 30.6. The patient's
hematocrit remained stable, above 30 through hospital day
#10, [**2131-3-26**].
Infectious disease - The patient was initially admitted on a
regimen of inhaled Tobramycin 300 mg q. 12 hours. The
patient continued this treatment throughout her Medicine
Intensive Care Unit stay and will continue on a schedule of
one month on and one month off, the present cycle of
Tobramycin is scheduled to end on [**2131-4-5**].
On hospital day #2 the patient had gram positive cocci on
gram stain of blood drawn off of the patient's PICC line and
the patient was started on Vancomycin. The resulting culture
was sparse growth of Staphylococcus epidermidis which was
felt likely to be a likely contaminate. The patient was
afebrile at this point with no leukocytosis. Therefore on
hospital day #4 the patient's Vancomycin was discontinued.
Through hospital day #10 ([**2131-3-25**]) the patient remained
afebrile with white blood cell counts in the range of 7 to
11.
Endocrine - On hospital day #4 the patient underwent a
Cosyntropin stimulation test to check for adrenal
insufficiency. The test was negative and the patient was not
started on any supplemental corticosteroids.
Pain - Throughout the patient's Medicine Intensive Care Unit
the patient experienced a significant amount of pain related
to manipulation of her gastrostomy tube as well as drainage
from the site of her gastrostomy tube. The patient was
treated with small doses of Morphine for this pain after the
failure of Ultram and Toradol to relieve the pain. At
present, the patient is receiving 1 to 2 mg of aliquots of
Morphine every two to four hours.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Name8 (MD) 24599**]
MEDQUIST36
D: [**2131-3-25**] 16:49
T: [**2131-3-25**] 18:26
JOB#: [**Job Number 108609**]
ICD9 Codes: 4280, 2767, 4168, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2755
} | Medical Text: Admission Date: [**2137-5-14**] Discharge Date: [**2137-5-24**]
Date of Birth: [**2080-10-24**] Sex: M
Service:
CHIEF COMPLAINT: The patient is a 56 year old patient of Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with known mitral valve disease referred for
outpatient cardiac catheterization.
HISTORY OF PRESENT ILLNESS: This is a 56 year old man who
reports a history of mitral valve disease and atrial
fibrillation first diagnosed approximately five years ago.
His most recent echocardiogram was from [**2137-4-19**]. This was
remarkable for mildly enlarged left ventricle with normal
systolic function. There was mitral valve prolapse with
moderate to severe mitral regurgitation along with severe
left atrial enlargement. The patient states he feels in his
usual state of health. He denies any chest pain, shortness
of breath or palpitations. He does have occasional lower
extremity edema. He denies claudication, orthopnea,
paroxysmal nocturnal dyspnea and light-headedness. Height
six feet three inches, weight 275 pounds.
PAST MEDICAL HISTORY:
1. Atrial fibrillation.
2. Mitral regurgitation.
3. Hypertension.
PAST SURGICAL HISTORY:
1. Bladder cancer treated surgically in [**2128**].
2. Varicocelectomy.
3. Hydrocelectomy.
4. Excision of pilonidal cyst.
5. Removal of extra digit as a child.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Coumadin 5 mg q.d.
2. Verapamil 240 mg q.d.
3. Coenzyme one q.d.
LABORATORY DATA: White count 7.5, hematocrit 46.1, platelets
286,000. Sodium 140, potassium 4.2, chloride 104, CO2 28,
blood urea nitrogen 18, creatinine 0.9. INR on admission was
1.53.
SOCIAL HISTORY: The patient is married and lives in
[**Location 3320**]. He works for airline loading planes.
The patient was admitted to the Cardiology service and
brought to the Cardiac Catheterization Laboratory. Please
see catheterization report for full details. In summary, the
catheterization showed 3+ mitral regurgitation with an atrial
septal defect, ejection fraction of 50%. and no significant
coronary artery disease. Following catheterization, the
patient was discharged home.
HOSPITAL COURSE: He was readmitted on [**2137-5-14**], directly to
the operating room at which time he underwent repair of his
mitral valve and atrial septal defect repair and a [**Month (only) 41692**]
procedure. Please see the operating room report for full
details.
In summary, the patient as stated earlier had a resection of
his mitral valve, the repair with a 28 [**Doctor Last Name 405**] ring and
atrial septal defect repair and a [**Month (only) 41692**] procedure. He was
transferred from the operating room to the Cardiothoracic
Intensive Care Unit. At the time of transfer, he had an
arterial line, Swan-Ganz catheter, atrial and ventricular
pacing wires and mediastinal chest tubes. At that time, his
mean arterial pressure was 69 with a CVP of 11. He had
Epinephrine, Milrinone, Nitroglycerin and Propofol infusing
at the time of transfer.
After arrival to the Intensive Care Unit, the patient was
weaned from the Epinephrine. His Milrinone was slowly weaned
during the course of operative day number one. A chest x-ray
done upon arrival to the Intensive Care Unit showed left
sided fluid collection. At that time, a #28 French chest
tube was placed. Unfortunately, we were unable to evacuate
the fluid collection at that time. Due to difficulty
oxygenating the patient, the patient was kept sedated
following his surgery.
On postoperative day one, the patient's sedation was
discontinued. He was weaned to pressure support ventilation.
At that time, he remained hemodynamically stable, however,
he did experience episodes of rapid atrial fibrillation. For
this, he was bolused with Amiodarone, however, he remained in
rapid atrial fibrillation despite the Amiodarone infusion.
On the morning of postoperative day three, the patient was
extubated with the assistance of anesthesia due to the fact
that he was a difficult intubation. On postoperative day
three, it was noted that the patient had a temperature to
102.7. At that time, he had a chest x-ray, blood, urine and
sputum cultures.
On postoperative day four, the patient remained
hemodynamically stable in atrial fibrillation despite being
maintained on an Amiodarone drip. All other cardioactive
medications, intravenous medications had been weaned to off
by that point. He remained in the Intensive Care Unit on
postoperative day four to further monitor his pulmonary
status.
On postoperative day five, the patient remained stable from
both pulmonary and cardiac state. He was bolused again with
another 150 mg Amiodarone and heparinized at that point for
persistent atrial fibrillation. Following his additional
bolus with Amiodarone, the patient was transferred to the
floor for continuing postoperative care and cardiac
rehabilitation.
Over the next several days, the patient's activity level was
increased with the assistance of the nursing staff and
physical therapy. He slowly progressed from an activity
standpoint. On postoperative day eight, it was decided that
the patient was stable and ready for discharge to
rehabilitation as soon as his INR was within therapeutic
range.
At that time, the patient's physical examination is as
follows: Vital signs revealed temperature 98, heart rate 60
and atrial fibrillation, blood pressure 101/57, respiratory
rate 22, oxygen saturation 93% on two liters. Weight
preoperatively is 122.7 kilograms and at discharge is 122.2
kilograms.
Laboratory data revealed a white count 9.6, hematocrit 32.2,
platelets 414,000. Prothrombin time 14.3, partial
thromboplastin time 26.7, INR 1.4. Sodium 140, potassium
4.4, chloride 103, CO2, blood urea nitrogen 21, creatinine
0.7, glucose 88.
On physical examination, the patient is alert and oriented
time three, moves all extremities, follows commands. Breath
sounds are somewhat decreased at the bases bilaterally;
otherwise clear to auscultation The heart sounds revealed
irregular rate and rhythm, S1 and S2, no murmurs. Sternum is
stable. Incisions with staples, open to air, clean and dry.
The abdomen is soft, nontender, nondistended, normoactive
bowel sounds. Extremities are warm and well perfused with 1+
pitting edema.
MEDICATIONS ON DISCHARGE:
1. Amiodarone 400 mg t.i.d. through [**2137-5-26**], and then 400
mg q.d.
2. Potassium Chloride 20 meq q.d.
3. Lasix 20 mg p.o. q.d. times one week.
4. Metoprolol 100 mg b.i.d.
5. Levofloxacin 500 mg q.d. times one week.
6. Colace 100 mg b.i.d.
7. Ranitidine 150 mg b.i.d.
8. Percocet 5/325 one to two tablets q4hours p.r.n.
9. Coumadin 5 mg q.d. and titrate to keep INR 2.0 to 3.0.
CONDITION ON DISCHARGE: The patient's condition is stable.
DISCHARGE DIAGNOSES:
1. Mitral regurgitation, status post mitral valve repair
with a 28 [**Doctor Last Name 405**] ring.
2. Patent ductus arteriosus repair.
3. Mays.
4. Atrial fibrillation.
5. Hypertension.
6. Bladder cancer.
7. Excision of pilonidal cyst.
8. Varicocelectomy.
9. Hydrocelectomy.
10. Removal of an extra digit as a child.
Th[**Last Name (STitle) 1050**] is to be discharged to rehabilitation.
Anticipated date of discharge is [**2137-5-23**]. He is to have
follow-up in wound clinic in two weeks and follow-up with his
primary care physician in three to four weeks and follow-up
with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2137-5-22**] 16:21
T: [**2137-5-22**] 17:44
JOB#: [**Job Number 95492**]
ICD9 Codes: 4240, 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2756
} | Medical Text: Admission Date: [**2163-4-16**] Discharge Date: [**2163-4-25**]
Date of Birth: [**2131-9-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Azithromycin / Rocephin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
CEREBRAL ANGIOGRAM
History of Present Illness:
31 year old hispanic male who was in usual state of health until
day of admission. He was doing stretching exercises at the
local gym when he had a sudden onset of headache. He went to an
OSH where CT scan demonstrated subarachnoid hemorrhage. He was
transferred to [**Hospital1 18**] for further eval.
Past Medical History:
DM type I
Social History:
employed
engaged - planning a wedding for this [**Month (only) 216**]
rare tob, no ETOH, no drugs or steroids however admits to taking
a "white pill" a week prior to admission for weight gain. He
does not know the makeup of the pill and states he only took it
once.
Family History:
non contibutory
Physical Exam:
98 96 161/69 16 100% RA
AAOx3 NAD
RRR
CTAB
soft NT/ND
no edema extrem warm
CN II-XII
Motor 5+ upper and lower extrem
coordination intact
sensation equal and intact
Pertinent Results:
[**Known lastname 81043**],[**Known firstname **] [**Medical Record Number 81044**] M [**2070-9-25**]
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2163-4-16**] 2:11 PM
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Doctor Last Name **] EU [**2163-4-16**] 2:11 PM
CTA HEAD W&W/O C & RECONS Clip # [**Clip Number (Radiology) 81045**]
Reason: ?aneurysmal bleed
Contrast: OPTIRAY Amt: 80
[**Hospital 93**] MEDICAL CONDITION:
31 year old man with hx of sudden onset worst HA of life,
mod/lg SAH on OSH
non-con CT head.
REASON FOR THIS EXAMINATION:
?aneurysmal bleed
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: AKSb SAT [**2163-4-16**] 5:25 PM
Focal SAH in the perimesencephalic and prepontine cisterns. No
definite
aneurysm or AVM identified. Possible etiologies include
perimesencephalic
(venous) bleed, or AVM/aneurysm obscured by hemorrhage. d/w
Neurosurg.
Final Report
INDICATION: 31-year-old with history of sudden onset worst
headache of life
with moderate subarachnoid hemorrhage on outside hospital CT.
Evaluate for
aneurysm.
No prior examinations available for comparison.
TECHNIQUE: Non-contrast CT of the head was performed, followed
by enhanced
CTA of the circle of [**Location (un) 431**] including multiplanar and
volume-rendered images.
NON-CONTRAST HEAD CT: There is high attenuation focal hemorrhage
within the perimesencephalic and prepontine cisterns. No
extension of hemorrhage within the ventricles and no evidence of
hydrocephalus. No additional foci of subarachnoid hemorrhage.
High attenuation area along the left tentorium
likely represents a sagittal sinus (2:11). The visualized
paranasal sinuses and mastoid air cells are normally pneumatized
and aerated.
CTA: The visualized course of intracranial carotid and vertebral
arteries and their major branches are normal. There is no
evidence of stenosis, occlusion, or aneurysm formation.
IMPRESSION: Focal subarachnoid hemorrhage within the
perimesencephalic and
prepontine cisterns, without a definite aneurysm seen on the
CTA. Differential considerations included a perimesencephalic
(venous) hemorrhage or an occult aneurysm or AVM.
Findings were discussed with the neurosurgical team at the time
of the exam.
The study and the report were reviewed by the staff radiologist.
[**Known lastname 81043**],[**Known firstname **] [**Medical Record Number 81044**] M [**2070-9-25**]
Radiology Report MRA NECK W&W/O CONTRAST Study Date of [**2163-4-17**]
12:39 PM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG SICU-A [**2163-4-17**] 12:39 PM
MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W&W/O
CONTRAST Clip # [**Clip Number (Radiology) 81046**]
Reason: eval for bleed
Contrast: MAGNEVIST Amt: 20
[**Hospital 93**] MEDICAL CONDITION:
31 M bodybuilder, stritching yesterday he had sudden onset
HA. CT at OSH shows SAH. No other complaints or deficits.
Loaded dilantin and given nimodpine at OSH. Transferred to
[**Hospital1 18**] for further management. Angio neg for aneurysm
REASON FOR THIS EXAMINATION:
eval for bleed
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: DFDkq SUN [**2163-4-17**] 6:12 PM
Subarachnoid hemorrhage in the perimesencephalic and prepontine
cisterns, as well as in the sulci of both convexities. Normal
MRA of the neck. MRA of the head is slightly limited by motion,
but no aneurysms are identified.
Final Report
INDICATION: Subarachnoid hemorrhage.
COMPARISON: Head CTA performed on [**2163-4-16**] and
conventional cerebral
angiogram performed on [**2163-4-16**].
TECHNIQUE: Sagittal T1-weighted and axial T1-weighted,
T2-weighted, FLAIR,
gradient echo, and diffusion-weighted images of the head.
Three-dimensional time-of-flight MRA of the head. Dynamic
coronal VIBE imaging of the neck obtained during intravenous
gadolinium administration. Following intravenous gadolinium
administration, multiplanar T1-weighted images of the head were
obtained.
HEAD MRI: T1 isointense and T2 hypointense blood products are
seen in the
perimesencephalic and prepontine cisterns, corresponding to the
subarachnoid hemorrhage seen on the non-contrast portion of the
preceding head CTA. In addition, there is high signal in the
sulci on FLAIR images involving the right frontal, bilateral
parietal, and bilateral occipital lobes. This is consistent with
additional subarachnoid hemorrhage which is occult by CT. There
is no evidence of edema, infarction, mass or other pathologic
enhancement in the brain. There is no evidence of a meningeal
mass. The ventricles are normal in size and configuration.
NECK MRA: The cervical common carotid, internal carotid, and
vertebral
arteries appear normal. The distal cervical internal carotid
arteries measure at least 4 mm in diameter.
HEAD MRA: The study is slightly limited by artifacts. Flow is
seen in the
intracranial internal carotid and vertebral arteries, and their
major
branches, without evidence of stenoses or aneurysms.
IMPRESSION:
1. Subarachnoid hemorrhage in the basal cisterns as well as in
the cerebral sulci.
2. Normal neck MRA.
3. Unremarkable head MRA.
[**Known lastname 81043**],[**Known firstname **] [**Medical Record Number 81044**] M [**2070-9-25**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2163-4-18**] 4:27
AM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG SICU-A [**2163-4-18**] 4:27 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 81047**]
Reason: eval for infiltrate
[**Hospital 93**] MEDICAL CONDITION:
31 year old man with SAH, w/ dark sputum and intermittent
low-normal O2
saturation. To eval for infiltrate.
REASON FOR THIS EXAMINATION:
eval for infiltrate
Preliminary Addendum
Preliminary reports are not available for viewing.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG SICU-A [**2163-4-18**] 4:27 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 81047**]
Reason: eval for infiltrate
[**Hospital 93**] MEDICAL CONDITION:
31 year old man with SAH, w/ dark sputum and intermittent
low-normal O2
saturation. To eval for infiltrate.
REASON FOR THIS EXAMINATION:
eval for infiltrate
Final Report
REASON FOR EXAMINATION: Decrease in saturations in a patient
with
subarachnoid hemorrhage.
Portable AP chest radiograph was reviewed with no comparison to
the prior
studies. There is a large opacity in the left lower lung most
likely
involving the left lower lobe and lingula. There is additional
opacity in the right lower lobe. The findings are concerning for
bilateral aspiration or multifocal pneumonia. Slight left
ventricle engorgement is present also may be projectional due to
the position of this film. No appreciable pleural effusion is
demonstrated.
Brief Hospital Course:
Pt was admitted through the emergency room after transfer from
OSH for perimesencephalic hemorrhage after working out at gym.
Pt was placed on dilantin and nimodipine and and a-line was
placed. Systolic BP was controlled to less than 140. A cerebral
angiogram was done on [**2163-4-17**] which was negative for aneurysm.
A CXR was done on [**2163-4-18**] for low O2 sats and dark sputum. The
findings were suggestive of pneumonia vs. aspiration however the
pt is afebrile without elevated WBC, so no antibiotics were
started at this time. A blood gas was obtained that showed
poosr oxygenation. This was discussed with the ICU attending
and CTA of the chest was then oobtained without evidence of PE.
Pt was supported on increasing amounts of O2 throughout the
night and on the am of [**2163-4-19**] it was decided that he would
need ventilatory support. Prior to intubation he was mentating
well and his neuro exm remianed stable. Consent for HIV testing
was obtained and found to be negative. Bronchoscopy for sputum
culture and or mucous plugging was performed. Lasix gtt was
started for ARDS treatment. He required mechanical ventilation
and was weaned to room air on [**4-20**] a CXR showed improved
bibasilar opacities prior to transfer to floor.
He was monitored on the surgical floor for 3 days and had a
repeat CTA which showed a
Normal CT of the head with no evidence of aneurysm formation.
Mild vasospasm
is noted at the distal basilar artery. He was cleared for
discharge he had no focal neurological deficits on discharge and
his headache was minimal. The patient felt comfortable managing
his diabetes as to his prior regiman. He was sent with a
prescription of Levaquin to finish his treatment of his
pneumonia.
Medications on Admission:
lantus, novuloge,
body building proteins and supplements
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. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-28**]
Tablets PO Q6H (every 6 hours) as needed for headache: DO NOT
DRIVE WHILE TAKING THIS MEDICATION.
Disp:*60 Tablet(s)* Refills:*0*
3. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID (3 times a day): YOU WERE PRESCRIBED THIS
MEDICATION TO PREVENT SEIZURE. DO NOT STOP TAKING IT UNLESS
DIRECTED BY A PHYSICIAN. .
Disp:*360 Tablet, Chewable(s)* Refills:*2*
4. Outpatient Lab Work
DILANTIN LEVEL FRIDAY [**2163-3-30**]
PLEASE FAX RESULTS TO PTS PRIMARY CARE OFFICE.
5. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 12 days: do not stop taking htis medication on your
own....you must complete the full course prescribed for you.
Disp:*144 Capsule(s)* Refills:*0*
6. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Perimesencaphalic hemorrhage
Respiratory failure/hypoxia requiring mechanical ventilation
Pneumonia = Community aquired
Hyperglycemia = DM I
MEDICATION REACTION / NEW ALLERGY TO AZITHROMYCIN AND ROCEPHIN
Discharge Condition:
NEUROLOGICALLY STABLE
Discharge Instructions:
Angiogram
YOU HAVE BEEN PRESCRIBED DILANTIN FOR SEIZURE CONTROL. DO NOT
STOP TAKING THIS ON YOUR OWN. YOUR PRIMARY CARE PHYSICIAN WILL
FOLLOW YOUR LEVELS. YOUR FIRST LEVEL TO BE DRAWN IS IN 5 DAYS
?????? Continue all other medications you were taking before, unless
otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your groin site should be well healed at this point.
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
- You should not return to work for one week
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room
Followup Instructions:
YOU SHOULD FOLLOW UP AT DR. [**Last Name (STitle) **]' OFFICE / NEUROSURGERY IN ONE
MONTH - Please call [**Telephone/Fax (1) **] to schedule an appointment
YOU SHOULD BE SEEN BY YOUR PRIMARY CARE PHYSICIAN WITHIN TWO
WEEKS OF DISCHARGE TO NOTIFGY HIM/HER OF YOUR HOSPITALIZATION
AND DIAGNOSIS'
YOU WERE SEEN BY [**Last Name (un) **] DIABETES SPECIALISTS WHILE HERE AT
[**Hospital1 18**]. THEY RECOMMEND YOU RETURN TO YOUR PRIOR GLUCOSE CONTROL
REGIME UPON DISCHARGE.
Completed by:[**2163-5-9**]
ICD9 Codes: 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2757
} | Medical Text: Admission Date: [**2146-10-23**] Discharge Date: [**2146-11-15**]
Date of Birth: [**2081-11-5**] Sex: M
Service: SURGERY
Allergies:
Demerol / Haloperidol / Ativan / Percocet
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Fatigue and Fevers, Melena
Major Surgical or Invasive Procedure:
Liver biopsy
[**First Name3 (LF) **] (Endoscopic Retrograde Cholangiopancreatography)
repeat [**First Name3 (LF) **] (Endoscopic Retrograde Cholangiopancreatography)
[**11-7**] - Exploratory laparotomy, duodenostomy,
and oversewing of bleeding location on the ampulla.
History of Present Illness:
64-year-old male with a past medical history of hepatitis C
cirrhosis and hepatocellular carcinoma who is status post liver
transplantation on [**2145-12-7**].
.
After his liver transplantation, his course was complicated by
recurrent hepatitis C with fibrosing cholestatic hepatitis. He
was treated with Infergen and ribavirin, but this was
discontinued as the patient developed seizures on this therapy.
His recurrent hepatitis C was therefore addressed by changing
his immunosuppression from Prograf to rapamycin. The switch to
rapamycin was also done due to the fact that he had
hepatocellular carcinoma, and evidence has demonstrated reduced
recurrence of HCC in patients on rapamycin therapy.
.
The patient was recently admitted to the hospital in early
[**Month (only) **] due to abnormal liver function tests. His liver biopsy
demonstrated moderate acute cellular rejection. He was therefore
treated with Solu-Medrol 500 mg daily for three days and then
discharged on oral prednisone. He currently takes prednisone 20
mg daily. He was readmitted to the hospital on [**2146-10-12**]. This
was due to the fact that he had worsening liver function tests,
with an ALT of 271 and an AST of 317. His liver biopsy
demonstrated no features of acute cellular rejection, but there
was evidence of grade 1 inflammation and stage I-II fibrosis.
His rapamycin levels at that time were elevated at 27.3, and
therefore this medication was held. The patient was discharged
on [**10-14**]. Upon discharge, he was told to have his rapamycin
levels checked on the 29th and then to restart this medication
on the 29th after getting his levels checked. These levels are
not available in the [**Hospital1 **] system, but the patient did restart
rapamycin.
.
The patient was seen in [**Hospital **] clinic on [**2146-10-19**] feeling relatively
well. A rapamycin level was drawn: 18.2 on [**10-20**] with plan for
followup [**2146-10-26**].
.
The patient describes being extremely fatigued for one week, but
decided to come to the ED when he had fevers to 102.8 last night
with chills. He describes having diarrhea [**2-21**] bm per day despite
using lomotil. However, he notes that his BM have not changed in
frequency or consistency recently- instead he has had diarrhea
since starting on an extensive course of liver medications,
including bactrim for prophyolaxis while on sirolimus and
prednisone taper. He does not that the color of his diarrhea has
changed in the past few days from brown to caramel colored. He
has some mild abdominal pain that he associates with his
diarrhea, but no RUQ pain. He denies chest pain, SOB, dysuria or
change in urinary frequency. He also denies confusion or change
in skin color or abdominal girth.
.
In the ED, initial vs were: 57 125/80 16 97%. CT abdomen/pelvis
in the ED showing no acute intraabdominal pathology. He was
started on PO vanc for presumptive C diff, and was given 1 mg
Rapamycin per GI recs.
Past Medical History:
-Bipolar disorder: Diagnosed in [**2129**], past suicide attempt in
the 70s during a manic phase or s/t to drug and alcohol abuse.
Had been stable on Wellbutrin and Lithium since [**29**] and 93
respectively, except for during a trial of IFN therapy in [**2138**]
where hospitalization was required.
- HCV: Genotype unknown. Liver biopsy in [**9-/2144**] showed stage 4
cirrhosis and small well-differentiated hepatocellular
carcinoma. Found to have grade 1 esophageal varices on EGD in
4/[**2143**]. Developed hepatic encephalopathy in [**2142**] requiring
hospitalization at [**Hospital1 2025**], started on lactulose with good effect.
Past treatments include peg interferon and ribavirin in [**2139**].
These meds were discontinued due to suicidal ideation. For
recent history please refer to HPI.
- HCC: Recently noted 1.4 cm enhancing lesion on liver imaging,
proved to be small, well-differentialed HCC on bx in [**9-26**] s/p
cadaveric liver transplantation on [**11-28**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**])
- Hypothyroidism. On levothyroxine as an outpatient.
- [**2145-12-7**] liver [**Month/Day/Year **]
- Psych: history of bipolar disorder managed with high dose
wellbutrin. prior suicide attempts requiring hospitalization.
Social History:
He lives [**Location (un) **] w/ wife, who is a nurse and two teenage
children. No [**Location (un) 23165**] beverage for 30 years. No tobacco use
ever.
Family History:
Non-contributory.
Physical Exam:
Gen: NAD
HEENT: MMM no lesions
CV: RRR no MRG
RESP: CTAB no WRR
ABD: soft, tender around incision site. No guarding or rebound
WOUND: Abdominal incision clean and dry, JP site recently opened
with no evidence of active drainage. JP with serous drainage
Ext: No LE edema
Pertinent Results:
Admission Labs:
[**2146-10-23**] 09:00AM URINE RBC-0-2 WBC-[**1-21**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2146-10-23**] 09:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG
[**2146-10-23**] 09:00AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2146-10-23**] 09:00AM PT-11.7 PTT-29.8 INR(PT)-1.0
[**2146-10-23**] 09:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2146-10-23**] 09:00AM WBC-5.1 RBC-4.02* HGB-11.0* HCT-32.7* MCV-81*
MCH-27.4 MCHC-33.6 RDW-14.8
[**2146-10-23**] 09:00AM ALT(SGPT)-252* AST(SGOT)-426* ALK PHOS-392*
TOT BILI-3.3*
[**2146-10-23**] 09:00AM GLUCOSE-191* UREA N-27* CREAT-1.1 SODIUM-133
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-21* ANION GAP-16
[**2146-10-23**] 09:12AM LACTATE-1.4
.
Imaging:
CT Ab/Pelvis [**2146-10-23**]:
IMPRESSION:
1. No acute abdominal pathology.
2. Interval decrease in free fluid surrounding the liver with
only a small amount remaining.
3. Interval removal of CBD stent without intra- or extra-hepatic
biliary ductal dilatation.
.
CXR [**2146-10-23**]:
FINDINGS: In comparison with study of [**5-31**], there is no interval
change or evidence of acute cardiopulmonary disease. No
pneumonia, vascular congestion, or pleural effusion.
.
[**Date Range **] report:
Successful biliary cannulation with the sphincterotome.
A caliber change was noted between the native and transplanted
bile ducts. At the anastamosis there was some resistance as an
8.5 mm balloon was pulled through. Otherwise normal
post-[**Date Range **] cholngiogram A 11cm by 10FR biliary stent was
placed successfully across the anastamosis [stent placement].
Otherwise normal [**Date Range **] to 3rd portion of duodenum.
.
Recommendations: If the LFTs improve following stent placement,
balloon dilation of the anastamosis could be performed in 1
month. If the LFTs fail to improve following stent placement, we
will remove the stent in 1 month. Juices when awake and alert,
then advance diet as tolerated. Further management as per
hepatology service.
[**2146-11-9**]:
RIGHT UPPER QUADRANT ULTRASOUND WITH DOPPLER:
There are no focal or textural abnormalities within the liver.
The common
bile duct measures 5 mm and is not dilated. The pancreatic body
and tail are
obscured by overlying bowel gas. However, the remainder of the
pancreas
appears normal. There is splenomegaly with the spleen measuring
14.7 cm.
Incidentally noted is a left renal cyst measuring 5.6 x 5.8 cm
in sagittal
dimension. A single view of the right kidney shows no
hydronephrosis.
ABDOMINAL DOPPLER: The left, main, and right portal veins are
patent with
hepatopetal flow. The hepatic veins are patent with normal
directional flow.
The main hepatic artery is patent with normal arterial Doppler
waveforms.
IMPRESSION:
1. Normal hepatic echotexture with no focal lesions.
2. Patent hepatic vasculature without evidence of portal vein
thrombosis.
3. Normal caliber common bile duct measuring 5 mm.
4. Splenomegaly.
Liver, allograft, core needle biopsy:
1. Moderate portal/periportal, and mild lobular mixed
inflammation including lymphocytes, plasma cells, occasional
neutrophils, and eosinophils. Occasional apoptotic hepatocytes
seen.
2. Prominent bile duct damage with infiltrating lymphocytes are
seen.
3. Focal portal endothelialitis [**Doctor Last Name **].
4. Trichrome stain shows increased portal fibrosis with septa
formation and focal minimal sinusoidal fibrosis (stage 2).
5. Iron stain shows minimal iron deposition in hepatocytes.
Note: The findings are consistent with recurrent viral
hepatitis C. There is also venulitis which is consistent with
acute cellular rejection.
Brief Hospital Course:
64-year-old male with a past medical history of hepatitis C
cirrhosis and hepatocellular carcinoma who is status post liver
transplantation on [**2145-12-7**] and presents with fevers at home
and diarrhea.
.
# Fevers (MICU added course, primary team please update): There
was concern for C.diff in the ED given diarrhea with fevers;
treatment was started with PO Vancomycin. Of note, the patient's
WBC is not elevated but he is immunosupressed so this is not
sensitive/expected. Of note, another concern in a patient with
known liver [**Year (4 digits) **] rejection would be SBP, but the patient
does not have ascites on exam or CT and has only mild tenderness
to abdominal palpation. Rest of infectious workup negative: U/A
negative, CXR negative. During his MICU course, he spiked a
fever to 100.6 on [**11-4**]. He was on daptomycin/zosyn at the time.
Patient was pan-cultured which grew nothing.
.
# GI Bleed: While in the hospital, the patient began to pass
burgundy colored stools with small blood clots on evening of
[**11-1**] and subsequently triggered on the floor for hypotension
(85/48). He was subsequently transferred to the MICU for closer
hemodynamic monitoring in setting of GI bleeding for which
colonoscopy indicated a bleeding at his sphincterotomy with
hemostasis acheived. He received 4 units of pRBC total. He did
have some maroon stools after the EGD, which may have
represented a slow ooze with stable Hgb. His hematocrits were
stable until the afternoon of [**11-4**] when he had a Hct drop to
25.9. He was transfused 1 unit, and sent to angio where they
could not located the bleeding vessel. He received another unit
PRBC that night, continued to have maroon stools and w/
continued low Hct's. Received 10 units as of [**2146-11-6**]. Had
positive tagged RBC scan, then went to angio on [**11-6**], but
unable to localize on arteriogram so transferred to [**Month/Year (2) **]
surgery service in case surgery indicated.
.
# S/P [**Month/Year (2) 1326**] (Immunosupression): Transplanted [**11-28**]. Had
episode of ACR s/p steroids and re-bx confirming no evidence of
rejection. patient being immunosuppressed with Rapamycin. Of
note, levels have been fluctuating lately. The patient was
continued on home med of Rapamune 1 daily and MMF 500 [**Hospital1 **] was
started by floor team. There was concern for rejection/HCV given
elevated AlkPhos. His levels were followed and re-dose as
appropriate
.
# Direct hyperbilirubinemia (MICU course, primary team to
update)
Patient had admission bilirubin of 3.3 with subsequent uptrend
to 12 mostly direct fraction with obvious jaundice. His recent
[**Hospital1 **] showed a patent extrahepatic system. The concern is for an
intrahepatic process or infectious etiology such as virus.....
.
# HCC: The patient is scheduled for a protocol CT
scan on [**2146-12-7**], which will be one year post-transplantation.
As of yet, he has not had recurrence of HCC. GI following.
.
# Psychiatric Issues incl. Bipolar Disorder: Continued
Modafinil, Seroquel, Keppra, Effexor
.
# Hypothyroidism: Continued Synthroid
The following is a brief summary of the [**Hospital 228**] hospital
course while on the [**Hospital 1326**] Surgery Service beginning [**11-7**]:
The patient was taken to the operating room for massive melena
s/p [**Month/Year (2) **] sphincterotomy on [**2146-11-7**]. See operative report for
full details. The patient was transferred to the SICU in good
condition. His SICU course was remarkable for post operative
delirium, for which a psychiatry consult was obtained. They
recommended Zyprexa at night and good sleep hygiene which were
followed. The patient's hematocrit stabilized and on POD 2 he
was transferred to the floor.
His NGT was discontinued on POD3, and the patient was started on
a clear liquid diet. Of note, the patient continued to have
melanotic bowel movements after his operation. His hematocrit
remained stable, and his hemodynamic status never faltered. He
was started on Ceftriaxone (later converted to PO Keflex) on POD
3 for erythema around his incision site. His diet was advanced
to regulars on POD4. At this time, his bowel movements began to
turn more brown in color. On POD5 he was given 1U PRBC's for a
Hct of 28.3, down from 31 the day before. He responded
appropriately. At this time his course was notable for
persistent serous drainage in his JP bulb, close to ~500cc a
day. By POD 8 the patient's pain was well controlled with oral
medication, and was eating and voiding with no difficulty. His
melena had completely resolved. He was ambulating with the
assistance of a walker. He was discharged on a 7 day course of
keflex for management of his wound incision. His JP drain was
left in, and the patient had VNA services arranged to help with
it's care and output recording. Lastly, the patient was given a
5 day course of oral lasix to aid with his lower extremity
edema.
Of note, the liver biopsy performed during his operation was
notable for recurrent HCV as well as acute rejection. See
pathology report for full details. His rapamycin was
transitioned to prograf in the interest of better wound healing,
and his levels were aimed at slightly higher values. Due to his
history of prior seizures on high dose prograf, his keppra
dosing was increased as well.
Medications on Admission:
Modafinil 100 mg daily.
Folic acid 1 mg daily.
Daily multivitamin.
Seroquel 25 mg. at bedtime.
Keppra 500 mg b.i.d.
Effexor 37.5 mg b.i.d.
Synthroid 100 mcg daily.
Hydroxyzine 25 mg p.o. q.i.d.
Cholestyramine 4 g p.r.n. for itching.
Bactrim 480 mg daily.
Omeprazole 20 mg daily.
Prednisone 10 mg daily.
Valganciclovir 450 mg daily.
Mycophenolate (Patient does not know dose; no notes mentioning
this)
Rapamycin-- patient has been holding for 2 days per GI reccs,
was given 1 mg today in ED
Discharge Medications:
1. modafinil 100 mg Tablet [**Date Range **]: One (1) Tablet PO qdaily ().
2. folic acid 1 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
4. venlafaxine 37.5 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2
times a day).
5. levothyroxine 100 mcg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
6. hydroxyzine HCl 25 mg Tablet [**Date Range **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
7. cholestyramine-sucrose 4 gram Packet [**Date Range **]: One (1) Packet PO
BID;PRN () as needed for itching.
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Date Range **]: One (1)
Tablet PO DAILY (Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Date Range **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. valganciclovir 450 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
11. mycophenolate mofetil 500 mg Tablet [**Date Range **]: One (1) Tablet PO
BID (2 times a day).
12. olanzapine 2.5 mg Tablet [**Date Range **]: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
13. levetiracetam 250 mg Tablet [**Date Range **]: Three (3) Tablet PO BID (2
times a day).
14. cephalexin 500 mg Capsule [**Date Range **]: One (1) Capsule PO Q6H (every
6 hours) as needed for wound infxn.
Disp:*28 Capsule(s)* Refills:*0*
15. hydromorphone 2 mg Tablet [**Date Range **]: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
16. prednisone 5 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily).
17. tacrolimus 1 mg Capsule [**Date Range **]: Two (2) Capsule PO twice a day.
Disp:*120 Capsule(s)* Refills:*1*
18. tacrolimus 0.5 mg Capsule [**Date Range **]: take as directed Capsule PO
as directed.
Disp:*180 Capsule(s)* Refills:*1*
19. Lasix 20 mg Tablet [**Date Range **]: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent hepatitis C
Acute Kidney Injury
GI bleed after sphincterotomy
incision cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for fever, fatigue, and increased diarrhea.
Because your LFTs were elevated, a liver biopsy was done, which
showed infection and recurrent hepatitis C. [**Hospital **] was done and
had a stent placed. Fevers continued with elevated liver
enzymes, a second [**Hospital **] was done with placement of 2 stents and a
procedure called a sphincterotomy was performed. After this
procedure you had bleeding. You went to the OR (Dr. [**First Name (STitle) **] to
stop the bleeding. Bleeding stopped.
The [**First Name (STitle) **] biliary duct stents have migrated down and are making
their way through your intestine. Please look at all of your BMs
to see if you pass 2 blue stents (tubes). If you do not pass
these stents, you will have an abdominal XRAY called a KUB on
[**First Name (STitle) 766**] [**11-21**]
CareGroup VNA services have been arranged to see you at home for
Physical therapy.
Empty and record all output from your JP drain.
You may shower.
No driving while taking pain medication.
No straining/heavy lifting/swimming/shoveling
You will need to have labs every [**Month/Day (4) 766**] and Thursday starting
Thursday [**11-17**] at [**Last Name (NamePattern1) 439**], [**Hospital 86**] [**Hospital 2577**] Medical
Office Building
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2146-11-21**] 10:30
Please reschedule your appointment with DERMATOLOGY AND LASER
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2308**], MD [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: RADIOLOGY
When: WEDNESDAY [**2146-12-7**] at 10:15 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2146-12-15**] 10:30
Completed by:[**2146-11-23**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2758
} | Medical Text: Admission Date: [**2171-9-28**] Discharge Date:[**2171-10-18**]
Date of Birth: [**2138-1-22**] Sex: M
ADMITTING DIAGNOSIS: Multitrauma, Status post unrestrained
passenger in a
motor vehicle accident.
33 y.o. male with unknown past medical history who was found
unrestrained motor vehicle accident in which he was the
driver. There was approximately 15 minute extrication time
from the vehicle. The patient was found to be transiently
hypotensive with systolic blood pressure in the 90s which
responded quickly to approximately 300 cc of fluid
resuscitation. The patient arrived in the Emergency
complaining of bilateral leg pain and back pain. He had a
and subsequently had to be intubated to facilitate full
trauma team evaluation.
There was a questionable loss of consciousness during the
accident.
PAST MEDICAL HISTORY: Unknown.
PAST SURGICAL HISTORY: Unknown.
ALLERGIES: Unknown.
MEDICATIONS: Unknown.
PHYSICAL EXAMINATION: Vital signs revealed pulse 55, blood
pressure 160/48. Head, eyes, ears, nose and throat,
atraumatic head with no obvious signs of injury. Tympanic
membranes were intact. No blood in the outer ears. Chest
was clear to auscultation bilaterally, nontender.
Cardiovascular, normal sinus rhythm. Abdomen was soft,
nontender, nondistended. Pelvis was stable and tender.
Rectal with normal tone, guaiac negative. Extremities with
left thigh deformity, palpable dorsalis pedis, posterior
tibial bilaterally, right open tibial-fibula fracture,
palpable posterior tibial but dorsalis pedis was nonpalpable
on the right side. Back, no obvious stepoff or deformity.
LABORATORY DATA: Radiographic studies, lateral cervical
spine showed C1 through C7 within normal limits, no obvious
fractures. The patient did have a left femur displaced,
comminuted fracture and an open Grade 2 right tibia-fibula
fracture. Computerized tomography scan of the head was
negative. Computerized tomography scan of the neck was also
negative. The patient had thoracolumbosacral films
subsequently which showed approximately 10% compression
fracture of T12.
HOSPITAL COURSE: The patient was seen in the Trauma Bay by
the Trauma Team where a full trauma evaluation was carried
out. He was started on intravenous fluids for resuscitation
and then was taken to the Operating Room for fixation of his
left femur and right tibia-fibula fractures. He had left
femur intramedullary rodding, he had transverse femoral shaft
fracture and a washout and fibular rodding of the right open
tibia-fibula fracture. The patient tolerated the procedure
well and postoperatively was transferred to the Surgical
Intensive Care Unit where he remained stable for the next few
days. He was subsequently extubated at which time he
complained of back pain. Orthopedic Spine was once again
consulted and recommendation for TLSO brace to be worn when
out of bed for six to twelve weeks was made. The patient was
subsequently fitted for a TLSO.
The toxicology screen during the common workup was positive
for alcohol and the patient also has a history of
recreational drug use. The patient was postoperatively noted
to have troponin leak with a troponin of 2.6 in the Surgery
Intensive Care Unit. The Cardiology was consulted and they
felt that the patient had a cardiac contusion in the setting
of a motor vehicle accident. He had persistent delirium
through [**9-10**] to 24 which is attributed to either
questionable head injury or over sedation from opioids or
benzodiazepines and it was felt unlikely to represent alcohol
withdrawal. His mental status improved by [**10-5**]. On
[**10-6**], he was noted to have left upper extremity
weakness and diminished left biceps and brachioradialis
reflexes. He had subsequent magnetic resonance imaging scan
of the head, demonstrated diffuse axonal injury, magnetic
resonance imaging scan of the neck with C5-6 and C6-7 disc
protrusion. On [**2171-10-10**] he underwent surgical
decompression of these herniations. On [**10-11**], the
patient started complaining of some dyspnea at rest
associated with some left-sided chest discomfort. His oxygen
saturations were a little lower than what they had been. He
was 93% on room air. His electrocardiogram showed a
persistent sinus tachycardia, inferior T waves without acute
change from previous study. Medicine was consulted and they
felt that the patient had left lower lobe pneumonia. He was
started on Ceftriaxone 1 gm intravenously q. 24 which
subsequently will be switched to Levaquin 500 mg p.o. q. day
for 14 days upon the patient's discharge. On [**2171-10-14**] the patient had swallow study requested for the
patient's continued inability to swallow. Speech swallow saw
the patient and recommended pureed diet with thick liquid,
positioning the patient upright for meals, staff supervision
at the time of meals and also a video-assisted swallowing
study. Neurology was also consulted on [**10-15**] regarding
the patient's continued mental state. He was unable to carry
out a normal thought process. He was unable to recall why he
was in the hospital and was perseverating about hunger and
not being able to call for help. Neurology consult saw the
patient and felt that his behavior represented diffuse axonal
injury and residual shortterm neurological deficit. They
recommended follow up in Behavioral Neurology Unit for
longterm cognitive neurologic issues as well as follow up in
the General [**Hospital 878**] Clinic with Dr. [**Last Name (STitle) **]. They felt
that the patient needed cognitive rehabilitation as well as
physical rehabilitation. The patient otherwise made steady
progress while in the hospital. A rehabilitation bed was
obtained for him and he was transferred to rehabilitation on
[**2171-10-17**].
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d., hold for systolic blood
pressure less than 100 and heartrate less than 55
2. Lovenox 30 mg b.i.d.
3. Ativan .5 mg p.o. b.i.d. prn
4. Colace 100 mg p.o. b.i.d.
5. Dulcolax 10 mg p.r. q. day prn
6. Percocet one to two tabs p.o. q. 4 hours prn
7. Droperidol .625 mg intramuscularly q. 6 hours prn
8. Levaquin 500 mg p.o. q. day times 14 days
DISCHARGE INSTRUCTIONS: Specific treatment and frequency -
The patient will be touch-down weightbearing on the right and
left lower extremity. He will TLSO for ten weeks when out of
bed.
Follow up appointments:
1. Follow up with Dr. [**First Name (STitle) 1022**] in two weeks, please call his
office to schedule an appointment, office # [**Telephone/Fax (1) 36310**].
2. Follow up in Behavioral Neurology Unit for longterm
cognitive/neurologic issues.
3. Follow up in the General [**Hospital 878**] Clinic with Dr.
[**Last Name (STitle) **]. Please call [**Telephone/Fax (1) 2756**] to reach Dr.[**Name (NI) 36311**]
office.
Diet - The patient is to have pureed diet with mixed thick
liquid. He is to position himself upright for meals. He
should be supervised at meals and should be monitored for
aspiration. If the patient seems to be coughing with meals
would seek medical attention. His medication should be
crushed and administered with applesauce.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] M.D.20-231
Dictated By:[**Name8 (MD) 36312**]
MEDQUIST36
D: [**2171-10-16**] 15:47
T: [**2171-10-16**] 17:09
JOB#: [**Job Number 36313**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2759
} | Medical Text: Admission Date: [**2137-4-1**] Discharge Date: [**2137-4-24**]
Date of Birth: [**2079-8-1**] Sex: M
Service: SURGERY
Allergies:
Neurontin
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Left leg pain and non healing ulcers left foot.
Major Surgical or Invasive Procedure:
[**2137-4-3**]:Serial arteriogram of left lower extremity.
[**2137-4-10**]: Left common femoral endarterectomy, Left femoral to
below-knee popliteal bypass graft using 8-mm Propaten graft,
ring. Left first toe open amputation.
[**2137-4-17**]: Left transmetatarsal amputation.
History of Present Illness:
57 yo male significant PVD, sp left SFA stent and right CFA
pseudoaneurysm presented to clinic with increased left foot pain
on [**2137-4-1**]. Ultrasound at the time showed no flow through the
stent. Left toes and lateral and medial malleolar ulcers all
appeared to have worsened since last visit so patient was
admitted to the hospital for IV antibiotics, wound care and
angiogram.
Past Medical History:
PVD, chronic diastolic CHF with LVEF >55% by TTE [**2-/2134**],
exercise MIBI in [**2-/2134**] with no reversible defects, CKD on
hemodialysis, hypertension, type 2 diabetes, alcohol abuse,
chronic anemia, prior left leg DVT (previously on warfarin),
peripheral neuropathy requiring long-term percocet/oxycodone
use.
Past Surgical History:
[**2131-7-5**]: LLE angio, AK-[**Doctor Last Name **] stenting
[**2131-10-26**]: I&D LLE abscess
[**2132-2-7**]: STSG to LLE ulcers
[**2132-5-19**]: RLE angio showing SFA occlusion
[**2132-5-20**]: R Fem-AK [**Doctor Last Name **] bypass with PTFE
[**2132-5-22**]: R second toe amp
[**2133-6-16**]: Left 2nd and 3rd toe debridements
[**2134-7-20**]: LUE AV graft
[**2136-3-8**]: LLE angio, SFA stent, 2nd, 3rd toe amps
[**2136-3-12**]: amp site debridement, VAC
[**2136-6-1**]: R heel debridement
[**2137-1-30**]: r 4th toe amp
Social History:
Lives at home with girlfriend. Retired. Denies ETOH consumption,
and denies recreational drug use.
Family History:
Diabetes mellitus in both parents.
Physical Exam:
Physical Exam:
Alert and oriented x 3
VSS
Neck: Supple, No jvd, trach midline
Lungs: CTA bilat
Abd: Soft, no m/t/o
Ext: Pulses: Left Femoral palp, DP dop ,PT dop
Right Femoral palp, DP dop ,PT dop
Feet warm, well perfused. TMA Incisions:c/d/i
Wounds: lateral and medial malleolar ulcers clean, scant
drainage. Covered with Acel dressing - this should not be
removed until office follow up.
Pertinent Results:
Other pertinent labs:
[**2137-4-1**] 7:15 pm SWAB Source: Left lower extremity non-healing
wound.
**FINAL REPORT [**2137-4-5**]**
GRAM STAIN (Final [**2137-4-1**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2137-4-5**]):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
STAPH AUREUS COAG +. RARE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final [**2137-4-5**]): NO ANAEROBES ISOLATED.
[**2137-4-23**] 05:31AM BLOOD WBC-4.9 RBC-3.03* Hgb-8.8* Hct-28.3*
MCV-93 MCH-28.9 MCHC-31.0 RDW-14.8 Plt Ct-174
[**2137-4-23**] 05:31AM BLOOD Glucose-91 UreaN-28* Creat-6.7* Na-129*
K-4.2 Cl-92* HCO3-26 AnGap-15
[**2137-4-11**] 07:09AM BLOOD ALT-5 AST-25 AlkPhos-53 TotBili-0.3
[**2137-4-23**] 05:31AM BLOOD Calcium-8.7 Phos-5.7* Mg-2.0
[**2137-4-23**] 10:55AM BLOOD Vanco-15.6
Brief Hospital Course:
57 yo male significant PVD, sp left SFA stent and right CFA
pseudoaneurysm presented to clinic for routine followup on
[**2137-4-1**]. Ultrasound at the time showed no flow through the
stent. Left toes and lateral and medial malleolar ulcers all
appeared to have worsened since last visit so patient was
admitted to the hospital for IV antibiotics, wound care and
angiogram. We were unable to cross the left SFA in-stent
occlusion on [**2137-4-3**] so we proceeded to left femoral to posterior
tibial bypass with left first toe amputation on [**2137-4-10**].
Because of ongoing concerns for healing and infecton we needed
to do a left TMA on [**2137-4-17**]. He did well with his multiple
procedures, worked with PT, tolerated a regular diet and
ambulated minimally with assistance.
1.PAD: Mr. [**Known lastname 732**] [**Last Name (Titles) 1834**] angiogram followed by Fem-PT bypass.
He had non healing gangrene of his toes and did ultimately
undergo a left TMA. He followed the bypass/TMA pathway and
progressed nicely during his stay.
2.Arterial Ulcerations: Mr. [**Known lastname 732**] was initialy treated with
santyl and silvadine for his left ankle ulcerations. Dr. [**Last Name (STitle) **]
ultimately placed an ACEL dressing, which will stay in place
until follow up on Thursday, [**5-2**].
3.ESRD: He was continued on his home dyalisis schedule of
tues/thurs/sat, and meds were renally dosed. He received
vancomycin with HD during his hospitalization, and will continue
to recieve it for 2 weeks at rehab.
4.ID: His left toe wound grew MRSA and he was treated with IV
vancomycin via HD protocol. Although he had a TMA, it was
decided that he should continue antibiotics for 2 weeks post
discharge.
5.DM: The patient was maintained on his home sliding scale. He
also monitored his diet as he does at home. His blood sugars
were well controlled.
Medications on Admission:
atorvastatin 80 mg daily, Spiriva 18 mcg daily, humalog SC
sliding scale, aspirin 81 mg daily, albuterol sulfate HFA 90 mcg
INH QID PRN SOB, hydralazine 25 mg Q6H, oxycodone 15 mg Q4-6
hours PRN peripheral neuropathy, amlodipine 5 mg daily,
Lac-Hydrin 12 % Lotion PRN dry skin, calcium acetate 667 mg TID,
cefazolin with HD, carvedilol 12.5'
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
3. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain: pt is on standing oxycodone at home
with pain contract from PCP. [**Name10 (NameIs) **] [**Name11 (NameIs) 101150**] in the post op
period.
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for asthma.
11. INSULIN:HUMALOG
Breakfast Lunch Dinner
Bedtime
0-70 mg/dL Proceed with hypoglycemia protocol
71-159 mg/dL 0 Units 0 Units 0 Units 0
Units
160-179 mg/dL 2 Units 2 Units 2 Units 2
Units
180-199 mg/dL 4 Units 4 Units 4 Units 4
Units
200-219 mg/dL 6 Units 6 Units 6 Units 6
Units
220-239 mg/dL 8 Units 8 Units 8 Units 8
Units
240-259 mg/dL 10 Units 10 Units 10 Units 10
Units
260-279 mg/dL 12 Units 12 Units 12 Units 12
Units
12. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours).
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
15. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous per
HD protocol for 2 weeks.
16. Nephrocaps 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left Lower Extremity Ischemia with gangrene
Non healing arterial ulcers
End Stage Renal Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: With Assistance, L heel weight bearing
Discharge Instructions:
You were admitted to the hospital on [**2137-4-1**] with an infection
in your left foot. We were unable to open the blockage in your
artery with balloon angioplasty or stenting so we needed to do a
bypass surgery on your left leg. After we improved the
circulation with surgery, it was felt that the open areas would
still not heal so we did a transmetatarsal amputation.
We started you on a new medication, plavix.
You have a special dressing on your left ankle. DO NOT REMOVE
the dressing. It will be changed by Dr. [**Last Name (STitle) **], only at your
follow up appt.
DISCHARGE INSTRUCTIONS FOLLOWING TRANSMETATARSAL AMPUTATION
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are restrictions on activity. On the side of your
transmetatarsal amputation(LEFT) you may bear weight on your
heel only for 4-6 weeks. You should keep this amputation site
elevated when ever possible.
You may use the heel of your amputation site for transfer and
pivots. Do not put any pressure on the amputation site.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next 14 days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
WOUND CARE:
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
Avoid pressure to your amputation site.
Followup Instructions:
Department: VASCULAR SURGERY
When: THURSDAY [**2137-5-2**] at 2:15 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2137-4-24**]
ICD9 Codes: 5856, 3572, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2760
} | Medical Text: Admission Date: [**2189-5-12**] Discharge Date: [**2189-5-20**]
Date of Birth: [**2189-5-12**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is the former
1.56 kilogram product of a 32 week gestation pregnancy born
to a 29 year-old G2 P1 to 2 Hispanic female, blood type O
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, group beta strep status
unknown. Estimated date of confinement was [**2189-7-7**].
Obstetrical history includes previous loss at 24 weeks. This
pregnancy was complicated by chronic hypertension with
superimposed pregnancy induced hypertension, asthma and
insulin dependent gestational diabetes. Mother also has
symptoms consistent with systemic lupus erythematosus. She
was transferred from [**Hospital 1474**] Hospital for management of her
hypertension. She received betamethasone on [**4-23**] and 15,
[**2189**]. She was taken to cesarean section for worsening
hypertension. The infant emerged active, required bulb
suctioning and blow by O2. Apgars were 7 at one minute and 8
at five minutes. She was admitted to the Neonatal Intensive
Care Unit for treatment of prematurity.
PHYSICAL EXAMINATION ON ADMISSION TO THE NEONATAL INTENSIVE
CARE UNIT: Weight 1.56 kilograms, length 42 cm, head
circumference 29 cm all approximately 50% percentile for 32
weeks gestation. General, active, nondysmorphic preterm
female with retractions. Head, eyes, ears, nose and throat
anterior fontanel soft and flat. Sutures slightly open and
mobile. Palette intact. Chest lungs equal sternal
retractions. Fair aeration. Cardiovascular S1 and S2
without murmur. Normal intensity. Pulses +2 and equal.
Abdomen soft with normoactive bowel sounds. No organomegaly.
Genitourinary, normal female. Neurological tone and reflexes
consistent with gestational age, active and alert.
HOSPITAL COURSE/PERTINENT LABORATORY DATA: 1. Respiratory:
[**Known lastname **] was placed on nasopharyngeal CPAP plus 6. She
rapidly weaned to room air. The CPAP was discontinued on day
of life number one and she has remained in room air through
the remainder of her Neonatal Intensive Care Unit admission.
She has not had any episodes of spontaneous apnea or
bradycardia during admission.
2. Cardiovascular: [**Known lastname **] has maintained normal heart
rates and blood pressures through admission. No murmurs have
been noted.
3. Fluid, electrolytes and nutrition: [**Known lastname **] had an
initial whole blood glucose of 22. She received a glucose
bolus and her glucoses have remained within normal limits
since that time. She was initially NPO and started on
intravenous fluids. Enteral feeds were started on day of
life number one and gradually advanced to full volume. At
the time of transfer she is on primi Enfamil or breast milk 4
to 5 to 26 calories per ounce, 4 calories by human milk
fortifier and 2 calories by medium chain triglyceride oil.
Her electrolytes were checked twice in the first week of life
and were within normal limits. Her weight at the time of
transfer is 1.45 kilograms up 10 grams for the past 24 hours.
Her low weight occurred on day of life four at 1400 grams.
4. Infectious disease: Due to her prematurity and
respiratory distress, [**Known lastname **] was evaluated for sepsis. Her
mother had been treated intrapartum with antibiotics. A CBC
was notable for a white blood cell count of 4700 with a
differential of 21% polys, 0% bands. A blood culture was
obtained and was no growth at 48 hours. [**Known lastname **] was not
treated with antibiotics. There have been no other
infectious disease concerns during admission.
5. Hematological: Hematocrit at birth was 50.3%. [**Known lastname **]
has not required any transfusions of blood products.
6. Gastrointestinal: [**Known lastname **] has required treatment for
unconjugated hyperbilirubinemia with phototherapy. Her peak
serum bilirubin occurred on [**2189-5-20**] was a total of 6.1/a
direct of 0.2 for an indirect of 5.9. She remains on
phototherapy at the time of transfer.
7. Neurological: [**Known lastname **] has maintained a normal
neurological examination throughout admission and there were
no neurological concerns at the time of discharge.
8. Sensory: [**Known lastname **] will require a hearing screen when she
reaches post gestational age of 34. She will not require
ophthalmologic follow up with birth weight over 1500 grams
and gestational age of 32 weeks.
9. Psycho/social: Parents are Spanish speaking and have
limited understanding of English. They were frequently
updated via interpreter.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to [**Hospital 1474**] Hospital for
continuing care. The primary care provider is [**Name Initial (PRE) **] family
practice physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**Hospital1 1474**],
[**State 350**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: Feeding,
150 cc per kilogram per day of primi Enfamil or breast milk
26 calories per ounce via gavage. Medications, Fer-In-[**Male First Name (un) **]
0.15 cc po pg q.d. dilution 25 mg per ml. State newborn
screen was sent on day of life number three and at discharge
with no notification of abnormal results to date. No
immunizations have been administered. Immunizations
recommended include Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 958**] for infants who meet
any of the following criteria: Born at less then 32 weeks,
born between 32 and 35 weeks with plans for day care during
RSV season, with a smoker in the household or with preschool
siblings, or chronic lung disease.
Influenza immunizations 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 care givers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSES:
1. Prematurity at 32 weeks gestation.
2. Transitional respiratory distress.
3. Suspicion for sepsis ruled out.
4. Hypoglycemia.
5. Unconjugated hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2189-5-20**] 06:50
T: [**2189-5-20**] 07:03
JOB#: [**Job Number 40401**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2761
} | Medical Text: Admission Date: [**2163-10-19**] Discharge Date: [**2163-10-28**]
Date of Birth: [**2085-2-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
transfer from [**Hospital3 22439**] with hypotension and a fever to
103.8F.
Major Surgical or Invasive Procedure:
central line placement
intubation
History of Present Illness:
Mr. [**Known lastname 22440**] is a 78-year-old gentleman with HTN, DM2, CAD s/p
MIx2, 3 vessel CABG in [**2142**] (LIMA-LAD, SVG-D1, SVG-OM1,
SVG-PDA), cath in [**4-/2163**] with stent to LAD, AFib on coumadin,
ischemic cardiomyopathy with EF 30%, NSVT with Pacer/[**Hospital 3941**]
transferred from OSH with fevers, hypotension. The patient was
discharged from [**Hospital1 18**] on [**10-18**] after ventricular ablation for
VT.
.
His most recent ICD firing was in [**2162-5-9**] which was felt to
have been induced by exercising on a stationary bicycle. As a
result, he underwent cardiac catheterization and received a
stent to his LAD. Since his discharge in [**Month (only) 116**], he has had
further chest discomfort and reevaluation of his coronary
arteries via cardiac catheterization on [**2163-8-16**] which showed a
patent LAD stent and no change in his coronary anatomy. In
[**Month (only) 216**], he was hospitalized in [**Location (un) 22441**] after he developed
acute onset chest discomfort and was admitted to an emergency
room with wide complex tachycardia at a rate of 130 beats per
minute. His ICD did not fire as it was programmed for faster
rates. Reportedly his arrhythmia self-terminated and the
question of atrial fibrillation with aberrency versus VT.
Patient was apparently stable as the arrhythmia lasted for an
hour and he never had syncope.
.
The patient was seen on [**9-28**] at [**Hospital **] clinic where heart histograms
suggested reasonable rate control of his atrial fibrillation
with his average heart rate 70-80 beats per minute.
Additionally, there is no significant amount of ventricular high
rates greater than 110 beats per minute which suggest that this
arrhythmia which occurred in [**Location (un) 22441**] was likely to be
ventricular tachycardia. He seems to tolerate the WCT
hemodynamicaly (no syncope), but has significant chest pain with
it. The patient was seen here on [**2163-10-18**] for an EP study that
resulted in 5 ablations of the 14 discovered foci. The
remaining foci was resistant to sustained Vtach by induction.
The patient was discharged on [**2163-10-19**]. He complained of
dysuria after discharge presumably from a traumatic foley tap in
the EP lab. While on the ferry to [**Hospital1 6687**] he developed acute
shortness of breath, chills, rigors and AMS. He was immediately
brought to the [**Hospital3 **] with a temperature of 103.7F
sating 100% on 15L NRB with a RR in the 30s and BP of 107/60
with a HR of 77. His WBC was 3, BUN was 38 and Cr and 2.1.
Anesthesia attempted to intubate him, but failed. He was given
80mg IV lasix, 0.25mg IV digoxin and 100mg IV lidocaine for
multiple PVCs. [**Location (un) 7622**] arrived and successfully intubated the
patient for transport, but the patient became acutely
hypotensive and was started on a dopamine and levophed drip and
was 3L net positive.
Past Medical History:
HTN
DM 2- recently diagnosed, diet controlled
CAD s/ MIx2 , 3 vessel CABG [**2142**], and stenting [**4-/2163**], AFib on
coumadin, ischemic cardiomyopathy with EF 30%, NSVT with
Pacer/ICD
Hypothyroidism
Obstructive sleep apnea (on Bipap)
Left hemi diaphragm dysfunction
s/p Right inguinal hernia repair
Hard of hearing (bilateral aids)
Social History:
Former smoker quit 40 years ago, daily [**2-11**] drinks alcohol, no
drug use.
Family History:
Grandfather with MI at age 74, Brother with strokes starting at
age 60.
Physical Exam:
T:99.7 BP:106/66 HR:80 RR:13 O2sat:97% intubated Wt 109
GEN: Intubated and sedated
HEENT: no supraclavicular or cervical lymphadenopathy, no jvp
elevation, no carotid bruits, no thyromegaly or thyroid nodules
RESP: Intubated
CV: RR, S1 and S2 wnl, no r/g 2/6 systolic murmur at apex.
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e. Some evidence of early venous stasis.
SKIN: no rashes/no jaundice
NEURO: sedated and intubated
ACCESS: 3 peripheral 18 gauge IV
Pertinent Results:
[**2163-10-19**] 11:44PM BLOOD WBC-15.0*# RBC-3.95* Hgb-13.4* Hct-39.8*
MCV-102* MCH-33.9* MCHC-33.3 RDW-14.3 Plt Ct-113*
[**2163-10-20**] 06:38PM BLOOD WBC-28.6* RBC-3.73* Hgb-13.1* Hct-37.8*
MCV-101* MCH-35.2* MCHC-34.8 RDW-14.7 Plt Ct-107*
[**2163-10-22**] 05:21AM BLOOD WBC-21.9* RBC-3.37* Hgb-11.8* Hct-33.7*
MCV-100* MCH-35.0* MCHC-35.0 RDW-14.9 Plt Ct-114*
[**2163-10-23**] 06:31AM BLOOD WBC-15.2* RBC-3.33* Hgb-11.6* Hct-33.5*
MCV-101* MCH-34.9* MCHC-34.6 RDW-14.8 Plt Ct-104*
[**2163-10-24**] 12:49AM BLOOD WBC-7.5# RBC-3.23* Hgb-11.3* Hct-33.1*
MCV-102* MCH-35.1* MCHC-34.3 RDW-14.6 Plt Ct-85*
[**2163-10-26**] 05:53AM BLOOD WBC-6.9 RBC-3.29* Hgb-11.5* Hct-32.7*
MCV-99* MCH-34.9* MCHC-35.1* RDW-15.3 Plt Ct-129*
[**2163-10-26**] 05:53AM BLOOD PT-18.0* PTT-30.4 INR(PT)-1.7*
[**2163-10-21**] 04:41AM BLOOD Glucose-163* UreaN-60* Creat-3.8* Na-134
K-4.8 Cl-103 HCO3-15* AnGap-21*
[**2163-10-23**] 06:31AM BLOOD Glucose-146* UreaN-57* Creat-3.0* Na-139
K-4.0 Cl-106 HCO3-21* AnGap-16
[**2163-10-26**] 05:53AM BLOOD Glucose-116* UreaN-47* Creat-2.1* Na-140
K-4.3 Cl-105 HCO3-25 AnGap-14
[**2163-10-24**] 12:49AM BLOOD ALT-314* AST-100* LD(LDH)-190 AlkPhos-104
Amylase-49 TotBili-5.9*
[**2163-10-25**] 05:55AM BLOOD ALT-198* AST-49* AlkPhos-117 TotBili-4.4*
[**2163-10-27**] 07:15AM BLOOD ALT-110* AST-36 AlkPhos-148* Amylase-160*
TotBili-4.4* DirBili-3.0* IndBili-1.4
[**2163-10-28**] 06:45AM BLOOD ALT-83* AST-36 LD(LDH)-169 AlkPhos-141*
Amylase-151* TotBili-3.8*
CXR: [**2163-10-25**]: Blunted costophrenic angles not specifically
suggesting effusion. Poorly defined retrocardiac opacity
probably representing atelectasis, cannot associate
consolidation. No overt CHF
U/S: [**2163-10-27**]: FINDINGS: Real-time ultrasound evaluation of the
abdomen reveals the liver to be homogeneous in echotexture
without evidence of focal lesion. The hepatic parenchymal
echogenicity is normal. The gallbladder demonstrates multiple
small hyperechogenic foci consistent with gallstones. There is
no intrahepatic biliary ductal dilatation, and the common duct
measures 5 mm. Main portal vein is patent with antegrade flow.
The pancreas is not well visualized due to gas. The spleen is
normal in size and echogenicity. The right kidney measures 11.8
cm and demonstrates a simple cyst in the mid pole measuring 2.2
cm. The left kidney measures 11.7 cm and demonstrates a simple
cyst in the mid pole measuring 1.9 cm. There is no evidence of
renal calculi or hydronephrosis. The aorta demonstrates
atherosclerotic changes.
IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis.
2. Bilateral renal cysts.
Brief Hospital Course:
78 y/o male with HTN, DM2, CAD s/p MIx2, 3 vessel CABG in [**2142**],
stenting of LAD on [**4-/2163**], AFib on coumadin, ischemic
cardiomyopathy with EF 30%, NSVT with Pacer/[**Hospital 3941**] transferred from
OSH intubated and on pressors with fevers and respiratory
distress 1 day s/p VT ablation at [**Hospital1 18**].
.
Sepsis:
Patient arrived to the OSH after a traumatic foley insertion
during an EP study on [**10-18**] with chills, rigors and a fever to
103.7F. Patient was started on vancomycin and zosyn for empiric
coverage of suspected complicated polymicrobial UTI.
Flavobacterium (resistance to tetracycline otherwise
pan-sensitive) and presumed enterococcus sensitive to vancomycin
and penicillin were cultured at the OSH. All blood, urine and
sputum cultures drawn here have been negative. Patient's
antibiotics were switched to Pen G and levoquin to cover the
enterococcus, flavobacterium and possible aspiration pneumonia.
Patient remained afebrile for 5 days prior to transfer and his
leukocytosis (WBC=28.6) resolved. The patient will continue on
Pen G until [**11-2**] to finish off a 14 day course of vancomycin
transitioned to pen G. He also received a 7 day course of zosyn
transitioned to levoquin for possible PNA.
.
Cardiac:
The patient underwent VT ablation on [**10-18**] resulting in 5
ablations of the 14 foci. The other 9 foci did not induce
sustained VT. The patient complained of dysuria after discharge
on [**10-19**] and began having chills and rigors with a temp of
103.7F at an OSH. He was transferred to the [**Hospital1 18**] CCU intubated
and on pressors for presumed septic shock. Shortly after
admission, the patient went into monomorphic VTACH with at least
two different morphologies. He failed ICD cardioversion x 3,
and he was finally paced terminated out of his VTACH. His pacer
was set at 80 BPM to maintain his blood pressure. He was
started on Vancomycin and Zosyn, and given 3 pressors with +7L
of fluid to maintain perfusion pressures for presumed septic
shock. The patient was weened off pressors and extubated over
the next three days without complications. His pacer was reset
to 60 bpm and he remained in Afib with a conduction in the
60-80's with occassional pacing on metoprolol 12.5mg PO BID.
When we attempted to raise his metoprolol to 25mg PO BID, he
became orthostatic with a rate of 60bpm and 100% paced. The
patient was restarted on his coumadin for afib after we pulled
the central line. His heparin was continued to bridge him to a
therapeutic INR. His INR at transfer was 1.7. The patient was
on amiodarone 200mg qd, asp 325mg qd, metoprolol 12.5mg [**Hospital1 **],
simvastatin 40mg qd, warfarin 4mg qhs and furosemide 80 qd at
the time of transfer. His blood pressure have ran in the
100's/50's. His home medications of digoxin, spironolactone and
cozaar were not restarted as his bp was too low. He will need
them added back on as his blood pressure tolerates.
.
Liver:
Patient's AST/ALT were elevated and have trended down to normal
during his hospital stay. This is likely due to shock liver
that has resolved. His lipase, alk phos and TBili trended up
during his hospital stay and was concerning for biliary
obstruction vs pancreatitis vs pancreatic cancer. Patient was
jaundiced and denied any abdominal pain. RUQ u/s revealed no
dilation of his common bile duct with no focal lesions of the
liver. His pancreas, however, could not be visualized during
the study. The following day, his lipase, tbili and alk phos
began to trend down and GI felt that the patient's enzyme bump
was caused by biliary sludge in the setting of his septic shock
and recommended a recheck lipase, alk phos and bili in a week.
.
ARF:
Patient Cr at discharge trended down to 2.0 down from 3.8 on
arrival. His baseline Cr is 1.6. His ARF was likely due to ATN
caused by septic shock.
.
Endocrine:
Patient's DM was treated with SSI and he was given his home dose
of levothyroxine to treat his hypothyroidism.
Medications on Admission:
Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Losartan 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Insulin Regular Human 100 unit/mL Solution Sig: as dir as dir
Injection ASDIR (AS DIRECTED).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
goal INR [**2-11**]. Please check INR daily and adjust coumadin as
needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-10**] Sprays Nasal
QID (4 times a day) as needed for nasal dryness.
13. Penicillin G Pot in Dextrose 2,000,000 unit/50 mL Piggyback
Sig: Two (2) million units Intravenous Q6H (every 6 hours) for
5 days: last day [**2163-11-2**]. million units
14. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: as dir as dir Intravenous ASDIR (AS DIRECTED): titrate to
PTT 60-80, may discontinue when INR > 2.0 for 3 days in a row.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Primary:
Septic shock from enterobacterium / flavobacterium
ventricular tachycardia
congestive heart failure
Secondary:
diabetes mellitus
chronic renal insufficiency
hypothyroidism
sleep apnea
Discharge Condition:
patient was feeling better, and stable for discharge to
[**Hospital3 **]
Discharge Instructions:
Please continue your medications. Some of your doses may have
been changed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1200 CC daily.
If you have shortness of breath, chest pain, dizziness, pass
out, or have other concerns, please call your primary care
physician or return to the ED.
Followup Instructions:
Please follow up with your PCP PEARL,[**Name9 (PRE) **] [**Name Initial (PRE) **] [**Telephone/Fax (1) 22442**] the
week after discahrge from rehab.
You have an appointment with Dr. [**Last Name (STitle) **] on [**2163-12-2**] at
3:40PM. Please call [**Telephone/Fax (1) 2934**] if you have any questions or
need to reschedule.
.
You have an appointment with [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7173**], NP on [**2163-11-16**] at
1PM. Please call [**Telephone/Fax (1) 285**] if you have any questions or need
to reschedule.
.
You also have an appointment set up for:
Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Date/Time:[**2164-5-21**] 11:00
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2164-5-21**] 11:00
Completed by:[**2163-10-29**]
ICD9 Codes: 5849, 4271, 4280, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2762
} | Medical Text: Admission Date: [**2153-4-10**] Discharge Date: [**2153-5-2**]
Date of Birth: [**2103-7-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Worsening liver failure, AMS
Major Surgical or Invasive Procedure:
EGD with PPFT placement
ERCP
PICC placement
History of Present Illness:
Please see MICU admission note for details. In brief, this is a
49 yo M with a history of ESRD, HTN, DM2, and chronic hepatitis
B (untreated) who presented to OSH ED with mental status changes
on [**2153-4-9**].
.
Notably he had a recent admission from [**Date range (1) 89889**] for worsening
liver failure. He was evaluated by GI, and had a liver biopsy on
[**2153-3-29**] that suggested cholestatic jaundice (though final result
pending and pathology slides sent to [**Hospital1 2025**]). His bilirubin was
noted to be as high as 18. However 5 days after discharge he was
noted to be confused with visual hallucinations, and "chronic
diarrhea" at rehab.
.
At the OSH, he was complaining of feeling weak and lethargic. He
was unable to ambulate, and was more jaundiced. He was treated
with rifaximin. Lactulose was avoided given his chronic diarrhea
and incontinence. At the time of transfer, he was reported to
have waxing and [**Doctor Last Name 688**] mental status with asterixis. During his
hospital stay, he was noted to have a bilirubin of 30.1. RUQ US
showed trace ascites and cholelithiasis, but no obstruction of
the biliary tract.
.
In the MICU, he was briefly hypotensive to the 80s systolic upon
admission but quickly improved to the 90s-110s systolic
overnight after 2L of NS. His MICU course was notable for some
confusion thinking he was in Domincan Republic and some
asterixis, which persists today.
.
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:
1. Chronic hepatitis B -never treated
2. ESRD on HD MWF
3. HTN
4. DM2
5. Inguinal candidiasis
6. Traumatic brain injury from MVA 10 years ago
Social History:
Lives in [**Hospital 31183**] Rehabilitation.
- Tobacco: None
- Alcohol: Heavy drinker until 11-12 years ago. Stopped drinking
at that time.
- Illicits: None
Family History:
No family history of liver disease. Heavy family history of
diabetes.
Physical Exam:
VS - Temp 98F, BP 97/61, HR 62, R 20, O2-sat 100% RA
GENERAL - jaundiced, thin, chronically ill appearing man in NAD,
AOx2 (thinks he's in [**Country 13622**] Republic in a place of business,
but states [**2153-4-17**] is the date)
HEENT - NC/AT, PERRLA, EOMI, sclerae markedly 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, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT, mildly distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - atrophied lower extremities, WWP, no c/c/e, 2+
peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-10**] throughout, sensation grossly intact throughout, + asterixis
Pertinent Results:
[**2153-4-10**] 08:29PM BLOOD WBC-9.6 RBC-3.05* Hgb-8.6* Hct-30.5*
MCV-100* MCH-28.0 MCHC-28.1* RDW-18.8* Plt Ct-335
[**2153-4-29**] 04:53AM BLOOD WBC-14.3* RBC-2.91* Hgb-8.9* Hct-28.7*
MCV-99* MCH-30.5 MCHC-30.9* RDW-20.6* Plt Ct-446*
[**2153-4-10**] 08:29PM BLOOD PT-17.8* PTT-36.1* INR(PT)-1.6*
[**2153-4-29**] 04:53AM BLOOD PT-18.3* PTT-40.2* INR(PT)-1.6*
[**2153-4-10**] 08:29PM BLOOD Glucose-153* UreaN-47* Creat-4.2* Na-128*
K-4.4 Cl-92* HCO3-23 AnGap-17
[**2153-4-29**] 04:53AM BLOOD Glucose-171* UreaN-60* Creat-3.3*#
Na-127* K-5.4* Cl-89* HCO3-23
[**2153-4-10**] 08:29PM BLOOD ALT-41* AST-93* LD(LDH)-190 AlkPhos-2052*
TotBili-30.6*
[**2153-4-29**] 04:53AM BLOOD ALT-58* AST-149* LD(LDH)-429*
AlkPhos-1486* TotBili-24.3*
[**2153-4-10**] 08:29PM BLOOD Albumin-2.9* Calcium-8.8 Phos-5.2* Mg-2.2
[**2153-4-29**] 04:53AM BLOOD Albumin-3.0* Calcium-10.1 Phos-2.2*
Mg-2.3
[**2153-4-12**] 05:10AM BLOOD calTIBC-138* Ferritn-3039* TRF-106*
[**2153-4-13**] 03:53PM BLOOD Triglyc-376*
[**2153-4-20**] 08:47AM BLOOD PTH-73*
[**2153-4-11**] 03:25AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2153-4-11**] 03:25AM BLOOD AMA-NEGATIVE
[**2153-4-11**] 07:20PM BLOOD PEP-NO SPECIFI IgG-1727* IgA-538* IgM-133
[**2153-4-12**] 04:05PM BLOOD HIV Ab-NEGATIVE
[**2153-4-11**] 03:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2153-4-12**] 06:07PM BLOOD Glucose-74 Lactate-0.8 Na-140 K-4.1
Cl-101
.
EGD [**2153-4-24**]
Impression: Esophagitis
Did not proceed further after close examination of the esophagus
as did not want to dislodge the feeding tube. Otherwise normal
EGD to fundus
Recommendations: Grade 3 esophagitis as seen on previous upper
endoscopy. Feeding tube visualized. No mass lesion or adherent
clot visualized as was on previous endoscopy. Continue PPI.
Further recommendations to be relayed to the inpatient team.
Brief Hospital Course:
MICU Course:
The patient was transferred from an OSH to [**Hospital1 18**] overnight and
was accepted to the MICU given concern for worsening
encephalopathy. He was protecting his airway at admission. He
received 2L IVF boluses for hypotension with good response. He
was started on lactulose. He was transferred to the floor <12
hours after admission to the MICU.
Floor course:
Mr. [**Known lastname 89890**] was a 49-year-old male with history history ESRD that
presented with subacute liver failure (started in late [**2152**])
with predominant cholestatic picture.
# Cholestatic hepatitis
He was found to have elevated ALP ~ 200s in [**9-15**] and ALT/AST in
40-50s. He had acute decline in [**Month (only) 956**] with bili 4, ALT/AST in
1000s suggestive of viral, toxic, shock, or vascular etiology.
He was discharged for follow-up with GI and missed all
appointments on four occasions. Several times throughout the
year he left the country without notifying dialysis and other
doctors. He was also diagnosed with hepatitis B in [**2153-2-6**]
(VL 7500). Hepatitis C negative. HIV negative. Bili 18 in [**Month (only) 958**].
He was discharged to rehab where he had diarrhea and
encephalopathy in early [**Month (only) 547**]. Admission labs significant for
bili 30 at OSH and transferred for further management. Biopsy
suggestive of hepatitis B as etiology. Labs not suggestive of
autoimmune cause. ERCP not suggestive of extrahepatic anatomical
causes. Biopsy from OSH read by [**Hospital1 18**] pathology showing
cholestatic hepatitis with prominent sinusoidal and
portal-portal bridging fibrosis consistent with fibrosing
cholestatic hepatitis although precise etiology of cirrhosis
remained unclear.
Treatment for hepatitis B was started with entecavir 1 mg PO
weekly with recent viral load of 83,400. Hepatitis D not
present.
He was started on lactulose and rifaximin for hepatic
encephalopathy. He was started on vitamin K for coagulopathy.
Urosidol and vitamin D/multivitamins were started for
cholestasis.
His discharge labs showed reduced T bili 24.4 from peak of 31.2.
While he was admitted, liver transplant was considered a
possible endpoint for his disease, and the transplant medical
and surgical evaluation was initiated. At the time of discharge,
he had not undergone pulmonary function testing. It is likely
that his general functional status and inparticular pulmonary
function will continue to improve as his malnutrition and
deconditioning are addressed at rehab. Pulmonary function
testing should be sought as an outpatient.
# Toxic-metabolic encephalopathy
Patient triggered on [**2153-4-13**] for altered mental status
secondary to anesthesia and lack of lactulose administration
during ERCP peri-procedural period. He was subsequently
stablized on a regimen that consisted of rifaximin alone with
preservation of mental status. At the time of discharge, he was
discharged on lactulose and rifaximin with clear mentation. On
the day of discharge he was A&Ox3.
# Thrush with esophagitis
Patient had candidal thrush based on EGD and pathology and was
started on 20-day course of micafungin given fluconazole was not
a good option in setting of hepatic dysfunction. Micagungin
therapy with be completed on [**5-7**].
# Severe malnutrition with refeeding syndrome
Patient has very poor nutrition secondary to underlying disease
and poor PO intake. Tube feeds were started during
hospitalization with resultant hypophosphatemia suggestive of
re-feeding syndrome. Electrolytes were monitored twice daily
with repletion. Additionally, his subsequent diarrhea was also
partly attributable to refeeding syndrome which resolved fully
by the time of discharge.
# Esophageal lesion
Patient noted to have esophageal lesion on endoscopy with
resultant chest CT suggestive of lesion arising from esophagus.
Repeat EGD revelaed no evidence of esophageal lesion with
apparent complete resolution.
# ESRD
He was maintained on dialysis throguhout admission and will
continue as an outpatient.
# DM2
He was well controlled on his current regimen and will continue
current regimen as an outpatient.
# Communication: Patient's family: [**Telephone/Fax (1) 89891**] [**First Name9 (NamePattern2) 89892**] [**Last Name (un) 72481**]
(ex-wife), [**Name (NI) **] [**Name (NI) 89890**] (son) [**Telephone/Fax (1) 89893**], primary contact,
eldest son and next of [**Doctor First Name **]. [**Name (NI) 9771**] [**Name (NI) 89890**] - Mother and [**Name (NI) 5321**]
[**Name (NI) 89890**] - Sister [**Telephone/Fax (1) 89894**]
Medications on Admission:
1. Norvasc 10mg po daily
2. Hydralazine 100mg po bid -held at OSH
3. Labetalol 600mg po bid -held at OSH
4. Nephrocaps 1 capsule daily
5. Rifaximin 550mg po bid
6. Oxycodone 5mg po q4-6h PRN pain
7. Lactulose 20mg po q4-6h
8. SSI
Discharge Medications:
1. labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. micafungin 100 mg Recon Soln Sig: One (1) Intravenous once a
day for 8 days: Complete 20 day course on [**2153-5-7**].
5. insulin lispro 100 unit/mL Solution Sig: 1-8 units
Subcutaneous ASDIR (AS DIRECTED).
6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
11. entecavir 1 mg Tablet Sig: One (1) Tablet PO 1X/WEEK (FR).
12. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
13. bismuth subsalicylate 262 mg/15 mL Suspension Sig: Fifteen
(15) ML PO QID (4 times a day) as needed for GI upset, diarrhea.
14. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
16. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: cholestatic hepatitis, toxic-metabolic encephalopathy,
diarrhea
Secondary: End-stage renal disease, candidal esophagitis, severe
malnutrition, refeeding syndrome, hepatitis B, diabetes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 89890**],
Your were transferred to [**Hospital1 18**] for worsening liver disease and
confusion. Your liver disease was evaluated, and you were placed
on medications to help this. You also have not been eating well,
so a feeding tube was placed to help you with nutrition. You
also received medication for diarrhea that improved. You will be
evaluated by transplant service to consider liver
transplantation. Please take your medication as prescribed and
keep your outpatient appointments.
.
The following changes have been made to your home medciations.
1. You have been STARTED on Micafungin 100 mg IV daily until
[**2153-5-7**]
2. You have been STARTED on Ursodiol 300 mg 2 times a day
3. CHANGED Multivitamin to Nephrocaps
4. You have been STARTED on Cholecalciferol (vitamin D3) 400
unit Tablet daily
5. You have been STARTED on Phytonadione 5 mg Tablet Daily
6. You have been STARTED on Pantoprazole 40 mg Tablet 2 time
daily
7. You have been STARTED on Sucralfate 1 gram Tablet 4 times a
day
8. You have been STARTED in Entecavir 1 mg Tablet once weekly
9. You have been STARTED on Cholestyramine-sucrose 4 gram Packet
2 times a day
10. You have been STARTED on bismuth subsalicylate 262 mg 4
times a day as needed for GI upset or diarrhea
.
No other changes have been made to your home medications.
Followup Instructions:
Department: TRANSPLANT
When: THURSDAY [**2153-5-10**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: TUESDAY [**2153-6-19**] at 2:40 PM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5856, 2761, 2760, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2763
} | Medical Text: Admission Date: [**2187-9-19**] Discharge Date: [**2187-10-5**]
Date of Birth: [**2134-1-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered mental status, fever
Major Surgical or Invasive Procedure:
[**9-23**]: CT guided drainage of RUQ fluid collection and drain
placement
History of Present Illness:
53M quadraplegic s/p MVA in [**2180**]. He is chronically vent
dependent through trach, has neurogenic bladder, SVC filter on
coumadin, and pacemaker for episodes of bradycardia/asystole
with suctioning or laying flat per his wife. [**Name (NI) **] began to
experience malaise, fevers to 100 at home starting [**9-1**]. Wife
and son with URI preceding symptoms. On morning of admission to
OSH, noted to have dark urine from suprapubic catheter.
At OSH found to have leukocytosis and complete left lung
opacification on CXR. Admitted to ICU. Waxing and [**Doctor Last Name 688**] mental
status beginning hospital day 4 with intermittent episodes of
tongue thrashing, head deviations, and grimacing. At baseline,
patient alert, oriented, very interactive with family.
Neurology did 20 min EEG on [**9-10**] showing slow back ground with
no Sz focus. He was started on keppra around [**9-10**] for
prophylaxis. Wife notes that pt missed several doses of baclofen
during admission.
His course was notable for multiple bronchs which revealed thick
mucous plugs that were not able to fully remove to reairate.
[**9-6**] BAL grew ecoli and klebsiella (no sensitivities reported),
TB negative. [**9-10**] BAL grew acinetobacter sensitive to zosyn and
klebsiella sensitive to cefepime, ctx, imipenem. Blood Cx [**9-5**]
grew staph epidermidis sensitive to oxacillin, cefazolin,
vancomycin and clindamycin, repeat cx [**9-14**] showed no growth.
Stool cx [**9-9**] C diff negative.Urine culture with Enterococcus
sensitive to vanco, levo, linezolid. Pt was treated initially w/
vanc and zosyn starting [**9-5**]. Of note, HCT drop 29.7 to 22.6 and
pt was transfused 4 units RBCs, no bleeding source identified.
On [**9-18**], he was transferred out of the ICU and found to have
fevers to 102, switched to vanc and cefepime.
He has a CVL since [**9-5**]. CT chest on [**9-9**] showed air
bronchograms, partial collapse on left lung. Head CT showed no
acute process. CXR [**9-18**] showed no change in left opacity w/ new
opacities on the right. Abdominal CT showed "inflammation of the
hepatic flexure," colonoscopy not performed. His vent settings
are AC 450, 15, 50%. His sats were 96% and last ABG was 7.44,
43, 77 from [**9-18**]. Transferred to [**Hospital1 18**] for continuous EEG
monitoring and further evaluation. Labs prior to transfer were
INR 4.37 (holding coumadin), WBC 12.9, hematocrit 32, platelet
500, Na 145, K 4.5, BUN 13, Creat 0.5.
Review of systems:
(+) Per HPI,
Per wife and daughter: no HA, no diarrhea, no bloody or tarry
stools, no nausea/vomiting prior to admission
Past Medical History:
-MVA [**2180**] resulting in C2/C3 fracture and quadriplegia
-respiratory failure, ventilator dependent with tracheostomy
placed [**2181**]
-Neurogenic bladder with suprapubic catheter changed every 3
weeks, most recently [**2187-9-5**] at OSH
-DVT s/p IVC, on warfarin
-Anxiety, depression on Lexapro
-Obesity
Social History:
Lives at home with wife. Chronically on vent but able to eat,
talks when cuff deflated. Usees wheelchair with family
assistance. Normal mental status at baseline. Patient is as
former police officer.
Family History:
Father CVA x2, deceased age 78. No h/o seizure or neurological
disorders. No MI. No CA.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.7 P78 151/95 99% on FiO2 33
General: somnolent, opens eyes to voice
Skin: 1x1.5cm sacral decubitus ulcer without surrounding
erythema or exudate; R subclavian line in place, no erythema or
induration of site
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: trach in place, tracheostomy without erythema or
dischargeCV: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Diffuse rhonchi bilaterally, exam limited to anterior
chest
Abdomen: moderately distended, soft, loud BS throughout,
suprapubic catheter in place with slight erythema, no discharge
Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis,
+edema bilateral feet and lower legs (@baseline per wife)
Neuro: somnolent, opens eyes to voice, unable to follow commands
Discharge Physical Exam:
Vitals: 97.6 P 60 100/46 R 17 100% (FiO2 40%)
General: awake and alert, nodding head appropriately to
questions
HEENT: Sclera anicteric, MM dry
Neck: trach in place, tracheostomy without erythema or discharge
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: clear to auscultation anteriorly
Abdomen: soft, nontender, nondistended, RUQ dressing
clean/dry/intact
Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis, 3+
edema bilateral feet and lower legs
Pertinent Results:
ADMISSION LABS
[**2187-9-19**] 11:19PM WBC-15.2* RBC-4.05* HGB-11.5* HCT-35.7*
MCV-88 MCH-28.4 MCHC-32.2 RDW-15.2
[**2187-9-19**] 11:19PM PLT COUNT-456*#
[**2187-9-19**] 11:19PM NEUTS-90.0* LYMPHS-5.7* MONOS-4.0 EOS-0.2
BASOS-0.1
[**2187-9-19**] 11:19PM PT-60.3* PTT-57.2* INR(PT)-6.0*
[**2187-9-19**] 11:19PM ALT(SGPT)-15 AST(SGOT)-11 CK(CPK)-31* ALK
PHOS-150* TOT BILI-0.5
[**2187-9-19**] 11:19PM ALBUMIN-3.7 CALCIUM-9.0 PHOSPHATE-2.6*#
MAGNESIUM-2.3
[**2187-9-19**] 11:19PM GLUCOSE-188* UREA N-20 CREAT-0.4* SODIUM-148*
POTASSIUM-3.1* CHLORIDE-107 TOTAL CO2-30 ANION GAP-14
[**2187-9-19**] 11:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2187-9-19**] 11:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
[**2187-9-19**] 11:20PM URINE RBC-16* WBC-4 BACTERIA-FEW YEAST-NONE
EPI-1
MICRO
[**2187-9-23**] 3:43 pm ABSCESS Source: RUQ fluid collection.
GRAM STAIN (Final [**2187-9-23**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2187-9-26**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2187-9-29**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2187-9-22**] 2:34 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2187-9-26**]**
GRAM STAIN (Final [**2187-9-22**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2187-9-25**]):
Commensal Respiratory Flora Absent.
IDENTIFICATION AND Susceptibility testing requested by
[**Last Name (LF) 13210**],[**First Name3 (LF) **] ([**Numeric Identifier 13211**]) [**2187-9-24**].
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
10,000-100,000 ORGANISMS/ML..
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
KLEBSIELLA PNEUMONIAE. ~6OOO/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
| PSEUDOMONAS AERUGINOSA
| | KLEBSIELLA
PNEUMONIAE
| | |
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- 4 S <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S <=0.25 S
GENTAMICIN------------ 4 S <=1 S
MEROPENEM------------- 1 S <=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
[**2187-9-21**] 8:00 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2187-9-21**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2187-9-24**]):
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
GRAM NEGATIVE ROD #3. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 4 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
LEGIONELLA CULTURE (Final [**2187-9-28**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
IMAGING
CXR [**2187-9-19**]: COMPARISON: [**2180-12-24**]. FINDINGS:
Tracheostomy tube in situ. The patient also has a right
subclavian vein catheter, the tip of the catheter projects over
the upper SVC. The patient has received a left pectoral
pacemaker, the course and position of the leads is unremarkable.
In the interval, the patient has developed a volume loss of the
left lung, associated to a diffuse fibrotic process and pleural
thickening. In addition, a parenchymal opacity at the right
upper lobe base is seen. This opacity might be more recent and
infectious in origin. The heart continues to be mildly enlarged.
Mild fluid overload is present. The parenchymal processes, if
clinically relevant, could be further evaluated by CT.
Continuous EEG [**2187-9-20**]: IMPRESSION: This is an abnormal
continuous ICU monitoring study. The background showed mixed
theta and delta activity, suggesting a moderate encephalopathy,
which is etiologically nonspecific. There are no epileptiform
discharges or seizures recorded
CT Guided Drainage of RUQ fluid collection [**2187-9-23**]: IMPRESSION:
Technically successful CT-guided drainage of the right upper
abdominal fluid collection yielding black fluid, uncertain
whether this is bilious or represents old blood products. Fluid
analysis is recommended. A colonic etiology should be considered
given the imaging findings. However if the fluid is bilious
consideration could be given to a perforated gallbladder.
Microbiology is pending.
CXR [**2187-9-24**]:Left lower lobe collapse is persistent. Peripheral
consolidation in the left upper lobe is unchanged. There has
been worsening of aeration in the left upper lobe likely new
atelectasis in the lingula. Right lower lobe atelectasis is
grossly unchanged. Cardiomediastinum is shifted towards the
left. Tracheostomy is in a standard position. Pacer leads are in
the standard position. NG tube tip is out of view below the
diaphragm. Right pigtail catheter tip is at the cavoatrial
junction.
CT Abd/Pelvis [**2187-10-2**]:IMPRESSION: 1. Significant improvement in
the right pericolonic fluid collection adjacent to the hepatic
flexure of the colon. Pigtail catheter remains in place. There
is only minimal residual phlegmon within this region. 2. Stable
bibasilar airspace consolidation with atelectasis and small
bilateral pleural effusions, greater on the left. Persistent
left pleural thickening and enhancement suggestive of underlying
chronic inflammation versus underlying infection as previously
mentioned. 3. Persistent soft tissue stranding in the right
flank without identifiable fluid collection. The above findings
were discussed with the resident in charge of patient, Erina
[**Last Name (un) **] at 5:50 p.m. on [**2187-10-2**]. The resident was
notified about the significant improvement of the fluid
collection since [**2187-9-21**]. Discussion was underway as to
possible removal of the right sided drainage catheter.
Brief Hospital Course:
Brief Course:
Mr. [**Known lastname **] is a 53 yo quadraplegic man s/p MVA in [**11/2180**],
chronically vent-dependent, who presented to an outside hospital
with fevers and AMS found to have fluid collection in colon near
hepatic flexure.
Active Issues:
# Altered Mental Status: Mr. [**Known lastname 64705**] altered mental status on
admission was likely delirium secondary to multiple factors,
possibly toxic metabolic encephalopathy from infection in the
setting of recent fevers and elevated WBC. Levetiracetam started
at the OSH was continued and continuous EEG monitoring was
performed given reported jerking movements of his face and head.
No seizure activity was shown on EEG and prophylactic
levetiracetam was continued until 2 days prior to discharge with
no recurrence of involuntary movements. Pt became increasingly
more alert and was able to communicate verbally with the trach
cuff deflated.
# Right upper quadrant fluid collection: Pt was found to have a
peri-colonic fluid collection adjacent to the hepatic flexure of
unclear etiology and underwent percutaneous drainage by IR on
[**2187-9-23**] with placement of a pigtail catheter in the area of the
fluid collection. The fluid was determined to be bilious
(bilirubin 31.5, gastro-occult negative) and thought to be
related to a gall bladder perforation, but HIDA scan did not
show evidence of acute cholecystitis. Fluid cultures showed no
growth. Bilious fluid drained continuously until [**10-2**] when there
was concern that the catheter was damaged. Repeat CT abd/pelvis
on [**2187-10-2**] showed significant improvement of the fluid
collection with minimal residual phlegmon and the drain was
removed at the bedside on [**10-3**]. Since the exact origin of the
fluid collection remains unclear, he will need to follow-up for
a colonoscopy after discharge. Because he is ventilator
dependent, the procedure is scheduled to be performed in the
[**Hospital1 18**] [**Hospital Unit Name 153**] on [**2187-11-13**]. Coumadin should be held 1 week prior to
colonoscopy.
# Respiratory failure: Patient has what appears to be chronic
left lung collapse. IP performed bronchoscopy on [**9-22**] which did
not show significant secretions to warrant treatments such as
cryotherapy to break up secretions and recruitment maneuvers
have not been able to open up airways. Left pleural effusing was
not thought to be large enough to warrent US/CT guided drainage.
A BAL grew Pseudomonas and Klebsiella for which he completed a
10 day course of meropenem on [**9-28**]. BAL also grew
Stenotrophomonas which was questionable for colonization rather
than infection, but he completed 8 day course of Bactrim on
[**10-2**]. He does not require further ID follow-up.
# Constipation: Patient was constipated for several days while
he was on tube feeds and dilated loops of small bowel seen on
KUB were suggestive of ileus. He began to have bowel movements
again after his bowel regimen was optimized and he was started
on a regular diet once his mental status improved.
# Edema: Patient has edema at baseline. Home furosemide dose was
started after confirmation of his home meds but patient was net
positive 13L at time of discharge. He had brisk diuresis to IV
lasix, but not to his PO regimen, possible to to bowel edema. On
discharge, his lasix was changed to torsemide 20mg PO BID. He
will need follow-up of his electrolyte panel after discharge.
# Repetitive facial movements: Mr. [**Known lastname **] had repetitive facial
movements early during admission which resolved after restarting
baclofen. 24 hour EEG was negative and prophylactic Keppra was
discontinued 2 days prior to discharge.
# Hypertension: Pt experienced intermittent episodes of HTN with
systolic blood pressures >180. These episodes seemed to
correlate with agitation and discomfort. Pain control was
optimized and hydralazine boluses were used to treat sustained
sbp >180. At the time of discharge, his blood pressures were at
his baseline with SBP in the 100s.
# Pain: Patient was monitored for pain control and treated with
his home dose of methadone 15mg [**Hospital1 **] prn.
# Coagulopathy. Likely due to poor nutrition and prolonged
antibiotics. Coumadin was held due to supratherapeutic INR (6)
on admission but home dose was restarted at discharge. He will
need to have a repeat INR as an outpatient.
# Anemia: Per OSH report, he received 4 units PRBCs prior to
transfer to [**Hospital1 18**], but the circumstances were unclear. His HCT
during admission decreased from 35.7 to 25.2 with no signs of
active bleeding. Workup for hemolysis and DIC was negative. He
had no signs of active bleeding and remained hemodynamically
stable without transfusion. This may be related to hemodilution
as his fluid balance was net positive as noted above.
Inactive Issues:
# Quadraplegia: Pt has been quadriplegic following remote MVA in
11/[**2180**]. Routine care was continued throughout admission.
Transitional Care Issues:
1. Code staus: DNR/DNI
2. Contact: Wife
3. Medication changes:
- START Torsemide 20mg [**Hospital1 **]
- STOP Furosemide 40mg [**Hospital1 **]
- RESTART Warfarin as you were taking it prior to this admission
4. Follow up:
-PCP
[**Name10 (NameIs) 64706**] readmit to [**Hospital Unit Name 153**] on [**11-13**] for colonoscopy
5. Pending labs: None
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Coumadin 3 mg PO 2X/WEEK (MO,FR)
Monday and Friday
2. Coumadin 2.5 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA)
Sun, Tue, Wed, Thurs, Sat
3. glimepiride *NF* 2 mg Oral daily
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Juven *NF* (arginine-glutamine-calcium Hmb) 7-7-1.5 gram Oral
[**Hospital1 **]
6. Dantrolene Sodium 50 mg PO TID
7. Multivitamins 1 TAB PO DAILY
8. Furosemide 40 mg PO BID
9. BuPROPion 200 mg PO BID
10. Guaifenesin ER 600 mg PO Q12H
11. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5
12. Escitalopram Oxalate 20 mg PO DAILY
13. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation [**Hospital1 **]
14. Lyrica 100 mg PO TID
15. Methadone 15 mg PO BID
16. Ascorbic Acid 500 mg PO TID
17. Baclofen 20 mg PO TID
18. Baclofen 40 mg PO QHS
19. BusPIRone 10 mg PO QID
20. Tizanidine 2 mg PO QID
21. Omeprazole 20 mg PO DAILY
22. Methadone 5 mg PO QHS:PRN pain
23. Tums 500 mg PO X2 PRN indigestion
24. Magic Bullets *NF* (bisacodyl) 10 mg Rectal Daily:PRN
constipation
25. Acetaminophen 650 mg PO Q4H:PRN pain
26. Miralax 17 g PO TID:PRN constipation
27. Colace 100 mg PO BID constipation
28. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
29. Neosporin 1 Appl TP QID
30. Povidone Iodine Full Strength Dose is Unknown TP ASDIR
31. Ibuprofen 600 mg PO Q8H:PRN pain
32. Magnesium Citrate 300 mL PO PRN DAILY constipation
33. Diazepam 5 mg PO Q6H:PRN spasms
34. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
35. Triple Antibiotic *NF*
(
n
eomycin-bacitracin-polymyxin;<br>neomycin-bacitracnZn-polymyxin)
3.5-400-5,000 mg-unit-unit/g Topical PRN rash/skin breakdown
36. Fentanyl Patch 25 mcg/h TP Q3DAYS PRN pain
37. ALPRAZolam 0.25 mg PO Q4H:PRN anxiety
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. ALPRAZolam 0.25 mg PO Q4H:PRN anxiety
3. Baclofen 20 mg PO TID
4. BuPROPion 200 mg PO BID
5. Escitalopram Oxalate 20 mg PO DAILY
6. Diazepam 5 mg PO Q6H:PRN spasms
7. BusPIRone 10 mg PO QID
8. Guaifenesin ER 600 mg PO Q12H
9. Ibuprofen 600 mg PO Q8H:PRN pain
10. Lyrica 100 mg PO TID
11. Tums 500 mg PO X2 PRN indigestion
12. Methadone 15 mg PO BID
13. Miralax 17 g PO TID:PRN constipation
14. Tizanidine 2 mg PO QID
15. Magic Bullets *NF* (bisacodyl) 10 mg Rectal Daily:PRN
constipation
16. Magnesium Citrate 300 mL PO PRN DAILY constipation
17. Colace 100 mg PO BID constipation
18. Coumadin 3 mg PO 2X/WEEK (MO,FR)
Monday and Friday
19. Coumadin 2.5 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA)
Sun, Tue, Wed, Thurs, Sat
20. Dantrolene Sodium 50 mg PO TID
21. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation [**Hospital1 **]
22. Fentanyl Patch 25 mcg/h TP Q3DAYS PRN pain
23. glimepiride *NF* 2 mg ORAL DAILY
24. Juven *NF* (arginine-glutamine-calcium Hmb) 7-7-1.5 gram
Oral [**Hospital1 **]
25. MetFORMIN (Glucophage) 500 mg PO BID
26. Multivitamins 1 TAB PO DAILY
27. Neosporin 1 Appl TP QID
28. Omeprazole 20 mg PO DAILY
29. Triple Antibiotic *NF*
(
n
eomycin-bacitracin-polymyxin;<br>neomycin-bacitracnZn-polymyxin)
3.5-400-5,000 mg-unit-unit/g Topical PRN rash/skin breakdown
30. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
31. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5
32. Torsemide 20 mg PO BID
RX *torsemide 20 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
33. Ascorbic Acid 500 mg PO TID
34. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
Discharge Disposition:
Home With Service
Facility:
Centrus Home Care
Discharge Diagnosis:
Primary:
1. Right upper quadrant fluid collection
2. Respiratory failure
Secondary;
1. Quadraplegia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
transferred here with fevers and delirium and were found to have
a fluid pocket in your abdomen which was drained. You also had
difficulty with your breathing for which we increased your
ventilation support and treated you for a lung infection. You
will be readmitted to the ICU for a colonoscopy on [**11-13**] to
further evaluate the cause of this abdominal fluid collection.
The following changes were made to your medications;
1. START Torsemide 20mg [**Hospital1 **]
2. STOP Furosemide 40mg [**Hospital1 **]
3. RESTART Warfarin as you were taking it prior to this
admission
Followup Instructions:
You will be directly readmitted to the [**Hospital Unit Name 153**] at [**Hospital1 18**] on [**11-13**], [**2187**], for your colonoscopy. Please stop taking your warfarin
1 week prior to this date.
Also, please call your PCP to schedule [**Name Initial (PRE) **] follow up appointment
for next week.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2187-10-6**]
ICD9 Codes: 0389, 5119, 2760, 2930, 2761, 4019, 2768, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2764
} | Medical Text: Admission Date: [**2118-10-8**] Discharge Date: [**2118-10-11**]
Date of Birth: [**2070-6-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Jaundice
thrombocytopenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Initial history and physical is as per ICU team.
.
This is a 48 year-old male with a history of ischemic CM (EF
15%), s/p CCY 5 years ago who initially presented to [**Hospital3 25354**] with mid abdominal pain and jaundice, found to
have CBD dilated to 8mm on ultrasound. He reports that he
developed mid severe abdominal pain ("gassy") beginning after
dinner on [**10-6**]. He denies N/V/diarrhea prior to admission, but
notes few nonbloody loose stools since admission because he has
not been able to eat. He further denies chest pain, cough. He
has had no dysuria or urinary frequency. He denies change in
skin, scleral color. He does endorse diffuse pruritis. Labs on
presentation revealed t. bili of 2.5-->5, alk phos 199, ALT/AST
32/28. WBC was 11K with 5% bands and he was febrile to 102.
Subsequent CT abd/pelvis at [**Hospital3 **] showed CBD dilated to
2cm. He was started on IV unasyn and flagyl was added for c.
diff coverage given recent hospitalization and abdominal pain.
During his 2 day stay, his creatinine bumped from 1.1 on
admission to 2.7 on day of transfer. Additionally, he normally
has SBPs in the 90s, but had readings into the 70s prior to
transfer at which time he was asymptomatic.
.
He is now being transferred to [**Hospital1 18**] for ERCP out of concern for
retained stone.
.
ROS: As above. Additionally, the patient denies any fevers,
chills, weight change. His appetite has been okay. No melena,
hematochezia, chest pain, shortness of breath. +2 pillow
orthopnea, no PND. No lightheadedness, gait unsteadiness, focal
weakness, vision changes, headache, rash (does endorse diffuse
pruritis).
.
Past Medical History:
CAD; s/p multiple MIs ([**2112**] and [**2116**]) s/p stents
Ischemic cardiomyopathy with EF 15% and severe MR s/p ICD
s/p cholecystectomy
Hyperlipidemia
Anemia
Peptic ulcer disease
Social History:
Quit smoking approximately 5 years ago; 30+ packyear history
prior to that. Rare EtOH. No other illicits. Previously had
his own construction business, but has been on disability since
most recent MI. Recently separated from his wife.
Family History:
NC
Physical Exam:
GEN: Well-appearing older than stated age
HEENT: EOMI, PERRL, + scleral icterus, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: no bruits, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Left lung base with fine rales 1/3 up. No
wheezes/rhonchi.
ABD: +BS, soft, TTP inferior to epigastrium and just to left of
umbilicus. No rebound/guarding.
EXT: Trace edema bilaterally.
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength and sensation
to soft touch no cyanosis. No ecchymoses, no petechiae. Areas
of excoriation on bilateral UEs from patient scratching.
Pertinent Results:
[**2118-10-9**] 12:45AM BLOOD WBC-7.1 RBC-4.30* Hgb-9.8* Hct-31.1*
MCV-72* MCH-22.7* MCHC-31.4 RDW-20.7* Plt Ct-9*
[**2118-10-9**] 12:45AM BLOOD Neuts-82.6* Bands-0 Lymphs-13.0*
Monos-2.6 Eos-1.6 Baso-0.2
.
[**2118-10-9**] 12:45AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-2+ Polychr-NORMAL Spheroc-1+ Ovalocy-1+
Target-1+ Schisto-1+ Burr-1+
.
[**2118-10-9**] 12:45AM BLOOD PT-19.1* PTT-36.9* INR(PT)-1.8*
.
[**2118-10-9**] 12:45AM BLOOD Glucose-83 UreaN-52* Creat-2.1* Na-129*
K-3.8 Cl-96 HCO3-20* AnGap-17
.
[**2118-10-9**] 12:45AM BLOOD ALT-13 AST-35 LD(LDH)-249 AlkPhos-105
Amylase-107* TotBili-11.5* DirBili-8.8* IndBili-2.7
.
[**2118-10-9**] 02:18AM BLOOD Ret Aut-2.8
[**2118-10-9**] 02:15AM BLOOD Fibrino-557* D-Dimer-6170*
[**2118-10-9**] 02:15AM BLOOD FDP-40-80*
[**2118-10-9**] 12:45AM BLOOD Hapto-115
.
[**2118-10-9**] 02:18AM BLOOD calTIBC-393 VitB12-1483* Folate-8.6
Ferritn-172 TRF-302
[**2118-10-9**] 02:18AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0 Iron-23*
.
[**2118-10-8**] CXR: IMPRESSION: Cardiomegaly without CHF or pneumonia.
.
[**2118-10-9**] LIVER U/S: IMPRESSION:
1. Echogenic portal triad, can be seen in the setting of
hepatitis.
2. Patent portal and hepatic veins, normal flow in the main
hepatic artery.
3. Large right pleural effusion.
4. Minimal perihepatic ascites.
5. Extra-hepatic biliary ductal dilatation, distal common duct
not visualized
due to overlying bowel gas. ERCP or MRCP can be performed if
further
evaluation is needed.
Brief Hospital Course:
48 year-old male with a history of CAD and ischemic
cardiomyopathy (EF 15%) who presented with abdominal pain and
jaundice with CBD dilatation on imaging.
.
1. Jaundice: Possible etiologies included acute hepatitis C
versus cholangitis versus choledocolithiasis. There was
evidence of CBD dilatation on OSH imaging. Interestingly
however, he wa found to be only mildly tender over RUQ rather
the majority of his discomfort is mid abdomen. No
rebound/guarding. T.bili elevation now to 11.5 (normal alk
phos). Could not perform MRCP to further evaluateas patient with
AICD. Unfortunately an ERCP could not be done because he had a
platelet count of 9 at admission. he was continued on Unasyn
while in the hospital. The patient was to be treated/worked up
further but he signed out AMA.
.
2. Thrombocytopenia: Heme/Onc was consulted for differential
including platelet clumping, DIC, TTP-HUS, medication induced.
No schistocytes were seen on smear. Unclear whether he received
SC heparin at OSH, but likely used there for prophylaxis.
Platelets at OSH were in the 250s and here, one day later, down
to 9 -> seems less c/w HIT. Heme/Onc feels this is most c/w ITP
given lack of schistocytes on peripheral smear. HITT antibody
was negative. The patient recevied was started on steroids. He
unfortunately signed out AMA before we could evaluate for a
clinical response.
.
3. ARF: Cr of 1.3 per OSH reports, but 2.1 on initial
presentation. Creatinine had risen to 2.7 but now normalized
with IVF. Concerning in the setting of his thrombocytopenia and
fever would be TTP-HUS, but appears to be pre-renal. Urine
lytes c/w this.
.
4. Hypotension: Baseline SBPs per patient run 80s-90s. Had
dipped as low as 70 systolic per OSH but patient was
assymptomatic. SBPs currently low 90s but suspect this was
related to his severe cardiomyopathy. Had previous concern for
infectious cause with fever at outside hospital but afebrile
since admit here. Responded to IVF.
.
5. Chronic systolic CHF secondary to ischemic cardiomyopathy (EF
15%): Appeared to be well compensated. The patients
antihypertensive meds and diuretics were initaially held because
of relative hypotension. [**Name2 (NI) **] will restart them as an outpatient.
.
6. CAD: Held beta blocker b/c of hypotension, held ASA for ERCP,
held statin d/t LFT abnormalities.
.
7. PUD: Given pt was on PPI as outpatient at which time
platelets were normal, this seemed to be a very unlikely cause
of the patients thrombocytopenia. PPI was continued.
.
# FEN: cardiac diet, replete lytes PRN.
.
# PPx: Venodynes.
.
# Code: FULL
.
# Dispo: The patient unfortunately signed out AMA. On the
morning he left, the patient was dressed and was about to walk
out the door when the nurse stopped him. I spent about one hour
talking to the patient trying to talk him out of signing out of
the hospital. Hr told me that he was frustrated about his whole
medical course. He was frustrated that he was transferred from
Loweell general for a procedure adn that it hasn't been done. I
explained to the pt that an ERCp could not be done because of
the risks associated with his low platelet counts and that an
MRCP could not be done because of his pacemaker. I explained to
him that his biggest problem was hi low platelet count and how
we were trying to fix it with steroids. I explained to the
patient that he would likely DIE if he left AMA. I warned him
that he was at very high risk of spontaneous bleeding, or that
his liver might fail further. I warned him that he could become
acutely anemic and induce another heart attack. Despite all my
efforts he could not be convinced to stay. The patient
expressed an understaning of his situation and is competent to
make his own medical decisions. the patient signed an AMA form
and this was placed in teh chart, I encouraged him to seek
medical attention immediately as soon as he felt ill.
Medications on Admission:
Medications on transfer:
Reglan 10mg IV q6h prn
Flagyl 500mg IV q6h
Morphine 3mg IV q2h prn
Pantoprazole 40mg IV bid
Unasyn 3g IV q6h (started [**10-6**])
ASA 325mg PO daily
Carvedilol 3.125mg [**Hospital1 **]
Digoxin 0.125 daily
Ibuprofen 600mg PO q6h prn
Simvastatin 20mg daily
Spironolactone 25mg [**Hospital1 **]
Simethicone 80mg qid
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO twice a
day.
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperbiliruninemia
Hepatitis A
Thrombocytopenia
Discharge Condition:
Unstable. Patient signed out AMA
Discharge Instructions:
Patient signed out AMA
Followup Instructions:
Patient signed out AMA
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2118-10-11**]
ICD9 Codes: 5849, 2761, 2875, 4589, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2765
} | Medical Text: Admission Date: [**2104-8-17**] Discharge Date: [**2104-8-23**]
Date of Birth: [**2043-6-8**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 7046**] is a 61 year old female with a PMH significant for
chronic RUQ abdominal pain and pancreas divisum admitted to the
Surgical service and now transferred to the [**Hospital Unit Name 153**] for tachycardia
and an increased oxygen requirement. The patient reports that
she developed acute onset [**11-15**] epigastric pain on the evening
of [**8-17**] described as constant dullness or aching with
intermitent sharp/stabbing pain made worse with movement with
associated SOB from abdominal pain with inspiration. Onset of
pain was preceded by nausea and NBNB emesis. The patient was
brought to the OSH ED, where she was found to have a lipase of
6000 and a RUQ U/S that was negative for cholelithiasis or
cholecystitis. She also had a CTAP that was suggestive of
necrotizing pancreatitis, and she was transeferrred to the [**Hospital1 18**]
surgical service for further management this afternoon.
.
Of note, the patient reports a 30+ year history of RUQ abdominal
pain of unclear etiology. Pain is described as intermitent
achiness somewhat similar to her current symptoms but in a
different location and much lower in intensity. Approximately 10
years ago, she presented to an OSH ED for these symptoms and was
diagnosed with pancreas divisum on ERCP.
.
At [**Hospital1 18**], the patient was placed on a dilaudid PCA with
improvement in her pain control. She was noted on the floor,
however, to be in sinus tachycardia up to 140 with an SaO2 that
decreased to low 90s on RA from mid to high 90s on initial
presentation with a venous lactate of 3.7. She was initially
treated with ciprofloxacin and flagyl which was held this
morning. She was then transferred to the [**Hospital Unit Name 153**] for further
management.
.
Currently, the patient is resting comfortably. Pain is well
controlled on PCA. Denies any CP/SOB, f/c/s, n/v, palpitations,
orthopnea, PND.
.
ROS: Last BM 3 days prior to admission. As above, otherwise
negative.
Past Medical History:
Pancreas divisum
Hypertension
Hyperlipidemia
Hypothyroidism
Duodenal ulcer
Hysterectomy
Tonsillectomy
Appendectomy
Social History:
Lives with 2 friends in [**Location (un) 8973**]. Patient is a nurse. Tobacco
- quit 20 years ago, 1 ppd x20 yrs. EtOH - 1 drink/month. No IV,
illicit, or herbal drug use.
Family History:
hyperlipidemia, HTN, RA
Physical Exam:
Gen: Age appropriate female resting comfortably in NAD
HEENT: Perrl, eomi, sclerae anicteric, MMM, OP clear without
lesions, exudate or erythema. Neck supple.
CV: Tachy S1+S2
Pulm: Fine [**Hospital1 **]-basilar rales bilaterally
Abd: Mildly distended, TTP throughout worst in epigastrum. No
rebound or guarding. Minimal BS
Ext: No c/c/e
Neuro: AO x3, CN II-XII intact.
Pertinent Results:
[**2104-8-23**] 02:00PM BLOOD WBC-13.5*
[**2104-8-23**] 07:40AM BLOOD WBC-16.4* RBC-3.86* Hgb-11.7* Hct-35.0*
MCV-91 MCH-30.2 MCHC-33.4 RDW-13.0 Plt Ct-473*
[**2104-8-22**] 06:25AM BLOOD WBC-13.5* RBC-3.91* Hgb-12.0 Hct-36.4
MCV-93 MCH-30.6 MCHC-32.9 RDW-13.1 Plt Ct-394
[**2104-8-21**] 01:20PM BLOOD WBC-15.2* RBC-3.85* Hgb-12.2 Hct-35.2*
MCV-92 MCH-31.7 MCHC-34.6 RDW-13.3 Plt Ct-375
[**2104-8-20**] 07:05AM BLOOD WBC-13.6* RBC-3.83* Hgb-11.9* Hct-35.5*
MCV-93 MCH-31.2 MCHC-33.7 RDW-13.4 Plt Ct-301
[**2104-8-19**] 04:00AM BLOOD WBC-12.4* RBC-4.58 Hgb-14.1 Hct-42.9
MCV-94 MCH-30.8 MCHC-32.8 RDW-13.4 Plt Ct-327
[**2104-8-18**] 06:20AM BLOOD WBC-11.3* RBC-5.12 Hgb-15.7 Hct-47.7
MCV-93 MCH-30.6 MCHC-32.9 RDW-13.6 Plt Ct-335
[**2104-8-17**] 07:45PM BLOOD WBC-8.8 RBC-5.44*# Hgb-17.4*# Hct-50.1*#
MCV-92 MCH-32.1* MCHC-34.8 RDW-13.1 Plt Ct-410
[**2104-8-17**] 07:45PM BLOOD Neuts-67 Bands-14* Lymphs-10* Monos-6
Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2104-8-17**] 07:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2104-8-23**] 07:40AM BLOOD Plt Ct-473*
[**2104-8-18**] 06:20AM BLOOD PT-14.7* PTT-27.4 INR(PT)-1.3*
[**2104-8-18**] 06:20AM BLOOD Plt Ct-335
[**2104-8-23**] 02:00PM BLOOD Na-135 K-3.3 Cl-99
[**2104-8-17**] 07:45PM BLOOD Glucose-178* UreaN-23* Creat-0.7 Na-134
K-5.1 Cl-100 HCO3-17* AnGap-22
[**2104-8-22**] 06:25AM BLOOD ALT-23 AST-24 AlkPhos-101 Amylase-32
TotBili-0.5
[**2104-8-17**] 07:45PM BLOOD ALT-32 AST-50* AlkPhos-93 Amylase-280*
TotBili-0.4
[**2104-8-23**] 07:40AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1
[**2104-8-19**] 04:00AM BLOOD Albumin-3.0* Calcium-8.1* Phos-1.6*
Mg-2.0
[**2104-8-22**] 09:27AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2104-8-22**] 09:27AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2104-8-22**] 09:27AM URINE
.
ABD US [**2104-8-19**]
1.Heterogenous appearance of the pancreas with surrounding
fluid, consistent
with the history of pancreatitis. There is evidence of
gallbladder sludge,
but no evidence of chololithiasis.
2. Small right pleural effusion.
Brief Hospital Course:
Ms. [**Known lastname 7046**] is a 61 year old female with pancreas divisum and
acute pancreatitis transferred to the [**Hospital Unit Name 153**] for tachycardia and
increasing O2 requirement.
.
# Acute pancreatitis: Pain much improved with dilaudid PCA.
Given elevated venous lactate and UOP ~30 cc/hr, patient was
intravascular volume deplete upon admission to ICU. Only risk
factor for acute pancreatitis at this time is pancreas divisum.
The patient improved overnight in the ICU with 200cc/hr of LR,
NPO, dilaudid PCA. She was afebrile, although her WBC increased
slightly from previous to 12. Her amylase/lipase were trending
down. Currently low suspicion for necrotizing pancreatitis
although outside hospital CT could not exclude, so will repeat
RUQ ultrasound this AM per surgery recs, and hold prophylactic
abx for now.
.
# Sinus tachycardia: Likely multifactorial in etiology including
pain and intravascular volume depletion in setting of third
spacing from pancreatitis. Given temporal association with
acute pancreatitis, less likely to be hyperthyroid or PE. No
indication for AV nodal blockade at this time as tachycardia is
likely compensatory and she has no cardiac history, and will
follow on telemetry.
.
# Respiratory: Patient with mildly increased supplemental oxygen
requirement now on 3L nc. Likely from large volume IVF in
setting of pancreatitis and third spacing, although CXR without
significant pulmonary edema at this time. Patient also with
small bilateral pleural effusions and rapid shallow breathing
from pain may also be leading to some atalectesis. Low
suspicion for developing ARDS from pancreatitis at this time. If
O2 requirement and tachycardia does not improve can also
consider PE, although it less likely clinically at this time.
There is also a small likelihood that this could be an
inflammatory pancreatic cancer, in which case the patient could
be hypercoaguable. Again, at this time we will watch clinically,
wean O2 as tolerated, and encourage incentive spirometry.
.
# HTN: Hold home lisinopril for now as patient is not
hypertensive.
.
# Hypothyroid: Continue home synthroid.
.
# Hyperlipidemia: Not currently on lipid-lowering regimen.
Patient cannot tolerate statin therapy secondary to myalgias.
Although it would be a very unlikely cause of her pancreatitis,
can consider TriG, chol labs workup as an outpatient as pt
states that her mother had values >1000.
.
# FEN: NPO, IVF, replete as necessary.
.
# PPx: Heparin SQ, PPI
.
# Access: PIV
.
# Code: Full (confirmed)
.
# Communication: Comments: Patient; PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (in [**Location (un) 9084**]); daughter is in town and will visit today
Medications on Admission:
Zestril 10qhs, Synthroid 112
Discharge Medications:
1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-8**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO twice a
day.
Disp:*90 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
pancreatic divisum and acute pancreatitis
.
Secondary:
pancreas divisum, one episode of pancreatitis 3-4 years ago;
hysterectomy, duodenal ulcer, tonsillectomy, appendectomy,
hypertension, hyperlipidemia, hypothyroidism
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
* if you have severe abdominal pain, unable to tolerate liquids,
have nausea or vomiting
* if you feel your heart racing fast or have irregular heart
beats
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 28529**] in [**2-8**] weeks [**Telephone/Fax (1) 1231**]
2. Please follow up with your PCP [**Last Name (NamePattern4) **] 1 week regarding your new
beta blocker you were started on while in the hospital.
3. Follow up with Dr. [**Last Name (STitle) **] in one month (cardiology).
Please call ([**Telephone/Fax (1) 2037**] to schedule an appointment.
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2104-11-27**]
ICD9 Codes: 2762, 5119, 4019, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2766
} | Medical Text: Admission Date: [**2159-9-10**] Discharge Date: [**2159-9-25**]
Service:ORTHO
HISTORY OF PRESENT ILLNESS: This is an 82 year-old woman
with a history of hypertension, status post cerebrovascular
accident with residual left sided weakness, status post right
CEA in [**2155**] who is admitted for an L4-S1 decompression/fusion
on [**9-10**]. The patient's postoperative course was
electrocardiogram with new T wave inversions laterally, but
otherwise not significantly changed. The patient ruled out
by enzymes after this incident and was transferred to the
floor. The patient also received intraoperative Labetalol
for hypertension. Telemetry overnight after her episode of
chest pain demonstrated premature ventricular contractions
and bigeminy. The patient was seen by cardiology consult
pressure control. On [**9-14**], the patient began to
develop paroxysmal atrial fibrillation with a rapid
ventricular response and was subsequently anticoagulated on
heparin and Coumadin and placed on Amiodarone. However, on
[**9-18**] the patient's hematocrit dropped from 36 to 24
with a decrease in blood pressure and was found to have a
rectus sheath hematoma. The patient received 6 units of
packed red blood cells, 5 units of fresh frozen platelets and
her anticoagulation reversed. The patient was transferred to
the SICU where arterial line was placed and the patient was
placed on Nipride.
On [**9-21**] the patient was stable and transferred to the
floor with a resorbing hematoma and a normal sinus rhythm.
She at that point was denying chest pain, shortness of
breath, lightheadedness, although she was having some
abdominal tenderness. She was noted to have been having some
trouble with po and is being followed by the speech and
swallow team and was also noted to have some confusion and
mental status changes.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Small vessel
cerebrovascular accident in [**2153-3-26**] with residual left
sided weakness. 3. Bilateral carotid stenosis status post
right CEA in [**2155**] and with left CVBD. In [**2159-5-27**] the
patient was noted to have mild right ICA plaque and 60 to 69%
[**Doctor First Name 3098**]. 4. Status post spinal fusion [**2159-9-10**]. 5.
Status post echocardiogram in [**2150**] demonstrating normal left
ventricular function and trace AI. Status post ETT in [**2150**]
with equivocal results. 6. Status post parotid gland
excision at [**Hospital1 2025**] for a tumor.
MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg po q day. 2.
Detrol 1 mg po b.i.d. 3. Cozaar 25 mg po t.i.d. 4. MVI 1
po q.d. 5. Zoloft 25 mg po q.d.
ALLERGIES: The patient is "sensitive" to Percocets.
SOCIAL HISTORY: The patient lives alone in an apartment in a
senior housing center with three children who visit her
regularly. The patient has always used a walker and receives
food from Meals on Wheels.
PHYSICAL EXAMINATION ON TRANSFER TO THE FLOOR FROM THE SICU
ON [**9-21**]: Vital signs blood pressure 155/72. Pulse 84.
97% on 2 liters. Respiratory rate 23. In general, this is
an elderly female in no acute distress lying comfortably in
bed. Mucous membranes are moist. Neck is with some positive
JVD. Heart regular rate and rhythm. Plus S1 S2. 3 out of 6
systolic murmur. Lungs with bilateral rales and decreased
breath sounds at bases. Abdomen with decreased bowel sounds,
soft, tender to palpation diffusely with no rebound.
Extremities 1+ edema. Neurological alert and oriented times
two. She knows full name, [**Hospital1 188**], [**2158**], but believes the month is [**Month (only) 547**]. She moves all
four extremities.
SIGNIFICANT LABORATORIES UPON TRANSFER TO FLOOR: White blood
cell count 17.8, hematocrit 30.8, urinalysis with positive
nitrites, 18 red blood cells, 23 white blood cells and urine
culture with 100,000 E-coli. Echocardiogram from [**9-20**]
with a hyperdynamic EF of 75%, trace AI, 1 to 2+ MR. Chest
x-ray from [**9-20**] with cardiomegaly, increased
interstitial markings and diffuse haziness of pulmonary
vessels consistent with a worsening congestive heart failure
and small bilateral pleural effusions.
HOSPITAL COURSE: General, this is an 82 year-old woman
status post laminectomy with a history of hypertension,
bilateral carotid stenoses and now this hospitalization is
complicated by chest pain in the PACU and the patient was
subsequently ruled out by myocardial infarctions, paroxysmal
atrial fibrillation, which was treated with anticoagulation
and the patient subsequently developed a rectus sheath
hematoma. The patient transferred to the [**Hospital Unit Name 153**] status post
rectus sheath hematoma for her hypotension and decreased
hematocrit, but four days later was doing quite well and was
transferred to medicine for management of her atrial
fibrillation and mental status changes and social issues on
[**9-21**].
1. Cardiovascular: A: Rate and rhythm. The patient with
new onset paroxysmal atrial fibrillation first noted on
[**9-13**] or 19. It was initially treated with
anticoagulation, but secondary to rectus sheath hematoma
anticoagulation was discontinued. Telemetry was continued
throughout the course of her hospitalization and the patient
had episodic paroxysmal atrial fibrillation. The patient was
loaded on 400 mg of Amiodarone b.i.d. after receiving a
several day course of intravenous Amiodarone. Lopressor was
increased to 75 mg t.i.d.
B: Coronary artery disease/ischemia. The patient with
episode of chest pain in PACU with lateral electrocardiogram
changes, but was subsequently ruled out by enzymes.
Echocardiogram as an inpatient revealed a hyperdynamic EF,
but no other significant changes other then some 1 to 2+
mitral regurgitation, which was new. No further workup was
done at this time and the patient remained pain free
throughout the course of her hospitalization. The patient
will be medically managed with Lopressor, aspirin, Cozaar.
C: Hypertension. Patient with elevated blood pressure
throughout the course of her hospitalization receiving
Labetalol intraoperatively. The patient was noted to be
hypotensive with systolic blood pressures under 100 when she
was in atrial fibrillation, but after transfer to the floor
this was not noted at any time. Cozaar was increased to 50
mg b.i.d., Lopressor was increased to 75 mg t.i.d. and
Hydrochlorothiazide was begun as the patient was still having
systolic blood pressures in the 150s and 160s.
D: cardiac: The patient was noted upon transfer to the floor
on [**9-21**] to have congestive heart failure on chest x-ray
and on examination and was gently diuresed with prn Lasix 20
mg intravenous with good resolution of her congestive heart
failure. The patient continued to have some slight crackles
on examination and trace leg edema, but was having good
oxygen saturation on room air.
2. Gastrointestinal: The patient was noted throughout her
hospital course to be having trouble tolerating po with
coughing and a question of aspiration. She was followed by
speech and swallow throughout the course of her
hospitalization and required all of her pills to be crushed.
Swallowing study on [**9-24**] demonstrated a poor bolus
formation with flow transit in oral phase and premature
spillage, but without evidence of aspiration or spillage.
The patient will continue on a soft solid diet with thin
liquids. The patient should take small bites and drink small
sips alternatively and should sit up in 90 degree position
when taking po. The patient seemed to tolerate this well
during this admission. Prevacid liquid 30 cc q day and
Colace were continued.
3. Infectious disease: Patient with urine cultures positive
for 100,000 E-Coli. She was continued on a five day course
of Levofloxacin. However, by [**9-25**] the patient was
still having low grade fevers to 99.5 and monitoring was
continued.
4. Endocrine: The patient with elevated blood glucoses
noted in the Intensive Care Unit, however, upon transfer to
the floor her finger stick blood sugars were taken four times
a day and were noted to be all within normal limits. Q.i.d.
D6 were discontinued.
5. Pulmonary: The patient maintained good oxygen
saturations upon transfer from the Intensive Care Unit on 2
liters of oxygen, however, after gentle diuresis the patient
was able to maintain saturations of 93% on room air.
6. Neurology: The patient was noted to be somewhat confused
and disoriented to place and time while in the Intensive Care
Unit, but upon transfer to the floor her mental status
cleared and the patient became alert and oriented times
three. The patient was still noted to have some residual
left sided weakness.
7. Hematology: The patient was noted to have a stable
hematocrit of 30 to 33 upon transfer to the floor from the
Intensive Care Unit status post her rectus sheath hematoma.
It is felt that her hematoma is likely resorbing at this
time. Will continue to monitor her hematocrit and guaiac all
stools.
8. Back: The patient is status post laminectomy and spinal
cord fusion. Her back wound is noted to be clean, dry and
intact throughout this admission and staples were removed on
[**9-25**] with no complications.
9. Disposition: The patient will be discharge to
rehabilitation where she will receive physical therapy,
occupational therapy and continued monitoring from speech and
swallow team. She should follow up with cardiology in three
to four weeks.
MEDICATIONS ON DISCHARGE: 1. Amiodarone 400 mg b.i.d. 2.
Cozaar 50 mg po b.i.d. 3. Aspirin 81 mg chewable four tabs
q day. 4. Zoloft 25 q.d. 5. MVI one q.d. 6. Detrol 1 mg
po b.i.d. 7. Lopressor 75 t.i.d. 8. Prevacid liquid 30 mg
po q.d. 9. Colace 100 po b.i.d. 10. Hydrochlorothiazide
25 mg po q day.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Paroxysmal atrial fibrillation.
2. Status post L4 to S1 decompression/fusion on [**9-10**].
3. Status post rectus sheath hematoma.
4. Urinary tract infection with E-coli.
5. Congestive heart failure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**]
Dictated By:[**Last Name (NamePattern1) 3864**]
MEDQUIST36
D: [**2159-9-25**] 10:00
T: 10/ 001 10:22
JOB#: [**Job Number 3865**]
ICD9 Codes: 9971, 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2767
} | Medical Text: Admission Date: [**2154-7-12**] Discharge Date: [**2154-7-13**]
Date of Birth: [**2110-6-3**] Sex: M
Service: MEDICINE
Allergies:
Nickel
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Dizziness, malaise.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
CC:[**CC Contact Info 63737**].
HPI: 44yo man with h/o hypertension, ESRD on hemodialysis
presenting with hypotension. The patient was admitted to [**Hospital1 18**]
[**Date range (1) 63738**] with chest pain, hypertensive urgency, and
diastolic CHF. Hospital course was complicated by hematemesis
and hemoptysis. He was discharged on five new antihypertensive
medications, which he reports taking regularly for the past
week. He was dialyzed today with 4kg removed, and then took all
his medications at one time. He developed a posterior headache,
not associated with dizziness, flashing lights, nausea, or
visual changes, and presented to the first aide booth [**Hospital1 14630**] where he works. Blood pressure on evaluation was 80/50, and
he was sent to [**Hospital1 18**] ED for further evaluation.
.
On arrival in the ED T 97.5 HR 95 BP 81/50 RR 20 93-94%RA. He
was mentating normally and headache had improved. He was treated
with 2L NS, and BP improved to 91/52 (MAP 60). He denies
dizziness, vision changes, chest pain, shortness of breath,
fever, chills, abdominal pain, nausea, diarrhea, dysuria, and
skin rashes.
.
PMH:
Hypertension
ESRD on hemodialysis (M,W,F) [**1-16**] HTN disease
.
Meds:
Renagel 800mg tid
Protonix 40mg daily
Aspirin 81mg daily
Calcium acetate 667mg tid
Lisinopril 40mg daily
Imdur 60mg daily
Amlodipine 10mg daily
Diltiazem 480mg daily
.
All: nickel - rash
.
SHx: Patient lives at [**Location 63739**] shelter. He works as a cook [**Hospital1 63740**].
Tob: [**12-16**] ppd x 15yrs
EtOH: 2 drinks/day
Illicits: occasional crack cocaine
.
FHx:
Mother with [**Name2 (NI) **], diabetes
Father d. lung ca
.
ROS: no fever, chills, sweats, change in appetite, vision
changes, palpitations, chest pain, shortness of breath, cough,
hemoptysis, abdominal pain, nausea, vomiting, diarrhea,
constipation, dysuria, hematuria, skin rashes.
.
PE: T 97.5 HR 78 BP 92/52 RR 14 97%RA
GEN: comfortable, NAD
HEENT: PERRL, anicteric, MMM, OP clear
Neck: JVP nondistended, no LAD, 4cm lipoma on posterior neck
CV: RRR, no mrg
Resp: CTAB
Abd: +BS, soft, NT, ND, no masses, no HSM
Back: nontender, 5cm lipoma over right scapula
Ext: no edema, 1+ DP pulses, left arm fistula
Neuro: A&Ox3, strength 5/5 throughout, sensation intact grossly
.
Labs: see end of record
CXR: pending
.
A/P: 44yo man with h/o HTN, ESRD on HD presenting with
hypotension
.
#. Hypotension: This episode of hypotension is most likely due
to hypovolemia c/b medication effect as it occurred after the
patient was dialyzed and then took five new medications
simultaneously at max dose. If hypotension persists, would need
to consider cardiac ischemia, CHF, sepsis, adrenal
insufficiency, but these seem less likely. Echo done during the
last hospitalization showed mild LVH, dilated LA, nml EF >55%.
- hold all antihypertensives; plan to add back slowly at reduced
doses and varying schedule
- rule out MI
- bolus NS to maintain MAP >60 with caution given ESRD and
oliguric
.
#. ESRD: M,W,F hemodialysis.
- will notify Renal team
- continue Renagel, calcium acetate
.
#. Metabolic alkalosis: There is no history of vomiting or
diuretic use. He does not have decreased ventiliation causing
hypercapnia, and thus this is not likely compensatory.
- recheck chemistries; consider ABG if persists
.
#. Hyperkalemia: Patient was dialyzed today. monitor closely and
give kayexelate if K+ rises further
.
#. FEN: renal, low sodium diet
.
#. PPx: pneumoboots, Protonix
.
#. Full Code
Past Medical History:
PMHx: denies cardiac history
1) ESRD [**1-16**] HTN, on HD MWF. On HD x 4yrs. LUE AVF. dry wt 210
lbs.
2) HTN:
Social History:
SHx: smokes <[**12-16**] ppd X 15 yrs. He drinks 2 alcoholic beverages
daily. Crack/cocaine use a few times per month.
Works as vendor in local stadium.
Family History:
FHx: Maternal GM and GF with hypertension. Mother with diabetes.
No family history of CAD or cancer.
.
Physical Exam:
S: Pt comfortable, denies chest pain; denies dizziness, denies
swelling or shortness of breath. No fevers, chills, sweats. Pt
would like to go home today.
PE: T 98.1; HR 87, (76-87); BP 100/64 (111-100/62-70); RR 18; O2
sat 99%RA
GEN: comfortable, NAD
HEENT: anicteric, MMM
Neck: JVP nondistended, lipoma on neck unchanged
CV: RR, no murmur or rub or gallop
Resp: CTAB
Abd: Soft, NT, ND.
Ext: no edema, left arm fistula
Neuro: A&Ox3
.
Pertinent Results:
Admission laboratories:
[**2154-7-12**] 09:44PM BLOOD Glucose-78 UreaN-24* Creat-6.1*# Na-144
K-5.4* Cl-97 HCO3-33* AnGap-19
[**2154-7-12**] 09:44PM BLOOD WBC-8.8 RBC-4.13*# Hgb-12.9*# Hct-40.8
MCV-99* MCH-31.3 MCHC-31.7 RDW-15.4 Plt Ct-271
[**2154-7-12**] 09:44PM BLOOD PT-13.0 PTT-28.3 INR(PT)-1.1
[**2154-7-12**] 09:44PM BLOOD Plt Ct-271
Cardiac enzyme cycle:
[**2154-7-12**] 09:44PM BLOOD CK-MB-3 cTropnT-0.11*
[**2154-7-13**] 06:15AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2154-7-13**] 01:30PM BLOOD CK-MB-NotDone cTropnT-0.11*
HD #2
[**2154-7-13**] 06:15AM BLOOD Glucose-112* UreaN-33* Creat-7.5*# Na-139
K-4.2 Cl-97 HCO3-29 AnGap-17
[**2154-7-13**] 06:15AM BLOOD Calcium-10.0 Phos-4.6* Mg-1.8
Brief Hospital Course:
This 44 year-old gentleman with a history of hypertension,
end-stage renal disease on hemodialysis, and illicit drug abuse.
He had had a recent admission to this hospital for hypertensive
urgency presented to the emergency department with hypotension
after taking his 5 BP medication just subsequent to his dialysis
yesterday. His blood pressure normalized after administration
of 2 boluses of 1L normal saline. He was admitted to the
medicine service. Throughout his brief stay, he remained
hemodynamically stable with blood pressure in the normotensive
range. At no time did he exhibit signs of cardiogenic shock or
sepsis. It was felt that his symptomatology and hypotension was
related to his taking blood pressure medications to soon after
his dialysis session.
It was felt that it was safe for the patient to go home. He was
advised to not take any of his blood pressure medications in the
4 -6 hour time period after each dialysis session and given a
prescription and schedule to take two of his antihypertensive
medications in the morning, and two at night. This was also
communicated to the attending physician that day, Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 4154**] who agreed with this. Discharge of patient was to be
arranged pending final evaluation from Dr. [**First Name (STitle) 4154**]. The patient,
however, grew impatient saying he needed to be at work soon. He
was given a letter excusing him from work and he seemed
satisfied with this and said he would wait for the attending.
The patient, however, did not wait for the attending's final
evaluation and subsequently left AMA soon thereafter. Attending
was notified.
In summary this is a 44 year-old gentleman with hypertension and
end stage renal disease on hemodialysiswho presented with
hypotension after taking all four blood pressure medications
shorly after a hemodialysis session. His hypotension resolved
and was hemodynamically stable upon leaving AMA. Reasons for
leaving AMA, not entirely clear. Issues and plan as follows:
.
1) Hypotension: Likely from taking BP medications too soon after
HD. Given schedule for taking 2 medications in morning, two at
night. Advised not to take antihypertensive medications at
least 4-6 hours after hemodialysis.
- ruled out for MI
.
2) ESRD: M,W,F hemodialysis.
- continue Renagel, calcium acetate
- Renal service notified.
.
3) Metabolic abnormalities: Alkalosis/hyperkalemia: K Trended
down to normal range, alkalosis resolved, long term managment
with dialysis.
4) FEN: renal, low sodium diet
.
5) PPx: pneumoboots, Protonix
.
6) Full Code
7) Left AMA, reasons unclear. It was safe for him to leave
although attending physician needed to see him for final
clearance. Claimed he needed to return to work so given note
excusing him from work. This did not prevent him from leaving
AMA.
Medications on Admission:
Renagel 800mg tid
Protonix 40mg daily
Aspirin 81mg daily
Calcium acetate 667mg tid
Lisinopril 40mg daily
Imdur 60mg daily
Amlodipine 10mg daily
Diltiazem 480mg daily
Discharge Medications:
1. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO every morning.
6. Imdur 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet
Sustained Release 24HR PO at bedtime.
7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO Every morning.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension from overdose of antihypertensive medications.
End stage renal disease, on hemodialysis.
Discharge Condition:
Good. Blood pressure in normal range. No dizziness or
lightheadedness. No chest pain.
Discharge Instructions:
Please wait at least 4 hours after your hemodialysis before
taking any of your medications.
Please return if you feel dizzy or lightheaded.
Followup Instructions:
Please follow up at the [**Hospital 3501**] Medical Foundation
ICD9 Codes: 2765, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2768
} | Medical Text: Admission Date: [**2171-12-17**] Discharge Date: [**2171-12-30**]
Date of Birth: [**2088-7-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
pulled out g-tube
Major Surgical or Invasive Procedure:
Right sided thoracentesis [**12-18**]
History of Present Illness:
83yo M with HTN, COPD, Atrial fibrillation, CABGx4 [**8-17**]
complicated by sternal dehiscence, who is s/p partial transverse
colectomy with primary anastomosis and partial gastrectomy on
[**2171-11-5**] (for feculent peritonitis) who presents with dislodgment
of his G-J tube today.
.
The patient has a long, complicated medical course that begins
in [**8-/2171**] when he was transferred to [**Hospital1 18**] for chest pain. He
was found to have 3VD and underwent 4 vessel CABG. His course
was complicated by sternal wound infection and dehiscence. The
patient was readmitted in [**9-/2171**] with a severe CDiff infection
treated with Vancomycin and Metronidazole.
.
The patient was again readmitted late [**2171-10-9**] for abdominal
distention and pain and was found to have feculent peritonitis.
The patient was treated with antibiotics and was s/p partial
transverse colectomy. His course was also complicated by wound
dehiscence.
.
After speaking to the physician at [**Hospital3 **], the patient
was referred to [**Hospital1 18**] for admission because of increasing
agitation in the past several days leading patient to pull his
GJ tube last night. Additionally, the patient was found to have
a positive UA last wednesday, started on Levofloxacin initially,
but transitioned to Imipenem on Monday after Cx grew Klebsiella.
.
The patient's son was also available to speak to and he stated
that his dad has become increasingly agitated over the past
several days. He stated that he also had increasing difficulty
breathing while laying back that was relieved by sitting upright
that has been worsening over the past several days.
.
In the ED, initial vs were 98.5 71 128/57 20 99% Trachmask.
General surgery placed a foley in patient's G tube site
temporarily. He was treated with CTX for his UTI. Pt was stable
on arrival to floor.
.
On the floor, the patient was rather lethargic, but was
intermittantly responsive. He denied any pain. Otherwise was
unable to get a thorough ROS.
Past Medical History:
- Coronary Artery Disease s/p CABG x 4 [**8-17**]; course c/b sternal
wound infection and dehiscence s/p sternal debridement with
plating and pectoral flap advancement; respiratory failure
necessitating tracheostomy and eventual PEG
- Chronic Atrial Fibrillation
- Ischemic Cardiomyopathy
- Stage 4 Sacral decubitus ulcer
- Peripheral vascular disease
- Hypertension
- Hypercholesterolemia
- h/o C Diff sepsis
- s/p Transverse colectomy [**10-18**] for feculant peritonitis, course
complicated by lower abdominal wound dehiscence.
- Loculated left sided pleural effusion s/p Pigtail toracentesis
- Chronic obstructive pulmonary disease
Social History:
Previously lived with wife (in-law apartment- daughter +fam live
nearby) but came to [**Hospital1 18**] from rehab. He is retired. Tobacco:
1ppd x 64yrs. ETOH: occasional but none recent.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Exam on admission:
General: lethargic, responsive to commands, difficult to assess
orientation
HEENT: Sclera anicteric, MMM, oropharynx clear, trach in place
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse fine crackles in L lung, decrease BC at R base
with crackles
CV: Irregular rate and rhythm, II/VI SEM at RUSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Lower
abdominal wound appears to be clean and healing by secondary
intention. G tube site appears non erythematous.
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2171-12-17**] 02:31AM BLOOD WBC-10.1 RBC-2.89* Hgb-8.6* Hct-26.2*
MCV-91 MCH-29.9 MCHC-33.0 RDW-19.9* Plt Ct-213
[**2171-12-24**] 05:59AM BLOOD WBC-6.9 RBC-2.59* Hgb-8.1* Hct-23.9*
MCV-93 MCH-31.1 MCHC-33.6 RDW-19.2* Plt Ct-173
[**2171-12-18**] 07:40AM BLOOD PT-13.2 PTT-27.0 INR(PT)-1.1
[**2171-12-17**] 02:31AM BLOOD Glucose-90 UreaN-57* Creat-1.4* Na-133
K-5.1 Cl-97 HCO3-28 AnGap-13
[**2171-12-24**] 06:38PM BLOOD Glucose-120* UreaN-44* Creat-0.8 Na-136
K-5.0 Cl-95* HCO3-33* AnGap-13
[**2171-12-18**] 07:40AM BLOOD Calcium-8.6 Phos-5.5* Mg-2.4
[**2171-12-24**] 06:38PM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0
[**2171-12-18**] 07:40AM BLOOD LD(LDH)-204
[**2171-12-24**] 05:59AM BLOOD Vanco-27.5*
[**2171-12-17**] 04:17AM BLOOD Type-ART FiO2-50 pO2-105 pCO2-49* pH-7.45
calTCO2-35* Base XS-8
[**2171-12-22**] 09:16AM BLOOD Type-ART pO2-79* pCO2-58* pH-7.40
calTCO2-37* Base XS-8
[**2171-12-22**] 09:16AM BLOOD Lactate-0.7
.
CT chest/abd/pelvis [**2171-12-24**]:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
.
CXR [**2171-12-23**]:
FINDINGS: Large right pleural effusion is likely unchanged.
Fluid layers
over the minor fissure and may be masking opacification of the
inferior aspect of the right upper lobe. The left base is not
included on this image. Mildpulmonary edema and stable severe
cardiomegaly also seen. Unchanged position of tracheostomy and
sternal fixation devices. No pneumothorax is seen.
IMPRESSION: Likely unchanged large right pleural effusion and
mild pulmonary edema with possible opacification of the right
upper lobe, cannot exclude pneumonia.
.
Pleural fluid [**2171-12-18**]:
NEGATIVE FOR MALIGNANT CELLS.
.
[**2171-12-18**] 9:15 am PLEURAL FLUID
GRAM STAIN (Final [**2171-12-18**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2171-12-21**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2171-12-24**]): NO GROWTH.
.
Replacement of g-tube [**2171-12-17**]:
IMPRESSION: Uncomplicated image-guided replacement of a 22
French MIC
gastrojejunostomy tube. The tube is ready for use.
.
[**2171-12-22**] 5:41 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2171-12-22**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): SQUAMOUS EPITHELIAL CELLS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
POTASSIUM HYDROXIDE PREPARATION (Final [**2171-12-22**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
FUNGAL CULTURE (Preliminary):
YEAST.
.
[**2171-12-22**] blood cx: pending
.
[**2171-12-17**] urine cx:
URINE CULTURE (Final [**2171-12-18**]): <10,000 organisms/ml.
.
MRSA SCREEN (Final [**2171-12-24**]): No MRSA isolated.
.
CT THORAX:
There is a tracheostomy. No pathologically enlarged mediastinal,
hilar,
internal mammary or axillary adenopathy. There is focal stenosis
identified at the bifurcation of the pulmonary artery with no
filling defects identified.
There is enlargement of the left atrium with associated
cardiomegaly and
three-vessel coronary artery disease. No pericardial effusion.
There is a
loculated right pleural effusion with a maximum thickness along
the
mediastinum of 2.5 cm (series 2, image 17) and also along the
lateral chest wall, maximum thickness 2.2 cm (series 2, image
25). It appears simple -no enhancement to suggest empyema. There
is a small dependent effusion identified within the left lower
lobe. There is atelectasis and consolidation of the right lower
lobe and the posterior segment of the left lower lobe. There is
a nodule identified at the inferior segment of the lingula
measuring 7 mm (series 2, image 40), unchanged and stable when
compared to prior imaging. No new nodules. There is some pleural
nodularity identified along the left lateral chest wall within
the left upper lobe measuring maximum thickness of 8 mm (series
2, image 30) anteriorly. Close attention to this on followup is
recommended.
.
CT ABDOMEN:
There is a low-density 6-mm lesion identified within segment VII
of the liver (series 2, image 50) too small to characterize but
most likely consistent with a simple hepatic cyst. The portal
vein is patent. No intra- or extra-hepatic biliary dilatation.
There has been prior cholecystectomy. There has been interval
decrease in size and the volume of abdominal ascites since prior
imaging. Spleen and pancreas are unremarkable. There is a left
adrenal nodule measuring 1.6 x 2.6 cm (series 2, image 59) and
this is stable in size since prior imaging. The previously
described calculus within the right mid ureter is not visualized
on today's study. No focal kidney lesion. No
retroperitoneal masses or adenopathy. There is extensive
vascular
calcification of the abdominal aorta with calcification seen at
the origin of both the SMA and celiac arteries and renal
arteries bilaterally. No
abnormally dilated thickened small or large bowel loop in the
visualized upper abdomen. There is an open abdominal wound as
before and within the lower midline there is a ventral hernia
containing a small bowel loop and fluid which appears simple
(series 2, image 95). No proximal obstruction and isunchanged
since prior CT.
.
CT PELVIS:
Small trace of ascites is identified in the right lower quadrant
(series 2,
image 94). Urinary catheter is noted within the bladder. The
prostate,
rectum are unremarkable. Uncomplicated sigmoid diverticulae. No
pelvic
adenopathy or free fluid. There is a gastrostomy tube in situ.
.
CT OSSEOUS SKELETON: There is a convex scoliosis of the lower
lumbar spine
convex to the right. There is a block vertebra of L4 on L5.
There is
multilevel degenerative change of the lumbar spine with vacuum
disc phenomenon and syndesmophytosis. SI joints are
unremarkable. Both hip joints are preserved. No osseous
destructive lesion. Sternostomy closure device is noted in situ.
.
IMPRESSION:
1. Loculated right pleural effusion with locules identified
along the right lateral chest wall and mediastinum. It appears
simple with no enhancement to suggest empyema.
2. Stable left lower lobe pulmonary nodule and pleural
nodularity and
attention on follow-up is recommended.
3. Interval reabsorption of the abdominal ascites since prior
imaging with a small ventral hernia with a small bowel loop
(series 301b, image 37) in the midline inferior to the
umbilicus.
Brief Hospital Course:
83yo M with HTN, COPD, Atrial fibrillation, CABG [**8-17**]
complicated by sternal dehiscence, who is s/p partial transverse
colectomy with primary anastomosis and partial gastrectomy on
[**2171-11-5**] for feculent peritonitis, severe tracheobronchomalacia
s/p bronch being transferred out of the MICU s/p respiratory
decompensation thought [**3-12**] to a mucous plug and acute delerium
now with improvement in both.
.
Respiratory distress: During the patient's hospitalization, the
patient was noted to be acutely tachypneic with a RR in the 40s
and saturations in the low 90s overnight on trach mask with a
radiographic/clinical evidence of pulmonary evidence. The
patient's clinical status improved initially with diuresis,
however he had similar symptoms on [**12-22**] prompting transfer to
the MICU. He responded well to a nebulizer treatment and
suctioning through his trach. His sats were maintained on a
trach mask throughout these episodes, but he did require
ambu-bag on the floor. He is afebrile with no leukocytosis,
however, was noted to have more sputum production. Bronchoscopy
was performed on admission to the ICU and showed severe
tracheobronchomalacia; erythema at the superior segment of the
right lower lobe, take off of the lingula, and LLL subsegments;
as well as granulation tissue at the LLL segment. His
presentation seems to be most consistent with mucous plugging
layered on top of severe tracheobronchomalacia noted on [**Last Name (un) 1066**]
when he arrived to the ICU.
.
The patient was initially started on empiric coverage for
pnemonia pending BAL cultures (vancomycin added to his ongoing
meropenem but vancomycin was discontinued on [**2171-12-24**]). He
remained quite short of breath and there was concern for a COPD
exacerbation. Prednisone was started on [**2171-12-23**] at 40mg daily
and was tappered to 20mg on [**12-27**] for a total of a 7 day course.
He was diuresed further with 80mg IV lasix. His BAL gram stain
showed gram negative rods and gram + cocci in clusters, however
his culture grew stenotrophomonas which and was thought to be a
contaminant.
.
His CXR was concerning for opacity in the lower aspect of his
right upper lobe. A CT chest/abd/pelvis was done which showed a
loculated and non loculate right pleural effusion. A pigtail
catheter was placed and 1L of sero-sanguinous fluid immediately
drained. An air leak was initially present but resolved. He put
out 400cc over the next 48hrs. His pigtail drain was pulled by
interventional pulmonary on [**2171-12-27**].
.
Agitation/Encephalopathy: On arrival to [**Hospital1 18**], the patient was
noted to be agitated and encephalopathic, likely in the setting
of his UTI and infection. The patient was initally restrained,
however improved with antibiotics. After the patient was
transferred to the MICU he acutely agitated and again required
restaints. He was likely having delirium in the setting of his
hospitalization and infection. He was continued on the trazodone
and his risperdone was up titrated. His reglan was discontinued
in case this was contributing to his AMS. Pt became somewhat
oversedated after risperidone uptitrated to 0.5mg at night so
dose was decreased back down to 0.25mg Qhs and mental status
stayed fairly stable on this dose.
- Continue Risperdone 0.25mg qHS and 0.25mg prn agitation
.
Atrial Fibrillation: Rate controlled on metoprolol tartrate
25mg [**Hospital1 **] which was uptitrated to 37.5mg [**Hospital1 **] given several
episodes of non-sustained ventricular tachycardia. The patient
was not on anticoagulation on admission, likely given his
multiple surgeries and and possible slow GI bleeding
necessitating intermittent blood transfusions. Given that the
patient has been intermittantly self removing his tracheostomy
and G tube, and multiple co-morbidies, anticoagulation was
deferred.
- Continue Metoprolol 37.5mg [**Hospital1 **]
- Continue ASA 81mg daily
.
Ventricular tachycardia: He had several long runs of his
ventricular tachycardia while in the ICU (30-40 beat runs). He
remained hemodynamically stable during these episodes. His
metoprolol was uptitrated from 25mg po BID to 37.5mg po BID and
it was expected that he would have baseline bradycardia as his
heart rate was trending between the 40s-60s. Further, during
sleep, patient was found to develop asymptomatic bradycardia
with heart rates in the 30s, which required no intervention in
the setting of other vital signs. This level of heart rate was
deemed acceptable in order to prevent his bursts of elevated HR
as there was no evidence of symptoms or reduced organ perfusion
during these episodes.
.
Klebsiella UTI: He completed a 7 day course of meropenem which
was discontinued on [**2171-12-24**]. He remained afebrile while in the
ICU with a normal white count.
.
Stage 4 Sacral Ulcer: The ulcer probes to bone, however per
orthopedics, the periosteum is intact with overlying granulation
tissue. His ESR/CRP were elevated. The wound appeared clean
with minimal drainage. The wound appears clean with minimal
drainage. Will need continued dressing changes.
.
Abdominal Wound Dehiscence: Lower abdominal wound appeaed to be
healing well by secondary intention, but does have some
yellowish drainage. There were no issues with this wound while
he was in the hospital.
.
Code Status: He is DNR but is trached and OK to be put on the
vent if he decompensates.
Medications on Admission:
Ferrous Sulfate 300mg liquid daily
Proscar 5mg daily
Fluoxetene 20mg daily
Furosemide 20mg daily
SCH
Reglan 5mg qAC and qHS
Metoprolol Tartrate 25mg [**Hospital1 **]
Ranitidine 150mg/10mL syrup [**Hospital1 **]
Risperdone 0.25mg qHS
Simethicone [**Hospital1 **]
Tiotropium 18mcg daily
Trazodone 12.5mg qHS
Zinc 220mg daily
Tylenol prn
Albuterol q6hrs prn
Opium tincture 3mg TID prn
Risperdal 0.25mg [**Hospital1 **] prn
Oxycodone 2.5mg q3hrs prn pain
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ml
Injection TID (3 times a day).
2. finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. metoclopramide 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO qachs.
4. fluoxetine 20 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
5. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Hospital1 **]: One (1)
5ml PO DAILY (Daily).
6. furosemide 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2
times a day).
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
9. risperidone 0.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
10. simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO BID (2 times a day).
11. zinc sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Last Name (STitle) **]:
One (1) Inhalation once a day.
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
14. 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.
15. opium tincture 10 mg/mL Tincture [**Last Name (STitle) **]: 3mg (0.33ml) PO TID
PRN.
16. Tylenol 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6hr PRN.
17. risperidone 0.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily) as needed for agitation.
18. aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary Diagnosis:
-G-tube repair
-Klebsiella UTI
-Loculated right sided pleural effusion s/p thoracentesis with
bilius fluid
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
evaluation of shortness of breath, treatment of multi-drug
resistant Klebsiella urinary tract infection, and replacement of
your G-J tube which was dislodged. You had an extensive amount
of fluid in your right lung which was drained and improved with
antibiotics. You were briefly in the ICU when you had difficulty
breathing likely due to a plug of mucous in your airway. You
received 1 blood transfusion in the ICU because your blood
levels were found to be low. You were also noted to have
elevated heart rate thought [**3-12**] to your atrial fibrillation so
your metoprolol was increased to control this.
.
The following changes were made to your medications:
- Metoprolol was increased to 37.5mg by mouth twice each day
- Rantitidine was stopped and replaced with lansoprazole 30mg
daily as extra protection against GI bleeding
- Furosemide was increased to 80mg by mouth daily
- Reglan was decreased to only Qhs
- Trazadone was stopped
- Oxycodone was stopped
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up with the physicians at your rehab facility.
Completed by:[**2171-12-31**]
ICD9 Codes: 5119, 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2769
} | Medical Text: Admission Date: [**2124-7-8**] Discharge Date: [**2124-7-24**]
Date of Birth: [**2070-10-22**] Sex: M
Service: MEDICINE
Allergies:
Tegretol / Lasix
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
IABP
Swan ganz x2
Cardiac catheterization
History of Present Illness:
53yo male with history of obesity, OSA, and depression who p/w
increasing SOB x5d. 5d ago he noted DOE while climbing flight of
stairs. It was sudden onset and not a/w nausea, CP, diaphoresis.
SOB persisted throughout day and was worse with lying flat. He
also reports significant bilat lower ex and abd edema and approx
5 lb weight gain in 2d. SOB persisted and was worsened with any
physical activity. He said he could "talk it down" until day of
admit when it worsened. He denies any cough, chills, fevers, or
chest pain. He has no hx of CAD, CHF and no new meds.
.
In the ED, 96.8 102/78 73 16 100% RA. Promptly went into HR of
130s with aflutter and SBP 120s. Exam showed cool extremities
and bibasilar rales. He was given Dilt 20 IV and 30 PO with HR
improvement to 110 and SBP 130 -> 80s. He needed 600 IVF. Neo
given intermittently with no improvement in HR. EKG aflutter
with NA, NI and ventricular rate of 130 w delayed RWP. Labs
showed Trop 0.02, CK 187, MB 10. INR 1.7, WBC 15.8, ARF (Cr 2.4)
and transaminitis (ALT [**2055**] and AST 736). Anion gap 17 and
lactate 3.4. CXR w pulm congestion. CT abd showed cirrhotic
liver with small ascites w small/mod bilateral pleural
effusions. He was given [**Last Name (LF) 94463**], [**First Name3 (LF) **] 325. ECHO in ED showed
mod MR so patient admitted to CCU for cardiogenic shock.
.
Currently, he is thirsty. On full ROS, he denies any dizziness,
HA, LH, nausea, CP, SOB. he reports increasing abdominal girth
and leg swelling over last several days. Denies any fevers,
chills, cough, sputum.
Past Medical History:
1. CARDIAC RISK FACTORS: hx HTN
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: no
3. OTHER PAST MEDICAL HISTORY:
Obesity
OSA
Depression
OCD
Social History:
-Tobacco history: never tobb
-ETOH: none since [**40**] yrs ago. Reports 30 beers/wk x10 yrs in
20s.
-Illicit drugs: prior cocaine, marijuana, halucinogenics but
none in 30 yrs. Never IVDU.
-Lives with wife; has two daughters. Not working.
-No recent travel
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission -
General Appearance: Overweight / Obese, Anxious
Head, Ears, Nose, Throat: Normocephalic, Oropharynx clear
without erythema, MMM
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic), tachycardic, regular, no murmur
appreciated. distant S1 and S2 without split. no heaves
appreciated.
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Diminished), (Left
DP pulse: Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
No(t) Clear : , Crackles : bilat bases. )
Abdominal: Distended, protuberant, dullness, no shifting
dullness. No organomeg appreciated. No rebound or guarding.
mild tenderness throughout.
Extremities: Right: 4+ pitting edema, Left: 4+ pitting edema,
cool extremities
Skin: No rashes
Neurologic: Attentive, Oriented x 3, Follows simple commands,
Responds to: vocal stimuli, Movement: Purposeful, Tone: Normal,
not increased
Pertinent Results:
==========
Labs
==========
On admission -
[**2124-7-8**] 05:25PM BLOOD WBC-15.8*# RBC-4.62 Hgb-14.3 Hct-41.5
MCV-90 MCH-31.0 MCHC-34.5 RDW-13.7 Plt Ct-268
[**2124-7-8**] 05:25PM BLOOD Neuts-75* Bands-1 Lymphs-14* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2124-7-8**] 05:25PM BLOOD PT-18.5* PTT-25.1 INR(PT)-1.7*
[**2124-7-8**] 05:25PM BLOOD Glucose-121* UreaN-86* Creat-2.4*#
Na-129* K-4.8 Cl-91* HCO3-21* AnGap-22
[**2124-7-8**] 05:25PM BLOOD ALT-[**2055**]* AST-736* CK(CPK)-187*
AlkPhos-178* TotBili-1.2
.
On discharge -
[**2124-7-24**] 06:45AM BLOOD WBC-10.9 RBC-4.22* Hgb-12.7* Hct-37.5*
MCV-89 MCH-30.0 MCHC-33.8 RDW-16.1* Plt Ct-320
[**2124-7-23**] 07:20AM BLOOD WBC-11.2* RBC-4.48* Hgb-13.0* Hct-40.1
MCV-90 MCH-28.9 MCHC-32.3 RDW-15.3 Plt Ct-270
[**2124-7-24**] 06:45AM BLOOD Glucose-85 UreaN-15 Creat-1.1 Na-142
K-3.6 Cl-106 HCO3-26 AnGap-14
[**2124-7-23**] 05:12PM BLOOD Glucose-97 UreaN-19 Creat-1.3* Na-141
K-5.2* Cl-105 HCO3-29 AnGap-12
[**2124-7-14**] 04:07AM BLOOD ALT-412* AST-86* AlkPhos-86 TotBili-1.0
[**2124-7-24**] 06:45AM BLOOD Digoxin-0.7*
==========
Radiology
==========
CT Abd/Pelvis [**2124-7-8**]
1. Findings suggestive of fluid overload, with small-to-moderate
bilateral
pleural effusions, with hilar fullness in the visualized lung
bases.
2. Nodular contour of the liver, which can be seen with
cirrhosis, with a
small amount of ascites.
3. Rounded hypodensities in the right lobe of the liver are
incompletely
characterized without intravenous contrast.
4. Cystic structure inferior to the third portion of the
duodenum. This is
of uncertain etiology with differential diagnostic
considerations including a fluid-filled normal bowel loop,
duplication cyst, and duodenal diverticulum.
.
===========
Cardiology
===========
C. Cath [**2124-7-11**]
1. Selective coronary angiography of this right dominant system
revealed
no angiographically apparent CAD.
2. An 8Fr 30cc intra-aortic balloon pump was inserted via a
right common
femoral artery with good diastolic augmentation and systolic
unloading.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Cardiogenic shock.
3. Insertion of IABP.
.
TTE [**2124-7-11**]
Mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. LV wall thicknesses normal. LV mildly dilated.
There is severe global left ventricular hypokinesis (LVEF =
20-25 %). Restrictive left ventricular filling pattern
suggestive of severe diastolic dysfunction. RV is dilated with
moderate global free wall hypokinesis. Normal aortic valve. 3 +
MR. [**First Name (Titles) **] [**Last Name (Titles) **] htn.
.
TTE [**2124-7-14**]
On IABP: There is severe global left ventricular hypokinesis
(LVEF = 20 %). RV with moderate global free wall hypokinesis.
Moderate (2+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. Off IABP: Overall LV
systolic function remains severely depressed with some subtle
increased systolic thickening of the anterior and lateral LV
segments (LVEF 25-30%). The degree of mitral regurgitation
increased to moderate to severe (3+). Compared with the prior
study (images reviewed) of [**2124-7-11**], overall LV systolic
function appears slightly improved and the degree of MR less
Brief Hospital Course:
# Cardiogenic shock: Patient admitted with cardiogenic shock.
Work up for causes was unremarkable, including Cath revealing
clean coronaries, HIV, Iron studies, RF, [**Doctor First Name **] and TSH. EF is
depressed globally without regional wall motion abnls and
improved on IABP. TTE showed mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. LV wall thicknesses
normal. LV mildly dilated. There is severe global left
ventricular hypokinesis (LVEF = 20-25 %). Restrictive left
ventricular filling pattern suggestive of severe diastolic
dysfunction. RV is dilated with moderate global free wall
hypokinesis. Normal aortic valve. Mild PA htn. TTE also showed
3+ MR, but it was unknown how much this complicated patient's
Cardiogenic shock picture. A repeat TTE on [**7-14**] showed minimal
improvement in EF on IABP and unchanged MR. In addition, patient
was admitted in A flutter and it was felt that this rhythm
disturbance on top of an already compromised EF caused the
patient to go into cardiogenic shock. Patient was initially
managed on Milrinone and Dopamine, but an IABP was placed during
patient's cardiac catheterization. Milrinone was eventually
weaned off and replaced by afterload reduction by ace
inhibitors, which were slowly titrated up and eventually, the
patient's IABP was able to be removed on [**2124-7-19**]. He was also
re-started on B-blocker therapy given his stable hemodynamics
after removal of the IABP. Given his massive total body volume
overload, the patient was agressively diuresed with a lasix drip
while in the CCU and managed to diurese several liters, however,
after less than 24 hours on the lasix drip the patient developed
a total body pruritic maculopapular rash concerning for a drug
rash. Given that lasix had been recently increased, it was
suspected that lasix was related to the rash and was
discontinued. The patient was switched to oral Ethacrynic acid
instead, as it contains no sulfa moiety in case this was
contributing to the patient's rash. The patient responded well
to oral Ethacrynic acid, and was able to be volume net negative
on 50mg daily.
.
# Coronaries: Cardiac biomarkers were flat when cycled. Cardiac
catheterization revealed clean coronaries. Patient was continued
on [**Date Range **] while in house.
.
# Cardiac Rhythm: On admission, the patient was in atrial
flutter. Per the patient, he had no prior history of AFib or
Flutter. During his hospitalization, he was transiently in
sinus rhythm after cardioversion in the OR on HD #2, but sinus
rhythm was not maintained throughout the hospitalization.
Patient was given a bolus of Amiodarone and eventually started
on Digoxin for rate control. In addition, after recovery from
cardiogenic shock, the patient was placed on a beta-blocker, but
despite this remained in paroxysmal atrial flutter throughout
this hospitalization. The patient was started on
anti-coagulation with coumadin and heparin during this
hospitalization given his paroxysmal AF, and PVD, as below.
.
# PVD: While in the CCU with an IABP the patient was noted to
have bilateral cool lower extremeties that appeared somewhat
cyanotic and mottled appearing. The patient's circulation to
his lower extremeties improved after removal of the IABP.
Vascular surgery was consulted and felt that the patient may
have been showering emboli given his significant PVD, and would
most likely benefit from being on anti-coagulation with coumadin
for at least the next few months.
.
# Respiratory failure: On HD#2, patient was intubated via nasal
airway in the setting of planned cardioversion. He
self-extubated on [**2124-7-13**] and did not require re-intubation with
no further episodes of respiratory distress this
hospitalization.
.
# Acute renal failure: Felt to be due to ATN in the setting of
shock. Cr gradually improved back to 1.1 at time of discharge
while on a stable diuretic regimen.
.
# ID: Patient spiked multiple fevers over the course of his
first week in the hospital. He was initially covered broadly
with vancomycin and zosyn given initial concern for sepsis.
Culture data remained negative and lines were removed without
growth of bacteria. Antibiotics were stopped on [**2124-7-16**] and
patient did not respike a temperature. In the setting of Tube
feeds, patient had some diarrhea but initial C diff toxins were
negative. On [**7-17**] the patient's stool was positive for C Diff and
he was started on a 14 day course of Metronidazole for
treatment.
.
# Rash: The patient developed a total body rash as described
above, felt to be a drug rash with lasix as the likely offending
[**Doctor Last Name 360**]. He recieved Benadryl, Sarna lotion, and topical
hydrocortisone cream with some improvement in his pruritis. The
rash stopped progressing after discontinuation of the lasix and
switching to ethacrynic acid as above.
.
# Depression: The patient's home dose of Seroquel and
Fluvoxamine were continued throughout his hospitalization.
.
# Transaminitis: Suspect most likely due to shock liver in the
setting of cardiogenic shock. The patient's transaminases
improved without intervention. A liver consult was initially
requested in case a heart transplant was necessary, and it was
deemed that the patient does not have cirrhosis advanced enough
to interfere with such a procedure should it become necessary.
Medications on Admission:
1. Provigil 200 daily
2. Seroquel 150 QHS
3. BiPap
4. Fluvoxamine 100mg [**Hospital1 **]
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Fluvoxamine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Ethacrynic Acid 25 mg Tablet Sig: Two (2) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*1*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*1*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
8. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash/ puritis.
Disp:*1 Tube* Refills:*0*
9. Carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*1*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritus.
Disp:*1 bottle* Refills:*0*
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Quetiapine 150 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO QHS (once a day (at
bedtime)).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: cardiogenic shock
Acute Systolic Congestive Heart Failure.
Discharge Condition:
Stable
Discharge Instructions:
You presented to the hospital with shortness of breath. You
were found to have profoud low blood pressure from your heart's
inability to squeeze. You were started on strong medications to
improve your heart's pump function. You transiently required a
balloon pump to help augment your heart's forward flow. Your
balloon pump was removed on [**2124-7-19**] and you are being discharged
on several new medications including: Ethacrynic acid,
Lisinopril and Carvedilol to help improve your heart's squeeze
potential. You are also being sent home on Amiodarone,
Digoxin, and Coumadin for your irregular heart beat.
Metronidazole, an antibiotic, is being prescribed for your
diarrhea, and you should take this for the next 8 days. Please
discuss with Dr. [**Last Name (STitle) 5717**] about setting up lung, liver and thyroid
testing now that you are on the amiodarone.
.
You were started on Coumadin, a powerful blood thinner to
prevent blood clots because of your atrial fibrillation. You
will need to check a coumadin level or INR frequently until the
level is between 2 and 3. You will see Dr. [**Last Name (STitle) 5717**] in 2 days and
can check your INR then at the [**Hospital3 **]. Please
call Dr. [**Last Name (STitle) 5717**] right away if you notice dark or bloody stools, a
nosebleed that won't stop, or vomiting blood.
.
Your home dose of Provigil was discontinued during this
hospitalization due to your critical illness. Please consult
with your primary care physician before restarting this
medication. You should continue taking all your other home
medications as before.
Please seek immediate medical attention if you experience chest
pain, shortness of breath, abdominal pain, nauasea,
palpitations, or any change in your baseline health status.
.
Please weigh yourself daily at home before breakfast. Call Dr.
[**First Name (STitle) 437**] is you have a weight gain or more than 3 pounds in 1 day
or 6 pounds in 3 days.
Please follow a low sodium diet.
Followup Instructions:
PCP/INR Check:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2124-7-26**] 11:10
Cardiology:
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**8-28**] at
9:00.
You will have an ECHO scheduled at ECHOCARDIOGRAM
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2124-8-28**] 8:00
Dr.[**Name (NI) 3536**] office may call you with an earlier appt.
Vascular Surgery:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2124-8-21**] 11:00 [**Hospital 6752**] Medical Building, [**Last Name (NamePattern1) 8028**].
Completed by:[**2124-7-24**]
ICD9 Codes: 5845, 2761, 2760, 2930, 4280, 311, 5715, 4240, 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2770
} | Medical Text: Admission Date: [**2182-12-25**] Discharge Date: [**2183-1-10**]
Date of Birth: [**2111-4-21**] Sex: M
Service: Cardiothoracic Surgery Service
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
gentleman with known coronary artery disease (status post a
myocardial infarction in [**2167**]) who presented to [**Hospital3 9683**] on [**12-20**] with progressive shortness of breath.
He had been treated for a presumed bronchitis approximately
three weeks prior to the admission and experienced minimal
relief of symptoms. He was admitted with a congestive heart
failure exacerbation and was aggressively diuresed. His peak
troponin value at the outside hospital was 0.4.
The patient denied any chest pain, nausea, diaphoresis, or
dizziness. The patient was transferred to [**Hospital1 346**] on [**12-26**] for a cardiac
catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Status post myocardial infarction in [**2167**].
3. Status post percutaneous transluminal coronary
angioplasty in [**2167**].
4. Anemia.
5. Gastrointestinal bleed in [**2179**].
6. Paroxysmal atrial fibrillation.
7. Gastroesophageal reflux disease.
8. Psoriasis.
9. Hypertension.
10. Dyslipidemia.
11. Aortic stenosis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: (Medications at home included)
1. Digoxin 0.25 mg by mouth once per day.
2. Lasix 20 mg by mouth once per day.
3. Accupril 20 mg by mouth once per day.
4. Aspirin 81 mg by mouth once per day.
5. Crestor 10 mg by mouth at hour of sleep.
6. Ferrous sulfate 325 mg by mouth twice per day.
7. Coumadin 7.5 mg by mouth once per day.
8. Cardizem 120 mg by mouth once per day.
MEDICATIONS ON TRANSFER:
1. Digoxin 0.25 mg by mouth once per day.
2. Lasix 40 mg by mouth once per day.
3. Accupril 20 mg by mouth once per day.
4. Aspirin 81 mg by mouth once per day.
5. Heparin drip.
SOCIAL HISTORY: The patient is retired. He is married with
four children. Alcohol use of approximately six drinks per
week. He quit tobacco use in [**2167**].
REVIEW OF SYSTEMS: The patient's review of systems was
positive for increased fatigue for the last three weeks. The
patient denies fevers, chills, palpitations, chest pain,
orthopnea, shortness of breath, cough, lower extremity edema,
or leg pain.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was
afebrile, his heart rate was 82 (in atrial fibrillation), and
his respiratory rate was approximately 20. On general
examination the patient was an obese white gentleman in no
apparent distress. Head, eyes, ears, nose, and throat
examination revealed the patient's oral mucosa was pink and
moist. The sclerae were anicteric. The pupils were equal,
round, and reactive to light. Cardiovascular examination
revealed an irregular rhythm with a [**3-8**] murmur heard best at
the apex. Respirations were even an unlabored. The lungs
were clear to auscultation bilaterally. Neck examination
revealed 2+ carotid pulses. No jugular venous distention.
No bruits were noted. Abdominal examination revealed the
abdomen was obese and softly distended. There were
hypoactive bowel sounds. Extremity examination revealed no
edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent
laboratories revealed the patient's white blood cell count
was 4.4, his hematocrit was 36.5, and his platelets were 140.
The patient's potassium was 4.2. The patient's blood urea
nitrogen was 20. The patient's creatinine was 1.3. His INR
was 1.7.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram was done
at that time which showed the patient was in atrial
fibrillation at 93 beats per minute with a left bundle-branch
block.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
and sent for cardiac catheterization.
The cardiac catheterization revealed 3-vessel coronary artery
disease and an ejection fraction of approximately 29%. The
3-vessel disease included the proximal left anterior
descending artery with an 80% stenosis, the left circumflex
with a 70% stenosis just after the first obtuse marginal, an
80% stenosis before LPL and the left posterior descending
artery, an 80% stenosis between the L-A and left posterior
descending artery, and a 90% stenosis of the right coronary
artery.
The patient was then referred to the Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for
coronary artery bypass grafting.
On [**2182-12-27**], the patient underwent coronary artery
bypass grafting times two with the left internal mammary
artery to the left anterior descending artery and a saphenous
vein graft to the obtuse marginal artery.
The surgery was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with Dr.
[**Last Name (STitle) 53911**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (physician [**Name Initial (PRE) **]) as
assistants. This surgery was performed under general
endotracheal anesthesia with a cardiopulmonary bypass time of
approximately 112 minutes and a cross-clamp time of 88
minutes.
The patient tolerated the procedure well and was transferred
to the Intensive Care Unit with two arterial and two
ventricular pacing wires. The patient was placed on
dobutamine, Levophed, and propofol drips. The patient was AV
paced at this time with a mean arterial pressure of 79.
By postoperative day one, the patient was weaned of his
dobutamine but remained on Levophed which was titrated to
correct a systolic blood pressure in the 80s. The patient
was also restarted on his digoxin and placed on
Neo-Synephrine.
The patient continued to do well from a respiratory
standpoint and was gently weaned off his ventilatory support
and eventually extubated on [**12-29**]. This was done
without any difficulty, and the patient was placed on nasal
cannula at 4 liters and was able to maintain an oxygen
saturation of greater than 98%.
From a cardiovascular standpoint, the patient remained in
atrial fibrillation with his rate controlled between 85 and
90 beats per minute. The Levophed was weaned off at this
time, and the Neo-Synephrine was slowly titrated down.
By postoperative day two, there was continuation of the
weaning of the patient's Neo-Synephrine. The patient's
insulin drip was quickly weaned to off, and the patient was
started on a heparin drip due to his chronic atrial
fibrillation. The patient remained in atrial fibrillation
with rare premature ventricular contractions noted. In
addition, his left bundle-branch block was still prominent.
By the end of the day, the patient was completely off the
Neo-Synephrine. The patient was started on Lasix and
achieved a moderate amount of diuresis. The patient was out
of bed with 2-person assistance and Physical Therapy to
follow.
On postoperative day three, the patient was transferred out
of the Cardiothoracic Surgery Recovery Unit to the Surgical
floor. The patient continued to be in atrial fibrillation
with heart rates approximately in the 90s. The patient
continued to be on a heparin drip at 600 units per hour. The
Foley catheter was removed on this day.
On postoperative day four, the patient experienced a moderate
amount of nausea and vomited once in the morning. The emesis
was maroon in color with coffee-grounds appearance. As a
result of this, the patient was seen by the Gastroenterology
Service. The patient had a abdominal x-ray done which
demonstrated several air/fluid filled loops of bowel
suggesting early postoperative ileus. The patient was placed
on a proton pump inhibitor and scheduled for an
esophagogastroduodenoscopy.
An esophagogastroduodenoscopy was done on [**2182-12-31**].
The esophagogastroduodenoscopy demonstrated erythema and
friability of the mucosa of the stomach with contact bleeding
noted in the fundus. These findings were compatible with
gastritis. The patient was advised to continue high doses of
the proton pump inhibitor.
By postoperative day five, the patient had further bouts of
nausea, vomiting, or abdominal pain. The patient still
complained of a fair amount of diarrhea and fecal
incontinence. The patient was tolerating his food without
any difficulty. The patient was advised to undergo a repeat
esophagogastroduodenoscopy following his discharge. The
patient continued to be in atrial fibrillation and was
started on beta blockade.
On [**2183-1-2**] the patient was evaluated by the
Cardiology Service in consultation for transient bradycardia.
The patient remained in atrial fibrillation with heart rates
dropping down to 40 to 50 beats per minute. The patient was
taken off his digoxin but continued with the beta blockade.
It was determined that there was no indication for a
pacemaker at this time, but the patient continued to be
followed by the Electrophysiology Service throughout his
hospital stay.
By postoperative day eight, the patient was started on his by
mouth diet following his bout of gastritis. The patient was
tolerating this diet well and not experiencing any further
bouts of nausea, vomiting, or diarrhea. The patient was
restarted on a heparin drip at 500 cc per hour for his atrial
fibrillation. The patient continued to be followed by
Physical Therapy and was making slow but steady progress.
The patient continued to be mildly unsteady with a wide gait.
There were some questionable mental status changes that were
noted throughout the day. This was manifested by short-term
memory loss and poor recollection of surgery. The patient
was noted to be disoriented to time, place, and person. As a
result, the patient was sent for a chest x-ray and an
electrocardiogram. Cardiac enzymes were sent which revealed
a transient increase of his creatine kinase value to 45 and
his troponin to 0.39. A Neurology consultation was called
regarding these recent findings. Recommendations from
Neurology indicated that the patient may be suffering from a
toxic/metabolic cause due to the waxing and [**Doctor Last Name 688**] of his
symptoms. As a result of this, the patient was extensively
examined for infectious or metabolic causes. A repeat
complete blood count, Chemistry-10, liver function tests
(including albumin and ammonia), and thyroid-stimulating
hormone were sent. Carotid Doppler studies were also done to
examine whether or not a poor blood flow was the culprit.
All of the studies proved to be negative.
Over the next couple of days the patient continued to have
transient short-term memory loss but regained orientation to
time, place, and self. Carotid Doppler studies indicated
patent carotids bilaterally.
The patient underwent a head computed tomography to rule out
a hemorrhage or infarction. This results of this study
indicated a few scattered low attenuations within the centrum
semiovale suggestive of chronic microvascular ischemic
changes. There were no hemorrhages noted. Due to this
questionable negative study, a magnetic resonance imaging was
completed as well. The magnetic resonance imaging indicated
no evidence of acute ischemia, but did reveal an increased
signal of the cortex of the left frontal lobe which was
consistent with a small prior infarction. There were also
hyperintensities noted within the periventricular white
matter indicating chronic microvascular infarction. In
addition, there were several lacunar infarctions noted in the
bibasilar vasoganglia.
The patient continued to be followed by Neurology. Per their
recommendations was placed on thiamine, folate, and a
multivitamin. Over the next few days, the patient continued
to do well with few instances of memory loss or
disorientation.
By postoperative day fourteen ([**2183-1-10**]), the patient
was doing well. The patient continued to be in atrial
fibrillation, but his blood pressure was holding steady with
peak systolic blood pressures of approximately 110 to 120.
The patient continued to have a pulse of approximately 80 to
90, but in atrial fibrillation. The patient had been placed
on Coumadin for several days and was at therapeutic levels.
It was felt that the patient was stable to be discharged to
home with further continuation and recovery of his cardiac
surgery along with outpatient Physical Therapy and
Occupational Therapy.
PHYSICAL EXAMINATION ON DISCHARGE: The patient's discharge
examination revealed his vital signs to be stable. His
temperature was 98.2 degrees Fahrenheit. His heart rate was
88 (in atrial fibrillation). Systolic blood pressures
between 80 and 112. His respiratory rate was 20. His oxygen
saturation was 95% on room air. In general, the patient was
alert and oriented times three. He was in no apparent
distress. Cardiovascular examination revealed a regular rate
and irregular rhythm. His sternal wound was clean, dry, and
intact only with Steri-Strips present. His lung examination
revealed that his breathing was even and nonlabored. His
lungs were clear to auscultation bilaterally. His abdomen
was soft, nontender, and nondistended. The patient's lower
extremities revealed 1+ edema with no erythema or rashes.
PERTINENT LABORATORY VALUES ON DISCHARGE: The patient's
white blood cell count was 8.9, his hematocrit was 27, and
his platelet count was 112. The patient's prothrombin time
was 15.2, his partial thromboplastin time was 54, and his INR
was 1.5. Chemistry-7 revealed the patient's sodium was 137,
potassium was 4.7, chloride was 103, bicarbonate was 23,
blood urea nitrogen was 20, and his creatinine was 1.1.
PERTINENT RADIOLOGY/IMAGING ON DISCHARGE: A chest x-ray
showed a very small left pleural effusion with no signs of
infiltrate.
DISCHARGE DISPOSITION: The patient was to be discharged to
home today (on [**2183-1-10**]). The patient was to be
discharged with home health care provided by [**Hospital3 **]
[**Hospital6 407**]. [**Hospital6 407**]
telephone number [**Telephone/Fax (1) 3633**].
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to please follow up with his
primary care physician/cardiologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**]) in one
to two weeks. Dr. [**Last Name (STitle) 4469**] was also contact[**Name (NI) **] prior to the
patient's discharge, and he stated that he would be able to
follow the patient's INR and Coumadin dosing.
2. The patient was instructed to please follow up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in four weeks.
CONDITION AT DISCHARGE: The patient's condition on discharge
was good; the patient was afebrile, ambulating independently,
pain well controlled on oral medications, and tolerating a
regular diet without difficulty.
MEDICATIONS ON DISCHARGE: (The patient was discharged on the
following medications).
1. Potassium chloride 20 mEq by mouth twice per day (times
seven days).
2. Colace 100 mg by mouth by mouth twice per day as needed
(for constipation).
3. Levofloxacin 500-mg tablets one tablet by mouth once per
day (times seven days).
4. Thiamine 100-mg tablets one tablet by mouth once per
day.
5. Folic acid 1-mg tablets one tablet by mouth once per
day.
6. Lasix 20-mg tablets one tablet by mouth twice per day
(times seven days).
7. Protonix 40-mg tablets one tablet by mouth q.12h.
8. Haloperidol 1-mg tablets one tablet by mouth twice per
day as needed (for agitation or anxiety times 10 days).
9. Coumadin 2.5-mg tablets two to three tablets by mouth at
hour of sleep (please dose to maintain an INR of 1.8 to 2.2).
The patient was instructed to have the first home dose on
[**1-10**] of 7.5 mg. The patient was further instructed to
take a dose on [**1-11**] and [**1-12**] of 5 mg of Coumadin
each. The patient was instructed to contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**]
on [**Last Name (LF) 766**], [**1-13**], as to the dosing for further Coumadin.
10. Atenolol 25-mg tablets one tablet by mouth every day.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting times two
(with left internal mammary artery to left anterior
descending artery and saphenous vein graft to obtuse
marginal).
2. Status post aortic valve replacement (#21 pericardial
valve).
3. Coronary artery disease.
4. Status post myocardial infarction in [**2167**].
5. Status post percutaneous transluminal coronary
angioplasty.
6. Status post gastrointestinal bleed in [**2179**].
7. Chronic atrial fibrillation.
8. Gastroesophageal reflux disease.
9. Psoriasis.
10. Hypertension.
11. Dyslipidemia.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 846**]
MEDQUIST36
D: [**2183-1-10**] 12:58
T: [**2183-1-10**] 14:24
JOB#: [**Job Number 53912**]
cc:[**Last Name (NamePattern1) 53913**]
ICD9 Codes: 4111, 4241, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2771
} | Medical Text: Admission Date: [**2183-1-7**] Discharge Date: [**2183-1-10**]
Date of Birth: [**2105-3-17**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
lightheadiness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77 yo M with CHF, afib and HTN presented to the ED from
[**Hospital **] clinic for hypotension. He was found on INR check
today to have a blood pressure about 40s on palp. In the ED,
found to have a blood pressure in the 80s. Inital vitals were
97.2 56 86/63 16 100% 4L. Received 250cc of fluid with increase
to 110s. Hypotensive again to the 80s, received 500cc with
return to 110s.
He reports feeling fatigued and lightheaded over the last couple
days. He reports drinking a glass or two of wine daily over the
weekend. His son reports that he sounded drunk on Sunday. He
denies any sick symptoms or contacts.
On arrival to the ICU, patient feels well and has no complaints.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
congestive heart failure
CAD
atrial fibrillation
stroke in [**2162**]
hypertension
hyperlipidemia
dysphagia
Social History:
He was born in [**Country 3587**] and then lived in [**Country 48229**].
Living in [**Hospital3 400**] in [**Location (un) 686**].
- Tobacco: None
- Alcohol: [**11-18**] glass wine/day
- Illicits: None
Family History:
Non contributory.
Physical Exam:
Admission Physical Exam:
VS: 97.3 83 90/70 97% 16
General: Alert, oriented, no acute distress
HEENT: MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irreg irreg, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2183-1-7**] 11:50AM BLOOD WBC-7.7 RBC-4.83 Hgb-14.8 Hct-43.5
MCV-90# MCH-30.6 MCHC-33.9 RDW-12.9 Plt Ct-302
[**2183-1-7**] 11:50AM BLOOD Neuts-71.2* Lymphs-18.9 Monos-8.5 Eos-0.9
Baso-0.5
[**2183-1-7**] 11:50AM BLOOD PT-31.9* PTT-36.8* INR(PT)-3.1*
[**2183-1-7**] 11:50AM BLOOD Glucose-77 UreaN-59* Creat-2.6* Na-130*
K-4.0 Cl-88* HCO3-31 AnGap-15
[**2183-1-7**] 11:50AM BLOOD cTropnT-< 0.01
[**2183-1-7**] 11:50AM BLOOD proBNP-949*
[**2183-1-7**] 11:50AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.3
[**2183-1-7**] 11:57AM BLOOD Lactate-1.4
[**2183-1-7**] 01:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2183-1-7**] 01:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-NEG
[**2183-1-7**] 01:30PM URINE Hours-RANDOM Creat-52 Na-40 K-17 Cl-32
[**2183-1-7**] 01:30PM URINE Osmolal-248
Micro:
Blood cultures pending x2
CHEST (PORTABLE AP): IMPRESSION: No acute cardiopulmonary
process. Stable cardiomegaly.
.
[**1-7**] EKG:
Atrial fibrillation with controlled ventricular response rate.
Intraventricular conduction delay of left bundle-branch block
morphology.
Probable prior inferior myocardial infarction. T wave inversions
in the
lateral and high lateral leads consistent with possible
ischemia. Clinical
correlation is suggested. Compared to the previous tracing of
[**2183-1-7**] the
findings are similar.
.
EKG [**1-7**]:
Atrial fibrillation with slow ventricular response. Left axis
deviation.
Intraventricular conduction delay of left bundle-branch block
type. Since the previous tracing of [**2176-6-6**] the rate is slower.
QRS voltage is more prominent in the limb leads. ST-T wave
abnormalities may be more prominent. Clinical correlation is
suggested.
.
CT HEAD W/O CONTRAST Study Date of [**2183-1-7**] 1:41 PM
There is no evidence of acute hemorrhage, edema, mass, mass
effect,
or new infarction. There is slit-like encephalomalacia in the
region of the right basal ganglia suggesting prior hemorrhage
with ex vacuo dilitation of the rigth lateral ventricle.
Prominent periventricular white matter hypodensities are seen,
most commonly due to chronic small vessel ischemic disease. The
basal cisterns appear patent and there is preservation of
[**Doctor Last Name 352**]-white differentiation elsewhere.
No fracture is identified. The paranasal sinuses, mastoid air
cells and
middle ear cavities are clear. No facial or cranial soft tissue
abnormalities are present.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Slit-like encephalomalacia in the area of the right basal
ganglia is
suggestive of prior hemorrhage.
3. White matter hypodensities most commonly due to chronic small
vessel
ischemic disease.
.
ECHO [**1-8**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. There is severe global left ventricular hypokinesis
(LVEF = 20-25%). Overall left ventricular systolic function is
severely depressed (LVEF= 20-25%). No masses or thrombi are seen
in the left ventricle. Right ventricular chamber size is normal
with mild global free wall hypokinesis. The ascending aorta is
mildly dilated. 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. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Severe global left
ventricular hypokinesis with severely depressed systolic
function (EF 20-25%). Normal right ventricular size with mild
right ventricular hypokinesis. Mildly dilated ascending aorta.
Mild mitral regurgitation
.
[**2183-1-10**] 06:30AM BLOOD WBC-6.8 RBC-4.71 Hgb-14.7 Hct-42.5 MCV-90
MCH-31.2 MCHC-34.5 RDW-12.7 Plt Ct-304
[**2183-1-9**] 05:45AM BLOOD WBC-7.2 RBC-4.54* Hgb-14.3 Hct-41.1
MCV-91 MCH-31.5 MCHC-34.8 RDW-12.8 Plt Ct-318
[**2183-1-7**] 11:50AM BLOOD WBC-7.7 RBC-4.83 Hgb-14.8 Hct-43.5
MCV-90# MCH-30.6 MCHC-33.9 RDW-12.9 Plt Ct-302
[**2183-1-7**] 11:50AM BLOOD Neuts-71.2* Lymphs-18.9 Monos-8.5 Eos-0.9
Baso-0.5
[**2183-1-10**] 06:30AM BLOOD Plt Ct-304
[**2183-1-10**] 06:30AM BLOOD PT-23.1* PTT-31.8 INR(PT)-2.2*
[**2183-1-9**] 05:45AM BLOOD Plt Ct-318
[**2183-1-9**] 05:45AM BLOOD PT-26.6* PTT-35.6 INR(PT)-2.6*
[**2183-1-8**] 09:05AM BLOOD PT-30.5* INR(PT)-3.0*
[**2183-1-7**] 11:50AM BLOOD Plt Ct-302
[**2183-1-7**] 11:50AM BLOOD PT-31.9* PTT-36.8* INR(PT)-3.1*
[**2183-1-10**] 06:30AM BLOOD Glucose-82 UreaN-28* Creat-1.3* Na-134
K-4.3 Cl-98 HCO3-29 AnGap-11
[**2183-1-9**] 05:45AM BLOOD Glucose-90 UreaN-34* Creat-1.4* Na-136
K-4.6 Cl-99 HCO3-31 AnGap-11
[**2183-1-8**] 05:38AM BLOOD Glucose-90 UreaN-42* Creat-1.6* Na-134
K-4.1 Cl-99 HCO3-27 AnGap-12
[**2183-1-9**] 05:45AM BLOOD CK(CPK)-190
[**2183-1-9**] 05:45AM BLOOD CK-MB-3 cTropnT-<0.01
[**2183-1-7**] 11:50AM BLOOD cTropnT-< 0.01
[**2183-1-7**] 11:50AM BLOOD proBNP-949*
[**2183-1-7**] 11:57AM BLOOD Lactate-1.4
[**2183-1-10**] 06:30AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8
Brief Hospital Course:
A/P: 77-year-old male with a history of systolic CHF with EF of
20%, atrial fibrillation on Coumadin, COPD, CAD who was admitted
to the MICU [**1-7**] with hypotension thought to be due to
hypovolemia now resolved after iv hydration.
.
#Hypotension: likely hypovolemia due to dehydration from
diuretic use and drinking of ETOH at home. Pt did not have any
infectious symptoms such as fever, leukocytosis or other
localizing symptoms. Hypotension resolved with 2L IVF. EKG not
suggestive of ischemia and cardiac enzymes were negative. TSH
and cortisol not pursued as pt's symptoms resolved after IV
fluids. However, BP still ranged at times from high 90's-110's
and pt was asymptomatic and ambulating without dizziness or
difficulty. Orthostatics were negative after IV hydration. Pt's
lasix, spironolactone, HCTZ, and [**Last Name (un) **] were held during admission
as well as tamsulosin. He was advised to continue to hold these
medications upon discharge. Carvedilol was restarted. ECHO was
repeated to ensure that cardiac function had not worsened and
was found to be similiar to prior with EF 20-25%. Pt will be
discharged on half dose of his valsartan 80mg daily.
++could have been due to increased ETOH prior to admit. Pt did
not have any suggestion of ETOH withdrawal during admission and
it did not appear that drinking ETOH is the norm for the
patient, but that he had more drinks than normal weekend prior
to admission. However, he should be continually advised to
refrain from excess ETOH given his CHF. Pt did not display signs
of clinical CHF during admission.
.
#acute on chronic renal failure-Presented with Cr 2.6. Baseline
1.2-1.5. Thought to be due to hypovolemia in the setting of
diuretic use. Improved during admission to baseline of 1.3 with
IVF and holding diuretics. Will continue to hold lasix, HCTZ,
spironolactone upon DC. Resumed valsartan at 80mg (1/2home dose)
upon DC. Pt should have repeat labs at his PCP appointment on
[**2183-1-16**] to ensure stability of renal function.
.
#Systolic heart failure: EF 20%. Pt did not appear to have acute
heart failure during admission. Repeat ECHO was unchanged from
prior. Carvedilol was restarted. Pt was given an rx for
valsartan 80mg daily ([**11-18**] home dose) upon discharge. His lasix,
spironolactone, and HCTZ were not restarted during admission. He
was set up with VNA services upon discharge to help monitor for
signs of clinical heart failure in this setting of medication
adjustment. BP range high 90's-110s during admission off these
agents. Pt should follow up with PCP and cardiology
(appointments listed below) in order to continue further
titration of these medications prn. Pt should have repeat
chemistry panel at upcoming PCP [**Name Initial (PRE) 648**]. Daily weights.
.
#Afib: rate controlled. Continued Carvedilol. INR initially
slightly supratherapeutic, but then starting [**1-8**] his home
regimen of 4mg alternating with 2mg daily was started. Started
with 4mg daily on [**1-8**]. INR can be rechecked at PCP's
appointment on [**2183-1-16**]. INR 3.1, 2, 2.6, 2.2 on day of DC.
.
#HLD: continued pravastatin
.
#BPH: held tamsulosin for now. Continued finasteride
.
#Reactive airways, ?COPD- continued inhalers, no sign of acute
exacerbation.
.
#FEN: cardiac diet
.
#PPX:
--therapeutic INR
.
FULL CODE
Emergency contact: [**Name (NI) **] (son) [**Telephone/Fax (1) 48232**]
.
Transitional issues
-close monitoring of volume status with lasix, HCTZ, and
spironolactone being held. Restart prn
-monitoring of chemistries, INR on [**2183-1-16**] PCP appointment
[**Name9 (PRE) 48233**] further discussion about ETOH intake
-consider TSH, cortisol should low grade hypotension continue to
be an issue
Medications on Admission:
Albuterol 2 puffs q4 hours SOB
Carvedilol 3.125mg [**Hospital1 **]
Finasteride 5mg daily
Fluticasone 50mcg per nostril [**Hospital1 **] runny nose
Fluticaseone 110mcg 2 puffs [**Hospital1 **]
Furosemide 20mg daily
Combivent 2 puffs PRB dyspnea
Pravastatin 40mg daily
Sildenafil 25mg 1/2-1 tab PRN
Spironolactone-HCTZ 25-25mg daily
Tamsulosin 0.4mg qHS
Valsartan 320mg tab, [**11-18**] tab daily
Warfarin 4mg QOD, 2mg QOD
Acetaminophen 650mg TID
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for dyspnea.
2. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. fluticasone 110 mcg/actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. fluticasone 110 mcg/actuation Aerosol Sig: One (1)
Inhalation twice a day.
6. Combivent 18-103 mcg/actuation Aerosol Sig: [**11-18**] Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
7. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. warfarin 2 mg Tablet Sig: One (1) Tablet PO QOD ().
10. warfarin 4 mg Tablet Sig: One (1) Tablet PO every other day.
11. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
Laboure Center VNS
Discharge Diagnosis:
hypotension
acute renal failure
chronic systolic heart failure
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with low blood pressure, fatigue, and kidney
injury. Your symptoms were thought to be due to dehydration
along with taking your medications for your heart. Your symptoms
improved with IV fluids and stopping some of your heart
medications. You did not have any signs of infection. Some of
your heart medications will continue to be held upon discharge.
However, it will be very important that you follow up with your
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8499**] and your cardiologist to determine when you
may resume these medications.
.
Medication changes:
1.stop lasix for now
2.stop HCTZ for now
3.stop spironolactone for now
4.DECREASE VALSARTAN TO 80MG DAILY, stop your 160mg dose
5.stop tamsulosin for now
-please be sure to keep your PCP appointment below. You may need
to restart some of these medications.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital1 7975**] ST HLTH CTR-KCSS
When: THURSDAY [**2183-1-16**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD [**Telephone/Fax (1) 7980**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: THURSDAY [**2183-1-23**] at 3:20 PM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 7975**] ST HLTH CTR-KCSS
When: FRIDAY [**2183-2-28**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD [**Telephone/Fax (1) 7980**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
ICD9 Codes: 5849, 2761, 4280, 2724, 496, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2772
} | Medical Text: Admission Date: [**2148-5-7**] Discharge Date: [**2148-5-13**]
Date of Birth: [**2089-8-17**] Sex: F
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
female with longstanding insulin-dependent diabetes who had
been noted to have slowly progressive chronic renal failure
believed secondary to her diabetes.
The patient had been evaluated for a living-related kidney
transplant by the Transplant Center. The patient had not
progressed to requiring dialysis; although, her glomerular
filtration rate was 16 mL per minute as of [**2148-2-11**].
The patient has had no uremic symptoms and continued to make
normal urine volumes. The decision was made to proceed with
a living-unrelated kidney transplant with a donor to be the
patient's husband.
PAST MEDICAL HISTORY:
1. Diabetes diagnosed in [**2115**] with associated retinopathy
and nephropathy.
2. Aseptic meningitis; possibility secondary to amoxicillin
use.
3. Migraine headaches with malignant hypertension.
4. Status post breast lumpectomy approximately 10 years ago
with a benign pathology.
5. Tonsillectomy.
6. Skin graft at the right ankle secondary to a skiing
accident.
7. Gastroparesis.
8. Gastroesophageal reflux disease.
9. Gout.
10. Hypothyroidism.
11. Hypercholesterolemia.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg by mouth once per day.
2. Effexor 75 mg by mouth once per day.
3. Renagel 400 mg by mouth three times per day.
4. Levoxyl 50 mcg by mouth once per day.
5. Lipitor 40 mg by mouth once per day.
6. Protonix 40 mg by mouth once per day.
7. Diovan 80 mg by mouth twice per day.
8. Diltiazem 120 mg by mouth once per day.
9. Erythropoietin 3000 units every week.
10. Ativan 1 mg by mouth as needed (for migraines).
11. Ambien 5 mg by mouth as needed (for sleep).
12. Quinine 325 mg by mouth as needed.
13. Humalog sliding-scale.
14. Lantus insulin 8.5 units at hour of sleep.
ALLERGIES: REGLAN (which causes trembling). Also, a
potential reaction to AMOXICILLIN.
SOCIAL HISTORY: The patient is married and occasionally uses
alcohol. The patient had a distant history of tobacco use
and quit while in her 20s.
FAMILY HISTORY: The patient has two brothers and one sister.
[**Name (NI) **] father died at an early age due to alcoholism. Her
mother is healthy, but has donated a kidney to one of the
patient's sisters. One of the patient's brothers has
diabetes, and the patient's sister also has diabetes.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
[**Hospital1 69**] on [**2148-5-7**] and
was taken to the operating room where she underwent a
living-unrelated kidney transplant (with the donor being her
husband).
The procedure was performed without complaints, and the
patient was thereafter transferred to the Postanesthesia Care
Unit for continued monitoring. In the Postanesthesia Care
Unit, the patient's urine output was initially good; ranging
from 30 cc to 50 cc per hour.
However, in the morning on postoperative day one her urine
output was noted to decrease to about 10 cc per hour. The
patient's. The patient's blood pressure was also noted to
trend down to a systolic blood pressure of 100. The patient
was started on a Neo-Synephrine drip to try and keep her
systolic blood pressure greater than 110 and later changed to
greater than 120. The patient's urine output was noted to
increase with this as well as with intravenous boluses of
fluid. Later in the morning on postoperative day one, the
patient was also started on Lasix with improvement in her
urine output.
The patient was seen by the Transplant Renal team. The cause
for the patient's decreased urine output was not absolutely
clear. The patient had a transplant kidney ultrasound which
revealed some slow flow through the lower pole of the kidney
which was believed likely secondary to the patient's anatomy.
The patient's central venous pressure was only 4 at the time.
The Transplant Renal team said to give the patient some
increased intravenous fluids with a goal central venous
pressure of greater than 10.
The patient's serum creatinine was also noted to increase to
a high of 2.8 on postoperative day two; gradually trending
down to a creatinine of 2.1 on the day of discharge. This
was believed secondary to some acute tubular necrosis.
The patient was also seen by the [**Last Name (un) **] Diabetes Center team
in consultation, and her insulin medications were adjusted
per their recommendations. The patient's immunosuppressive
medications were dosed per her usual protocol.
By postoperative day four, the patient appeared adequately
fluid resuscitated with some signs of fluid overload. The
patient was started on Lasix.
By postoperative day five, the patient was less fluid
overloaded and had responded well to her Lasix with a urine
output of 5 liters on the day before and almost 1 liter on
the first shift that day.
By postoperative day six, the patient was deemed stable and
ready for discharge.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. End-stage renal disease.
2. Status post living-unrelated kidney transplant.
MEDICATIONS ON DISCHARGE:
1. Percocet one to two tablets by mouth q.4h. as needed.
2. Dulcolax 10 mg by mouth twice per day as needed.
3. Diabetic medications as recommended by the [**Last Name (un) **]
Diabetes Center.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 15473**] in the [**Hospital 1326**] Clinic within one to two weeks
following discharge.
2. The patient was also instructed to follow up with her
[**Last Name (un) **] endocrinologist within one to two weeks following
discharge.
3. The patient was also instructed to follow up with
transplant nephrologist within one to two weeks following
discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], M.D. [**MD Number(1) 15476**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2148-5-15**] 01:05
T: [**2148-5-16**] 10:54
JOB#: [**Job Number 34103**]
ICD9 Codes: 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2773
} | Medical Text: Admission Date: [**2182-1-3**] Discharge Date: [**2182-1-11**]
Date of Birth: [**2104-1-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
[**2182-1-4**] Coronary Artery bypass Graft x 2 (SVG to Ramus, SVG to
OM), Aortic Valve Repalcement w/ 21mm CR Magna Tissue Valve,
MAZE procedure
[**2182-1-3**] Cardiac Catheterization
History of Present Illness:
77 y/o male with known Aortic Stenosis and Coronary Artery
Disease who has been medically managed since [**2174**]. Referred for
cardiac cath to re-evaluate AS and CAD given increase in dyspnea
on exertion and fatigue.
Past Medical History:
Coronary Artery Disease, Aortic Stenosis, Paroxysmal Atrial
Fibrillation, Hypercholesterolemia, Rheumatic fever (as child),
Arthritis, Duodenal Ulcer, Benign Prostatic Hypertrophy s/p
prostate surgery [**2163**], Skin Cancer s/p excision from Nose [**2168**].
s/p Elbow surgery d/t bursa, s/p Tonsillectomy, s/p
Appendectomy, s/p Left Knee surgery
Social History:
Retired. Denies Tobacco or ETOH use.
Family History:
Non-contributory
Physical Exam:
VS: 90 20 132/75 124/77 5'[**84**]" 200#
General: WD/WN male in NAD, lying flat after cath
Skin: Unremarkable, -lesions
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD, carotid bruit vs. radiation of murmur
Chest: CTAB -w/r/r
Heart: RRR w/ 4/6 SEM with radiation to carotids
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, 2+ pulses throughout, spider
veins
Neruo: MAE, A&O x 3, non-focal
Pertinent Results:
[**2182-1-5**] CT: 1. No evidence of retroperitoneal hematoma. 2. Below
the left inguinal ligament, tiny hyperdense foci adjacent to the
adductor compartment may represent small residual hematoma, and
are likely related to catheterization in this region. 3.
Moderately large bilateral pleural effusions with compressive
atelectasis. 4. Minimal pneumomediastinum and anterior chest
wall subcutaneous emphysema consistent with recent surgery.
[**2182-1-3**] Cath: 1. Selective coronary angiography revealed a right
dominant system with patent LMCA. The LAD, LCA and the RCA had
mild plaquing. The Ramus had a 90% ostial lesion. There was a
torally occluded small diagonal branch that filled via
collaterals from the RCA. 2. Left ventriculography was deferred.
3. Hemodynamic assessment showed normal right and mildy elevated
left sided filling pressures and preserved cardiac output. There
was a 50 mm Hg transortic gradient consistent with severe aortic
stenosis.
PCI of the ramus intermedius.
[**2182-1-3**] CNIS: There is less than 40% right ICA stenosis and less
than 40%left ICA stenosis with antegrade flow in both vertebral
arteries
[**2182-1-3**] Echo: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF 70-80%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets are
severely thickened/deformed. There is moderate aortic valve
stenosis Mild to moderate ([**12-11**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. There is severe mitral annular
calcification. There is mild mitral stenosis secondary to the
annular calcification. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is no pericardial
effusion.
[**2182-1-3**] CXR: The cardiac silhouette, mediastinal and hilar
contours are normal. The pulmonary vasculature is normal and
there is no pneumothorax. The lungs are clear without
consolidations or effusions. The surrounding soft tissue and
osseous structures demonstrate mild degenerative changes in
thoracic spine.
[**2182-1-11**] 06:55AM BLOOD WBC-12.6* RBC-4.10* Hgb-12.3* Hct-35.9*
MCV-88 MCH-29.9 MCHC-34.2 RDW-17.2* Plt Ct-158
[**2182-1-11**] 06:55AM BLOOD Plt Ct-158
[**2182-1-10**] 06:35AM BLOOD PT-13.3* INR(PT)-1.2*
[**2182-1-11**] 06:55AM BLOOD UreaN-25* Creat-1.2 K-4.1
[**2182-1-10**] 06:35AM BLOOD Glucose-97 UreaN-27* Creat-1.1 Na-140
K-4.1 Cl-99 HCO3-33* AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 32890**] [**Last Name (Titles) 1834**] a cardiac cath on [**1-3**] which revealed
severe Aortic Stenosis with one vessel disease. Cardiac surgery
was consulted and he [**Month/Year (2) 1834**] pre-operative testing. On [**1-4**] he
was brought to the operating room where he [**Month/Year (2) 1834**] an aortic
valve replacement, coronary artery bypass graft x 2 and MAZE
procedure. Please see operative report for surgical details.
Patient tolerated the procedure well and was transferred to the
CSRU for invasive monitoring in stable condition. Later on op
day he continued to have significant amount of post-operative
bleeding and was brought back to the operating room for
re-exploration. Please see separate dictated operative report.
He was then taken back to the CSRU. He remained intubated until
post-op day three secondary to poor oxygenation. He was started
on a Lasix gtt and his chest tubes were removed on post-op day
one/two. His platelet count started to trend down (lowest was
47) and he was tested for HIT. On post-op day three he appeared
to have an expanding abdomen with hypotension and a CT was
performed. CT revealed no retroperitoneal bleed. On post-op day
three he was weaned from sedation, awoke neurologically intact
and was extubated. HIT panel came back negative. By discharge
his platelets increased to 158. On post-op day five his
epicardial pacing wires were removed, Coumadin was restarted and
he was transferred to the telemetry floor. Since extubation he
did have some confusion and disorientation w/ hallucinations and
Haldol was started. Mr. [**Name14 (STitle) 32891**] was very decompensated and
physical therapy worked with him for strength and mobility
throughout hospital course. He was ready for discharge to rehab
on POD #7.
Medications on Admission:
Lasix 60mg qd, Digoxin 0.125mg T/TH/S/S, Digoxin 0.25mg M/W/F,
Aspirin 81mg qd, Celebrex, NTG gtt, Vit C, Vit E, MVI, Coumadin
(last dose 1/21)
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO qd ().
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400 mg daily x 1 week ([**1-16**]), then 200 mg ongoing .
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day.
10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare, [**Location (un) 3320**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery bypass Graft x 2
Aortic Stenosis s/p Aortic Valve Repalcement
Paroxysmal Atrial Fibrillation s/p MAZE procedure
PMH: Hypercholesterolemia, Rheumatic fever (as child),
Arthritis, Duodenal Ulcer, Benign Prostatic Hypertrophy s/p
prostate surgery [**2163**], Skin Cancer s/p excision from Nose [**2168**].
s/p Elbow surgery d/t bursa, s/p Tonsillectomy, s/p
Appendectomy, s/p Left Knee surgery
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) 5310**] in [**1-12**] weeks
Dr. [**Last Name (STitle) 26909**] in [**12-11**] weeks
Completed by:[**2182-1-11**]
ICD9 Codes: 5185, 2875, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2774
} | Medical Text: Admission Date: [**2104-8-4**] Discharge Date: [**2104-8-9**]
Date of Birth: [**2062-9-27**] Sex: F
Service: PLASTIC
Allergies:
Penicillins / Vaccine/Toxoid Preps,Combo. Classifier / Morphine
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
s/p Right Skin Sparing Mastectomy and Breast Reconstruction with
bilateral [**Last Name (un) 5884**] Flap
Major Surgical or Invasive Procedure:
Right Skin Sparing Mastectomy and Breast Reconstruction with
bilateral [**Last Name (un) 5884**] Flap
History of Present Illness:
41-year-old female with stage II invassive ductal Ca, HER-2/neu
positive s/p chemotherapy and radiation and left radical
mastectomy who presents for right skin sparing mastectomy,
breast reconstruction with bilateral [**Last Name (un) 5884**] flaps.
Past Medical History:
hypertension, cardiomyopathy secondary to chemotherapy,
hypothyroidism, guillain-[**Location (un) **] syndrome at age 14
Social History:
works as occupational therapist in the [**Location (un) 686**] Program for
frail elders
Family History:
n/a
Physical Exam:
VS: Afebrile, VSS
Constitutional: Well appearing, no acute distress
Neck: No masses
CV: RRR, no murmurs
Resp: CTAB, no wheezes or crackles
Breast: Flaps viable bilaterally with incisions c/d/i, JP drains
x4 with serosanguinous fluid
Abd: Soft, mildly TTP, nondistended, +BS, incisions c/d/i
Ext: Warm, distal pulses palpable bilaterally
Skin: Face, neck and chest is normal
Musculoskeletal: Normal to gait and station
Spine, Pelvis and Extremities: Stable
Psychiatric: Normal to judgment, insight, memory, mood and
affect
Pertinent Results:
[**2104-8-6**] 06:00AM BLOOD WBC-7.2 RBC-3.49* Hgb-10.3* Hct-30.9*
MCV-89 MCH-29.5 MCHC-33.3 RDW-13.8 Plt Ct-249
[**2104-8-5**] 04:20AM BLOOD WBC-7.6# RBC-4.02* Hgb-11.4* Hct-34.9*
MCV-87 MCH-28.3 MCHC-32.6 RDW-13.6 Plt Ct-235
[**2104-8-6**] 06:00AM BLOOD Plt Ct-249
[**2104-8-6**] 06:00AM BLOOD PT-12.2 PTT-27.0 INR(PT)-1.0
[**2104-8-5**] 04:20AM BLOOD Plt Ct-235
[**2104-8-6**] 06:00AM BLOOD Glucose-131* UreaN-7 Creat-0.6 Na-138
K-4.3 Cl-104 HCO3-27 AnGap-11
[**2104-8-6**] 06:00AM BLOOD Calcium-8.7 Phos-1.8*# Mg-1.8
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
[**2104-8-4**] and had Right Skin Sparing Mastectomy and Breast
Reconstruction with bilateral [**Last Name (un) 5884**] Flap. The patient tolerated
the procedure well.
Neuro: post-operatively the patient received Dilaudid IV/PCA
with adequate pain control. When she tolerated oral intake, the
patient was transitioned to an oral pain medication regimine.
Cardiovascular: the patient remained stable throughout her
admission. Her vital signs were routinely monitored.
Pulmonary: the patient remained stable throughout her admission.
Her vital signs were routinely monitored.
GI/GI: post-operatively the patient was given IV fluids until
tolerating PO intake. Her diet was advanced when appropriate.
She was also started on a bowel regimine to prevent constipation
in the setting of narcotic pain medications. Foley catheter was
removed on hospital day 2 and intake/output were closely
monitored.
ID: post-operatively the patient was started on IV Clindamycin
which was then switched to PO Clindamycin prior to discharge.
The patient was closely watched for any signs or symptoms of
infection.
Prophylaxis: The patient received subcutaneous heparin for DVT
prophylaxis and pneumoboots. She was also encourage to ambulate
as much as possible.
At the time of discharge on [**8-10**] the patient was doing well,
ambulating, tolerating a regular diet with good pain control on
oral regimine. Her vital signs were stable and her incisions
looked healthy.
Medications on Admission:
lisinopril 40 mg daily, toprol XL 100 mg daily, simvastatin 20
mg daily, levothyroxine 137 mcg daily, fluconazole, sertraline,
Zometa, calcium, vitamin D3, omeprazole, lorazepam prn, vicodin
prn, ibuprofen prn, and exemestane
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: 1.5 Tablets PO once a day for 30
days.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): please take while on narcotic pain medications.
Disp:*30 Capsule(s)* Refills:*0*
3. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**3-17**]
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Exemestane 25 mg Tablet Sig: One (1) Tablet PO QDay ().
6. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO three
times a day for 2 weeks: Please take until instructed to stop at
follow up.
Disp:*42 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
S/P Right Skin Sparing Mastectomy and Breast Reconstruction with
[**Last Name (un) 5884**] Flap Bilateral
Discharge Condition:
Good
Discharge Instructions:
Return to the ER if:
- you are vomiting and cannot keep in fluids or your medications
- if you have shaking chills, fever > 101.5, increased redness +
swelling or discharge from your incision, chest pain,
shortness of
breath or any other symptoms which concern you
- any serious change in your symptoms
- please resume all regular home medications and take new meds
as
ordered
- do not rive or operate heavy machinery while taking narcotic
pain
medications. You may have constipation when taking narcotic
pain
medications. You should continued drinking fluids and taking
stool
softeners and high fiber foods.
- avoid strenuous activity
- avoid pressure to your chest or abdomen
- you may shower but avoid soaking wounds prior to approval from
your
surgeon
You are also being discharged with drains in place. Drain care
is a clean procedure. wash your hands thoroughly with sopa and
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Followup Instructions:
Please confirm your appointment with Dr. [**First Name (STitle) **] at the time and
number listed below.
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], MD Phone:[**Telephone/Fax (1) 6331**]
Date/Time:[**2104-8-15**] 9:15
ICD9 Codes: 4254, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2775
} | Medical Text: Admission Date: [**2125-11-25**] Discharge Date: [**2125-12-4**]
Date of Birth: [**2050-11-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Keflex
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
75 year old with intermittent substernal chest pain, STE 7mm in
leads II,II, aVF, and 3mm STD V2-V3. Patient was evaluated at
[**Hospital1 **] with cardiac cath and subsequently had IABP placement
and transferred to [**Hospital1 18**] for cardiac cath.
Major Surgical or Invasive Procedure:
s/p cabg x4
s/p Cypher stent to SVG to ramus
History of Present Illness:
75 year old male with HTN, GERD, hypercholesteremia, TIA x 9yrs
ago no deficits. PTA Pt reported several day of intermittent
episodes of substernal chest pain, which worsened one day PTA.
Pt saw Dr. [**Last Name (STitle) 3549**] c/o [**6-12**] substernal chest pain. EKG revealed
STE in inferior leads, and STD in V2-V3. Pt treated with ASA,
Plavix, Loperssor, SL NTG, Heparin, and Integrelin. Cardiac
Cath showed RCA 50% prox, 80%PDA, LAD mid occlusion, RAMUS 90%
prox, LCx and Left main without significant disease. Patient
had IABP placed and was transferred to [**Hospital1 18**] for CABG.
Past Medical History:
Hypertension, GERD, TIA x 9 years ago no deficit,
Hyperlipidemia.
Social History:
Patient admits to Etoh use, history of smoking, has quit.
Denies IVD abuse.
Family History:
Denies early CAD, otherwise noncontributory
Physical Exam:
Vital signs stable
HEENT, EOMI
trachea midline, no jvd, or carotid bruits
breath sounds CTA, respirations unlabored
I/ VI holosystolic murmur (likely due to IABP), regular rate and
rhythm, S3 present
No peripheral edema, distal pulses 2+ x4 extremities
Neuro grossly intact
pleasant affect cooperative with exam
Pertinent Results:
[**2125-12-3**] 09:35AM BLOOD WBC-12.9* RBC-4.75# Hgb-14.9# Hct-43.7#
MCV-92 MCH-31.3 MCHC-34.0 RDW-14.5 Plt Ct-361#
[**2125-11-30**] 03:38AM BLOOD WBC-15.1* RBC-3.49* Hgb-11.0* Hct-30.9*
MCV-88 MCH-31.6 MCHC-35.8* RDW-14.6 Plt Ct-86*
[**2125-12-3**] 09:35AM BLOOD Plt Ct-361#
[**2125-12-3**] 09:35AM BLOOD Glucose-106* UreaN-18 Creat-1.2 Na-135
K-3.9 Cl-96 HCO3-26 AnGap-17
Brief Hospital Course:
75 year old male with substernal chest pain admitted for CABG
for CAD, triple vessel disease demonstrated on cardiac cath.
Patient underwent CABGx4(LIMA to Diag, SVG to distal LAD, SVG
to Ramus, SVG to PDA) on [**2125-11-27**] with Dr. [**Last Name (STitle) 2230**] and Dr.
[**Last Name (STitle) 8420**]. Patient had post operative hypotension with EKG
changes and was taken to the cath lab for evaluation. Grafts
patent, pressors weaned to diminish vasospasm gradually. IABP
continued for pressure support. On POD#2 IABP was weaned to
1:2, patient started on Vancomycin. WBC decreased to 21.3(down
from 23.2). Diuresis continued with lasix. On POD #3 SBP 159,
captopril increased to 12.5, lopressor begun, vancomycin 1g q12
continued, WBC decreased to 15. Patient eval 'd by PT,
considered not yet ready. On POD #4 pacing wires d/c'd.
Lipitor 10mg started, SBP 100, Urine culture showed Klebsiella,
E.Coli>100,000 sensitive to Bactrim, vancomycin d/c'd. On POD#6
patient to be evaluated and treated by PT. Bactrim for 7 days
for UTI. On POD #7 patient will be transferred to rehab
facility.
Medications on Admission:
asa, nexium, inderal, detrol
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 5 days.
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. 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*
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] [**Doctor Last Name **] hospital/TCU
Discharge Diagnosis:
s/p cabg x4
s/p CVA [**30**] years ago
HTN
GERD
s/p stent to SVG to ramus
acute MI
Discharge Condition:
good
Discharge Instructions:
shower over wounds and pat dry
no lotions, creams or powders to incisions
no lifting greater than 10# for 10 weeks
no driving for one month
Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**2-4**] weeks
follow up with [**Last Name (un) 11427**] in [**2-4**] weeks
follow up with Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2125-12-4**]
ICD9 Codes: 5990, 2875, 9971, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2776
} | Medical Text: Admission Date: [**2174-9-27**] Discharge Date: [**2174-10-5**]
Date of Birth: [**2096-3-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Univasc / Tetanus & Diphtheria Tox,Adult / Zoloft
/ Remeron
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Increased Dyspnea
Major Surgical or Invasive Procedure:
Pulmonary intubation (at OSH)
History of Present Illness:
78 y/o woman with CAD multiple PCIs (9 stents), CHF with
preserved ejection fraction, mild pulm hypertension, CVA, HTN,
NIDDM, PVD, and microscopic colitis who presented to [**Hospital1 **] [**Location (un) 620**]
on the night of [**9-26**] with fever, severe dyspnea, wheezing,
malaise, nausea, and one episode of watery diarrhea. On
presentation, she was hypoxemic to 70% on RA. She had crackles
and wheezing on lung exam. CXR showed possible LLL infiltrate,
pulmonary edema. The patient received aspirin, 40mg IV lasix,
and 750mg IV Cipro. Initially, the patient was given metoprolol
and the rest of her home meds including losartan, aspirin,
[**Date Range 4532**], and lipitor were continued. She was placed on BiPap.
Overnight, she developed more dyspnea and hypoxemia and O2 sat
dropped to 82% on NRB. ABG was 7.32/32/54 on BiPap. The patient
was intubated started on lasix gtt, nitro gtt, and heparin gtt.
On arrival to the floor, patient was intubated but awake, able
to answer questions and follow commands, and in no acute
distress. She denied any chest pain or abdominal pain. Vitals on
transfer were 99.4, 111/49, 64, 15, 100% on 100% FIO2.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Hyperlipidemia, Hypertension
2. CARDIAC HISTORY:
-Extensive CAD s/p multiple stents
-CABG: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
# H/o CVA [**2157**]
# Visceral stenosis (70% stenosis of the celiac, SMA, and [**Female First Name (un) 899**]
followed by [**Doctor Last Name **])
# PVD
# DM II - not on insulin
# Hypertension
# Migraine headaches
# Gastritis - no peptic ulcer disease history.
# Depression x30 years, initially reactive
Social History:
Widowed, daughter lives with her. Previously independent.
-Tobacco history: Denies
-ETOH: Will have one drink when she goes out to dinner.
Family History:
Mother had CAD and MI. Father died at a young age of MI.
Physical Exam:
On Admission:
VS: 99.4, 111/49, 64, 15, 100% on 100% FIO2.
GENERAL: 78yo female. Intubated but awake and in NAD. Able to
answer questions and follow commands.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP 8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 1/6 systolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: mechanical ventilations. Decreased lung sounds at left
lung base, crackles in LLL.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace edema. Palpable DP pulses. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
On Discharge:
GENERAL: 78yo female. Alert and oriented x3 and in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP 7cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 systolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: trace fine bibasilar crackles, normal work of breathing,
no accessory muscle use
ABDOMEN: Soft, NTND. No HSM or tenderness. + BS
EXTREMITIES: No edema. Palpable DP pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Labs on Admission:
[**2174-9-27**] 10:27AM BLOOD WBC-16.0*# RBC-2.46*# Hgb-7.5*#
Hct-23.1*# MCV-94 MCH-30.6 MCHC-32.5 RDW-14.2 Plt Ct-266#
[**2174-9-28**] 01:57AM BLOOD PT-15.0* PTT-54.3* INR(PT)-1.4*
[**2174-9-28**] 01:57AM BLOOD Ret Aut-1.2
[**2174-9-27**] 10:27AM BLOOD Glucose-191* UreaN-46* Creat-2.2* Na-141
K-4.5 Cl-111* HCO3-21* AnGap-14
[**2174-9-27**] 10:27AM BLOOD Calcium-8.2* Phos-4.7* Mg-1.9
[**2174-9-27**] 02:06PM BLOOD Type-ART pO2-69* pCO2-37 pH-7.33*
calTCO2-20* Base XS--5
[**2174-9-27**] 10:24PM BLOOD Type-ART PEEP-5 FiO2-40 pO2-94 pCO2-28*
pH-7.42 calTCO2-19* Base XS--4 Intubat-INTUBATED
[**2174-9-27**] 02:06PM BLOOD Lactate-1.0
Hemeatology Labs:
[**2174-9-28**] 01:57AM BLOOD Ret Aut-1.2
[**2174-9-28**] 05:40PM BLOOD calTIBC-140* Ferritn-842* TRF-108*
Cardiac Labs:
[**2174-9-27**] 10:27AM BLOOD CK-MB-17* cTropnT-1.17*
[**2174-9-27**] 02:28PM BLOOD CK-MB-19* MB Indx-6.9* cTropnT-1.25*
[**2174-9-27**] 02:28PM BLOOD CK(CPK)-277*
[**2174-9-27**] 07:52PM BLOOD CK-MB-19* MB Indx-7.1* cTropnT-1.32*
[**2174-9-27**] 07:52PM BLOOD CK(CPK)-267*
[**2174-9-28**] 01:57AM BLOOD CK-MB-12* MB Indx-6.0 cTropnT-1.34*
[**2174-9-28**] 01:57AM BLOOD CK(CPK)-200
[**2174-9-28**] 09:53AM BLOOD CK-MB-11* cTropnT-1.32*
[**2174-9-28**] 05:40PM BLOOD CK-MB-9 cTropnT-1.37*
[**2174-9-28**] 05:40PM BLOOD CK(CPK)-174
[**2174-9-30**] 06:11AM BLOOD CK-MB-6 cTropnT-1.59*
[**2174-9-30**] 06:11AM BLOOD CK(CPK)-77
[**2174-10-1**] 04:03AM BLOOD CK-MB-5 cTropnT-1.55*
[**2174-10-1**] 04:03AM BLOOD CK(CPK)-51
UA:
[**2174-9-27**] 11:35PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2174-9-27**] 11:35PM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-1
[**2174-9-27**] 11:35PM URINE CastHy-17*
[**2174-9-29**] 05:36PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2174-9-27**] 11:35PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.009
[**2174-9-29**] 05:36PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
Microbiology:
[**2174-9-27**] 11:35 pm URINE Source: Catheter.
**FINAL REPORT [**2174-9-29**]**
URINE CULTURE (Final [**2174-9-29**]): NO GROWTH.
[**2174-9-27**] 10:27 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2174-10-3**]**
Blood Culture, Routine (Final [**2174-10-3**]): NO GROWTH.
[**2174-9-27**] 2:27 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2174-10-3**]**
Blood Culture, Routine (Final [**2174-10-3**]): NO GROWTH.
[**2174-9-27**] 11:35 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2174-10-3**]**
Blood Culture, Routine (Final [**2174-10-3**]): NO GROWTH.
[**2174-9-28**] 1:00 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2174-9-30**]**
GRAM STAIN (Final [**2174-9-28**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2174-9-30**]): NO GROWTH.
Blood Culture [**2174-9-28**]: NGTD x 6 days
Images/Studies:
EKG [**2174-9-27**]: Sinus rhythm. Slight ST segment elevation with T
wave inversions in the anterior leads raises concern for
evolving myocardial infarction. Clinical correlation is
suggested. Inferior ST-T wave changes may also be due to
ischemia. Compared to tracing #1 there are now deep T waves seen
in leads V3-V6 raising concern for ischemia. Clinical
correlation is suggested.
EKG [**2174-9-28**]: Sinus rhythm. ST segment elevation with T wave
inversions seen in the anterior precordial leads raises concern
for ischemia. Inferior ST-T wave changes also raise some concern
for ischemia. Compared to tracing #2 no interim change.
EKG [**2174-10-1**]:Sinus rhythm. Left atrial abnormality. Compared to
the previous tracing of [**2174-9-28**] there is further evolution of
recent or ongoing anterolateral and apical myocardial
infarctions. Clinical correlation is suggested.
EKG [**2174-10-2**]: Sinus rhythm with increase in rate as compared to
the previous tracing of [**2174-10-1**]. There is further evolution of
acute anterolateral and apical myocardial infarctions. Followup
and clinical correlation are suggested. The Q-T interval remains
prolonged.
CXR [**2174-9-27**]: Endotracheal tube with distal tip in the right
mainstem bronchus. Unchanged bilateral pulmonary edema and left
lower lung atelectasis with possible pleural fluid.
CXR [**2174-9-28**]: The left mid and lower lung consolidation is
redemonstrated, concerning for large infectious process
associated with pleural effusion. Patient continues to be in
interstitial pulmonary edema, moderate in severity. The ET tube
tip is 4 cm above the carina. NG tube is in the stomach.
CXR [**2174-9-29**]: Small right and moderate left pleural effusions
are grossly unchanged allowing the difference in position of the
patient. Cardiomediastinal contours are unchanged, partially
obscured by the pleural and parenchymal abnormalities. Moderate
pulmonary edema is stable. Left mid and left lower lobe
consolidations are unchanged.
Labs on Discharge:
[**2174-10-5**] 06:00AM BLOOD WBC-11.3* RBC-2.40* Hgb-7.3* Hct-22.6*
MCV-94 MCH-30.6 MCHC-32.5 RDW-14.2 Plt Ct-424
[**2174-10-5**] 06:00AM BLOOD Glucose-201* UreaN-58* Creat-1.9* Na-142
K-4.0 Cl-111* HCO3-18* AnGap-17
[**2174-10-5**] 06:00AM BLOOD Mg-2.2
Brief Hospital Course:
78 y/o woman with CAD s/p multiple PCIs (9 stents), CHF with
preserved ejection fraction, mild pulmonary hypertension, CVA,
HTN, NIDDM, PVD, and microscopic colitis who presented to [**Hospital1 18**]
[**Location (un) 620**] with dyspnea and hypoxemia c/b acute respiratory failure
requiring intubation and tranferred to [**Hospital1 18**].
# NSTEMI/CAD: Patient with significant prior history of 3 vessel
CAD s/p multiple PCIs and stents. Enzymes positive and trending
up at [**Hospital1 18**] [**Location (un) 620**], EKG upon arrival here with T-wave
inversions in V3-V6. Cardiac enzymes were trended and peaked and
plauteued on HOD 2. She was continued on a heparin gtt to
complete 48 hour treatment. Home ASA, [**Location (un) 4532**], statin, and
metoprolol were continued. On HOD 4 there was concern for
evolving changes on EKG. Cardiac enzymes at that time were
elevated to trop of 1.59, however with flat CK and CKMB. A cath
was considered, however it was determined not to be acute
evolution and not urgent. Will likely need cath as an
outpatient.
# Diastolic Heart Failure: Patient with history of diastolic CHF
with preserved ejection fraction. Initially not significantly
volume overloaded on exam, weight is similar from recent
cardiology visit. Likely flash pulmonary edema due to sustained
hypertension and tachycardia (patient with another recent
admission to [**Location (un) 620**] for flash pulmonary edema in setting of
gastritis). The patient was diuresed with IV lasix bolus prn.
She recieved 40 mg IV on HOD 1 with poor response. She recieved
80mg IV x 2 on HOD 2 with ok response. On HOD 4 she recieved
120mg IV lasix in the AM with poor UOP and then recieved 5 mg
metolazone followed by 120 mg IV lasix with good UOP response.
On HOD 6 patient appeared dry and required 500 cc of fluids. The
patient was initially managed with nitro gtt for afterload
reduction, but then was transitioned to home hydralazine,
amlodipine, losartan, and imdur. The medications were adjusted
and patient was discharged on the following regimen: hydralazine
50mg TID, isosorbide 120mg daily, and losartan 50mg daily for
afterload and 20mg lasix daily for diuresis.
# Pneumonia: Elevated WBC with LLL opacity on CXR on admission.
Patient recieved 750 of cipro at OSH and was initially started
on levofloxacin 500mg q48h upon arrival to [**Hospital1 18**]. The patient
then spiked a fever on HOD 1 and she was broadened to cefepime
and vanc to cover for HCAP given recent hospitalization. She was
treated for 8 days with day 1 of treatment 10/09/10/10, patient
completed antibiotics on day of discharge ([**10-5**]).
# Hypoxic respiratory failure: Likely due to a combination of
pulmonary edema and pneumonia. Patient was intubated on arrival.
Propofol and fentanyl were used for sedation. The patient was
successfully extubated on HOD 2.
# Gout Flair: The patient developed gout flare (right podagra)
on [**10-3**]. She was started on oxycodone 2.5 mg Q6H for pain.
Secondary to patient's renal function colchicine and NSAIDs were
avoided. She was therefore started on prednisone 30 mg x 1 day,
20 mg AM x 1 day, and then will complete slow taper over 7 days.
# Normocytic Anemia: Patient with Anemia dating back to [**2163**]. As
low as this admission previously in [**2171**]. Patient with Hct of 23
on admission. Patient with normal reticulocyte count and iron
studies consistent with anemia of chronic disease (low iron, low
TIBC, high ferritin). Patient was started on iron
supplementation and will need GI workup as an outpatient to rule
out GI loss as part of low iron. Patient's Hct was trended and
she remained stable and asymptomatic and did not require blood
transfusion. Hct on discharge of 22.6.
# CKD: The patient has a history of CKD with Cr ranging from 1.7
- 3.3 over the last 1.5 years. Baseline appears to be low 2's.
Cr on admission of 2.2. Medications were renally dosed and
nephrotoxins were avoided when possible. Cr was trended and 1.9
on discharge.
# Type II diabetes: The patient's home metformin was held and
the patient was maintained on humalog ISS.
# Hypertension: The patient's home medications were initially
held and she was on nitro gtt on arrival. She was weaned off
nitro gtt and home medications were restarted as tolerated.
Eventually she was on home amlodipine, losartan, hydralazine,
metoprolol, and Imdur.
# Hyperlipidemia: Home atorvastatin was continued.
# Depression: Home mirtazapine was continued. Patient on
desvenlafaxine at home, not on formulary at [**Hospital1 18**], gave
venlafaxine in the meantime to avoid SSRI withdrawl.
# Hypothyroidism: Home levothyroxine continued.
Transitional Issues:
- [**Month (only) 116**] need outpatient Cath.
- Needs GI work up as an outpatient.
- Patient insturcted to weigh self every morning, and call Dr
[**Last Name (STitle) 2903**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3
days.
-Patient to have chem-7 on Monday [**2174-10-10**] with results sent to
Dr. [**Last Name (STitle) 2903**]
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 150 mg PO BID
2. Losartan Potassium 50 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Mirtazapine 45 mg PO HS
5. HydrALAzine 50 mg PO TID
6. Furosemide 20 mg PO DAILY
7. Atorvastatin 80 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
9. Omeprazole 20 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Amlodipine 10 mg PO DAILY
12. traZODONE 75 mg PO HS:PRN insomnia
13. Levothyroxine Sodium 100 mcg PO DAILY
14. Zolpidem Tartrate 5 mg PO HS
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
17. Pristiq *NF* (desvenlafaxine) 50 mg Oral daily
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Mirtazapine 45 mg PO HS
8. traZODONE 100 mg PO HS:PRN insomnia
9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
10. Nitroglycerin SL 0.3 mg SL PRN chest pain
11. Omeprazole 20 mg PO DAILY
12. Escitalopram Oxalate 5 mg PO DAILY
13. Furosemide 20 mg PO DAILY
14. HydrALAzine 50 mg PO TID
15. Losartan Potassium 50 mg PO DAILY
16. PredniSONE 10 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg one tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
17. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily
Disp #*45 Tablet Refills:*2
18. Outpatient Lab Work
Please check chem-7 on Monday [**2174-10-10**] with results to Dr. [**Last Name (STitle) 2903**]
at Phone: [**Telephone/Fax (1) 2205**]
Fax: [**Telephone/Fax (1) 7922**]
ICD9: 428
19. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Non ST elevation myocardial precautions
Hospital Acquired Pneumonia
Acute on Chronic Diastolic congestive heart failure
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname 34407**],
You were transferred to [**Hospital1 18**] a fever and trouble breathing. You
were found to have a pneumonia and were treated with 8 days of
intravenous antibiotics. You also were in heart failure with too
much fluid on board and we gave you diuretics to remove the
extra fluid.
Changes to your home medications include:
-CHANGE metoprolol to once daily formulation (metoprolol
succinate XL 150mg daily)
-START prednisone for your gout flare. You will take 3 more days
of prednisone at home. Please call Dr. [**Last Name (STitle) 2903**] if the gout returns.
-START iron for your anemia
Weigh yourself every morning, call Dr [**Last Name (STitle) 2903**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days. Please take all
of your medicines as directed.
It was a pleasure taking care of your during your
hospitalization and we wish you the best going forward.
Followup Instructions:
Please make an appt to see Dr. [**Last Name (STitle) **] in 1 month.
.
Department: [**State **]When: Thursday [**2174-10-13**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Completed by:[**2174-10-6**]
ICD9 Codes: 486, 2930, 4280, 5859, 4439, 4168, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2777
} | Medical Text: Admission Date: [**2196-8-5**] Discharge Date: [**2196-8-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Upper endoscopy with one clip placed on bleeding blood vessel at
the base of an ulcer in the stomach.
History of Present Illness:
This is a [**Age over 90 **] year old male, holocaust survivor with history of
CAD with 3VD s/p multiple PCIs with stenting to LAD and LMCA,
HTN, DM II, RAS, PVD who presents to [**Hospital1 18**] ED from home after
large episode of melena along with coffee ground emesis.
Patient reports that he was at home when he had a notable large
black stool which was loose. Patient then had an episode of
nausea and coffee ground emesis. EMS was called and found
patient with SBP in 70s. Patient also had coffee ground emesis
on floor surrounding him. Patient was brought to the [**Hospital1 18**] for
further evaluation.
In the ED: Temp 97.2, BP 70/p, HR 60, RR 16, 95% RA. GI was
consulted and patient received Protonix 80mg IV followed by gtt
8mg /hr. Given 1uPRBC. Insulin Reg 10u x 1, 2mg IV Morphine,
Calcium Gluconate and d50. Patient also complaining of chest
pain and received NTG SL x 3 with resolution of pain. ECG done
which showed anterolateral ST depressions
On arrival to the floor, patient continued to complain of [**6-30**]
chest pain which was his typical angina. Patient reports
baseline angina when walking up his stairs at home. He takes
NTG with relief. He denies any current N/V, palpitations,
diaphoresis or radiating pain.
Past Medical History:
CAD: [**5-26**]
Three vessel coronary artery disease.
Bilateral renal artery stenosis.
Diabetes
hypertension
hyperlipidemia
carotid artery disease- [**2193-3-12**] u/s: 50% [**Country **], 50-60% [**Doctor First Name 3098**],
External carotid artery stenosis > 50% on the left.
[**2182**] Left Carotid Endarterectomy
CRI
Social History:
Social History: Patient is married. His wife requires a lot of
care at home for which they have [**Name Initial (MD) **] visiting NP at least weekly
and visiting nurses as needed. His son is from out of town. The
patient is a survivor of the Holocaust. 7 p-y h/o tobb quit
[**2157**], has 2 sons, one is dentist. No EtOH.
Family History:
(?) [**Name (NI) 41900**] [**Name (NI) **] unclear
Physical Exam:
Tmax: 35.6 ??????C (96 ??????F)
Tcurrent: 35.6 ??????C (96 ??????F)
HR: 72 (72 - 81) bpm
BP: 109/30(51) {109/30(51) - 136/67(73)} mmHg
RR: 17 (13 - 24) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Height: 64 Inch
Gen: NAD, lying comfortably in bed
HEENT: anicteric sclerare, EOMI, PERRLA, +arcus senilus
Neck: no LAD
CVS: +S1/S2, +II/VI SEM RUSB, RRR
ABD: +BS, NT/ND, no guarding, no hepatomegaly
EXT: no peripheral edema, +2 distal pulses
Neuro: AAOx3, CN II-XII intact
Pertinent Results:
.
[**2196-8-5**] 11:53PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2196-8-6**] 05:12AM BLOOD CK-MB-10 MB Indx-9.9* cTropnT-0.08*
[**2196-8-6**] 05:12AM BLOOD cTropnT-0.12*
[**2196-8-6**] 11:12AM BLOOD CK-MB-12* MB Indx-10.4* cTropnT-0.16*
[**2196-8-6**] 09:22PM BLOOD CK-MB-NotDone cTropnT-0.22*
[**2196-8-7**] 08:50AM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2196-8-7**] 03:55PM BLOOD CK-MB-7 cTropnT-0.16*
.
[**2196-8-5**] 09:00PM BLOOD WBC-5.1 RBC-3.02* Hgb-9.9* Hct-29.9*
MCV-99* MCH-32.7* MCHC-33.1 RDW-14.7 Plt Ct-127*
[**2196-8-6**] 01:10AM BLOOD Hct-26.9*
[**2196-8-6**] 05:12AM BLOOD WBC-3.8* RBC-3.19* Hgb-10.5* Hct-30.0*
MCV-94 MCH-32.8* MCHC-34.9 RDW-16.9* Plt Ct-69*
[**2196-8-6**] 09:22PM BLOOD Hct-28.7* Plt Ct-49*
[**2196-8-7**] 08:50AM BLOOD WBC-3.2* RBC-3.61* Hgb-11.6* Hct-33.3*
MCV-92 MCH-32.3* MCHC-35.0 RDW-16.6* Plt Ct-63*
[**2196-8-8**] 02:21AM BLOOD WBC-2.2* RBC-3.44* Hgb-10.5* Hct-31.4*
MCV-91 MCH-30.4 MCHC-33.4 RDW-16.0* Plt Ct-45*
.
[**2196-8-8**] 02:21AM BLOOD Glucose-180* UreaN-18 Creat-1.1 Na-142
K-3.9 Cl-109* HCO3-29 AnGap-8
[**2196-8-8**] 02:21AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.0
Brief Hospital Course:
# GI Bleed: GI was consulted and did an EGD which showed 2
antral ulcers, one with a bleeding vessel. The vessel was
clipped with one clip and bleeding was stopped. Patient was kept
on [**Hospital1 **] PPI and D/C'd on this as well. There were no further
episodes of bleeding per rectum, hematemesis, or melena.
Patient's plavix and ASA were held initially. After consulting
with his cardiologist the plavix was d/c'd and patient was
re-started on ASA.
# Chest Pain: In setting of anemia and tachycardia, patient had
recurrent episodes of chest pain throughout his stay with
troponins peaking at 0.22 and increasing CKs without ever
reaching an abnl level. At some points the pain was likened to
his normal angina and at others the patient felt it was [**1-23**] his
Right shoulder pain from a previous fracture. Patient's ekg
showed lateral ST depressions in V2-V6 unchanged whether patient
had pain or not. This was responsive to morphine and nitro
paste. Patient was discharged with nitro and tylenol with codein
for the pain which is how he manages it at home.
# DMII ?????? Patient with history of DM. Kept on RISS while on
floor.
# PVD ?????? held ASA, Plavix as above. restarted ASA on d/c.
# HTN ?????? held antihypertenisives at first given hypotension
associated with UGIB. Patient was discharged on all of his home
meds as BP had come up after transfusions and EGD.
# Hyperkalemia ?????? Patient with hyperkalemia on arrival, possible
[**1-23**] ACEi and hypovolemia. Received Kayexalate x 1. Further K
levels were WNL.
# ARF ?????? Cr of 1.9 on admission, likely in setting of hypovolemia
from UGIB, improved on arrival to ICU after IVF boluses PRN and
transfusions.
#. Nutrition: Patient was initally kept NPO for the EGD. Diet
was then advanced to diabetic diet which patient tolerated well.
Medications on Admission:
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day.
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day.
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours) as needed.
10. Plavix 75mg PO daily
11. Isosorbide Mononitrate 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*
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Eighteen (18) units Subcutaneous twice a day.
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day.
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day.
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours) as needed.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. Isosorbide Mononitrate 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*
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Eighteen (18) units Subcutaneous twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1.Upper GI bleed
2.Angina
Secondary Diagnosis:
1. CAD
2. Diabetes Mellitus
3. Hypertension
Discharge Condition:
Bleeding resolved. Stable.
Discharge Instructions:
You were admitted for a bleed in your stomach from an ulcer. A
clip has been placed on the ulcer to stop the bleeding. We have
discontinued your plavix as it can contribute to bleeding. You
should no longer take this medication. We have started you on
omeprazole for your stomach ulcers. You should take this
medication twice per day as prescribed.
You have had an ultrasound of your heart to assess how well it
is functioning. Your PCP should review the record at your
upcoming appointment.
Please take the rest of your medications as prescribed.
You should follow-up with your primary care physician on the
date and time scheduled below.
Please call your PCP or come to the ED if you develop any chest
pain, shortness of breath, dizziness, light-headedness, bright
red blood in your stool or black tarry stools.
Followup Instructions:
Please call your doctor of come to the ED if you have
light-headedness, dizziness, chest pain, shortness of breath,
abdominal pain, bright red blood per rectum, dark or tarry
stools, or blood in your vomitus.
Completed by:[**2196-8-8**]
ICD9 Codes: 5849, 2859, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2778
} | Medical Text: Admission Date: [**2177-9-14**] Discharge Date: [**2177-9-24**]
Date of Birth: [**2177-9-14**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 74089**] is the second
born of twins, born at 31 and 1/7 weeks gestation to a 36
year-old, G4, P2 now 3 woman. These were diamniotic,
dichorionic twins. The mother's OB history is notable for a
full term delivery in [**2166**], infertility and 3 spontaneous
abortions occurring at 7, 9 and 5 weeks. The mother's
history is also notable for an ovarian cyst and anxiety
treated with Zoloft.
PRENATAL SCREENS: Blood type 0 positive, antibody negative,
Rubella immune, RPR nonreactive, hepatitis surface antigen
negative.
This pregnancy was complicated by hypertension and growth
discordancy with this twin being the growth restricted twin.
The growth restriction was noted 2 weeks prior to delivery.
The mother was treated with a complete course of
betamethasone at that time. Full fetal surveys were normal
due to the lower gestational age. The mother was transferred
from [**Name (NI) **] Hospital. She underwent a Cesarean section under
spinal anesthesia for worsening pre-eclampsia. There was no
preterm labor. Artificial rupture of membranes occurred at
delivery with clear fluid. There was no intrapartum fever or
other clinical evidence of chorioamnionitis. There was no
intrapartum antibiotic therapy. This infant emerged vigorous
at delivery. She was bulb suctioned, dried and received blow-
by oxygen. Apgars were 9 at 1 minute and 9 at 5 minutes. She
was admitted to the NICU for treatment of prematurity.
Anthropometric measurements upon admission to the NICU:
Weight was 1.150 kg, 10th percentile. Length 35 cm, less
than 10th percentile. Head circumference 26 cm, less than
10th percentile. Physical exam upon discharge: Weight 1.18
kg, length 38 cm, head circumference 26 cm. General:
Nondysmorphic, active, preterm female in room air. Skin warm
and dry. Color pink. Well perfused. HEENT: Anterior
fontanel open and flat. Sutures opposed. Neck and mouth
normal. Palate intact. Chest: Breath sounds clear, equal,
well aerated. Easy respirations. Cardiovascular: Regular
rate and rhythm, no murmur. Normal S1 and S2. Femoral pulses
+2. Abdomen soft, nontender, nondistended, no masses. Cord
remnant healing. Genitourinary: Normal preterm female.
Extremities: Moving all equally. Hips stable. Neuro:
Active with appropriate tone and reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: This infant was placed on continous
positive airway pressure. Upon admission to the NICU,
she had no oxygen requirement. She transitioned to room
air on day of life #2 and has continued in room air
since that time. She was treated for apnea of
prematurity with caffeine. At the time of discharge, she
is breathing comfortably in room air with oxygen
saturations greater than 98%. She has rare episodes of
apnea and bradycardia.
2. Cardiovascular: This infant has maintained normal heart
rates and blood pressures. No murmurs have been noted.
At the time of discharge, baseline heart rate is 140 to
160 beats per minute with a recent blood pressure of
72/46 mmHg. Mean arterial pressure of 53 mmHg.
3. Fluids, electrolytes and nutrition: This infant was
initially n.p.o. and treated with IV fluids via an
umbilical venous catheter. Enteral feeds were started on
day of life 2 and gradually advanced to full volume. At
the time of discharge, she is taking 150 ml/kg per day
by gavage of preemie Enfamil 24 calorie per ounce
formula. Weight on the day of discharge is 1.18 kg.
Serum electrolytes were checked 4 times in the first
week of life and were all within normal limits.
4. Infectious disease: Due to her prematurity and her
unknown group beta strep status of her mother, this
infant was evaluated for sepsis upon admission to the
Neonatal Intensive Care Unit. An initial white blood
cell count was 8000 with 18% polymorphonuclear cells and
0% band neutrophils. A blood culture was obtained prior
to starting IV ampicillin and gentamycin. The white
blood cell count was repeated on day of life #2 and had
risen to 9,600 with a differential of 46%
polymorphonuclear cells. The blood culture was no growth
at 48 hours and the antibiotics were discontinued.
5. Hematologic: Hematocrit at birth was 45.7%, a platelet
count of 187,000. On day of life #2, the platelet count
had fallen to 125,000. A repeat platelet count on day
of life 4 was 147,000. This infant did not receive any
transfusions of blood products.
6. Gastrointestinal: This infant required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin was 7.6 mg/dl. She received
approximately 4 days of phototherapy. Her rebound
bilirubin off phototherapy for 24 hours was on [**2177-9-21**]
and was 5.6 mg/dl total.
7. Neurologic: A head ultrasound was performed on
[**2177-9-22**] with all results being within normal limits.
This infant has maintained a normal neurologic exam
during admission. There were no neurologic concerns at
the time of discharge.
8. Sensory:
Audiology: Hearing screening has not yet been performed and
is recommended prior to discharge.
Ophthalmology: This infant will require a screening eye exam
for retinopathy of prematurity. Eyes have not yet been
examined. She is due for her first eye exam the week of
[**2177-10-4**].
1. Psychosocial: [**Hospital1 69**]
social work has been involved with the family. The
contact social worker is [**Name (NI) 4457**] [**Name (NI) 36244**] and she can be
reached at [**Telephone/Fax (1) 70445**].
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to [**Hospital **] Hospital for
continuing level II care.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 803**] [**Last Name (NamePattern1) 74092**], MD, [**Last Name (un) **], [**Hospital1 **], [**Numeric Identifier **], telephone number [**Telephone/Fax (1) 74099**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: 150 ml/kg/day of preemie Enfamil 24 calories
per ounce formula by gavage.
2. Medications:
Caffeine citrate 7 mg pg once daily.
1. Iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age. All
infants fed predominantly breast milk should receive
Vitamin D supplementation at 200 i.u. (may be provided
as a multi-vitamin preparation) daily until 12 months
corrected age.
2. Car seat position screening is recommended prior to
discharge.
3. State newborn screens were sent on [**9-17**] and [**2177-9-24**].
There has been no notification of abnormal results to
date.
4. Immunizations: No immunizations administered.
5. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease or (4) hemodynamically significant
congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 31 and 1/7 weeks gestation.
2. Twin #2 of twin gestation.
3. Transitional respiratory distress.
4. Suspicion for sepsis ruled out.
5. Apnea of prematurity.
6. Unconjugated hyperbilirubinemia.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2177-9-24**] 03:18:10
T: [**2177-9-24**] 05:29:39
Job#: [**Job Number 74100**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2779
} | Medical Text: Admission Date: [**2199-8-30**] Discharge Date: [**2199-9-11**]
Date of Birth: [**2121-11-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
left hemiplegia
Major Surgical or Invasive Procedure:
MERCI procedure- (Mechanical Embolus Removal in Cerebral
Ischemia) Thoracentesis x2
Nephrostomy tube replacement
History of Present Illness:
77-year-old male with history gastric CA metastatic and atrial
fibrillation, who developed acute onset aphasia, eye movement
abnormalities and left-sided hemiplegia during an
ultrasound-guided thoracentesis on [**2199-8-30**] for malignant pleural
effusion. Patient had been off of coumadin for 10 days for the
thoracentesis. Code stroke was called and patient was
transferred to the ED. A CTA revealed a large thrombus in tip of
the basilar artery, not extending into PCA's. He was taken
emergently to angio, where embolectomy and intrarterial tPA
injection was performed. Ischemia time was 4 hours; EBL was
minimal, and he received 2U plts for plt count of 25. Patient
was transferred to the SICU for postop care.
Past Medical History:
Stage IV gastric malignancy
Atrial Fibrillation
Hypertension
Hyperlipidemia
BPH
Depression/Anxiety
Osteoarthritis
Obstructive Uropathy s/p right percutaneous nephrostomy
Social History:
His wife died in [**2193**] due to metastatic lung cancer. He
previously lived alone but recently moved in with his son &
daughter. [**Name (NI) **] is retired, previously working 40 years in the
airline industry as a maintenance supervisor. Has family
nearby who are involved in his care. Smoked 1ppd x 20 years
tobacco, quitting in the [**2158**]. Social alcohol. No recreational
drugs.
Family History:
Father died of pneumonia at 64 years old; unknown other medical
issues. Mother died of pneumonia at 53 and had asthma.
Physical Exam:
VS: T 96.8, BP: 116/63, P:81, RR: 18, 98% on 1L
GEN: Elderly male in NAD, NC in place
CV: normal rate, ireg rhythm, normal s1, s2, no mr/g
PULM: decreased breath sounds and dull to percussion over RLL,
LLL, clear in other lung fields
EXT: 2+ edema to mid-tibia, DP, PT pulses 1+
Pertinent Results:
Hematology
[**2199-9-11**] 06:00AM BLOOD WBC-5.7 RBC-2.86* Hgb-8.9* Hct-28.0*
MCV-98 MCH-31.2 MCHC-31.8 RDW-17.1* Plt Ct-257
[**2199-9-10**] 12:43AM BLOOD WBC-6.1 RBC-2.98* Hgb-9.4* Hct-29.3*
MCV-98 MCH-31.4 MCHC-31.9 RDW-16.9* Plt Ct-238
[**2199-9-9**] 05:00AM BLOOD WBC-4.6 RBC-2.92* Hgb-9.2* Hct-28.4*
MCV-97 MCH-31.5 MCHC-32.3 RDW-16.8* Plt Ct-210
[**2199-8-31**] 03:05AM BLOOD WBC-5.8 RBC-2.94* Hgb-9.0* Hct-27.2*
MCV-93 MCH-30.6 MCHC-33.1 RDW-14.9 Plt Ct-129*
[**2199-8-30**] 10:05PM BLOOD WBC-7.0 RBC-2.89* Hgb-9.3* Hct-25.9*#
MCV-90 MCH-32.1*# MCHC-35.9*# RDW-14.8 Plt Ct-121*#
[**2199-8-30**] 03:30PM BLOOD WBC-9.3 RBC-3.72* Hgb-10.7* Hct-34.8*
MCV-94 MCH-28.8 MCHC-30.8* RDW-14.8 Plt Ct-34*#
[**2199-9-10**] 12:43AM BLOOD Neuts-70 Bands-0 Lymphs-10* Monos-19*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2199-9-9**] 05:00AM BLOOD Neuts-62 Bands-1 Lymphs-18 Monos-17*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2199-9-5**] 06:00AM BLOOD Neuts-52 Bands-2 Lymphs-29 Monos-13*
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-2*
[**2199-8-30**] 10:05PM BLOOD Neuts-81.9* Lymphs-16.2* Monos-0.7*
Eos-1.1 Baso-0
[**2199-9-10**] 12:43AM BLOOD PT-13.8* PTT-35.0 INR(PT)-1.2*
[**2199-9-9**] 05:00AM BLOOD PT-13.9* PTT-33.5 INR(PT)-1.2*
[**2199-9-7**] 05:06AM BLOOD PT-13.7* PTT-34.1 INR(PT)-1.2*
[**2199-9-6**] 04:08AM BLOOD PT-13.9* PTT-53.6* INR(PT)-1.2*
[**2199-9-4**] 02:29AM BLOOD PT-18.0* PTT-142.8* INR(PT)-1.6*
[**2199-9-3**] 04:30PM BLOOD PT-25.2* PTT-150* INR(PT)-2.4*
[**2199-9-3**] 08:30AM BLOOD PT-28.1* PTT-63.3* INR(PT)-2.8*
[**2199-9-3**] 02:00AM BLOOD PT-22.8* PTT-56.0* INR(PT)-2.2*
[**2199-9-2**] 10:30PM BLOOD PT-21.4* PTT-45.7* INR(PT)-2.0*
[**2199-9-2**] 01:13PM BLOOD PT-23.1* PTT-53.7* INR(PT)-2.2*
[**2199-9-2**] 08:24AM BLOOD PT-22.0* PTT-57.2* INR(PT)-2.1*
[**2199-8-30**] 03:30PM BLOOD PT-15.5* PTT-24.6 INR(PT)-1.4*
[**2199-8-30**] 01:20PM BLOOD PT-15.2* INR(PT)-1.3*
[**2199-8-30**] 10:05PM BLOOD FDP-40-80*
[**2199-8-30**] 05:30PM BLOOD Fibrino-213
[**2199-9-4**] 02:29AM BLOOD Ret Aut-0.5*
Chemistries:
[**2199-9-12**]: Creatinine is 2.0
[**2199-9-11**] 06:00AM BLOOD Glucose-97 UreaN-35* Creat-2.0* Na-140
K-4.5 Cl-105 HCO3-29 AnGap-11
[**2199-9-10**] 12:43AM BLOOD Glucose-92 UreaN-29* Creat-1.7* Na-143
K-4.6 Cl-108 HCO3-28 AnGap-12
[**2199-9-9**] 05:00AM BLOOD Glucose-86 UreaN-27* Creat-1.3* Na-141
K-4.4 Cl-106 HCO3-28 AnGap-11
[**2199-9-3**] 03:22AM BLOOD Glucose-105* UreaN-35* Creat-1.2 Na-139
K-4.0 Cl-112* HCO3-20* AnGap-11
[**2199-9-2**] 02:12PM BLOOD Glucose-109* UreaN-41* Creat-1.4* Na-136
K-4.2 Cl-106 HCO3-21* AnGap-13
[**2199-8-31**] 06:09AM BLOOD Glucose-101* UreaN-49* Creat-1.4* Na-131*
K-4.6 Cl-99 HCO3-25 AnGap-12
[**2199-8-31**] 03:05AM BLOOD Glucose-102* UreaN-48* Creat-1.3* Na-133
K-4.6 Cl-100 HCO3-25 AnGap-13
[**2199-8-30**] 10:05PM BLOOD Glucose-117* UreaN-49* Creat-1.3* Na-130*
K-4.7 Cl-98 HCO3-26 AnGap-11
[**2199-8-30**] 03:30PM BLOOD Glucose-116* UreaN-53* Creat-1.5* Na-133
K-5.1 Cl-97 HCO3-21* AnGap-20
[**2199-9-11**] 06:00AM BLOOD ALT-46* AST-39 LD(LDH)-251* AlkPhos-1010*
TotBili-0.7
[**2199-9-10**] 12:43AM BLOOD ALT-60* AST-56* LD(LDH)-274*
AlkPhos-1171* TotBili-0.9
[**2199-9-1**] 03:03AM BLOOD ALT-50* AST-42* LD(LDH)-363* AlkPhos-457*
TotBili-0.8
[**2199-8-30**] 10:05PM BLOOD ALT-61* AST-45* LD(LDH)-339* CK(CPK)-81
AlkPhos-390* TotBili-0.8
[**2199-9-6**] 04:08AM BLOOD GGT-1139*
[**2199-9-10**] 12:43AM BLOOD Albumin-2.9* Calcium-8.4 Phos-3.2 Mg-1.9
[**2199-9-5**] 06:00AM BLOOD Albumin-2.7* Calcium-8.5 Phos-2.5* Mg-1.9
[**2199-9-4**] 02:29AM BLOOD Albumin-3.0* Calcium-8.7 Phos-1.9* Mg-2.1
Iron-31*
[**2199-8-30**] 10:05PM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.3 Mg-2.1
Cholest-153
Cardiac Enzymes:
[**2199-9-6**] 04:08AM BLOOD CK-MB-3 cTropnT-0.79*
[**2199-9-5**] 06:00AM BLOOD CK-MB-4 cTropnT-0.84*
[**2199-9-3**] 03:22AM BLOOD CK-MB-9 cTropnT-0.59*
[**2199-9-2**] 02:12PM BLOOD CK-MB-10 MB Indx-9.6* cTropnT-0.70*
[**2199-8-31**] 06:09AM BLOOD CK-MB-6 cTropnT-0.40*
[**2199-8-30**] 10:05PM BLOOD CK-MB-7 cTropnT-0.39*
[**2199-8-30**] 03:30PM BLOOD cTropnT-0.35*
Other:
[**2199-9-4**] 02:29AM BLOOD calTIBC-194 Ferritn-2235* TRF-149*
[**2199-8-30**] 10:05PM BLOOD %HbA1c-6.1* eAG-128*
[**2199-8-30**] 10:05PM BLOOD Triglyc-186* HDL-44 CHOL/HD-3.5
LDLcalc-72
[**2199-8-30**] 10:05PM BLOOD TSH-0.98
ABG:
[**2199-9-1**] 08:57AM BLOOD Type-ART pO2-167* pCO2-47* pH-7.32*
calTCO2-25 Base XS--2
[**2199-8-31**] 06:05PM BLOOD Type-ART pO2-160* pCO2-42 pH-7.37
calTCO2-25 Base XS-0
[**2199-8-31**] 05:17AM BLOOD Type-ART pO2-127* pCO2-45 pH-7.37
calTCO2-27 Base XS-0
[**2199-8-30**] 10:42PM BLOOD Type-ART pO2-202* pCO2-43 pH-7.40
calTCO2-28 Base XS-1
Chest X-ray [**2199-9-8**]:
IMPRESSION: PA and lateral chest compared to [**8-9**] through
[**9-3**]:
Moderate left pleural effusion is reaccumulating relative to
[**9-1**]. There is no pneumothorax. Right pleural effusion
including a fissural
component is chronic. No pulmonary edema. Heart size is top
normal. Right
infusion port catheter ends in the mid SVC. Presence of small
pulmonary
nodules would be obscured by the extensive overlying pleural
abnormalities.
[**2199-9-6**] Liver/ Gallbladder US:
1. Mild intrahepatic biliary dilatation, though with common bile
duct within normal limits in size. MRCP could be performed to
assess for relationship of hepatic metastases to intrahepatic
ducts if intervention is planned.
2. Multiple known hepatic metastasis is incompletely evaluated
on this study.
3. Layering sludge within the gallbladder.
4. Small amount of intra-abdominal ascites.
[**2199-9-6**]: Right Femoral US:
Pseudoaneurysm of the right common femoral artery. Size has
slightly increased from 1.7 to 1.9 mm in the sagittal plane
only.
[**2199-9-2**]: CT Abdomen/Pelvis:
1. No evidence of retroperitoneal hematoma.
2. Right nephrostomy tube in stable position. Similar extent of
mild left
hydronephrosis and hydroureter. Retained contrast within the
left kidney,
likely from recent CT two days prior, is compatible with
obstructive
nephropathy.
3. Similar extent of bilateral pleural effusions with associated
compressive atelectasis and right middle lobe collapse.
4. Metastatic gastric adenocarcinoma with unchanged omental and
hepatic
metastases.
5. Increased anasarca, pulmonary edema, and size of abdominal
ascites,
suggestive of volume overload.
[**2199-8-31**]: ECHO
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion. There
is an anterior space which most likely represents a prominent
fat pad.
IMPRESSION: No left ventricular thrombus seen. Normal global
biventricular systolic function. Mild pulmonary hypertension.
[**2199-8-30**] MRI HEAD:
MPRESSION: Multiple small acute infarcts are identified in both
parietooccipital lobes and cerebellar hemispheres without
definite acute
infarct within the brainstem. Small vessel disease and brain
atrophy.
[**2199-8-30**]: CT Head and Neck:
1. Thrombosis of the basilar artery. Possible perfusion defects
concerning
for infarct within the brainstem; however, CT perfusion is
suboptimal for the evaluation of the posterior circulation. MRI
could be performed for further evaluation.
2. Extensive focal atherosclerosis with marked narrowing of the
left
subclavian artery just proximal to the takeoff of the left
vertebral artery. No other areas of significant stenosis or
aneurysm formation are seen.
Brief Hospital Course:
#. Basilar stroke: Patient was transferred to [**Hospital1 18**] on [**2199-8-30**]
for acute stroke. He was treated with MERCI and intra-arterial
TPA: The patient's neuro status was closely monitored. He was
transitioned from a heparin gtt to lovenox given recent embolic
stroke and hypercoaguable state in setting of malignancy. The
patient was cleared for a regular diet after a speech and
swallow evaluation.
#. Right common femoral artery pseudoaneurysm: Patient s/p
mechanical and chemical thrombectomy via right common femoral
artery puncture, and was found to have small right common
femoral artery pseudoaneurysm. He had a repeat ultrasound on
[**2199-9-6**] which showed the pseudoaneurysm had slightly increased
in size from 1.7 to 1.9 mm in the sagittal plane only. Vascular
surgery was following, and did not feel there was a need for
intervention. The patient's HCT remained stable.
#. Hypoxia: Likely secondary to pleural effusions (malignant).
CXR on [**2199-9-3**] had shown stable reticular nodular pattern in
right lung likely representing lymphatic obstruction, a stable
right pleural effusion, and increased opacification in left lung
likely representing increased atelectasis and increased pleural
effusion. The patient's supplemental O2 was gradually weaned as
tolerated. Repeat CXR on [**2199-9-8**] showed increased pleural
effusion and patient had a repeat thoracentesis on [**2199-9-11**] prior
to discharge. A post-procedure chest x-ray was done and there
were no complications from the procedure.
#. [**Last Name (un) **]: Patient has h/o bilateral hydronephrosis, likely
secondary to obstructive uropathy. s/p right nephrostomy tube in
08/[**2198**]. Prior to this admission, the patient had been scheduled
for bilateraly stent placement on [**2199-9-12**]. His left stent showed
hematuria and had poor output in setting of creatinine increase
from 1.3->1.7, his left nephrostomy tube was placed. On
discharge, his creatinine was 2.0. This lab test should be
repeated.
#. Stage IV gastric CA: Patient recently diagnosed with gastric
cancer, and gastric biopsy returned positive for poorly
differentiated adenocarcinoma infiltrating through the deep
mucosal layer. Cytology from the peripancreatic lymph nodes was
also
positive for malignant cells consistent with adenocarcinoma.
Patient started first cycle of chemotherapy with epirubicin,
oxaliplatin and capecitabine on [**2199-8-22**]. Given recent
complications in course, chemo currently on hold. His cell
counts were monitored closely in setting of recent chemo.
#. Atrial Fibrillation: Patient rate-controlled with metoprolol.
Coumadin had been held initially for thoracentesis, and was not
restarted in setting of stroke and low platelet count. Patient
was previously on argatroban gtt, but placed on heparin gtt
after rise in platelets and exclusion of HIT. Patient will need
long-term anticoagulation in setting of recent embolic stroke
and hypercoagulable state. He was started on lovenox.
#. Hypertension: BP was well-controlled after transfer to
medical oncology service. The patient was continued on
metoprolol for both rate control and BP control.
Medications on Admission:
Coumadin 5 mg daily
Digoxin 0.125 mg daily
Lisinopril 20 mg daily
Simvastatin 40 mg daily
Vicodin 1 tab Q4-6H PRN
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation. Tablet(s)
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
6. 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.
7. 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.
8. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
10. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
11. Outpatient Lab Work
Please check CBC, Na, K, Cl, HCO3, BUN, Creatinine, Glucose on
[**2199-9-13**]. Please fax results to Dr. [**Last Name (STitle) **] (Fax #[**0-0-**]).
12. Zofran 4 mg Tablet Sig: 1-2 Tablets PO three times a day as
needed for nausea.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
Primary:
Cerebral Vascular Accident
Secondary:
Metastatic Gastric Cancer w/ obstruction of left ureter
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure being involved in your care, Mr. [**Known lastname **].
1. Stroke: You were admitted to [**Hospital1 18**] for management of your
acute stoke. You had a procedure to remove a clot from a major
artery in your brain. This helped to prevent your stroke from
causing more damage to your brain. You were also treated with
blood thinners to prevent more clots from forming.
2. Cancer: You have been diagnosed with metastatic gastric
cancer. You were not given any cancer treatments during this
admission. You should follow-up with your oncologist as an
outpatient as to when you should restart chemotherapy.
3. Atrial Fibrillation: You have atrial fibrillation, which is
an abnormal heart rhythm. The fast rate was controlled with
metoprolol, a drug that slows your heart rate down.
4. Pleural effusion: You had a thoracentesis (Draining of fluid
from around the lung) on two occasions during your hospital
course.
5: The following changes were made to your medications:
-ADDED Lovenox 80 mg subcutaneous injection twice a day
-STOPPED Lisinopril, Coumadin, Digoxin, Vicodin
-ADDED Senna, Docusate, Miralax
-ADDED Metoprolol 37.5 mg TID (three times per day)
Followup Instructions:
Please keep the following appointments:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2199-9-19**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 10280**], PA [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2199-9-19**] at 1 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7634**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2199-9-19**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
** please discuss your chemotherapy questions w/ your oncologist
at this time***
Per urology, they would like to reschedule your stent placement
for a later time, they are cancelling your appointment for
tomorrow as you need to get stronger first.
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
ICD9 Codes: 5849, 2761, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2780
} | Medical Text: Admission Date: [**2156-12-4**] Discharge Date: [**2156-12-8**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
R Sided weakness, confusion, and aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo RH woman who was in her usual state of health until
last night at 8pm when she began complaining of right hand
difficulty - poor grip, currently taking aleve for "arthritis".
She was at a restaurant with her family and kept repeating, "I
don't know what's going on." Repeated actions - kept eating
bread, held butter and said, "Where's the butter?" Then
suddenly
the right side of her body was weak. EMS arrived and took her to
OSH where she was found to have a left sided occipito-parietal
bleed (films not available at this time). Transferred to [**Hospital1 18**]
for neurosurgical backup. Was admitted to Neurosurgical ICU
overnight, given dexamethasone, did well and is now being called
out to the floor, neurology service.
Per daughter ([**Name (NI) 60095**]) and son [**First Name8 (NamePattern2) **] [**Name (NI) **]), there was no
preceeding headache, no history of hypertension, no tobacco
smoking. [**Name (NI) **] father died of an MI at age 54 but all other
family members have longevity. At baseline she is fully
functional, lives alone, no dementia or weakness.
Past Medical History:
tachycardia - on digoxin, atenolol, followed by Dr. [**First Name (STitle) **] [**Name (STitle) 60096**]
cardiology [**Telephone/Fax (1) 58549**]
s/p hysterectomy for "bladder pressure", not cancer
h/o skin cancer (not melanoma per daughter)
h/o "worrisome personality"
Social History:
no tob/etoh/drugs, husband deceased in [**2143**] of prostate CA,
3 kids all live in MA, very involved. Son [**Name (NI) **] [**Name (NI) **] (dentist)
Home [**Telephone/Fax (1) 60097**], cell [**Telephone/Fax (1) 60098**], beeper [**Telephone/Fax (1) 60099**],
office [**Telephone/Fax (1) 60100**]
Family History:
dad died of MI at age 54, mom lived to be [**Age over 90 **] yo, brother
in his 90's, sisters in their 80's. All 3 kids healthy.
Physical Exam:
Vitals: 98.7, HR 58-70 NSR, BP 128-148/50-60's, 19, 97% RA
I/O: [**Telephone/Fax (1) 60101**], LOS 695cc neg, FS 166-175
GEN: NAD, pleasant
HEENT: NC/AT, anicteric sclera, mmm
NECK: supple, no masses
CHEST: CTA bilat
CV: RRR without mur
ABD: soft, NT/ND, +BS, no HSM
EXTREM: no edema
NEURO:
Mental status:
Patient is alert, awake, pleasant affect.
Oriented to person only, does not know place, time (year/season)
nor president.
Poor attention - names DOWF, but not backwards.
Language is fluent with intermittant comprehension, repitition
OK, no dysarthria. Names some items "My fingers", "My knuckles"
but does not name watch. + perseveration.
+ apraxia - unable to show me how she brushes teeth, ? neglect.
Unable to calculate, + left/right mismatch. Unable to test
memory.
Cranial Nerves:
I: deferred
II: Visual acuity: not tested. Visual fields: cannot test
reliably. Pupils:3->2 mm, consenual constriction to light.
III, IV, VI: EOMS full, gaze conjugate. No nystagmus or
ptosis.
V: jaw strength OK
VII: right lower face droop
VIII: hearing intact to finger rubs
IX, X: gag reflex present bilaterally. Symmetric elevation of
palate.
[**Doctor First Name 81**]: trapezius [**5-5**] on left only
XII: tongue midline without atrophy or fasciulations.
Sensory: Withdrawls in all extremities to painful stimuli,
unable to recognize objects placed in her hands bilaterally,
exam limited by inattention.
Motor:
Normal bulk, tone. No fasciculations. + right drift. No
adventitious movements.
Strength:
Delt Tri [**Hospital1 **] WE WF FE FF IP* QD Ham DF PF Toe
RT: 4 3 5 4+ 5 4+ 5 0 0 0 0 0 wigglex1
* poor cooperation for formal strength testing for right leg.
Did better with right arm.
Reflexes: No grasp, glabellar, snout, palmomental or [**Doctor Last Name **].
No
Jaw jerk.
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 2 2 2 3 2 up
LEFT: 2 2 2 2 2 mute
Coordination: unable to test
Gait:unable to test at this time.
Pertinent Results:
[**2156-12-4**] 10:00PM BLOOD WBC-10.09 RBC-4.20 Hgb-13.5 Hct-38.3
MCV-91 MCH-32.1* MCHC-35.2* RDW-13.2 Plt Ct-135*
[**2156-12-4**] 10:00PM BLOOD Neuts-81* Bands-3 Lymphs-10* Monos-5
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2156-12-4**] 10:00PM BLOOD PT-13.0 PTT-22.7 INR(PT)-1.1
[**2156-12-4**] 10:00PM BLOOD Glucose-151* UreaN-12 Creat-0.8 Na-131*
K-5.9* Cl-95* HCO3-27 AnGap-15
[**2156-12-5**] 03:14AM BLOOD Glucose-166* UreaN-11 Creat-0.7 Na-135
K-3.8 Cl-97 HCO3-24 AnGap-18
[**2156-12-6**] 05:33AM BLOOD Phenyto-16.0
MR HEAD W/O CONTRAST [**2156-12-5**] 1:22 AM
IMPRESSION: Recent left occipital lobe hemorrhage. No other
sites of hemorrhage identified. No hydrocephalus or shift of
midline structures.
MR CONTRAST GADOLIN [**2156-12-5**] 8:10 AM
IMPRESSION
1. No discrete focus of enhancement is identified within the
brain, though
there is probably some enhancement of the brain along the
margins of the
left parietal-occipital hemorrhage
MRA BRAIN W/O CONTRAST [**2156-12-6**]
IMPRESSION
1. Negative MRA of the circle of [**Location (un) 431**]
Brief Hospital Course:
Pt admitted on [**12-4**] from OSH with L parieto-occipital
hemorrhage. Pt initially seen and admitted by the neursurgical
service into the NSICU. Pt started on mannitol, dilantin, with
strict SBP control < 140. An MRI W and W/O contrast performed
without evidence of a mass lesion. Pt then transferred to the
Neurology service for further management on [**12-5**]. Pt was stable
overnight from admission and was therefore transferred to the
floor. Pt began to show improvement with increased strength and
decreased confusion and aphasia. An MRA was performed which was
without evidence of an AVM. Speech and swallow eval performed on
[**12-6**], Pt able to tolerate full PO intake. PT/OT consulted, and
rehabilition recommended. Pt continued improving neurologically,
PO intake well tolerated, and there were no acute events during
the hospital course. Pt discharged to rehab on [**12-8**] in stable
condition.
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 5 days.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left occipito-parietal hemorrhage
Discharge Condition:
Stable
Discharge Instructions:
Please return for all follow-up appointments
[**Last Name (un) **] all medications as directed
Return to the ER for any increased weakness, confusion, blurry
vision, numbness, nausea/vomitting, headaches, chest pain,
shortness of breath or general malaise
Followup Instructions:
Please call [**Telephone/Fax (1) 2574**] to schedule a follow-up appointment
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2156-12-8**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2781
} | Medical Text: Admission Date: [**2136-8-31**] Discharge Date: [**2136-9-5**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Name14 (STitle) 102673**] is a 57 YOF with a history of type I diabetes,
complicated by polyneuropathy and gastroparesis, as well as a
history of CVA, [**Doctor Last Name 933**] disease, and untreated hep C from blood
transfusion who has had multiple admissions for DKA (last
admitted [**8-20**] to [**8-29**] for DKA, previously in [**Month (only) 116**], and two other
times before that this year) who presented to the ED with
hyperglycemia. Her VNA came to her house today and noted the bg
>600 so she gave her 19 units of humalog at 11:30 am. She
reports that her bg usually run in the 300s when she checks
them. However yesterday and today (since her discharge) her
sugars were elevated to over 500. She states she has been
taking her glargine 24 units at bedtime. In the past her DKA
had been precipitated by UTIs, but currently she denies any
infectious symptoms. She states that she did not start "feeling
bad" until today and this was due to her urinating a lot and
feeling fatigued. She otherwise denies dysuria, CP, SOB,
rhinorrea, sinus pain, HA, cough, nausea, [**Month (only) **], diarrhea, or
rash.
Of note, the patient's recent hospitalization was complicaetd by
an episode of unresponsiveness. A full work up was negative
other than the presence of benzodiazepines on tox screen when
the pt was reportedly not prescribed any. Her room was serached
and no medications were found. It was recommended after her
hospitalization that she discontinue her diazepam and percocet.
She was also evaluated by psychiatry who thought she should
establish care as an outpatient and undergo neuropsychological
testing. SW was also called to investigate options for [**Hospital 4382**] placement. Her only medication change was a decrease in
losartan for her outonomic neuropathy causing hypotension.
In the ED, initial vitals were: 98.9 110 113/58 14 100%. The
patient was well appearing. Labs were notable for Na 125,
bicarb 10, and anion gap 29, glucose 665. She had >1000 glucose
and 40 ketones on UA, but neg LE, nitrites, or bld. WBC was
11.4, Hct 29.5. Lactate was 3.6 and pH 7.38. Cxr: no focal
infiltrate, no effusion, no acute intrathoracic process. She
was given 3 L IVF in ED, given 10 units regular insulin, and
started on an insulin gtt at 7U/hr. Repeat fs was in the 400s.
SHe was then given NS with 40 mEq K. Access: 22G L hand, 20G
PIV.
On the floor, pt appeared comfortable. ROS as per HPI, + for
diffuse abd pain, that she says is there chronically and is from
her gastroparesis. Otherwise, denies fever, chills, headache,
sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, [**Hospital **],
diarrhea, constipation, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies rashes or skin changes.
Past Medical History:
---Type I DM: diagnosed at age 5, multiple hospitalizations for
DKA and hyperglycemia. Complicated by retinopathy, severe
peripheral
neuropathy, and gastroparesis with marked constipation.
-- DKA has been complicated by CVA, 3 episodes suspected
(including [**2135-5-14**] episode)
--Diabetic polyneuropathy
--Hypertension
--Grave's disease, on MMI
--Reactive airway disease
--Seronegative arthritis, followed in rheumatology
--Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
not on antiviral therapy; acquired from a blood transfusion in
[**2110**]. Had previous liver biopsy without significant fibrosis.
Never been treated with antivirals.
--GERD
--Status post bilateral knee arthroscopies
--Migraine headaches
-Asthma
-s/p TAH
-Depression
-Mouth surgery for removal of tumors
--Bilateral foot drop requiring wheelchair use
Social History:
Patient lives in an apt building. She has a son, daughter and
another brother who live on another floor. She is a never smoker
and does not use alcohol or drugs. She has not worked for many
years. She uses a wheelchair at baseline.
Family History:
Mother died of colon cancer. There are multiple family members
with DM.
Physical Exam:
Admission Physical Exam:
Vitals: T: 100 BP: 143/60 P: 103 R: 11 O2: 99%
General: somnolent, closes eyes and drifts off to sleep during
conversation, oriented, no acute distress
[**Year (4 digits) 4459**]: Sclera anicteric, hyperpigmentation around right eye, dry
MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, no murmurs
Abdomen: + BS, soft, mildly tender to palpation, non-distended,
no rebound tenderness or guarding
GU: foley
Ext: warm, well perfused, 2+ pulses, no edema.
Neuro: CN 2-12 intact, 4/5 strength in all extremities, but poor
effort with rest of neuro exam
Discharge Physical Exam:
Vitals: 98.3, 150/94, 94, 20, 97% RA
General: Awake, alert, NAD
[**Year (4 digits) 4459**]: Sclera anicteric, hyperpigmentation around right eye, dry
MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, no murmurs
Abdomen: + BS, soft, moderately tender on left, non-distended,
no rebound tenderness or guarding
GU: foley
Ext: warm, well perfused, 2+ pulses, no edema.
Neuro: CN 2-12 intact, 4/5 strength in all extremities
Pertinent Results:
# Admission Labs:
[**2136-8-31**] 01:50PM BLOOD WBC-11.4*# RBC-3.11* Hgb-9.8* Hct-29.5*
MCV-95 MCH-31.4 MCHC-33.2 RDW-15.2 Plt Ct-485*
[**2136-8-31**] 01:50PM BLOOD Neuts-86.3* Lymphs-11.4* Monos-1.9*
Eos-0.2 Baso-0.2
[**2136-8-31**] 01:50PM BLOOD PT-11.9 PTT-24.8 INR(PT)-1.0
[**2136-8-31**] 01:50PM BLOOD Glucose-665* UreaN-35* Creat-1.8* Na-125*
K-4.4 Cl-86* HCO3-10* AnGap-33*
[**2136-8-31**] 01:50PM BLOOD ALT-48* AST-28 AlkPhos-87 TotBili-0.3
[**2136-8-31**] 01:50PM BLOOD Lipase-38
[**2136-8-31**] 01:50PM BLOOD Albumin-3.5 Calcium-9.1 Phos-4.5# Mg-2.0
[**2136-8-31**] 02:05PM BLOOD Type-ART Temp-37.1 Rates-/16 FiO2-20
pO2-133* pCO2-19* pH-7.38 calTCO2-12* Base XS--10 Intubat-NOT
INTUBA Vent-SPONTANEOU Comment-GREEN TOP
[**2136-8-31**] 02:05PM BLOOD Glucose-GREATER TH Lactate-3.6* Na-126*
K-4.3 Cl-93*
# CBC:
[**2136-8-31**] 01:50PM BLOOD WBC-11.4*# RBC-3.11* Hgb-9.8* Hct-29.5*
MCV-95 MCH-31.4 MCHC-33.2 RDW-15.2 Plt Ct-485*
[**2136-9-1**] 07:36AM BLOOD WBC-14.9* RBC-3.17* Hgb-9.7* Hct-29.4*
MCV-93 MCH-30.7 MCHC-33.1 RDW-15.7* Plt Ct-526*
[**2136-9-1**] 12:48PM BLOOD WBC-14.8* RBC-3.22* Hgb-10.0* Hct-29.6*
MCV-92 MCH-31.0 MCHC-33.8 RDW-15.6* Plt Ct-555*
[**2136-9-2**] 01:51AM BLOOD WBC-10.4 RBC-3.05* Hgb-9.3* Hct-28.3*
MCV-93 MCH-30.6 MCHC-33.0 RDW-15.9* Plt Ct-474*
[**2136-9-3**] 06:05AM BLOOD WBC-7.7 RBC-2.70* Hgb-8.3* Hct-25.2*
MCV-93 MCH-30.7 MCHC-32.9 RDW-16.2* Plt Ct-384
[**2136-9-4**] 05:55AM BLOOD WBC-5.9 RBC-2.76* Hgb-8.7* Hct-25.5*
MCV-93 MCH-31.7 MCHC-34.3 RDW-16.5* Plt Ct-315
[**2136-9-5**] 06:31AM BLOOD WBC-5.7 RBC-2.82* Hgb-8.9* Hct-26.9*
MCV-96 MCH-31.6 MCHC-33.0 RDW-16.8* Plt Ct-334
[**2136-8-31**] 01:50PM BLOOD Neuts-86.3* Lymphs-11.4* Monos-1.9*
Eos-0.2 Baso-0.2
# Coags:
[**2136-8-31**] 01:50PM BLOOD PT-11.9 PTT-24.8 INR(PT)-1.0
[**2136-8-31**] 01:50PM BLOOD Plt Ct-485*
[**2136-9-1**] 07:36AM BLOOD Plt Ct-526*
[**2136-9-1**] 12:48PM BLOOD Plt Ct-555*
[**2136-9-2**] 01:51AM BLOOD Plt Ct-474*
[**2136-9-3**] 06:05AM BLOOD Plt Ct-384
[**2136-9-4**] 05:55AM BLOOD Plt Ct-315
[**2136-9-5**] 06:31AM BLOOD Plt Ct-334
# Lytes:
[**2136-8-31**] 01:50PM BLOOD Glucose-665* UreaN-35* Creat-1.8* Na-125*
K-4.4 Cl-86* HCO3-10* AnGap-33*
[**2136-9-1**] 03:55AM BLOOD Glucose-112* UreaN-22* Creat-1.2* Na-135
K-4.2 Cl-104 HCO3-23 AnGap-12
[**2136-9-1**] 12:48PM BLOOD Glucose-105* UreaN-15 Creat-1.0 Na-134
K-4.4 Cl-102 HCO3-20* AnGap-16
[**2136-9-1**] 11:50PM BLOOD Glucose-123* UreaN-11 Creat-0.9 Na-134
K-4.1 Cl-103 HCO3-20* AnGap-15
[**2136-9-2**] 03:30PM BLOOD Glucose-268* UreaN-10 Creat-1.0 Na-133
K-4.0 Cl-101 HCO3-25 AnGap-11
[**2136-9-3**] 06:05AM BLOOD Glucose-29* UreaN-10 Creat-0.9 Na-136
K-3.5 Cl-104 HCO3-29 AnGap-7*
[**2136-9-4**] 05:55AM BLOOD Glucose-75 UreaN-11 Creat-0.9 Na-139
K-4.1 Cl-104 HCO3-30 AnGap-9
[**2136-9-5**] 06:31AM BLOOD Glucose-279* UreaN-16 Creat-0.9 Na-132*
K-4.5 Cl-96 HCO3-30 AnGap-11
# LFTs:
[**2136-8-31**] 01:50PM BLOOD ALT-48* AST-28 AlkPhos-87 TotBili-0.3
# Lipase:
[**2136-8-31**] 01:50PM BLOOD Lipase-38
# Alb, Ca, Mg, Phos:
[**2136-8-31**] 01:50PM BLOOD Albumin-3.5 Calcium-9.1 Phos-4.5# Mg-2.0
[**2136-9-1**] 03:55AM BLOOD Calcium-8.3* Phos-2.1*# Mg-1.7
[**2136-9-1**] 12:48PM BLOOD Calcium-8.3* Phos-2.3* Mg-1.7
[**2136-9-2**] 01:51AM BLOOD Calcium-8.2* Phos-2.3* Mg-1.7
[**2136-9-3**] 06:05AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.7
[**2136-9-4**] 05:55AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.7
[**2136-9-5**] 06:31AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.7
# Tox Screen:
[**2136-9-1**] 12:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2136-8-31**] 10:38PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
# Blood Gases:
[**2136-8-31**] 02:05PM BLOOD Type-ART Temp-37.1 Rates-/16 FiO2-20
pO2-133* pCO2-19* pH-7.38 calTCO2-12* Base XS--10 Intubat-NOT
INTUBA Vent-SPONTANEOU Comment-GREEN TOP
[**2136-8-31**] 08:46PM BLOOD Type-ART pO2-154* pCO2-37 pH-7.40
calTCO2-24 Base XS-0
[**2136-8-31**] 11:46PM BLOOD Type-ART pH-7.35
[**2136-9-1**] 04:18AM BLOOD Type-CENTRAL VE pH-7.39
# U/A
[**2136-8-31**] 02:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
# Blood Cultures:
[**2136-8-31**] BCx: Pending
# Urine Culture:
[**2136-8-31**] UCx: Negative
# MRSA:
[**2136-8-31**] MRSA Screen: Negative
# [**2136-8-31**] EKG:
Sinus tachycardia. Compared to the previous tracing of [**2136-8-24**]
there is no
change.
# [**2136-8-31**] Cxr:
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
Assessment:
Ms. [**Known lastname 18741**] is a 57 YOF with DMI with multiple admissions for
DKA who presented in DKA.
Active Diagnoses:
# Diabetic Keto Acidosis: BG > 600 with anion gap 29 and
ketonuria. Pt was given 4 L NS in the ED (the 4th with K+) and
started on insulin gtt. Upon arrival to the floor, she was
continued on the insulin gtt and on repeat fs her bg was 100.
Insulin gtt was stopped and she was given [**1-22**] amp D50. She
recieved 25 units of Lantus. However, patient was not able to
take po [**2-22**] nausea, so insulin and D10 were continued and she
was given Reglan and Zofran for nausea. Her gap remained closed.
[**Last Name (un) **] was consulted who felt it was OK to stop the gtts and
check FS q4 hours. She was placed on 20 of Lantus [**Hospital1 **], and ISS
when she started to eat. She remained stable taking PO and was
transferred to the general medical floor. On the floor she had
two episodes of hypoglycemia, one to the 30's and one to the
40's. These were treated with glucose and resolved. [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recs her evening dose of Lantus was stopped completely and she
had no further episodes of hypoglycemia. She was sent on 20
units of lantus in the am with humalog SSI. Given her multiple
admissions for DKA and her poor glycemic control it is
questionable that the patient has been compliant with her
insulin, which may have been the cause for this current
presentation. Pt discharged from hospital 2 days prior to
admission with bg reportedly 180-280 the day of discharge. She
has many admission for DKA and is followed closely by [**Last Name (un) **].
She has no other obvious signs of infection on history to
precipitate DKA and UA and CXR do not support UTI or PNA.
We had a long meeting with the pt, her daughter, nursing, social
work, case management to discuss her multiple admissions for
DKA. The patient explained that her social situation has been
so stressful lately that she "may miss" insulin doses because
she is so distracted with other aspects of her life. She is
wheel chair bound and her biggest request is to get a letter
(which was written and given to the daughter) saying that she
needs a wheel chair accessible apartment. We stressed to her
that close follow up with VNA and her endocrinologist were
integral to controlling her Diabetes and not bouncing back to
the hospital in DKA. She explained that she does not want to
burden her family but will accept daily VNA if this will help
her to control her Diabetes. A plan was set in place to have
daily home VNA and close endocrine follow up to make sure that
she does not bounce back to the hospital.
# Abdominal Pain: Left sided abdominal pain. Pt reports this
pain is baseline. Been worked up extensively per past notes in
OMR without clear etiology. No periotneal signs on exam.
Possibly just due to DKA. Pain treated with home oxycodone.
# Hypoglycemia: Exact etiology unknown. Pt was on less insulin
than she is supposedly on at home. Pt had BG in the 30's on
[**2136-9-3**]. In the 40's on [**2136-9-4**]. Insulin scale adjusted [**First Name8 (NamePattern2) **]
[**Last Name (un) **] recs. [**Last Name (un) **] docs believe the best way to titrate her
insulin dose would be as an outpatient where she is home and
eating what she would normally eat. Pt has an appointment with
[**Last Name (un) **] [**2136-9-6**].
# Somnolence: Pt was drowsy and fell asleep easily early during
admission. She remained oriented when aroused. On previous
admission concern for benzodiazepine use causing somnolence. She
is also on many anticholinergic medications which could be
contributing. Her urine tox screen was negative. Her sedative
medications were held during this admission but she was sent on
them at discharge.
# ARF: Likely from volume depletion in the setting of DKA. She
was given IVF with resolution of her [**Last Name (un) **]. Cr 0.9 on discharge.
Chronic issues:
# Diabetic polyneuropathy and gastroparesis. Pt continued on
reglan, amitriptyline.
# Hypertension. Pt hypertensive througout most of admission.
Losartan initially held in the setting of [**Last Name (un) **]. Restarted later.
She was not aggressively diuresed given dehydration on
admission. Will leave definitive management up to the PCP.
# Grave's disease; s/p RAI [**2129**]. Pt continued on methimazole
througout admission.
# Reactive airway disease, allergies. Pt continued on albuterol
PRN, advair and montelukast.
# Seronegative arthritis. Pt continued on sulfasalazine.
# Depression. Pt continued on amitriptyline.
# Ecchymotic right eye. Was noted on prior admission, pt states
this is from itching her eye. INR normal on [**2136-8-31**]. Not
further worked up.
Transitional Issues:
1. Further titration of insulin regimen to ensure that she has
adequate glucose control in her home environment.
2. Possible titration of BP medications.
3. Her social situation will need further attention. There is
real question as to whether the patient is omitting insulin
doses in order to go into DKA in an attempt to show how disabled
she is so that she can get a different apartment. From our
perspective, we have given her the letter she requested saying
that she needs a wheel chair accessible apartment. We stressed
to her that she needs to take her insulin and that the VNA will
help with this. She does not want help with her insulin from
her family because she does not want to burden them but we
explained that it is much more of a burden to them if she keeps
bouncing back to the hospital in DKA. This should be restressed
to the patient in the future. This patient is at very high risk
to present yet again in DKA in the future if her social/psych
issues are not further addressed.
Medications on Admission:
(from previous d/c summary)
1. amitriptyline 50 mg HS
2. fluticasone-salmeterol 250-50 mcg/dose [**Hospital1 **]
3. methimazole 10 mg TID
4. montelukast 10 mg Qday
5. pantoprazole 40 mg Qday
6. polyethylene glycolQday
7. simvastatin 10 mg Qday
8. sulfasalazine 500 mg [**Hospital1 **]
9. prochlorperazine maleate 10 mg [**Hospital1 **]
10. docusate sodium 100 mg [**Hospital1 **]
11. gabapentin 300 mg [**Hospital1 **]
12. metoclopramide 10 mg QIDACHS
13. calcium carbonate 200 mg TID
14. cholecalciferol (vitamin D3) 400 unit Qday
15. ferrous sulfate 300 mg (60 mg iron) Qday
16. hyoscyamine sulfate 0.375 mg ER [**Hospital1 **]
17. oxycodone-acetaminophen 5-325 mg [**Hospital1 **] PRN pain
18. losartan 25 mg Qday
19. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units
Subcutaneous at bedtime.
20. Humalog Mix 75-25 13 units Q day
21. Humalog 100 unit/mL Solution Sig: Per sliding scale
Discharge Medications:
1. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
twice a day as needed for nausea: as needed for nausea.
10. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. hyoscyamine sulfate 0.375 mg Capsule,Extended Release 12 hr
Sig: One (1) Capsule,Extended Release 12 hr PO BID (2 times a
day).
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
18. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Humalog 100 unit/mL Solution Sig: Dose Per Sliding Scale
units Subcutaneous four times a day: Please take insulin dosages
based on your home sliding scale.
20. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day: Please give patient 300 unit insulin
pen. Please take 20 units in the morning.
Disp:*1 pen* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
Discharge Diagnosis:
Diabetic Ketoacidosis
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 Ms. [**Known lastname 18741**],
You were admitted to the hospital with high blood sugars. While
you were here we treated you with IV fluids and insulin and you
improved. Unfortunately, while you were here you also had 2
episodes of low blood sugars which we treated and you improved.
As we discussed in our family meeting today, the key to
preventing rehospitalization lies in close follow up with [**Last Name (un) **]
(appointment tomorrow), daily home nursing visits, and allowing
close supervision by members of your family to help you manage
your challenging disease. We also encourage you to visit your
gastroenterologist (appointment this fall) to better manage your
gastroparesis, which contributes to the difficulties in
controlling your blood sugar.
The following changes were made to your medications:
CHANGE Lantus Insulin from twice per day to one dose per day, 20
units, in the morning.
STOP the Humalog Mix
We have made you an appointment to follow up with your Diabetes
doctor tomorrow, [**2136-9-5**]. Additionally we have made you an
appointment with your regular doctor below.
Thank you for allowing us to participate in your care. We wish
you a speedy recovery.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: Thursday [**2136-9-6**] 11:00am
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9241**]
Location: UPHAMS CORNER HEALTH CENTER
Address: [**University/College 17629**], [**Location (un) **],[**Numeric Identifier 58270**]
Phone: [**Telephone/Fax (1) 7538**]
Appointment: Friday [**2136-9-14**] 1:30pm
ICD9 Codes: 5849, 3572, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2782
} | Medical Text: Admission Date: [**2156-9-7**] Discharge Date: [**2156-9-17**]
Date of Birth: [**2107-5-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Transfer from [**Hospital1 18**] [**Location (un) 620**] for worsening hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 49yoM with advanced anorectal carcinoma s/p
anterior pelvic resection and colostomy, XRT and chemo with a
recent admission to [**Hospital1 18**] for metastatic mets to the spine
([**8-7**]) who presented to [**Hospital1 18**] [**Location (un) 620**] on [**2156-9-2**] with 3 days of
nausea, vomiting and increasing shortness of breath and dry
cough. On initial evaluation at [**Location (un) 620**], O2 sats were found to
be 88% on RA. Admission CXR revealed what was thought to
represent b/l pneumonia so he was started on levofloxacin. WBC
was elevated to 17K with 93% neutrophils at that time. A CT
chest performed on [**9-3**] showed diffuse b/l reticularity, b/l
lower lobe dense consolidation vs. atelectasis and b/l
effusions.
.
Over the course of his [**Location (un) 620**] stay, O2 requirement increased
daily from 2L->3L-->5L and then last evening he was placed on
NRB. He received 10mg IV lasix last evening without improvement
in respiratory status. Additionally, he was tranferred to the
ICU and was placed on Bipap overnight with some decrease in WOB.
CTA chest was ordered at [**Location (un) 620**] today to r/o PE, but pt. was
unable to tolerate laying flat, less because of worsened
dyspnea, more as a result of severe back pain [**3-5**] to his bony
mets. Given suspiscion for PE, he was started empirically on
heparin gtt prior to transfer.
.
Most recent ABG prior to transfer while on NRB was 7.48/29/57.
.
ROS: + fatigue, + anorexia, no fevers and chills. He does
endorse dry mouth. No chest pain. He has been having some lower
extremity edema (L>R) without orthopnea or PND. He does say he
has been having shortness of breath over the past few days with
cough, but not prior to this. Nausea and vomiting has improved,
but not taking good PO given need for NRB/bipap. No current
lower back pain.
Past Medical History:
PMH:
# Anal/Rectal cancer, metastatic to spine T12,L1,L3,L4 and
paraspinal retroperitoneal mass around L2, mets to lungs, liver
# Rectal fissure
# Hearing impaired, wears hearing aids
.
ONC HX: Diagnosed in [**3-8**] by rectal mass resection and biopsy
demonstrating anal adenocarcinoma, he received chemoradiation
with mitomycin and 5-FU up until [**Month (only) 958**] of this [**2154**], and had an
anterior pelvic resection and pathology revealed a T3, N0
adenocarcinoma. He then received adjuvant 5-FU and leucovorin,
which was completed on [**2154-9-30**]. In he noticed some new
lumps above his left clavicle. He had a x-ray of the clavicle
done which was unremarkable. biopsy of a left cervical node that
was consistent with his anal
adenocarcinoma, and he was then treated with FOLFOX and Avastin
winter [**2155-8-2**]. Patient tolerated these treatments reasonably
well, but did experience prolonged myelosuppresion (low plts)
and due to adequate response, the treatment was stopped. Last
dose in [**3-17**], cycle initiated [**2156-3-3**].
Social History:
Married, lives in [**Location 620**] with wife, no children, works as
Physicist, cat at home. No tobacco, social ETOH.
Family History:
Mother deceased [**7-8**], stroke and pancreatic ca
Physical Exam:
PE: T 98.9 HR 128 BP 100/65 RR 30-38 O2 sat 91-96% NRB
HEENT: PERRL, dry MM
Neck: Large left sided supraclavicular LN, neck supple
CV: Sinus tachy, no mrg apprec.
Resp: Decreased BS bibasilar, crackles mid lateral lung field
(unable to sit pt. fully forward [**3-5**])
Abd: Ostomy bag with liquid brown output
Ext: Nonpitting edema LLE, no palpable cord nor calf pain, RLE
w/o edema, 2+ DP/PT pulses b/l
Neuro: CN 2-12, strength, sensation grossly intact
Pertinent Results:
[**2156-9-2**] CXR at OSH: New bibasilar patchy opacities, most likely
representing an underlying pneumonia.
.
[**2156-9-3**] CT chest from OSH: Interval increase in pulmonary
metastases
and hepatic metastases. Development of hilar and mediastinal
lymphadenopathy. Interval development of bilateral pleural
effusions,
underlying atelectasis or consolidation. Interval increase in
periaortic lymphadenopathy. Development of large left
supraclavicular lymph node.
.
EKG: Sinus tachy to rate of 135, nml axis, no significant ST/T
wave changes.
.
[**2156-9-11**] bilateral LE Doppler US: neg for DVT
.
[**2156-9-16**] LUE Doppler US: neg. for DVT
Brief Hospital Course:
The patient is a 49yoM with h/o of metastatic anorectal ca to
spine, liver, lungs presents with worsening hypoxia in the
setting of nonproductive cough. He was found to have probable
lymphangitic spread of metastatic disease and transferred to
[**Hospital1 18**] for close respiratory monitoring and possible
chemotherapy. Hospital course by problem is as follows:
.
# Hypoxic/hypercarbic respiratory distress: In review of [**9-3**]
chest CT, reticular pattern appears c/w lymphangitic spread of
his disease and was likely the major precipitant in the
decompensation of his respiratory status. Had been on face mask,
but clinical evidence of increasing resp distress
persisted(increased work of breathing, increased O2 requirement,
tachycardia), and the patient was intubated on [**9-14**] for
worsening respiratory distress and hypercarbia.
Broad spectrum antibiotic coverage with zosyn, vancomycin, and
azithromycin was initiated on admission for a question of PNA on
admission CXR with leukocytosis and left shift.
.
# Fever: The patient spiked temperatures to 101s-102s during
hospital course. There was no clear source of fevers. Infectious
etiology was a possibility (e.g. VAP), but it was difficult to
assess for new infiltrate on CXR and the patient was on
broad-spectrum antibiotics (zosyn, vancomycin, and azithromycin)
for the duration of admission. All cultures were negative to
date. DVT/PE was considered with LUE swelling on exam; however
Doppler US was negative for DVT. Etiolgy may be related to fever
of malignancy.
.
# Sinus tachycardia: The patient demonstrated sinus tachycardia
for the duration of admission. Etiology was most likely
physiologic (tachypnea, fever, profound hypoxemia) with stable
hemodynamics. There was lack of response to IVF boluses, making
hypovolemia less likely. This was monitored closely for concern
for development of tachyarrythmia.
.
# Metastatic anorectal ca: Last chemo in 2/[**2156**]. With known
metastatic disease to bone, liver, lungs (worsening liver mets
on [**9-3**] CT as well as hilar/mediastinal LNs). XRT in [**Month (only) 205**]
performed for back pain [**3-5**] to his bony mets (low
thoracic-lumbar spine). His cancer has previously been very
chemosensitive, but since last treatment, appears to have rapid
progression of disease given imaging as outlined above. The
patient completed cycle of 5FU and G-CSF, which was tolerated
well without significant side effects; however, there was little
effect on metastatic disease during chemotherapy. During
hospital course the patient developed a leukocytosis, most
likely due to G-CSF treatment. Towards the end of his hospital
course he developed a pancytopenia, likely related to the
progression of his disease.
.
# Thrombocytopenia: The patient is chronically thrombocytopenic
w/ platelet count 65K-154K in review of OMR labs, with evidence
of declining platelets during admission. Heparin was held
briefly for the question of HIT, but was restarted after HIT Ab
panel was negative. Most likely etiology is either progression
of metastatic disease versus 5FU treatment.
.
# ?DVT/PE: On admission the patient was started on a therapeutic
heparin drip for concern of PE given hypercoagulable state,
tachycardia, and tachypnea. He was unable to tolerate CTA per
back pain from spinal metastases. Heparin drip was discontinued
on [**2156-9-11**] after LE doppler US were negative for DVT.
.
# FEN: The patient had evidence of hypernatremia that responded
well to free water repletion; this was likely hypovolemic
hypernatremia given his poor po intake. He was maintained on TPN
given the inability to take po during admission, and was started
on tube feeds after intubation.
.
# During admission the patient was maintained on [**Last Name (LF) 32111**], [**First Name3 (LF) **]
IV PPI, and heparin (gtt or sq) for prophylaxis.
.
# Communication: Wife is patient's HCP [**Doctor First Name **] [**Telephone/Fax (3) 32112**]
.
# Code: After discussion with the patient's oncologist and the
ICU team regarding the lack of response to chemotherapy and the
poor prognosis, the patient and his family decided to opt for
comfort measures. On [**2156-9-17**], while the family was present the
patient was bolused with fentanyl and was extubated to room air
with a respiratory rate of 10. He became asystolic and was
pronounced dead at 9:35am.
Medications on Admission:
Meds on admission to [**Location (un) 620**]:
1. MS Contin 10 twice a day, last dose on day of admission.
2. Zofran p.r.n.
3. Protonix 20 daily.
.
Medication on transfer:
1. Heparin gtt
2. Levaquin 500 mg qday (Day 1 = [**2156-9-2**])
3. Prilosec 20 mg po qday
4. Zofran 4 mg IV q8 hr prn
5. Duonebs q 4-6 hr prn
6. Ativan 1 mg po q6 hr prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure secondary to lymphangitic spread of
anorectal carcinoma
Discharge Condition:
Expired
ICD9 Codes: 486, 5119, 2875, 2761, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2783
} | Medical Text: Admission Date: [**2113-6-15**] Discharge Date: [**2113-6-20**]
Date of Birth: [**2031-6-5**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
infected PPM
Major Surgical or Invasive Procedure:
lead and pacemaker extraction
Temporary pacer
Pacer insertion left chest
History of Present Illness:
Mr [**Known lastname **] is an 82-yo man with complete heart block s/p dual
chamber [**Company **] pacemaker [**10/2101**] with RV lead revision [**2-/2112**]
and recent device infection in [**1-/2113**], hypertension,
dyslipidemia, GERD, and BPH, who presented today with continued
device infection for lead and device extraction. The procedure
was prolonged due to significant fibrosis of the pacer leads,
and he was noted to have purulent material that was extracted
and sent to the microbiology lab for analysis. Given his history
of complete heart block and hypotension with his ventricular
escape rhythm, a temporary screw-in external pacemaker was
placed in the right IJ. Intra-operative TEE was unremarkable,
but he did require Neosynephrine in the OR for hypotension that
was thought to be due to the prolonged anesthesia. Given the
significant infection, the wound was left open, to close by
secondary intention, with plan to treat with IV antibiotics over
the weekend and re-implant a pacemaker next week.
.
With regards to the recent device infection in [**2113-1-12**],
this was initially treated with IV vancomycin, but that was
discontinued due to development of fever and rash. He was
instead treated with a full course of IV linezolid. The site was
noted to have significantly improved, and he was seen in [**Hospital **]
clinic at the end of [**Month (only) 404**] at which point the site was
considered to be healed. Per the patient, the site was stable
for over 3 months, but he then developed a new area of erythema
over the left lateral aspect of the pocket, with blistering. He
was seen for this complaint in [**Hospital **] clinic on [**2113-6-7**]. He denies
any fevers or chills but has been experiencing pain at the
pacemaker site with his usual activity. His WBC was 5.1 with a
normal differential on [**2113-6-12**], and he was admitted today for
lead and device extraction for continued infection versus new
pocket site infection.
.
On arrival to the CCU, the patient was hypotensive with SBP in
the 60s. He received a 200cc NS IVF bolus with improvement to
the 90s. He complains of left-sided chest pain as well as pain
and tingling in his fingers bilaterally, left worse than right.
There is no weakness or numbness of the hands. The pains are
intermittent. ECG showed V-pacing at 60 bpm. STAT TTE showed no
obvious effusion or depressed ventricular function, and STAT CXR
was also unremarkable. His external pacemaker rate was increased
from 60 to 80 bpm. IV Linezolid was started for possible
septicemia. He did not require any further IVF or vasopressor
support.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. 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, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: [**2101**] ([**Company 1543**] Sensi SEDR01)
3. OTHER PAST MEDICAL HISTORY:
* Complete heart block status post initial permanent pacemaker
implantation in [**2101**] with subsequent RV lead revision and
generator change in [**2112-2-12**] (Dual Chamber [**Company 1543**]
Sensia SEDR01).
* Device infection in [**2113-1-12**], initially treated with IV
vancomycin, which was discontinued due to development of fever
and rash. Then treated with full course of IV linezolid.
* Hypertension.
* Hyperlipidemia.
* GERD.
* BPH.
Social History:
He is married with five grown children. He does not smoke and
drinks only on occasion. No illicit drug use. He is a retired
landscaper.
Family History:
His father died of emphysema, and his mother had diabetes. All
five grown children are well and healthy. No family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
VS: T= 95.8F, BP= 68/43, HR= 60, RR= 18, O2 sat= 100% 4L NC.
GENERAL: WD/WN elderly man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NC/AT. PERRL/EOMI. Sclera anicteric. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. MMM, OP clear.
NECK: Supple, JVP not measurable [**2-13**] RIJ temporary pacer.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1-S2, but muffled heart sounds. 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.
ABDOMEN: Soft, NT/ND. No HSM or tenderness. No abdominial
bruits.
EXTREMITIES: WWP, no c/c/e. No femoral bruits.
SKIN: No rashes or lesions.
NEURO: Awake, A&Ox3, moving all extremities appropriately.
PULSES:
Right: Femoral 2+ DP 1+ Radial 1+
Left: Femoral 2+ DP 1+ Radial 1+
Pertinent Results:
[**2113-6-15**] 05:51PM BLOOD WBC-10.9# RBC-3.32* Hgb-10.0* Hct-29.6*
MCV-89 MCH-30.1 MCHC-33.8 RDW-13.8 Plt Ct-202
[**2113-6-15**] 05:51PM BLOOD PT-14.7* PTT-28.7 INR(PT)-1.3*
[**2113-6-15**] 05:51PM BLOOD Glucose-137* UreaN-20 Creat-0.8 Na-141
K-3.7 Cl-111* HCO3-20* AnGap-14
[**2113-6-15**] 05:51PM BLOOD Calcium-7.6* Phos-2.9 Mg-1.6
[**2113-6-20**] 09:00AM BLOOD WBC-7.8 RBC-3.29* Hgb-10.0* Hct-29.4*
MCV-89 MCH-30.4 MCHC-34.1 RDW-14.2 Plt Ct-222
[**2113-6-19**] 06:20AM BLOOD PT-12.7 PTT-21.8* INR(PT)-1.1
[**2113-6-20**] 09:00AM BLOOD Glucose-169* UreaN-23* Creat-1.0 Na-139
K-4.4 Cl-102 HCO3-29 AnGap-12
[**2113-6-19**] 06:20AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
[**2113-6-15**] 1:45 pm SWAB LEFT SHOULDER.
GRAM STAIN (Final [**2113-6-15**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
SENSITIVITIES REQUESTED BY DR. [**First Name (STitle) 488**] .
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2113-6-19**]): NO ANAEROBES ISOLATED.
Blood Cx [**6-16**] and [**6-17**] NGTD
ECHO [**6-15**]
The left atrium is markedly dilated. The left atrium is
elongated. No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal. There is moderate
global left ventricular hypokinesis (LVEF = 35 - 40 %). The
right ventricle displays mild to m oderate global free wall
hypokinesis. There are complex (>4mm) atheroma in the aortic
arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
leaflets and pulmonic leaflets are not well seen. There is a
trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study.
After lead extraction, there were no significant changes and no
signs of an enlarging pericardial effusion.
ECHO [**6-15**]
There is symmetric left ventricular hypertrophy. The left
ventricular cavity is very small. Left ventricular systolic
function is hyperdynamic (EF>75%). There is no pericardial
effusion.
CXR: [**2113-6-20**]
Since yesterday, right-sided dual-chamber pacemaker still ends
in expected
position. There is no pneumothorax. Small bilateral pleural
effusion
increased, still tiny. Hyperinflation is unchanged. The
cardiomediastinal
silhouette is stable. There is no other change.
ECG:
Baseline artifact. Sinus or atrial paced or ventricular paced
rhythm.
Since the previous tracing of [**2113-1-23**] atrial pacing is probably
new at a faster
rate.
Brief Hospital Course:
82-yo man with complete heart block s/p dual chamber pacemaker
with RV lead revision and recent device infection who presented
with continued device infection for lead and device extraction,
found to have significant infection of the pacer pocket and lead
fibrosis, now s/p external temporary pacemaker placement and
awaiting treatment with IV antibiotics prior to re-implantation
of permanent pacemaker.
.
# Infected pacemaker - He was seen for this complaint in [**Hospital **]
clinic on [**2113-6-7**]. He denies any fevers or chills but has been
experiencing pain at the pacemaker site with his usual activity.
His WBC was 5.1 with a normal differential on [**2113-6-12**], and he was
admitted on [**6-15**] for lead and device extraction. On arrival to
the CCU, the patient was hypotensive with SBP in the 60s. He
received a 200cc NS IVF bolus with improvement to the 90s. He
complained of left-sided chest pain as well as pain and tingling
in his fingers bilaterally, left worse than right. There is no
weakness or numbness of the hands. The pains are intermittent.
ECG showed V-pacing at 60 bpm. STAT TTE showed no obvious
effusion or depressed ventricular function, CXR was also
unremarkable. His external pacemaker rate was increased from 60
to 80 bpm. He was started on IV Linezolid. He did not require
any further IVF or vasopressor support. The patient underwent
pacer and lead extraction on [**2113-6-15**] without complication. A
temporary pacer was also placed after removal. The patient
remained stable and blood cx were NGTD. He was seen by ID who
recommended 2 weeks of linezolid from pacer extraction [**2113-6-15**].
The patient had a new pacemaker placed on [**2113-6-19**] without
complication. CXR showed no PTX and leads in proper position.
His wound culture eventually grew coag-neg staph. The patient
will have both ID and EP follow-up with weekly labs. The
patient remained afebrile and pacemaker was working properly.
# complete heart block (rhythm) - See above for management of
pacemaker. The patient had his lead and pacer extracted on
[**2113-6-15**]. A temporary external pacemaker in right IJ was placed.
He was monitored on tele. A new pacemaker was placed on [**2113-6-19**]
without complication.
# coronaries - The patient has no known CAD or findings of CAD
on ECG. He remained chest pain free. He was continued on home
ASA.
.
# pump - The patient had an intra-op EF 35-40% with moderate
global LV hypokinesis. He remained clinically euvolemic.
# hypertension - The patient's anti-hypertensives were intially
held secondary to his hypotension. Once his pressures had
stabilzed he was restarted on lisinopril 10mg and home
metoprolol succinate 12.5mg at the time of discharge.
# dyslipidemia - stable, continued home statin
.
# diabetes - stable, continued home Actos and ISS. He was also
continued on a diabetic diet.
# GERD - stable, continued home H2B
# BPH - His flomax was initally held secondary to hypotension,
but restarted once stable.
Medications on Admission:
Lisinopril 20mg daily
Lovastatin 20mg daily
Metoprolol succinate 12.5mg daily
Actos 15mg daily
Zantac 150mg daily PRN
Flomax 0.4mg daily
Aspirin 325 mg daily
Vitamin C 500mg daily
Vitamin B12 500mcg daily
Glucosamine-Chondroitin 500mg-400mg daily
Loratadine 10mg QHS
Multivitamin daily
Aleve 220mg daily PRN
Vitamin E 400unit daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO four times a day as
needed for pain.
3. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO daily ().
4. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for indigestion.
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO once a day.
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.
9. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Loratadine 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Outpatient Lab Work
Please draw CBC on [**2113-6-27**] when pt comes to see Dr. [**Last Name (STitle) **],
call results to the ID fellow Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 432**]
15. Outpatient Lab Work
Please check CBC by VNA on [**2113-7-4**] and call results to ID
fellow, Dr. [**Last Name (STitle) **] at [**Hospital1 18**] at [**Telephone/Fax (1) 432**].
16. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 9 days: last day [**2113-6-28**].
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
Complete Heart Block
Pacemaker site infection
Discharge Condition:
stable.
Discharge Instructions:
You had a pacemaker pocket infection that necessitated the
pacemaker to be removed and another pacemaker was placed on the
right side of your chest. You are on Linezolid antibiotic to
treat this infection. You will be seen by Dr. [**Last Name (STitle) **] in 1
week to look at the new pacemaker and the old pacemaker site.
While you are on the antibiotics, you will need to have weekly
labs checked. This can be done by the VNA. A plastic surgeon saw
your left chest wound. They feel that it will heal well and
deferred care to Dr. [**Last Name (STitle) **].
New medicines:
1. Linezolid: an antibiotic to treat the pocket infection.
Please follow the dietary restrictions given to you by Dr.
[**Last Name (STitle) **].
2. Please decrease your Lisinopril to 10 mg at night. This may
be increased again by Dr. [**Last Name (STitle) **].
.
Please do not take any showers until Dr. [**Last Name (STitle) **] tells you to.
You may take a bath and wash your hair but don't get the pacer
dressings wet. If the dressings fall off, cover with dry sterile
gauze and tape. NO lifting more than 5 pounds with your right
arm, no lifting that arm over your head.
.
Please call Dr. [**Last Name (STitle) **] if you have any fevers, chills,
sweating, increasing redness or pain at either pacer site, light
headedness, chest pain or any other worrying symptoms.
Followup Instructions:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2113-6-27**] 11:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2113-6-27**] 12:20
.
Primary Care:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 20**] [**Name Initial (NameIs) **]. Phone: [**Telephone/Fax (1) 77179**] Date/Time: Please
make an appt to be seen in [**2-14**] weeks.
Completed by:[**2113-6-20**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2784
} | Medical Text: Admission Date: [**2130-7-31**] Discharge Date: [**2130-8-5**]
Date of Birth: [**2067-4-24**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
No Drug Allergy Information on File
Attending:[**Location (un) 1279**]
Chief Complaint:
V-fib arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization s/p mLAD stent
EP study with placement of biventricular pacemaker/ICD
History of Present Illness:
This is a 63 y/o male with hx of anterior MI [**2113**], NSVT first
noted [**2119**] maintained on quindine since, who was eating dinner
after playing golf on [**7-31**] and had a VFib arrest. A physician
at the scene started CPR and EMS arrived and defibrillated him.
He was taken to Caritas [**Hospital3 **], intubated, and mediflighted to
[**Hospital1 18**]. He stayed in the CCU overnight and was extubated and
transferred to the floor on [**8-1**]. Prior to his event, he had no
complaints and was feeling fine, doing well on the quinidine.
Past Medical History:
Hx 24 pk years
Nephrolithiasis
CHF (ischemic)
Social History:
Tobacco use, 24 p/y hx
Family History:
Has a sister who also has had a pacer/ICD placed (unknown
reason)
Physical Exam:
T: 98.7 BP: 101/60 P: 83 R: 18 96% RA Wt: 103.3 kg
Gen: alert and oriented, short term memory much improved, the
only thing he doesn't remember are the exact circumstances of
his arrest
Neck: no JVD
Lungs: CTA bilaterally, no w/r/c
CV: RRR, no m/r/g
Chest: pacer pocket with hematoma, unchanged. Firm, nontender,
no erythema. Bruising tracking under the pressure dressing.
Abd: soft, nt/nd. +bs.
Ext: 2+ dp pulses, no c/c/e. R groin cath site without hematoma
or bruit, nontender. 2+ left radial pulse.
Pertinent Results:
[**2130-8-5**] 06:50AM BLOOD WBC-10.3 RBC-3.67* Hgb-11.5* Hct-34.7*
MCV-95 MCH-31.3 MCHC-33.1 RDW-14.3 Plt Ct-131*
[**2130-8-5**] 06:50AM BLOOD PT-12.6 PTT-23.8 INR(PT)-1.0
[**2130-8-5**] 06:50AM BLOOD Glucose-128* UreaN-13 Creat-1.2 Na-141
K-3.8 Cl-104 HCO3-27 AnGap-14
[**2130-8-3**] 06:25AM BLOOD CK(CPK)-116
[**2130-8-2**] 10:00PM BLOOD CK(CPK)-136
[**2130-8-1**] 12:56PM BLOOD CK(CPK)-166
[**2130-8-1**] 06:34AM BLOOD ALT-58* AST-39 CK(CPK)-193*
[**2130-7-31**] 08:42PM BLOOD CK(CPK)-238*
[**2130-8-1**] 12:56PM BLOOD CK-MB-3 cTropnT-<0.01
[**2130-8-1**] 06:34AM BLOOD CK-MB-4 cTropnT-<0.01
[**2130-7-31**] 08:42PM BLOOD cTropnT-<0.01
[**2130-8-5**] 06:50AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
[**2130-8-1**] 06:34AM BLOOD Triglyc-138 HDL-32 CHOL/HD-3.7 LDLcalc-59
LDLmeas-66
[**2130-7-31**] 08:42PM BLOOD Digoxin-0.9 Quinidi-1.6*
Brief Hospital Course:
Mr. [**Known lastname 7929**] was originally sent to the CCU, where he was
monitored on tele overnight in anticipation of having a cath/EP
study once he was more stable. He had no further episodes of
VFib. On the floor, he did have a few runs of NSVT (5-7 beats)
that were asymptomatic. He was extubated on the morning of
[**8-1**], and originally had some cognitive deficits involving his
short term memory. At first, he wasn't responding to questions
at all, but this had resolved by the time he came to the floor.
Originally he would forget things seconds after being told, but
this had completely resolved by the day of discharge. He had
been previously placed on coumadin as an outpt for a depressed
EF, and this was held while a heparin drip was begun. He was
maintained on a heparin drip until his cath. At his cath, they
found:
1. Coronary angiography demonstrated a right dominant
circulation with
severe two vessel coronary artery disease. LMCA had no
significant
disease. LAD had 80% stenosis before and involving the origin
of D2 and
after S1 (with collaterals to RCA). LAD was totally occluded
after the
large D2. D2 supplies apex and collaterals to RCA. Lcx had a
large OM
branch and was free of significant disease. RCA was totally
occluded at
promixial to mid segment.
2. Limited resting hemodyanics revealed moderately elevated left
and
righ sided filling pressures. mRA was 14 mmHg, and RVEDP was 16
mmHg.
RVSP was mildly elevated at 43 mmHg. mPCW was elevated at 23
mmHg.
Fick calculated cardiac output and index were perserved at 6.1
L/min and
2.8 L/min/m2, respectively.
3.Successful Rotational Atherectomy and stenting of the mid LAD
lesion with a 2.75x23mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] with a 3.0x15mm
NC Ranger
baloon inflated at 20 atms.
An Echo done on [**8-1**] showed:
Severely dilated left ventricle with extensive systolic
dysfunction c/w multivessel CAD or other diffuse process.
Mild-moderate aortic
regurgitation. Mild aortic stenosis. Mild mitral regurgitation.
Compared with the report of 12/93 (tape unavailable for review),
the left
ventricular cavity is now more dilated, overall systolic
function is more
depressed, aortic regurgitation has increased.
He also had an EP study performed while he was here, and they
recommended ICD placement which was done on [**8-3**]. This was
complicated by a minor hematoma in the pocket of the pacer, that
did not grow in size and remained nontender. He was given
vancomycin x3 doses and was sent home on Keflex for a total of 5
days. The evening of the pacer placement, the pt was noted to
be tachycardic to the 120s. An EKG showed sinus tach. It was
felt this was likely [**2-6**] beta-blocker withdrawal, as it had been
approx 4-5 days since he had last had his BB (originally had
lower bp in CCU, systolic 100s so the BB had been held). This
was restarted with good pulse control, although on ambulation he
still got up into the 100s and so his Toprol dose was increased
on d/c. In terms of his other medications, his digoxin and
quinidine were discontinued. It was felt he did not need to be
on anticoagulation with coumadin, given the questionable hx of
LV clot that was not seen on repeat echo, and given that he
would be at least on ASA and plavix. His Lasix and Lisinopril
were not increased all the way back to his previous home doses,
as it was felt he would have a better EF given his [**Hospital1 **]-v pacing
and may not need as high a dose. He had a UTI which was treated
with a 7 day course of Bactrim. He did have a low-grade temp
(100.6) on [**8-3**] and [**8-4**], but had 2 CXR's negative for
infiltrate and no localizing signs of infection other than his
UTI. His pacer site specifically did not look infected. He was
discharged home with instructions to f/u with Dr. [**Last Name (STitle) **] in
[**4-11**] weeks and his PCP/Cardiologist Dr. [**Known firstname **] [**Last Name (NamePattern1) 7931**] within [**1-6**]
weeks.
Medications on Admission:
ASA
Atorvastatin
Protonix
Lasix 60 mg qd
Mag Oxide
Lopressor 100 mg [**Hospital1 **]
Lisinopril 10 mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 6 months: do not stop taking this medication
without talking to your cardiologist. Please rediscuss
continuing this medication with your cardiologist after 6
months.
Disp:*30 Tablet(s)* Refills:*5*
4. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
5. 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*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed. Tablet(s)
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
8. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days.
Disp:*16 Capsule(s)* Refills:*0*
10. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: 1.5
Tablet Sustained Release 24HRs PO once a day.
Disp:*45 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Ventricular Fibrillation Arrest
Coronary Artery Stenosis
Urinary Tract Infection
Ischemic Cardiomyopathy, depressed ejection fraction
Discharge Condition:
stable.
Discharge Instructions:
Please take all medications as directed.
Followup Instructions:
Please make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] within the
next 4-6 weeks. His office number is [**Telephone/Fax (1) 7332**].
Please follow up with your PCP and cardiologist, Dr. [**Last Name (STitle) 7931**],
within [**1-6**] week of discharge from the hospital. I know he has
partially retired, so please clarify with him if he can still be
your PCP and cardiologist or if he has someone else he
recommends. We can send Dr. [**Last Name (STitle) 7931**] your discharge plan as
discussed.
You should also follow up in the pacemaker clinic next week as
scheduled. Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2130-8-10**] 3:30
ICD9 Codes: 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2785
} | Medical Text: Admission Date: [**2169-6-5**] Discharge Date: [**2169-6-8**]
Date of Birth: [**2169-6-5**] Sex: M
Service: NB
HISTORY: Baby boy [**Known lastname 67870**] was the 2.39 kg product of a term
gestation born to a 32-year-old G2, P0 now 1 mother.
Prenatal screens - B positive, AB negative, RPR nonreactive,
rubella immune, hepatitis surface antigen negative, GBS
negative. This pregnancy was reportedly unremarkable. The
infant was born via spontaneous vaginal delivery 6 hours
after rupture of membranes. There was no intrapartum fever
and the mother did not receive intrapartum antibiotics. At
delivery, the infant emerged vigorous with Apgars of 8 and 9.
He was admitted to newborn nursery. In the newborn nursery
the infant had difficulty maintaining temperature and blood
sugars and has required periods under warming lights for the
temperature that had declined to 96.9, 97.3, and 97, with his
Dextrostix having ranged from 38 to 48. He has been sleepy
with limited interest in feeding and has fed up to half an
ounce with only finger feeding. Due to these concerns, the
infant was brought to the newborn intensive care unit for
further evaluation and management.
PHYSICAL EXAMINATION: Weight 2.365 grams (down 35 grams from
birth weight), small for gestational age infant responsive to
examination, quiet at rest, in no distress. Skin warm and
dry, pink. Capillary refill approximately 1.5 to 2 seconds.
Fontanel soft and flat. Palate intact. Ears and nares normal.
Neck supple. Chest clear to apex. No grunting, flaring or
retracting. CARDIOVASCULAR: Regular rate and rhythm. No
murmurs. ABDOMEN: Soft. No hepatosplenomegaly. No masses.
Quiet bowel sounds. GENITOURINARY: Normal male. Testes
descended. Anus patent. EXTREMITIES: No lesions. BACKS AND
HIP: Normal. NEUROLOGIC: Responsive to examination but
diminished spontaneous activity. Normal tone, weak suck,
intact grasp.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: The infant has been stable in room air throughout
hospital course.
CARDIOVASCULAR: The infant has had no cardiovascular issues.
FLUIDS, ELECTROLYTES AND NUTRITION: The infant was admitted
to the newborn intensive care unit and placed on 60 cc per kg
per day of D10W in light of the fact that the infant had
showed no interest in enteral feedings. D-stix normalized and the
infant has been euglycemic with the initiation of his dextrose.
He weaned off his IV over the next 24 hours. He is currently ad
lib feeding breast milk or Similac 20 calorie with stable
glucoses.
GASTROINTESTINAL: No issues.
HEMATOLOGY: Hematocrit on admission was 37.8. The infant has
not required any blood transfusions.
INFECTIOUS DISEASE: CBC and blood culture obtained on
admission to the newborn intensive care unit in light of
lethargy and hypoglycemia. CBC was benign and blood cultures
remained negative at 48 hours. The infant did not receive any
antibiotics.
NEUROLOGIC: The infant has been appropriate for gestational
age.
SENSORY: Hearing screen was performed with automated auditory
brain stem responses and the infant passed bilaterally.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**Location (un) 15749**] Pediatric
Group. Telephone No.: [**Telephone/Fax (1) 67871**].
FEEDS AT DISCHARGE: Continue ad lib breast feeding or
Similac 20 calorie.
MEDICATIONS: Not applicable.
CAR SEAT POSITION SCREEN: Not applicable.
STATE NEWBORN SCREEN: Sent per protocol and results are
pending.
DISCHARGE DIAGNOSES:
1. Hypoglycemia.
2. Thermoregulation.
3. Small for gestational age infant.
4. Rule out sepsis with antibiotics.
Dictated By:[**Last Name (NamePattern1) 58682**]
MEDQUIST36
D: [**2169-6-7**] 23:31:11
T: [**2169-6-8**] 00:46:22
Job#: [**Job Number 67872**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2786
} | Medical Text: Admission Date: [**2112-10-28**] Discharge Date: [**2112-11-15**]
Date of Birth: [**2059-8-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Basal cell carcinoma of the anterior chest wall with erosion and
chest wall bleeding with cough.
Major Surgical or Invasive Procedure:
[**2112-10-28**]: Radical sternectomy and placement of a VAC dressing.
[**2112-11-2**]: Chest wall reconstruction and omental flap.
[**2112-11-2**]:
1. Major reconstruction of chest wall, post-traumatic.
2. Right latissimus muscle flap.
3. Bilateral pectoralis muscle flap.
4. Local advancement flap 30 cm2.
5. Split-thickness skin graft to trunk 625 cm2.
6. Placement of negative pressure wound therapy.
History of Present Illness:
The patient is a 53-year-old gentleman who has had a basal cell
carcinoma of the anterior chest wall for approximately 10 years
without treatment. On
presentation in the emergency room he was exsanguinating from
this tumor and had lost approximately 500 to 1000 mL of blood
acutely and had dropped his hematocrit to 28. The tumor was a
fungating mass which smelled infected and had eroded clearly on
exam. This was also seen on CT scanning through the majority of
the sternal body and manubrium. It did not appear to be invading
the heart or great vessels. Thoracic surgery was consulted for
evaluation and treatment.
Past Medical History:
HIV
Basal cell carcinoma
Social History:
Divorced, with 2 children. Lives alone. [**First Name5 (NamePattern1) 892**] [**Name (NI) 20179**] (brother is
contact) Works out of home as a masseuse. Quit smoking in [**2086**].
Occasional ETOH. No IVDU.
Family History:
Noncontributory
Physical Exam:
VS: T: 97.3 HR: 87 SR BP: 122/78 Sats: 98% RA
General: Pleasant in no apparent distress
Neuro: Alert and oriented x 4 without focal deficits. PERRLA,
Moves all extremities to command.
HEENT: normocephalic, mucus membranes moist
Resp: clear breathsounds t/o
CV: RRR normal S1,S2 at apex, no MRG or JVD
Chest: sternal bed healing without redness, drainage, covered
with xeroform, gauze and ABD pads.
Abd:soft, NT, ND
Ext: warm BUE, BLE, without edema. Left thigh graft healing with
xeroform dressing adhered.
Right PICC line intact without redness, swelling or drainage at
the site.
Pertinent Results:
[**2112-11-14**] 04:42PM BLOOD WBC-6.6 RBC-3.10* Hgb-8.7* Hct-26.7*
MCV-86 MCH-28.1 MCHC-32.7 RDW-17.8* Plt Ct-746*
[**2112-11-11**] 05:51AM BLOOD WBC-7.5 RBC-3.21* Hgb-9.1* Hct-27.2*
MCV-85 MCH-28.3 MCHC-33.4 RDW-17.1* Plt Ct-796*
[**2112-11-14**] 04:42PM BLOOD PT-14.6* PTT-26.3 INR(PT)-1.3*
[**2112-10-28**] 07:16AM BLOOD WBC-9.4 Lymph-27 Abs [**Last Name (un) **]-2538 CD3%-67
Abs CD3-1712 CD4%-15 Abs CD4-375 CD8%-51 Abs CD8-1295*
CD4/CD8-0.3*
[**2112-11-14**] 04:42PM BLOOD Glucose-112* UreaN-10 Creat-0.6 Na-136
K-3.5 Cl-101 HCO3-29 AnGap-10
[**2112-11-12**] 04:51AM BLOOD Glucose-104* UreaN-10 Creat-0.5 Na-135
K-3.3 Cl-103 HCO3-27 AnGap-8
[**2112-10-28**] 07:16AM BLOOD Glucose-113* UreaN-4* Creat-0.9 Na-124*
K-4.1 Cl-89* HCO3-27 AnGap-12
[**2112-11-8**] 05:23PM BLOOD ALT-13 AST-26 AlkPhos-53 TotBili-0.7
[**2112-11-7**] 02:04AM BLOOD ALT-12 AST-15 LD(LDH)-157 AlkPhos-49
Amylase-77 TotBili-0.3
[**2112-11-14**] 04:42PM BLOOD Mg-1.8
[**2112-11-12**] 04:51AM BLOOD Calcium-7.3* Phos-3.2 Mg-1.8
[**2112-10-28**] 09:02PM BLOOD Calcium-8.7 Phos-4.2 Mg-1.5*
[**2112-11-9**] 01:52PM BLOOD Type-ART O2 Flow-3 pO2-97 pCO2-33*
pH-7.55* calTCO2-30 Base XS-6 Intubat-NOT INTUBA Vent-CONTROLLED
Chest xray on [**2112-11-12**]:
Portable AP chest radiograph was compared to prior study from
[**2112-11-11**].
Left apical pneumothorax has slightly increased in the interim,
moderate. The right chest tube is in unchanged position. There
is also small right apical pneumothorax, grossly unchanged as
compared to [**2112-11-11**]. The position of the fixators of
the anterior chest wall is unchanged as well as there is no
change in the cardiomediastinal silhouette. The amount of
pneumothorax on the left is minimal. Right pleural effusion is
unchanged.
Micro:
[**2112-10-28**] 6:42 pm TISSUE Site: STERNUM STERNAL TUMOR
MASS.
**FINAL REPORT [**2112-11-4**]**
GRAM STAIN (Final [**2112-10-28**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 109581**] @ 1115PM [**2112-10-28**].
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
TISSUE (Final [**2112-11-4**]):
REPORTED BY PHONE TO DR [**Last Name (STitle) **],[**Doctor First Name 109447**] [**2112-10-29**] 1145AM.
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH.
PROTEUS MIRABILIS. RARE GROWTH.
Further workup requested by DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**] ([**Numeric Identifier 37310**]).
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| PSEUDOMONAS AERUGINOSA
| | STAPH AUREUS
COAG +
| | |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S 2 S
CEFTAZIDIME----------- <=1 S 4 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=1 S 2 S <=0.5 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM-------------<=0.25 S 1 S
OXACILLIN------------- 0.5 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
ANAEROBIC CULTURE (Final [**2112-11-1**]):
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
MRSA SCREEN (Final [**2112-11-10**]): No MRSA isolated.
URINE CULTURE (Final [**2112-10-30**]): NO GROWTH.
Pathology:
DIAGNOSIS:
1. Left rib cartilage (A):
Cartilage, no malignancy identified.
2. Skin, subcutaneous tissue, and chest wall tissue including
portion of ribs, sternal tumor, resection (B-H):
Baso-squamous carcinoma, deeply invasive into chest wall,
ulcerated, approximately 17 mm. thick.
Margin clearance:
- Superior margin: 5 mm.
- Right superior: 1 mm.
- Left superior: 2 mm.
- Deep margin: Positive, focally, center of tumor.
Four lymph nodes, no carcinoma seen.
Note: Sections of bone are being decalcified, the findings of
which will be reported in the addendum.
Brief Hospital Course:
Mr. [**Known lastname 20179**] came to the [**Hospital1 18**] Emergency room on [**2112-10-28**] for a
large fungating, foul smelling anterior sternal basal cell
carcinoma which was bleeding. Initial bedside hemostasis was
obtained with cautery, sutures and surgicell in the Emergency
room. A CT chest revealed complete erosion of anterior chest
wall soft tissues and the mid sternal body, without invasion
into the heart or great vessels. Thoracic and Plastic surgery
was consulted. The patient was then taken to the Operating room
on [**2112-10-28**] where he underwent radical sternectomy with wound
vac placement. He was transferred to the ICU intubated given the
extensive change to the thoracic cavity for further management.
While in the SICU he required fluid challenges and neosynephrine
for hypovolemia with good response. He remained intubated and
was taken back to the operating room on [**2112-11-2**] with Plastic
and Thoracic surgery for Major reconstruction of chest wall,
with right latissimus muscle flap, bilateral pectoralis muscle
flap, local advancement flap 30 cm2, split-thickness skin graft
to trunk 625 cm2 and placement of negative pressure wound
therapy. He transferred back to the SICU intubated for
increased narcotics requirement for adequate pain control. The
pain service was consulted and once his pain was well controlled
he extubated on [**2112-11-7**]. He transferred to the Floor on
[**2112-11-10**] hemodynamically stable.
Drains & Chest tubes: Right and left chest tubes were removed
[**2112-11-11**], with stable postpull films. JP drains x 4 at
anastomosis site remained with serousanguious drainage. The JP
#4 was discontinued on date of discharge. Plastic surgery will
followup in a week from discharge for further management,
including drains.
Nutrition: The patient was given tube feedings via dobhoff while
intubated. He was seen by Speech and Swallow on [**2112-11-11**], who
cleared him for a regular diet with thin liquids which he
tolerated.
CV: The patient while on the floor was hemodynamically stable in
normal sinus rhythm.
Renal: A foley catheter which was placed initially on [**2112-10-28**]
and discontinued on [**2112-11-14**]. The patient voided well after
removal. Two urine cultures done inhouse were negative.
Sternal wound: VAC dressing managed by the plastic team. On
[**2112-11-14**] the VAC dressing was removed, with instruction for
further dressing changes with xeroform and light gauze fluff and
ABD pads to cover, changing daily.
ID: Infectious disease was consulted [**2112-10-30**]. Initially he was
started on Vancomycin and once the sternal wound cultures grew
Beta-Strep A he was switched to Unasyn and Clindamycin. Once
the final Intraoperative tissue specimen consisting of sternum
and tumor revealed a polymicrobial infection including MSSA,
Pseudomonas, Proteus and B. fragilis on [**2112-11-3**] he was
transitioned to a 6 week course of Imipenem for monotherapy of
the above Polymicrobial Sternal Osteomyelitis.
HIV: His HAART regime was restarted immediately postoperatively.
He was followed by his [**Hospital1 778**] medicine team while inhouse.
PICC: placed [**2112-11-1**] 54 cm R basilic: CXR revealed the right
PIC catheter ends in the SVC.
Neuro: pain control requiring ketamine drip with episodes of
hullcinations and confusion. Once the Ketamine drip was stopped
his mental status improved. His pain was well controlled
oxycodone and tylenol on discharge. During his confusion in the
ICU Head CT was done and negative for any acute abnormality.
Heme: Required 7 units of PRBC, 4 FFP, 1 plts in OR [**2112-11-2**].
His INR elevated to 3.3 on [**2112-11-8**] which he was given vitamin K
for.
The patient was seen by physical therapy and deemed a candidate
for rehab. The patient was screened and accepted at [**Hospital 57609**]
rehab. He was deemed stable for discharge to rehab on [**2112-11-15**],
with close outpatient followup with infectious disease, plastic
surgery and thoracic surgery. He will also have weekly labs.
Medications on Admission:
1. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. lamivudine 300 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. lamivudine 300 mg Tablet Sig: One (1) Tablet PO once a day.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for pain.
6. Imipenem-Cilastatin 500 mg IV Q6H
7. 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.
8. 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.
9. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**]
Discharge Diagnosis:
Basal cell carcinoma of the anterior chest wall.
HIV.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
The patient is transferring to [**Hospital3 **] in
[**Hospital1 8**] with the following discharge instructions:
Strict sternal precautions: no lifting, pushing or pulling
greater than 10 pounds for 2 months at least and until cleared
by physician.
[**Name10 (NameIs) **] chest PT.
No lying on stomach.
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (plastic surgeon) at [**Telephone/Fax (1) 6331**] if wound
bed becomes red, drains, opens, or if any wound concerns. They
are also managing JP drains:
Drain Care: 3 [**Location (un) 1661**] bulbs to suction. Cleanse insertion site
with mild soap and water or sterile saline, pat dry, and place a
drain sponge daily and as needed. Apply a drain sponge if
needed. Monitor and record quality and quantity of output.
Empty bulb frequently. Ensure that the drain and bulb are
secured to the patient. Monitor for signs of infection or
dislocation.
Sternal dressing: Cover with xeroform and light gauze fluffs
with ABD pad, changing daily.
Left leg xeroform dressing to stay on until it sloughs off. Call
plastic surgery at above number if any concerns regarding this
wound.
Call Dr.[**Name (NI) 2347**] office immediately at [**Telephone/Fax (1) 2348**] if
fevers greater than 101.5, coughing, shortness of breath, or any
sternal instability or chest pain.
Right PICC line per protocol.
Antibiotics: imipenem-cilistatin 500mg IV q6hrs, duration to be
determined by infectious disease.
DO NOT DISCONTINUE until approved by [**Hospital1 18**] infecious disease
department.
LABS: Check weekly CBC with differential, BUN/Creatinine, LFT's,
ESR, CRP and fax all laboratory results 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.
While on narcotics take stool softeners to prevent constipation.
Work with physical therapy, walking three times per day to
improve function.
Followup Instructions:
**Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Plastic surgery) on [**2112-11-25**]
at 1115am in [**Hospital Unit Name **] on [**Last Name (NamePattern1) 439**]. [**Location (un) 442**] 5A
**Follow-up with [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2112-12-1**] 3:30 [**Hospital Ward Name 23**] [**Location (un) **] [**Hospital1 18**] [**Hospital Ward Name **].
Get a chest xray 30 minutes prior to this appointment on the [**Location (un) **] radiology.
**Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2112-12-1**] 9:50 Infectious Disease [**Last Name (NamePattern1) **] Ground
Floor
**Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2112-12-29**] 9:30
Infectious Disease [**Last Name (NamePattern1) **] Ground Floor
Completed by:[**2112-11-15**]
ICD9 Codes: 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2787
} | Medical Text: Unit No: [**Numeric Identifier 75439**]
Admission Date: [**2182-12-9**]
Discharge Date: [**2182-12-14**]
Date of Birth: [**2182-12-9**]
Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname **] was admitted at 3 days old, 36-
[**2-27**] weeker at birth. This infant was admitted to the NICU
for observation after significant dusky episode was noted
during carseat testing. The obstetrician was Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], pediatrician, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. This mother
is a 37-year-old G2 P0 now 1 woman with a past medical
history remarkable for colon cancer treated with surgical
resection and chemotherapy in [**2178**]. An IUFD at 35 weeks'
gestation, prenatal screens, blood type O-negative, antibody
negative, GBS unknown, HBSAG negative, RPR nonreactive,
Rubella immune. This delivery was by C-section, as a repeat
C-section. AROM was at the time of delivery. This was an
uncomplicated delivery. The infant emerged with Apgars of 9
and 9.
NEWBORN COURSE: The infant has been doing well in the
newborn nursery, taking [**1-22**] to 1-1/2 ounces of formula per
feeding. Stable cardiorespiratory status and the patient was
brought to the NICU carseat testing and noted to have an
episode of duskiness with O2 saturations of 57 while in the
carseat.
PHYSICAL EXAMINATION: Showed a birth weight of 2680 g and a
weight on admission to the NICU of 2480 g. HEENT: Anterior
fontanelle soft and flat. Normal facies. Intact palate.
Clear and equal breath sounds. Normal S1 and S2. No murmur.
Abdomen: No hepatosplenomegaly. Normal female. Hips:
Stable. Skin: Clear. Neurologic: Tone normal. Very
active and alert. Suck and swallowing normal. Appears well
coordinated.
SUMMARY OF HOSPITAL COURSE: By systems.
Respiratory: The infant has remained on room air since
admission to the NICU, but has had apneic and desaturation
episodes daily, while in the NICU. She is presently 5 days
old, with the most recent being 3 desaturations in the past
24 hours. Otherwise, saturations remain stable on room air
between spells.
Cardiovascular: The infant has maintained cardiovascular
stability while in the NICU.
Fluid, electrolytes and nutrition: The infant has been ad
lib oral feeding of Enfamil 20 calories per ounce and takes
approximately 90 mL/kg per day. Most recent weight was 2435
g on [**2182-12-14**], which was down 35 g in 24 hours. No
electrolytes have been measured on this baby.
GI: [**Name2 (NI) **] bilirubin was 10.7/0.3, and that was on day of life
5. Most recent bilirubin prior to that was on day of life 3,
[**2182-12-12**], with results of 8.3/0.3. Infant has not
required any phototherapy thus far.
Hematology: The infant's blood type is O-positive, DAT
negative. Hematocrit on admission to the NICU was 50, with a
platelet count of 488,000. The infant has required no blood
product transfusions.
Infectious disease: CBC and blood culture were screened on
admission to the NICU. The infant was started on ampicillin
and gentamicin. The CBC remained normal with no bands. No
left shifts. The infant received 48 hours of ampicillin and
gentamicin, which were subsequently discontinued on [**2182-12-14**], when the blood culture remained negative.
Neurology: Other than the apneic and dusky episodes, the
infant has maintained a normal neurologic examination.
Sensory:
CONDITION AT DISCHARGE: Fair.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 **] Level
2 Nursery. Name of primary pediatrician is Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], telephone number ([**Telephone/Fax (1) 56989**].
CARE RECOMMENDATIONS: Ad lib oral feeds of Enfamil 20 cal
per ounce. No medications at discharge. Iron and vitamin D
supplementation.
1. Iron supplementation is recommended for pre-term and low
birth weight infants until 12 months corrected age.
2. All infants fed predominantly breast milk should receive
vitamin D supplementation at 200 international units,
which may be provided as multivitamin preparation daily
until 12 months corrected age.
3. Car seat position screening is recommended prior to
discharge. State newborn screens were sent on [**12-12**], [**2182**]. Results are pending.
IMMUNIZATIONS RECEIVED: Infant received the hepatitis B
vaccine on [**2182-12-11**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following full criteria:
a. Born less than 32 weeks.
b. Born between 32 and 35 weeks with 2 of the
following, either daycare during RSV season, a smoker
in the household, neuromuscular disease, airway
abnormalities, or school age siblings;
c. Chronic lung disease;
d. Hemodynamically significant congenital heart
defect.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age, and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
3. This infant has not received a Rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of pre-term infants at or following
discharge from the hospital, if they are clinically
stable and at least 6 weeks', but fewer than 12 weeks'
of age.
FOLLOWUP: Follow-up appointment should be with the
pediatrician after discharge from [**Hospital3 **].
DISCHARGE DIAGNOSES: Prematurity and apnea of prematurity.
Sepsis ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Doctor Last Name 75440**]
MEDQUIST36
D: [**2182-12-14**] 11:02:34
T: [**2182-12-14**] 12:35:30
Job#: [**Job Number 75441**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2788
} | Medical Text: Admission Date: [**2115-4-2**] Discharge Date: [**2115-4-30**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
Throat swelling
Major Surgical or Invasive Procedure:
Endotracheal intubation
Placement of central venous catheter
Placement of triple-lumen foley catheter
History of Present Illness:
85 y.o. M with hx of HTN, AFib, GERD p/w with 1 wk hx of neck
swelling, dyspagia of solids and liquids, felt to have
supraglottitis, started on high dose steroids. He initially was
started on steroids, but developed delirium and agitation,
requiring intubation for airway protection. Steroids were
weaned off. The cause of his supraglottitis was thought to be
angioedema [**1-24**] ACE-I, however pt states that he has been taking
his medicines for a long time. Pt extubated, but had worsening
stridor, hypoxemia and reintubated electively. He then
self-extubated on [**4-9**], but on [**4-12**] was found to be
unresponsive, hypercarbic and in PEA arrest, and reintubated.
Given atropine, epi and on pressors for 1 day. Pt finally
extubated on [**4-16**], no respiratory problems since then.
Otherwise MICU course complicated by rapid AF requiring IV
lopressor, large amount of secretion, and sputum cx's with
e.coli and pseudomonas, started on Zosyn on [**4-15**] for sinusitis
by head CT on [**4-14**]. In addition, pt has required NGT for
nutrition given concern for aspiration, however pulled out
earlier today. Video swallow study earlier today showed some
evidence of aspiration and assymetrical neck swelling.
On further hx pt admits to preceding subjective fever, denies
chills. Also admits to lots of rhinorrhea, nasal congestion. +
sick contacts with grandchildren. He denies chills, diarrhea,
cough, shortness of breath, urinary sx's, rash, recent
medication changes. He is followed at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**] VA. He was
born in [**Male First Name (un) 1056**], moved to US in [**2060**], unclear status of
vaccinations.
Past Medical History:
chronic AFib-anticoagulation on coumadin s/p DCCV in 12/99
HTN
Borderline CAD - cath [**11/2109**]- 2. Selective coronary angiography
reveals a right dominant system with two vessel disease. The
left main tapers distally to a 40% stenosis. There is ostial
disease of all vessels at the trifurcation: LAD 60%, ramus
40-50%, LCX 50%. The RCA is small, but dominant, without focal
stenosis.
?CAD -s/p IMI
diabetes mellitus
COPD
BPH/Increased PSA
Hypercholesterol
OA- knees
-Possible Osggod Schlatter right knee
Syncope [**4-/2107**] - neg w/u (tilt, EP, DSE)
GI bleed [**10-24**]
-EGD: [**10-24**] - Single non-bleeding ulcer at antrum, single non-
bleeding superficial ulcer in duodenum
-Colonoscopy [**10-24**] - polyps (HP x 2, TA x 1)
[**8-/2114**]- ext hemorrhoids
Social History:
110 pack year smoking hx, quit 3 years ago, occais etoh. Lives
alone, independent in all adl's
Family History:
NC
Physical Exam:
T 98.9 P 83 BP 128/47 RR 18 O2 96% RA, wt 88 kg complains of
mild sob when flat
Gen: no respiratory distress, no noticable gurgling, minimal
drooling
HEENT: EOMI, PERRLA, +trismus, erythema, difficult to visulize
tonsills, swelling R>L
LN: +submandibular lymph nodes right>L
Lungs: CTA x 2
Heart: s1 s2 no m/r/g
Abd: soft nt/nd +bs
Ext: no c/c/e
CN II-XII intact
AOx3
Pertinent Results:
[**4-2**] Neck CT:
FINDINGS: A moderate amount of soft tissue swelling is seen
within the peritonsillar region with no definite focal
low-attenuation lesion to suggest abscess. A preponderance of
soft tissue swelling is seen within the supraglottic region. No
pathologically enlarged nodes are identified.
Of note, significant amount of ossification is seen within the
anterior cervical spine consistent with DISH. This region of
ossification is displacing soft tissue anteriorly.
IMPRESSION:
1. Soft tissue density within predominantly supraglottic region
with no definite evidence peritonsillar abscess.
2. No evidence of lymphadenopathy.
3. DISH causing anterior soft tissue displacement of the
pharynx.
.
[**4-3**] Head CT:
FINDINGS: There is no evidence of intracranial bleed, mass
effect, shift of normally midline structures. Within the left
cerebellum, there is a focal area of low density, likely
representing volume averaging. No major vascular territorial
infarct is seen. No evidence of hydrocephalus. Small air-fluid
levels are seen within the sphenoid sinuses and mucosal
thickening is present within the ethmoid sinuses. The maxillary
sinuses and ethmoid air cells are clear.
IMPRESSION: No evidence of intracranial hemorrhage.
Sinusitis
.
[**4-14**] Sinus CT:
NON-CONTRAST SINUS CT: Mucosal thickening is seen in the right
maxillary sinus. Minor mucosal thickening is seen in the ethmoid
air cells. Both sphenoid sinuses show air fluid levels and
mucosal thickening. There is scattered opacification of the
mastoid air cells. No bony destruction is seen. The patient has
a smallbore nasogastric feeding tube. A tiny focus of air is
seen between the dens and the anterior ring of C1; the
atlantoaxial interval is still within normal limits. The right
ostiomeatal unit is not patent, although the left is. The nasal
septum deviates to the right of midline. Anterior clinoid
processes are not pneumatized. The sphenoid sinus septum inserts
roughly on the midline.
IMPRESSION: Sinusitis, slightly worse compared to the CT scan of
[**2115-4-7**].
.
[**4-22**] Neck CT
FINDINGS: The patient is status post extubation. Previously
noted lobulated soft tissue swelling in the supraglottic region
is not identified in the present scan. Oropharynx and
hypopharynx are patent and symmetric. No significant
lymphadenopathy. Note is made of cervical spondylosis, as noted
previously. The visualized portions of the lung apices are
clear. No suspicious lytic or blastic lesions.
IMPRESSION: Previously noted supraglottic soft tissue swelling
is not identified. Cervical spondylosis.
.
TTE:
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *6.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - E Wave Deceleration Time: 132 msec
TR Gradient (+ RA = PASP): *40 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s)
Conclusions:
The left atrium is markedly dilated. The right atrium is
moderately dilated. The inferior vena cava is dilated (>2.5 cm).
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular systolic function is normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present.
Mild to moderate ([**12-24**]+) aortic regurgitation is seen. The mitral
valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
.
[**2115-4-2**] 02:00AM BLOOD WBC-11.5* RBC-4.60 Hgb-13.4* Hct-39.9*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.2 Plt Ct-223
[**2115-4-6**] 01:30AM BLOOD WBC-12.0* RBC-4.47* Hgb-12.8* Hct-38.7*
MCV-87 MCH-28.6 MCHC-33.0 RDW-15.3 Plt Ct-196
[**2115-4-13**] 04:11AM BLOOD WBC-11.9* RBC-3.58* Hgb-10.5* Hct-31.5*
MCV-88 MCH-29.4 MCHC-33.5 RDW-16.3* Plt Ct-240
[**2115-4-24**] 05:20AM BLOOD WBC-10.0 RBC-3.08* Hgb-9.4* Hct-28.4*
MCV-92 MCH-30.4 MCHC-33.0 RDW-19.2* Plt Ct-381
[**2115-4-2**] 02:00AM BLOOD Neuts-87.1* Lymphs-8.1* Monos-4.4 Eos-0.3
Baso-0.1
[**2115-4-7**] 02:30AM BLOOD Neuts-87.3* Lymphs-7.7* Monos-4.0 Eos-0.5
Baso-0.4
[**2115-4-14**] 04:30AM BLOOD Neuts-87.9* Lymphs-8.3* Monos-3.1 Eos-0.5
Baso-0.1
[**2115-4-2**] 03:20AM BLOOD PT-34.4* PTT-31.9 INR(PT)-3.7*
[**2115-4-4**] 01:35PM BLOOD PT-68.8* PTT-36.2* INR(PT)-8.8*
[**2115-4-5**] 03:00AM BLOOD PT-24.8* PTT-29.2 INR(PT)-2.5*
[**2115-4-24**] 05:20AM BLOOD PT-12.8 PTT-29.0 INR(PT)-1.1
[**2115-4-2**] 02:00AM BLOOD Glucose-154* UreaN-16 Creat-0.9 Na-137
K-3.5 Cl-100 HCO3-26 AnGap-15
[**2115-4-6**] 01:30AM BLOOD Glucose-148* UreaN-21* Creat-0.9 Na-143
K-3.4 Cl-108 HCO3-25 AnGap-13
[**2115-4-13**] 04:11AM BLOOD Glucose-161* UreaN-31* Creat-2.0* Na-150*
K-3.6 Cl-116* HCO3-25 AnGap-13
[**2115-4-24**] 05:20AM BLOOD Glucose-108* UreaN-12 Creat-1.0 Na-143
K-4.2 Cl-109* HCO3-22 AnGap-16
[**2115-4-3**] 10:00PM BLOOD ALT-22 AST-57* CK(CPK)-3122* AlkPhos-69
Amylase-338* TotBili-0.7
[**2115-4-5**] 03:00AM BLOOD ALT-25 AST-48* CK(CPK)-1270* AlkPhos-65
Amylase-384* TotBili-0.7
[**2115-4-19**] 05:00AM BLOOD ALT-23 AST-28 AlkPhos-68 TotBili-1.4
[**2115-4-13**] 04:11AM BLOOD CK(CPK)-69
[**2115-4-3**] 03:06AM BLOOD Lipase-23
[**2115-4-5**] 03:00AM BLOOD Lipase-21
[**2115-4-2**] 02:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2115-4-3**] 10:00PM BLOOD CK-MB-13* MB Indx-0.4 cTropnT-0.04*
[**2115-4-4**] 03:04AM BLOOD CK-MB-13* MB Indx-0.5 cTropnT-0.03*
[**2115-4-12**] 01:25PM BLOOD CK-MB-6 cTropnT-0.01
[**2115-4-2**] 05:55AM BLOOD Calcium-8.4 Phos-1.9* Mg-1.6
[**2115-4-19**] 05:00AM BLOOD calTIBC-192* TRF-148*
[**2115-4-3**] 03:06AM BLOOD VitB12-337 Folate-7.9
[**2115-4-3**] 03:06AM BLOOD TSH-0.25*
[**2115-4-4**] 03:04AM BLOOD Free T4-1.2
[**2115-4-5**] 03:00AM BLOOD C4-18
[**2115-4-24**] 05:20AM BLOOD C4-24
[**2115-4-2**] 02:00AM BLOOD Digoxin-0.5*
[**2115-4-2**] 02:10AM BLOOD Lactate-1.7
Urine
Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks
LG NEG TR NEG TR NEG NEG 5.0 TR
RBC WBC Bacteri Yeast Epi TransE RenalEp
>50 [**6-1**]* FEW NONE 0-2
CYTOLOGY ATYPICAL.
Rare atypical urothelial cells present singly and in loose
clusters.
Squamous cells, histiocytes, neutrophils and red blood cells.
Micro:
Blood cultures 4/11, [**4-11**], [**4-12**]: No growth.
Blood culture [**4-14**]: Presumptive PROPIONIBACTERIUM ACNES [**12-26**]
bottles
[**4-2**]: Monospot negative
[**4-2**] Throat Culture: Beta-hemolytic, non group-A strep, sparse
growth
[**4-2**]: Respiratory virus screen negative on nasopharyngeal
aspirate
[**4-3**] Urine culture negative
[**4-7**] Sputum: No growth
[**4-11**] Sputum:
ESCHERICHIA COLI
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S 16 I
CEFTAZIDIME----------- <=1 S =>64 R
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- 0.5 S =>4 R
GENTAMICIN------------ <=1 S 4 S
IMIPENEM-------------- <=1 S I
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S 8 I
PIPERACILLIN---------- =>128 R =>128 R
PIPERACILLIN/TAZO----- <=4 S 64 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**4-11**] Stool: C. diff negative
[**4-14**] RPR nonreactive
[**4-14**] Sputum: E. Coli and P. aeruginosa
.
[**4-18**] Video Swallow:
VIDEO OROPHARYNGEAL SWALLOW EXAMINATION: An oral and pharyngeal
video fluoroscopy swallowing study was performed in
collaboration with the Speech and Language Pathology division.
Various consistencies of barium including thin liquid,
nectar-thickened liquid and puree consistencies were
administered.
A single spot fluoroscopic image again demonstrates ossification
of the anterior longitudinal ligament of the cervical spine,
which is unchanged from recent neck CTs on [**4-2**] and [**4-7**], [**2114**].
The oral phase of the study was notable for mild impairment of
bolus formation and control without premature spillover. The
pharyngeal phase was notable for moderate-to-severely impaired
laryngeal elevation and valve closure. There was absent
epiglottic deflection. Following swallow, mild residue remained
in the pharynx and spilled into the airway after the swallow.
In the AP position, bilateral vocal fold adduction was observed.
Left pharyngeal swelling was noted with the left piriform sinus
nearly completely effaced. There was penetration into the
laryngeal vestibule with all consistencies before and after
swallowing. There was aspiration of small amounts of all
consistencies following the swallow due to spillage of material
from the laryngeal vestibule and piriform sinuses. There was a
spontaneous cough upon aspiration.
IMPRESSION: Moderate pharyngeal dysphagia with aspiration of
small amounts of all consistencies after the swallow. A
combination of left pharyngeal swelling and chronic ossification
of the anterior longitudinal spinal ligament contributes to the
swallowing difficulty.
.
[**4-22**] Video Swallow:
An oral and pharyngeal swallowing videofluoroscopy was performed
today in collaboration with the speech and language pathology
division. Various consistencies of barium including thin liquid,
nectar-thickened liquid, puree, and ground cookies and pudding
were administered.
The oral phase was notable for mildly impaired bolus formation
control and anterior to posterior tongue movement. There was
premature spillover of thin and nectar-thickened liquids into
the pharynx prior to initiation of the swallow.
The pharyngeal phase was notable for mild delay in the
pharyngeal swallow. There was moderate-to-severe impairment of
laryngeal elevation and valve closure. Epiglottic deflection was
not demonstrated. Mild-to-moderate amounts of puree and ground
consistencies were retained in the valleculae to a greater
extent than in the piriform sinuses.
In the anterior to posterior position swelling of the left
pharynx was again demonstrated, but improved compared to prior
study last week.
There was penetration of thin and nectar-thickened liquids into
the laryngeal vestibule before and during the swallow. There was
aspiration of thin and nectar-thickened liquids before and after
the swallow. There was a spontaneous cough upon aspiration.
IMPRESSION: Overall improved oropharyngeal swallowing function
compared to [**2115-4-18**] but continued aspiration of thin and
nectar-thickened liquids before and after the swallow.
Improvement in left pharyngeal swelling.
Brief Hospital Course:
# s/p PEA arrest - unclear etiology. Likely secondary to
hypoxia, hypercarbic respiratory acidosis, copious secretions.
Became temporarily hypotensive on pressors with CEs negative.
Pressors quickly weaned without difficulty. Treated with
aggressive suctioning, albuterol/atrovent/flovent.
.
# Supraglottitis - Treated initially with Unasyn. Resolved over
span of [**10-5**] days. Etiology remains unclear. Throat culture
grew sparse B-hemolytic, non-Group-A strep. EBV, blood cultures,
nasopharyngeal aspirate for respiratory viruses all negative.
Possibly angioedema secondary to ACEI, which was immediately
d/c'ed on admission. On [**4-3**], pt became acutely agitated,
thought to be [**1-24**] steroid psychosis. Intubated for airway
protection in setting of increased need for sedation. Patient
extubated uneventfully on [**4-5**]. D/c'd Unasyn and Decadron on
[**4-5**] as unclear that these interventions were adding any
benefit. ENT re-eval on [**4-6**] without signs of edema. On [**4-6**],
again became increasingly stridorous, acidotic, hypoxic after
ativan/haldol for agitation and re-intubated. Self-extubated on
[**4-9**]. Reintubated after PEA arrest, as above. Serial neck CTs
demonstrated gradual resolution of soft tissue edema, but did
demonstrate diffuse ossification of the anterior longitudinal
ligament, which likely limits functional reserve, predisposing
Mr. [**Known lastname 66593**] to respiratory distress with small amount of
soft tissue swelling. Speech and swallow evaluation from [**4-7**]
and [**4-18**] demonstrated evidence of aspiration, and Mr.
[**Known lastname 66593**] was kept NPO with NGT in place. As mental status
cleared, repeat S&S evaluation done on [**4-23**], which demonstrated
improvement. Was placed back on carefully observed PO diet, with
repeated teaching regarding safe PO intake. On [**4-23**], consulted
Allergy, who thought it would be safe to restart low-dose [**Last Name (un) **],
as a) possible infectious etiology, and b) relatively small
cross-over effect in likelihood between ACEI and [**Last Name (un) **].
Experienced episode of relative hypotension to SBP 80 after two
doses [**Last Name (un) **], and was d/c'ed prior to d/c. However, did not
experience any resporatory compromise; therefore, should
ACEI/[**Last Name (un) **] become important to Mr. [**Doctor Last Name 66594**] future
medical management, it should be reasonably safe.
.
# Delirium/Psychosis: Probable ICU psychosis vs. steroid
psychosis. Also with positive sputum cultures and leukocytosis,
possible constributing infection component. Received high doses
Haldol in ICU, QTc remained stable. Head CT neg [**4-3**], [**4-7**],
[**4-14**]. Psychiatry followed and left recommendations regarding
sedating meds for agitation. Mental status improved around
[**4-22**], scheduled Haldol d/c'ed, with continued options for prn
Haldol and Seroquel.
.
# CAD: H/o IMI. Cath [**2108**] with 2VD - LAD 60%, LCX 50%. PMIBI at
VA [**11-26**] without ischemic changes. CE neative after PEA arrest.
Maintained on ASA, titrated up BB, reinstituted [**Last Name (un) **] on [**4-23**],
but d/c'ed after episode of hypotension to SBP 80.
.
# HTN- Home regimen includes fosinopril, atenolol, hctz,
terazosin, nifedipine.
Held antihypertensives given hypotension in ICU. Also
experienced episode of relative hypotension to 80/palp on [**4-25**]
after reintroduction of [**Last Name (un) **] to regimen of metoprolol, terazosin,
and [**Last Name (un) **] d/c'ed.
.
# Afib- remains in chronic A fib. Held coumadin in setting of
supratherapeutic INR, held lopressor/dilt/digoxin in acute
setting. Achieved rate control once reintroducing metoprolol.
Restarted coumadin [**4-26**]. Will need to have INR monitored and
coumadin adjusted to goal INR [**1-25**].
.
# Urinary retention/hematuria - Experienced gross hematuria,
initially in setting of supratherapeutic INR. Experienced
concommitant urinary retention, likely [**1-24**] to clots. Had 24
french 3 way catheter with continuous bladder irrigation in ICU,
d/c'd [**4-12**] as urine cleared. Gross hematuria returned once
called out to floor, with persistent clots despite flushing and
changing foley. Reinstituted 3-way CBI, with urology
consultation. Urine cytology demonstrated atypical cells. Will
need close f/u by urology for outpatient cystoscopy for possible
bladder CA. He will need to renew his application for Freecare
before an outpatient appointment can be made.
.
# FEN - While NPO, fed via Dobhoff w/ TF's - Promote with
fiber, free water flushes. After POs reinstituted, maintained on
pureed solids, nectar-thick liquids, with closely observed
feeding. Aspiration precautions instituted.
#Code- Full Code
Medications on Admission:
1) ALBUTEROL 90/IPRATROP 18MCG 200D PO INHL INHALE 2 ACTIVE
PUFFS BY MOUTH FOUR TIMES A DAY
2) ASPIRIN 81MG EC TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE
DAY
3) ATENOLOL 100MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE
(S)
4) CAPSAICIN 0.075% CREAM APPLY THIN FILM TO SKIN TWICE ACTIVE
A DAY FOR LOCALIZED PAIN
5) CODEINE 30MG/ACETAMINOPHEN300MG TAB TAKE 1 TABLET BY ACTIVE
MOUTH THREE TIMES A DAY FOR PAIN
6) DIGOXIN (LANOXIN) 0.125MG TAB TAKE ONE TABLET BY ACTIVE
MOUTH EVERY DAY
7) DOCUSATE NA 100MG CAP TAKE ONE CAPSULE BY MOUTH TWICE ACTIVE
A DAY TO SOFTEN STOOL
8) FOSINOPRIL NA 20MG TAB TAKE TWO TABLETS BY MOUTH ACTIVE EVERY
MORNING AND TAKE ONE TABLET EVERY EVENING INCREASE IN DOSE
[**2113-6-27**]
9) HYDROCHLOROTHIAZIDE 25MG TAB TAKE ONE TABLET BY MOUTH ACTIVE
EVERY DAY
10) MENTHOL 10%/METHYL SALICYLATE 15% CREAM APPLY ACTIVE
MODERATE AMOUNT TO SKIN EVERY DAY AS NEEDED FOR
KNEE ARTHRITIS
11) NIFEDIPINE (ADALAT CC) 30MG SA TAB TAKE (DO NOT ACTIVE
CRUSH) ONE TABLET BY MOUTH EVERY DAY FOR HEART
12) OMEPRAZOLE 20MG SA CAP TAKE ONE CAPSULE BY MOUTH ACTIVE
EVERY MORNING 30 MINUTES BEFORE BREAKFAST
(REPLACES RABEPRAZOLE)
13) PSYLLIUM SF ORAL PWD TAKE 1 TABLESPOONFUL BY MOUTH ACTIVE
EVERY DAY (DISSOLVE IN 8OZ WATER/JUICE BEFORE
DRINKING)
14) SIMVASTATIN 80MG TAB TAKE ONE-HALF TABLET BY MOUTH AT ACTIVE
BEDTIME FOR REDUCING CHOLESTEROL
15) TERAZOSIN HCL 5MG CAP TAKE ONE CAPSULE BY MOUTH AT ACTIVE
BEDTIME
16) WARFARIN (COUMADIN) NA 2MG TAB TAKE ONE AND ONE-HALF ACTIVE
TABLETS BY MOUTH EVERY EVENING EXCEPT TAKE TWO TABLETS EVERY
MONDAY TO PREVENT BLOOD CLOTS(ANTICOAGULATION)
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*30 Suppository(s)* Refills:*2*
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime):
Restarted coumadin [**4-26**] - will need INR checked [**5-2**].
Disp:*120 Tablet(s)* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation prn as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
9. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO once a day.
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Supraglottitis
Hematuria
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with supraglottitis, and were intubated in the
ICU. Your swelling has resolved. You were also treated for blood
in your urine, and it is very important that you follow up with
urology. .
You also need to have your coumadin level checked on Thursday,
[**5-2**].
Followup Instructions:
It is important that you follow up at urology clinic with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**]. You will need to finalize your Freecare renewal
before an appointment can be made, but when this is done, you
should call [**Telephone/Fax (1) 5727**] for an appointment.
.
If you have trouble arranging urology follow-up with Dr.
[**Last Name (STitle) 770**], you should try to arrange this through the [**Location 1268**]
system.
ICD9 Codes: 4275, 496, 2762, 5849, 2720, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2789
} | Medical Text: Admission Date: [**2111-11-25**] Discharge Date: [**2111-12-9**]
Date of Birth: [**2028-5-11**] Sex: F
Service: MEDICINE
Allergies:
aspirin / Lactose
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Hypoxia/Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83F history of CAD CHF presenting from a nursing facility with
hypoxia to the 70s. She is baseline dementia and is not
complaining of any pain. She is alert and oriented to self only
but will answer questions.
Overall, history is unclear, since patient is unable to provide
detailed history. Per ED, she was sent from a nursing facility
with hypoxia into 70s.
Her nephew reports that about a week ago she was at [**Hospital 26260**]
hospital with some "discomfort", unclear exactly what it was,
however. He reported that she was going to undergo a cardiac
catherization, but this did not happen for some reason. Since
then she has been living at [**Doctor First Name 4233**] house by herself and not
having any major concerns. She did have a cough that he noted
today only, but not clear how long that this has been going on.
In the ED, initial vs were: Temp of 101.4, Tachycardic into
120s, blood pressure in 80s, a central line was placed into her
groin, given that she was not cooperative with other access
sites, and she was started on norepinephrine for blood pressure
support after getting 2Liters of NS IV. UA was notable for Hazy
urine, with neg Leuk, WBC 10, few Bact, No epis, and negative
for Nitrites. Labs were notable for WBC 18.6, with 82%Neuts, 1
band, 10Lymphs. Troponin <0.01. An EKG showed sinus tachycardia
at HR of 120, QTc of 456, Normal Axis. No concerning ST changes.
Urine culture was sent off. Patient was given Vancomycin, Zosyn
Past Medical History:
Memory impairment
Microcytic anemia
Absolute glaucoma of right eye
Not Taking Medication as Directed
Bullous Keratopathy
PSEUDOPHAKIA
GLAUCOMA - PRIMARY OPEN ANGLE
TOBACCO DEPENDENCE
Social History:
Obtained from Patient, and Atrius OMR)
Grew up in [**Doctor First Name 26692**], moved to MA 20 years ago permanently,
also lived in [**Location 92535**]. Her husband was from MA. Married in the
[**2059**], deceased in [**2089**] (she is not sure of details). No
children of her own but many nieces and nephews. Lives in
apartment with kitchenette, is a senior building, no communal
meals. They bring her meals for lunch and dinner.
Current Everyday Smoker -- 0.2 packs/day for 60 years
ETOH only socially; rarely
Family History:
Sister heart disease, Tuberculosis,
Father - CAD, PVD
Physical Exam:
Admission:
VS: T: 97.3, P: 131, RR: 27, BP: 155/93, 100% on 4L NC
Gen: NAD, comfortable, coughing intermittently
HEENT: OP clear, dry MM
Neck: supple, no LAD
CV: RRR, S1/S2, no MRG appreciated
Lungs: CTAB, no w/r/r
Abd: soft, NT, ND, NABS
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
Skin: wound on back
Pertinent Results:
Admission labs:
[**2111-11-24**] 11:00PM BLOOD WBC-18.6* RBC-4.57 Hgb-10.8* Hct-33.0*
MCV-72* MCH-23.7* MCHC-32.7 RDW-13.6 Plt Ct-200
[**2111-11-24**] 11:00PM BLOOD Neuts-82* Bands-1 Lymphs-10* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2111-11-25**] 06:32AM BLOOD PT-14.4* PTT-38.6* INR(PT)-1.3*
[**2111-11-24**] 11:00PM BLOOD Glucose-137* UreaN-17 Creat-1.0 Na-143
K-3.6 Cl-105 HCO3-27 AnGap-15
[**2111-11-24**] 11:00PM BLOOD ALT-14 AST-29 AlkPhos-62 TotBili-0.8
DirBili-0.2 IndBili-0.6
[**2111-11-24**] 11:00PM BLOOD cTropnT-<0.01
[**2111-11-24**] 11:00PM BLOOD proBNP-518
[**2111-11-25**] 06:32AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.8
[**2111-11-24**] 11:28PM BLOOD Glucose-134* Lactate-1.6 K-3.5
[**2111-11-25**] CT CHEST
1. No evidence of acute aortic syndrome or acute pulmonary
embolus.
2. Soft tissue density nodal mass surrounding the right lower
lobe bronchus and [**Last Name (LF) 56207**], [**First Name3 (LF) **] be infectious in nature or may
represent a neoplasm. Right lower lobe consolidation is present,
which may represent post-obstructive changes, infection in the
appropriate clinical setting or aspiration.
3. Markedely enlarged thryoid gland with multple hypodense
lesions, consider thyroid unltrasound exam for further
assessment.
4. Prominent centrilobular emphysema involving primarily upper
lobes.
5. A 6-mm endobronchial lesion at the left main bronchus, may
represent an
endobronchial neoplasm, hamartoma and small mucous nodele.
6. Intrahepatic biliary ductal dilatation. Gallbladder is
distended without gallbladder wall thickening or pericholecystic
fluid collection.
7. Left renal cysts.
Brief Hospital Course:
83F history of CAD CHF presenting from a nursing facility with
hypoxia to the 70s, hypotension, fever of 101.4, and
leukocytosis. Initially admitted to the MICU, started on empiric
treatment for HCAP and COPD exacerbation. She showed some signs
of improvement at times throughout her course, but experienced
numerous setbacks, including intermittent tachycardia,
hypotension, guaic positive stool concerning for an acute GI
bleed, and acute encephalopathy. She then had profound
respiratory decompensation on [**2111-12-7**]. This resulted in a
shift in the focus of care to comfort-centered care. She passed
away peacefully at 04:26 am on [**2111-12-9**]. Please [**Last Name 788**] problem
summaries below for further details on the antecedent causes of
her death.
# Acute hypercarbic respiratory failure: found around 11 AM on
[**12-7**] to be unresponsive to sternal rub or nailbed pressure.
She was tachypneic, but actually less so than her baseline, and
O2 sats were also baseline. ABG obtained showing pH 7.03, pCO2
138. Started on BiPAP briefly while we contact[**Name (NI) **] her nephew
[**Name (NI) **], who decided upon arrival to change her care to comfort
measures only (CMO). In terms of the etiology of her
decompensation, this is still not entirely clear. The family
has granted an autopsy, which may help provide some information.
# Pneumonia: Presented with new infiltrates on CXR and CT chest,
consistent with possible post-obstructive type pneumonia in RLL
due to RLL bronchus mass vs. HAP/HCAP. She was started initially
on Vancomycin and Pip/Tazo in the ED, added azithromycin in MICU
for atypical coverage. Urine legionella negative. Infiltrates
improved on CXR and CT chest, however she is still required O2
and was perstently tachypneic. Switched to linezolid [**12-1**] from
vanco, given ?VRE UTI and persistently low vanco troughs. She
was on day 13 of antibiotics when she decompensated (see above).
# Severe COPD exacerbation: Respiratory status worsened by
presumed COPD exacerbation, which left her quite wheezy, "tight"
and tachypneic nearly all the time. She was started on steroids
at 40 mg qday, which we began to taper after 5 days. She was
also given nebulizers around the clock and continued on her
advair.
# Lung mass: soft tissue mass suspicious for lung CA seen on CT
on admission here. Obtained records from [**Location (un) 1121**] with CT
read-- can see the mass encasing the RLL bronchus and the
endobronchial lesion in left bronchus. Repeated non-contrast
chest CT done [**12-1**], no significant changes to the mass or the
degree of bronchus constriction. Her family was originally
interested in pursuing a diagnosis on this mass, but it was felt
that a biopsy would not be worth the risk during her acute
illness, especially given that she was on plavix for a recent
medically-managemed NSTEMI. Futher work up was deferred, but
knowledge of this lesion helped play a role in the family's
decision to ultimately make her CMO.
Medications on Admission:
None Per chart. One note mentions the following medications:
Latanoprost (XALATAN) 0.005 % Ophthalmic Drops 1 drop to both
eyes at bedtime
Brinzolamide (AZOPT) 1 % Ophthalmic Drops, Suspension 1 drop to
both eyes two times daily
Methazolamide 25 mg Oral Tablet 1 tablet daily
Methazolamide 25 mg Oral Tablet TAKE 1 TABLET TWICE A DAY FOR 3
MONTHS
Brimonidine 0.2 % Ophthalmic Drops INSTILL 1 DROP IN THE LEFT
EYE TWICE DAILY
Brinzolamide (AZOPT) 1 % Ophthalmic Drops, Suspension INSTILL 1
DROP TO LEFT EYE TWO TIMES DAILY (AZOPT) [3 MONTH SUPPLY]
Latanoprost (XALATAN) 0.005 % Ophthalmic Drops Instill 1 drop in
left eye at bedtime/ generic
Brimonidine 0.2 % Ophthalmic Drops INSTILL ONE DROP INTO BOTH
EYES TWICE DAILY
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute hypercarbic respiratory failure
Severe COPD exacerbation
Pneumonia
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 5849, 2760, 5990, 4589, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2790
} | Medical Text: Admission Date: [**2153-1-18**] Discharge Date: [**2153-1-23**]
Date of Birth: [**2076-2-11**] Sex: M
Service: VASCULAR SURGERY
CHIEF COMPLAINT: Disabling claudication, right greater than
left.
HISTORY OF PRESENT ILLNESS: This is a 76-year-old white male
with type 2 diabetes, osteoarthritis, who developed bilateral
calf claudication. He had an outpatient arteriogram on
[**2152-12-29**], at [**Hospital6 256**].
The patient complained of progressive bilateral calf
claudication after 100 ft for the previous year. He denied
rest pain or foot ulcerations. He presented for an elective
right lower extremity bypass graft.
PAST MEDICAL HISTORY:
1. Type 2 diabetes.
2. Osteoarthritis.
3. Peripheral vascular disease.
PAST SURGICAL HISTORY:
1. Left hip replacement.
2. Arthroscopy, left knee.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION:
1. Glucophage.
2. Glyburide.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives with his wife. They live
in a mobile home. He uses a cane to ambulate. He still
drives a car. He smokes pipe tobacco. He does not drink
alcohol.
PHYSICAL EXAMINATION: Vital signs: Pulse 61, respirations
12, supine blood pressure right arm 93/46, oxygen saturation
99% on room air, weight 185 lbs, height 5 ft 8 in. General:
The patient was an alert, cooperative white male in no acute
distress. HEENT: Normocephalic. Tongue midline. Neck: No
jugular venous distention. Carotids palpable. No bruits.
Chest: Lungs clear. Heart: Regular, rate and rhythm
without murmur. Abdomen: Soft and nontender. Bowel sounds
positive. No bruits. Rectal: Exam deferred. Extremities:
There were arthritic changes in extremities. No ulcers of
feet. Pulse exam: Carotid pulses 1+ bilaterally. Radial
pulses 2+ bilaterally. Femoral pulses 2+ bilaterally. Pedal
pulses with Doppler signals bilaterally. Neurological:
Grossly intact.
LABORATORY DATA: WBC 7.5, hemoglobin 14.7, hematocrit 42.5,
platelet count 193,000; PT 12.4, PTT 26.1, INR 1.0; potassium
4.6, BUN 27, creatinine 1.0, glucose 133; urinalysis
negative.
Chest x-ray showed no acute pulmonary disease.
Electrocardiogram showed normal sinus rhythm at a rate of 63,
AV conduction delay, old inferior/posterior myocardial
infarction.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2153-1-18**], following a right femoral to peroneal in
situ saphenous vein graft. At the end of surgery, the
patient had a warm foot with a palpable graft pulse and
Doppler signals of the right pedal pulses.
Intraoperatively the patient became bradycardiac and became
hypertensive. He was treated with intravenous Lopressor. He
required a few boluses of Neo-Synephrine.
Postoperatively the patient was very hypertensive. He was
treated with intravenous Nitroglycerin. About ten minutes
later, he became severely bradycardiac with a heart rate in
the 20s. He received 1 mg IV Atropine. He remained alert.
Cardiology was consulted and recommended continuing telemetry
for the patient's postoperative Wenckebach rhythm which they
felt was primarily secondary to intraoperative drugs,
especially beta-blockers. They recommended avoiding
beta-blockers and using ACE inhibitors, diuretics,
Nitroglycerin or Hydralazine for blood pressure control.
They felt that a temporary pacemaker was not indicated at the
time. They followed the patient during the course of
admission.
The patient had another episode of asymptomatic sinus
bradycardia in the 30s on [**2153-1-21**]. Cardiology
requested that the patient have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts ordered.
The patient is to follow-up with Dr. [**Last Name (STitle) 73**], EPS, in [**2-13**]
weeks.
Physical Therapy assessed the patient on [**2153-1-21**].
The patient requested a [**Hospital 3058**] rehabilitation stay near
his home in [**Location (un) **]. The patient lives in a mobile home with
his wife and feels he is not able to manage at home.
At the time of dictation, the patient has a warm right foot
with a palpable graft pulse and Doppler signals of the right
pedal pulses. His incision is clean, dry, and intact, and
his right foot is warm.
The patient will follow-up with Dr. [**Last Name (STitle) 1391**] in about two
weeks for surgical staple removal. Dr.[**Name (NI) 1392**] office
should be called for an appointment, [**Telephone/Fax (1) 1393**].
DISCHARGE MEDICATIONS:
1. Glyburide 10 mg p.o. b.i.d.
2. Metformin 500 mg p.o. t.i.d.
3. Regular Insulin sliding scale.
4. Heparin 5000 U subcue q.12 hours.
5. Percocet 1-2 tabs p.o. q.4-6 hours p.r.n. pain.
6. Tylenol 325-650 mg p.o. q.4-6 hours p.r.n.
DISPOSITION: [**Hospital **] rehabilitation facility.
CONDITION ON DISCHARGE: Satisfactory.
PRIMARY DIAGNOSIS:
1. Disabling claudication.
2. Right femoral to peroneal in situ saphenous vein graft on
[**2153-1-18**].
SECONDARY DIAGNOSIS:
1. Asymptomatic bradycardia; [**Doctor Last Name **] of Hearts will be placed
on [**2153-1-22**].
2. Type 2 diabetes.
3. Osteoarthritis.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2153-1-22**] 14:11
T: [**2153-1-22**] 14:12
JOB#: [**Job Number 53999**]
ICD9 Codes: 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2791
} | Medical Text: Admission Date: [**2170-6-29**] Discharge Date: [**2170-7-3**]
Date of Birth: [**2140-11-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Mitral Regurgitation
Major Surgical or Invasive Procedure:
Minimally Invasive Mitral Valve Repair Utilizing a 26mm [**Doctor Last Name 405**]
Annuloplasty Band
History of Present Illness:
29 year old gentleman with a recently diagnosed heart murmur by
his primary care physician [**Last Name (NamePattern4) **] [**3-17**]. Work-up was significant for
[**4-13**]+ mitral regurgitation and an ejection fraction of 52%.
Although he is currently asymptomatic, when pressed he will
admit to chest discomfort with activity.
Past Medical History:
Polysubstance Abuse
Past Bronchitis
ORIF left ankle
Social History:
Lives with roomates in recovery house. Smokes 1 pack per day
currently. No drugs for past 9 months.
Family History:
Father with MI in his 50's. Aunt with valvular disease.
Physical Exam:
Pulse; 59 BP: (R) 120/70 (L) 117/69 Weight 210
GEN: No acute distress
SKIN: Unremarkable
HEENT: Benign
NECK: Supple
CHEST: Clear
HEART: RRR, IV/VI systolic murmur
ABD: Benign
EXT: No edema. 2+ pulses throughout
Pertinent Results:
[**2170-7-3**] 05:40AM BLOOD Hct-27.6*
[**2170-7-2**] 06:33AM BLOOD WBC-5.5 RBC-2.87* Hgb-8.5* Hct-25.1*
MCV-87 MCH-29.7 MCHC-34.0 RDW-12.0 Plt Ct-146*
[**2170-7-2**] 06:33AM BLOOD Plt Ct-146*
[**2170-7-2**] 06:33AM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-142
K-3.6 Cl-105 HCO3-30* AnGap-11
[**2170-7-3**] 05:40AM BLOOD Mg-1.8
CXR [**2170-7-1**]
IMPRESSION: 1) No definite pneumothorax.
2) Worsened aeration in both lung bases as described.
EKG [**2170-6-29**]
Normal sinus rhythm
Left atrial abnormality
Possible old inferior infarct
Since previous tracing of [**2170-6-4**], no significant change
Brief Hospital Course:
Mr. [**Known lastname 54135**] was admitted to the [**Hospital1 1170**] on [**2170-6-30**] for surgical management of his mitral valve
disease. He was taken to the operating room where he underwent a
minimally invasive mitral valve repair utilizing a 26mm [**Doctor Last Name **]
annuloplasty band. Postoperatively he was taken to the cardiac
surgical intensive care unit for monitoring. On postoperative
day one, Mr. [**Known lastname 54135**] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. Toradol and dilaudid were started for pain. On
postoperative day two, he was transferred to the cardiac
surgical step down unit for further recovery. He was gently
diuresed towards his preoperative weight. The physical therapy
service was consulted for assistance with his postoperative
strength and mobility. Beta blockade was started and titrated
for optimal heart rate and blood pressure control. Mr. [**Known lastname 54135**]
continued to make steady progress and was discharged to his home
on postoperative day four. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Multivitamin
Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): Continue for 1 month.
Disp:*120 Tablet(s)* Refills:*1*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day: Take for 1 month.
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*0*
6. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Minimally invasive mitral valve repair for severe mitral
regurgitation
Discharge Condition:
Good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
Report any weight gain of more then 2 pounds in 24 hours.
Report any fevers greater then 101.5
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks. Please call for appointment.
Dr. [**Last Name (STitle) 4469**] (cardiologist) in 2 weeks. Call for appointment.
Dr. [**Last Name (STitle) **] (PCP) in [**3-16**] weeks. Call for appointment
Completed by:[**2170-7-3**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2792
} | Medical Text: Admission Date: [**2164-3-10**] Discharge Date: [**2164-3-14**]
Date of Birth: [**2105-9-8**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Demerol
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Transfer from outside hospital for evaluation of ventricular
tachycardia with AICD in place.
Major Surgical or Invasive Procedure:
Cardiac catheterization on [**2164-3-10**]
EP procedure on [**2164-3-12**]
History of Present Illness:
Mr. [**Known lastname 18036**] is a 58 year-old man with severe premature CAD
status post CABG X 2 (redo in [**2153**]) and multiple PTCAs, with
known single patent SVG to LAD, cardiomyopathy with EF 35%
status post AICD placement (per patient, had arrhythmia) also
with PAF on Coumadin therapy, HTN, and hypercholesterolemia,
transferred from [**Hospital 1121**] Hospital for further management of
VT/AIDC firing.
Mr. [**Known lastname 18036**] claims that he has been feeling unwell for the past
few weeks since reprogramming of his AICD. This is confounded by
2 recent diarrheal illnesses (last 2 weeks PTA), and a URI. He
also notes progressive dyspnea on exertion and increased use of
NTG for anginal symptoms over the past 5 weeks. + cough. On the
day prior to admission, 45 minutes after using his NTG for
exertional angina, while sitting at home, he "fell asleep or
lost consciousness" and woke up 2/2 shock from AICD. He
presented to the hospital for further evaluation.
At the OSH, cardiac enzymes were flat (CK 54, 59). He had 2
further defibrillations from AICD, each time with "dosing off"
prior to the shock. One of these episodes was captured on
telemetry and showed monomorphic VT. At the patient's request,
transfer to [**Hospital1 18**] was arranged for further care.
At [**Hospital1 18**], he was taken straight to the cath lab. Angiography
revealed patent SVG to LIMA with 50-60% in-stent restenosis,
likely chronic. He was transferred to the CCU for close
monitoring.
Past Medical History:
1. CAD, status post MI at ages 25, 29, 32 and 47 years-old.
- Status post 2-vessel CABG in [**2135**] with SVG-->LAD, SVG-->Diag
- Status post redo CABG in [**2153**] with LIMA to LAD, SVG to OM, SVG
to PDA, SVG to D1.
- Status post SVG stent in [**2158**].
- Last cath [**2162**] with SVG to LAD patent, all other grafts
closed. EF 35%.
- Status post AICD placement for primary prevention in [**2162**].
2. Ischemic cardiomyopathy, with EF 35% on last cath.
3. Hypertension
4. Hypercholesterolemia
5. Atrial fibrillation on Coumadin
6. Status post cholecystectomy
Social History:
He is disabled and a former carpenter. He spends most of his
time on household chores and taking care of his grandchildren.
Former smoker, quit 25 years ago. He rarely uses alcohol.
Family History:
Family history significant for premature CAD (brother who died
of MI at age 42, 2 other brothers died [**3-7**] CAD), DM type 2,
hypertension, and hyperlipidemia.
Physical Exam:
Physical examination on admission to CCU:
VITALS: T 97.2, HR 60 regular, BP 161/84, RR 20, Sat 99% on 2L
via NC
GEN: Looks well. In NAD.
HEENT: Anicteric. MMM.
NECK: JVP not elevated.
RESP: Ronchorous breath sounds anteriorly. Diffuse wheezing.
CVS: Normal S1, S2. No S3, S4. No murmur or rub.
GI: Obese abdomen. Abdomen soft and non-tender.
EXT: Cool. Right femoral bruit, no bruit on left. No palpable
hematoma. Faint pedal pulses present in both lower extremites.
No pedal edema. Bilateral lower extremity scars.
NEURO: Alert and oriented X 3.
Pertinent Results:
Pertinent laboratory data on admission:
CBC:
WBC-6.9 RBC-4.35* HGB-13.1* HCT-38.0* MCV-87 MCH-30.0 MCHC-34.4
RDW-14.2
NEUTS-77.8* LYMPHS-15.2* MONOS-3.4 EOS-3.4 BASOS-0.3
PLT COUNT-216
Chemistry:
GLUCOSE-114* UREA N-20 CREAT-1.1 SODIUM-135 POTASSIUM-4.0
CHLORIDE-101 TOTAL CO2-24 ANION GAP-14
ALT(SGPT)-12 AST(SGOT)-18 CK(CPK)-81 ALK PHOS-66 AMYLASE-36 TOT
BILI-0.6
cTropnT-0.08*
ALBUMIN-4.1
Coagulation profile:
PT-20.0* PTT-41.1* INR(PT)-2.5
EKG [**2164-3-9**]: NSR, 62. A paced, IVCD. No pathologic Qs.
EKG [**2164-3-10**] after cath: Probable sinus rhythmm, rate 72.
Intraventricular conduction delay with ST-T wave changes.
Anterolateral ST-T wave changes which may be consistent with
left ventricular hypertrophy and intraventricular conduction
delay. A paced. Diffuse anterolateral TWI and ST segment
depression.
********************
[**2164-3-10**]: CARDIAC CATHETERIZATION:
1. Selective coronary angiography revealed severe native three
vessel
coronary artery disease. The LMCA had severe diffuse disease.
The LAD
had a proximal occlusion at the origin of the vessel. The LCX
had a
proximal total occlusion with bridging collaterals. The RCA had
a
proximal total occlusion with left to right and bridging
collaterals.
2. Selective graft angiography of the SVG to LAD revealed 50 to
60%
instent restenosis. The graft gave collaterals to the LCX and
RCA.
3. Arterial conduit angiography revealed a large patent native
RIMA.
4. Resting hemodynamics demonstrated mildly elevated left sided
pressures (mean PCWP 19 mmHg) with a normal cardiac index (3
l/min/m2).
5. The right femoral arteriotomy was closed successfully with an
angioseal device.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate SVG to LAD instent restenosis.
3. Mild ventricular diastolic dysfunction.
4. Patent native RIMA.
5. Angioseal to right femoral arteriotomy.
*******
[**2164-3-12**] ECHO:
1. The left atrium is moderately dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed (LVEF 30-35%). Resting
regional wall motion abnormalities include inferolateral and
inferior akinesis with basal and mid inferoseptal hypokinesis.
The basal lateral wall was not well seen but probably
hypokinetic.
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic root is moderately dilated.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
6.The mitral valve leaflets are structurally normal. Moderate to
severe ([**3-8**]+) mitral regurgitation is seen.
7.There is no pericardial effusion.
8. There is an echogenic density in the right atrium and
ventricle consistent with a pacemaker lead.
******
[**2164-3-11**] CXR: Pacemaker tips in satisfactory position. The heart
is enlarged. No failure is seen. There is a soft infiltrate in
the anterior segment of the right upper lobe. Increased
opacification in the right lower lobe is also present. I suspect
pneumonia in both of these areas.
IMPRESSION: Right upper and probable right lower lobe pneumonia,
cardiomegaly, no failure.
Brief Hospital Course:
58 year-old male with long-standing history of CAD s/p CABG X 2
(redo in [**2153**]), ischemic cardiomyopathy with EF 35%, paroxysmal
atrial fibrillation on Coumadin therapy, s/p AICD placement 2
years ago, transferred from OSH after firing of AICD, found to
have monomorphic VT, on Lidocaine drip. Status post cath at
[**Hospital1 18**], with SVG to LAD graft patent with 50-60% in-stent
restenosis.
1) VT: The EP service was consulted on admission. Device
interrogation revealed no programmed antitachycardia pacing and
elevated pacing thresholds. A VT detection zone was added, and
atrial pacing output was increased to 5V, while V pacing was
increased to 3.5V. Per EP, Sotalol was increased to 120mg PO
BID, with plan to D/C Lidocaine. Overnight, Mr. [**Known lastname 18036**] had a
6-beat run of monomorphic VT while off Lidocaine, which was
restarted, and eventually weaned on hospital day #2 without
recurrence of his VT. While in hospital, telemetry revealed
mostly A-pacing, V-sensing.
He was taken to the EP lab on [**2164-3-12**], which revealed no
mappable VT or scar for substrate mapping. No ablation done. Per
EP, Sotalol was discontinued, and he was started on amiodarone
400 mg PO TID on [**2164-3-13**] (LFTs and TFTs normal prior to
initiation of Amiodarone therapy).
The etiology of his VT (given 2 years without events) remains
unclear at discharge. On admission, his monomorphic VT was
initially felt to be scar-based (despite the absence of Qs on
EKG) but EP procedure revealed no mappable VT. He was ruled out
for MI on admission (peak troponin 0.08), but ischemia remains a
concern.
He was discharged on Amiodarone 400 mg PO TID for 7 days
(total), then 400 mg PO BID for 7 days, then 400 mg PO QD. He
will need PFT's as an out-patient while on Amiodarone. He will
follow-up with Dr. [**Last Name (STitle) 101044**] for his AICD.
2) CAD/angina: His history was initially concerning for
accelerating anginal symptoms. Cardiac catheterization revealed
50-60% instent restenosis of the SVG to LAD graft, likely
chronic in nature. He was ruled out for MI (peak troponin 0.08).
While on the floor, Mr. [**Known lastname 18036**] had 2 further anginal episodes.
EKG on both occasions revealed dynamic EKG changes, with deeper
ST depressions in the lateral leads.
In hospital, he was continued on ASA, plavix, Lisinopril
(titrated up to 20 mg daily), and Imdur. Cardiac surgery was
consulted, with recommendation to proceed with repeat redo CABG
+/- MVR (moderate to severe MR) +/- Maze procedure. Surgery was
deferred given given ongoing treatment for probable pneumonia
(see below). Pre-op work-up done, and carotid Doppler and vein
mapping performed prior to discharge per cardiac surgery
service. He has a scheduled appointment on [**2164-3-21**] with Dr.
[**Last Name (STitle) 101045**].
A lipid profile in hospital revealed LDL 124, suboptimal in this
patient with severe CAD (goal <70). Mr. [**Known lastname 18036**] is already on
Crestor 40 mg PO QD, Gemfibrozil 600 mg PO BID and Zetia 10 mg
PO QD. Per pharmacy, there has been no proven added benefits
with higher doses of Crestor and Zetia. We will leave this to
his PCP to address.
3) CHF: A repeat echo was performed on [**2164-3-11**], which revealed
LVEF 30-35%, with inferolateral and inferior akinesis, basal and
mid inferoseptal hypokinesis, as well as moderate to severe MR.
[**Name13 (STitle) **] in hospital, he was continued on Lisinopril. Digoxin was
decreased to 0.125 mg PO QD given initiation of Amiodarone.
Lasix should be resumed at home (patient contact[**Name (NI) **]) at
pre-admission dose.
He will need follow-up Digoxin levels as an out-patient.
4) History of atrial fibrillation: Coumadin was held in hospital
and he was kept on Heparin IV. Coumadin resumed at a lower dose
at discharge (2 mg PO QHS) given concomitant Amiodarone and
Azithromycin therapy. Plan to have INR check on Monday [**3-19**].
5) Cough/wheezing: Mr. [**Known lastname 18036**] was noted to have significant
wheezing on admission and a CXR was suspicious for RUL and
possible RLL pneumonia. However, patient afebrile, with normal
WBC. Nonetheless, given his cough, he was initially started on
Levofloxacin, changed to Azithromycin given the arrhythmogenic
potential of Levofloxacin. He will complete a 5-day course of
Azithromycin 500 mg PO QD. Given his significant wheezing, he
was also started on a Prednisone taper, as well as Advair and
bronchodilator therapy via nebulizers. He was much improved at
the time of discharge.
Medications on Admission:
Imdur 60 mg PO QD
Ecotrin 325 mg PO QD
Sotalol 80 mg PO BID
Gemfibrozil 600 mg PO BID
Captopril 12.5 mg PO TID
Protonix 40 mg PO QD
Lasix 20 mg PO QD
Zetia 10 mg PO QD
Coumadin 4 mg PO QD
Digoxin 0.25 mg PO QD
Crestor 40 mg PO QD
NTG spray prn
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: [**2-5**]
inhalation Inhalation every 4-6 hours.
Disp:*1 inhaler* Refills:*2*
8. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) inhalations
Inhalation four times a day.
Disp:*1 inhaler* Refills:*2*
9. Rosuvastatin Calcium 20 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
10. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Please have your INR checked on [**3-19**]. .
Disp:*30 Tablet(s)* Refills:*2*
11. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day): Please take 400 mg three times daily for 5 more
days (last on [**2164-3-19**]), then 400 mg twice daily (start on
[**2164-3-20**]) for 7 days, then 400 mg daily (start on [**2164-3-27**])
ongoing. .
Disp:*180 Tablet(s)* Refills:*2*
12. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 3 days: Last doses on [**2164-3-17**].
Disp:*6 Capsule(s)* Refills:*0*
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day
for 5 days: Please take 40 mg (4 tabs) on [**2164-3-15**], then 20 mg
daily (2 tabs) for 2 days, then 10 mg (1 tab) daily for 2 days,
then stop. .
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease
Cardiac dysrythhmia - ventricular tachycardia
Congestive heart failure
Hypertension
Probable pneumonia
Discharge Condition:
Patient discharged home in stable condition.
Discharge Instructions:
You have a scheduled appointment with Dr. [**Last Name (STitle) 25059**] on Monday
[**3-19**] at 1300. It is important that you go to this
appointment. Please have your PT/INR checked on Monday as well.
Please call Dr.[**Name (NI) 101046**] office and schedule an appointment to
see him witihin 2 weeks of discharge given the recent AICD
changes.
Please call you PCP or return to the hospital if you develop
chest pain not relieved with NTG or if you develop
light-headedness, dizziness, or palpitations.
Followup Instructions:
You have a scheduled appointment with Dr. [**Last Name (STitle) 25059**] on Monday
[**3-19**] at 1300. It is important that you go to this
appointment. Please have your PT/INR checked on Monday as well.
Please call Dr.[**Name (NI) 101046**] office and schedule an appointment to
see him witihin 2 weeks of discharge given the recent AICD
changes.
Completed by:[**2164-3-15**]
ICD9 Codes: 4271, 4280, 486, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2793
} | Medical Text: Admission Date: [**2174-5-16**] Discharge Date: [**2174-5-25**]
Date of Birth: [**2113-6-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
[**2174-5-16**] Coronary artery bypass grafting x1 ( SVG to
RAMUS)/Aortic valve replacement( [**Street Address(2) 17009**]. [**Male First Name (un) 923**] mechanical
valve)
History of Present Illness:
This 60 year old man, known to our
service, who has a history of hypertension, hyperlipidemia,
diabetes and prior smoking. He has been followed for at least
the
past ten years with serial echocardiograms for aortic valve
disease. Previously his testing had been at [**Hospital 86642**], but he has recently switched his medical care to the
[**Hospital1 **]. Referred for surgical evaluation after
cardiac cath on [**2174-3-3**] revealed severe aortic stenosis and
coronary artery disease.
Past Medical History:
Aortic Stenosis and Insufficiency
CAD
postop A Fib
HTN
Hyperlipidemia
DM
Chronic Leukocytosis
Mild diverticulitis noted on colonoscopy [**11/2173**]
Social History:
single, lives with his signficiant other; works for media
company making educational material. has past hx of tobacco
years ago; drinks only occasionally at social events
Family History:
non-contributory
Physical Exam:
Height: 5'7" Weight: 198#
General: well-developed male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur 3/6 systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema: trace
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: trans murmur Left: trans murmur
Pertinent Results:
PREBYPASS
A patent foramen ovale is present. A left-to-right shunt across
the interatrial septum is seen at rest. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The descending thoracic aorta is mildly dilated. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Moderate
(2+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen.
POSTBYPASS
Biventricular systolic function is preserved. There is a well
seated, well functiong bileaflet mechanical valve in the aortic
position. AI is present which is normal in quantity and location
for this type of prosthesis. The exam is otherwise unchanged
from the prebypass exam.
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) **] [**2174-5-16**] 12:53
[**2174-5-21**] 05:30AM BLOOD WBC-16.5* RBC-3.55* Hgb-10.5* Hct-30.0*
MCV-85 MCH-29.6 MCHC-35.0 RDW-15.0 Plt Ct-335
[**2174-5-21**] 05:30AM BLOOD PT-30.1* PTT-30.9 INR(PT)-3.0*
[**2174-5-21**] 05:30AM BLOOD Glucose-96 UreaN-21* Creat-0.9 Na-139
K-3.6 Cl-106 HCO3-27 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 3311**] was admitted on [**5-16**] and underwent surgery with Dr.
[**Last Name (STitle) **]. He was transferred to the CVICU in stable condition on
titrated propofol and insulin drips. He was extubated the
following morning. He went into A Fib and was treated with
amiodarone. Coumadin was started for a mechanical AVR. He was
transferred to the floor on POD #3 to begin increasing his
activity level. He was gently diuresed toward his preop weight.
He continued to progress and was cleared for discharge to home
with VNA by Dr. [**Last Name (STitle) 914**] on POD #five. His first blood draw will
be Monday [**5-23**] with results to the [**Hospital1 18**] [**Hospital 620**] [**Hospital **]. Target INR 2.0-3 for mechanical AVR/atrial fibrillation.
Medications on Admission:
Atenolol 75 mg [**Hospital1 **]
Lisinopril 60 mg daily
Metformin 1000 mg [**Hospital1 **]
Nifedipine SR 90 mg daily
Simvastatin 20 mg daily
Aspirin 81 mg daily
Mag. oxide 400 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] through [**5-26**]; then 200 mg [**Hospital1 **] [**Date range (1) 21202**]; then
200 mg daily ongoing.
Disp:*60 Tablet(s)* Refills:*1*
7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*28 Tablet(s)* Refills:*2*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day for 2
weeks.
Disp:*56 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
13. Outpatient Lab Work
Coumadin will be followed by the [**Hospital 18**] [**Hospital3 271**] in
[**Location (un) 1411**] ([**Telephone/Fax (1) 86643**]. INR to be drawn on [**5-23**]. INR goal for a
mechanical AVR/afib [**12-22**].
14. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses: Coumadin will be followed by the [**Hospital 18**]
[**Hospital3 271**] in [**Location (un) 1411**] ([**Telephone/Fax (1) 86643**]. INR to be drawn
on [**5-23**]. INR goal for a mechanical AVR/afib [**12-22**].
.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1376**] [**Location (un) **]
Discharge Diagnosis:
AS/AI/ CAD s/p AVR/cabg x1
postop A Fib
NIDDM
HTN
hyperlipidemia
mild diverticulitis ( on colonoscopy [**11-28**])
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 Right/Left - healing well, no erythema or drainage.
Edema :
1+ throughout
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 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
**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:
Coumadin will be followed by the [**Hospital 18**] [**Hospital3 271**] in
[**Location (un) 1411**] ([**Telephone/Fax (1) 86643**]. INR to be drawn on [**5-22**]. INR goal for a
mechanical AVR/afib 2-2.5.
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) **] Thursday [**6-23**] at 1:00 PM
Please call to schedule appointments with your:
Primary Care Dr.[**Last Name (STitle) **] in [**11-20**] weeks
Cardiologist Dr. [**Last Name (STitle) 86644**] in [**11-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? mechanical AVR/ A Fib
Goal INR 2.0-2.5
First draw Sunday [**5-22**]
Results to [**Hospital 18**] [**Hospital3 **]
phone [**Telephone/Fax (1) 10413**]
Completed by:[**2174-5-21**]
ICD9 Codes: 4241, 9971, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2794
} | Medical Text: Admission Date: [**2102-2-13**] Discharge Date: [**2102-2-17**]
Service: [**Hospital1 139**] Firm
HISTORY OF PRESENT ILLNESS: This is an 87-year-old woman
with history of COPD who presents with decreased mental
status, mumbling, anorexia, and dyspnea for the last 2-3
days. In [**2101-10-8**] the patient was admitted to the
[**Hospital1 69**] MICU for COPD
exacerbation and pneumonia, intubated for respiratory failure
times 24 hours, given Levaquin and steroids and then
discharged on [**2101-11-1**]. She was recently readmitted to the
MICU on [**2102-1-29**] with an ABG of 7.18, PCO2 122, PO2 217 on
non invasive ventilation with improvement in mental status
and ABG to 7.4/63/56. Her hypercarbia was thought to be
secondary to Opioids and Benzos. She was not given steroids
during that admission. Now patient presents with decreasing
mental status, mumbling, anorexia and dyspnea times 2-3 days.
No fevers, chills, nausea, vomiting, chest pain,
palpitations, abdominal pain or cough. The patient arrived
by ambulance from home, was somnolent but arousable to verbal
stimuli. Her vital signs on admission, temperature 98.8,
blood pressure 126/34, pulse 91, respiratory rate 30 and O2
sats of 75% on room air, with increasing to 93% on four
liters of oxygen. Her ABG at that time was PH 7.22, PCO2 95,
PO2 85 on four liters of oxygen. Bi-pap ventilation was
initiated with increase in sats to 93 to 97%. She was more
awake with the bi-pap ventilation. Her next gas showed
improvement with PH 7.24, PCO2 87 and PO2 of 62. Upon
initial presentation to the MICU her white blood cell count
was 20.4 and subsequently she was given one dose of Levaquin.
She was hydrated with D5 normal saline. Upon stabilization
of her respiratory status, she was transferred to the [**Hospital1 139**]
service on [**2102-2-14**].
PAST MEDICAL HISTORY: COPD, on home O2 2-3 liters for last
four years. Adenocarcinoma of the rectum, status post
resection, LAR [**4-/2098**]. Lower back pain. Osteoarthritis.
Anxiety. Migraine headaches. SIADH. Osteoporosis. Old
lacunar infarct in the right coronary radiata.
ALLERGIES: Doxycycline.
MEDICATIONS: On admission, Albuterol 2 puffs [**Hospital1 **], Atrovent 2
puffs tid, Ritalin 5 mg q day, Colace 100 mg po bid, Zantac
150 mg po bid, Klonopin 0.5 mg [**Hospital1 **], Darvon 65 mg po q 6 hours
prn, Megace 40 mg/ml 1 tsp qid, Serevent 2 puffs [**Hospital1 **].
SOCIAL HISTORY: The patient is divorced, lives with her two
sons at home. History of tobacco use, quit 20 years ago,
prior to that 40 pack year history. No ethanol, no IV drug
use, no exercise.
PHYSICAL EXAMINATION: On transfer to [**Hospital1 139**] service,
temperature 97.4, pulse 82, blood pressure 138/60,
respiratory rate 18, O2 saturation 97% on 35% venti mask.
General, alert and oriented times two, no apparent distress.
Pulmonary, decreased breath sounds bilaterally, no wheezes or
crackles. Cardiovascular, regular rate and rhythm, S1 and
S2. Abdomen, nontender, non distended, positive bowel
sounds, soft. Extremities, no cyanosis, erythema or edema.
LABORATORY DATA: White blood cell count 12.6, hematocrit
33.6, platelet count 291,000, sodium 132, potassium 4.8,
chloride 31, CO2 36, BUN 27, creatinine 0.6, glucose 141,
calcium 8.4, phosphorus 2.6, magnesium 1.9.
HOSPITAL COURSE:
1. Pulmonary: Through the rest of her course on the [**Hospital1 139**]
firm the patient's pulmonary status remained stable. She did
not require any bi-pap at night and her O2 requirements
slowly decreased to baseline level of [**3-12**] liters. Her O2
saturation at time of discharge was 93% on two liters of
oxygen. The patient's respiratory decompensation was thought
to be secondary to excessive Benzodiazepines, narcotics on
top of her underlying COPD. The patient's white blood cell
count decreased over the course of her stay in the hospital.
Since there was no radiographic evidence of pneumonia, the
patient was not continued on antibiotics. No steroids were
initiated.
2. Infectious Disease: The patient's white blood cell count
decreased over the course of her stay in the hospital. The
patient remained afebrile throughout the course of her stay
in the hospital. The patient had femoral line placed in her
femoral vein. Initial sets of blood cultures drawn through
the femoral line grew coagulase negative staphylococcus and
corynebacterium. Subsequently the femoral line was removed
and the tip was sent for culture. The tip culture also grew
coagulase negative staphylococcus and corynebacterium. Prior
to starting Vancomycin, two surveillance cultures were drawn
peripherally. The patient was started on Vancomycin for
empiric treatment. The surveillance cultures remained
negative at time of discharge and subsequently the Vancomycin
was stopped. The patient remained afebrile throughout the
course of her stay in the hospital. The patient's white
blood cell count trended down through her course in the
hospital.
3. GI: The patient's hematocrit remained stable throughout
her course of stay in the hospital. Her stool was guaiac
positive. Given her history of rectal carcinoma, she will
need a follow-up colonoscopy as an outpatient. She remained
hemodynamically stable throughout the course of her stay in
the hospital.
4. Neuro: The patient's mental status improved with
improvement in her respiratory status. The change in mental
status that brought her to the hospital was likely secondary
to her hypercarbic respiratory distress.
DISCHARGE DIAGNOSIS:
1. Hypercarbic respiratory failure secondary to
Benzodiazepine and narcotic use.
DISCHARGE MEDICATIONS: Atrovent MDI 2 puffs tid, Serevent
MDI 2 puffs [**Hospital1 **], Albuterol MDI 2 puffs q 4-6 hours prn,
Tylenol prn, Zantac 150 mg po bid, Colace 100 mg po bid,
Ritalin 5 mg po q day, Megace 40 mg/ml, 1 tsp qid.
DISCHARGE CONDITION: Fair. Discharged to home with skilled
nursing and VNA, home PT. Patient to follow-up with PCP, [**Last Name (NamePattern4) **].
[**First Name (STitle) 216**].
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2102-2-17**] 17:19
T: [**2102-2-21**] 10:08
JOB#: [**Job Number 19214**]
ICD9 Codes: 496, 2765, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2795
} | Medical Text: Admission Date: [**2131-5-16**] Discharge Date: [**2131-5-30**]
Date of Birth: [**2061-8-17**] Sex: F
Service: MEDICINE
Allergies:
Lasix / Diuril
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
epistaxis
Major Surgical or Invasive Procedure:
nasal packing
History of Present Illness:
69yo with hx of MVR (mechanical), anemia of chronic disease
(transfusion-dependent), COPD/emphysema and IPF with trans trach
on home O2 presented 5 days ago with epistaxis that had been
intermitent over last 3 weeks prior to admission which has been
chronic issue while on coumadin with negative work up. In ED
was packed by ENT with bilateral packings which required
continuous O2 monitoring and stay in the MICU, she was monitored
and IR guided emolization was considered, but pt declined the
required general anesthesia for an elective procedure with risk
of stroke as well from emolization. Now bleeding has slowed
down with minimal packing and she feels better, but still with
right sided facial pain/pressure from the packing and possible
nerve injury. Also stay complicated by conjunctivitios stable on
e-mycin eye drops. No other shortness of breath or pain or
other symptoms except constipation with pain meds. She is
anxious to be about transfer to floor and increased ambulation
so she can go home.
Past Medical History:
1. Chronic obstructive pulmonary disease. The patient uses
4 liters of oxygen at home. Pulmonary function tests on [**2131-3-13**]
showing FEV1 of 1.39L (80%), FEV1/FVC 75%, DLCO of 17.34 (25%
decrease since [**8-30**])
2.Idiopathic pulmonary fibrosis.
3. Frequent Nose bleeds--no etiology other than coumadin despite
extensive work ups
4. Placement of transtracheal oxygen cath due to O2 contrib. to
epistaxis. Has needed recanulation x1
5. Anemia due to MVR, CRI-- baseline 30
6. MVR (metal) replaced in [**2125**] due to acute MR
7. Hypertension.
9. Hypercholesterolemia.
9. Hypothyroidism.
10. MRSA/VRE colonization (negative swabs for both in [**8-30**])
11. Sinus node dysfunction s/p DDD [**Date Range 4448**] in [**2125**]
12. Congestive heart failure with echocardiogram [**Month (only) 956**]
[**2130**] with an EF of 40%, mild global hypokinesis, mitral valve
regurgitation with trivial mitral regurgitation, 3+ tricuspid
regurgitation, mild pulmonary artery systolic hypertension.
13. Meniere's disease, tinnitus, diminished hearing bilaterally.
14. Breast cancer treated with radical mastectomy of right
breast. No chemotherapy. No radiation therapy.
15. Spinal arthritis.
16. Myopia, corrected with glasses.
17. Cataracts.
Social History:
The patient lives in [**Location 2624**] with her husband. The patient works
in human resources for the State of [**State 350**] promoting
diversity. The patient has a 36 pack year history of smoking,
having smoked 1 ppd from the ages of 14 to 50. Quit with the
help of acupuncture. The patient uses alcohol occasionally. no
IVDU.
Family History:
There is no known history of bleeding or clotting disorders.
There is a family history of muscle cramps. Her father had
polymyositis and her mother had [**Name2 (NI) 500**] cancer.
Physical Exam:
VS: HR 53 BP 131/52 Sat 100% on 4L transtracheal O2
GEN aao, nad
HEENT PERRL, MMM, ecchymosis right peri-nasal area, bilateral
packing in place without blood, transtracheal cath in place for
O2
CHEST CTAB with occasional bibasilar crackles R>L, and
occasional end exp wheezes bilaterally, +right sided scar
CV RRR, mechanical S1, nl S2
ABD soft NT, slightly distended, +BS
EXT no edema, 2+DP pulses bilaterally
Neuro CN II-XII intact sensation, but with mildly decreased
right motor muscle strength
Pertinent Results:
[**2131-5-16**] 04:15PM GLUCOSE-108* UREA N-26* CREAT-1.4*
SODIUM-149* POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-33* ANION
GAP-8
[**2131-5-16**] 04:15PM IRON-55
[**2131-5-16**] 04:15PM calTIBC-312 VIT B12-1587* FOLATE-GREATER TH
FERRITIN-633* TRF-240
[**2131-5-16**] 04:15PM WBC-4.2 RBC-2.89* HGB-9.1* HCT-28.3* MCV-98
MCH-31.6 MCHC-32.3 RDW-15.1
[**2131-5-16**] 04:15PM NEUTS-74.8* LYMPHS-15.2* MONOS-4.9 EOS-4.9*
BASOS-0.1
[**2131-5-16**] 04:15PM PLT COUNT-114*
[**2131-5-16**] 04:15PM PT-20.2* PTT-50.0* INR(PT)-2.6
[**2131-5-15**] 11:45PM HCT-27.1*
[**2131-5-15**] 11:45PM PT-18.4* INR(PT)-2.1
Brief Hospital Course:
69F with COPD, IPF, HTN, on coumadin for MVR here with epistaxis
s/p packing and control of bleeding.
1)Epistaxis: initially required nasal packing by ENT which
required continuous O2 monitoring, but remained stable and
although embolization was considered, it was not done because
patient did not want elective intubation which would have been
required for the procedre and with the risk of stroke with
embolization this procedure was deferred. The packing was
eventually removed and an absorbable intranasal packing was
placed and nares kept moist with ocean spray and vaseline. She
did have occasional episodes of minimal epistaxis which was
managed with courses of afrin and supportive measures and her
hematocrit remained stable after 3 total units of blood
transfusions. She was continued on ancef while packing remained
in place. She did have some pressure headaches from the packing
which was stable on percocet and dilaudid as needed.
2)s/p MVR: for severe mitral regurgitation 6 yrs ago-- stable
for now-- initially coumadin held and reversed with vitamin K
and 2units of FFP and eventually she was restarted on coumadin
with goal INR around 2.5-3.0 as her risk of bleeding is
significant. During her stay she was bridged with heparin until
INR was therapeutic.
3)Anemia: acute on chronic with blood loss anemia on top of
anemia of chronic disease with baseline hematocrit around 30.
She was transfused total of 3units of PRBC and her hematcrit
remained stable above 30 during the rest of her stay, she was
also restarted on her home epogen regemin.
4)COPD/IPF: stable at baseline home O2 via trans-tracheal
catheter. Drainage from trans-tracheal catheter was managed by
interventional pulmonary team with periodic strippings and
bronchoscopies as above. Otherwise she was continued on her
home doses of albuterol, combivent and inhaled steroids.
5)CHF: 40% EF, but stable and euvolemic-- continued on home
bumex and [**Last Name (un) **]
6)Hypothyroid: stable on home thyroid meds
Medications on Admission:
Coumadin 7 x6 days and 12mg x1 day
bumex 1mg qd
levoxyl 112mcg qd
lipitor 20mg qd
cozaar 50mg qd
quinine 260BID
tums [**Hospital1 **]
Flovent
Combivent
Mucinex DM 600BID
Discharge Medications:
1. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BIDWM (2 times a day (with meals)).
7. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-28**]
Puffs Inhalation Q6H (every 6 hours) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
12. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q4H (every
4 hours).
13. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal QID (4 times a day).
Disp:*1 bottle* Refills:*2*
14. Warfarin Sodium 1 mg Tablet Sig: Seven (7) Tablet PO at
bedtime.
15. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
16. Outpatient Physical Therapy
Please continue to follow up with your pulmonary and respiratory
therapists for care of your trans-tracheal catheter and
stripping as you need to for diagnosis of COPD and interstitial
lung disease
17. Erythromycin 5 mg/g Ointment Sig: 0.5 inch Ophthalmic four
times a day for 4 days.
Disp:*qs tube* Refills:*0*
18. Oxymetazoline HCl 0.05 % Aerosol, Spray Sig: One (1) Spray
Nasal [**Hospital1 **] (2 times a day) for 3 days.
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
epistaxis
blood loss anemia
anemia of chronic disease
chronic anticoagulation for mitral mechanical valve
chornic pulmonary obstructive disease
interstitial pulmonary fibrosis
Discharge Condition:
good, ambulating without difficulty and breathing comfortably on
2L of oxygen via tran-tracheal catheter
Discharge Instructions:
Please call your PCP or return if you have any increase in
bleeding from your nose, shortness of breath or pain. Please
continue all your medications as prescribed.
Followup Instructions:
Please see your PCP [**Last Name (NamePattern4) **] [**8-5**] days.
Please have your INR checked in the next 2 days and get your
trans-tracheal catheter followed by IP as you have been prior to
admission.
Please follow up with your ENT Dr [**Last Name (STitle) 1837**] within the next
month.
Provider: [**Name10 (NameIs) **] CALL Where: NONE CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-6-5**] 9:00
Provider: [**Name (NI) 2482**] [**Name (NI) 2483**], PT, CCS Where: [**Hospital6 29**]
REHAB SERVICES (DYSPNEA) Phone:[**Telephone/Fax (1) 2484**] Date/Time:[**2131-6-13**]
10:15
Provider: [**Name10 (NameIs) **] CALL Where: NONE CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-7-3**] 9:00
Completed by:[**2131-5-30**]
ICD9 Codes: 2851, 4280, 4240, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2796
} | Medical Text: Admission Date: [**2141-11-8**] Discharge Date: [**2141-11-14**]
Date of Birth: [**2087-7-26**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 54 year old gentleman
who presented to [**Hospital1 69**]
Emergency Room the beginning of [**Month (only) **], with complaints of
dizziness, shortness of breath and chest discomfort. At that
time, the patient ruled out for myocardial ischemia. The
patient underwent stress test subsequently which was positive
and was referred to [**Hospital1 69**] for
cardiac catheterization.
PAST MEDICAL HISTORY: Hypertension.
Arthritis.
Status post hernia repair.
ALLERGIES: Penicillin.
MEDICATIONS:
1. Folic acid.
2. Indocin.
3. Aspirin 325 mg a day.
SOCIAL HISTORY: The patient is married and works as an
emergency medical technician.
LABORATORY DATA: Preoperative laboratory evaluation included
a creatinine of 1.3.
HOSPITAL COURSE: On [**11-8**], the patient underwent cardiac
catheterization which showed a left ventricular end diastolic
pressure of 18. Ejection fraction was 60 percent. Totally
occluded left anterior descending after first diagonal.
Severe diffuse disease of the right coronary artery with 80
percent stenosis.
The patient was referred to Dr. [**Last Name (STitle) 70**] for operative
management of his coronary disease. On [**11-9**], the
patient was taken to the operating room by Dr. [**Last Name (STitle) 70**] and
underwent a coronary artery bypass graft times two with left
internal mammary artery to left anterior descending and
saphenous vein graft to posterior descending artery. Total
cardiopulmonary bypass time was 50 minutes; cross clamp time
was 35 minutes. The patient was transferred to the Intensive
Care Unit in stable condition on Neo-Synephrine and Propofol
infusion. The patient was weaned and extubated from
mechanical ventilation on his first postoperative evening.
He remained hemodynamically stable. On postoperative day
number one, he was transferred from the Intensive Care Unit
to the regular part of the hospital. His chest tubes were
removed without incident. The patient began ambulating with
physical therapy. The patient was started on Lasix and beta
blockers. On postoperative day number two, his Foley
catheter and pacing wires were removed.
The patient's hematocrit on postoperative day number two was
found to be 22.8 and the patient was complaining of some
light headedness with exertion. The patient was transfused
one unit of packed red blood cells which he tolerated well.
His post transfusion hematocrit was 28. By postoperative day
number four, the patient was working with physical therapy
and he was able to ambulate 500 feet and climb one flight of
stairs. On postoperative day number five, the patient was
cleared for discharge to home.
CONDITION ON DISCHARGE: Temperature maximum of 99.6; pulse
90 and sinus rhythm; blood pressure 114/64; respiratory rate
of 18; room air oxygen saturations were 93 percent.
Neurologically, the patient was awake, alert and oriented
times three. Examination was nonfocal. Heart was regular
rate and rhythm without rub or murmur. Respiratory: Breath
sounds were clear bilaterally. Gastrointestinal: Positive
bowel sounds. Abdomen was soft, nontender, nondistended.
Chest x-ray on [**11-13**] showed small bilateral effusions and
bilateral atelectasis. Extremities were warm and well
perfused with trace pitting edema. Sternal incision was
clean, dry and intact without erythema or drainage. The
right lower extremity vein harvest port sites at knee and
upper thigh were clean, dry and intact without erythema or
drainage. The right thigh had a moderate amount of
ecchymosis.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Zantac 150 mg p.o. twice a day.
3. Aspirin 325 mg p.o. once daily.
4. Plavix 75 mg p.o. once daily.
5. Dilaudid 2 mg tablets, one p.o. every four to six hours
prn.
6. Iron sulfate 325 mg p.o. once daily.
7. Vitamin C 500 mg p.o. twice a day.
8. Lasix 20 mg p.o. once daily times five days.
9. Potassium chloride 20 meq p.o. once daily times five days.
10. Lopressor 75 mg p.o. twice a day.
11. Lipitor 20 mg p.o. once daily.
The patient is to be discharged to home in stable condition.
He is to follow-up with Dr. [**Last Name (STitle) **] in one to two weeks. He
is to follow-up with Dr. [**Last Name (STitle) 5293**] in one to two weeks and he
is to follow-up with Dr. [**Last Name (STitle) 70**] in five to six weeks.
DISCHARGE DIAGNOSES: Coronary artery disease.
Status post coronary artery bypass graft.
Hypertension.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2141-11-15**] 17:51:51
T: [**2141-11-15**] 21:08:21
Job#: [**Job Number **]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2797
} | Medical Text: Admission Date: [**2122-11-19**] Discharge Date: [**2122-11-25**]
Date of Birth: [**2042-1-10**] Sex: M
Service: NEUROSURGERY
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Aphasia secondary to left SDH reaccumulation
Major Surgical or Invasive Procedure:
L craniotomy for L SDH evacuation
History of Present Illness:
Pt 80yo with recent admission to [**Hospital1 18**] for neurosurgical
intervention on [**2122-11-12**]. The pt had a left craniotomy for
evacuation of a subdural hematoma. He represented from the
rehabilitation center with word finding difficulty, aphasia
since [**11-18**] with worsening headache as well.Exam was notable for
dysarthria.
Past Medical History:
1.AAA repair
2.Gout
3.hypertension
4. CVA X2
5.Elevated cholesterol
6. Left CEA.
Social History:
Married, resides at home with wife. Retired [**Name2 (NI) 80233**] worker
Family History:
non-contributory
Physical Exam:
Afebrile. VSS per nursing record. The patient was slurred in
speech. He had difficulty naming glasses and watch but followed
commands consistently. He exhibited a subtle right pronator
drift. The remainder of the examination was otherwise
unremarkable.
Brief Hospital Course:
Pt 80yo with recent admission to [**Hospital1 18**] for neurosurgical
intervention on [**2122-11-12**]. The pt had a left craniotomy for
evacuation of a subdural hematoma. He represented from the
rehabilitation center with word finding difficulty, aphasia
since [**11-18**] with worsening headache as well.Exam was notable for
dysarthria. Therefore, on [**11-19**] the pt underwent a redo left
craniotomy and evaculation of recollected SDH. His subdural
drain was removed on POD2. The patient's aphasia has improved
daily following the re-evacuation. Sequential head CT revealed
no evidence of rehemorrhage. He was transferred from the SICU
to the regular floor on [**11-22**] and continues to do well. After
evaluation by PT/OT, the patient was discharged to
rehabilitation.
At the time of discharge, his pronator drift had resolved. His
speech was baseline and fluent. He was able to name three
common objects without difficulty. His neurologic examination
was non-focal.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Headache.
10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) as needed for UTI: Last dose on
[**11-29**].
12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): Continue for 10 days
last dose on [**12-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
s/p L Sub Dural Hematoma
Discharge Condition:
Stable
Discharge Instructions:
?????? Have staff or a family member check your incision daily for
signs of infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed on [**11-29**].
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing in 7
days and fax results to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE HAVE SUTURES REMOVED ON [**11-29**] either by the rehab staff
or by VNA if home.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**First Name (STitle) **]
TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
Completed by:[**2122-11-24**]
ICD9 Codes: 2749, 2859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2798
} | Medical Text: Admission Date: [**2138-5-28**] Discharge Date: [**2138-6-4**]
Date of Birth: [**2069-9-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
transferred from OSH after airway compromise following CABG
[**2138-5-11**] for eval of TBM seen on bronchoscopy.
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
68 yo male s/p CABG [**2138-5-11**] c/b inominate artery compromise.
Post op had airway compromise and bronch revealed
TBM-transferred for eval.
Past Medical History:
PAST MEDICAL HISTORY:
CRI, baseline Cr 1.2
Diabetes with peripheral neuropathy.
paroxysmal A-fib on coumadin
H/O multiple myeloma(Dr. [**Last Name (STitle) 66059**], last chemo 3 weeks ago); ?left
femur
hypertension
CAD-stentx2 [**2135**]
Social History:
smoke [**1-21**] ppd for 30-40 years, quit 20 y ago, used to drink but
quit in his 30s. Was in the navy once, then became meat cutter.
now retired. no drug use. currently lives with wife.
Family History:
CAD in family
Physical Exam:
PHYSICAL EXAMINATION:
T96.9 P87 BP107/44 R18 97% 4L
Gen- pleasant Caucasian male in no apparent distress
HEENT- anicteric, PERRLA, moist mucus membrane, normal
oropharynx, neck supple
CV- regular, no r/m/g
RESP- clear bilaterally(anterior)
ABDOMEN- soft, nontender, nondistended
EXT- no edema
NEUROLOGICAL:
.
Mental status: AAOx2. He thinks that this is [**2108**]. Able to say
month of year forward but not backward. Comprehension intact;
follows commands. Speech fluent. Normal affect.
.
Cranial Nerves:
I: Not tested
II: PERRL, 2->1 mm
III, IV, VI: EOMI
V: Facial sensation intact and symmetric to PP, LT.
VII: Face symmetric with intact strength.
VIII: Hearing intact bilaterally to finger rub
IX, X: Palatal elevation symmetric
[**Doctor First Name 81**]: SCM, trapezius strength intact
XII: Tongue midline without fasciculations
.
Motor: Normal bulk. No pronator drift.
.
Delt Tri [**Hospital1 **] WE FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB
RT: 5 4 5 5 5 5 5 5 5 5 5 5 5
LEFT: 5 4 5 5 5 5 5 4 4 5 5 5 5
.
Sensation: decreased sensation in lower extremities bilaterally
up to level of ankle, decreased proprioception in lower
extremity, normal sensation and proprioception in upper
extremity
.
Reflexes: Bic T Br Pa Ac
Right 0 0 0 0 0
Left 0 0 0 0 0
Toes equivocal
.
Coordination: FNF, H->S intact
.
Gait: Deferred because patient is very afraid to stand.
.
Pertinent Results:
CT trachea
1. No evidence of tracheobronchomalacia or stenosis.
2. Findings that may be consistent with recent median sternotomy
and thoracic surgery if sternotomy was performed within the past
15 days. Please correlate with time of surgical procedure.
3. Several slightly enlarged mediastinal nodes which are likely
hyperplastic but could be followed to ensure resolution or
stability if warranted clinically.
4. Bilateral small pleural effusions with likely lower lobe
atelectasis.
5. Splenic hypodensity which could represent a hemangioma or
possibly an infarct. Consider ultrasound for further
characterization, if warranted clinically.
[**2138-5-30**]: ECHO
Conclusions:
Technically suboptimal study due to poor image quality.
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The
aortic valve is not well seen, but Doppler does not suggeste
aortic stenosis.
No aortic regurgitation is seen. The mitral valve is not well
seen. No
definite mitral regurgitation is seen. The pulmonary artery
systolic pressure
could not be determined. No pericardial effusion is seen.
Brief Hospital Course:
Pt was admitted to the ICU from OSH after reportedly suffering
V-fib arrests prior to transfer. Once stabilized, pt underwent a
bronchoscopy [**2138-5-29**] that showed no evidence of TBM. CTA
confirmed no TBM. transferred from ICU on HD #3. Evaluated by
neurology for autonomic dysfxn. Recommended Tilt table and other
recommendations: Evidence of autonomomic dysfunction on formal
testing (full report to follow). Pt. had labile blood
pressures,
which if sustained, may cause symptoms of orthostatic
intolerance. Autonomic dysfunction may be secondary to DM
and/or
multiple myeloma. With regards to his neuropathy, this may be
related to DM, multiple myeloma, and/or Velcade.
Treatment recommendations:
For treatment we recommend ample hydration and salt intake.
Generally, we recommend 2L of fluid and 10gm of salt per day.
Given his recent cardiac history, this may not be possible to
achieve, but maximize therapy as can be tolerated. Avoid
medications that may worsen orthostatic hypotension.
Deconditioning will also contribute to this problem and we
recommend physical therapy as tolerated. Light compression
stockings and an abdominal binder may help prior to physical
therapy. It may be necessary to avoid heavy compression given
his diabetic neuropathy. If he remains orthostatic and is
unable
to tolerate physical therapy, it may be necessary to start low
dose midodrine, 2.5mg at 7am, noon, and 4pm. This can be
titrated up as needed by 2.5mg per dose. As it may contribute
to
supine hypertension, it should not be given after 4pm or prior
to
the patient lying supine. Another option would be to dose
midodrine prior to physical therapy. If midodrine is started,
it
would be best to check orthostatic blood pressures 1/2 hour
before the dose, and [**1-21**] after the dose.
Medications on Admission:
NPH 48units QAM, 20units Q10pm; Novolog 12units QAM, 20units
Q5pm; Coumadin 7.5mg QHS -Patient and wife deny that pt is
taking coumadin. I have called his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
[**Telephone/Fax (1) 73038**]-awaiting call back.
Tricor 160'
Metoprolol 50"
ASA 81'
Temazepam 30 QHS PRN
Procrit PRN
Velcade? (Chemo Every other week)
Zometta?
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. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
Daily ().
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. NPH insulin
48 units sq aqm, 20units q10pm
8. novolog
12 units qam, 20 nuits q5pm
9. finger stick
ac and qhs
Discharge Disposition:
Extended Care
Facility:
Rehab Hospital of [**Doctor Last Name **]
Discharge Diagnosis:
autonomic dysfunction
Discharge Condition:
deconditioned
Discharge Instructions:
Follow up with your primary care doctor and cardiologist after
you leave rehab. for medication review.
Followup Instructions:
Follow up your cardiologist and your primary care doctor after
you leave rehab.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2138-6-4**]
ICD9 Codes: 5859, 4280, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2799
} | Medical Text: Admission Date: [**2123-3-30**] Discharge Date: [**2123-4-9**]
Date of Birth: [**2053-4-12**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain, SOB
Major Surgical or Invasive Procedure:
[**2123-3-30**] Embolization of the distal superior epigastric artery
and the inferior epigastric artery
[**2123-4-1**] TEE
[**2123-4-8**] PEG placement
History of Present Illness:
69 yoM with resolving pneumonia, presents with 2 days of
progressive dyspnea and LUQ pain. He noted an expanding tender
mass this morning and came to ED. ON CT scan he was noted to
have a large, extravasating rectus sheath hematoma in the Left
side. On admission the patient was taking daily prednisone and
azithromycin for chronic obstructive pulmonary disease and
community acquired pneumonia. He was not taking any
anticoagulant medications.
Past Medical History:
HTN, non melanoma skin cancer, COPD
PSHx: multiple skin lesion excisions
Social History:
Lives with partner x 12 years. Divorced. Active lifestyle.
Family History:
Father died of MI in his 70's
Physical Exam:
Vital signs: T P BP RR O2
Constitutional: Alert and oriented to person and time
Neuro:
Cardiac: Regular rate, irregular rhythm, no murmurs/rubs/gallops
Lungs: Clear to auscultation, bilaterally
Abdomen: Soft, moderately tender, non-distended, + left flank
hematoma
Extremities: Left upper and lower extremity hemiplegia, Left
lower extremity hematoma
Wounds:
Physcial examination upon discharge: [**2123-4-9**]
General: resting comfortably, oriented to place and time,
follows commands
Vital signs: t=98.5, bp=119/87,hr=73, resp. rate 18, oxygen
saturation 98%( 2.5 liters oxygen
CV: N s1, s2, -s3, -s4
LUNGS: Clear
ABDOMEN: soft, non-tender, PEG tube with dsd
NEURO: Follows commands, speech garbled, right pupil 5mm, +
reaction, left pupil 3mm, + reaction, left upper and lower ext.
flaccid, muscle st. right upper and lower ext. +5+5
Pertinent Results:
[**2123-3-30**] CT ABD & PELVIS WITH CONTRAST: Large left rectal sheath
hematoma with active extravasation possibly from a left anterior
epigastric artery
CT HEAD W/O CONTRAST: No acute intracranial process
03/23/11MRA BRAIN/NECK W&W/O CONTRAST : 1. Multiple bilateral
hyperacute infarcts involving the bilateral cerebellar
hemispheres, right pontomedullary junction, left occipital lobe,
and right posterior corona radiata. These findings are most
consistent with likely "shower" of emboli from a central source,
in this case, related to atrial fibrillation, with possible
additional thromboembolic propagation from aortic arch catheter
manipulation. 2. Abrupt, short-segment luminal narrowing of
proximal basilar artery and right superior cerebellar artery
origins, which may represent thrombo-embolic material or less
likely, dissection. This abnormality predisposes to posterior
circulation infarcts.
3. Diffuse bilateral foci of susceptibility, mismatched to
infarct locations. These most likely represent microhemorrhage
from hypertensive vasculopathy. However, amyloid angiopathy,
nonocclusive thromboemboli, and Gelfoam/air embolization cannot
be completely excluded. 4. Mild non-flow-limiting stenoses of
bilateral vertebral artery origins. Multiple cerebellar
infarcts, basilar arterial narrowing
[**2123-4-1**] ECHO: No spontaneous echo contrast or thrombus in the
left or right atrium or biatrial appendages. Preserved global
left ventricular systolic function. No clinically significant
valvular disease. There is a suggestion of a very small patent
foramen ovale. Mildly dilated ascending aorta.
[**2123-4-3**] CTA CHEST W&W/O C&RECON & CT ABD & PELVIS WITH CO:1.
Rectus sheath hematoma appears slightly larger, but overall has
changed its distribution and appears to have tracked more
laterally than the prior examination. Extravasation cannot be
determined on this study, but there appears to be no obvious
pooling of contrast on late-phase images that were acquired. 2.
Mild stranding of the subcutaneous tissue extending from the
flanks to the left thigh is new from the most recent prior
examination. 3. No evidence of central pulmonary embolism;
however, smaller vessels were not well opacified due to
suboptimal contrast bolus and due to motion degradation. 4. Tiny
left-sided pleural effusion and bibasilar atelectasis noted. 5.
Area of alveolar infiltrate in the left lung base may be
infective. Right upper lobe area of infiltrate likely represents
scarring. 6. Nasogastric tube tip is proximal, at the distal
esopagus-gastric junction
[**2123-4-6**] CHEST (PORTABLE AP): In comparison with the study of
[**4-5**], there are continued low lung volumes without evidence of
acute pneumonia, vascular congestion, or pleural effusion.
Enlargement of the cardiac silhouette persists. Feeding tube
again extends to the distal stomach.
[**2123-4-7**] 05:15AM BLOOD WBC-10.5 RBC-3.58* Hgb-11.1* Hct-33.2*
MCV-93 MCH-31.1 MCHC-33.5 RDW-15.0 Plt Ct-524*
[**2123-4-6**] 12:35AM BLOOD WBC-9.8 RBC-3.42* Hgb-10.8* Hct-31.1*
MCV-91 MCH-31.5 MCHC-34.6 RDW-15.2 Plt Ct-431
[**2123-4-5**] 01:37AM BLOOD WBC-8.1 RBC-3.23* Hgb-10.1* Hct-29.1*
MCV-90 MCH-31.3 MCHC-34.8 RDW-15.2 Plt Ct-340
[**2123-3-30**] 05:30PM BLOOD Neuts-82.5* Lymphs-12.7* Monos-4.5
Eos-0.1 Baso-0.2
[**2123-3-30**] 12:50PM BLOOD Neuts-68.7 Lymphs-25.6 Monos-4.7 Eos-0.5
Baso-0.6
[**2123-4-7**] 05:15AM BLOOD Plt Ct-524*
[**2123-4-7**] 05:15AM BLOOD PT-12.8 PTT-21.3* INR(PT)-1.1
[**2123-4-6**] 12:35AM BLOOD Plt Ct-431
[**2123-4-2**] 02:24AM BLOOD Fibrino-696*#
[**2123-3-31**] 02:17AM BLOOD Fibrino-317
[**2123-4-3**] 06:00AM BLOOD ESR-128*
[**2123-4-3**] 08:30PM BLOOD Fact V-104 FactVII-81 FacVIII-192* Fact
X-71 FacXIII-NORMAL
[**2123-4-3**] 08:30PM BLOOD VWF AG-PND VWF CoF-235*
[**2123-4-8**] 05:25AM BLOOD Glucose-114* UreaN-33* Creat-1.1 Na-147*
K-4.2 Cl-110* HCO3-26 AnGap-15
[**2123-4-7**] 05:15AM BLOOD Glucose-116* UreaN-30* Creat-1.0 Na-148*
K-4.4 Cl-110* HCO3-29 AnGap-13
[**2123-4-6**] 12:35AM BLOOD Glucose-118* UreaN-28* Creat-0.9 Na-145
K-3.9 Cl-107 HCO3-29 AnGap-13
[**2123-4-5**] 01:37AM BLOOD Glucose-114* UreaN-22* Creat-0.9 Na-142
K-3.7 Cl-104 HCO3-28 AnGap-14
[**2123-3-31**] 10:32AM BLOOD ALT-33 AST-26 CK(CPK)-253 AlkPhos-26*
TotBili-0.4
[**2123-3-31**] 02:17AM BLOOD CK(CPK)-266
[**2123-3-31**] 10:32AM BLOOD CK-MB-3 cTropnT-<0.01
[**2123-3-31**] 02:17AM BLOOD CK-MB-4 cTropnT-<0.01
[**2123-3-30**] 06:23PM BLOOD CK-MB-4 cTropnT-<0.01
[**2123-3-30**] 12:50PM BLOOD cTropnT-<0.01
[**2123-4-8**] 05:25AM BLOOD Calcium-9.1 Phos-5.0* Mg-2.6
[**2123-4-7**] 05:15AM BLOOD Calcium-9.8 Phos-5.3* Mg-2.6
[**2123-4-6**] 12:35AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.6
[**2123-4-1**] 01:14AM BLOOD Triglyc-164* HDL-42 CHOL/HD-3.3
LDLcalc-63
[**2123-4-1**] 01:14AM BLOOD TSH-0.62
[**2123-4-4**] 02:43AM BLOOD CRP-198.3*
[**2123-3-30**] 05:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2123-4-4**] 01:13AM BLOOD Lactate-0.9
[**2123-4-3**] 09:34AM BLOOD Lactate-0.8
Brief Hospital Course:
The patient was seen in the emergency department and was found
to have a large rectus sheath hematoma. CT indicated active
extravasation and the patient was taken to the IR suite for an
emergent embolization. At the initiation of the procedure, the
patient became tachycardic, hypotensive, and a code blue was
called. He was minimally responsive and required intubation. He
was found to be in rapid atrial fibrillation and required
cardioversion to maintain his pressures. This was successful in
converting him to a normal rhythm and his emergent embolization
was continued. No active extravasation was demonstrated,
although a coil was placed in the superior epigastric and gel
foam in the inferior. Following the procedure the patient was
taken to the TSICU for further recovery. He was found to have a
dense left sided hemiparesis and the Neuro-Stroke team was
consulted. He was started on amiordarone for maintainence of his
normal sinus rhythm. CT and MRI head were obtained and these
showed multiple small cerebellar infarcts as well as a narrowed
basilar artery. On [**4-1**] the patient tolerated extubation well,
but had some difficulty with speech. A TEE was obtained that
demonstrated no thrombus. The following day he was transferred
to the floor for further recovery. After this, he developed
respiratory distress and returned to the ICU. LENI's and CT PE
protocol were obtained, and these were negative for DVT/PE. He
was given 1 unit of prbcs for continued decrease in HCT and
lasix for diuresis with good improvement in his respiratory
status. He was transferred to the floor for further recovery.
Following tranfer to the floor, the patient remained stable from
a neurological, cardiovascular and pulmonary standpoint. Given
his ongoing alteration in mental status and limited attempts at
swallowing with a trial of applesauce it was determined that he
would require long-term enteral nutrition. The family wished to
proceed with a PEG which was placed on [**4-8**]. Tube feedings were
resumed and were well tolerated a goal which met 100% of energy
and protein needs.
He was re-evaluated by Speech Language Pathology on [**4-9**], as they
were unable to complete their assessment on [**4-5**]. The SLP
recommended NPO status in addition to tube feedings. He was
also evaluated by Occupational and Physical Therapy who
recommended ongoing rehabilitation at a rehab facility to which
he will be discharged. At this time, the patient remained
stable, afebrile with stable vital signs. Per discussion with
his PCP and neurology, he will be discharged without
anticoagulation aside from daily aspirin. The patient was
tolerating a tube feedings, receiving PT an OT, voiding
adequately with a foley catheter in place, and with well
controlled pain. The patient and family received discharge
teaching and follow-up instructions.
Neurology service recommended bp between 140-180 systolic. For
this reason, he did not resume his oral anti-hypertensive agents
while he was recovering and he was receiving intravenous
metoprolol every 6 hours.
Medications on Admission:
HCTZ, 'other BP med'
Discharge Medications:
1. aspirin 300 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as
needed for wheeze.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection TID (3 times a day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime:
via feeding tube.
6. ipratropium bromide 0.02 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left Rectus Sheath Hematoma
Embolic cerebellar CVA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital following the development of a
left rectus sheath hematoma, which was embolized by
Interventional Radiology. However, following the procedure, an
embolic stroke occured resulting in left sided hemiparesis. It
was felt that your intake will not be sufficient to meet your
energy and protein needs at this time and will require
supplemental tube feeding while you are undergoing
rehabilitation. Therefore, a feeding tube was placed and tube
feedings were intiated which will meet your nutritional needs.
Additionally, a swallow evaluation was performed in which a
recommendation was made that you do not take food by mouth at
this time. You will be discharged to Braintrain rehabilation
facility with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications or if you are not tolerating your tube feeings.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
**You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Incision Care:
* Inspect feeding tube site for redness, discharge.
Because you did experience a stroke, please be aware of:
*Any changes in your speech, vision, or muscle weakness right
side
*Increased confusion, or change in your mental status
Followup Instructions:
Please contact the Acute Care Service at [**Telephone/Fax (1) 600**] to make a
follow-up appointment within 2-3 weeks.
Follow up with Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] Date/time: [**6-1**] at 2 pm.
[**Hospital Ward Name 23**] Bldg [**Location (un) **]. Pls call ([**Telephone/Fax (1) 15319**] two weeks
before appointment to ensure date and time and to ensure you are
registered.
Completed by:[**2123-4-9**]
ICD9 Codes: 5789, 4019, 2724 |
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