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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2800
} | Medical Text: Admission Date: [**2100-9-28**] Discharge Date: [**2100-10-1**]
Date of Birth: [**2020-7-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
80 y.o. female with history of small cell lung ca. s/p RUL
resection transferred from OSH for 1 day history of hemoptysis.
.
Pt states that early this morning at 2am she woke up with a
coughing sensation, when she looked at the tissue she noted
bright red blood streaks. She called her son who drove her to
[**Name (NI) **] [**Name (NI) **] hospital. There in the hospital she had ?3 more
episodes of hemoptysis that was noted to be the same amount ie
"bloody blotches" as opposed to gross hemoptysis. At the outside
hospital her labs were notable for WBC 8.7, Hct 35.1, Plt 368,
unremarkable chemistry panel with Creatinine of 0.9. She also
underwent a chest CTA to eval her hemoptysis, per ED signout it
was read as no P. Embolism, tumour burden or infection. She was
then med flighted to [**Hospital1 18**] ED for further evaluation. Her vitals
in the OSH were noted to be BP 122/77, P99, RR 18, Sat 94% on
RA.
.
Her labs were overall unremarkable with no leukocytosis, Hct of
36.6. Chemistry panel was also unremarkable. ED presented films
to Radiology here who confirmed no P. embolism, tumour burden or
infection. Emphysema was noted but not bronchiectasis. Pt was
transferred to the ICU for airway observation and possible
bronchoscopy. ED called IP to notify them of pt in case of gross
hemoptysis.
.
She denies any recent fevers, chills, nausea, vomiting,
hematemesis, abdominal pain, melena, BRBPR. She does endorse
some shortness of breath over the past few weeks. She also has
2lb weight loss over 4 weeks, denies any ankle edema, pleuritic
c/p. Does endorse some sternal pain occuring over the past 3
weeks which hurt with palpation, not anginal in nature. She does
endorse a chronic daily cough with expectorant.
Past Medical History:
Small Cell (slow growing) Lung CA s/p RUL resection
HTN
HLD
Social History:
+tobacco history is now down to 1/2 ppd x 62 years. Has only
tried to quit once but restarted. She denies any EtoH or
recreational drug use. She used to work at Itron working with
"radio tubes".
Family History:
son with small cell lung cancer
Physical Exam:
On admission:
Vitals: T:97.1, BP: 122-137/70-78, P: 88-91, R: 27-29, O2 sat:
97-98% on 2L.
General: Elderly Caucasian Female with face mask, mildly
tachypneic in NARD.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Borderline tachycardia (100), regular rhythm, normal S1 +
S2, no murmurs, rubs, gallops. Sternum is tender to palpation.
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
Pertinent Results:
CXR [**2100-9-28**]
FINDINGS: No previous images. There is surgical change involving
the right upper zone with extensive fibrotic scarring and some
retraction of the mediastinal contours to this side. Surgical
clips are seen. The findings are consistent with prior operative
procedure for cancer and possibly some post-radiation changes.
Nevertheless, there is no evidence of acute focal pneumonia.
.
Bronchoscopy prelim: no source of bleeding below the cords,
?role for ENT evaluation
.
ON ADMISSION:
[**2100-9-28**] 01:20PM BLOOD WBC-7.5 RBC-4.20 Hgb-12.1 Hct-36.6 MCV-87
MCH-28.8 MCHC-33.1 RDW-13.8 Plt Ct-431
[**2100-9-28**] 01:20PM BLOOD Neuts-80.5* Lymphs-11.4* Monos-4.7
Eos-2.8 Baso-0.4
[**2100-9-28**] 01:20PM BLOOD PT-12.2 PTT-28.6 INR(PT)-1.0
[**2100-9-28**] 01:20PM BLOOD Glucose-99 UreaN-16 Creat-0.8 Na-139
K-4.4 Cl-100 HCO3-27 AnGap-16
[**2100-9-29**] 06:00AM BLOOD Calcium-10.0 Phos-3.9 Mg-2.3
.
ON DISCHARGE:
[**2100-10-1**] 10:20AM BLOOD WBC-10.4 RBC-4.00* Hgb-11.6* Hct-35.5*
MCV-89 MCH-29.1 MCHC-32.7 RDW-13.4 Plt Ct-427
[**2100-10-1**] 10:20AM BLOOD Plt Ct-427
[**2100-10-1**] 10:20AM BLOOD Glucose-177* UreaN-19 Creat-1.1 Na-140
K-4.2 Cl-98 HCO3-30 AnGap-16
[**2100-10-1**] 10:20AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.3
[**2100-9-30**] 05:15PM BLOOD TSH-0.82
Brief Hospital Course:
80 y/o female with COPD, lung cancer s/p RUL excision 5 years
ago who presented with hemoptysis.
.
## Hemoptysis: pt had history of mild hemoptysis, concerning for
possibility of malignancy or possible bronchiectasis. No
evidence of airway or hemodynamic compromise. OSH CTA [**2100-9-28**]:
No pulmonary embolism, tumor burden or infection. U/A wnl and
without evidence of pulmonary-renal syndrome. CXR showed
evidence of prior surgery in the right upper lobe with fibrosis
and retractions. Aspirin was held in setting of bleeding. Hct
was stable throughout admission (discharge Hct 35.5).
Bronchoscopy was performed and no source of bleeding was found
in the tracheobronchial tree, and no evidence for tumor
recurrance noted. Upper airway, or nasopharyngeal source of
bleeding could not be excluded, and patient may require
outpatient ENT evaluation at the discretion of her primary care
doctor (small amount of blood above the vocal cords suggestive
of an upper airway source of bleeding). Patient completed four
days of azithromycin for possible bronchitis while admitted, and
will complete the 5 day course on discharge. Aspirin was resumed
on discharge. Pt discharged on azithromycin, cough suppressant,
saline nasal spray. She may need ENT follow-up as an outpatient
in order to assess her upper airway, and this will be
communicated with her PCP.
.
## COPD: occasional wheezing on physical exam, without
respiratory distress. She was maintained on home regimen of
spiriva, ipratropium, and albuterol nebulizers.
.
## HTN: stable, continued on home regimen of Diovan/HCTZ
.
## HLD: stable, continued on home regimen of Simvastatin
.
## GERD: stable, continued on home regimen of Omeprazole.
Medications on Admission:
ASA 325mg daily
Tylenol 1gm qHS
Simvastatin 20mg qHS
Omeprazole 20mg daily
Diovan 80mg-12.5mg 1/2 tabs daily
MVI 1 tab daily
Spiriva 1 INH daily
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: 0.5 Capsule PO DAILY
(Daily).
2. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
7. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
9. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Sodium Chloride 0.65 % Drops Sig: 1-2 drops Nasal every [**3-29**]
hours as needed for dry nose, bloody cough from upper airway
source.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. hemoptysis
Discharge Condition:
good, without hemoptysis, with stable hematocrit, ambulatory,
tolerating food well
Discharge Instructions:
You were admitted for evaluation of bloody cough. During your
hospitalization you received a bronschoscpy to look into your
lungs and evaluate for the source. No active bleeding was noted
and no pulmonary cause for the bleeding was found. You will
likely require outpatient Ear, Nose, Throat evaluation with
camera study, to evaluate this bloody cough. On discharge, your
blood counts were stable and you did not have evidence of bloody
cough for the day prior to discharge.
.
Medications changed during your admission:
- START azithromycin 250 mg for one day to complete course for
bronchitis
- START sodium chloride nasal spray, [**12-25**] sprays to both nostrils
every 4-6 hours
.
Please call your doctor or return to the emergency department if
you develop chest pain, shortness of breath, sudden weakness,
dizziness, large amounts of bloody cough, blood in vomit, or any
other concerning symtoms.
Followup Instructions:
An appointment has been made for [**2100-10-12**] at 2:30 pm
with your primary care doctor. Please call [**Telephone/Fax (1) 84402**] to
confirm, and if you have any questions.
Completed by:[**2100-10-2**]
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2801
} | Medical Text: Admission Date: [**2155-6-27**] Discharge Date: [**2155-6-28**]
Date of Birth: [**2086-10-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
elective admit for coiling of R ICA aneurysm
Major Surgical or Invasive Procedure:
Angiogram [**2155-6-27**]
History of Present Illness:
The patient had a headache associated with neck discomfort and
fever for which she was evaluated at [**Last Name (un) 1724**] on [**2155-5-14**]. She had a
Head CT scan which was notable for a 7 mm partially calcified
aneurysm in the circle of [**Location (un) 431**] and also a
lumbar puncture. Was noted to have low O2 sats on room air and
hypokalemia on her blood work. Was discharged on [**2155-5-15**].
She presented electively on [**2155-6-27**] for coiling of her Right ICA
aneurysm
Past Medical History:
aneurysm, dyslipidemia, gout, PNA, obesity
Social History:
social EOTH, past smoker but none in recent futuure
Family History:
noncontrib
Physical Exam:
On Admission:
c/o headache, full strength, sensation intact, no drift, neuro
intact
On Discharge:
eye opening spontaneous, awake alert and oriented x 3, no
pronator drift, full strength in all extremities, groin site
c/d/i no hematoma, bleeding
Pertinent Results:
[**2155-6-27**] 01:00PM WBC-6.9 RBC-4.55 HGB-13.2 HCT-39.2 MCV-86
MCH-29.0 MCHC-33.6 RDW-13.3
[**2155-6-27**] 01:00PM PLT COUNT-285
[**2155-6-27**] 01:00PM PT-11.9 PTT-22.9 INR(PT)-1.0
Brief Hospital Course:
presented electively on [**2155-6-27**] for coiling of Right ICA
aneurysm. the coiling was done without complications and she
was sent to the ICU for observation. She remained stable
overnight and on the morning of [**2155-6-28**] she was deemed fit for
discharge to home.
Medications on Admission:
Cozaar 12.5mg QD, toprol XL 25mg QD, Nexium 20mg QD, fluvoxamine
200mg [**Hospital1 **], simvastatin 30mg QD, wellbutrin 200mg QD.
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Fluvoxamine 50 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
6. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
8. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
R ICA aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please call [**Telephone/Fax (1) 1669**] to schedule a follow up appointment
with Dr. [**First Name (STitle) **] to be seen in 4 weeks.
You will need a non contrast head CT before your follow up
appointment. Please call [**Telephone/Fax (1) 1669**] to schedule.
Completed by:[**2155-6-28**]
ICD9 Codes: 2724, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2802
} | Medical Text: Admission Date: [**2130-8-17**] Discharge Date: [**2130-8-18**]
Date of Birth: [**2057-4-9**] Sex: F
CHIEF COMPLAINT: The patient was admitted to the C-MED
Service at 4 a.m. The patient's chief complaint was chest
pain.
with known 3-vessel disease who refused coronary artery
bypass graft with daily rest angina, who presents with chest
pain lasting for 45 minutes. The patient was in her usual
state of health until 9:30 that day until she began having
the chest pain. She took Rolaids and nitroglycerin times
three, and the pain resolved. The total time of chest pain
was approximately 45 minutes.
The patient was pain free on arrival to the Emergency Room.
She did have some diaphoresis. No nausea or vomiting. She
took an aspirin on the way to the Emergency Department. No
specific complaints on arrival to the Emergency Department.
No melena. No bright red blood per rectum. No constipation.
The patient refused a blood transfusion in the Emergency
Room.
PAST MEDICAL HISTORY: (Significant for)
1. Coronary artery disease. Catheterization in [**2125-4-9**] showed 3-vessel disease, left anterior descending
artery, left common circumflex, and first obtuse marginal,
and second obtuse marginal, and right coronary artery. The
patient refused coronary artery bypass graft in [**2125**].
Echocardiogram in [**2130-6-9**] showed a normal ejection
fraction, mild aortic insufficiency, and mild mitral
regurgitation.
2. Also significant for diabetes mellitus.
3. Hypertension.
4. Increased cholesterol.
5. H. pylori, status post treatment.
MEDICATIONS ON ADMISSION: Medications on arrival included
aspirin 325 mg p.o. q.d., lisinopril 10 mg p.o. q.d.,
diltiazem 120 mg, Lipitor 10 mg p.o. q.d., atenolol 25 mg
p.o. q.d., Isordil 20 mg p.o. t.i.d., Protonix 40 mg p.o.
q.d., NPH 30 units q.a.m. and 20 units q.p.m., sublingual
nitroglycerin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with her family. No
tobacco use. No drug abuse. No smoking.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs were blood
pressure of 154/50, heart rate of 70, respiratory rate of 16.
In general, in no acute distress. HEENT revealed mucous
membranes were moist. Pupils were equal, round, and reactive
to light and accommodation. Cardiovascular revealed a
regular rate and rhythm, S1 and S2. No murmurs, rubs or
gallops were appreciated. Pulmonary was clear to
auscultation bilaterally. Abdomen was soft, nontender, and
nondistended. Guaiac-negative. Extremities had no edema.
Neurologically, alert and oriented times three. Cranial
nerves II through XII were intact.
LABORATORY DATA ON ADMISSION: Laboratories were significant
for a white count of 6.1, hematocrit of 27.8 (down from her
baseline of 30.6). PT of 25, INR of 0.9. Chem-7 was within
normal limits. First CK/MB was 138. The patient had an LDL
of 163, HDL of 35.
RADIOLOGY/IMAGING: Chest x-ray had no congestive heart
failure. No infiltrates.
Electrocardiogram revealed normal sinus rhythm at 76 beats
per minute, normal axis. ST depressions in V4 and V3 through
V6; new compared with the one done on [**2130-7-18**].
IMPRESSION: Impression was a 73-year-old female with
3-vessel disease who refused coronary artery bypass graft
with daily angina who presented to the Emergency Room with
chest pain which resolved on arrival, also with anemia but
refused transfusion.
HOSPITAL COURSE: The patient was admitted to the C-MED
Service and at that time was ruled out for myocardial
infarction. The patient initial creatine kinase was 138, the
next one was 141, the next one was 142 with a negative MB
throughout.It was strongly recommended that she undergo repeat
cardiac catheterization with almost certainly the need for
surgical revascularization on this admission. Despite prolonged
discussions with the patient she adamently refused to consider
this option (as had been the case in the past).
DISCHARGE DISPOSITION: The patient refused to consider repeat
catheterization, and after many spoke
with her she simple refused it, and the patient was
discharged home on [**2130-8-18**], on her regular
medications. She was given an additional prescription for
sublingual nitroglycerin which she had run out of.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 94877**]
MEDQUIST36
D: [**2130-8-18**] 10:20
T: [**2130-8-24**] 16:21
JOB#: [**Job Number **]
ICD9 Codes: 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2803
} | Medical Text: Admission Date: [**2124-10-13**] Discharge Date: [**2124-10-19**]
Date of Birth: [**2039-1-25**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2124-10-13**] EXPLORATORY LAPAROTOMY, abdominal washout and [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] for perforated ulcer [**Location (un) **]
History of Present Illness:
85F w/ h/o of chronic naproxen use for arthritis, presented
to [**Hospital6 19155**] earlier today for worsening abd
pain
that started on Tuesday. Pain was sharp and located on L abd.
Denied ever having this pain before. Pain worsened over next
few
days and became more diffuse but patient was tolerating PO's and
passing flatus until earlier today where she had nausea and
minimal emesis and has not passed flatus. At OSH, she had CT
abd
w/ PO contrast that caused more abd pain. She was transferred
to
[**Hospital1 18**] for possible gastric perforation. She denies F, C, CP,
SOB, hematemesis, BRBPR, recent weight loss, prior EGDs. Last
c-scope 3 yrs ago w/ only diverticulosis.
Past Medical History:
diverticulosis, HTN, hypercholesterolemia, hypothyroidism
Social History:
Lives alone, no tobacco, no ETOH
Family History:
Noncontributory
Physical Exam:
Temp 97.9 HR 68 BP 139/79 RR 20 O2 sat 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: diminished bowel sounds, mildly firm, nondistended, +TTP
diffusely, more localized at epigastrium, +guarding, no palpable
masses
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
ADMISSION LABS:
[**2124-10-13**] 11:59PM GLUCOSE-119* UREA N-25* CREAT-1.7* SODIUM-137
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-20* ANION GAP-15
[**2124-10-13**] 11:59PM WBC-19.6* RBC-4.21 HGB-12.1 HCT-37.1 MCV-88
MCH-28.8 MCHC-32.7 RDW-13.8
[**2124-10-13**] 11:59PM PLT COUNT-191
[**2124-10-13**] 11:59PM PT-13.2 PTT-28.2 INR(PT)-1.1
LABS DURING HOSPITAL STAY:
[**2124-10-19**] 04:55AM BLOOD WBC-10.0 RBC-4.00* Hgb-11.3* Hct-33.8*
MCV-85 MCH-28.2 MCHC-33.4 RDW-14.0 Plt Ct-229
[**2124-10-13**] 11:59PM BLOOD Neuts-82* Bands-4 Lymphs-7* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2124-10-13**] 11:59PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2124-10-19**] 04:55AM BLOOD Plt Ct-229
[**2124-10-19**] 04:55AM BLOOD Glucose-93 UreaN-17 Creat-1.0 Na-136
K-2.8* (POTASSIUM REPLETED ON MORNING OF THISRESULT) Cl-101
HCO3-28 AnGap-10
Brief Hospital Course:
She was admitted to the Acute Care Surgery team and taken to the
operating room for exploratory laparotomy, abdominal washout,
[**Location (un) **] patch-omental patch repair of anterior duodenal ulcer,
and placement of drain. IV Zosyn was started. Postoperatively
she was taken to the ICU for close hemodynamic monitoring due to
postoperative hypotension where she required Neo gtt. She
received fluid resuscitation as well. Once stable the Neo was
weaned off and she was extubated and transferred to the floor
the following day.
Upon transfer to the floor she progressed as expected. Her diet
was re-introduced slowly for which she has been able to tolerate
and home medications restarted with exception of Naprosyn. Her
JP drain output has been followed very closely as well and on
day of discharge had put out approx 200 cc's in the previous 24
hours. The decision was made to keep the JP in place and to
follow up in [**Hospital 2536**] clinic in a week to assess removal. A record of
her daily outputs should accompany her to her follow up
appointment.
The IV antibiotics were stopped after she developed a macular
pruritic rash on her extremities; this improved immediately
following stopping the Zosyn.
Her fluid volume status was noted to be positive for several
liters requiring diuresis with Lasix IV based on her exam and
chest radiographs. She also required intermittent repletion of
her potassium with this diuresis. [**Male First Name (un) 14261**] for her LE edema were
applied.
She was evaluated by Physical therapy and is being recommended
for short term rehab after her acute hospital stay. She was
discharged to rehab on [**2124-10-19**] and will follow up in the [**Hospital 2536**]
Clinic in 1 week.
Medications on Admission:
atenolol 12.5', amlodipine 2.5', Benicar 20', naproxen 500'',
levothyroxine 75', statin qhs (?name/dose)
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. olmesartan 20 mg Tablet Sig: One (1) Tablet PO daily ().
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
9. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] House Nursing Home - [**Location 9583**]
Discharge Diagnosis:
Perforated duodenal ulcer
Postoperative hypotension secondary to hypovolemia
Pleural effusion
Hypokalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with a perforated ulcer
requiring an operation to repair this. Following your surgery
your dietary intake was placed on hold for a few days and then
slowly restarted. Now that you are able to tolerate a diet we
are preparing for your discharge.
During your hospital stay you were found to have some excess
fluid in your body requring that you be given a diuretic to get
rid of the excess fluid. Once your body weight returns to normal
it is likely you will no longer need this medication.
You may resume your home medications with the exception of any
NSAID's (non steroidal anit-inflammatory agents) and/or aspiring
containing products.
Followup Instructions:
Follow up in next Thursday in Acute Care Surgery Clinic to
evlaute your wounds and to possibly remove your JP drain. Upon
discharge from the hospital please call [**Telephone/Fax (1) 600**] for an
appointment.
Please also follow up with your primary care providers following
discharge from the hospital or rehabilitation facility. You or
your family will needto call for an appointment.
Completed by:[**2124-10-24**]
ICD9 Codes: 5849, 4019, 2720, 2449, 2768, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2804
} | Medical Text: Admission Date: [**2154-7-27**] Discharge Date: [**2154-7-30**]
Date of Birth: [**2103-4-11**] Sex: M
Service: SURGERY
Allergies:
seafood / Iodine / Erythromycin Base
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Multiple facial fractures after a motorcycle crash beginning of
[**Month (only) 205**]
Major Surgical or Invasive Procedure:
[**2154-7-27**] OPEN REDUCTION INTERNAL FIXATION RIGHT SUPERIOR ORBIT
FRACTURE, ZYGOMATIC FRONTAL SINUS AND LEFORT FRACTURE
History of Present Illness:
51-year-old male who
was initially seen at [**Hospital3 **] emergency department on
[**2154-7-21**] after being transferred from an outside
hospital following a motorcycle collision where he sustained
multiple facial fractures. He was transferred to [**Hospital1 346**] for evaluation and treatment of his
facial injuries and on his arrival Oral Maxillofacial Surgery
was consulted for evaluation of the facial injuries. At the
time, Ophthalmology was also consulted for evaluation and
found that he had elevated intraocular pressure of the right
eye for which he underwent a right lateral canthotomy with
subsequent return to normal pressure by Ophthalmology in the
emergency department. The patient was also evaluated by
Neurosurgery at the time for evidence of CSF rhinorrhea as
well as a small area of pneumocephalus on his CAT scan.
During his admission, Ophthalmology and Neurosurgery followed
him and he was eventually cleared from Neurosurgery as his
CSF leak resolve and Ophthalmology also cleared him for
discharge and the patient was discharged. The patient was
seen by Oral Maxillofacial Surgery as an outpatient where it
was discussed in detail, planned for reconstruction of his
right upper and mid face. At that appointment, all risks,
benefits, alternatives, and complications were discussed with
the patient in detail including the risks of damage to his
eye, blindness and risk of opening up a CSF leak and damage
to the brain. It was discussed with the patient that
consultation with Neurosurgery would be done preoperatively
in order to have them available if there was, in fact, dural
tear and CSF leak found during the operation. The patient
also was seen by Ophthalmology again as an outpatient prior
to the surgery and the patient was cleared by the
Ophthalmology team for open reduction internal fixation of
his orbital and frontal sinus fractures. Therefore, the
patient was scheduled for surgery on [**2154-7-27**].
Past Medical History:
Asthma, Hx Lyme dz ([**2154**]), Depression
Social History:
Lives w girlfriend. Unemployed [**Name2 (NI) **]. Reports
multiple psychosocial stressors including terminally ill mother
and recent death of two sons. [**Name (NI) 1139**]: ~50pack yr hx-quit [**2151**].
EtOH: 12 drinks/day. Drugs: Denies
Family History:
Reports strong family history of diabetes and CAD.
Pertinent Results:
[**2154-7-27**] 08:31PM GLUCOSE-171* UREA N-8 CREAT-0.6 SODIUM-138
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-27 ANION GAP-11
[**2154-7-27**] 08:31PM ALT(SGPT)-17 AST(SGOT)-25
[**2154-7-27**] 08:31PM ALBUMIN-3.2* CALCIUM-8.2* PHOSPHATE-3.6
MAGNESIUM-1.8
[**2154-7-27**] 08:31PM WBC-14.8* RBC-3.53* HGB-11.5* HCT-33.5*
MCV-95 MCH-32.6* MCHC-34.3 RDW-13.2
[**2154-7-27**] 08:31PM PLT COUNT-317
Brief Hospital Course:
He was admitted to the Acute Care team following his surgery
performed by OMFS. He underwent open reduction internal fixation
of right frontal sinus anterior table, right superior orbit and
lateral wall fractures, right zygomaticomaxillary complex
fractures, and right maxillary fractures as well as extraction
of teeth numbers 30 and 32, and enucleation of right frontal
sinus mucocele/cyst. Two drains were left in place; the first
drain was removed on POD#3 and the second one on POD#4. His
initial dressing was removed and replaced with a dry dressing.
His pain is being controlled with both Ibuprofen and Oxycodone
prn. His home medications were restarted and he is tolerating a
regular soft diet without any problems.
He is being discharged home and will follow up in [**Hospital 40530**] clinic at
[**Hospital6 **] next week.
Medications on Admission:
Celexa, ProAir, Symbicort
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day): mouth rinse and spit.
Disp:*900 ML(s)* Refills:*2*
2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. 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.
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
8. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: take with food.
Disp:*120 Tablet(s)* Refills:*0*
11. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
12. bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
TID (3 times a day) for 10 days: apply to right eye.
Disp:*1 tube* Refills:*0*
13. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic HS (at bedtime): apply to right eye.
Disp:*1 tube* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Displaced complex right superior orbit, right frontal sinus
orbital wall, zygomaticomaxillary complex and maxillary
fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for repair of your multiple
facial fractures.
AVOID blowing your nose; you should also not drink through a
straw - these activities cause increased pressure on your facial
fractures.
You should sleep with your head on at least 2 pillows.
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have 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.
* 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.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Follow up next week at [**Hospital6 **] [**Hospital 40530**] Clinic: [**Last Name (NamePattern1) 89055**], [**Location (un) 86**], [**Numeric Identifier 13108**]; Yawkey Bldg; [**Location (un) 89056**]; call
[**Telephone/Fax (1) 68463**] for an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2154-8-6**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2805
} | Medical Text: Admission Date: [**2124-1-17**] Discharge Date: [**2124-1-25**]
Date of Birth: [**2079-9-8**] Sex: M
Service: SURGERY
Allergies:
Mefoxin
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
LGIB
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
44yM with Ehlers Danlos syndrome type IV presents with rectal
bleeding for a few hours. Patient has a h/o LGIBs in the past
few months requiring multiple transfusions. He does not have any
dizziness or abdominal pain but does note that the character of
his stools is darker than usual compared to his previous bleeds.
Hct at OSH on presentation 43.0.
Past Medical History:
1. Ehlers-Danlos syndrome, type 4 with bowel bleeds (mesenteric
artery bleed)
2. bilateral club feet, with ankle surgeries
3. RP bleed in [**2119**], no intervention
4. Celiac artery aneurysm
5. GERD
6. HTN
7. Left inguinal hernia repair
8. Left eye blindness
9. Bilateral carotic artery aneurysm
Social History:
No smoking, no drug, no EtOH, works in computers
Family History:
Non-Contributory
Physical Exam:
Gen: talkative, awake and alert
HEENT: EOMI, PERRL, nares patent, oropharynx without erythema or
exudate
Neck: no masses
CV: RRR, no m/r/g
Resp: CTA bilaterally
Abd: soft, NTND, no organomegaly
Ext: no c/c/e
Neuro: aao x 4
Pertinent Results:
[**2124-1-25**] 06:25AM BLOOD Hct-31.8*
[**2124-1-24**] 05:03AM BLOOD Hct-31.0*
[**2124-1-23**] 04:47AM BLOOD WBC-2.7* RBC-3.84* Hgb-11.1* Hct-32.7*
MCV-85 MCH-29.0 MCHC-34.0 RDW-16.3* Plt Ct-220
Brief Hospital Course:
Patient was admitted and received DDAVP as well as 1U PRBCs for
a slowly dropping Hct from 43 to 34.7. He was kept NPO and
maintained on iv fluids. A GI consult was obtained who
recommended serial Hct's as well as a bowel prep for a
colonoscopy. A colonoscopy performed on HD2 demonstrated
multiple clots in the colon, but with no obvious source of
bleeding. He continued to receive PRBCs as needed for a slow
drop in his Hct. He did intermittently have episodes of bloody
stool. He was kept NPO and started on parenteral nutrition. The
option of surgery was discussed with the patient, however, he
opted for a repeat colonscopy which was performed on HD8. The
colonoscopy revealed an area of ulceration near the anastamotic
site of the colon. Per the recommendations of the GI team, the
patient was started on Rowesa enemas and ursodiol tid. He had no
further episodes of melena and his hematocrit stabilized. He
tolerated a regular diet and was discharged to home with enemas
and po protonix. He was instructed to follow up with Dr. [**Last Name (STitle) **]
as well as with Dr. [**First Name (STitle) 679**] to discuss future options and potential
surgery for his recurrent LGIB.
Medications on Admission:
actigall 300'', protonix 40'
Discharge Medications:
1. Mesalamine 4 g/60 mL Enema Sig: 60mL Rectal DAILY (Daily).
Disp:*1000 cc* Refills:*2*
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
lower GI bleed
Discharge Condition:
stable
Discharge Instructions:
- you may shower
- you should resume your regular diet
- you should resume all home medications - incorporating the
changes made in your medications while in the hospital
vomiting, chest pain, shortness of breath, bleeding from your GI
tract, or any other concern.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] at the time of your GI
appointment with Dr. [**First Name (STitle) 679**]. Dr.[**Name (NI) 18535**] office will contact you
with details. Call Dr.[**Name (NI) 18535**] office at [**Telephone/Fax (1) 18052**] if you
have any questions or concerns.
ICD9 Codes: 5789, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2806
} | Medical Text: Admission Date: [**2169-6-26**] Discharge Date: [**2169-7-18**]
Date of Birth: [**2108-3-31**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
genetic male, status post sex change operation, with a past
medical history of asthma, who has been intubated once
before, and chronic obstructive pulmonary disease, who
complained of an upper respiratory infection for two days
prior to admission. She was complaining of increased
shortness of breath, took three nebulizers on her own before
calling the ambulance. She also started a prednisone taper
one day prior to admission. She complained of productive
white sputum. After not improving with this self-treatment,
she called an ambulance and was given nebulizers x 3 by the
EMTs. Her saturations at that time were 88 to 91%. She
denied any chest pain, palpitations, nausea, vomiting, or
lightheadedness. She was able to talk in complete sentences
after ten nebulizer treatments while in the Emergency Room.
Oxygen saturation was 98% on 4 liters, and she was
hemodynamically stable. Solu-Medrol 125 mg was given.
At approximately 5 A.M., the patient's shortness of breath
increased despite prior nebulizer treatments. She also had
an episode of decreased heart rate and a question of asystole
with spontaneous return of her pulse. Treatment for
hyperkalemia was initiated. She was ventilated with a bag
valve mask, and by report, there were subsequent episodes of
asystole associated with increased resistance to bagging.
She ultimately was intubated for asystole and respiratory
decompensation. She was started empirically on Levaquin 500
mg intravenously, and transferred to the Medical Intensive
Care Unit for further treatment and monitoring.
PAST MEDICAL HISTORY:
1. PPD positive. The patient is status post INH treatment
in [**2161**].
2. Right foot cellulitis
3. Reactive airway disease status post intubation x 1,
status post tracheostomy x 1, baseline peak flows are 275
4. Question of chronic obstructive pulmonary disease, no
documented pulmonary function tests, however, patient on 4
liters of oxygen at home at baseline
5. Type 2 diabetes
6. Paroxysmal atrial fibrillation
7. Status post sex change operation. The patient is a
genetic male.
8. Hepatitis C positive
9. Hepatitis B positive
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Prednisone, albuterol, Atrovent
metered dose inhalers, Serevent metered dose inhaler, Flovent
metered dose inhaler, Glucophage, Coumadin, Wellbutrin.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives alone, has one sister,
[**Name (NI) **] [**Name (NI) 4887**], who lives in [**State 4260**]. Her phone number is
[**Telephone/Fax (1) 39494**]. The patient is retired. Occasional alcohol
use. No current tobacco use, quit smoking cigarettes
approximately 15 years ago.
PHYSICAL EXAMINATION: In general, the patient is an obese
black male, who is intubated and sedated. Head, eyes, ears,
nose and throat shows the patient to be normocephalic,
atraumatic head. The pupils are fixed. The endotracheal
tube is in place. There is a well-healed tracheostomy scar.
Neck examination is difficult due to body habitus. Jugular
venous pressure cannot be assessed. The lung examination
shows diffuse wheezes bilaterally, with decreased breath
sounds throughout. Heart examination shows the heart to be
distant, S1 and S2 are normal. There are no murmurs, gallops
or rubs. The abdomen is obese and soft. There are positive
bowel sounds throughout. The bladder is enlarged and tapped
to approximately halfway up the abdomen. The extremities are
without clubbing or cyanosis, but there is 2+ edema in the
lower extremities. The neurological examination is limited,
but the patient does withdraw appropriately to pain, and she
moves all extremities. On genitourinary examination, the
patient is status post orchiectomy, and the Foley is unable
to be passed.
LABORATORY DATA: On admission, white count 19.3, hematocrit
29.2, platelets 93. Differential shows 75% neutrophils, 18%
lymphocytes, and 7% monocytes. PT is 24, PTT 37, INR 3.8.
Sodium 135, potassium 9.8, chloride 97, bicarbonate 26, BUN
47, creatinine 3.5, glucose 259. AST 27, ALT 34, CK 133,
albumin 3.7, amylase 51. Total bilirubin 0.2. Initial
arterial blood gas shows the patient to be acidotic with a pH
of 7.2, PCO2 of 86, and PO2 of 490, lactate level 5.1.
STUDIES: Electrocardiogram on admission shows an accelerated
idioventricular rhythm with likely retrograde atrial
activation. Chest x-ray showed mild to moderate pulmonary
vascular redistribution with early interstitial edema and
alveolar edema seen prominently in the mid to lower lung
zones. It also showed a possible left basilar retrocardiac
opacity. The endotracheal tube was in satisfactory position.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for further monitoring and treatment.
1. Cardiovascular: The patient was hemodynamically stable
when admitted. An A-line was placed for close monitoring of
blood pressures. She was initially in a junctional rhythm on
electrocardiogram, most likely secondary to hyperkalemia.
She was ruled out for a myocardial infarction with negative
enzymes, and emergent hemodialysis was obtained to treat her
hyperkalemia. Her electrolytes were aggressively normalized.
Her potassium came down nicely with the hemodialysis.
Another reason for her abnormal rhythm was felt to be due to
Digoxin toxicity. Therefore, her Digoxin was held and
allowed to drift down out of the toxic range. Ms. [**Known lastname **]
continued in paroxysmal atrial fibrillation, going in and out
of atrial fibrillation with rapid ventricular rates and
sporadic conversions into normal sinus rhythm. Throughout
her episodes of atrial fibrillation, she remained
hemodynamically stable. She was started on amiodarone and
diltiazem to help control her atrial fibrillation, and a
cardiac echocardiogram was obtained. It showed a mildly
dilated left atrium and aorta. Left ventricular ejection
fraction was normal at greater than 55%. Her atrial
fibrillation finally broke on [**7-5**]. Her diltiazem drip
was weaned off, and her amiodarone drip was converted to oral
amiodarone.
After the 23rd, she had a few episodes of paroxysmal atrial
fibrillation, but would rapidly convert back into a sinus
rhythm with occasional premature atrial contractions. Again
throughout these arrhythmias, she remained essentially
hemodynamically stable. She was continued on a heparin drip
throughout, having it only being shut off for a few invasive
procedures, which will be discussed in the following
sections. She was then started on Coumadin for atrial
fibrillation prophylaxis on [**7-14**].
At the time of discharge, the patient is in sinus rhythm with
occasional premature atrial contractions. She is
hemodynamically stable, with systolic blood pressures ranging
from the low 100s to 150s, and she is on Coumadin with a goal
INR of 2 to 3.
2. Renal: As already stated, the patient was admitted in
acute renal failure. She was given urgent hemodialysis for
hyperkalemia, and she had good response to this. Her acute
renal failure was felt to be secondary to obstruction, given
her increased bladder size and the inability to place a
Foley. She eventually had a Foley placed with the fiberoptic
scope. This was needed since she had a distal urethral
stricture. After these two interventions, as well as
hydration, the patient's renal function rapidly improved and,
at discharge, her creatinine was 0.6.
3. Pulmonary: The patient was intubated on the 13th for
respiratory distress, likely secondary to ventilatory failure
from reactive airway disease and chronic obstructive
pulmonary disease. She also was noted to have a pneumonia on
chest x-ray, and Levaquin was started empirically.
Eventually her sputum grew out pseudomonas aeruginosa, and
her chest x-ray was worsening. Piperacillin was added to her
antibiotic regimen on [**7-1**]. However, this failed to
improve the patient's pulmonary status, and on the 21st, the
piperacillin was changed to ceftazidime, and she was
continued on a course of ceftazidime and Levaquin for ten
days.
She had numerous trials to wean her from the ventilator,
however, when placed on pressure support ventilation alone,
the patient would repeatedly become tachypneic, with arterial
blood gases that showed increasing PCO2s, indicating
respiratory fatigue, and she would have to be switched back
to assist control ventilation to rest.
After two weeks of intubation, it was decided to have the
patient be given a tracheostomy in order to facilitate
weaning. It was attempted at the bedside on [**7-11**], but
was unsuccessful due to the scar tissue from the previous
tracheostomy. Therefore, it was performed in the operating
room on [**7-12**], with no complications. In addition to the
patient's pseudomonas pneumonia, which appeared to be treated
adequately, the patient also began to experience increased
secretions around [**7-11**]. Sputum samples were obtained
again, which grew out methicillin resistant staphylococcus
aureus. She was started on vancomycin for this on [**7-13**],
and will receive a total of a ten day course.
4. Infectious Disease: As already stated above, the patient
was treated for pseudomonas pneumonia with a ten day course
of ceftazidime and Levaquin, although it should be noted that
the patient was on Levaquin for several days prior to
initiation of the ceftazidime treatment. She also was found
to have methicillin resistant staphylococcus aureus in her
sputum, and at discharge, is in the process of completing a
ten day course of vancomycin. The patient never had positive
blood cultures.
At the time of this dictation, the patient also is having
some foul diarrhea, and is currently being tested for C.
difficile.
5. Gastrointestinal: Throughout the [**Hospital 228**] hospital
stay, she was maintained on various tube feeds. Originally
she seemed to be possibly aspirating or regurgitating, so
they were held, but eventually they were able to be titrated
up to goal. She was started on Reglan for increasing bowel
motility. She had a gastrojejunostomy tube placed for
feeding while in rehabilitation. It was placed on [**2169-7-13**], by Interventional Radiology. There were no
complications.
6. Hematology: At admission, the patient was found to have
a hematocrit originally of 29.2, which dropped to 26.9 with
hydration. It remained at a baseline of approximately 24 to
26 until her tracheostomy, after which it dropped to 22.8.
She received one unit of packed red blood cells after the
procedure, with a good response, and her hematocrit increased
back up to a range of 25 to 27. Iron studies were done,
which showed the patient to be likely iron deficient as well
as having an anemia of chronic disease. She was started on
iron sulfate for this.
7. Endocrine: The patient's diabetes was kept in control
originally with an insulin drip. This was eventually changed
to a regular insulin sliding scale, and the current plan is
to switch her to NPH insulin when her tube feeds are stable.
8. Fluids, electrolytes and nutrition: The patient's
electrolyte status was corrected as needed. At the time of
discharge, her nutrition is supplied with Peptamen tube feeds
at 40 cc/hour. She is gradually being increased to a goal
rate of 80 cc/hour. She also is continued on a multivitamin,
500 mg twice a day of vitamin C, and 220 mg daily of zinc
sulfate.
CONDITION AT DISCHARGE: Stable
DISCHARGE MEDICATIONS:
1. Peptamen tube feeds, goal is 80 cc/hour
2. Colace 100 mg by mouth twice a day
3. Regular insulin sliding scale: For a fasting sugar of
0-60, 1 amp of D-50; for a fasting sugar of 61-200, 2 units
of regular insulin; for a fasting sugar of 201-300, 4 units
of regular insulin; for a fasting sugar of 301-350, 6 units
of regular insulin; for a fasting sugar of 351-400, 8 units
of regular insulin; for a fasting sugar greater than 400, 10
units of regular insulin and notify physician
4. Ferrous sulfate suspension 325 mg by mouth three times a
day
5. Reglan 10 mg intravenously/intramuscularly four times a
day
6. Combivent metered dose inhaler two puffs every six hours
7. Protonix 40 mg by mouth once daily
8. Flovent metered dose inhaler two puffs twice a day
9. Amiodarone 400 mg by mouth once daily, to be changed on
[**8-6**] to 200 mg by mouth once daily
10. Senna two tablets by mouth once daily
11. Nystatin swish and swallow three times a day
12. Vancomycin 1 gram intravenously twice a day, last dose to
be given on [**2181-7-22**]. Prednisone taper. At discharge, the patient is on 10 mg
by mouth once daily.
14. Ativan 5 mg by mouth four times a day, to be decreased by
20% total dose per day
15. Coumadin, titrate for an INR of 2 to 3
16. Tylenol 650 mg by mouth every six hours as needed
17. Morphine 2 to 5 mg intravenously every two to four hours
as needed for pain
18. Haldol 1 mg intravenously every two hours as needed for
agitation
19. Haldol 1 to 2 mg intravenously three times a day as
needed
DISCHARGE FOLLOW UP: The patient will be followed by the
attending at rehabilitation. The exact rehabilitation the
patient is going to is still pending at the time of this
dictation.
DISCHARGE DIAGNOSIS:
1. Respiratory failure
2. Pneumonia
3. Paroxysmal atrial fibrillation
4. Acute renal failure
5. Status post tracheostomy
6. Status post gastrojejunostomy
7. Anemia of chronic disease
8. Type 2 diabetes
[**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**]
Dictated By:[**Last Name (NamePattern1) 6859**]
MEDQUIST36
D: [**2169-7-17**] 01:24
T: [**2169-7-17**] 01:51
JOB#: [**Job Number 30282**]
ICD9 Codes: 2767, 5849, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2807
} | Medical Text: Admission Date: [**2109-6-13**] Discharge Date: [**2109-6-20**]
Date of Birth: [**2039-12-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
hypotension s/p BiV-ICD placement in OR
Major Surgical or Invasive Procedure:
Surgical epicardial lead placement of BiV pacemaker
Placement of BiV pacemaker.
Central line placement.
History of Present Illness:
69M with DM, non-ischemic CM (EF 20-25%)s/p bivi/ICD placement
in OR with hypotension/decreased urine output. Clean
coronaries on cath 4/[**2108**]. Attempt at BiVi implant in [**Country 11150**]
unsuccessful. Transfer to [**Hospital1 18**] [**6-12**] for re-attempt. RV lead
placed OK but could not place CS lead. To OR [**6-14**] for
epicardial LV lead. Tolerated procedure well. Post op, SBP
down to 80s from baseline 110-120, UOP down to 9cc/hr. Pt has
received 3L IVF since OR.
Past Medical History:
CM (EF 20-25%)
LBBB
DM
CRI
Enlarged prostate
Social History:
pt traveled from [**Country 11150**] for BiV-ICD placement. Nephew is
radiologist here at [**Hospital1 18**]
Physical Exam:
T: 101.8/100.8 P: 100-110 BP:99-110/57-63 RR: 18-27 )2: 98-99%
I/O: 4610/1050 (630ccUOP, 350 cc CT (dark serosanguinous
drainage)
CT no longer on wall suction
Gen: pt sitting up in bed, appears uncomfortable, but NAD
HEENT: PERRL, sclerae anicteric, mm-dry; no JVP appreciated
Cardiac: rrr; +SEM, ? diastolic murmur
lungs: cta ant
abd: soft, + distention, no suprapubic pain but diffuse upper
epigastric pain on palpation (LUQ most signficant pain per pt)
ext: warm/dry; +DP pulses
Pertinent Results:
[**2109-6-13**] 10:00AM GLUCOSE-124* UREA N-21* CREAT-1.2 SODIUM-140
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
[**2109-6-13**] 10:00AM CALCIUM-9.9 PHOSPHATE-3.5 MAGNESIUM-2.0
[**2109-6-13**] 10:00AM WBC-7.7 RBC-5.36 HGB-13.5* HCT-42.5 MCV-79*
MCH-25.1* MCHC-31.7 RDW-18.1*
[**2109-6-13**] 10:00AM PLT COUNT-280
[**2109-6-13**] 10:00AM PT-11.7 PTT-20.4* INR(PT)-0.9
Brief Hospital Course:
Mr. [**Known lastname 1603**] is a 69M who is s/p operative BiV/ICD placement c/b
hypotension and decreased urine output. In particular, after
placement of BiV pacemaker/ICD, the patient developed
hypotension. He was placed on Neosynephrine for a short period
of time and responded well with MAPs >65. Initially the
differential of the hypotension included sepsis, cardiogenic
shock, tamponade, and dehydration. However, 2 ECHO's did not
show evidence of tamponade, and the swan catheter did not
support cardiogenic shock. The fever and elevated white count
was consistent with sepsis, especially in the setting of
presumed PNA and lung infiltration. Zosyn and vanco were
started for presumed nosocomial infection or infection d/t
surgery. BB, ACE, and lasix, and aldactone were initially held,
but losartan waw restarted and titrated up to home dose, and
[**Last Name (un) 61755**] was started and kept at 1/2 home dose. Lasix IV was
subsequently used when patient demonstrated fluid overload,
improving the patient's breathing and clinical status.
After pacemaker/ICD placement on [**6-13**], the patient was started
on Vanc per recommendations of CSurg. He was atrial-sensed and
v-paced. On [**6-16**] he was found to be in a-fib and intermittent
VT. Initially the plan was to wait until [**6-17**] for DCCV and load
the patient with ibutilide and lidocaine and start him on amio
on [**6-16**]. However, the patient was hypotensive and concern there
was concern that was causing this hypotenion. The patient was
cardioverted on [**6-16**] and returned to sinus rhythm (V paced).
In regards to ID, the Pt spiked a fever to 101.8 post-op.
Pneumonia was considered as a cause of the fever and hypotension
for several reasons, including complicated OR course of
intubation and adjusting lung volumes as needed for placement of
leads of pacemaker, developing a new productive cough, and
having infiltrates on CXR. Pt was started on vancomycin per
protocol of pacemaker placement and given dose of levofloxacin
in PACU for fever. However, in the CCU levo was changed to zosyn
due to concern for nocosomial infection and to avoid prolongued
QT interval, and this was continued until discharge. Laboratory
data did not definitively confirm the source of infection, as
sputum cultures revealed only moderate growth of oropharyngeal
flora ([**6-17**], after antibiotics had already begun), urine
cultures were negative, and blood cultures did not demonstrate
growth.
In regards to his CHF and cardiac status, digoxin was held d/t
dig toxicity (level 1.3), while ASA and zocor were continued.
As hypotension improved metoprolol was added, as well as
losartan and coreg. BP tolerated these medication additions
well
Patient has underlying diabetes and was placed on an insulin
sliding scale while in the hospital. He also received SQ
heparin and protonix as prophylactic measures for DVT and
gastric bleed, respectively. The patient remained full code
during this hospitalization.
Medications on Admission:
losartan 100
lasix 40
aldactone 25
digoxin 0.25 M-F, hold S and Sun
Coreg 12.5 [**Hospital1 **]
Ticlid (held 4d PTA)
ASA 325 (held 2d PTA)
MVI
Terazosin 2
protonix 40
amaryl 2
zocor 5
Insulin H. Actrapid 20-20-0, H. Mixtard 0-0-26
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take a total of 400 mg (2 tablets) [**Hospital1 **] for 2 days
(until [**6-23**]), then take 200 mg (1 tablet) [**Hospital1 **] for 7 days, then
take 200 mg (1 tablet) qD from then on.
Disp:*120 Tablet(s)* Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Losartan Potassium 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) ML Injection ONCE (once) for 1 doses.
10. Please return to your normal insulin regimen.
Discharge Disposition:
Home
Discharge Diagnosis:
Non-ischemic cardiomyopathy
Type 2 Diabetes
Hypertension
Cardiac Arrhythmia
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Fluid Restriction: 1.5 liters per day.
Take your medications as instructed. Please follow up with
electrophysiology on [**6-28**].
Followup Instructions:
DEVICE CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2109-6-28**] 1:30pm.
You will have an appointment with Dr. [**Last Name (STitle) **] after your
device clinic appointment.
ICD9 Codes: 4280, 4254, 4240, 0389, 486, 2765, 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2808
} | Medical Text: Admission Date: [**2113-3-20**] Discharge Date: [**2113-3-24**]
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: This is an 88-year-old female
with known short term memory loss who came to the Emergency
Room complaining of mental status changes for approximately
three days prior to coming into the Emergency Room.
According to the family, she has become aggressively
confused. Her speech was garbled which was incomprehensible.
The patient did have a fall on [**2113-3-10**], but did not lose
consciousness. The patient did not have headache, nausea or
vomiting. A CT scan showed a small subdural hematoma in the
frontal region of the left side. No midline shift, mild mass
effect 2 cm hematoma. MRI showed no apparent strokes.
PAST MEDICAL HISTORY:
1. Dementia
2. Chronic obstructive pulmonary disease
3. Depression
4. Hypothyroidism
MEDICATIONS:
1. Paxil
2. Ativan
3. Darvon
4. Vioxx
5. Synthroid
6. Aspirin
ALLERGIES: The patient has no drug allergies.
PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 127/80, pulse 82, respirations
18, 100% SAO2 and temperature 98.6??????.
GENERAL: The patient appeared stated age, lying in bed in
wrist restraints, leaning forward, looking at her arms
occasionally.
HEAD, EARS, EYES, NOSE AND THROAT: Sclerae are white. Neck
supple, no jugular venous distention or bruits, a prominent
radiating murmur to both carotids.
LUNGS: Clear bilaterally.
CARDIOVASCULAR: Regular rhythm and rate, soft S1, normal S2
with a 3/6 systolic murmur radiating to carotids.
ABDOMEN: Normal bowel sounds, soft, nontender, nondistended.
EXTREMITIES: Warm, no edema, prominent joint deformity of
DIP and PIP joints of both hands and feet.
NEUROLOGIC: The patient was awake, alert and intermittently
cooperative. Will mimic some movements by closing her eyes,
sticking out her tongue or holding up her arms. Closed her
eyes on command inconsistently. Speech fluent with frequency
paraphasic errors and neologisms. Her voice quality and
intonation seemed normal. Comprehension was impaired and she
could not read.
FUNDUSCOPIC EXAM: Normal vasculature with sharp optic discs.
External ocular movements full without nystagmus. Pupils
were reactive to light directly and consensually and
accommodation. Motor exam was limited by cooperation. She
had slight upper drift of the right upper extremity. She
could push away with both upper extremities. Sensory
withdrew to crude touch in all extremities.
LABS: The patient's CBC was normal. Chem-7 was normal.
Urinalysis had 6 to 10 epis and greater than 50 white blood
cells, many bacteria.
HOSPITAL COURSE: The patient was admitted to the Neurologic
Intensive Care Unit for close observation. She was started
on Dilantin prophylactically. The patient continued to
improve daily with speech and language comprehension
improving. The patient also had SV therapy consult while in
the Intensive Care Unit. The patient was transferred to R5,
the floor, on [**3-22**]. At that time, she had a CT scan before
transfer which was unchanged. The patient continued to
improve during the rest of her hospital stay. Facial droop
which was noted on admission, she had a right facial droop,
also improved. Her speech and language comprehension
improved daily. The patient also had physical therapy and
occupational therapy consult. Recommendation for short term
rehabilitation was recommended. The patient appears to be
back to baseline normal dementia.
The patient will be discharged to short term rehabilitation
facility.
DISCHARGE MEDICATIONS:
1. Darvon
2. Combivent
3. Paxil 20 mg once a day
4. Ativan 0.5 mg tid
5. Synthroid 0.75 mg q day
6. Flagyl 500 mg po bid for 7 days
CULTURE: Urine culture did come back positive for
Gardnerella vaginalis. The patient will be started on Flagyl
as noted.
FOLLOW UP: The patient needs to follow up in three weeks
with CT scan prior to follow up appointment.
The patient was in stable condition at time of discharge.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2113-3-24**] 08:45
T: [**2113-3-24**] 09:27
JOB#: [**Job Number 40400**]
ICD9 Codes: 5990, 496, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2809
} | Medical Text: Admission Date: [**2159-8-24**] Discharge Date: [**2159-9-5**]
Date of Birth: [**2096-5-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Vomiting, lethargy, and headache.
Major Surgical or Invasive Procedure:
EVD placement
History of Present Illness:
63-year-old male with history of ESRD secondary to diabetic
nephropathy on hemodialysis MWF, Hepatitis C with cirrhosis,
pacemaker for ischemic cardiomyopathy, diabetes mellitus,
hyperlipidemia, recently discharged from [**Hospital6 2561**]
[**8-21**] for a middle ear infection and has continued to feel unwell
since discharge. History is provided by wife and brother as
well
as chart review. On the morning of admission, the patient was
in
the bathroom vomiting and his wife had heard a fall. He was
found on the ground and complained of right occipital headache
and generalized weakness. He was initially responsive and able
to converse with his family however became for somnolent over
the
next thirty minutes and continued to vomit. He had to be
carried
to bed but family did not note any focal motor deficits.
Patient
was taken to [**Hospital6 2561**] by EMS and was noted to be
arousable only to painful stimuli. He was noted to have BP
244/128 and CT head showed a thalamic bleed with
intraventricular
extension. He was given vitamin K 5 mg, mannitol 50 gm,
labetalol 100 mg IV (total), ativan 2 mg x1, etomidate 20 mg,
rocuronium 70 mg, and loaded with dilantin. He was intubated
and
transferred to [**Hospital1 18**] for further care. In the Emegency
Department an EVD was placed by neurosurgery. He was started on
a nicardipine drip and transferred to the SICU. As per
patient's
wife, home SBP ranges 130-190 and had been "very high" during
his
recent hospitalization at [**Hospital3 **].
Past Medical History:
HTN
HLD
Diabetes Mellitus
ESRD on HD MWF
Central retinal vein occlusion (R)
Pacemaker for ischemic cardiomyopathy
OSA
Depression
Recent otitis media
Social History:
Unable to obtain at this time.
Family History:
Mother with two strokes in her 60s.
Physical Exam:
Physical exam on admission;
VS; T 99 BP 170/84 P 62 RR 14 100% on vent
Gen; intubated, sedated
CV; regular rate and rhythm, S1 and S2 present
Pulm; CTA anteriorly
Abd; soft, nontender
Extr; no edema
Neuro; Unarousable to painful stimuli (off propofol). Pupils
2mm
and minimally reactive. No blink to threat. Face symmetric.
Unable to test oculovestibular reflex [**2-19**] C-collar. Increased
tone, lower extremities > upper extremities. No spontaneous
movement but withdraws to pain in left arm and leg. Upgoing
toes
bilaterally.
Pertinent Results:
WBC 3.3, HCT 34.7, Platelets 118
Na 132, K 3.9, Cl 98, CO2 22, BUN 27, Cr 5.9, gluc 272
Trop 0.30
PT 13.4, PTT 30.3, INR 1.1
Serum tox neg
CT head; Extensive interventricular hemorrhage extending from
the
lateral ventricles to the third and fourth ventricles with
associated ventriculomegaly. Focus of acute hemorrhage
immediately adjacent to the left lateral ventricle likely
involving the left thalamus and may represent source with
interventricular extension, an underlying mass/lesion/vascular
malformation cannot be excluded in this region.
CT C-spine; no fracture or malalignment.
EEG [**8-27**];
IMPRESSION: A diffusely slowed and monotonous record was seen
representative of a diffuse and moderate to moderately severe
encephalopathy.
CT head [**8-30**];
There has been removal of the right ventriculostomy catheter
with a small
amount of residual blood tracking along the prior path through
the frontal
lobe. Overall, the left thalamus hemorrhage appears similar in
extent to the
prior examination. There remains unchanged amount of
intraventricular
hemorrhage layering posteriorly within the lateral ventricles.
There is
persistent diffuse subarachnoid hemorrhage, which is unchanged
from the prior
examination. The ventricles sizes are enlarged, but unchanged.
There are
areas of periventricular low attenuation likely related to
chronic small
vessel ischemic disease.
The left mastoid opacification is unchanged from prior
examination. There are
no new bony abnormalities on this exam.
Brief Hospital Course:
Mr. [**Known lastname 931**] is a 63-year-old male with hx ESRD on HD, DM,
HTN, HLD, ischemic
cardiomyopathy, and HCV, presented with large left thalamic
bleed with significant
intraventricular extension, s/p EVD in ED (OP at 30 cm H2O).
Given location of hemorrhage as well as his longstanding history
of uncontrolled hypertension, etiology was most likely thought
to be hypertensive, and his fall was likely secondary to his
bleed.
Hospital course by problem;
1) Neurology; The patient was admitted to the NeuroICU after an
EVD was placed given the hydrocephalus on exam. He was started
on a nicardipine drip for blood pressure control. He was
started on labetalol and carvedilol in attempt to wean the
nicardipine drip with goal SBP < 160. Norvasc 5 mg daily was
added [**8-31**]. His EVD was removed [**8-29**] and a repeat CT head has
been essentially unchanged. He was started on keppra 500mg [**Hospital1 **]
[**8-31**] for anti-seizure prophylaxis given his recent EVD and it is
thought that he may continue this for one month. He could not
have an MRI because of his pacemaker. A CT head was done showing
with early uncal herniation, increased cerebral edema. EEG with
flattened activity. The patient expired on [**2159-9-5**].
2) Respiratory; The patient was intubated at time of arrival and
had a tracheostomy [**8-28**]. There are no other active respiratory
issues.
3) ID; The patient had a recent diagnosis of otitis media. In
addition due to his EVD he was maintained on cefazolin for
prophylaxis. This was discontinued when his EVD was removed on
[**8-29**]. He has been afebrile with no leukocytosis and cultures
from the time of admission have been negative. However on [**8-31**]
a repeat CXR showed a possible RLL consolidation suggestive of
pneumonia. He was started on ciprofloxacin [**8-31**].
4) CV; The patient was monitored on telemetry and troponins were
stable at 0.30. It was thought this was secondary to his stroke
and end stage renal disease. As the cardiac enzymes were level
during the hospital course it was not thought to be cardiac in
etiology. Initially he was hypertensive and managed as
indicated above. During the course of his ICU stay the patient
developed hypotension requiring mulitple fluid boluses.
5) Heme; The patient's hematocrit, coags, and platelet count
have been stable.
6) Metabolic/Endocrine/Renal; The patient was followed by the
nephrology service, receiving dialsyis qMWF. His fingersticks
were well-controlled with a regular insulin sliding scale.
7) Abd/GI; The patient was followed by the liver service as he
was already known to them given his hepatitis C. He had been on
inteferon prior to admission but it was recommended to
discontinue at this time as it has not been effective. Tylenol
intake was limited to 2g daily. A PEG tube was placed [**8-28**].
Medications on Admission:
Lisinopril 20 mg [**Hospital1 **]
Coreg 25 mg [**Hospital1 **]
Celexa 20 mg daily
Amoxicillin
Oxycodone
Lasix 80 mg on nondialysis days
Gemfibrozil 600 mg [**Hospital1 **]
Pegasus 130 mcg sub q qweek
Renagel 800 mg tid
Trazadone 7.5 mg daily
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Left thalamic hemorrhage with intraventricular involvement,
likely hypertensive in etiology.
Discharge Condition:
Deceased
Completed by:[**2160-2-12**]
ICD9 Codes: 431, 5856, 486, 2724, 2859, 5715, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2810
} | Medical Text: Admission Date: [**2173-4-8**] Discharge Date: [**2173-4-13**]
Date of Birth: [**2101-8-29**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: This 71 year-old male, well
known to our service with known abdominal aortic aneurysm
with an attempt at endovascular repair one year ago which
failed secondary to significantly calcified aortic vessels.
The aneurysm has gone from 6 cm to 7.9 over less than a year.
He denies any symptoms. He is now admitted for endovascular
repair of his abdominal aortic aneurysm.
PAST MEDICAL HISTORY: Abdominal aortic aneurysm,
hypertension, history of pulmonary edema, history of atrial
fibrillation, history of chronic pancreatitis secondary to
alcohol abuse, history of gastritis with gastrointestinal
bleed secondary to aspirin use, history of congestive heart
failure with ejection fraction calculated at 20 percent on
echocardiogram in [**2171-4-24**] with severe hypokinesis, mild
atrial insufficiency and mild mitral regurgitation, history
of transient ischemic attacks, history of gout, history of
sick sinus syndrome, history of retinal vein occlusion.
PAST SURGERY: Coronary artery bypasses in [**2167**], LIMA to th e
LAD, saphenous vein graft to the PDA, obtuse marginal, aortic
dissection repair. Attempted abdominal aortic aneurysm
endovascular veiled with a right internal iliac artery
dissection requiring a fem-fem bypass, status post
biventricular pacemaker for sick sinus syndrome, atrial
flutter, ablation, laparoscopic cholecystectomy,
appendectomy, remote. Cardiac catheterization on [**2-25**] showed
an occluded right common iliac and a large infrarenal
abdominal aorta. Patient underwent stenting of the common
and external iliac arteries.
SOCIAL HISTORY: He is married. He has not had alcohol in
the last year. He is a 60 pack year smoker who has not
smoked in the last year.
FAMILY HISTORY: Is positive for cancer and abdominal aortic
aneurysm.
MEDICATIONS ON ADMISSION: Include repropazole 20 mg q.d.,
allopurinol 300 mg q.d., Carbopol 9.375 mg b.i.d., lisinopril
20 mg q.d., Dicloxacillin 150 mg q.d., Plavix 75 mg q.d.,
amiodarone 300 mg q.d., Lasix 40 mg q.d., Pancrease 250 mg
with meals, trazodone 25 mg at h.s., p.r.n., alprazolam .25
mg p.r.n. He denies any drug allergies.
REVIEW OF SYSTEMS: Is unremarkable.
PHYSICAL EXAMINATION: Vital signs 99, 80, 20, O2 saturation
98 percent on room air, blood pressure 188/69. General
appearance: alert, cooperative male, oriented times three.
HEENT examination was unremarkable. Carotids are palpable
with 1/4 pulse without bruits. There is no jugular venous
distention. Chest examination: lungs are clear to
auscultation with increased expiratory phase. Heart is I/VI
systolic ejection murmur. There is no rub. Abdominal
examination is nontender, nondistended. Bowel sounds times
four, no masses or bruits noted. Rectal examination was
normal tone, heme negative, no masses. Neurologic
examination is intact.
ADMITTING LABORATORIES: Included CBC white count 6.4,
hematocrit 38, platelets 177,000, PT/INR and PTT were normal.
BUN 18, creatinine 1.1. Arterial blood gases: 7.45, 38, 90,
27 and 2.
HOSPITAL COURSE: Patient was admitted the day prior to the
anticipated procedure and was intravenous hydrated and
Mucomyst protocol was instituted. He underwent in the
catheterization laboratory peripheral angiogram with
angioplasty and stent placement of the common iliac artery
and external iliac artery. He then went to the operating
room and attempted endovascular repair was attempted. The Left
iliac sysyem was too calcified and small to accept the device so
the procedure was aborted.
The
left common femoral artery was explored and repaired. The
patient was transferred to the post anesthesia care unit in
stable condition. He postoperatively remained
hemodynamically stable. Cardiology was requested to see the
patient because of hypotension which was probably relieved
with volume. The diastolic was 15 to 22, MAP was greater
than 60, pulmonary wedge pressure was 15 to 20, CVP was 18 to
12. Patient continued on his Levophed with good effect.
Recommendations were serial CKs and troponin level, continue
fluid resuscitation. Once off pressors and with normal
systolic pressure consider diuresis dictated by filling
pressures. Postoperative day one there were no overnight
events. Levophed was weaned. Patient was extubated. He
remained n.p.o. He was transferred to the Vascular Intensive
Care Unit once off pressors and extubated. Postoperative day
two there were no overnight events. Hematocrit remained
stable at 34. BUN 11, creatinine 0.7. His calcium and
magnesium were repleted. His examination was unremarkable.
His pulmonary catheter was converted to CVP. His diet was
advanced as tolerated. There was some thrombocytopenia and
serial platelet counts were obtained. Postoperative day
three patient showed improvement in his platelet count. BUN
and creatinine remained stable. Patient required diuresis of
intravenous Lasix of 40 on [**4-11**] intravenous on [**4-12**]
intravenous on [**4-13**] and 80 intravenous on [**4-14**]. With
improvement in his weight at the time of discharge, patient's
weight was 80.4 kilos. Preoperative weight was 75.5. He was
4.9 kilos above his preoperative weight. He was 6 liters
positive. With discussion with the primary care physician
and his cardiologist, Dr. [**First Name (STitle) **], regarding diuretic
management at discharge they felt the patient could be
discharged because he is improving on his fluid balance and
that he should be discharged on 40 mg of Lasix b.i.d.
Patient should follow up with Dr. [**First Name (STitle) **] on Friday, the 23rd,
for electrolytes and assessment.
The remaining hospital course was unremarkable. The patient
was discharged in stable condition. He is instructed to
maintain his weight and keep those recorded, to [**Name8 (MD) 138**] M.D. if
he has any fever, chills or sweats, any drainage, redness or
swelling of the groins. The patient was discharged on his
pre-admission medications with an adjustment in his Lasix
dosing from 40 mg q.d. to 40 mg b.i.d. for [**4-15**] and [**4-16**].
DISCHARGE DIAGNOSIS:
1. Abdominal aortic aneurysm, expanding, asymptomatic,
attempted endovascular repair, failed. Status post
angiography with external iliac and common iliac angioplasty
with stent placement.
2. Hypotension secondary intervascular volume depletion
requiring vasopressor support treated and corrected. Patient
stable.
3. Thrombocytopenia secondary to attempted endovascular
intervention, stable.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2173-4-14**] 14:04
T: [**2173-4-14**] 14:59
JOB#: [**Job Number 95451**]
ICD9 Codes: 2851, 2875, 2765, 496, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2811
} | Medical Text: Admission Date: [**2162-12-30**] [**Month/Day/Year **] Date: [**2163-1-3**]
Date of Birth: [**2094-10-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1865**]
Chief Complaint:
dark stools, shortness of breath.
Major Surgical or Invasive Procedure:
small bowel enteroscopy
History of Present Illness:
The patient is a 68M with h/o CAD s/p CABG '[**48**], AS , ischemic CM
with EF 45% and h/o GI due to AVMs in the past who now p/w 4
days of maroon colored stool, stomach upset and also with
increased weight. The patient reports being in his usual state
of health until 3 days ago when he noticed that his stool had
been becoming darker and had some bright red blood. He has been
noticing some exertional CP (stabbing pain in chest) and dyspnea
when walking around the house and from the house to the car. He
also had an episode 2 days ago of stabbing chest pain when lying
down to go to sleep. His symptoms were relieved with a SL
nitroglycerin. Also noticed dizziness and lightheadedness over
the past 24 hours.
.
ROS: weight prior to [**Holiday **] was 184. over past month has
been creeping up up to between 195-200 over last few days. pt
reports he "gets in trouble with SOB when over 190". + throbbing
pain in left hand over last few days.
.
In the ED an NGL was negative, he was given a PPI. Two 18g
peripheral IV's were placed. His SBP's remained approximately
100-110's with HR in the 60's. Original EKG was without ischemic
changes. While in the ED, the patient began to experience jaw
pain and a repeat EKG showed new ST depressions and T wave
inversions. He was transfused 2 units of [**Holiday **]. Also the patient
had a K=6 and was treated with insulin/amp D50/ bicarb/and
calcium gluconate.
Past Medical History:
-- CABG '[**48**] (LIMA-LAD, SVG LAD, SVG OM)
-- Cath [**10/2162**]: Three vessel native coronary artery disease,
patent grafts, moderate aortic stenosis, patent previously
placed stents, elevated left sided filling pressure.
-- Stress test [**2162-5-24**]: Poor functional status. 3.5 minutes of
exercise on [**Doctor Last Name 4001**] protocol. EF 30% and multiple fixed
perfusion defects and minor inferior defect.
-- multiple coronary stents in [**2160**],[**2161**], and [**2162**]
-- Aortic stenosis: [**Location (un) 109**] 0.8 mm Hg.
-- Ischemic CM/CHF - diastolic, systolic EF 45%, recent admit
for
diuresis in late [**6-8**].
-- DM2, last HgA1c in [**2162-10-3**] of 7.1
-- Anemia: baseline HCT 31-33
-- Hypothyroidism
-- OSA on CPAP
-- Depression
-- CKD- with baseline Cr 1.5-2.0
-- hypercholesterolemia
-- OA
-- Gout
-- IBS-diarrhea predominant
-- Obesity
-- PVD
-- UGI and LGI bleeding secondary to AVMs
Social History:
Lives with his wife in [**Name (NI) 5110**]. Retired [**Doctor Last Name **], worked for
[**Location (un) 86**] Globe for >45 years. Denies smoking, ETOH, or "other
funny stuff". Has 1 daugther who lives in [**State 4260**] and 2 sons who
live locally.
Family History:
There is no family history of premature coronary artery disease
or sudden death
Physical Exam:
PE: T: BP:104/31 HR:81 RR: 22 O2 100% RA
Gen: Pleasant, well appearing, NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD, No JVD. No thyromegaly.
CV: 3/6 SEM
LUNGS: good breath sounds b/l, minimal crackles at bases
ABD: NT/ND, small areas of ecchymosis from insulin injections
EXT: no c/c/e; discoloration consistent with chronic venous
stasis
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
Pertinent Results:
[**2162-12-30**] 05:30PM BLOOD WBC-6.7 RBC-2.81* Hgb-9.3* Hct-26.2*
MCV-93 MCH-33.3* MCHC-35.7* RDW-15.7* Plt Ct-176
[**2162-12-31**] 12:29AM BLOOD Hct-26.5*
[**2163-1-1**] 03:09AM BLOOD WBC-7.3 RBC-3.59* Hgb-11.6* Hct-32.7*
MCV-91 MCH-32.2* MCHC-35.4* RDW-16.1* Plt Ct-144*
[**2163-1-2**] 09:35AM BLOOD WBC-7.0 RBC-3.76* Hgb-12.3* Hct-34.2*
MCV-91 MCH-32.8* MCHC-36.1* RDW-16.4* Plt Ct-147*
[**2163-1-3**] 06:35AM BLOOD WBC-7.4 RBC-3.46* Hgb-11.9* Hct-32.0*
MCV-93 MCH-34.5* MCHC-37.3* RDW-18.6* Plt Ct-153
[**2163-1-3**] 03:15PM BLOOD WBC-8.5 RBC-3.51* Hgb-11.4* Hct-32.0*
MCV-91 MCH-32.4* MCHC-35.6* RDW-15.8* Plt Ct-126*
[**2162-12-30**] 05:30PM BLOOD Plt Ct-176
[**2163-1-1**] 09:15PM BLOOD Plt Ct-161
[**2163-1-3**] 03:15PM BLOOD Plt Ct-126*
[**2162-12-30**] 05:30PM BLOOD Glucose-97 UreaN-112* Creat-2.9*# Na-133
K-6.3* Cl-104 HCO3-19* AnGap-16
[**2163-1-1**] 09:15PM BLOOD Glucose-130* UreaN-66* Creat-2.0* Na-136
K-4.8 Cl-103 HCO3-19* AnGap-19
[**2163-1-2**] 09:35AM BLOOD Glucose-181* UreaN-53* Creat-1.8* Na-138
K-5.0 Cl-103 HCO3-24 AnGap-16
[**2163-1-3**] 06:35AM BLOOD Glucose-165* UreaN-52* Creat-1.5* Na-134
K-4.7 Cl-104 HCO3-20* AnGap-15
[**2162-12-30**] 05:30PM BLOOD CK(CPK)-105
[**2162-12-31**] 12:29AM BLOOD CK(CPK)-104
[**2162-12-31**] 09:06AM BLOOD CK(CPK)-98
[**2162-12-31**] 07:56PM BLOOD CK(CPK)-94
[**2162-12-30**] 05:30PM BLOOD CK-MB-8 cTropnT-0.11*
[**2162-12-31**] 12:29AM BLOOD CK-MB-7 cTropnT-0.07*
[**2162-12-31**] 09:06AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2162-12-31**] 07:56PM BLOOD CK-MB-NotDone cTropnT-0.12*
.
.
[**2163-1-1**] EKG: NSR, 78BPM, no STE, STD, normal axis, intervals.
TWI in avL only.
.
[**2162-12-31**] EGD - single nonbleeding 18mm dudoneal ulcer.
Brief Hospital Course:
Pt was admitted to the medical intensive care unit in
hemodynamically stable condition, with ongoing dark stools.
.
.
# GI bleeding. Pt is a a 68 M with h/o recurrent GI bleeding
from AVMs, CAD s/p CABG, CHF (EF45%) who presented [**12-30**] with 4d
of dark colored stools, stomach upset, and dyspnea, found to
have HCT of 26. He was felt to be hemodynamically stable (97.2
94/39 64 18 98%RA). NGL was negative in ED, initial EKG showed
ST depression and TWI. Creatinine was slightly elevated, K was
6 on admission. Pt received insulin/bicarb/calcium gluconate, 2U
PRBC, and 2L NS in the Emergency Department. He was then
transferred to the MICU (HR 65 BP 119/32 100%2L), seen by the GI
service, and transfused 2U [**Name (NI) **] (pt received a total of 4U
PRBC), with hct stabilizing at 32. EGD performed on [**12-31**]
revealed a non-bleeding duodenal ulcer.
.
Pt was transferred to the general medical floor. Repeat HCT was
stable 32-34. He continued to have dark stools without frank
bleeding, despite stable HCT and SBPs. H. pylori serologies
were obtained which were unremarkable. Pt was treated with
sucralfate and [**Hospital1 **] protonix as per GI service recommendation.
He was discharged home on [**2163-1-3**] with instructions to follow-up
with his gastroenterologist within 2-3 weeks. In addition, he
was instructed to follow-up with his primary care physician
[**Name Initial (PRE) 176**] 2 weeks regarding restarting his Bumex and xaroxolyn as
below.
.
.
# cardiac:
# ischemia - pt presnted with dynamic EKG changes while in ED
(deeping of inverted T's and ST depressions), this was felt
likely to represent demand ischemia in the setting of GI
bleeding and anemia. His symptoms of SOB were resolved s/p 2U
PRBC, and did not recur during his admission. Pt was seen by
the cardiology service in the ED who recommended correcting his
anemia, and managing him medically.
.
Pt's aspirin and plavix were initially held, but were restarted
once pt's hematocrit stabilized in light of his s/p recent
placement of cypher stent in [**5-8**]. Pt was instructed to
follow-up with his cardiologist within 4 weeks regarding the
specific duration of his plavix therapy in light of his multiple
recurrent GI bleeding episodes. Pt was otherwise discharged on
his prior cardiac regimen of toprol 50mg qdaily, imdur 60 mg
qdaily, zetia 10mg po qdaily, and simvastatin 80 mg po qdaily.
.
# pump - pt with h/o CHF (EF 45%), on standing bumex, zaroxlyn
and zestril at home. these medications were held in the MICU
[**2-4**] UGIB and ARF. Zestril was restarted prior to [**Month/Day (2) **]. Pt
was discharged home with instructions not to take his bumex or
zaroxlyn until seen by his PCP, [**Name10 (NameIs) 151**] whose nurse practitioner he
had an appointment 2d after [**Name10 (NameIs) **], given his lack of
clinical volume overload and still resolving ARF.
.
# rythym - pt remained in NSR during his hospitalization.
.
.
# Acute on Chronic Renal Failure - etiology of pt's ARF was felt
most likely hypoperfusion/prerenal in the setting of GI
bleeding. Creatinine peaked at 2.9, and came down to 1.5 at
time of [**Name10 (NameIs) **] (baseline 1.4-1.7) with IVF hydration. Pt
restarted on his Zestril, but discharged with instructions not
to take his prior bumex and zaroxlyn until seen by PCP who will
assess volume status and follow pt's CRI. Pt has an appointment
with his [**Name8 (MD) 6435**] NP 2-3d after [**Name8 (MD) **].
.
.
# DM2: pt was continued on his previous regimen of NPH
60qam/50qpm and humalog 30qam/20qpm. He was given additional
coverage as needed with humalog sliding scale.
.
# Hypothyroidism: pt was continued on his home regimen of
synthroid 200mcg qd.
.
# Hyperlipidemia: pt was continued on his home regimen of
pravastatin 60 qhs.
.
# Gout: pt has a h/o of gout for which he is treated with
allopurinal. He was continued on this regimen, though initially
dosed QOD [**2-4**] ARF. As his renal function improved, this was
switched to daily dosing. On [**1-2**] pt developed right knee
pain. Ultrasound and doppler studies were obtained to rule out
[**Hospital Ward Name **] cyst and aneurysm. Pt was afebrile without elevated WBC
count, thus septic arthritis was felt unlikely. Pt was treated
with oxycodone 5mg prn with good releif. NSAIDs, colchicine,
and prednisone were avoided given pt's ARF and GIB respectively.
Pt was discharged home with a 7d supply of oxycodone. Should
his pain persist, he was instructed to follow-up with his PCP.
.
# Depression: cont Zoloft.
.
# OSA: pt continued to use his own CPAP at night.
.
# dispo - pt discharged home with strict instructions to
follow-up with GI within 2-3 weeks regarding his chronic GI
bleeding, and ongoing dark stools despite stable HCT. he was
instructed to follow-up with cardiology regarding duration of
plavix therapy. he was instructed to follow-up with his PCP/PCP
nurse [**Name9 (PRE) 3525**] regarding restarting bumex and zaroxlyn and
future follow-up of his creatinine.
Medications on Admission:
allopurinol 150mg po qday
ambien 5mg qhs prn
asa 325mg qday
bumex 0.5mg [**Hospital1 **]
calcitriol 0.25mg qday
carafate 1 gram qid
ferrous sulfate 325mg qday
insulin humulin N as directed
insulin humulin R as directed
isosorbide mononitrate 60mg qday
levoxyl 200mcg qday
NTG 0.4mg sl q5 minutes prn chest pain x3
plavix 75mg qday
protonix 40mg qday
simvastatin 80mg qday
spironolactone 25mg qday
toprol xl 50mg qday
zaroxlyn 2.5mg prn for increasing weight
zestril 5mg qday
zetia 10mg qday
zoloft 50mg qday
[**Hospital1 **] Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for hand or knee pain for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
14. Humalog (insulin)
Please take 30 Units with breakfast and take 20 Units with
dinner.
15. NPH (insulin)
please take 60 Units with breakfast and take 50 Units with
dinner.
16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
17. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN CHEST PAIN as needed for chest pain: place one
tablet under toungue if you develop chest pain, may repeat up to
three times, take 5 minutes apart. if used, please call your
PCP or the emergency department. .
18. Levoxyl 200 mcg Tablet Sig: One (1) Tablet PO once a day.
19. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
[**Hospital1 **] Disposition:
Home
[**Hospital1 **] Diagnosis:
upper gi bleeding
[**Hospital1 **] Condition:
stable
[**Hospital1 **] Instructions:
please continue to take all of your medications as prescribed.
you were discharged with a new perscription for oxycodone for
knee pain x 5 days. your protonix was increased to twice daily.
Please continue to weigh yourself every morning, [**Name8 (MD) 138**] MD if
weight increases by > 3 lbs. Adhere to 2 gm sodium diet
.
your bumex and zaroxylyn were discontinued, you should wait
until you are seen by dr. [**Last Name (STitle) **] or her nurse practitioner to
restart these if you have more edema.
.
if you have recurrent vomitting of blood, or bloody stools,
chest pain, shortness of breath, fevers, chills, or other
worrisome symptoms, please contact your primary care physician
or the emergency department.
Followup Instructions:
upon arriving home, please contact your gastroenterologist and
arrange to be seen within 2-3 weeks regarding your ongoing GI
bleeding.
.
please contact your primary care physician and arrange to be
seen within 2-3 weeks regarding restarting your bumex.
.
please contact your cardiologist and arrange to be seen within
4-6 weeks regarding continuing to take aspirin and plavix.
Provider: [**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) 11298**], RN,BSN,MSN Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2163-1-6**] 12:00
.
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2163-1-11**] 1:00
.
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2163-2-3**] 2:30
ICD9 Codes: 4280, 5859, 5849, 2749, 2720, 2449, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2812
} | Medical Text: Admission Date: [**2113-11-21**] Discharge Date: [**2113-12-4**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
[**2113-11-21**] - CABGx3(LIMA-LAD, SVG-OM, SVG-PDA). Aortic Valve
Replacement (21mm [**Company 1543**] Mosaic Ultra Porcine Valve)
Bronchoscopy
thoracentesis
History of Present Illness:
This 84 year old white female with long standing complaints of
exertional chest
pressure and dyspnea and a LBBB underwent a stress test today.
The stress
test was positive for complaints of chest pressure and negative
for EKG changes. Nuclear imaging showed no evidence of ischemia
or wall
motion abnormalities. She was sent to the emergency room for
evaluation and was treated for CHF on her CXR with Lasix.
She was then transfered to [**Hospital1 18**] for cardiac catheterization.
Past Medical History:
Hypothyroidism
Hyperlipidemia
Hypertension
Social History:
married and living with husband. Two children
live in triple [**Doctor Last Name **] above and below pt.
Family History:
noncontributory
Physical Exam:
Discharge:
VS T97.9 HR 69 SR BP 116/57 RR 22 O2sat 93% 2LNP
Neuro: A&Ox3. Non focal exam
Lungs- decreased BS at bases, occ. rhonchi.
Cor- RRR no murmur. Sternum stable, incision CDI
Abd: soft, NT/ND/+BS
Exts- trace edema, warm. palpable pulses
Pertinent Results:
[**2113-11-21**] 06:09PM UREA N-12 CREAT-0.7 CHLORIDE-112* TOTAL
CO2-26
[**2113-11-21**] 06:09PM WBC-16.1* RBC-2.77*# HGB-8.9*# HCT-26.1*
MCV-94 MCH-32.2* MCHC-34.2 RDW-12.8
[**2113-11-21**] 06:09PM PLT COUNT-146*
[**2113-11-21**] 06:09PM PT-14.4* PTT-38.4* INR(PT)-1.3*
[**2113-11-21**] 05:23PM GLUCOSE-126* LACTATE-3.4* NA+-139 K+-4.1
CL--111
[**2113-12-4**] 01:12AM BLOOD WBC-14.2* RBC-3.50* Hgb-10.8* Hct-32.6*
MCV-93 MCH-30.9 MCHC-33.2 RDW-14.6 Plt Ct-436
[**2113-12-4**] 01:12AM BLOOD Plt Ct-436
[**2113-11-28**] 03:25AM BLOOD PT-15.2* PTT-32.4 INR(PT)-1.3*
[**2113-12-4**] 01:12AM BLOOD Glucose-102 UreaN-26* Creat-0.7 Na-142
K-3.7 Cl-106 HCO3-30 AnGap-10
[**2113-11-21**] ECHO
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage. Overall left ventricular systolic function is mildly
depressed (LVEF= 40 - 45 %). Hypokinesis of the septum and
inferior walls is seen.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is severe aortic
valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is
seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient initally had moderate LV systolic depresson. An
infusion of epinephrine was started. LV systolic fxn returned to
mild depression. RV systolic fxn was good.
A prosthetic aortic valve is well-seated and functional. No leak
is seen. A residual peak gradient of 30 mmHg is seen.
Aorta intact.
[**Known lastname **],[**Known firstname **] E [**Medical Record Number 79735**] F 84 [**2029-2-10**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2113-12-1**] 7:19
AM
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with
REASON FOR THIS EXAMINATION:
s/p thoracentesis evaluate re-expansion?
Final Report
REASON FOR EXAM: Followup pleural effusion post left
thoracentesis and
pulmonary edema.
Comparison is made with prior studies of [**11-29**] and 13.
Low lung volumes are unchanged. Moderate cardiomegaly is table.
Mild-to-
moderate pulmonary edema is unchanged. Left lower lobe
retrocardiac opacity
has increased likely due to atelectasis. There is a small amount
of left
pleural effusion. NG tube tip is out of view below the
diaphragm. Sternal
wires are aligned. Left subclavian catheter tip is in the SVC.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: FRI [**2113-12-1**] 2:33 PM
Brief Hospital Course:
Ms. [**Known lastname 69335**] was admitted to the [**Hospital1 18**] on [**2113-11-21**] for surgical
management of her aortic valve and coronary artery disease. She
was taken directly to the operating room where she underwent
coronary artery bypass grafting and an aortic valve replacement.
Please see operative note for details. She weaned from bypass on
epinephrine and nitroglycerine in stable condition. She was
transferred to the ICU.
She was acidotic and treated with fluid resuscitation, Levophed
and Milrinone. hemodynamics stabilized and lactates cleared by
the morning after surgery. Pressors were weaned and discontinued
over the first three days. She was extubated on the second day
after surgery, but required reintubation for fatigue and
increased work of breathing. Amiodarone was utilized for AF
control with eventual restoration of SR .A chest CT was done to
evaluate for effusions. A small to moderate Rt effusion was and
a thoracentesis yielded 400cc of fluid. Bronchoscopy on [**11-27**]
for small amounts of white secretions.
Diuresis was continued and CV remained stable. AcE inhibition
and beta blockade were begun and advanced to adequate levels.
The ventilator was weaned and she was again extubated on [**11-28**].
BiPAP was utilized nocturnally and aggressive pulmonary toilet
was performed. She improved and BiPAP was stopped after [**12-1**].
A speech and swallowing evaluation was done and she was cleared
for ground solids and thin liquids, to be advanced as tolerated.
With strength improving and pulmonary status stable she was
ready for discharge to a rehabilitation facility.
Her CXR shows low volumes, consistent with poor inspiratory
effort, but no effusions or infiltrates. Labs are stable.
Follow up requirements,medications and precautions are outlined
in the discharge paperwork.
Medications on Admission:
lipitor 20', levothyroxine 150', mevacor 20', lopressor 50',
ASA 81', pletal 100'
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
2. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Year (2) **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
3. Levothyroxine 50 mcg Tablet [**Month/Year (2) **]: Three (3) Tablet PO DAILY
(Daily).
4. Atorvastatin 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Year (2) **]: 2.5 mg Inhalation Q4H (every 4 hours).
7. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) IH
Inhalation Q6H (every 6 hours).
8. Fluticasone 110 mcg/Actuation Aerosol [**Month/Year (2) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Captopril 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO BID (2
times a day).
13. Lasix 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
14. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: One (1) PO once a
day.
15. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: see
sliding scale Subcutaneous AC & HS: 120-160:2units SQ
161-200:4units SQ
210-240:6units SQ
241-280:8unitsSQ.
16. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
aortic stenosis
coronary artery disease
s/p aortic valve replacement & coronary artery bypass grafts
[**2113-11-21**]
Hypercholesterolemia
hypertension
Hypothyroidism
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month ([**Telephone/Fax (1) 170**])
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
Please follow-up with Dr. [**Last Name (STitle) 1637**] in [**2-19**] weeks ([**Telephone/Fax (1) 14655**])
Completed by:[**2113-12-4**]
ICD9 Codes: 4241, 5185, 5119, 2762, 4280, 4019, 2449, 2720, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2813
} | Medical Text: Admission Date: [**2181-12-28**] Discharge Date: [**2182-1-5**]
Date of Birth: [**2095-11-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 6807**]
Chief Complaint:
Syncope.
Major Surgical or Invasive Procedure:
Cardiac catheterization for balloon valvuloplasty
Temporary pacing wire placement after procedure
Holter monitor placement
History of Present Illness:
86 year old woman with critical AS (valve area < 0.8cm2, mean
gradient 59, peak gradient of 85), parkinson's disease,
orthostatic hypotension previously on droxidopa), who presents
with one episode of syncope last night. Patient was recently
admitted to [**Hospital1 18**] from [**Date range (1) 29273**] for dyspnea attributed to
pulmonary edema secondary to critical AS, diastolic CHF, and
mod/severe mitral regurg and/or early pneumonia (lives at senior
housing). She was started on levofloxacin for a 5 day course,
diuresed with lasix, and her droxidopa was held (due to ?
increased afterload [**2-7**] norepi effects exacerbating CHF). She
is on no home lasix. Unfortunately patient is a poor historian.
On the day of admission, patient went for a ten minute walk and
felt lightheaded and fatigued. She felt "crummy" but denies
frank lightheadedness or vertigo. She went to sit on her cough
and lost consciousness per report for 2-3 minutes. Her eyes
were reported to remain open and she did have urinary
incontinence. There was no seizure activity or tongue biting.
When she regained consciousness her speech was garbled but is
without any focal deficits. Denies chest discomfort,
palpitations, cough, fevers, chills, recent travel.
.
In the ED, initial VS: 97.4 75 150/72 18 100%. Labs notable for
HCT 25 (baseline 25-27), WBC 7, UA without evidence of
infection. CXR shows improved airation of right lung with small
right pleural effusion, retrocardiac consolidation with left
sided pleural effusion, consistent with infection though final
read is pending.
.
Patient is now breathing comfortably on the floor without acute
complaints.
Past Medical History:
- aortic stenosis: gradient 37, valve area of 1.1 in 10/[**2178**].
- hyperlipidemia
- hypertension
- right bundle-branch block
- orthostatic hypotension
- Parkinson's disease, autonomic dysfunction
- Chronic anemia
- B12 deficiency
- osteoporosis
- gastroesophageal reflux disease
- sensory motor peripheral polyneuropathy
- periodic sleep movements with restless legs syndrome.
- hx of CBD stone in [**10-13**] requiring ERCP ([**Hospital1 112**])
- s/p trans urethral resection bladder lesion [**10/2178**] ([**Hospital1 112**])
- s/p L mastectomy ~[**2173**] for breast cancer
Social History:
She is a writer who continues to be active editing a local
newspaper. She has one son. She does have a trainer and help
with some of her activities of daily living and is currently
considering [**Hospital3 **].
-Tobacco history: None, Quit tobacco 30yrs ago
-ETOH: None
-Illicit drugs: None
Family History:
Brother and father with heart disease/CAD.
Noncontributory to admission
Physical Exam:
VS - 98.6 150/80 75 20 97% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear
NECK - supple, no cervical LAD
LUNGS - Clear to auscultation, no rhonchi/wheezes, no accessory
muscle use
HEART - RRR, 3/6 SEM harsh late peaking at RUSB with radiation
throughout precordium and to carotids, no rub/gallop, nl S1-S2
ABDOMEN - NABS, soft NTND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no edema, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3,
Pertinent Results:
Complete Blood Count:
[**2181-12-28**] 06:11PM BLOOD WBC-7.5# RBC-2.77* Hgb-8.3* Hct-25.3*
MCV-91 MCH-30.0 MCHC-32.8 RDW-12.8 Plt Ct-191
[**2181-12-29**] 06:50AM BLOOD WBC-6.7 RBC-2.73* Hgb-8.2* Hct-25.2*
MCV-92 MCH-30.1 MCHC-32.6 RDW-13.1 Plt Ct-176
[**2181-12-30**] 04:50AM BLOOD WBC-7.1 RBC-2.64* Hgb-8.2* Hct-24.1*
MCV-91 MCH-30.9 MCHC-34.0 RDW-12.8 Plt Ct-178
[**2181-12-31**] 05:10AM BLOOD WBC-7.4 RBC-3.18* Hgb-9.8* Hct-29.0*
MCV-91 MCH-30.9 MCHC-33.8 RDW-13.2 Plt Ct-188
[**2182-1-1**] 07:15AM BLOOD WBC-7.0 RBC-3.15* Hgb-9.7* Hct-29.0*
MCV-92 MCH-30.8 MCHC-33.6 RDW-12.9 Plt Ct-193
Basic Metabolic Profile:
[**2181-12-28**] 06:11PM BLOOD Glucose-141* UreaN-22* Creat-0.9 Na-141
K-3.8 Cl-105 HCO3-26 AnGap-14
[**2181-12-29**] 06:50AM BLOOD Glucose-95 UreaN-18 Creat-0.9 Na-140
K-4.0 Cl-105 HCO3-29 AnGap-10
[**2181-12-30**] 04:50AM BLOOD Glucose-96 UreaN-18 Creat-0.8 Na-142
K-4.5 Cl-107 HCO3-30 AnGap-10
[**2181-12-31**] 05:10AM BLOOD Glucose-94 UreaN-22* Creat-0.8 Na-141
K-4.3 Cl-104 HCO3-30 AnGap-11
[**2182-1-1**] 07:15AM BLOOD Glucose-94 UreaN-20 Creat-0.9 Na-141
K-4.4 Cl-104 HCO3-31 AnGap-10
[**2181-12-29**] 06:50AM BLOOD ALT-4 AST-49* LD(LDH)-221 CK(CPK)-55
AlkPhos-64 TotBili-0.2
[**2181-12-29**] 06:50AM BLOOD Albumin-3.4* Calcium-9.1 Phos-4.6* Mg-2.0
[**2181-12-30**] 04:50AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0
[**2181-12-31**] 05:10AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
[**2182-1-1**] 07:15AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.2
[**2181-12-29**] 02:45PM BLOOD CK(CPK)-49
[**2181-12-31**] 05:10AM BLOOD CK(CPK)-30
[**2181-12-31**] 12:55PM BLOOD CK(CPK)-30
[**2181-12-29**] 06:50AM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-12-29**] 02:45PM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-12-31**] 05:10AM BLOOD CK-MB-1 cTropnT-<0.01
[**2181-12-31**] 12:55PM BLOOD CK-MB-1 cTropnT-<0.01
[**2181-12-28**] 06:11PM BLOOD Iron-20*
[**2181-12-31**] 05:10AM BLOOD PT-11.1 PTT-31.3 INR(PT)-1.0
[**2181-12-29**] 06:50AM BLOOD Ret Aut-1.7
[**2181-12-28**] 06:11PM BLOOD calTIBC-250* VitB12-1721* Folate-GREATER
TH Ferritn-153* TRF-192*
[**2181-12-29**] 06:50AM BLOOD Hapto-198
[**2181-12-29**] 05:45PM BLOOD %HbA1c-5.4 eAG-108
Urine:
[**2181-12-28**] 07:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2181-12-28**] 07:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
ECG [**2181-12-28**]: Sinus rhythm. Left atrial abnormality. Complete
right bundle-branch block. Left ventricular hypertrophy.
Non-diagnostic repolarization abnormalities. Compared to the
previous tracing of [**2181-12-23**] multiple abnormalities as noted
persist without major change.
ECG [**2181-12-31**]: Sinus rhythm. Right bundle-branch block. Compared
to the previous tracing there is no significant change.
ECG [**2182-1-3**]: Sinus rhythm. RBBB with first degree AV block (PR
252).
ECG [**2182-1-3**] (6 hours after previous): Sinus, RBBB, resolution
of first degree AV block (PR 135).
Chest Radiograph (PA and Lat) [**2181-12-28**]: IMPRESSION: Left lung
base consolidation with associated pleural effusion. Small right
pleural effusion is present with improved aeration of the right
lung.
Chest Radiograph (PA and Lat) [**2181-12-31**]: FINDINGS: As compared to
the previous radiograph, there is moderate improvement, with
larger lung volumes and improved ventilation of the basal lung
areas.
On the right, a plate-like atelectasis along the minor fissure
persists, but the pre-existing medial basal opacity has
substantially decreased in extent and severity. On the left,
the pre-existing retrocardiac atelectasis is also improved.
The bilateral pleural effusions, better visualized on the
lateral than on the frontal radiograph, are not substantially
changed. The size of the cardiac silhouette is constant. No
newly appeared parenchymal opacities.
Echo [**1-3**]:
Mild (1+) aortic regurgitation is seen. An eccentric,
posteriorly directed jet of moderate to severe (3+) mitral
regurgitation is seen.
IMPRESSION: Limited study/Focused views. Mild aortic
regurgitation. Mean transaortic valvular gradient 30 mmHg.
Moderate to severe posteriorly directed mitral regurgitation.
Compared with the prior study (images reviewed) of [**2181-12-25**],
the mean transaortic valvular gradient has decreased from 59
mmHg to 30 mmHg status-post aortic valvuloplasty. Given the
limited nature of the current study a comprehensive comparison
of all parameters could not be made.
Cardiac Cath [**1-3**]:
1. Selective coronary angiography of this right-dominant system
demonstrated single-vessel CAD. The LMCA was normal. The LAD had
30%
stenosis in the proximal vessel segment. The LCX was normal, but
had a
large OM branch with 80% proximal stenosis. The dominant RCA had
30%
stenoses in the proximal and mid-vessel segments.
2. Resting hemodynamics revealed mildly elevated right-sided
filling
pressures and moderately elevated left-sided filling pressures.
The
measured RVEDP was 10mmHg and LVEDP was 20mmHg. There was mild
pulmonary
artery hypertension with a mean PAP of 28mmHg. There was severe
systemic
arterial hypertension with a measured central aortic pressure of
163/74/110. Cardiac output/index were preserved and calculated
at
5.1L/min and 3.3 L/min/m2, respectively. There was critical AS
with a
measured mean gradient of 63mmHg. [**Location (un) 109**] calculated by Gorlin
equation was
0.6cm2.
3. Left ventriculography was deferred.
Brief Hospital Course:
86 year old woman with critical AS (valve area <0.8cm2),
Parkinson's disease, autonomic dysfunction, orthostatic
hypotension, generalized neuropathy, recent hospitalization for
pneumonia vs. pulmonary edema who presents with syncope.
.
# Syncope: Thought to be multifactorial as each of the following
were likely contributing factors: known critical aortic
stenosis, parkinson's disease with associated autonomic
dysfunction, and orthostatic hypotension with the recent
discontinuation of pressure supporting droxidopa several days
prior. Cardiac enzymes and telemetry unremarkable. Neurology
consulted and did not see evidence of acute stroke/TIA.
Orthostatics were floridly positive and patient was started on
midodrine with gentle diuresis as needed in lieu of afterload
effects. The most likely culprit was thought to be known
critical aortic stenosis, and cardiothoracic surgery,
interventional cardiology, and atrius cardiology were all
consulted to discuss potential interventions - i.e., surgical
aortic valve replacement, balloon valvuloplasty, and
percutaneous aortic valve replacement. Patient was not deemed
to be a surgical candidate. Patient was medically optimized
with midodrine 2.5mg PO TID and diuresed as needed. She was
also transfused one unit of prbcs for likely symptomatic anemia.
Patient underwent balloon valvuloplasty with a decrease in her
mean gradient from 60 to 30. After valvuloplasty while in the
lab, she had an episode of complete heart block in the setting
of RBBB which resolved by the end of the case and was
transferred to the CCU. Temporary pacing wires were placed but
were not needed as she had no further episodes after the case
was completed and were pulled. She did have some residual PR
prolongation to ~250ms, however this resolved over a matter of
hours and she remained in her native sinus rhythm with right
bundle branch block for greater than 24 hours after the
procedure. She had a holter monitor placed to evaluate for
possible arrhythmogenic cause for her syncope. This will be
interrogated at a later date.
.
# Critical AS/severe MR: Euvolemic on exam, asymptomatic with
stable oxygenation. Patient was gently diuresed in lieu of her
dependence on preload and the initiation of midodrine, an
afterload increasing [**Doctor Last Name 360**]. After her valvuloplasty, she
required no further diuresis or change in her fluid management.
She will follow-up with Dr. [**Last Name (STitle) **] in 1 month for consideration
and further evaluation for percutaneous aortic valve replacement
and possible PCI for her 80% large OM lesion.
.
# Parkinsons: Stable, was continued on home stalevo and
pregabalin. Midodrine initiated as above.
.
# Anemia: Uncertain etiology, but suspect anemia of chronic
disease. B12, folate, iron studies, haptoglobin, and
reticulocyte count unremarkable. Will need outpatient f/u.
Medications on Admission:
1. cholecalciferol (vitamin D3) 1,000 unit daily
2. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit daily
3. multivitamin daily
4. mirtazapine 30 mg PO qHS
6. folic acid 400 mcg daily
7. Stalevo 100 25-100-200 mg q3H between hours of 6AM and 9PM
8. pregabalin 50 mg [**Hospital1 **] and 100mg qHS
9. polyethylene glycol 3350 17 gram/dose PO PRN constipation
Discharge Medications:
1. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Stalevo 100 25-100-200 mg Tablet Sig: One (1) Tablet PO q3H
during the hours of 6AM and 9PM ().
7. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
8. pregabalin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
10. midodrine 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Critical aortic stenosis
Autonomic dysfunction
Orthostatic hypotension
Parkinson's disease
Mitral regurgitation
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 taking care of you at [**Hospital1 827**]. You were admitted to the hospital after losing
consciousness at home. We believe that this is likely secondary
to worsening function of your heart valve (critical aortic
stenosis) in combination with your body's difficulty with
regulation of your blood pressure regulation (autonomic
dysfunction). During your last hospitalization, your
experimental drug droxidopa was discontinued, and this also
likely contributed to your episode of loss of consciousness.
In the hospital, you were evaluated by our cardiothoracic
surgeons, interventional cardiologists, and general cardiology
team. After a discussion between the multiple groups, you
underwent balloon angioplasty of your aortic valve to open it.
This resulted in good improvement in the blood flow through the
valve.
You were also transfused one unit of blood during your
hospitalization.
We have made the following changes to your medications:
- STOP droxidopa
- START midodrine 2.5mg by mouth three times a day
- START aspirin 81mg (baby aspirin) by mouth once per day
Please keep your appointments as listed below.
You also have a Holter monitor which you will wear to monitor
your heart rate for an extended period of time.
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2182-2-1**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4241, 4168, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2814
} | Medical Text: Admission Date: [**2151-5-5**] Discharge Date: [**2151-5-31**]
Date of Birth: [**2090-3-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
CHIEF COMPLAINT: OSH transfer for gram positive bacteremia
REASON FOR CCU ADMISSION: NSTEMI with persistent chest pain
despite nitro gtt
Major Surgical or Invasive Procedure:
status post transesophageal echocardiogram
cardiac catheterization with 5 drug eluting stents to the left
circumflex artery
History of Present Illness:
Mr. [**Known lastname 64793**] is a 61 y/o man with a history of CAD, s/p CABG and
AVR x 2 (details below) and on coumadin. In [**2139-1-22**] he
was in [**Country 32814**] racing speed boats and had a syncopal episode.
He was transferred to [**Location (un) 2848**] where he was diagnosed with severe
AS and was subsequently transferred to [**Hospital1 112**] where he underwent
AVR and CABG x2 (SVG to OM, SVG to RCA, 25 mm CE pericardial
valve). He underwent redo AVR/CABG at [**Hospital1 18**] with Dr. [**Last Name (STitle) **]
(St. [**Male First Name (un) 923**] 21 mm mechanical AVR, SVG to PDA) in [**2147**] due to
cardiac cath showing occluded SVG to RCA, EF 51%, [**Location (un) 109**] 0.4 cm2,
peak AV gradient 70, LAD 20%, CX 50%, distal RCA 80%.
He initially presented to [**Location (un) 11248**] on [**2151-5-4**] with fevers
followed by chills and rigors. He thought he had the flu. Of
note, he had 2 rigorous dental cleanings about three weeks ago
without Abx coverage. On admission there, his WBC was 16 and his
INR was 4.6. U/A and Ucx were negative. Blood cx was positive
for gram positive cocci in chains and clusters, which turned out
to be penicillin sensitive strep viridans.
On the [**Hospital1 1516**] service, the patient underwent treatment with
penicillin and gentamicin. The patient underwent 2 TEEs which
were negative for any significant vegetation or abscess. The
aortic valve also looked normal. The patient's blood and urine
cultures remained negative, as did a c diff toxin. The patient
underwent a CT head which was negative for any evidence of
embolic disease, however, on a CT abdomen/pelvis he was noted to
have a splenic infarction. CT surgery evaluated the patient and
felt that there was no need for surgery at this time. On
[**2151-5-12**], the patient developed substernal chest pain that
radiated to the left arm and shoulder along with significant
diaphoresis. The EKG revealed ST elevations in aVR and ST
depressions in the precordial and lateral leads, along with STD
in I and aVL. The pain was refractory to nitro gtt and therefore
was admitted to the CCU for pain management and further
monitoring.
In the CCU, the patient claims his pain is only [**1-31**] after nitro
gtt and morphine. The patient is also complaining of
simultaneous acute on chronic back.
REVIEW OF SYSTEMS:
He denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
black stools or red stools. He denies current fevers, chills or
rigors. 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. He also denies exertional
angina or prior MI.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
AVR / Cabg x2 [**2139**] at [**Hospital1 112**] (SVG to OM, SVG to RCA, 25 mm CE
pericardial valve)
s/p left elbow [**Doctor First Name **].
s/p right ankle [**Doctor First Name **].
MI
RHFever
atrial fibrillation
Social History:
lives alone
previously worked as a truck driver
smoked 1+ ppd x 40 years
no ETOH or recreational drugs
Family History:
CAD and s/p CABG in mother and CVA in father (died of CVA at 49)
Physical Exam:
VS: 97.7 81 133/79 (R arm) 142/76 (L arm) 22 94% 2LNC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple JVP not elevated
CARDIAC: PMI in 5th intercostal space, midclavicular line.
Irregular, normal S1, mechanical S2. III/VI systolic murmur at
RUSB. No lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Moderate rhales
bilaterally 1/2 up fields
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No perepheral stigmata of embolic disease
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: Cranial nerves [**3-5**] intact, [**5-26**] LE strength and UE
strength, light touch intact throughout.
PULSES:
Right: Radial 2+ DP 2+
Left: Radial 2+ DP 2+
Pertinent Results:
REPORTS:
ECHO [**2151-5-6**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch and descending thoracic aorta. A mechanical
aortic valve prosthesis is present. The aortic valve prosthesis
leaflets appear to move normally. No masses or vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen.
[The amount of regurgitation present is normal for this
prosthetic aortic valve.] The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. An eccentric, anteriorly
directed jet of moderate (2+) mitral regurgitation is seen.
IMPRESSION: No vegetations seen. Normal appearing mechanical
aortic valve. Moderate eccentric, anteriorly directed mitral
regurgitation.
CT ABDOMEN/PELVIS [**2151-5-15**]:
1. No evidence of abscess.
2. Area of hypoenhancement within the spleen, concerning for
splenic infarct.
3. Cholelithiasis without evidence of cholecystitis.
CTA HEAD [**2151-5-8**]
CONCLUSION: Normal study. No evidence of hemorrhage, infarction,
or
aneurysm.
ECHO [**2151-5-12**]:
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch and descending thoracic
aorta to 40 centimeters from the incisors. The aortic valve
prosthesis leaflets appear to move normally. No masses or
vegetations are seen on the aortic valve. No aortic valve
abscess is seen. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. An eccentric jet of mild to moderate
([**1-23**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is a small echodensity
measuring approximately 0.2 cm x 0.6 cm on the tricuspid valve
that is likely consistent with thickened/torn chordae, but
cannot rule out vegetation. There is no pericardial effusion.
IMPRESSION: Preserved left ventricular systolic function. Normal
functioning mechanical aortic valve without evidence of
vegetation or abscess. Small echodensity on the tricuspid valve,
likely thickened chordal structure, but cannot exclude
vegetation.
Compared with the prior study (images reviewed) of [**2151-5-6**],
the tricuspid valve echodensity is better visualized on the
current study (was probably prsent on the prior). All other
findings are similar.
[**2151-5-24**]: CARDIAC CATHETERIZATION
1. Coronary angiography in this right dominant system
demonstrated
three vessel disease. The LMCA had diffuse 50% stenosis. The LAD
had
mild diffuse disease with moderate disease in the 1st diagonal
branch.
The LCx was occluded as was the ramus intermedius. The RCA had
serial
70% stenoses.
2. Arterial conduit angiography demonstrated occluded SVG-OM
and
SVG-RCA grafts. The LIMA and RIMA as well as both subclavian
arteries
were patent and without stenoses.
3. Successful PCI of the native LCx into the OM1 branch with a
2.5x8mm
Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 55492**] and four (4) overlapping 2.5x12mm Promus
[**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 22595**]. The proximal portion was post-dilated to 3.0mm.
4. Successful closure of the right femoral arteriotomy site
with a 6F
Perclose device.
5. Limited resting hemodynamics revealed mild systemic arterial
hypotension with SBP 95mmHg and DBP 58mmHg.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Occluded saphenous vein grafts to the RCA and OM.
3. Successful PCI of the LCx with DES.
Brief Hospital Course:
Mr. [**Known lastname 64793**] is a 61 year-old gentleman with a history of
rheumatic fever, AVR and CABG x2 (SVG to OM, SVG to RCA, 25 mm
CE pericardial valve), and redo AVR/CABG with Dr. [**Last Name (STitle) **] (St.
[**Male First Name (un) 923**] 21 mm mechanical AVR, SVG to PDA) in [**2147**] who was
transferred from the [**Hospital1 1516**] Service with gram positive bacteremia
and suspicion for endocarditis who developed substernal chest
pain concerning for ACS.
1. CHEST PAIN/ACS: Patient's symptoms were concerning for
unstable angina and in combination with convincing EKG changes
and troponin elevation of 0.37 confirmed diagnosis of NSTEMI.
However, it was unclear if the myocardial damage was caused by
plaque rupture, or a thromboembolic event from a vegetation? The
latter was favored given unexplained splenic infarction and
diagnosis of endocarditis. Demand ischemia was less likely as
patient did not have tachycardia or hypotension. ASA was
increased to 325mg PO daily, atorvastatin increased to 80mg PO
daily and nitro gtt was continued and was initially unable to be
weaned secondary to persistent angina /SOB/diaphoresis/EKG
changes. Morphine was also used periodically with good effect.
Tachycardia seemed to correlate with angina therefore patient
was also rate controlled with metoprolol 25mg PO TID increased
to 37.5mg PO TID which assisted in successful rate control.
Heparin gtt was also started on [**2151-5-15**] as pt still with
intractable pain and to cover for possibility of thrombus
occluding the coronary vasculature. Plavix and catheterization
was deferred secondary to supratherapeutic INR peaked at 4.5,
and also because surgery for endocarditis has not yet been ruled
out. The patient was tentatively scheduled for a diagnostic and
possibly therapeutic catheterization on Monday [**2151-5-17**] however
this was deferred to the future. He remained chest pain free
while in the CCU. Due to his persistent cough and underlying
reactive airways disease, metoprolol was discontinued in favour
of diltiazem. After diuresis, he was transferred to the floor.
After transfer, he had an episode of atrial flutter with RVR
associated with severe chest pain. He was given diltiazem for
rate control and morphine for pain control. Pain resolved with
slowing of heart rate. After repeat chest pain, it was decided
to take patient for cardiac catheterization. Cardiac
catheterization on [**2151-5-24**] revealed 3 vessel coronary artery
disease. Previous saphenous vein grafts to the RCA and OM were
completely occluded. Pt underwent successful stenting of the
native LCx into the OM1 branch with a 2.5x8mm Cypher [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 55492**] and four overlapping 2.5x12mm Promus [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 22595**]. He
was started on Plavix after catheterization and tolerated the
procedure without complications.
2. ENDOCARDITIS: Patient with 1 major and 3 minor criteria with
fever, mechanical valve, evidence of emobolic disease with
splenic infarct, and [**4-25**] blood cultures growing strep viridans
drawn within 40 minutes of eachother. Worsening PR delay highly
concerning for abscess, however TEE x 3 have been negative for
revealing vegatations or abscesses. PR delay stabilized after
[**2151-5-13**]. Patient was continued on penicillin G x 6 weeks (will
continue as outpatient) and gentamicn x 2 weeks (start date
[**2151-5-6**]). Multiple surveillance blood cultures were negative to
date. If PR interval remains stable and no abscess on 4th TEE,
surgery unlikely to intervene. CT head negative for mycotic
aneurysm. CT abdomen which initially yielded a splenic infarct
(likely thromboembolic) was repeated on [**2151-5-15**] which revealed
evolution of splenic infact and right lower lobe pneumonia. Pt
did not undergo repeat TEE during admission. A PICC line was
placed on [**5-18**] without complications. He completed 2 week
course of gentamicin during admission and continued penicillin
for completion of planned 6 week course, to end on [**6-18**]. He will
have outpatient lab work faxed to Dr. [**First Name (STitle) **] from the Infectious
Disease service.
3. ATRIAL FIBRILLATION- He was rate-controlled with beta-blocker
initially, but due to concerns of underlying reactive airways
disease and pt's wheezing, this was changed to diltiazem, which
he tolerated well. Coumadin being held in setting of
supratherapeutic INR. Goal INR 2.5-3.5 for valve and afib. Pt
started on heparin gtt on [**2151-5-15**]. After transfer to the floor
from the CCU, he went into atrial flutter/fibrillation with RVR
and associated chest pain. His rate was controlled with
diltiazem, as he has a history of reactive airways disease and
had experienced wheezing with beta-blockers. He had 2 more
episodes of RVR during his admission (last episode on [**5-30**]) that
were quickly rate controlled with IV Diltiazem. By the time of
discharge, diltiazem was changed to 120 mg daily Extended
Release. He was also loaded with amiodarone and was discharged
with instructions for tapering his amiodarone dose. Pt's INR was
carefully monitored on heparin gtt when coumadin was added back
after catheterization. Once INR was therapeutic for 24h, heparin
gtt was discontinued and INR at time of discharge was 3.9. He
will have INR checked on Wednesday [**6-2**] and have the results
faxed to his outpatient cardiologist.
3. TRANSAMINITIS- Most likely secondary to zosyn as was started
on [**2151-5-4**] and stopped on transfer on [**2151-5-6**] and has been
trending down since. [**Month (only) 116**] be secondary to statin, however pt had
been on statin in [**2147**] and had normal LFTs so less likely.
Thromboembolic disease to liver is also possible, less likely
given lack of CT abnormalities. Viral hepatitis ruled out after
negative viral studies, and RUQ U/S was also negative. LFTs were
trended, decreased slowly and finally resolved by time of
discharge.
4. HYPONATREMIA: On presentation, pt's sodium had dropped to
127. Serum and urine osms most consistent with SIADH, without a
clear culprit. Patient was found to also have some free water
excess secondary to D5W in nitro gtt which was also likely
contributing. This was switched to NS, which improved the
hyponatremia to 128. We started a fluid restriction on [**2151-5-15**]
and the hyponatremia remained stable at ~130-132.
6. NORMOCYTIC ANEMIA: At beginning of [**Hospital **] hospital course, his
HCT slowly trended down to high 20s probably secondary to excess
phlebotomy. Iron studies most c/w anemia of chronic
inflammation. Baseline in low 30s. Pt will need scheduled
outpatient colonoscopy if not already completed.
Medications on Admission:
MEDICATIONS (confirmed with patient):
- lipitor 40 mg daily
- coumadin 5 mg daily
- aspirin 81 mg daily
- fish oil
- MTV
.
MEDICATIONS (on transfer from OSH):
- lipitor 40 mg daily
- vancomycin
- zosyn
- metoprolol tartrate 25 mg [**Hospital1 **]
- pantoprazole 40 mg daily
- nicotine patch 21 mg TD daily
- aspirin 81 mg daily
- coumadin being held for supratherapeutic INR
.
MEDICATIONS (on transfer from [**Hospital1 1516**])
Acetaminophen 325-650 mg PO/NG Q4H:PRN
Aspirin 81 mg PO/NG DAILY
Atorvastatin 40 mg PO/NG DAILY
Bisacodyl 10 mg PO DAILY:PRN constipation
Docusate Sodium 100 mg PO BID
Gentamicin 80 mg IV Q8H day 1 = [**2151-5-6**]
Lorazepam 0.5-1 mg PO/NG HS:PRN insomnia
Metoprolol Succinate 50 mg PO/NG Daily
Nitroglycerin 0.25-0.6 mcg/kg/min IV DRIP TITRATE TO relief of
CP
Pantoprazole 40 mg PO Q24H
Penicillin G Potassium 3 million units IV Q4H
Senna 1 TAB PO/NG [**Hospital1 **] constipation
Zolpidem Tartrate 10 mg PO HS
traZODONE 25 mg PO/NG HS insomnia
Discharge Medications:
1. Outpatient Lab Work
Weekly CBC, LFT's and Creatinine done after discharge and faxed
to ID office at [**Telephone/Fax (1) 432**], Attn: [**Last Name (LF) **],[**First Name3 (LF) **]
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for Chest pain:
Take up to 3 tablets 5 minutes apart. Call 911 if you still have
chest pain after 3 tablets.
Disp:*25 Tablet, Sublingual(s)* Refills:*0*
4. Penicillin G Potassium 5,000,000 unit Recon Soln Sig: 3
million units Injection every four (4) hours for 19 days.
Disp:*114 [**First Name3 (LF) 4319**]* Refills:*0*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for left shoulder pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
start on [**6-7**].
Disp:*30 Tablet(s)* Refills:*2*
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. 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.
13. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 syringes* Refills:*0*
14. Sodium Chloride 0.9 % 0.9 % Solution Sig: Three (3) ML
Injection Q8H (every 8 hours) as needed for line flush.
Disp:*30 ML(s)* Refills:*3*
15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. DILT-CD 120 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home solutions
Discharge Diagnosis:
PRIMARY:
1. strep viridians bacteremia
2. coronary Artery disease
.
SECONDARY:
1. Atrial fibrillation
2. Acute Diastolic congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure being involved in your care, Mr. [**Known lastname 64793**].
You were admitted to the hospital for bacteria in the
bloodstream which could be causing an infection in your valve.
Given your mechanical valve, you underwent a TEE. This did not
show an infection on your heart valve. You met with the
infectious disease doctors, who recommended intravenous
antibiotics for a total of 6 weeks. The last day of this is
[**2151-6-18**].
.
NEW MEDICATIONS/MEDICATION CHANGES:
1. START Penicillin to treat the blood infection, your last day
of this is [**2151-6-18**].
2. Decrease coumadin to 2 mg daily (do NOT take today's dose of
coumdain)
3. Increase aspirin to 325 mg daily
4. Stop taking fish oil, this can interfere with the coumadin
5. Use Nitroglycerin as instructed if you have chest pain at
home
6. Start Plavix every day for at least one year. Do not stop
taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 11250**] tells you
to.
7. Take Percocet as needed for shoulder pain
8. Start amiodarone to control your heart rate. Take 2 tablets
every day until [**6-6**], then decrease to 1 tablet per day.
9. Start Lisinopril 2.5 my daily to help your heart pump better
10. Start Furosemide (lasix) to get rid of extra fluid in your
body.
11. check your INR on Wednesday [**6-2**], Your goal INR is
2.0-3.0
IT WOULD BE BEST TO TRY AND MOVE THIS APPOINTMENT TO TUESDAY [**6-1**]
12. Start Diltiazem Sustained-Release 120mg ONCE PER DAY to help
control your heart rate
.
Please seek medical attention for fevers, chills, chest pain,
shortness of breath, abdominal pain, or any other concerns.
Followup Instructions:
Infectious Disease:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2151-6-18**]
11:00
.
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **]-[**Doctor First Name 10588**] S. Phone: [**Telephone/Fax (1) 11254**]
ICD9 Codes: 486, 7907, 4280, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2815
} | Medical Text: Admission Date: [**2160-3-6**] Discharge Date: [**2160-3-12**]
Date of Birth: [**2083-6-5**] Sex: M
Service: SURGERY
Allergies:
Hydrochlorothiazide
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
Urosepsis, Respiratory depression
Major Surgical or Invasive Procedure:
Emergent intubation
Percutaneous nephrostomy tube placement.
Central line placement
Foley catheter placement
History of Present Illness:
76 year old gentleman with a complicated and prolonged recent
medical course including recent SBO, AVR presented with sepsis,
hypotension, respiratory distress, and fever
Past Medical History:
Colon CA s/p colectomy/5-FU, CLL, Lung nodule s/p resectioin,
HTN, cachexia, dementia, GERD, SBO not requiring surgical
intervention.
Social History:
patient lives at home with wife. [**Name (NI) **] gradually become more
demented and eating less over the past year.
Family History:
non-contributory
Physical Exam:
On admission
104.0 120 82/40 24 98%
Appeares in distress
Tachycardia
CTA bilaterally
Abdomen soft, distended, bilateral lower quadrant tenderness,
reducable hernia
Guiac negative rectal exam
Pertinent Results:
[**2160-3-12**] 02:45AM BLOOD WBC-14.7* RBC-3.78* Hgb-10.0* Hct-31.1*
MCV-82 MCH-26.5* MCHC-32.2 RDW-16.8* Plt Ct-272
[**2160-3-10**] 04:06AM BLOOD WBC-19.3* RBC-3.36* Hgb-8.8* Hct-27.8*
MCV-83 MCH-26.3* MCHC-31.8 RDW-16.8* Plt Ct-248
[**2160-3-9**] 12:40AM BLOOD WBC-14.4* RBC-3.22* Hgb-8.6* Hct-26.5*
MCV-82 MCH-26.6* MCHC-32.4 RDW-16.7* Plt Ct-217
[**2160-3-8**] 04:08AM BLOOD WBC-27.7* RBC-3.42* Hgb-9.3* Hct-27.9*
MCV-82 MCH-27.4 MCHC-33.5 RDW-17.0* Plt Ct-279
[**2160-3-7**] 04:33AM BLOOD WBC-30.1* RBC-3.45* Hgb-9.5* Hct-28.3*
MCV-82 MCH-27.6 MCHC-33.6 RDW-16.7* Plt Ct-296
[**2160-3-6**] 11:09PM BLOOD WBC-49.0*# RBC-3.79* Hgb-9.9* Hct-31.2*
MCV-82 MCH-26.2* MCHC-31.8 RDW-16.0* Plt Ct-382
[**2160-3-12**] 02:45AM BLOOD Plt Ct-272
[**2160-3-11**] 03:34AM BLOOD Plt Ct-216
[**2160-3-11**] 03:34AM BLOOD PT-15.0* PTT-40.9* INR(PT)-1.3*
[**2160-3-10**] 04:06AM BLOOD Plt Ct-248
[**2160-3-7**] 04:33AM BLOOD PT-16.6* PTT-47.2* INR(PT)-1.5*
[**2160-3-6**] 11:09PM BLOOD Plt Ct-382
[**2160-3-6**] 05:20PM BLOOD Plt Ct-310
[**2160-3-12**] 02:45AM BLOOD Glucose-51* UreaN-17 Creat-0.6 Na-148*
K-3.7 Cl-112* HCO3-29 AnGap-11
[**2160-3-11**] 03:34AM BLOOD Glucose-137* UreaN-19 Creat-0.7 Na-144
K-3.8 Cl-113* HCO3-26 AnGap-9
[**2160-3-6**] 11:09PM BLOOD Glucose-128* UreaN-54* Creat-1.4* Na-145
K-4.1 Cl-115* HCO3-17* AnGap-17
[**2160-3-6**] 01:35PM BLOOD Glucose-137* UreaN-60* Creat-1.5* Na-139
K-5.6* Cl-109* HCO3-15* AnGap-21*
[**2160-3-6**] 01:35PM BLOOD ALT-127* AST-58* CK(CPK)-61 AlkPhos-141*
Amylase-60 TotBili-0.5
[**2160-3-6**] 01:35PM BLOOD cTropnT-0.02*
[**2160-3-12**] 02:45AM BLOOD Calcium-7.2* Phos-2.3* Mg-1.9
[**2160-3-11**] 11:00AM BLOOD Mg-1.9
[**2160-3-6**] 11:09PM BLOOD Calcium-7.4* Phos-4.5 Mg-1.5*
[**2160-3-6**] 01:35PM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.6 Mg-2.0
[**2160-3-11**] 08:19AM BLOOD Type-ART Temp-37.5 Rates-/23 Tidal V-600
PEEP-5 FiO2-50 pO2-83* pCO2-45 pH-7.41 calHCO3-30 Base XS-2
Intubat-INTUBATED
[**2160-3-11**] 11:12AM BLOOD K-4.5
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2160-3-9**] 12:52 PM
CHEST (PORTABLE AP)
Reason: Please evaluate for infiltrates
[**Hospital 93**] MEDICAL CONDITION:
76 year old man w/ sepsis, s/p intubation, removal of PICC
REASON FOR THIS EXAMINATION:
Please evaluate for infiltrates
PORTABLE CHEST ON [**2160-3-9**] AT 13:25
INDICATION: Sepsis, PICC line removal.
COMPARISON: [**2160-3-8**]
FINDINGS:
The tip of the ETT remains high 8 cm above the carina. Dr.
[**Last Name (STitle) 31839**] was informed of this finding at 7:55 p.m. on [**2160-3-9**].
The right CVL remains in place and there is no PTX. No new
consolidations are seen and there is continued blunting at the
right CP angle.
IMPRESSION:
Stable appearance versus prior with ETT tip still high, as
discussed above.
RADIOLOGY Preliminary Report
PERC NEPHROSTO [**2160-3-7**] 11:08 AM
PERC NEPHROSTO
Reason: please place percutaneous nephrostomy tube per urology.
Do n
Contrast: OMNIPAQUE
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with
REASON FOR THIS EXAMINATION:
please place percutaneous nephrostomy tube per urology. Do not
crush or manipulate kidney stone, perc neph only for
decompression.
HISTORY: 76-year-old man with urosepsis and obstructive left
ureteral stone presents for nephrostomy tube placement in the
left kidney. Prior CT scan had shown an exophytic ring lesion at
the mid third of the left kidney, suspected to possibly
represent a cystic/necrotic renal cell carcinoma.
RADIOLOGISTS: Dr. [**First Name (STitle) **] [**Name (STitle) **], Dr. [**First Name (STitle) 379**] [**Name (STitle) **], Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 380**], and Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Doctor Last Name **]. Drs. [**Last Name (STitle) 380**] and [**Name5 (PTitle) **]
[**Name5 (PTitle) **], the attending radiologists, were present and supervised
the entire procedure.
FINDINGS/TECHNIQUE: Informed consent was obtained before the
procedure. The intubated patient was placed prone on the
angiographic table. 1% lidocaine was administered for local
anesthesia over the left flank. Ultrasound imaging of the left
kidney was performed which demonstrated moderately distended
renal pelvis and calyces, several cysts, and a cystic exophytic
lesion suggestive of a renal cell carcinoma previously
demonstrated by the CT scan.
Using ultrasound guidance, a 22-gauge Chiba needle was advanced
towards the collecting system of the left kidney. This
collecting system was difficult to visualize by ultrasound at
the level of the lower pole of the kidney. Attempts to opacify
the collecting system through the Chiba needle were
unsuccessful.
Fluoroscopy and ultrasonography showed that the window available
for percutaneous access was relatively [**Name2 (NI) 15015**], between the spine
medially, aerated bowel laterally, ribs cranially and the left
iliac [**Doctor First Name 362**] caudally. In addition, the cystic exophytic lesion
mentioned above was adjacent to the only posterior calyx of the
mid third of the kidney. Lastly, the lower pole calyces were not
visible by ultrasound. Therefore, it was decided to access the
posterolateral calyx of the mid third of the kidney. This was
done successfully without much difficulty, again using the Chiba
needle and real-time ultrasound guidance. Cloudy urine obtained
on aspiration was sent for culture. A percutaneous antegrade
nephrostogram was performed. It demonstrated moderately dilated
collecting system of the left kidney with no passage of contrast
into the mid ureter.
An 0.018 nitinol wire was advanced and the needle was exchanged
for an Accustick system which was positioned in the left renal
pelvis. The inner dilators and the wire were removed, and a
0.035 guidewire was coiled within the left renal pelvis. The
sheath was exchanged for an 8-French nephrostomy with the
pigtail formed within the left renal pelvis. The catheter was
connected to the bag drainage. It was secured to the skin with
StatLock and 0 silk stitch. Sterile dressing was applied and the
patient was transported to the ICU in good condition. Ultrasound
images were obtained before and after obtaining the percutaneous
nephrostomy access.
COMPLICATIONS: No immediate complications.
IMPRESSION: Percutaneous nephrostogram demonstrated moderate
hydronephrosis on the left with ureteral obstruction in the mid
ureter. An 8 French left nephrostomy tube was placed
percutaneously under ultrasound and fluoroscopic guidence and
connected to external bag drainage.
DR. [**First Name (STitle) 39935**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39936**]
DR. [**First Name (STitle) 16722**] [**Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16723**]
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2160-3-6**] 6:51 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: eval for PE
Field of view: 38 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with h.o SBO now with rigid abd and distention,
cough, fever and tachy with hypoxia
REASON FOR THIS EXAMINATION:
eval for PE
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 76-year-old man with history of small bowel obstruction
now with rigid abdomen and distention who presents with cough,
fever, and tachycardia.
TECHNIQUE: Multidetector axial images of the chest, abdomen and
pelvis were obtained with oral and IV contrast. 130 cc Optiray.
Coronal and sagittal reformatted images were obtained.
CT CHEST: Although not optimized for it, no pulmonary embolism
is identified. Aortic and coronary calcifications are
identified. The heart size is normal. Mediastinal lymph nodes do
not meet CT criteria for pathologic enlargement. There is no
axillary or hilar lymphadenopathy. There are patchy bilateral
lower lobe opacities as well as bibasilar atelectasis. No
pleural or pericardial effusions are identified. Endotracheal
and nasogastric tubes are noted.
CT ABDOMEN: The liver, gallbladder, pancreas, spleen and adrenal
glands are unremarkable. Again identified in the left kidney is
a 2.5 x 2 cm solid and cystic lesion highly concerning for renal
neoplasm. A very unusual manifestation of infection or wall
thickeneing about a renal cyst is in the differential.
Additional low- attenuation foci, consistent with cysts are
again seen. The previously seen 1.9 x 1.1 cm renal calculus has
now descended into the ureteropelvic junction and is causing
mild hydronephrosis and perinephric stranding. The
corticomeduallary junciton is preserved. The right kidney is
stable in appearance with a cyst and multiple additional low-
attenuation foci which likely represent cysts but are too small
to be fully characterized. There is prominent dilatation of
small bowel loops up to 5 cm. The distal most loops are
decompressed but fluid filled. The colon contains both air and
fluid. There is no free air or free fluid. No mesenteric or
retroperitoneal lymphadenopathy is identified.
CT PELVIS: Air and Foley catheter are observed in the bladder.
The sigmoid colon and rectum are fluid filled. There is no free
fluid and no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions. Right hip prosthesis is noted.
IMPRESSION:
1. Large left ureteropelvic junction stone which is causing mild
hydronephrosis.
2. Dilated small bowel loops with decompressed but fluid-filled
distal small bowel and colon suggestive of an ileus pattern or
partial small-bowel obstruction.
3. Bilateral lower lobe patchy opacities concerning for
aspiration or developing pneumonia.
4. Redemonstration of 2.5-cm enhancing solid and cystic left
renal lesion concerning for renal cell carcinoma. Ddx includes
very unusual manifestation of abcess or wall thickening about a
cyst. Further evaluation with MRI is strongly recommended.
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] in respiratory distress and
with hypotension. He was intubated and fluid resuscitated.
Antibiotics were started. CT scan showed . Large left
ureteropelvic junction stone which is causing mild
hydronephrosis.
2. Dilated small bowel loops with decompressed but fluid-filled
distal small bowel and colon suggestive of an ileus pattern or
partial small-bowel obstruction.
3. Bilateral lower lobe patchy opacities concerning for
aspiration or developing pneumonia.
4. Redemonstration of 2.5-cm enhancing solid and cystic left
renal lesion concerning for renal cell carcinoma. Ddx includes
very unusual manifestation of abscess or wall thickening about a
cyst. Given these findings fevers and hypotension were
attributed to urosepsis. Patient was transferred to the
intensive care unit. A percutaneous nephrostomy tube was placed
to decompress the kidney and antibiotics were continued.
Patients improved clinically and remained hemodynamically
stable. Patients fever subsided. Ventilatory support was weaned
and patient was extubated on [**2160-3-11**].
Given patients long progressive clinical decline, the patient,
his wife and family decided that no further heroic measures
should be undertaken. He was made DNR/DNI and was discharged
home with hospice care on comfort measures only on [**2160-3-12**].
Discharge Medications:
1. Ativan Elixir
2mg/mL. Take 0.5-1 mg every 2 hours as needed for agitation,
anxiety
10 ml per vial. Dispense 5 vials.
[**Month (only) 116**] refil 5 times.
2. Medication
Morphine sulfate (MSO4) 20 mg per 1 cc.
2-20 mg every 1-2 hour SC injection
120cc vial. Dispense 3 vials
[**Month (only) 116**] refil 4 times.
3. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1)
Sublingual every four (4) hours for 7 days.
Disp:*42 drops* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Urosepsis, septic shock
ARF
Discharge Condition:
Fair to home with Hospice care.
Discharge Instructions:
Discharge home with hospice care.
Comfort measures only.
Followup Instructions:
No follow up necessary.
Completed by:[**2160-3-12**]
ICD9 Codes: 0389, 5849, 5990, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2816
} | Medical Text: Admission Date: [**2123-1-3**] Discharge Date: [**2123-1-14**]
Date of Birth: [**2072-3-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
CC:[**CC Contact Info 70721**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 50 y/o female found at 0530 by police being assaulted,
attacker physically banging back of patients head against
concrete. Pt was awake with slurred speech at scene was GSC 13
at [**Hospital1 1474**] became disorientated and combative at [**Hospital 1474**]
Hospital and was intubated. A head CT showed a right sided
subdural greatest width of 4mm along entire right side and small
left sided subdural hematoma. She was transferred here for
further management. She had a witnessed seizure in our ER.
Past Medical History:
PMH:
Obesity
NIDDM
HTN
Anxiety
PSH:
Has old burr holes on CT of head / per pt they are from surgery
for SDH after being struck by a car at age 21.
Social History:
ALL: Unsure, drug use coccaine
Family History:
unknown
Physical Exam:
on admission
VS: T: BP 165/107 P 72 R16 SaO2 98%
Gen: Obese intubate
HEENT: +Head Laceration occipital area
Card: RRR
Lungs: Bilateral breath sounds
Abd: Soft non distended obese
Neuro: Examined off sedation (Propathol for 5 minutes)
Pupils 3mm bilaterally minimally reactive
Quickly awoke open eyes
Moved all extremities very strongly
Not following commands
currently :
awake aox3 with nonfocal neuro exam. Has difficulty with
position sense in rue however when isolated/ the motor exam in
this extremity is full/ she is ambulatory with a walker and
voiding/ tolerating regular diet.
Pertinent Results:
Labs: Na:142 K:3.7 Cl:109 TCO2:30 Glu:114 freeCa:1.11
Lactate:2.0
WBC 20.1 plt 167 hct 45.4
PT: 11.5 PTT: 24.3 INR: 1.0
Head CT: Right sided subdural hematoma along entire right side
measuring between 7mm (temporal area) and 11mm posterior area.
Small left sided subdural also noted. No shift, no compression
of ventricles.
CT HEAD W/O CONTRAST [**2123-1-9**] 10:18 AM
CT HEAD W/O CONTRAST
Reason: F/u head CT.
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman s/p assault with head bleed.
REASON FOR THIS EXAMINATION:
F/u head CT.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post assault with head bleed. Followup.
NON-CONTRAST HEAD CT: Comparison with [**2123-1-4**]. Again
seen is a large right subdural hematoma overlying most of the
right temporal, parietal, and occipital cerebral convexity. It
is not significantly changed in size. A small amount of
subarachnoid blood seen at the vertex of the right parietal lobe
again identified. Small amount of low density fluid outlining
the right frontal cerebral convexity is again noted, slightly
increased, now measuring approximately 5 mm in greatest axial
dimension, as opposed to 3 mm previously. Though it exerts mild
mass effect on the underlying right frontal cerebral cortex, it
does not cause significant shift of midline structures. Large
amount of encephalomalacia in the inferior right frontal lobe is
again identified. An 8 mm focus of high-density material
representing blood in the medial inferior right frontal lobe.
Tiny amount of blood in the left occipital [**Doctor Last Name 534**]. No
hydrocephalus, or acute major vascular or territorial infarct is
identified. Small amount of extra-axial blood outlining the
right side of the falx again noted. Significant scalp hematoma
along the right parietal region. Bony structures are notable for
bilateral parietal bur holes and frontal bur holes. Frontal,
ethmoid, sphenoid, and maxillary sinuses are almost completely
opacified. Bilateral mastoid air cells are also almost
completely opacified. There is partial pneumatization of both
features apices. Many of these air cells are also filled with
fluid.
IMPRESSION: Slightly increased frontal low density subdural
collections since the previous study. The previously noted
bilateral high densitu subdurals are unchanged. No other
significant new abnormalities.
The study and the report were reviewed by the staff radiologist
CHEST (SINGLE VIEW) [**2123-1-11**] 3:11 PM
CHEST (SINGLE VIEW)
Reason: assess pneumonia
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with (+)sputum cx
REASON FOR THIS EXAMINATION:
assess pneumonia
CHEST, SINGLE AP FILM
History of cough.
Right subclavian CV line is in mid SVC. No pneumothorax. Heart
size is within normal limits. There has been significant
resolution of the bibasilar opacities since the prior study of
[**2123-1-7**], with minimal residual atelectasis in the left
lower lobe. A small focal ill-defined opacity is present in the
right midzone, not clearly identified on the prior film and of
uncertain cause, but recommend revaluate on short-term followup
exam. to determine if additional workup such as chest CT is
indicated.
Brief Hospital Course:
Pt was admitted to the TICU where she was monitored closely.
She had repeat CT of head which showed stable SDH. Sh remained
intubated until [**1-7**]. her exam improved daily. CXR on [**1-6**]
showed concern for pneumonia and she was started on levaquin.
Diet was advanced and tube feedings were stopped. She was
transferred to the floor on [**1-9**]. On 27th cxr showed improved
PNA with samll opacity in right midzone/ She had RUE weakness
during this stay which is improved to 5/5 strength however she
remains with poor position sense in that RUE. We recommend she
follow up with her PCP for EMG for eval of that rue in about [**7-23**]
weeks from date of injury. For this weakness she had an EEG to
r/u sz / and then contunuous EEG / results= OBJECT: BDESIDE EEG,
[**Date range (1) 70722**]. RULE OUT SEIZURES. THERE WERE
NO PUSHBUTTON ACTIVATIONS.
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
FINDINGS:
ROUTINE SAMPLING: Began on the morning of [**1-7**] and showed
a
widespread, but also a bit slow, [**7-22**] Hz background in most
areas,
including frontal. There were also some bursts of generalized
delta
slowing. Modest amounts of additional focal delta slowing were
evident
in the left anterior quadrant. The background patterns persisted
throughout the recording.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular tachycardia with a
rate of
approximately 105.
SPIKE DETECTION PROGRAMS: Showed no clear epileptiform
discharges.
SEIZURE DETECTION PROGRAMS: There were four entries in these
files.
These showed some lead artifact and movement artifact but no
electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were none.
IMPRESSION: This telemetry captured no pushbutton activations.
Intermittent recording showed a slow background with an anterior
predominance. This suggests medication effect. Focal
abnormalities (in
the left fronto-central region) were less common than on the
previous
day's recording. There were no epileptiform features. Overall,
the
medication effect or encephalopathy appears less profound than
on the
previous recording.
She also has noted on CT /thyroid nodules/which we recommended
f/u with PCP for as well. She is maintained on dilantin for this
injury as well as history of sz. PT/OT evals done/.
She is improving daily and is being set up for d/c to extended
care facility.
Medications on Admission:
unknown
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO TID (3 times a day) as needed for pain.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days: as of [**1-13**] - pt is day #8 of
10days.
12. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ac hs.
Discharge Disposition:
Extended Care
Facility:
St Josephs [**Hospital 731**] Nursing Home - [**Hospital1 1474**]
Discharge Diagnosis:
Bilateral traumatic SDH
pneumonia
Discharge Condition:
neurologically improved
Discharge Instructions:
Call for mental status changes [**Telephone/Fax (1) **] or return to nearest
emergency room.
Followup Instructions:
follow up with neurosurgery at [**Telephone/Fax (1) **] in 6 weeks with a
head CT follow up with PCP for out patient EMG to check for
brachioplexus injury in Right arm if strength does not improve.
This should be done about 6-8 weeks from your date of injury.
You should also have follow up of thyroid nodules noted on cat
scan and small opacity noted on chest xray / these should be
followed by your primary care doctor.
Completed by:[**2123-1-14**]
ICD9 Codes: 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2817
} | Medical Text: Admission Date: [**2192-9-20**] Discharge Date: [**2192-9-25**]
Date of Birth: [**2126-3-22**] Sex: M
Service: MEDICINE
Allergies:
Seroquel / Valsartan
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
66 yo Hispanic male with history of HTN, DM2 and CKI and
schizophrenia who has had 3-4weeks of intermittent chest pain
presented to the ED via ambulance. At approximately 1pm, he was
returning from the supermarket when he suddenly felt mild
epigastric pain. This pain gradually became severe with
radiation to the back. He then became dizzy and felt his legs
were wobbly. He lost consciousness and fell to the ground on
his left side. He did not hit his head. Broke his fall with
his left elbow but denies pain. Bystanders called for an
ambulance. EKG in the ED revealed inferior ST elevations
seemingly in the mid to distal RCA. Code STEMI was called. He
went directly to the cath labwhere catheterization revealed the
right side was initially accessed and he was found to have 70%
promixal stenosis 60% midstenosis and 90% distal stenosis with
three overlapping DES placed. Next, the left side was accessed
and had 80% distal left main without stent. There was thrombus
present. Cardiology consulted CT [**Doctor First Name **] for CABG consult after
one year. He is currently chest pain free after intervention.
.
Of note, per last PCP [**Name Initial (PRE) **] [**2192-8-20**] pt had been c/o
intermittent chest discomfort x several months. EKG revealed
new precordial-lateral T wave invesions, and so his PCP advised
nuclear stress test. There is no record that this was done. In
addition, he has had an extensive history of palpitations which
have been attributed to anxiety. His PCP personally took him to
get a holter monitor on the [**9-11**], but he notes that he returned
this early and was not wearing it today.
.
In the ED, v/s were 126/82 72 18 98% on RA. He was A&Ox3 and
able to report story. He was given Aspirin 325mg, 4L of oxygen,
Plavix 600mg x1, Heparin 5000 units IV, and Integrillin 14.4mg
IV.
Past Medical History:
-HTN
-DM2, last A1C 6.8, recent weight gain after abilify (A1C 11) -
stopped it, now A1c as above
-CKI, baseline creatinine 1.5
-fatty liver/NASH, concern for progression of disease
-paranoid schizophrenia, not on any antipsychotics
-anxiety
-allergies (seen by ENT and [**Hospital 9039**] clinic)
-Headaches
-dysphagia, s/p barium swallow [**2184**]
Social History:
The patient quit smoking over 20 years ago. He
quit drinking alcohol over 35 years ago. He denies the use of
illicit drugs. Compliant with medications at home, but anxious
when talking about them. Lives by himself. Moving to a new
facility
Family History:
His mother died after a bypass operation in [**2154**]
at age 65.
Physical Exam:
Admission Exam
VS: afeb 121/65 78
GEN: NAD, supine after cath
HEENT: PERRLA, EOMI, anicteric, MMM
neck: supple, no LAD, no JVD, no bruits
CV: RRR, nl s1, s2, no s3, s4 no m/r/g
LUNGS: CTAB no w/r/c anteriorally
ABD: +BS, soft, NT, mildly distended, no HSM appreciated
EXT: wwp, no LE edema, DP 2+ intact bilaterally
NEURO: A&0X3, CN 2-12 intact, 5/5 strength throughout
GROIN: hematoma, tenderness at site
Pertinent Results:
[**9-21**] CXR: "IMPRESSION: No evidence of acute cardiopulmonary
abnormality."
.
[**9-21**] Echo: "Conclusions: The left atrium and right atrium are
normal in cavity size. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The estimated cardiac index is normal (>=2.5L/min/m2).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Compared
with the prior study (images reviewed) of [**2190-6-17**], the
findings are similar."
Brief Hospital Course:
66 y/o Spanish-speaking M w/ DM2, HTN, CKI, and prior tobacco
abuse admitted for STEMI s/p cardiac catheterization, found to
have three-vessel disease.
.
#STEMI/CORONARIES: History of HTN, DM, and obesity presented
with sudden onset chest pain, found to have STEMI and
three-vessel disease. Three drug-eluting stents were placed in
the RCA. Patient completed 18 hour course of integrillin and was
started on daily plavix, aspirin, metoprolol and statin. CT
surgery was consulted and recommended CABG; however, pt
initially declined. Because of some doubt as to whether patient
has capacity, Psychiatry was consulted. Psychiatry did not
believe that patient had capacity at that moment, however
discussion with pt's PCP and family suggested patient does have
capacity at baseline. A family meeting was then set up which
further described the risks and benefits of the surgery. Patient
agreed to have a CABG. Pt will follow up with cardiology and CT
surgeons outpatient.
.
#HTN: ACEI (captopril) and beta-blocker (metoprolol) therapy
continued.
#DIABETES: Last A1c 6.8. His oral hypoglycemics were held and he
was placed in ISS.
#CKI: Stable, with creatinine at baseline 1.5 or lower.
.
#SCHIZOPHRENIA: Stable, appropriate affect, mildly anxious, not
currently on any antipsychotics. Per PCP, [**Name10 (NameIs) **] has tried Abilify
in the past, which did not help his psychiatric state but did
result in insulin resistance and increased his weight. Abilify
was stopped. Patient's psychiatric provider also [**Name (NI) 653**] and
reported that patient was non-compliant with his psychiatric
regimen.
.
#NASH: The patient's outside providers are concerned about
cirrhosis, given elevated INR and thrombocytopenia. The patient
has not had the appropriate work-up and does not currently have
a transaminitis. Hepatitis serologies were negative.
.
#DEPRESSION: Continued on home Celexa. Psychiatry recc
discontinuing the benzodiazepine (clonazepam).
Medications on Admission:
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth daily
CITALOPRAM [CELEXA] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day
CLONAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1.5
Tablet(s) by mouth twice a day as needed for anxiety
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays each nostril
once a day
GLIPIZIDE - 5 mg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
PIOGLITAZONE [ACTOS] - 45 mg Tablet - 1 Tablet(s) by mouth daily
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL] - (OTC) - 325 mg Tablet - [**11-19**] Tablet(s)
by mouth every six (6) hours as needed for pain
ASPIRIN [ASPIR-81] - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - use as
directed for daily home glucose testing
DOCUSATE SODIUM - 250 mg Capsule - 1 Capsule(s) by mouth twice a
day
LANCETS [SOFT TOUCH LANCETS] - Misc - Use as directed for blood
sugar monitoring up to once to twice daily as needed
ONE TOUCH ULTRA SYSTEM - Kit - FOR TWICE A DAY HOME GLUCOSE
TESTING
SIMETHICONE - 80 mg Tablet, Chewable - 1 Tablet(s) by mouth
three
times a day as needed for gastric discomfort
SIMETHICONE - 180 mg Capsule - 1 Capsule(s) by mouth twice a day
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for abd discomfort.
6. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. clonazepam 1 mg Tablet Sig: 1.5 Tablets PO twice a day as
needed for anxiety.
10. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
11. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO four times a day
as needed for pain.
13. docusate sodium 250 mg Capsule Sig: One (1) Capsule PO twice
a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Diabetes Mellitus
Chronic Kidney Disease
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a heart attack that was caused by blockages in your
coronary arteries. One of the arteries was cleared and opened
with 3 drug eluting stents. The other 2 arteries still have
blockages and we have recommended bypass surgery for this. A
family meeting has been held and it was decided you would go
home today and return for the surgery.
.
Medication changes:
1. STOP taking Atenolol, Omeprazole, and Pioglitazone (Actos)
2. Start taking Aspirin (increase to 325mg) and Plavix 75 mg
every day for at least one year. Do not stop taking Plavix and
aspirin together or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] tells you
to. This is extremely important to prevent another heart attack.
3. Start taking Metoprolol Succinate to control your heart rate
4. Start taking Ranitidine to prevent heartburn
5. STart taking Lisinopril to lower your blood pressure
6. Increase the simvastatin to 40 mg daily
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2192-10-5**] at 2:10 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: FRIDAY [**2192-10-26**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call Dr.[**Name (NI) 10342**] office after you get home to schedule a
date for surgery
ICD9 Codes: 2875, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2818
} | Medical Text: Admission Date: [**2170-6-17**] Discharge Date: [**2170-6-26**]
Date of Birth: [**2097-3-10**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
left arm, leg, face weakness.
Major Surgical or Invasive Procedure:
placement of right ICA stent
History of Present Illness:
73 yo M, had been vacationing in [**Location (un) **] with his wife.
When they returned, pt was tired and went to bed, roughly 10 pm,
which was the last time pt was seen at his baseline. Per pt's
wife, the pt was quite restless in bed, and had managed to
displace himself so that his extremities were hanging off the
bed. When she awoke him to reposition at about 1:20 am, he
grabbed his walker which he normally uses for support and found
that he could not support wieght on his left arm. He also found
his left leg to be weak.
The patient's wife called EMS, and pt was brought to the ED.
CODE STROKE was called at 2:42 am; this neurology resident was
at
the bedside at 2:45 am.
Initial NIH Stroke Scale score was 12:
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 0
2. Best gaze: 1
3. Visual fields: 0
4. Facial palsy: 1
5a. Motor arm, left: 3
5b. Motor arm, right: 0
6a. Motor leg, left: 2
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 2
Past Medical History:
TIA
frontal dementia
active herpes zoster
hyperlipidemia
DM
overactive bladder
Social History:
lives with wife. Former CPA. Son is a plastic surgeon.
Family History:
NC
Physical Exam:
T- 97.6F BP-137/25 HR-58 RR-20 O2Sat 96%RA
Gen: Lying in bed, sitting upright in NAD
HEENT: NC/AT, moist oral mucosa
Neck: no carotid bruit; no LAD
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, but not place or date. Speech is
fluent, but dysarthric with normal comprehension and repetition,
but he has trouble phonating at times; He has trouble
particularly with gutteral sounds (g's and k's). naming intact
to high frequency objects.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Extraocular movements intact bilaterally, (although
much difficulty in looking to the left (neglects). no nystagmus.
Sensation intact V1-V3. Left facial droop (mild). Hearing
intact to finger rub bilaterally. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. Clonus at anlkles B/L
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 1 1 1 1 1 1 4 3 3 3 4 4 4 4
Sensation: Intact to light touch, (+) extinction to DSS
Reflexes:
+2 at [**Hospital1 **], tri's, BR's B/L. 1+ at the knees and ankles b/l,
however, on ankle jerk, get several beats clonus b/l.
Toes downgoing on R, upgoing on left
Coordination: finger-nose-finger normal on R, unable to perform
on L.
Gait: not tested.
Romberg: not tested
Pertinent Results:
[**2170-6-20**] 05:58AM BLOOD WBC-8.5 RBC-3.39* Hgb-10.2* Hct-28.6*
MCV-84 MCH-30.1 MCHC-35.7* RDW-13.9 Plt Ct-178
[**2170-6-19**] 02:52AM BLOOD WBC-6.9 RBC-3.41* Hgb-10.2* Hct-27.8*
MCV-82 MCH-29.9 MCHC-36.7* RDW-14.5 Plt Ct-145*
[**2170-6-18**] 03:11AM BLOOD WBC-6.6 RBC-3.65* Hgb-11.0* Hct-30.0*
MCV-82 MCH-30.0 MCHC-36.6* RDW-14.4 Plt Ct-157
[**2170-6-17**] 03:05PM BLOOD WBC-5.2 RBC-4.31* Hgb-12.7* Hct-36.3*
MCV-84 MCH-29.4 MCHC-34.9 RDW-14.3 Plt Ct-141*
[**2170-6-17**] 02:35AM BLOOD WBC-5.6 RBC-4.33* Hgb-13.0* Hct-36.3*
MCV-84 MCH-30.0 MCHC-35.8* RDW-14.3 Plt Ct-147*
[**2170-6-17**] 02:35AM BLOOD Neuts-61.8 Lymphs-27.9 Monos-6.5 Eos-2.9
Baso-0.8
[**2170-6-20**] 05:58AM BLOOD Plt Ct-178
[**2170-6-20**] 05:58AM BLOOD PT-14.1* PTT-62.3* INR(PT)-1.2*
[**2170-6-19**] 02:52AM BLOOD Plt Ct-145*
[**2170-6-18**] 03:11AM BLOOD Plt Ct-157
[**2170-6-17**] 03:05PM BLOOD Plt Ct-141*
[**2170-6-17**] 03:05PM BLOOD PT-14.7* PTT-57.4* INR(PT)-1.3*
[**2170-6-17**] 02:35AM BLOOD Plt Ct-147*
[**2170-6-17**] 02:35AM BLOOD PT-14.1* PTT-29.0 INR(PT)-1.2*
[**2170-6-20**] 05:58AM BLOOD Glucose-142* UreaN-10 Creat-1.1 Na-141
K-3.9 Cl-110* HCO3-25 AnGap-10
[**2170-6-19**] 02:52AM BLOOD Glucose-143* UreaN-11 Creat-0.8 Na-141
K-3.7 Cl-110* HCO3-24 AnGap-11
[**2170-6-18**] 03:11AM BLOOD Glucose-158* UreaN-15 Creat-1.0 Na-141
K-3.9 Cl-108 HCO3-25 AnGap-12
[**2170-6-17**] 03:05PM BLOOD Glucose-122* UreaN-20 Creat-1.0 Na-139
K-4.2 Cl-105 HCO3-26 AnGap-12
[**2170-6-17**] 02:35AM BLOOD Glucose-146* UreaN-28* Creat-1.2 Na-139
K-4.1 Cl-103 HCO3-25 AnGap-15
[**2170-6-17**] 03:05PM BLOOD CK(CPK)-38
[**2170-6-17**] 02:35AM BLOOD ALT-16 AST-21 CK(CPK)-39 AlkPhos-82
TotBili-0.5
[**2170-6-17**] 03:05PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2170-6-17**] 02:35AM BLOOD CK-MB-3 cTropnT-0.02*
[**2170-6-20**] 05:58AM BLOOD Calcium-9.0 Phos-2.5* Mg-1.9
[**2170-6-19**] 02:52AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.6
[**2170-6-18**] 03:11AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.4*
[**2170-6-17**] 03:05PM BLOOD Calcium-9.3 Phos-2.5* Mg-1.7
[**2170-6-17**] 02:35AM BLOOD Cholest-121
[**2170-6-17**] 06:21AM BLOOD %HbA1c-5.9
[**2170-6-17**] 02:35AM BLOOD Triglyc-152* HDL-31 CHOL/HD-3.9
LDLcalc-60
[**2170-6-17**] 02:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
This 73 yo man was admitted as a CODE STROKE with significant
left sided weakness, worst in the arm, but also present in the
leg and face. He also had significant neglect of his left side.
Because the time he was last seen at baseline was several hours
before the initial assessment, he was not considered for IV tPA
and because the intracranial vessels were read as normal with
no thrombus, no IA tPA was given. The CTA showed patent
incranial vessels, with a tight stenosis in the extracranial
R-ICA, suggesting hypoperfusion or artery-to-artery embolism as
most likely. We did recommend to hydrate the pt gently, keep him
lying flat on his back, and to start an IV heparin gtt, with
PTT's checked Q6hrs. Because a tight R-ICA stenosis was
appreciated, [**Country **] was stented after plavix loading. The patient
had an initial transient improvement in his symptoms, such that
the left arm was able to move against gravity, however, we
suspect that the pt completed his infarct as he subsequently
lost motor function in his left arm again.
The pt was monitored in the neuro ICU for ~48 hours after
stent placement and then transferred to the neurology stroke
floor. His left neurological deficits remained fairly stable, as
the pt remained unable to move the LUE, had about 2/5 strength
in the LLE, with a persistent L facial droop. His level of
neglect did improve, and he was able at least recognize his left
arm as being his own (a fact with which he had a problem
previously). His mental status also fluctuated somewhat,
however, pt was at least oriented to self, place, and season by
discharge [**2170-6-21**]. Pt did have some ongoing agitation/confusion
and his right arm was restrained for his own safety, as he had
previously removed his foley catheter, and scratched his
abdominal zoster infection excessively.
The pt worked with PT/OT during his inpatient admission and
should continue to do so at rehab.
Medications on Admission:
Lipitor 10 mg Qday
Aricept 5 mg Qday
Plavix 75 mg Qday
Detrol LA 4 mg Qday
Hyzaar 50/12.5 mg Qday
Uroxatral 10 mg Qday
MVI 1 tab Qday
Ativan 0.25 mg QHS PRN
Calcium 500 mg Qday
Prilosec 20 mg Qday
Vit D 1 cap Qday
Sertraline 150 mg Qday
Valacyclovir 1 tab TID
Glucophage XR 1000 mg Qday
Toprol XL 25 mg Qday
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itch/pain at zoster site.
9. Hyzaar 50-12.5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Uroxatral 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
11. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
12. Glucophage XR 500 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
right occipital/parietal stroke.
Discharge Condition:
stable
Discharge Instructions:
You have had a stroke and were found to have a narrowing of your
right carotid artery, which may have contributed to your stroke.
To help this, you received a stent to your right carotid, and
you should remain on the anti-platelet drug plavix. Please
return to the ER if you experience any sudden weakness, change
in sensation, headache, visual changes, nausea, vomiting,
clumsiness of your limbs, change in speech, or anything else
that concerns you seriously.
Followup Instructions:
Please follow up with PCP: [**Name10 (NameIs) 1239**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 719**]
neurological follow up with Dr. [**Last Name (STitle) **]: [**Telephone/Fax (1) 1694**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2170-6-21**]
ICD9 Codes: 7907, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2819
} | Medical Text: Admission Date: [**2150-5-22**] Discharge Date: [**2150-6-2**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 63-year old
female with a past medical history of stage III lung cancer
(status post chemotherapy, XRT, and left pneumonectomy in
[**2150-2-16**]), left lower extremity DVT, hypertension,
atrial fibrillation, and recent C. difficile colitis. She was
discharged from [**Hospital1 69**] on [**4-14**] following a prolonged hospitalization with respiratory
failure and left pneumonectomy. Since this time she has
resided at [**Hospital1 700**]. Her course at [**Hospital1 5593**] was complicated by pneumonia (for which she was
treated with Levaquin), left lower extremity DVT (for which
she is Coumadin), C. difficile colitis and altered mental
status (thought secondary to cerebral hypoxia during her long
surgery), prerenal azotemia, and most recently hypotension.
On [**2150-5-21**] she had a systolic pressure down to the 70s
which improved to 90s with an IV fluid bolus. However, given
persistent hypotension and multiple medical problems she was
transferred back to [**Hospital3 **] MICU for further management.
On arrival she was noted to be hypotensive with systolic
pressures to the 80s and tachycardic, in rapid AFib to the
160s. The patient was given a IV boluses with mild
improvement in blood pressure. A chest x-ray was notable for
a right upper lobe infiltrate and right pleural effusion. She
was also noted to have increased secretion. In the emergency
department she received vancomycin, ceftazidime, Flagyl, and
Solu-Medrol for possible bronchospasms. No fevers reported.
PAST MEDICAL HISTORY: Tobacco abuse (100-pack-year), stage
III lung cancer diagnosed in the Fall of [**2148**], status post
left pneumonectomy complicated by respiratory failure and
tracheostomy placement, status post chemotherapy and XRT,
status post J-tube insertion, thrombocytopenia with possible
HIT, hypothyroidism, DVT of left upper extremity,
hypertension, hypercholesterolemia, atrial fibrillation, CHF,
pleural effusions, C. difficile colitis, pneumonia.
ALLERGIES: A possible allergy to HEPARIN (HIT).
SOCIAL HISTORY: A 100-pack-year history of tobacco. No
alcohol. No drugs. Married. Son recently died.
MEDICATIONS: Epogen 10,000 units q. Thursday, iron 300
daily, Prevacid 30 daily, Synthroid 25 daily, Lopressor 50
b.i.d., Flagyl 500 t.i.d., Coumadin 4 mg daily, digoxin 0.25
daily, amiodarone 400 daily, Compazine 10 mg p.r.n., Tylenol
p.r.n., Ultracal 30 mL/h.
PHYSICAL EXAMINATION: Temperature of 99.3, blood pressure of
80/40, heart rate of 93, ventilator SIMV with pressure
support of 18, 450 x 20, 0.4, saturating 95%. HEENT revealed
anicteric. The mucous membranes were moist. The neck was
supple. Tracheostomy site was clear. CV was irregular. No
murmur. Lungs with decreased left breath sounds. Scattered
rhonchi and exploratory wheeze, predominantly on the right.
Abdomen was soft and nontender. J-tube site was clear. Groin
with right femoral line. Extremities with 2+ lower extremity
edema and 2+ left upper extremity edema. Heel with a small 1-
cm ulceration. The skin with numerous ecchymoses on the upper
extremities, black fungating lesion on the abdomen. On
neurologic exam, unable to speak with PMV response to
commands. Moved all extremities. Toes were down. Reflexes
were 1+ throughout.
LABORATORY DATA: White count of 13.6 (down from 15.7),
hematocrit of 28.4, MCV of 105, platelets of 117. Sodium of
147, potassium of 4.1, chloride of 102, bicarbonate of 40,
BUN of 36, creatinine of 0.2, glucose of 72. INR of 2.2.
Cortisol level was pending. Digoxin was 0.7. ABG revealed
7.53/54/64, lactate of 1. Urinalysis with 0 to 2 white blood
cells, negative nitrites, negative leukocytes.
RADIOLOGIC STUDIES: A chest x-ray with tracheostomy in
satisfactory position. Status post a left pneumonectomy.
Right upper lobe and right lower lobe alveolar opacification.
Moderate bilateral pleural effusions. No pneumothorax.
EKG with AFib.
HOSPITAL COURSE:
1. RESPIRATORY FAILURE: Throughout course the patient
remained dependent on ventilator despite treatment with
antibiotics and diuresis of pleural effusions.
1. HYPOTENSION: Initially thought secondary to hypovolemia,
however did not improve with IVF administration. The
patient was administered broad spectrum antibiotics and
stress-dose steroids, but remained on Levophed throughout
most of hospital stay.
1. INFECTION: Treated for nosocomial pneumonia with broad
spectrum coverage. Remained afebrile for most of stay.
1. ATRIAL FIBRILLATION: Rate controlled as blood pressure
tolerated with beta blocker, amiodarone, and digoxin.
1. C. DIFF. COLITIS: Continued Flagyl.
1. UPPER EXTREMITY DVT: Continued Coumadin. Hesitant to
heparinize in the setting of possible history of HIT.
1. MIXED ACID BASE DISORDER: With respiratory acidosis and
concomitant metabolic alkalosis either due to compensation
contraction alkalosis and benign prerenal azotemia
secondary to hypovolemia. Improved somewhat with IV fluid
hydration.
1. MEDULLARY BLEED: On [**2150-5-31**] the patient was noted to
have asymmetric pupils and decreased responsive. A STAT
head CT revealed medullary bleed with cervical cord and
possible pontine involvement. Neurology was consulted.
Anticoagulation was held, and she received FFP and
protamine. Neurosurgery did not have further
recommendations. She was given Decadron for possible edema
and appropriate blood pressure control. The family was
made aware, and after an extensive family meetings it was
decided to make the patient CMO.
DISCHARGE STATUS: She passed away comfortably on a morphine
drip on [**2150-6-2**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 48404**]
Dictated By:[**Doctor Last Name 54274**]
MEDQUIST36
D: [**2151-4-30**] 12:41:39
T: [**2151-4-30**] 14:36:26
Job#: [**Job Number 54275**]
ICD9 Codes: 431, 486, 4280, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2820
} | Medical Text: Admission Date: [**2142-5-7**] Discharge Date: [**2142-7-14**]
Date of Birth: [**2084-9-20**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Wound Dehiscence
Major Surgical or Invasive Procedure:
Exploratory Laparotomy
Repair with Mesh
VAC dressing
STSG
History of Present Illness:
This is a 57-year-old male with renal cell carcinoma metastatic
to the thoracic
spine. He also had several pulmonary nodules which are of
unclear significance. He previously had undergone left
nephrectomy and placement of metallic hardware in the back for
stabilization. The patient was maintained on a tyrosine kinase
inhibitor with potent antiangiogenic properties. I had first
encountered the patient in [**2141-10-26**] when he presented with
perforated diverticulitis. At that time, after a failed attempt
at conservative management, I had performed
a sigmoid colectomy with end-sigmoid colostomy. The patient
failed to heal either the stoma tunnel or his midline wound
completely. Presumably, this was due to his study drug which was
reinstituted after the surgery. Over a few months, I had
observed the gradual development of a small ventral hernia.
However, on the day of surgery, the patient presented to the
medical oncology clinic with acute enlargement of the hernia. I
evaluated him and felt that he was at risk for evisceration and
transferred him emergently to the [**Hospital3 **] [**Hospital Ward Name 517**]. After
arriving there, he ruptured the peritoneal investment overlying
the hernia and small bowel was observed to be present outside of
the abdomen. Therefore, he was taken to the operating room for
closure and exploration.
Past Medical History:
exlap, end colostomy c Hartmann's for perf'd sigmoid colon [**10-30**]
renal cell CA s/p L nephrectomy [**2139**]
h/o herpes zoster
T5 vertebrectomy secondary metastases
h/o nasal polyps
sp resect of benign R knee mass
Social History:
lives in [**Location (un) 538**] with wife
quit tobacco 1 yr ago, no EtOH
Family History:
NK
Physical Exam:
Gen: Obese male, apparent pain and discomfort, agitated.
CV: RRR, no M/R/G
Lungs: Rhonchi diffusely
Abd: obese with wound dihiscence, bowel protruding from wound.
Ext: mild pedal edema, + 2 pulses
Pertinent Results:
Cardiology Report ECG Study Date of [**2142-5-7**] 9:36:00 PM
Sinus tachycardia. Baseline artifact precludes adequate
interpretation. Left
anterior fascicular block. Right bundle-branch block. Compared
to the previous
tracing of [**2142-5-8**] the rate is increased. Otherwise, no
diagnostic interim
change.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
104 164 160 382/442.57 80 -78 55
CHEST (PORTABLE AP) [**2142-5-9**] 8:26 AM
CHEST (PORTABLE AP)
Reason: Please eval for cardiopulmonary process, compare to
prior CX
[**Hospital 93**] MEDICAL CONDITION:
57 yo male POD #2 s/p ex-lap and repair of bowel evisceration
transferred to ICU with respiratory distress.
REASON FOR THIS EXAMINATION:
Please eval for cardiopulmonary process, compare to prior CXR
[**5-8**]
INDICATION: Postop day two for repair of bowel evisceration,
respiratory distress.
COMPARISON: [**2142-5-8**].
UPRIGHT AP VIEW OF THE CHEST: Patient is status post posterior
thoracic spinal fusion with vertebral body cage device again
noted. Marked cardiomegaly is unchanged. The aorta is tortuous.
Pulmonary edema has nearly completely resolved. No focal
consolidation, pleural effusions, or pneumothorax is present.
Resection of several left-sided ribs is again demonstrated. New
right internal jugular central venous catheter tip is positioned
within the distal SVC.
IMPRESSION: Unchanged marked cardiomegaly with near complete
resolution of pulmonary edema.
CHEST (PORTABLE AP) [**2142-5-14**] 8:56 AM
CHEST (PORTABLE AP)
Reason: Eval for PNA
[**Hospital 93**] MEDICAL CONDITION:
57 yo male POD #2 s/p ex-lap and repair of bowel evisceration c
fever
REASON FOR THIS EXAMINATION:
Eval for PNA
HISTORY: Status post bowel repair with fever.
COMPARISON: [**2142-5-9**].
CHEST: AP semi-upright view. The right internal jugular central
venous catheter tip is in the superior vena cava. There is no
pneumothorax. Cardiac and mediastinal contours are unchanged.
There is no pulmonary edema. The lungs are clear. Spinal fusion
hardware and evidence of left upper rib resection is again
noted.
IMPRESSION: No evidence of pneumonia.
SCROTAL U.S. [**2142-5-17**] 5:36 PM
SCROTAL U.S.
Reason: Hydrocele? Prostatitis?
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with tender scrotal edema and +UTI
REASON FOR THIS EXAMINATION:
Hydrocele? Prostatitis?
INDICATION: 57 year male with scrotal tenderness.
There are no prior studies for comparison.
SCROTAL ULTRASOUND: The right testicle measures 2.9 x 3.4 x 3.7
cm. The left testicle measures 3.4 x 2.9 x 3.7 cm. The
echogenicity of the testicles is normal. Increased vascularity
is seen in a heterogeneous right epididymis. There is a
moderate-sized complex right hydrocele and pyocele cannot be
excluded. There is a small-to-moderate sized left hydrocele.
There is a small left epididymal head cyst.
IMPRESSION: Right-sided epididymitis with complex hydrocele. A
pyocele cannot be excluded.
CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST
Reason: History of renal cancer, now post-op with shortness of
breat
Field of view: 50 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with
REASON FOR THIS EXAMINATION:
History of renal cancer, now post-op with shortness of breath,
chest pain, and desaturation; is there a PE?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: History of renal cancer now postop shortness of
breath, question PE.
COMPARISON: [**2142-3-15**].
TECHNIQUE: MDCT non-contrast and contrast-enhanced axial CT
imaging of the chest with multiplanar reformats was performed.
In addition, contrast- enhanced CT axial imaging of the abdomen
and pelvis with multiplanar reformats was also performed.
CT CHEST WITH CONTRAST: Evaluation for pulmonary embolus is
limited secondary to respiratory motion. However, the main and
proximal pulmonary arteries enhance without filling defects. The
heart and other great vessels of the mediastinum are
unremarkable. Within the mediastinum are multiple new
pathologically enlarged lymph nodes, not present in [**2142-2-24**].
The largest is a precarinal node measuring 22 x15 mm. A 12-mm
subcarinal and multiple greater than 12-mm subcarinal nodes are
present as well as a 14-mm precarinal node. These are all new or
increased in size since priro scan. No pathologic axillary
adenopathy is identified. Bilateral enlarged hilar adenopathy is
also present and markedly increased from the interval. The
largest node is a left hilar node measuring 22 x 12 mm. There
has also been interval enlargement of a large spinal mass
encompassing multiple thoracic vertebrae. A vertebral fixation
hardware and a spinal canal stent is in place. Small bilateral
pleural effusions are unchanged. Lung windows demonstrate
several pulmonary nodules, increased in size, including a 7- mm
right lower lobe nodule, previously 3 mm. Note that the target
lesions do not reflect the progression of tumor as the left
upper lobe nodule (target 1) today measures 14 x 8 mm,
unchanged. Target lesion 2, a upper lobe nodule measures 12 x 12
mm, unchanged. Increased interstitial markings and engorged
pulmonary vessels.
CT ABDOMEN WITH CONTRAST: The liver enhances homogeneously. A
hypodense 15- mm cyst in the left lobe is unchanged. No
suspicious lesions are identified. A 15-mm soft tissue nodule in
the gallbladder is not apparent on the previous study. This is
of unclear etiology, possibly a metastasis. The pancreas,
spleen, stomach, and small bowel loops are within normal limits.
Target lesion #3, a left adrenal nodule, measures 34 x 30 mm,
increased since prior study here it measured 27 x 24 mm.
Multiple small retroperitoneal lymph nodes have also enlarged in
the interval. The patient is status post left nephrectomy. The
right kidney is normal. No free air or free fluid is present in
the abdomen.
CT PELVIS WITH CONTRAST: Contrast is present within the Hartmann
pouch. The bladder, seminal vesicles and prostate are normal. No
pathologic adenopathy is identified. No free fluid or free air
is present. Note is made of bilateral fat-containing inguinal
hernias.
BONE WINDOWS: Besides the large mass involving multiple
mid-to-upper thoracic vertebrae as described above, no new
suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
1. Limited study, but no evidence for pulmonary embolus.
2. Disease progression with multiple new enlarged mediastinal,
hilar nodes and and pulmonary nodules. Interval enlargement of
the thoracic spine mass and enlargement of the left adrenal
nodule and retroperitoneal nodes. The target lesions are
unchanged and do not reflect progression.
3. ? Mild CHF.
4. Unchanged small bilateral pleural effusions and associated
atelectasis.
A preliminary report was provided overnight to the resident
taking care of the study. "Limited study due to motion. No
saddle or main artery PE. Evaluation of segmental branch is
limited. Bilateral pleural effusions and atelectasis. M.
[**Doctor Last Name 24949**]."
MR HEAD W & W/O CONTRAST [**2142-6-13**] 10:15 AM
MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN
Reason: Altered mental status; non-specific head CT.
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with
REASON FOR THIS EXAMINATION:
Altered mental status; non-specific head CT.
MR HEAD
HISTORY: 57-year-old male with altered mental status,
nonspecific head CT.
TECHNIQUE: Multiplanar multisequence images of the brain were
obtained using the standard departmental protocol with
administration of gadolinium.
FINDINGS: Comparison is made to a head CT dated [**2142-6-12**].
There are no masses or mass effect. There are no areas of
abnormal enhancement.
There are scattered cerebral periventricular white matter T2
hyperintensities, which likely represent microangiopathic
changes.
There is enlargement of the ventricles, sulci, basal cisterns,
consistent with atrophy.
The cervicomedullary junction is normal. The major flow voids
are normal.
Minimal mucosal thickening of the ethmoid and sphenoid sinuses
are seen.
The visualized orbits are normal.
No focal bony abnormalities are seen.
CHEST (PORTABLE AP) [**2142-6-14**] 1:41 AM
CHEST (PORTABLE AP)
Reason: eval pna, effusion, edema
[**Hospital 93**] MEDICAL CONDITION:
57 yo male POD #2 s/p ex-lap and repair of bowel evisceration c
hypoxia
REASON FOR THIS EXAMINATION:
eval pna, effusion, edema
REASON FOR EXAMINATION: Followup of patient with pneumonia and
effusion after abdominal operation.
AP supine chest radiograph compared to the previous film from
[**2142-6-13**].
IMPRESSION:The moderate cardiomegaly and widened mediastinum are
stable. The enlargement of the pulmonary vessels is slightly
more pronounced than it was on the previous film representing
worsening of the pulmonary edema which is of mild degree. There
is new left lower lobe atelectasis involving most of the left
lower lobe. There is no pneumothorax or sizable pleural
effusion. The spinal fusion hardware is in unchanged position.
Cardiology Report ECHO Study Date of [**2142-6-14**]
PATIENT/TEST INFORMATION:
Indication: Congestive heart failure. Left ventricular function.
Height: (in) 72
Weight (lb): 255
BSA (m2): 2.36 m2
Status: Inpatient
Date/Time: [**2142-6-14**] at 13:31
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W026-1:26
Test Location: West SICU/CTIC/VICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: *4.1 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 250 msec
TR Gradient (+ RA = PASP): *27 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical
quality, a focal
LV wall motion abnormality cannot be fully excluded. Overall
normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - body habitus.
Conclusions:
1. 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%).
2. The aortic valve leaflets are mildly thickened.
3. The mitral valve leaflets are mildly thickened.
CHEST (PORTABLE AP) [**2142-6-17**] 5:50 AM
CHEST (PORTABLE AP)
Reason: eval edema
[**Hospital 93**] MEDICAL CONDITION:
57 yo male POD #2 s/p ex-lap and repair of bowel evisceration
s/p bronchoscopy [**6-14**] for mucus pluggin
REASON FOR THIS EXAMINATION:
eval edema
CLINICAL HISTORY: Status post laparotomy, postoperative day two.
CHEST: The heart remains enlarged and widening of the aorta is
again seen. Some upper zone redistribution is present suggesting
some mild failure, but it is not significantly changed since the
prior chest x-ray of [**6-16**]. The right effusion has resolved.
IMPRESSION: Mild failure is still present. Resolution of right
effusion.
CHEST (PORTABLE AP) [**2142-6-21**] 8:10 PM
CHEST (PORTABLE AP)
Reason: acute process
[**Hospital 93**] MEDICAL CONDITION:
57 yo male c ?CHF
REASON FOR THIS EXAMINATION:
acute process
57-year-old male with concern for CHF.
COMPARISON: [**2142-6-17**].
AP PORTABLE CHEST: The spinal fixation construct is unchanged.
There is stable mild cardiomegaly and mediastinal widening.
There are probable small bilateral pleural effusions. Patchy
bilateral airspace opacities are noted, which are slightly more
prominent compared to [**2142-6-17**].
IMPRESSION: Small bilateral pleural effusions. Patchy bilateral
airspace opacity likely represents mild congestive failure;
however, pneumonia cannot be entirely excluded.
RENAL U.S. [**2142-6-22**] 9:18 AM
RENAL U.S.
Reason: 57 year old man met renal cell CA now in acute renal
failure
[**Hospital 93**] MEDICAL CONDITION:
57 year old man met renal cell CA now in acute renal failure.
REASON FOR THIS EXAMINATION:
57 year old man met renal cell CA now in acute renal failure.
INDICATION: Patient with metastatic renal cell carcinoma now on
acute renal failure. History of left nephrectomy.
COMPARISON: CT of the abdomen and pelvis of [**2142-6-13**].
RENAL ULTRASOUND: The right kidney measures 12.7 cm. There is no
hydronephrosis, stone, or mass of the right kidney. The left
kidney is absent. The known left adrenal nodule could not be
visualized on this ultrasound examination. The bladder was
empty.
IMPRESSION: Unremarkable ultrasound appearance of the right
kidney.
CT ABDOMEN W/O CONTRAST [**2142-6-29**] 5:25 PM
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST
Reason: Please assess aggregate tumor burden.
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with metastatis renal cell carcinoma.
REASON FOR THIS EXAMINATION:
Please assess aggregate tumor burden.
CONTRAINDICATIONS for IV CONTRAST: Recent ATN
INDICATION: Renal cell carcinoma, please assess aggregate tumor
burden.
COMPARISON: [**2142-6-13**].
TECHNIQUE: Non-contrast axial CT imaging of the chest, abdomen
and pelvis with coronal and sagittal reformats was reviewed.
CT CHEST WITHOUT CONTRAST: There is a new patchy opacity in the
right upper lobe. Interstitial lines and engorged pulmonary
vessels indicate degree of pulmonary edema. Evaluation of the
lung windows is limited secondary to marked respiratory motion.
Moderate right pleural effusion has enlarged in the interval.
There is moderate associated right lower lobe atelectasis. There
is a small left pleural effusion. A peripheral fluid attenuation
nodularity of the left apex may represent a small amount of
loculated pleural fluid. This is incompletely evaluated, and
pleural-based tumor may need to be considered. This is
unchanged. Pathologic mediastinal and hilar adenopathy is
unchanged from [**2142-6-13**]. The pleural nodules previously
identified are less well characterized on today's study given
respiratory motion, effusions, and pulmonary edema. There is a
very small pericardial effusion.
There has been no interval change in the large spinal mass with
vertebral fusion rods and vertebral body metallic cage.
Evaluation of this mass is limited secondary to the hardware.
CT ABDOMEN WITHOUT CONTRAST: Hypodense lesion in the left lobe
of the liver is unchanged, possibly a cyst, but not fully
characterized on today's study. No suspicious lesions
identified. The gallbladder, pancreas, spleen, stomach, small
bowel loops are unchanged. Right kidney is unchanged with a
small amount of perinephric stranding. Adjacent to the lower
pole of the right kidney is a 1.6-cm fluid density nodule,
unchanged. There is no hydronephrosis. The right adrenal gland
is normal. Left adrenal mass is unchanged, measuring 3.4 x 3.0
cm. Multiple small but suspicious retroperitoneal adjacent nodes
are present, not markedly changed in the interval. There is no
free air or free fluid.
CT PELVIS WITH CONTRAST: Note is made of anterior wall defect
and stoma in the left lower quadrant. The Hartmann pouch
contains contrast. The bladder is decompressed about a Foley.
There are bilateral fat-containing inguinal hernias. No
pathologic adenopathy, free air, or free fluid is present in the
pelvis.
BONE WINDOWS: Besides the previously mentioned thoracic spinal
mass, no suspicious lesions are identified.
IMPRESSION:
1. Enlarging right moderate pleural effusion with associated
atelectasis. Small left pleural effusion, possibly loculated
with associated atelectasis.
2. New right upper lobe patchy opacity that represents atypical
edema versus pneumonia in the proper clinical setting. Engorged
pulmonary vessels and septal lines indicate mild pulmonary
edema.
3. No significant change in metastatic disease in the chest or
abdomen including pathologic mediastinal nodes, large thoracic
spinal mass, and left adrenal mass with adjacent adenopathy.
Brief Hospital Course:
The patient went to the OR emergently on [**2142-5-7**]. He had Vicryl
mesh in place and a wound VAC covering his abdomen. His stoma
was pink and functioning. He was instructed to remain on bed
rest for 7 days post-op.
He was hypertensive and tachycardic in the PACU. Acute Pain
Service was called and he was started on a Dilaudid PCA, with
good effect. He was ordered for Cefazolin and Flagyl.
#Respiratory
On POD 1, he had respiratory distress with a respiratory rate of
24 and brief apnea episodes. He appeared to have sleep apnea,
although there is nothing documented in his history for sleep
apnea. His fluids were decreased, nebulizers were ordered, an
ABG was 7.43/37/85/25/0. Labs were checked and CXR done. The
patient was transferred to the ICU for continued care of his
respiratory distress. He was stable in the ICU and the
respiratory issues was likely related to sleep apnea. He
returned to the floor on POD 2.
On POD 37 ([**2142-6-13**]) he was transferred to the ICU secondary to
respiratory distress. His pO2 was 56. He was intubated soon
after arriving to the ICU and had metabolic alkalosis. He
received 2 Units of PRBCs. A CT showed no evidence of a PE, a
CXR showed some CHF, and a MRI of his brain showed no acute
changes. He received Lasix with a good response. A bronchoscopy
was performed that showed increased secretions in the left
mainstem. He remained intubated for 3 days (extubated [**2142-6-17**]),
and was tolerating extubation. He continued to receive nebulizer
treatments and chest PT as tolerated. His respiratory status
continued to be tenuous. He received Lasix, with good response,
for increased SOB on [**2142-6-23**]. He received aggressive pulmonary
toilet for suspected pneumonia. Chest PT was difficult due to
the back pain.
#Code Status
DR. [**Last Name (STitle) 519**] met with the family on [**2142-6-14**] and [**2142-6-16**] to discuss
further care for this patient. He was made DNR at this time. A
family meeting with Dr. [**Name (NI) 519**], wife and son on [**2142-6-30**] resulted in
absolute DNR/DNI status and he was made "comfort measures only".
#Renal Consult
After several days of diuresis with Lasix, his creatinine was
rising (up to 4.2 on [**2142-6-23**]) and he was noted to have ARF. His
Vanco level was 26.1 on [**2142-6-19**]. His antibiotics and diuretics
were held. We monitored his fluid status closely and he received
several fluid boluses to increase his urine output.
A renal ultrasound was negative. He was thought likely to have
ATN as the etiology. He may intravascularly depleted secondary
to a low albumin.
His labs gradually improved and the creatinine slowly came down
and the Vanco level was 9.3 on [**2142-6-25**]. His urine output began
to improve. On [**2142-7-7**] his BUN was 27, and Cr was 1.4.
#Nutrition Consult
The patient was instructed on a Renal Diet and menu choices. He
and his wife were instructed to choose high protein, low sodium,
low potassium and low phosphate foods.
#Physical Therapy
Physical Therapy worked with him on a consistent basis. He
continued to be very deconditioned and functionally dependent
due to the prolonged bed rest and hospitalization. He was
Hoyered out of bed daily, received chest PT, and range of motion
exercises. Due to the abdominal wound, activity was limited to
ensure proper wound healing and decrease the risk of dehiscence.
The patient was intermittently confused at the beginning of his
hospitalization. His narcotics were D/C'd and the patient began
to clear. He was not complaining of pain.
His abdomen remained soft, with decreased bowel sounds. He was
on a regular diet. His ostomy was in place and the stoma pink.
He continue on bedrest until POD 7. He was then assisted to the
chair using the [**Doctor Last Name 2598**] lift and he was allowed to sit in a
wheelchair.
A air mattress was in place to help maintain skin integrity and
he wore pneumoboots for DVT prophylaxis.
[**2142-5-11**], POD 4, his VAC dressing was changed, some scant
granulation tissue was noted. The VAC dressing was again changed
on [**2142-5-14**] and [**2142-5-19**], with granulation tissue noted.
Subsequent VAC changes occurred on [**8-4**], [**6-1**] and every [**1-27**]
days thereafter.
On [**2142-6-21**] (POD 45) he went to the OR for a Skin graft split
thickness to the abdominal wound from the right thigh. The
abdominal wound had a VAC dressing in place; the thigh wound was
dressed.
On [**2142-6-29**] the VAC dressing was removed. The skin graft appeared
to be in excellent condition with nice, pink tissue forming.
Xeroform dressing and dry gauze was. His mental status continued
to wax and wane with periods of confusion as his hospitalization
continued.
#Pain Consult
He was complaining of increased pain ([**2142-6-19**]), especially to
his back. The Chronic Pain service recommended medication
adjustments and his pain was in much better control. He was
requiring more Morphine on HD 53 for increased pain. The Pain
service recommended increased fentanyl patch from to 200mcg/hr,
increased oxycontin to 40mg [**Hospital1 **].
# Urology
A urine culture on [**2142-5-14**] showed P. Aeruginosa and Gram
negative rods. He was started on Cipro. Urology was consulted
for scrotal swelling. An ultrasound revealed a right-sided
epididymitis with complex hydrocele. A repeat urine culture
showed E.coli resistant to Cipro. He was kept on Cipro for the
epididymitis and added Ampicillin for UTI. A post-void residual
was 15 cc. A urine culture on [**2142-5-26**] revealed Klebsiella
Pneumoniae, pan resistant. A urine culture on [**2142-5-29**], again
showed Klebsiella Pneumoniae. The Ampicillin was D/C'd.
#Heme
His platelet count went from 192 to a low of 66 and gradually
climbed up to the low 100's. His labs were watched closely and
his heparin products were held.
#Tachycardia
The patient was tachycardic in the low 100's with a BP of
130/80. One unit of PRBC was given for a HCT of 28.5. His HR
settled in the 80's.
#PALLIATIVE CARE
A plan was develped with the palliative care physician and his
oncologist Dr. [**Last Name (STitle) **]. It was thought that due to his poor
performance status and overall condition that resumed chemo
would have little benefits greater than burdens.
Medications on Admission:
Decadron 2', Darvocet, Fentanyl patch, sunitinib (=Sutent),
roxicet prn, ranitidine50", Zofran prn.
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
8. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
9. Morphine 10 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed.
10. Fentanyl 100 mcg/hr Patch 72HR Sig: Two (2) Patch 72HR
Transdermal Q48H (every 48 hours).
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Wound Dehiscence
Ventral Hernia Repair
Discharge Condition:
Poor
Code status: Do not resuscitate (DNR/DNI)
Comments: Family meeting with Dr. [**Name (NI) 519**], wife and son on [**2142-6-30**]
resulted in absolute DNR/DNI status
Corroborated with: [**Last Name (LF) **],[**First Name3 (LF) **] E. on [**2142-6-30**] at 1130
Discussed with: health care proxy
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered
Wound Care
Ostomy Care
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 519**] as needed for wound issues. Call
([**Telephone/Fax (1) 5323**] to schedule an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2142-7-13**]
ICD9 Codes: 5990, 5845, 2875, 486, 5119, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2821
} | Medical Text: Admission Date: [**2125-2-27**] Discharge Date: [**2125-3-2**]
Date of Birth: [**2068-7-24**] Sex: F
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: This is a 66 year-old female who
was recently admitted and discharged from [**Hospital1 346**] for fever, malaise and pleuritic
chest pain who was found to have a moderate pericardial
effusion on [**2-21**] that was stable on repeat echocardiogram
on [**2-23**]. The patient was discharged on [**2-25**] and had
a near syncopal episode while walking from bed to her
bathroom one day prior to admission. She saw her primary
care physician on the day of admission who referred her to
the Emergency Department for further workup. Bedside
echocardiogram in the Emergency Department at that time done
by the emergency physicians showed a large pericardial
effusion and upon cardiology consult was determined to have
RV diastolic collapse with a tamponade physiology. The
patient was taken to the catheterization laboratory
emergently and tamponade physiology was confirmed. A
percutaneous drain was placed and 600 cc of thin bloody fluid
was removed and the drain was left in place. Repeat
echocardiogram after drain placement showed only trace
effusion. The patient currently feels well. She denies any
travel, tuberculosis exposure, weight loss, fevers or chills,
gastrointestinal bleeding. She had a normal mammogram
approximately one year ago. She has never had a colonoscopy
before. She has had no recent change in her bowel habits.
No bloody stools or melena. Her last menstrual period was in
[**2115**] and she has had no vaginal bleeding or discharge since.
She is a nonsmoker. She has never worked with pipe fitting
or shipyards or construction. She was newly diagnosed
hypothyroid in [**2124-9-30**]. She states that she had a
thyroid ultrasound and was told she had cysts in her thyroid.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Gastroesophageal reflux disease.
3. Hypothyroidism.
4. Osteoarthritis.
MEDICATIONS:
1. Protonix 40 mg q.d.
2. Levoxyl 75 mg q.d.
3. Ibuprofen 400 mg q.i.d.
4. HCTZ 12.5 mg q.d.
5. Tylenol prn.
ALLERGIES: Sulfa, which causes her hives.
SOCIAL HISTORY: She runs a day care.
PHYSICAL EXAMINATION: Temperature 100.1. Heart rate 100 to
115. Blood pressure 100 to 136/40 to 60, satting 95% on room
air, breathing about 20 times a minute. No acute distress.
Very pleasant female. Examination status post tube placement
to drain pleural effusion. HEENT she has a mild right sided
ptosis, otherwise mucosa are moist in the throat and nares
are unremarkable. The neck has flat neck veins. There are
no bruits. Supple without any lymphadenopathy. Lungs are
clear to auscultation bilaterally. Heart examination is
regular rate, normal S1 and S2 without any murmurs. Abdomen
is soft, nontender, with normal bowel sounds. The
extremities have 1+ edema bilaterally that is nonpitting.
Neurological examination grossly intact.
LABORATORY: CBC is only remarkable for a slightly elevated
white blood cell count of 14.4 with 69% polys and 23%
lymphocytes. Unremarkable INR. TSH was 0.19, which is low.
Chem 7 is unremarkable. Chest x-ray revealed cardiomegaly
pretapping of effusion. Electrocardiogram was sinus tach of
100 with very low voltage and electrical alternans. After
drainage of effusion and sinus tach with better voltage and
normal axis and intervals.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for observation. She had no further symptoms. The
catheter was pulled and a repeat echocardiogram immediately
the same day of pulling revealed no accumulation of effusion.
She was monitored for another day while an etiology other
then viral was sought for the pericardial effusion. Her PPD
was negative. She has no symptoms of occult malignancy. A
CT of the chest, abdomen and pelvis was obtained, which was
negative for suspicion of malignancy. [**Doctor First Name **] titer was
negative. Rheumatoid factor was also negative. The 710 cc
of bloody fluid that came from the pericardial sac was
assessed for malignant cells by pathology, none were found.
The patient's thyroid medication was adjusted. She had
another repeat TTE prior to discharge two days after catheter
pull, which revealed only a trace amount of pericardial
effusion. At this point it was felt that she was stable for
discharge with close outpatient follow up by her primary care
physician as well as an outpatient colonoscopy in the future.
DISCHARGE DIAGNOSES:
1. Pericardial effusion with cardiac tamponade, due to
negative metastatic presumed secondary to viral etiology
prodromal symptoms and negative workup for rheumatologic,
tuberculosis, or malignancy.
2. Hypothyroidism. The patient is actually in a
hyperthyroid state. Medications adjusted appropriately. To
be followed by primary care physician.
3. Hypertension.
4. Osteoarthritis.
5. Gastroesophageal reflux disease.
DISCHARGE MEDICATIONS:
1. Tylenol one to two tabs po q 4 to 6 hours prn.
2. Levothyroxine 75 mcg tablets po q.d.
3. Protonix 40 mg po q.d.
4. HCTZ 12.5 mg po q.d.
5. Ibuprofen 400 mg po t.i.d. prn pain.
6. Norvasc 5 mg po q.d.
FOLLOW UP: She will follow up with her primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] within the next five days who
will arrange her repeat echocardiogram in the next week as
well as an outpatient colonoscopy and annual mammogram.
DISCHARGE CONDITION: The patient is discharged to home in
improved and stable condition status post pericardiocentesis.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D.12.988
Dictated By:[**Last Name (NamePattern1) 4791**]
MEDQUIST36
D: [**2125-4-2**] 08:29
T: [**2125-4-4**] 13:38
JOB#: [**Job Number 17259**]
ICD9 Codes: 5119, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2822
} | Medical Text: Admission Date: [**2157-5-1**] Discharge Date: [**2157-7-1**]
Date of Birth: [**2089-10-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
67M with fever and cough
Major Surgical or Invasive Procedure:
[**2157-6-1**] CABG x 4 (LAD, PDA, [**Last Name (LF) **], [**First Name3 (LF) **])
Cardiac cath
History of Present Illness:
Pt is a 67yo homeless man with pmh sig for "enlarged heart" who
presents to the ED by EMS complaining of fever/chills and
productive cough with progressively worsening SOB over the past
3-4 days.
Denies palp/n/v. Has had diaphoresis. No orthopnea/pnd.
In the [**Name (NI) **] pt had increased O2 requirements to 100% NRB, given
solumedrol, ceftriaxone, azithromycin. Given elevated cardiac
enzymes, EKG changes pt started on heparin drip.
Past Medical History:
?cardiomegaly
knee pain
Social History:
+smoker
former golf pro
homeless
+ former alcohol use - quit 7 yrs ago
no ivda
Family History:
unable to obtain
Physical Exam:
T 96.9 HR 98 BP 70/50
AC 500X18 Fio2 100% RR 20
GEN: using accessory muscles to breath, diaphoretic
NECK: JVD to mandible
CARD: Tachycardia, no mrg, no s3s4
LUNGS: b/l soft exp wheeze, no rales, decreased bs on left lower
lung field
ABD: soft nt nd nabs
EXT: cool, no edema
NEURO: AAO x 3, mae
rectal guiac neg
Pertinent Results:
[**2157-6-5**] 02:16AM BLOOD WBC-6.3 RBC-3.31* Hgb-10.1* Hct-28.9*
MCV-87 MCH-30.7 MCHC-35.1* RDW-16.4* Plt Ct-110*
[**2157-6-30**] 05:45AM BLOOD PT-11.0 PTT-23.8 INR(PT)-0.9
[**2157-6-30**] 05:45AM BLOOD Glucose-91 UreaN-17 Creat-0.8 Na-137
K-4.4 Cl-101 HCO3-25 AnGap-15
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2157-6-30**] 1:27 PM
CHEST (PA & LAT)
Reason: pleural effusion
[**Hospital 93**] MEDICAL CONDITION:
67 yo M s/p cabgx4, avr [**6-1**]
REASON FOR THIS EXAMINATION:
pleural effusion
REASON FOR THE STUDY: Assessment for pleural effusion in a
patient after CABG.
TECHNIQUE: PA and lateral views of the chest, and the study is
compared to the previous one done on [**2157-6-4**].
FINDINGS: Heart, mediastinal and hilar contours are normal.
Lungs are clear. There are no pleural effusions or pneumothorax.
Impression:Normal study. No evidence of pleural effusion.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Cardiology Report ECHO Study Date of [**2157-6-1**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for AVR/CABG
Height: (in) 67
Weight (lb): 145
BSA (m2): 1.77 m2
BP (mm Hg): 109/67
HR (bpm): 65
Status: Inpatient
Date/Time: [**2157-6-1**] at 11:20
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% (nl >=55%)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: 2.5 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: *3.0 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 36 mm Hg
Aortic Valve - LVOT Diam: 2.0 cm
Aortic Valve - Valve Area: *0.8 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thickness. Normal LV cavity size. Mild
global LV
hypokinesis. Mildly depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal
inferior -
hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo; basal anterolateral - hypo; mid anterolateral - hypo;
anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex -
hypo;
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Focal calcifications in aortic root. Focal calcifications
in ascending
aorta. Normal descending aorta diameter. Simple atheroma in
descending aorta.
Focal calcifications in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic
valve leaflets. Moderate AS. Mild to moderate ([**12-6**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
for the
patient.
Conclusions:
PRE-CPB No atrial septal defect is seen by 2D or color Doppler.
Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is
normal. There is mild global left ventricular hypokinesis.
Overall left
ventricular systolic function is mildly depressed. Right
ventricular systolic
function is borderline normal. There are simple atheroma in the
descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve
leaflets are severely thickened/deformed. There is moderate
aortic valve
stenosis. Mild to moderate ([**12-6**]+) aortic regurgitation is seen.
The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
POST-CPB Patient is receiving epinephrine by infusion. Normal
right
ventricular systolic function. Left ventricle with septal
"bounce" consistent
with ventricular pacing. Overall systolic function is slightly
improved from
pre-CPB. Bioprosthesis in aortic valve position is well seated
and displays
normal leaflet function. There is trace valvular AI. No other
changes from
pre-CPB.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD on [**2157-6-1**] 15:52.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 67910**])
Brief Hospital Course:
The pt. was admitted on [**2157-5-1**] to the MICU and intubated for
respiratory distress and profound acidosis. He was on Levophed
for hypotension and had bacteremia and sepsis. His pneumonia
was treated with Ceftriaxone and Azythromycin and was on Levo
for quite some time. He had an echo on admission which revealed
an EF of 55% and no wall motion abnormality. He eventually had
a NSTEMI and refused cardiac cath. He eventually agreed and
underwent cardiac cath on [**2157-5-13**] which revealed: 70%LM stenosis,
prox 80%LAD, 50% [**Date Range **] 1, 80% [**Date Range **] 2, 90% prox LCX, 100% L PDA,
mod. AS with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.9 cm2 and a peak gradient of 30mmHg,
and [**12-6**]+MR. Cardiac surgery was consulted and he needed to wait
for surgery until he was off Plavix for 5 days, and he had 2
teeth extracted.
On [**2157-6-1**] he had a CABGx4(LIMA->LAD, SVG->PDA, [**Date Range **], and
OM)/AVR w/ 23mm Magna Pericardial valve. The cross clamp time
was 136 mins. and total bypass time was 166 mins. He tolerated
the procedure well and was transferred to the CSRU on Epi,
Nitro, and Propofol. He was agitated and followed by psychiatry
who recommended Haldol. He was extubated on POD#1 and had his
chest tubes d/c'd on POD#3. His epicardial pacing wires were
d/c'd on POD#3 and he was weaned off Levophed. He was
transferred to the floor on POD#4 and continued to progress. He
remained in the hospital for the next 3 weeks to have his
sternum heal as he will be released to a homeless shelter and
will need to be completely independent. He completed an
application for the [**Location (un) 18437**] and will hopefully get a bed
and agree to live there in the next month. He was discharged in
POD#30 in stable condition.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
CAD
Pneumonia
Sepsis
NSTEMI
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No heavy lifting or driving.
Shower, No baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**First Name (STitle) **] (PCP at [**Name9 (PRE) 1268**] VA) 1-2 weeks
Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 [**Telephone/Fax (1) 58913**]
Completed by:[**2157-7-1**]
ICD9 Codes: 0389, 4254, 486, 2875, 2851, 3051, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2823
} | Medical Text: Admission Date: [**2188-11-21**] Discharge Date: [**2188-12-4**]
Date of Birth: [**2121-12-3**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a 66yo F PMHx Afib, HTN, DM, now off her medications for
8 weeks [**2-6**] inability to afford them, who initially presented to
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital with progressive shortness of breath,
found to be in atrial fibrillation with RVR complicated by
hypotension, now transferred to [**Hospital1 18**] for further management.
Patient reports that 8 weeks prior to current presentation, she
ran out of her medications, (which included digoxin, lisinopril,
carvedilol, diltiazem, lasix, coumadin) and was unable to afford
new medications. She reports that starting 2 weeks prior to
current admission, she developed intermittent shortness of
breath and palpitations. In the days preceeding her admission,
these episodes increased in frequency and severity, and were
also accompanied by subjective fevers and chills, without
headache, nausea, cough, pleuritic chest pain. At OSH, labs
significant for elevated lactate, leukcytosis; Patient
reportedly underwent bedside TTE demonstrating LVEF10%. Pt
received levofloxacin+zosyn and was transferred to [**Hospital1 18**] for
further management.
.
In the ED, initial vitals were 155 135/75 30. Patient was
loaded with amiodarone, given IV vancomycin and admitted to CCU
for further management. On arrival to CCU, patient was
dyspneic, but reported feeling comfortable and was without
complaint.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia
2. CARDIAC HISTORY:
- Atrial fibrillation
Social History:
Lives w Husband in [**Name2 (NI) 91157**], two grown-up children. Retired.
History of tobacco use, quit >10yrs ago, denies etoh, illicits
Family History:
Father with MI in 50s.
Physical Exam:
ADMISSION EXAM:
VS: 126 92/74 30 93% on 5L
GENERAL: Tachypnic, comfortable, appropriate
HEENT: NCAT, sclera anicteric, PERRL, OP clear
NECK: JVD to angle of the mandible
CARDIAC: Tachy w/o audible m/r/g.
LUNGS: Resp labored w acccessory muscle use, crackles throughout
no wheezes or rhonchi.
ABDOMEN: Soft, obese NT/ND
RECTAL: blood tinged stool
EXTREMITIES: Cool, blue-ish extremiteis
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
.
Discharge Exam:
VS: Tmax/current 98.3/96.6, HR 47-104 RR 18-24 BP 90-136/58-69
O2 sat 99% 2L
FS: 106/167/142
I/O 24H: 1600/2550
I/O 8H: 160/800
Weight: 107.9
.
Tele: Afib 70's-159 with activity
.
GENERAL: obese female sitting in chair, no tachypnea at rest but
tachycardia up to 159 with activity
HEENT: mucous membs moist, no lymphadenopathy, JVD at 10cm
CHEST: lung sounds clear but dim throughout
CV: irreg irreg, NL S1S2, no M/G/R
ABD: Obese, soft, nontender, non-distended, + BS. no
rebound/guarding.
EXT: 1+ DP/PT, 1+ pitting edema bilaterally up to ankle
NEURO: AOX3 & neurologically intact. Strength 4/5 adequate and
equal bilateral upper and lower extremities, sensation intact.
SKIN: Warm and dry, no rash, no open sores or abrasions. Right
and left great toes with cyanotic tips, right foot second toe
also has cyanosis. Per husband, these are improving. Bilateral
upper extremity ecchymosis from blood draws
PSYCH: Appears less depressed and fatigued today
Pertinent Results:
[**2188-11-21**] 08:45PM BLOOD WBC-24.2* RBC-4.56 Hgb-12.4 Hct-39.8
MCV-87 MCH-27.3 MCHC-31.3 RDW-16.1* Plt Ct-119*
.
[**2188-12-4**] 09:15AM BLOOD WBC-13.6* RBC-5.13 Hgb-12.9 Hct-43.8
MCV-85 MCH-25.1* MCHC-29.5* RDW-15.7* Plt Ct-357
.
[**2188-11-21**] 08:45PM BLOOD Neuts-88.8* Lymphs-7.5* Monos-3.3 Eos-0.1
Baso-0.3
.
[**2188-12-1**] 06:40AM BLOOD Neuts-84.4* Lymphs-10.3* Monos-3.9
Eos-1.1 Baso-0.1
.
[**2188-11-21**] 08:45PM BLOOD PT-30.9* PTT-38.4* INR(PT)-3.0*
.
[**2188-12-4**] 09:15AM BLOOD PT-39.4* INR(PT)-3.9*
.
[**2188-11-23**] 05:55AM BLOOD FDP-10-40*
.
[**2188-11-22**] 02:15PM BLOOD FDP-40-80*
.
[**2188-11-26**] 07:30AM BLOOD ESR-27*
.
[**2188-11-21**] 08:45PM BLOOD Glucose-180* UreaN-71* Creat-1.8* Na-127*
K-5.0 Cl-95* HCO3-14* AnGap-23*
.
[**2188-12-4**] 09:15AM BLOOD Glucose-182* UreaN-23* Creat-1.6* Na-132*
K-4.1 Cl-88* HCO3-32 AnGap-16
.
[**2188-11-22**] 04:41AM BLOOD ALT-794* AST-1023* CK(CPK)-270*
AlkPhos-242* TotBili-4.6*
.
[**2188-12-1**] 06:40AM BLOOD ALT-45* AST-26 LD(LDH)-248 AlkPhos-116*
TotBili-1.2
.
[**2188-11-22**] 04:41AM BLOOD CK-MB-8 cTropnT-0.01
[**2188-11-21**] 08:45PM BLOOD cTropnT-<0.01
.
[**2188-11-22**] 04:41AM BLOOD Calcium-9.2 Phos-6.4* Mg-2.4
.
[**2188-11-23**] 05:55AM BLOOD Hapto-78
[**2188-11-22**] 02:15PM BLOOD Hapto-64
.
[**2188-11-22**] 09:42PM BLOOD TSH-1.7
.
[**2188-11-26**] 07:30AM BLOOD CRP-78.1*
.
[**2188-12-4**] 09:15AM BLOOD Vanco-34.6*
.
[**2188-11-30**] 11:20AM BLOOD Digoxin-1.5
.
[**2188-11-22**] 01:52AM BLOOD Lactate-7.4*
[**2188-11-24**] 05:07AM BLOOD Lactate-1.7
.
[**2188-11-21**] CHEST (PORTABLE AP) - There is moderate cardiomegaly
and moderate vascular congestion. There is no pneumothorax and
no lung consolidation to suggest pneumonia.
.
[**2188-11-23**] CHEST (PORTABLE AP) - As compared to the previous
radiograph, there is no relevant change. Moderate cardiomegaly
with mild-to-moderate fluid overload. No newly appeared focal
parenchymal opacities, but pre-existing areas of predominantly
retrocardiac atelectasis persist. No evidence of pleural
effusions.
.
[**2188-11-25**] ART EXT (REST ONLY) - Doppler evaluation was performed
of both lower extremity arterial systems at rest. All waveforms
are triphasic bilaterally from the femoral to dorsalis pedis
artery. The right ABI is 1.3, on the left is 1.06. Pulsed volume
recordings are essentially normal.
.
[**2188-11-26**] MR HEAD W & W/O CONTRAS - No acute infarction. No foci
of abnormal enhancement in the brain parenchyma within the
limitations above. Correlate clinically to decide on the need
for further workup or followup. A small focus of enhancement is
noted in the left thalamus, curvilinear in shape and may relate
to vascular enhancement. Attention on close followup can be
considered to assess stability/progression. No definite
increased signal intensity is noted in this location on the
FLAIR sequence.
.
[**2188-11-29**] CT CHEST, ABD & PELVIS WITH CO - Bilateral segmental
pulmonary emboli which also involved the right main pulmonary
artery. Left greater than right bilateral pleural effusions.
Bilateral multifocal peripheral airspace opacities, which could
represent infection versus infarction.
.
[**2188-12-1**] ECHO - The left atrium is moderately dilated. No left
atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal with moderate to severe global hypokinesis (LVEF = 25
%). A moderate sized (1cm) mobile echodensity is seen in the
left ventricular apex most c/w a thrombus. The right ventricular
cavity is moderately dilated with moderate global free wall
hypokinesis. 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. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-6**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion. Left ventricular hypokinesis with
likely apical thrombus. Right ventricular cavity enlargement
with free wall hypokinesis. Moderate pulmonary artery
hypertension. Mild-moderate mitral regurgitation. Compared with
the prior study (images reviewed) of [**2178-11-23**], the apical left
ventricular thrombus is smaller (previously 1.6cm on review of
the prior study) and pulmonary artery hypertension is now
quantified.
Brief Hospital Course:
This is a 66 year-old Female with a history of Atrial
fibrillation, Hypertension, Diabetes mellitus type 2 who has
been off medications for months given financial concerns who
presented with shortness of breath found to have A.fib with
rapid ventricular response, hypoxia and tachypnea, and a
clinical picture concerning for cardiogenic shock.
.
# ACUTE SYSTOLIC CONGESTIVE HEART FAILURE - The patient
presented with 2-weeks of worsening CHF in the setting of
medication non-compliance with associated atrial fibrillation
from atrial stretch in the setting of volume overload, with
rapid ventricular response. Bedside 2D-Echo evaluation showed a
dilated right ventricule with hypokinesis and an LVEF of 20%.
Acute systolic failure was attributed to her tachymyopathy from
atrial fibrillation in the setting of her bilateral pulmonary
emboli. She had no history or EKG evidence to suggest ischemic
origins to her cardiac failure. She responded to aggressive
diuresis. Her CT scan showed bilateral pleural effusions which
responded to diuresis. She was discharged on a regimen including
a beta-blocker, spironolactone, digoxin and Torsemide 20 mg PO
daily (decreased from a higher dose given her creatinine
elevation), with a goal for diuresis of 0.5L daily. The patient
will need resumption of her ACEI when her creatinine stabilizes.
Of note, a repeat 2D-Echo on [**12-1**] showed a left ventricular
hypokinesis with likely apical thrombus. Right ventricular
cavity enlargement with free wall hypokinesis was noted.
Moderate pulmonary artery hypertension was also noted. She also
had mild-moderate mitral regurgitation. Compared with the prior
study (images reviewed) of [**2178-11-23**], the apical left
ventricular thrombus is smaller (previously 1.6cm on review of
the prior study) and pulmonary artery hypertension is now
quantified.
.
# ATRIAL FIBRILLATION - Initally rate controlled with Diltiazem
drip and digoxin on admission the CCU. She was then transitioned
to PO Metoprolol with good rate control at rest but HR in 120's
when pt is ambulating. Increasing nodal blockers has been
difficult because of up to 4 second pauses in the evening and at
night. As her PE and deconditioning improves, it is hoped that
her HR will moderate. She was initially anticoagulated with IV
heparin gtt and transitioned to warfarin. Her INR eventually
became supratherapeutic and we awaited PICC placement given her
INR was greater than 3. She will need PICC placement for
antibiotic duration once her INR is appropriate. Her
electrolytes were monitored and she was maintained on telemetry.
.
# LEFT VENTRICULAR THROMBUS - Of note, a repeat 2D-Echo on [**12-1**]
showed a left ventricular hypokinesis with likely apical
thrombus. Compared with the prior study (images reviewed) of
[**2178-11-23**], the apical left ventricular thrombus is smaller
(previously 1.6-cm on review of the prior study) and pulmonary
artery hypertension is now quantified. She remained
neurologically stable. She did have MR imaging of the brain on
[**11-26**] which showed no acute infarction. She had no foci of
abnormal enhancement in the brain parenchyma within the
limitations above. Overall her neurologic exam remained
reassuring. She will continue on anticoagulation as mentioned
above for atrial fibrillation, as well as for the atrial
thrombus.
.
# BILATERAL SUBSEGMENTAL PULMONARY EMBOLI - The patient was
initially admitted with hypoxia and tachypnea with response to
diuretics in the setting of a CHF exacerbation; a CT chest,
abdomen and pelvis on [**2188-11-29**] showed bilateral segmental
pulmonary emboli which also involved the right main pulmonary
artery. Left greater than right bilateral pleural effusions were
also noted. She was heparinized on admission and was maintained
on this until successful bridge to Coumadin dosing. Again, her
INR eventually became supratherapeutic and she required a
Coumadin hold. This will need to be resumed when her INR is
appropriate. A goal of [**2-7**] is ideal and she will need outpatient
monitoring. She will likely require 6 months of therapy.
.
# MULTIFOCAL AIRSPACE OPACIFICATION, PNEUMONIA - on [**2188-11-29**],
her CT imaging demonstrated bilateral multifocal peripheral
airspace opacities, which could represent infection versus
infarction per the radiology report. Given her hospitalization,
HCAP was suspected, although a CAP masked on admission by her
CHF exacerbation is certainly a possibility. She remained
afebrile with an improving leukocytosis (which was 24.2 on
admission, now 13.6 on discharge and trending downward) and she
remained afebrile. She will continue on a 14-day course of
Vancomycin and Zosyn for HCAP (healthcare associated pneumonia).
The Vancomycin will be extended further for reasons discussed
below.
.
# COAGULASE NEGATIVE STAPHYLOCOCCUS BACTEREMIA - the patient
presented with outside hospital blood cultures that were
positive for coagulase negative Staphylococcus, although
cultures remained negative while hospitalized here on subsequent
surveillance draws. She will continue on Vancomycin for a total
of 28-days per Infectious disease specialist consultation. Her
Vancomycin level on the day of discharge was elevated at 34.6
and this should be rechecked and her dose adjusted accordingly.
.
# GUAIAC POSITIVE STOOL - The patient was also noted to have
trace blood in the stool on exam earlier in her admission, but
she denied any melena or hematochezia prior to presentation. She
was monitored closely for further bleeding issues. She had no
further issues with melena or hemodynamic instability. Her
hematocrit remained stable.
.
# HYPERTENSION - The patient presented in cardiogenic shock and
her hypertension was more of a historical issue at that time.
Once she was euvolemic and diuresis was completed, her
beta-blocker and anti-aldosterone [**Doctor Last Name 360**] was reinitiated. Her
Torsemide was also started and titrated to appropriate dosing
given her creatinine. Her home ACEI was held given her renal
insufficiency and will need to be restarted. She should not be
restarted on her home [**Last Name (un) **].
.
# TRANSAMINITIS - the patient was noted to have a significant
transaminitis on admission with AST in the 800s and ALT in the
1000s attributed to cardiogenic hepatic congestion from volume
overload. She also demonstrated a hyperbilirubinemia which
improved with diuresis as well. Once she was adequately
diuresed, her LFTs improved. Her Pravastatin was held in the
this setting and should be restarted as an outpatient. Her home
fish oil was held and should be restarted at a later time.
.
# MEDICATION NON-COMPLIANCE - the patient was seen by Social
Work while admitted, who attempted to resolve her financial
issues surrounding non-compliance. The notes from social work
team are attached.
.
# HYPERLIPIDEMIA - Initially her Pravastatin was held given her
acute transaminitis in the setting of cardiogenic shock with
congestive hepatopathy; but this resolved and we resumed her
statin medication.
.
# PERIPHERAL TOE DISCOLORATION - Patient was noted to have
bluish hue and discoloration of her peripheral lower extremity
digits following her cardiogenic shock picture with poor distal
perfusion. Her serial pulse exam was monitored and was
reassuring; and she had no evidence of tissue necrosis or
infection. Continue to monitor as outpatient.
.
TRANSITION OF CARE ISSUES:
1. The patient will need resumption of her ACEI when her
creatinine stabilizes.
2. Torsemide dosing was decreased to 40 mg PO daily given renal
insufficiency and adequate diuresis. Monitor electrolytes
serially.
3. Vancomycin trough of 34.6 on discharge. Please hold dose and
resume medication for total duration following assessment of her
Vanc level. Please check Vanco trough tomorrow as Vancomycin
decreased to 750 mg [**Hospital1 **] today for vanco level 34.6.
4. Monitor daily weights.
5. Monitor for symptoms of fluid overload. Adjust diuresis
accordingly.
6. IV Vancomycin, last day will be [**2188-12-19**]. INR 3.9 this am so
PICC line not placed, can be done when INR < 3.0.
7. Please check INR, Chem-7, vanco level and LFT's tomorrow
[**12-5**].
8. Patient will need heparin drip if INR < 2.0 with pulmonary
emboli and AF/RVR.
9. Please wean off oxygen to keep O2 sats > 93%.
10. Please check chem-7, CBC and LFT's weekly while patient is
on IV antibiotics.
11. Will need Echocardiogram in about 4-6 weeks to check EF on
medical therapy.
12. Please titrate nodal blockers carefully as patient has had
pauses of up to 4 seconds on high dose beta-blockers.
Medications on Admission:
- lisinopril 10mg daily
- Calcium 600 +vitamin D daily
- Fish Oil (? dose) daily
- Digoxin 125mcg daily
- ASA 325mg daily
- Carvedilol 12.5mg [**Hospital1 **]
- Diltiazem 180mg daily
- Lasix 40mg daily (second pill if leg edema)
- Coumadin 2mg, was taking 3pills daily *as directed per INR
- KCl 20meq [**Hospital1 **]
- Metformin 1000mg [**Hospital1 **]
- Losartan 50mg daily
- Omeprazole 40mg daily
- Pravastatin 40mg daily
Discharge Medications:
1. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. vancomycin in D5W 1 gram/200 mL Piggyback Sig: Seven Hundred
Fifty (750) mg Intravenous Q 12H (Every 12 Hours) for 15 days:
Decreased from 1000mg on [**2188-12-4**]. Please check vanco level on
[**2188-12-5**]. Last day [**12-19**]. .
3. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
4. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 gram Intravenous Q8H (every 8 hours) for 10 days.
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical twice
a day as needed for fungal infection.
6. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day: Hold SBP <
100, HR < 55.
9. insulin lispro 100 unit/mL Solution Sig: 0-12 units
Subcutaneous four times a day: Please check fingersticks before
meals. .
10. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. pravastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Cardiogenic shock
Hypoxia
Atrial fibrillation
Hypertension
Dyslipidemia
Diabetes
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 taking care of you at [**Hospital1 18**].
You were admitted to the hospital in cardiogenic shock after
stopping all your medications for 8 weeks. This caused your
heart to weaken and fluid retention. It is extremely important
that you take all of your medicines as prescribed to avoid
coming back to the hospital.
Your heart function is very weak so we have restarted your heart
medications and added some other medications to help your heart
work better, you will need another echocardiogram in about a
month to see if your heart function has improved. We started a
medicine called torsemide to get rid of extra fluid. Your weight
at discharge is 236 pounds. You will need to weigh yourself
every day when you get home and call Dr. [**Last Name (STitle) 13310**] if your weight
increases more than 3 pounds in 1 day or 5 pounds in 3 days.
You developed an infection in your blood while you were in [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] Hospital. You were treated with an intravenous
antibiotic called vancomycin for this infection. You will need
to continue the Vancomycin for 15 more days.
At the same time, you appeared to have a pneumonia and was
started on another antibiotic called Zosyn, you will need 10
more days of this medicine. Blood clots were also found in your
lungs which is causing your shortness of breath and oxygen need.
The warfarin that you take for your atrial fibrillation will
also prevent these clots from getting worse and the clots will
slowly dissolve.
You had an MRI on [**2188-11-26**] for concern that you were not acting
like yourself. The MRI showed no acute changes and you seemed to
improve back to your baseline.
.
We made the following changes to your medicines:
1. Start taking vancomycin for the infection in your blood
2. Start taking Zosyn for your pneumonia
3. Continue warfarin for your atrial fibrillation and the clots
in your lungs. You will need this medicine indefinitely.
4. Change the carvedilol to metoprolol to slow your heart rate'
5. Take Torsemide instead of furosemide to remove extra fluid
6. STOP taking Metformin for now, you can restart this once your
kidney function is better
7. STOP taking lisinopril and losartan for now until your kidney
function improves. This medicine is important to help you heart
pump better.
8. STOP taking fish oil and ditiazem
9. Decrease aspirin to 81 mg daily
10. STOP taking potassium regularly for now
Followup Instructions:
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 12023**]
Phone: [**Telephone/Fax (1) 25076**]
Appt: [**12-25**] at 2:30pm
ICD9 Codes: 486, 2762, 4280, 4019, 2724, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2824
} | Medical Text: Admission Date: [**2113-6-26**] Discharge Date: [**2113-7-6**]
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Progressive exertional dyspnea.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 108767**] is an 85 year-old
gentleman with a history of severe aortic stenosis. His most
recent echocardiogram was performed on [**2113-4-7**], which
revealed symmetric left ventricular hypertrophy with an
ejection fraction of 60%. There was severe aortic stenosis
with a peak gradient of 82 mmHg, mean 55 mmHg and a valve
area of 0.6 cm squared. Mr. [**Known lastname 108767**] has noticed shortness
of breath with exertion that has progressed over the past six
to twelve months. His symptoms have worsened to the point
that he has difficulty walking down the [**Doctor Last Name **]. Mr. [**Known lastname 108767**]
was therefore evaluated by cardiac catheterization, which
revealed severe aortic stenosis and elevated filling
pressures. His LMCA was remarkable for osteal and distal 30%
stenoses, left anterior descending coronary artery 70% mid
stenosed after the mid diagonal. Left circumflex and right
coronary artery were remarkable for luminal irregularities.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Aortic stenosis
and mild MR. 3. Mild dementia. 4. Hypothyroidism. 5.
Benign prostatic hypertrophy. 6. Degenerative joint
disease. 7. Vitamin B-12 deficiency.
PAST SURGICAL HISTORY: None.
MEDICATIONS: Accupril 40 mg q day, Flomax 0.4 mg q day,
ascorbic acid 500 mg q day, vitamin E 400 IU q.d., calcium
carbonate one po b.i.d., Paxil 30 mg q.h.s., Levothyroxine 25
micrograms q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Mr. [**Known lastname 108767**] lives at the [**Hospital 24979**] [**Hospital **]
Nursing Home with his wife. [**Name (NI) **] is DNR/DNI.
PHYSICAL EXAMINATION: Heart rate 78. Blood pressure 112/70.
Head is normocephalic, atraumatic. Neck is supple with
bilateral systolic carotid bruits. Heart is regular rate and
rhythm. Systolic murmur. Lungs were clear to auscultation
bilaterally. Abdomen soft, nontender, nondistended with
normoactive bowel sounds. Extremities without clubbing,
cyanosis or edema.
HOSPITAL COURSE: Mr. [**Known lastname 108767**] was taken to the Operating
Room on [**6-28**] for coronary artery bypass graft times one
and aortic valve replacement. Coronary artery bypass grafts
included a left internal mammary coronary artery to left
anterior descending coronary artery. Aortic valve was
replaced with a 21 mm CERS pericardial valve. The operation
was performed without complications. Mr. [**Known lastname 108767**] was
subsequently transferred to the Cardiac Surgical Intensive
Care Unit. On the evening of the surgery Mr. [**Known lastname 108767**] was
found to have a systolic blood pressure in the 40s and no
pulse could be found. This event was found to be due to lack
of pacemaker capture. Mr. [**Known lastname 108767**] was reintubated and
mechanically ventilated. The pacemaker began to recapture
spontaneously with good effect on his heart rate and blood
pressure. Mr. [**Known lastname 108767**] also had some atrial fibrillation in
the days following surgery, which were controlled with
intravenous medications. Because Mr. [**Known lastname 108767**] remained
dependent on external pacemaker post surgically he was
evaluated by EP who placed an electronic internal pacemaker.
Mr. [**Known lastname 108767**] [**Last Name (Titles) 8337**] this well and his heart rate and
blood pressure have remained stable since. Mr. [**Known lastname 108767**] was
then transferred to the floor on postoperative day six.
His stay on the floor was remarkable for some drainage from
the inferior edge of his wound. His incision was dressed and
changed accordingly. Clindamycin was started and will be
continued for a two week course. On postoperative day eight
Mr. [**Known lastname 108767**] is felt to be stable for transfer back to his
nursing home.
PHYSICAL EXAMINATION ON DISCHARGE: Temperature 99.4. Pulse
86. Blood pressure 130/84. Respirations 18. O2 sat 91% on
room air. His heart is regular rate and rhythm. Lungs were
clear to auscultation bilaterally. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities were remarkable for trace edema. His incision is
dressed, but is dry, clean and intact.
DISCHARGE MEDICATIONS: Levothyroxine 25 micrograms q day,
Paxil 30 mg q day, calcium carbonate 1000 mg b.i.d., Ascorbic
acid 500 mg q.d., Tamsulosin 0.4 mg q.h.s, Ipratropium
bromide two puffs IH q.i.d. prn, Docusate 100 mg po b.i.d.,
Aspirin 325 mg q.d., Captopril 50 mg t.i.d., Clindamycin 300
mg q 6 hours times two weeks. Ibuprofen 600 mg q 8 hours
prn. Tylenol 500 to 1000 mg q 4 to 6 hours prn, multi
vitamin one tab q day, Lasix 20 mg q.d. times three days.
K-Ciel 20 milliequivalents q day times three days.
FO[**Last Name (STitle) 996**]P: Mr. [**Known lastname 108767**] should follow up with Dr. [**Last Name (Prefixes) 411**] in four weeks. He should follow up with Dr. [**Last Name (STitle) 1016**] in
three to four weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Mr. [**Known lastname 108767**] is to be discharged to a
nursing home.
DISCHARGE DIAGNOSIS:
Status post aortic valve replacement and coronary artery
bypass graft times one.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (un) 108768**]
MEDQUIST36
D: [**2113-7-6**] 07:54
T: [**2113-7-6**] 08:54
JOB#: [**Job Number 108769**]
ICD9 Codes: 4241, 4280, 9971, 4019, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2825
} | Medical Text: Admission Date: [**2181-9-4**] Discharge Date: [**2181-9-10**]
Date of Birth: [**2111-9-9**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69 year old women with dyspnea on exertion and leg swelling x1
week. The pt has a history of COPD and is at home baseline at
2L. The pt reports that for the past week she's been having
increasing shortness of breath particularly when walking, using
3 pillows at night to sleep and could not sleep laying flat, and
that her legs have been swelling up bilaterally. The pt
reported the ED at [**Hospital1 **] where she was evaluated, and had
a CXR that showed "mild pulmonary edema", she had an elevated
BNP of 1400, and one negative troponin while there, with an ECG
NSR 95 NANI, no STTWc, but no comparison. The pt was diuresed
1300ml there with IV Lasix 40, and was given SoluMedrol, and
then transferred to [**Hospital1 18**] due to full capacity there. The
working diagnosis of her admission was COPD exacerbation versus
new onset CHF. The pt endorsed headaches for the past week as
well. The pt reportedly did not endorse fever or chills, nausea
or vomiting, productive cough, chest pain, rhinorrhea,
congestion, sore throat, diarrhea, constipation, BRBPR, melena,
dysuria or hematuria.
Past Medical History:
COPD, on home O2 (2L at baseline)
Anxiety
Chronic musculoskeletal pain
Social History:
Lives in [**Location 1411**] with daughter [**Name (NI) 803**], daughter [**Name (NI) **] lives next
door. Retired worker from WGBF station.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
Vitals: p79 100/61, r16
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: with crackles diffusely
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace pitting edema
bilaterally
On DISCHARGE:
T 97.2 BP 114/56 HR 82 RR 18 O2Sat 97% on 2L NC
Lungs with some crackles remaining diffusely, particularly at
lower bases
no pedal edema
Pertinent Results:
[**2181-9-4**] 01:00AM BLOOD WBC-11.6* RBC-4.90 Hgb-10.4* Hct-35.7*
MCV-73* MCH-21.1* MCHC-29.0* RDW-16.6* Plt Ct-303
[**2181-9-10**] 06:40AM BLOOD WBC-8.3 RBC-4.37 Hgb-9.2* Hct-34.0*
MCV-78*# MCH-21.0* MCHC-27.0* RDW-17.8* Plt Ct-298
[**2181-9-4**] 01:00AM BLOOD Neuts-95.6* Lymphs-3.6* Monos-0.6*
Eos-0.1 Baso-0.1
[**2181-9-4**] 01:00AM BLOOD PT-14.3* PTT-26.4 INR(PT)-1.2*
[**2181-9-4**] 01:00AM BLOOD Glucose-138* UreaN-16 Creat-0.7 Na-136
K-4.2 Cl-93* HCO3-38* AnGap-9
[**2181-9-10**] 06:40AM BLOOD Glucose-83 UreaN-12 Creat-0.7 Na-140
K-3.7 Cl-96 HCO3-37* AnGap-11
[**2181-9-4**] 05:55AM BLOOD CK(CPK)-26*
[**2181-9-5**] 03:48AM BLOOD ALT-14 AST-15 CK(CPK)-22* AlkPhos-88
Amylase-20 TotBili-0.3
[**2181-9-5**] 03:48AM BLOOD CK(CPK)-23*
[**2181-9-4**] 01:00AM BLOOD cTropnT-<0.01
[**2181-9-4**] 05:55AM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-9-5**] 03:48AM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-9-5**] 03:48AM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-9-5**] 11:50AM BLOOD cTropnT-<0.01
[**2181-9-6**] 03:34AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0
[**2181-9-10**] 06:40AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.3
[**2181-9-4**] 12:20PM BLOOD Calcium-8.5 Phos-3.3 Mg-2.3 Iron-21*
[**2181-9-4**] 12:20PM BLOOD calTIBC-502* Ferritn-4.2* TRF-386*
[**2181-9-4**] 12:20PM BLOOD TSH-1.5
[**2181-9-5**] 04:02AM BLOOD Type-ART pO2-118* pCO2-174* pH-7.11*
calTCO2-59* Base XS-17 Intubat-NOT INTUBA
[**2181-9-5**] 04:54AM BLOOD Type-ART Temp-36.8 Tidal V-500 PEEP-5
pO2-448* pCO2-81* pH-7.36 calTCO2-48* Base XS-16
Intubat-INTUBATED Vent-CONTROLLED
[**2181-9-5**] 12:06PM BLOOD Type-ART Rates-10/0 Tidal V-500 PEEP-5
FiO2-30 pO2-185* pCO2-76* pH-7.37 calTCO2-46* Base XS-14
Intubat-INTUBATED Vent-CONTROLLED
[**2181-9-6**] 01:02PM BLOOD Type-ART pO2-63* pCO2-76* pH-7.38
calTCO2-47* Base XS-15 Intubat-NOT INTUBA
[**2181-9-5**] 04:06AM BLOOD Lactate-0.7
[**2181-9-5**] 08:03AM BLOOD Lactate-1.0
[**2181-9-5**] 12:06PM BLOOD Lactate-0.8
[**2181-9-5**] 04:06AM BLOOD freeCa-1.13
[**2181-9-5**] 08:03AM BLOOD freeCa-1.04*
[**2181-9-5**] 12:06PM BLOOD freeCa-1.19
[**2181-9-5**] 12:04PM BLOOD O2 Sat-75
STUDIES:
CXR
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Assess ET tube.
CXXR [**2181-9-5**]
ET tube tip is in the right main bronchus, should be pulled back
4-5 cm to
standard position. NG tube tip is out of view below the
diaphragm. Cardiac
size is top normal. There is no evident pneumothorax or pleural
effusion.
The patient has known COPD. Mild right apical thickening is of
unknown
chronicity. Right lower lobe opacity is new could be due to
atelectasis, but aspiration cannot be excluded and attention in
followup study is recommended
CXR 9/29/1
FINDINGS: Removal of right internal jugular vascular catheter
with no visible pneumothorax. Standard position of endotracheal
tube, nasogastric tube terminates in the stomach. Heart size
remains normal. No focal areas of consolidation are evident
within the lungs. Mild elevation of left
hemidiaphragm is unchanged.
Brief Hospital Course:
Pt is a 69 y/o woman with PMHx significant for COPD requiring 2L
oxygen at home and anxiety presenting with COPD exacerbation and
?mild CHF.
COPD/Hypercapneic Respiratory Failure: Pt found to have FEV1 of
19%, putting her in the very severe staging of Gold's criteria
and was gently diuresed. Pt was started on azithromycin 500 mg
X1 and then 250 mg daily. On hospital day #1 she became
increasingly somnolent and found to have a PCO2 of 179. She was
transferred to the ICU. Unclear etiology of patients respiratory
failure. Potential etiology included ativan use in the setting
of COPD, however this was an extremely small dose and the
patient had been taking it routinely in the evening at home.
Recent respiratory infection as a trigger could not be ruled
out. Cardiac cause has also been entertained, but pt had
negative troponin X3 and no EKG changes suggestive of STEMI.
Additionally her TTE was normal. Infectious workup has been
negative. Pt was intubated upon transfer to MICU. Her
antiobiotcs and steroids were continued. Pt was successfully
extubated on 2nd day of MICU. She continued to maintain good O2
sats on floor.
Prednisone was started at 40 mg, with a plan to taper 10 mg
every 2 days. Pt was also treated with albuterol and
ipratropium neb. After return to the floor
salmeterol-fluticasone was initiated. Pt needs a pulmonologist,
has never previously seen one. We scheduled an appointment for
her in the [**Hospital 2182**] clinic here at [**Hospital1 18**]. She will be discharged and
go to outpatient pulmonary rehab.
#. Altered Mental Status: Initially on the floor pt was very
stable, with no trouble breathing or complaints otherwise.
Laughing and conversing with the team. That evening, there was
concerned for her behavior. The team reported that she was
acting "normal" when she was admitted but became increasingly
more confused. The floor team did not report that the pt was
aphasic or had clear neurological deficit with any laterality or
focality, but was somnolent appearing. ABG done on the pt on
the floor showed pCO2 of 179, and in the setting of her
worsening mental status and increased work of breathing, a
trigger was called and the pt intubated on the floor then
transfered to the unit. On arrival to the MICU the pt was
comfortably sedated, hemodynamically stable. Hypercarbia or
hypoxia seem like a reasonable diagnoses. Her mental status
resolved upon the resolution of hypercarbia and extubation. Pt
did not exhibit any signs or symptoms of worsening
hypoxia/hypercapnia when she returned to the floor.
##UTI- Patient had a urinalysis with trace leukocytes, 35 WBC
and few bacteria performed yesterday, UCx pending. Patient has
no complaints of urinary urgency/frequency or dysuria but had a
foley in place during MICU stay.Pt started on cipro for UA
showing whites and bacteria and leukesterase, but culture came
back with ~[**2169**] units and cipro was DCd due to this minimal
bacterial burden.
#. Borderline Iron Deficiency Anemia: We started PO iron after
pt came out of the MICU. There is concern for GI
malignancy/other pathology in a postmenopausal woman with such
significant level of Fe deficiency (ferritin was 4). we would
suggest increasing her iron dosing further to TID on discharge,
now limited by constipation. She will likely need to have a
virtual colonoscopy as it would be ill-advised for her to
undergo the amount of sedation required for a colonoscopy.
#.Home 02 - pt has difficulty wearing home O2 at night due to
loud noise of machine. We have contact[**Name (NI) **] the company to assess
this.
#. Anxiety: This is not an active issue insofar as she normally
takes lorazepam 0.5mg [**Hospital1 **]. We discontinued this medication.
#. Chronic MSK Pain: at baseline.
Pt was maintained as full code during the entire
hospitalization.
TRANSITIONAL ISSUES:
Iron deficiency anemia - pt needs to have colonoscopy, likely
needs virtual as her respiratory issues make it so she would
have difficulty tolerating sedation.
Medications on Admission:
Lorazepam 0.25mg [**Hospital1 **] (discontinued on evening of transfer)
Zofran 4mg IV x1
Senna daily
Colace 100mg [**Hospital1 **]
Lasix 40mg IV x1
Acetaminophen 325-650 mg Q6H prn pain/fever
Abuterol 0.083% nebs Q4H prn SOB
Ipratropium Bromide nebs Q6H prn SOB
ASA 81mg daily
Tiotropium Bromide 1 CAP inhaled daily
Heparin SC 5000 units TID
Discharge Medications:
1. services
Patient needs hospital bed. Diagnosis: COPD and CHF. Patient has
to sleep with bed elevated.
2. pulmonary rehabilitation
Outpatient pulmonary rehabilitation
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*30 * Refills:*2*
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
Disp:*QS * Refills:*0*
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
Disp:*30 * Refills:*0*
7. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*QS * Refills:*0*
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*QS Disk with Device(s)* Refills:*0*
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. prednisone 10 mg Tablet Sig: follow taper directions Tablet
PO once a day for 16 days: - [**9-11**] - 8: 30 mg (3 tabs of 10
mg) daily
- [**9-16**] - 12: 20 mg (2 tabs of 10 mg) daily
- [**9-20**] - 16: 10 mg (1 tab of 10 mg) daily
.
Disp:*30 Tablet(s)* Refills:*0*
11. simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO twice a day as needed for gas.
Disp:*40 Tablet, Chewable(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
no services
Discharge Diagnosis:
PRIMARY:
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your
hospitalization. You came in with shortness of breath, and your
difficulty breathing progressed to the point where you were not
responsive, so you were intubated and taken to the ICU. We
treated you for a COPD exacerbation with steroids and
antibiotics, and your breathing improved so you came back to the
floor, where you continued to improve. Also, we found that you
have very low iron in your blood and low red blood cell count.
This could represent blood loss from the GI tract, so it is
important to discuss this with your primary care doctor and
possibly see a gastroenterologist.
Please make the following changes to your medications:
1. STARTED prednisone:
- [**9-11**] - 8: 30 mg (3 tabs of 10 mg) daily
- [**9-16**] - 12: 20 mg (2 tabs of 10 mg) daily
- [**9-20**] - 16: 10 mg (1 tab of 10 mg) daily
2. STARTED advair inhaler 1 inh [**Hospital1 **]. Please use this every day.
3. STARTED simethicone for gas pain. You can take this up to 4
times a day as needed for gas pain
4. STARTED docusate twice a day as needed for constipation.
5. STARTED iron (ferrous sulfate) twice daily for your anemia.
Inhalers:
1. CONTINUED your home tiotropium.
2. ADDED albuterol inhaler every 6 hours as needed for shortness
of breath or wheezing
3. STARTED albuterol nebulizer treatment every 6 hours for
shortness of breath or wheezing
4. STARTED ipratropium nebulizer treatment every 6 hours for
shortness of breath or wheezing
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2181-9-12**] at 10:10 AM
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: WEDNESDAY [**2181-9-12**] at 10:30 AM
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2181-9-12**] at 10:30 AM
With: DR. [**Last Name (STitle) 91**] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name:[**First Name8 (NamePattern2) 8826**] [**First Name8 (NamePattern2) 19115**] [**Last Name (NamePattern1) **],MD
Specialty: Primary Care
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**] CENTER
Address: [**Street Address(2) 3861**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 3858**]
When: Friday, [**9-14**] at 10:15am
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2826
} | Medical Text: Admission Date: [**2110-9-17**] Discharge Date: [**2110-9-20**]
Date of Birth: [**2110-9-17**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**First Name4 (NamePattern1) **] [**Known lastname 5395**] was born at 36-1/7
weeks gestation to a 34-year-old gravida 2, para 0, now 1
woman. Prenatal screens are blood type B positive, antibody
negative, Rubella immune, RPR nonreactive, hepatitis surface
antigen negative and Group B Strep. positive. This pregnancy
was complicated by increased liver function tests prompting
an induction of labor. The labor failed to progress and so
the infant was delivered by cesarean section. Rupture of
membranes occurred at delivery. There were no sepsis risk
factors. Apgars were 8 and 1 minute and 8 at 5 minutes.
The birth weight was 3,160 g. The birth length was 47 cm and
the birth head circumference was 35.5 cm.
PHYSICAL EXAMINATION: Admission physical examination reveals
a vigorous non-dysmorphic preterm infant. The anterior
fontanelle is soft and flat. Palate is intact. Neck and mouth
are normal, mild nasal flaring, red reflex deferred. Chest
with mild intercostal retractions, good breath sounds
bilaterally, no crackles. Heart with regular rate and rhythm,
no murmur. Femoral pulses are present. Abdomen is soft,
nontender and nondistended, no organomegaly, bowel sounds
active, patent anus. There was a 3-vessel umbilical cord,
normal female genitalia and age-appropriate tone and
reflexes.
NEONATAL INTENSIVE CARE UNIT COURSE BY SYSTEMS: Respiratory:
[**Doctor First Name **] required nasal cannula oxygen for the 1st 12 hours of
life when she weaned to room air where she has remained with
comfortable respirations. Lungs sounds are clear and equal.
She has had no apnea, bradycardia or desaturation. An
arterial blood gas soon after admission was pH of 7.29, pCO2
of 49, pO2 of 53, bicarbonate 25 and base deficit of -3. On
exam, her respirations are comfortable, lung sounds clear and
equal.
Cardiovascular Status: She has remained normotensive
throughout her NICU stay. She has a heart with regular rate
and rhythm, no murmur. She is pink and well-perfused.
Fluids, Electrolytes and Nutrition Status: Her weight at the
time of transfer is 2,995 g. Enteral feeds were begun on day
of life #1 and advanced to full feedings on day of life #2.
At the time of transfer, she is eating 20 calorie per ounce
Enfamil on an ad lib schedule, taking approximately 60
ml/kg/day. She has remained euglycemic during her NICU stay.
Her set of electrolytes at 24 hours of age was a sodium of
141, potassium 6.2, a hemolyzed specimen, and chloride 112.
Gastrointestinal Status: Bilirubin at 24 hours of life was
total 4.9, direct 0.2. Bilirubin on day of life #3 was total
of 8.5, direct 0.2. There are no gastrointestinal issues.
Hematology: She has received no blood product transfusions
during her NICU stay. Her hematocrit on admission was 42.5
and platelet count of 262,000.
Infectious Disease Status: She was started on ampicillin and
gentamicin at the time of admission for sepsis risk factors.
On admission, her white count was 11.8 with a differential of
29 polys and 2 bands. Antibiotics were discontinued after 48
hours when the infant was clinically well and blood cultures
remained negative.
Sensory: Hearing screening has not yet been performed and is
recommended prior to discharge.
Psychosocial: The parents have been very involved in the
infant's care throughout her NICU stay.
CONDITION ON DISCHARGE: The infant is discharged in good
condition. She is discharged to the newborn nursery.
PEDIATRICIAN: Primary pediatric care will be provided by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Pediatric Associates of [**Hospital1 1474**].
RECOMMENDATIONS AFTER DISCHARGE: Feedings: Every 3-4 hours
with a maximum interval of 4 hours of Enfamil 20.
She is discharged on no medications.
A car seat position screening test should be completed prior
to discharge.
A state newborn screen was sent on [**2110-9-20**].
She has received no immunizations prior to transfer.
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following 3
criteria - i) born at less than 32 weeks; ii) born between
32 and 35 weeks with 2 of the following - day care during
RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; or
iii) with chronic lung disease.
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.
DISCHARGE DIAGNOSES:
1. Prematurity at 36-1/7 weeks gestation.
2. Status post transitional respiratory distress.
3. Sepsis ruled out.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2110-9-20**] 02:51:02
T: [**2110-9-20**] 07:45:36
Job#: [**Job Number 63523**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2827
} | Medical Text: Admission Date: [**2204-12-13**] Discharge Date: [**2204-12-14**]
Date of Birth: [**2125-2-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**12-13**] intubation
[**12-13**] left femoral CVL
[**12-13**] left subclavian CVL
[**12-14**] arterial line
History of Present Illness:
Mr. [**Known lastname 26812**] is a 79 year old man with a history of metastatic
non-small cell lung cancer who presented to the ER today with
dyspnea for the past 2 days. He had recently undergone
thoracentesis on [**2204-11-29**] with 700 cc of fluid drained. He has
been on Bactrim for treatement of Moraxella found on BAL culture
on [**2204-11-29**].
In the emergency department, initial vitals: 97.7 88 132/52 28
90% 4L NC. US and CXR showed a large left-sided pleural
effusion. He was seen by IP who performed a thoracentesis at
the bedside which drained 2L of bloody fluid.
Post-thoracentesis CXR showed persistent collapse of left
hemithorax. He was treated emperically with Levofloxacin for
concern for infection. He was then admitted to the oncology
floor.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- known left lung pulmonary nodule since [**2199**], followed with
serial imaging.
- [**2204-11-8**] developed dyspnea with exertion, dry cough,
left sided chest discomfort and fatigue
- [**2204-11-4**]: imaging showed left-sided pulmonary mass,
mediastinal/hilar adenopathy, left pleural effusion and
impending left airway obstrcution
- [**Date range (3) 33359**]: admitted to [**Hospital1 18**] for evalution, CT
[**2204-11-29**] showed complete obstruction of the left upper lobe with
post obstructive upper lobe collpase with small to moderate left
pleural effuison, paraesophageal lymph node, mulitple
prevascular lymph nodes and aortopulmonary lymph nodes. There
was also a lytic lesion in the lateral aspect of the left 6th
rib and focal lucent area in the right T11 vertebra.
- [**2204-11-29**]: bronchoscopy and thoracentesis with 700 ccs of
ser-sanguinous fluid. The pleural fluid, lymph nodes stations
7, 4R, 4L and 11 showed adenocarchioma
post-obstructive pneumonia with Moraxella catarrhalis. He was
treated with supplemental oxygen and antibiotics (levofloxacin -
to complete the course within the next few days). Tumor cells on
pleural effusion cell block S11-[**Numeric Identifier 33360**] were positive for [**Last Name (un) **] 31,
B72.3 and CK7, and negative for CD68, TTF-1, p63, WT-1 and
calretinin.
- [**2204-12-7**]: PET scan showed FDG avid large left hilar tumor
causing compression of the left upper lobe bronchus with LUL
collapse, extensive FDG avid mediastinal adenopathy a loculated
moderate left pleural effusion and extensive FDG avid osseous
metastasis.
- [**2204-12-7**]: MRI Brain negative for brain mets
PAST MEDICAL HISTORY:
Hypertension
Hypercholesterolemia
CAD s/p CABG [**2192**], depressed EF per report
CKD with creatinine > 1.5
Nephrolithiasis [**2203**]
Hernia Repair
Social History:
Lives in [**Location (un) 5089**] with wife; previously in [**Location (un) **]. He
worked as a maintenance worker in various roles.Quit smoking at
age 42. Started smoking at age 12 and smoked 1 and [**12-10**] pack-per
day until age 42. This places him at an
approximate 45-pack-year history of smoking. The patient denies
chronic alcohol use/abuse. The patient denies significant
exposures to asbestos or chemicals in prior work. No exposure to
radiation.
Family History:
The patient's father died from unknown causes.
Mother died from sepsis (toxemia). There is no other history of
cancer in the family.
Physical Exam:
VS T97.1 BP 110/70 HR 85 RR20 92% on 4L
GENERAL: alert and oriented, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: Decreased breath sounds on the left. Thoracentesis drain
in place with bloody fluid draining.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses
Pertinent Results:
LABS:
On admission:
[**2204-12-13**] 09:25AM BLOOD WBC-16.7* RBC-3.79* Hgb-10.7* Hct-32.0*
MCV-85 MCH-28.3 MCHC-33.5 RDW-13.8 Plt Ct-302
[**2204-12-13**] 09:25AM BLOOD Neuts-78.3* Lymphs-16.0* Monos-4.3
Eos-0.9 Baso-0.6
[**2204-12-13**] 09:25AM BLOOD PT-13.6* PTT-25.9 INR(PT)-1.3*
[**2204-12-13**] 09:25AM BLOOD Glucose-158* UreaN-47* Creat-2.3* Na-138
K-4.0 Cl-99 HCO3-23 AnGap-20
[**2204-12-13**] 09:13PM BLOOD ALT-51* AST-33 LD(LDH)-355* CK(CPK)-44*
AlkPhos-65 TotBili-0.2
During PEA arrest:
[**2204-12-13**] 09:13PM BLOOD WBC-13.6* RBC-2.96* Hgb-8.5* Hct-27.6*
MCV-93# MCH-28.8 MCHC-30.9* RDW-14.1 Plt Ct-232
[**2204-12-13**] 09:13PM BLOOD Neuts-50.3 Lymphs-43.2* Monos-5.1 Eos-0.9
Baso-0.5
[**2204-12-13**] 09:13PM BLOOD Glucose-309* UreaN-41* Creat-2.1* Na-136
K-4.0 Cl-110* HCO3-10* AnGap-20
[**2204-12-13**] 09:13PM BLOOD CK-MB-2 cTropnT-<0.01
[**2204-12-13**] 09:13PM BLOOD Albumin-2.3* Calcium-7.8* Phos-6.6*#
Mg-2.0
[**2204-12-13**] 09:18PM BLOOD Type-[**Last Name (un) **] pH-6.93* Comment-GREEN TOP
Post-arrest trends:
CBC
[**2204-12-13**] 10:16PM BLOOD WBC-14.0* RBC-2.64* Hgb-7.8* Hct-24.3*
MCV-92 MCH-29.5 MCHC-32.0 RDW-14.4 Plt Ct-186
[**2204-12-14**] 01:49AM BLOOD WBC-17.2* RBC-4.37*# Hgb-12.8*#
Hct-37.8*# MCV-87 MCH-29.3 MCHC-33.9 RDW-14.0 Plt Ct-209
[**2204-12-14**] 05:57AM BLOOD WBC-15.7* RBC-4.12* Hgb-11.9* Hct-35.4*
MCV-86 MCH-28.8 MCHC-33.6 RDW-14.1 Plt Ct-190
[**2204-12-14**] 02:56PM BLOOD WBC-16.7* RBC-4.11* Hgb-12.2* Hct-35.3*
MCV-86 MCH-29.8 MCHC-34.6 RDW-14.5 Plt Ct-178
Coags:
[**2204-12-13**] 10:16PM BLOOD PT-17.3* PTT-31.4 INR(PT)-1.6*
[**2204-12-14**] 01:49AM BLOOD PT-15.5* PTT-28.3 INR(PT)-1.5*
[**2204-12-14**] 05:57AM BLOOD PT-16.2* PTT-29.5 INR(PT)-1.5*
[**2204-12-14**] 02:56PM BLOOD PT-18.3* PTT-150* INR(PT)-1.7*
Chem 10:
[**2204-12-13**] 10:16PM BLOOD Glucose-253* UreaN-40* Creat-2.0* Na-139
K-3.2* Cl-111* HCO3-15* AnGap-16
[**2204-12-14**] 01:49AM BLOOD Glucose-254* UreaN-43* Creat-2.1* Na-141
K-3.9 Cl-109* HCO3-16* AnGap-20
[**2204-12-14**] 05:57AM BLOOD Glucose-287* UreaN-45* Creat-2.4* Na-139
K-4.3 Cl-106 HCO3-22 AnGap-15
[**2204-12-14**] 02:56PM BLOOD Glucose-162* UreaN-44* Creat-2.6* Na-140
K-3.9 Cl-107 HCO3-20* AnGap-17
[**2204-12-13**] 10:16PM BLOOD Calcium-8.2* Phos-8.9*# Mg-1.9
[**2204-12-14**] 01:49AM BLOOD Calcium-8.0* Phos-6.0*# Mg-1.6
[**2204-12-14**] 05:57AM BLOOD Albumin-2.4* Calcium-7.8* Phos-5.0*
Mg-1.6
[**2204-12-14**] 02:56PM BLOOD Calcium-7.9* Phos-4.9* Mg-1.5*
LFTS:
[**2204-12-13**] 10:16PM BLOOD ALT-114* AST-115* LD(LDH)-472* AlkPhos-54
TotBili-0.2
[**2204-12-14**] 01:49AM BLOOD ALT-231* AST-231* AlkPhos-90 TotBili-0.6
[**2204-12-14**] 05:57AM BLOOD ALT-205* AST-198* CK(CPK)-100 AlkPhos-83
TotBili-0.8
IMAGING:
[**12-13**] CT chest:
1. At least partially loculated large left pleural effusion,
stable in size
since [**2204-12-7**] study but progressed since [**2204-11-29**]. New
left pigtail catheter appears appropriately coiled deep within
the left
costophrenic angle.
2. Known left hilar mass causing left bronchial compression with
complete
collapse of the left upper lobe, stable, and near complete
collapse of the
left lower lobe, progressed since [**2204-11-29**].
3. Lytic lesions involving the left lateral sixth rib and
vertebral body T12,
most consistent with bony metastatic disease. Multiple other
bony sites of
disease are better evaluated on the [**2204-12-7**] PET-CT.
[**12-13**] post-intubation CXR:
The endotracheal tube is in standard placement. Large left
pleural effusion
developed in the setting of left upper lobe collapse is larger
now than it was
at 1:00 p.m. shifting the mediastinum further to the right and
collapsing the
remainder of the left lung as before. Nasogastric tube ends in
the stomach.
New right infrahilar consolidation is presumably atelectasis.
[**12-14**] Echo:
The left atrium is normal in size. The coronary sinus is dilated
(diameter >15mm). Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Left ventricular
systolic function is hyperdynamic (EF 75%). The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with severe global free wall hypokinesis.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload, with marked ventricular
interaction. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. The tricuspid regurgitation jet is eccentric. There is
severe pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. The main pulmonary
artery is dilated. The branch pulmonary arteries are dilated.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2204-11-30**], severe right ventricular pressure and
volume overload with marked ventricular interaction are now
present. Findings are consistent with acute-on-chronic right
ventricular strain.
[**12-14**] Bilateral LENIs:
IMPRESSION: Findings consistent with deep vein thrombosis within
the
Preliminary Reportbilateral popliteal and posterior tibial veins
and right peroneal vein.
Brief Hospital Course:
Mr. [**Known lastname 26812**] is a 79 year old man with a history of stage IV
NSCLC with recurrent pleural effusions and left-sided collapse
who presented for dyspnea and was s/p a thoracentesis with 2L
pleural fluid removed which was bloody.
Upon admission, he was sent immediately to radiology for CT
chest, and at that time was feeling dyspneic but was in no
distress. On arrival back up to the floors, he was found to be
hypoxic, and shortly thereafter lost his pulse. A code blue was
called. On arrival, chest compressions had been started. Rhythm
was analzyed and pt was found to be in PEA arrest. He was given
2 rounds of Epi 1mg with ~ 10mins of CPR, with recovery of
pulse. He was intubated and transferred to the unit.
On arrival to the ICU, VS were Temp 96.0 HR 104 BP 118/64 RR 23
O2 sat 67%. Vent settings CMV FiO2 100% Tv 550 RR 20 PEEP 5. Pt
appeared mildly uncomfortable and was started on
fentanyl/versed. Within a few minutes of arrival, he lost pulse
and was coded again. He was given 2 amps of bicarb, 1 calcium
gluconate, and 1mg Epi with return of pulse. He was transfused
PRBC's. His initial lactate during resuscitation returned at
10.8.
Bedside echo was performed and showed right sided volume
overload with underfilling of LV. Bedside bronchoscopy was
performed and showed severe extrinsic compression of left
bronchus from known hilar mass, but there were no secretions or
mucous plugs. He was also started on empiric vancomycin and
zosyn in case sepsis was playing any role in his acute decline.
He was aggressively resuscitated with IV fluids and
phenylephrine and norepinephrine were started to help support
blood pressures. He was also transfused 4 units of PRBCs for
6pt drop in Hct, and empiric anticoagulation was deferred. He
stabilized overnight on these supportive measures, and latate
trended down.
In the morning [**12-14**], Heparin gtt was started. Formal echo
confirmed rigth heart strain with under filling of the left
ventricle, and bilateral DVTs were found on LENIs. He required
uptitration on his pressors throughout the morning, suggesting
worsening shock. Though it was medically indicated due to his
hemodynamic instability, the team decided to speak with the
family first about goals of care prior to starting lysis
therapy. A family meeting was held with the patient's son [**Name (NI) **]
(HCP), daughter-in-law [**Name (NI) **], Dr. [**Last Name (STitle) **] from the ICU, Dr.
[**Last Name (STitle) **] from oncology, and the rest of the members of the ICU
team. Upon [**Last Name (STitle) **] discussion of all risks and benefits of
treatment and his overall poor prognosis, the family decided to
forgo clot lysis and change his management to comfort focused
care. He was started on a morphine drip, pressors were
withdrawn, and he was extubated. He passed away peacefully with
family at his side around 6:20 pm.
Medications on Admission:
Atorvastatin 40 mg PO daily
Lorazepam 0.5 mg PO BID PRN anxiety
Metoprolol 25 mg PO BID
Nifedipine XL 30mg PO daily
NTG 0.4 mg PO PRN chest pain
Omeprazole 20 mg PO daily
Aspirin 81 mg PO daily
Vitamin D 400 IU PO daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Stage IV lung cancer
PEA arrest
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 5180, 4275, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2828
} | Medical Text: Admission Date: [**2145-8-17**] Discharge Date: [**2145-8-20**]
Date of Birth: [**2075-8-12**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Increasing fatigue and DOE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69 yo M with hx of HOCM x 15 yrs, HTN, hyperchol, remote tob
abuse who presents for ETOH ablation after being symptomatic on
maximal medical therapy and echo showing peak LV aortic pressure
grad 20 at rest and 80 post pvc and 94 after valsalva. Over the
last one year, patient has noticed increased DOE while walking
on a treadmill associated with SSCP after 1 mile walk.
+dizziness. no diaphoresis/n/v.
Past Medical History:
HOCM, HTN, hyperchol
Social History:
Quit smoking forty years ago
no alcohol useno drug use
Family History:
no MI
Brother- bypass at age of 80
son may be developing HOCM
Physical Exam:
vitals: 96.4 HR: 54 RR: 18 BP: 137/77 96% on RA
GEN: NAD
HEENT: MMM, PERRLA, EOMI, no JVD, no bruits
CV: regular rate, nl s1, s2, [**12-25**] Syst crescendo decrescendo
murmur heard best at LUSB that increases when patient holds
breath,
[**12-25**] holosystolic murmur radiating to axilla
LUNGS: Clear to auscultation blt
AbD: soft, nt, nd. nabs
Ext: no c,c,e 2+DP, TP pulses
Pertinent Results:
[**2145-8-19**] 06:00AM BLOOD WBC-7.9 RBC-4.52* Hgb-14.8 Hct-41.2
MCV-91 MCH-32.8* MCHC-35.9* RDW-13.0 Plt Ct-158
[**2145-8-18**] 05:34AM BLOOD WBC-7.6 RBC-4.59* Hgb-14.4 Hct-43.0
MCV-94 MCH-31.4 MCHC-33.5 RDW-13.4 Plt Ct-180
[**2145-8-17**] 07:48PM BLOOD WBC-6.9 RBC-4.40* Hgb-14.0 Hct-39.7*
MCV-90 MCH-31.9 MCHC-35.4* RDW-12.9 Plt Ct-167
[**2145-8-19**] 06:00AM BLOOD Plt Ct-158
[**2145-8-18**] 05:34AM BLOOD Plt Ct-180
[**2145-8-18**] 05:34AM BLOOD PT-13.0 PTT-26.0 INR(PT)-1.1
[**2145-8-17**] 07:48PM BLOOD Plt Ct-167
[**2145-8-17**] 07:48PM BLOOD PT-13.0 PTT-28.3 INR(PT)-1.1
[**2145-8-19**] 06:00AM BLOOD Glucose-104 UreaN-14 Creat-1.0 Na-138
K-4.2 Cl-103 HCO3-26 AnGap-13
[**2145-8-18**] 04:52PM BLOOD K-4.1
[**2145-8-18**] 05:34AM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-137
K-4.4 Cl-105 HCO3-22 AnGap-14
[**2145-8-17**] 07:48PM BLOOD Glucose-96 UreaN-15 Creat-0.9 Na-138
K-3.5 Cl-105 HCO3-23 AnGap-14
[**2145-8-19**] 06:00AM BLOOD CK(CPK)-547*
[**2145-8-18**] 04:52PM BLOOD CK(CPK)-1013*
[**2145-8-18**] 05:34AM BLOOD CK(CPK)-1445*
[**2145-8-17**] 07:48PM BLOOD CK(CPK)-1233*
[**2145-8-18**] 04:52PM BLOOD CK-MB-92* MB Indx-9.1* cTropnT-2.52*
[**2145-8-18**] 05:34AM BLOOD CK-MB-176* MB Indx-12.2* cTropnT-2.15*
[**2145-8-17**] 07:48PM BLOOD CK-MB-165* MB Indx-13.4* cTropnT-1.12*
[**2145-8-19**] 06:00AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.1
[**2145-8-18**] 05:34AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0
[**2145-8-17**] 07:48PM BLOOD Calcium-8.5 Phos-4.2 Mg-1.9
[**2145-8-17**] 03:15PM BLOOD Type-ART pO2-74* pCO2-37 pH-7.42
calHCO3-25 Base XS-0 Intubat-NOT INTUBA
[**2145-8-17**] 03:15PM BLOOD O2 Sat-95
Brief Hospital Course:
CATH: L. dominant, LAD + LCX mild dz, RA 11, RV 50/15, PA 50/18,
PCWP 16, LVEDP 24, CO/CI 4.5/2.2, SVR 1849, PVR 320, resting
aortic grad = 8; gradient increased to 99 with dobutamine.
Initial A/P:
1. Cor- mild CAD. ASA, bb
2. Pump- EF preserved; mod MR, s/p EtOH ablation now
- cont dilt, bisoprolol
- serial EKGs and CEs post etoh ablation
3. Rhythm- temporary pacer for poss complic of CHB. cont to
monitor for 48 hrs.
4. full code
5. contact- wife, daughter.
Patient also had once episode of chest pain ([**2151-1-21**]) SSCP, that
did not radiate post-procedure that resolved with morphine. no
other associated symptoms. Patiet did not have any complications
in house. He did have some paced beats on his telemtry during
first twently four hours. Patient was transferred from unit to
the floor 48 hours after procedure. Patient should follow up
with Dr. [**Last Name (STitle) **] in four weeks and primary cardiologist in three
weeks. Also, patient should follow up with Dr. [**Last Name (STitle) **].
Medications on Admission:
Aspirin
Diltiazem
Bisoprolol
Discharge Medications:
Aspirin 81 mg
Diltiazem 240 mg
Bisoprolol 20 mg [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
SEVERE HYPERTROPHIC CARDIOMYOPATHY\SEPTAL ETHANOL ABLATION
Discharge Condition:
stable
Discharge Instructions:
please take your medications as directed in discharge
instructions. Please follow up with Dr. [**Last Name (STitle) **]
please go to ER or call your doctor if you develop SOB, CP,
Palpitations, or lighheadedness
Followup Instructions:
please follow up with Dr. [**Last Name (STitle) **] in four weeks (patient should
call [**Telephone/Fax (1) 10548**]) and your primary cardiologist within three
weeks- please call for appointment
Please follow up with Dr. [**Last Name (STitle) 55478**] [**Name (STitle) **] (PCP) within two weeks-
please call for appt.
Completed by:[**2145-8-20**]
ICD9 Codes: 4240, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2829
} | Medical Text: Admission Date: [**2156-8-1**] Discharge Date: [**2156-8-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
epigastric/chest pain
Major Surgical or Invasive Procedure:
ERCP with stent placement, no sphincterotomy seconary to
supratheraputic INR
History of Present Illness:
HPI: 87yo man with h/o CAD s/p CABG [**2141**], mult PCI since,
ischemic CMY with LVEF 35%, Afib on coumadin, possible AS and/or
MR, diet controlled DM2, ?CRI, gout, who presented to [**Hospital **]
Hospital at 4am on [**2156-8-1**] with pain in his epigastrium and
chest, and was transferred here out of concern for cholangitis.
The patient reports intermittent discomfort in his chest and
epigastrium which began 1-2 weeks ago, with no precipitating
factors such as exertion or food. He describes it as a cramping
pain, with radiation to his R shoulder, but not to his back or
arms. He did say that it felt worse at night while lying down.
The pain felt different than his prior angina, and he treated it
with Tylenol with some relief. However, on the night PTA, the
pain recurred and he was unable to get back to sleep. His wife
called EMS, and he was [**Name (NI) 4045**] to [**Hospital **] Hospital. ROS is notable
for: chronic DOE, prehaps with some increase over baseline;
increase in his RLE swelling (has chronic L>R edema from prior
surgeries; denies F/C/V, diarrhea, constipation, changes in
stool or urine color or frequency. He does have some erythema
and swelling of his left 5th digit, which started 3 weeks ago,
and which he thinks may have been from a bug bite.
At [**Hospital **] Hospital, he was found to have EKG without change and
normal cardiac enzymes. CXR showed bilateral pleural effusions,
L>R. He was felt to be in CHF on exam, given Lasix for diuresis.
His labs came back with WBC 12.4 with 88% PMNs, 8% bands, and
abnl LFTs (AST 122, ALT 54, AP 307, TBili 3.3, DBili 2.5, TProt
7.3, Alb 3.5). His lipase was elevated at 2214, and his BUN and
Cr were elevated at 36/1.4, unclear if chronic or acute. An abd
u/s revealed several small gallstones in the gallbladder,
without thickening of his GB walls, and with no biliary
dilatation. He received Levaquin + CTX, vomited once and
received Zofran. His INR was 2.8, and he was given 5mg Vit K sq
once (no FFP). After discussion with the ERCP fellow at [**Hospital1 18**],
the patient was transferred here for further care and plan for
ERCP.
Past Medical History:
CAD s/p CABG [**2141**], mult PCI since
ischemic cardiomyopathy with LVEF 35%
cardiac murmur consistent with MR
Afib on coumadin
DM2, diet controlled
CKD (?)
gout
Social History:
SH: lives at home with his wife on the [**Location (un) 1121**]; previously
smoked pipes and cigars, quit several years ago and then
restarted, quit again 2 weeks ago. Rare etoh use. No illicits.
Worked as a Master Craftsman for GTE until 21y ago, since
retired. Still crafts things for enjoyment. Does not have a
garden or work outside often.
.
Family History:
noncontributory
Physical Exam:
Afebrile, mild hypertension to 140/100, sats >90% on room air
Gen -- pleasant, cooperative
HEENT -- poor dentition, op clear, anicteric sclera, conjunctiva
nonerythematous, neck supple, no carotid bruit.
Heart -- regular, holosystolic murmur at apex not radiating to
carotids
Lungs -- clear bilaterally
Abd -- soft, nontender, mildly distended, appropriate bowel
sounds
Ext -- no edema, rash or lesion
Gait -- unsteady
Pertinent Results:
[**2156-8-1**] 07:20PM GLUCOSE-69* UREA N-36* CREAT-1.6* SODIUM-139
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-28 ANION GAP-14
[**2156-8-1**] 07:20PM ALT(SGPT)-64* AST(SGOT)-141* ALK PHOS-309*
AMYLASE-901*
[**2156-8-1**] 07:20PM DIGOXIN-0.8*
[**2156-8-1**] 07:20PM WBC-16.6* RBC-3.54* HGB-13.0* HCT-38.9*
MCV-110* MCH-36.6* MCHC-33.4 RDW-15.4
[**2156-8-1**] 07:20PM NEUTS-74* BANDS-20* LYMPHS-2* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-1* NUC RBCS-1*
Brief Hospital Course:
Mr. [**Known lastname **] is an 87 year old male admitted [**2156-8-4**] as a trasfer
from [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 4046**] to the [**Hospital Unit Name 153**] for sepsis/pancreatitis.
1. pancreatitis/E.coli septicemia -- ERCP revealed obstructive
gallstone, and a stent was placed. Outside blood cultures
positive for pan sensitive E. coli. He received antibiotics,
including initially rocephin at outside hospital, ampicillin on
transfer, then ciprofloxacin since [**8-5**], with a stop date
planned for [**2156-8-16**]. A follow up appointment as an outpatient
for repeat ERCP and stent removal should be planned for [**4-12**]
weeks post discharge (initial ERCP date [**2156-8-4**]). He improved
dramatically after ERCP, with no abdominal pain and tolerating a
full diet on discharge.
2. acute renal failure -- improved to baseline with Lasix and
supportive care of sepsis. ACE inhibitor and digoxin held.
3. CAD/ischemic cardiomyopathy -- some question of ACS on
admission, however no ECG changes and symptoms consistent with
pancreatitis. His antiplatelet medications were held due to
interventions, and should be held 10 days post ERCP. His beta
blocker was restarted when he improved from his inital
presentation. A statin was added during his hospitalization as
well, and should be followed up with liver enzymes and lipid
profile in 5 weeks after discharge. His home dose Lasix was
restarted as well, three days prior to discharge.
4. atrial fibrillation/coumadin -- Mr. [**Known lastname **] received FFP on
presentation in order to perform ERCP. After the procedure, it
was restarted at his home dose of 4 mg po qhs. However, his INR
was affected by the simulateous administration of ciprofloxacin,
and was supratheraputic to 3.6 on [**2155-8-12**]. It was held the night
prior to discharge, with instructions for the rehab facility to
follow INR closely, and adjust coumadin appropriately. He was
rate controlled appropriately throughout his hospitalization,
although his digoxin was held secondary to renal insufficiency.
It can be restarted at the discretion of his primary physician.
5. hypertension -- mildly elevated blood pressures in the latter
part of his hospitalization, controlled with Lasix and
metoprolol. ACE inhibitor held initially because of renal
insufficiency. Restarted day prior to discharge. He should
have Crt/potassium checked one week after restarting ace
(instructions given to rehab facility).
Medications on Admission:
unknown
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. lisinopril 5 mg po qday
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4047**] Nursing & Rehabilitation Center - [**Location (un) 4047**]
Discharge Diagnosis:
1. gallstone pancreatitis s/p ERCP with stent placement
2. E.coli sepsis, resolved
3. acute renal failure, resolved
Discharge Condition:
stable
Discharge Instructions:
You were hospitalized with gallstone pancreatitis in the ICU.
You had acute renal failure, which recovered to your normal
kidney function. You will be discharged to a rehabilitation
facility in order to gain strength and continue to receive help
with your medications.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 3278**] in one week. You should be evaluated
as an outpatient for obstructive sleep apnea.
The gastroenterology outpatient clinic will call you with a
follow up appointment for ERCP and common bile duct stent
removal.
ICD9 Codes: 5849, 5119, 4280, 4240, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2830
} | Medical Text: Admission Date: [**2192-2-24**] Discharge Date: [**2192-2-25**]
Date of Birth: [**2129-1-22**] Sex: M
Service: MEDICINE
Allergies:
Nifedipine / Wellbutrin
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Atrial Fibrillation
Major Surgical or Invasive Procedure:
failed electrical cardioverion for atrial fibrillation
lumbar puncture
History of Present Illness:
63M with metastatic esophageal cancer. Went out for newspaper
today, tripped on side walk and fell. Came to ED for evaluation
of head lac and knee pain. All trauma films negative except for
small hematoma. Pt cleared to be discharged. Got up to go to the
bathroom and heart rate jumped to 200s. Received 6mg, then 12mg
of adenosine without termination, then IV Dilt 10mg x2. SBP
dropped from 140 to 80. Temp to 102 with rigors. 150mg amio and
SBP now down to 75. Then attempted cardioversion first at 200J,
then 250J without success. An additional 150mg of amio was
given. He was then started on neo for low BP and given 250mg
digoxin. Pt converted to sinus rhythm 10 minutes later and BP
came up to 126/53. He was given a total of 5L NS and maintained
on a neo gtt. His HCT at the time of admission was 24.5, no
other lab values were available for comparison. Pt had a CT scan
to rule out PE that was negative for clot but did show COPD and
peripheral nodular consolidations. He was also noted to have a
temp of 101.3. Got Tylenol in the ED. CT abd/pel no hematoma or
free air.
.
On arrival to the floor, vitals 97.9 68 120/75 20 98% on 2L. Pt
initially on neo but able to discontinue immediately with stable
blood pressures. Pt unable to provide detailed history. Oriented
x2. Complains of productive cough, sore throat, belly pain and
some numbness on the medial plantar surface of his left foot,
unchanged from baseline.
Past Medical History:
Metastatic Esophageal Cancer s/p Rads completed [**2-15**], diagnosed
in [**7-21**]. failed chemo
G-tube placement [**2-20**]
hx of PAF first diagnosed one month ago
COPD
Hypertension
Hyperlipidemia
Depression
Ruptured Appendix
Hernia Repair x2
seizure disorder secondary to wellbutrin
Severe burns when a child
"Stomach resection"
Social History:
smoked 2ppd since age 15, now since dx, only smoking minimally.
No current alcohol use but has history of heavy use. No
illicits. Lives in [**Location **] but has been staying at the [**Hospital 7137**] while getting treated at [**Hospital1 2177**]. Completed radiation therapy
on [**2-15**]. HCP, Mother, [**Name (NI) **], [**Telephone/Fax (1) 81199**]. [**Name2 (NI) 4084**] married, worked in
sales and construction. Mother and sister taking care of him
now.
Family History:
M - Healthy
F - Died of cancer
Physical Exam:
Vitals: 98.7, BP 151/85, HR 80, RR 20, 95%RA
Gen: Male appears older than stated age, Somewhat confused and
tangential, occasion whole body twitches
HEENT: NC, Lac over left eye, vertical nystagmus
NECK: Skin changes from radiation, neck full
RESP: Coarse, bronchial breath sounds
CV: RRR, no MRG
ABD: soft, diffusely TTP, BS+, PEG in place
EXT: no edema, DP's 2+
Pertinent Results:
[**2192-2-23**] 07:30PM WBC-8.0 RBC-2.60* HGB-8.7* HCT-24.3* MCV-93
MCH-33.6* MCHC-36.0* RDW-15.9*
[**2192-2-23**] 07:30PM NEUTS-88.7* LYMPHS-6.0* MONOS-4.7 EOS-0.4
BASOS-0.3
[**2192-2-23**] 07:30PM PLT COUNT-134*
[**2192-2-23**] 07:30PM CALCIUM-8.6 PHOSPHATE-3.6 MAGNESIUM-1.3*
[**2192-2-23**] 07:30PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-135
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12
[**2192-2-24**] 12:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2192-2-24**] 12:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2192-2-24**] 01:00AM LACTATE-1.1
[**2192-2-24**] 04:08AM HGB-8.3* calcHCT-25
.
CTA Chest - 1. No pulmonary embolus.
2. Peripheral opacities are nonspecific with a differential that
includes
atypical or less likley eosinophilic pneumonia or BOOP/COP.
3. Right upper lobe pulmonary nodules are concering for
metastatic disease.
4. Moderate emphysematous changes.
.
CT abd/pel - 1. Satisfactory PEG position.
2. No hematoma or free air.
3. Low density renal lesion may represent cyst or neoplasm.
Further
characterization (perhaps with ultrasound) recommended.
.
Knee XR - No traumatic injury identified in either knee. There
is no
significant underlying degenerative joint disease.
CT Neck - 1. No fracture or malalignment.
2. Multilevel moderate-to-severe degenerative change, with canal
narrowing at C4-C6. In this setting, there is increased risk for
ligamentous and cord injury, and MRI is more sensitive for these
entities.
3. Emphysema.
4. Thyroid lesion. Please correlate with clinical exam and
biochemical
profile. If indicated, consider US for further evaluation.
.
CT Head - 1. Left frontal subgaleal hematoma.
2. No fracture or other site of hemorrhage.
[**2192-2-24**] Carotid ultrasound:
There is minimal diffuse wall thickening in some areas of
calcific plaque
involving both carotid systems. The peak systolic velocities on
the right are 53, 60, 69, 100, and 88 cm/sec for the proximal,
mid, and distal ICA and CCA and ECA respectively. Similar values
on the left are 76, 66, 66, 91, and 100 cm/sec. There is
antegrade flow involving both vertebral arteries. The ICA/CCA
ratios are within the normal range. IMPRESSION: No significant
ICA or CCA stenosis bilaterally.
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. 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. Moderate
[2+] tricuspid regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. Moderate
tricuspid regurgitation. Mild pulmonary hypertension.
Brief Hospital Course:
63M with metastatic esophageal cancer who initially presented
after falling and went into afib as he was leaving the hospital.
In the setting of heart rate of 160s drop SBP to 80. After
adenosine x2, dilt x2, cardioversion x2 and dig, pt converted to
sinus and blood pressure responded. He was transferred to the
floor on neo which was promptly discontinued on arrival to the
floor and the patient maintained his BP in the 120. Patient
received LP for question of altered mental status, but waxing
and [**Doctor Last Name 688**] at baseline despite normal electrolytes and no
evidence of brain mets.
Atrial Fibrillation - now in sinus rhythm, s/p adenosine x2,
dilt x 2, amio bolus x2, cardioversion x2 then dig. Patient was
placed on amino drip for 48 hours and d/c with dilt PO daily.
PCP/HEM/ONC TO DETERMINE RISKS/BENEFITS OF ANTICOAGULATION
Community acquired [**Name (NI) **] Pt spike temp in setting of new
tachycardia. Has had productive cough x1 day and now altered
mental status. Intially was treated empirically for hospital
acquired PNA and meningitis, will go with vanc, ceftriaxone, and
ampicillin. From clnical picture, CTA chest, will treat as CAP
with 5d course of azithromycin. No flouroquinonlone because of
seizure history in the setting of wellbutrin. Cultures negative
at the time of discharge.
Anemia - HCT on admission 24, down to 22 following 5L of fluid.
Do not know baseline. Though patient has esophageal cancer, this
is lower than would be expected. CT no eveidence of bleeding in
Head/C/A/P. INR 1.5. Unknown if on anticoagulation at baseline.
Transfused 1 u pRBCs
Hypotension - Resolved. Likely [**1-16**] tachycardia.
.
Esophageal Cancer - s/p radiation on [**2-15**]. Extent of mets
unknown. Patient has care at [**Hospital1 2177**], patient is NPO, has G-tube
for feeds. Pain management as outpatient regimen, since there is
no change in mental status.
FEN - G-tube feeds.
Proph - pneumoboots, sc heparin
Code - DNR/DNI
Contact - Mother, [**Name (NI) **], [**Telephone/Fax (1) 81199**]
PCP/HEM/ONC TO DETERMINE RISKS/BENEFITS OF ANTICOAGULATION
Medications on Admission:
Jevity 2 cans TID
Thiamine
Folic Acid
K-dur
Colace
Mg Oxide
Diltiazem 120 mg qd
Percocet
Lidocaine viscous 2% soln q 4h
Peridex
MS Contin 45mg q12h
Celexa 10mg qd
Advair
Spiriva
Albuterol
ASA 81
Lipitor
Protonix
Remeron
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed.
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-16**]
Puffs Inhalation Q6H (every 6 hours).
7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
14. DILT-XR 120 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
16. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Morphine 15 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO Q12H (every 12 hours).
18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
19. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
paroxymal atrial fibrillation
Metastatic Esophageal Cancer s/p Rads completed [**2-15**], diagnosed
in [**7-21**].
Discharge Condition:
stable, in sinus, normotensive
Discharge Instructions:
You were admitted for a mechanical fall and developed atrial
fibrillation with hypotension and failed electrical
cardioverion. You were treated in the intensive care unit and
placed on medication to resolve your abnormal heart rhythm which
returned to [**Location 213**] for 24 hours prior to discharge. You were
found to have a small pneumonia and you are to take a course of
antibiotics.
You are to take medication to prevent the abnormal heart rhythm
and antibiotics to treat the pneumonia. You are to take a full
dose aspirin and diltizem since it was clarifed that you do not
have an allergy to this medication and were given this
medication in the hospital without problems.
Please return to the ED if you develop chest pain, shortness of
breath, or palpitations.
Followup Instructions:
with [**Hospital1 2177**] this week, as previously scheduled
PLEASE DETERMINE WITH PCP/HEM/ONC RISKS AND BENEFITS FOR
ANTICOAGULATION FOR YOUR PARXYMOXAL ATRIAL FIBRILLATION
Completed by:[**2192-2-25**]
ICD9 Codes: 486, 4589, 4019, 2724, 3051, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2831
} | Medical Text: Admission Date: [**2162-4-2**] Discharge Date: [**2162-4-9**]
Service: MEDICINE
Allergies:
Heparinoids
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
transfer for biliary obstruction
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
85 year old male with CAD s/p CABG X 3, post-op AF, HTN, ESRD on
HD initially admitted [**2162-4-2**] to SICU from [**Hospital1 **]
with hyperbilirubinemia, fever, and left pleural effusion. His
CABG c/b mediastinal hemorrhage requiring re-exploration
[**2162-3-6**], prolonged vent wean requiring trach ([**2162-3-15**]) and PEG
([**2162-3-24**]), acute on chronic renal failure requiring dialysis, and
persistent post-op atrial fibrillation. He was transferred to
[**Hospital **] rehab [**2162-3-30**] shortly after which he was noted to be
febrile (102.8 [**2162-4-1**]) with bili 7.5 and jaundice -> [**Hospital1 18**]
SICU.
Following admit, he was pan-cx (sputum, blood) started
empirically on vanco/levo for ?cholangitis. An Abd U/S [**4-3**]
showed stones/sludge in gallbladder and the pt underwent ERCP
[**2162-4-5**] which showed diffuse dilation of CBD up to 10 mm without
filling defects (although gallstones noted in GB), and dilation
of pancreatic duct to 6 mm. A stent was placed in the common
bile duct with recommendation to repeat ERCP in 3 mos to
evaluate for change. CXR w/ left pleural effusion, the size of
which decreased following hemodialysis. On [**4-5**] the patient was
started on Bactrim for Stenotrophomonas growing from sputum. The
patient was transferred to the MICU for further management.
The patient can only answer yes or no questions. He denies chest
pain, abdominal pain, nausea, vomiting, fevers, chills, or
diarrhea.
Past Medical History:
1) CAD
- cath [**2162-3-1**] 30% LM, 90% LAD, 70% RCA, 60% OM
- CABG X 3 [**2162-3-5**]
2) Right carotid stenosis: 80-99% by U/S
3) ESRD on HD
- RIJ tunneled HD catheter [**2162-3-29**]
4) AF: developed post-CABG
5) DJD
6) HTN
7) PVD
8) prostate CA s/p XRT
9) Rirght renal artery stenosis; left kidney renal artery
occlusion
10) bilateral THR
11) s/p appy
13) bilateral inguinal hernia repeair
14) ?HIT Ab
15) hypothyroidism
Social History:
no tobacco, no ethanol
Family History:
non-contributory
Physical Exam:
PE: Tc 98.8, Tm 100.5 ( 4 p.m. [**4-5**]; afebrile X >12h), pc 78, pr
70s-80s, bpc 114/51, bpr 110-120s/40s-70s, resp 20 98% PS 12,
PEEP 5, FiP2 40%, TV 450
Gen: elderly, alert, answering yes/no questions and obeying
simple commands, NAD
HEENT: Pupils equal, non-reactive to light, EOMI, OMMM, OP
clear, trach in place with moderate yellow secretions.
Cardiac: irregularly irregular, no m/r/g. Well-healing sternal
scar
Pulmonary: coarse BS throughout with occasional ronchi,
decreased breath sounds at bases bilaterally L>R
Abd: hypoactive BS, NT/ND, no masses, no HSM
Ext: No cyanosis or edema. Bilateral heel ulcers, clean-based.
Pneumoboots in place
Neuro: Face symmetrical, EOMI, moves all 4 extremities, 2+ DTR
[**Name (NI) **] bilaterally, 1+ DTR LE bilaterally, withdraws all 4
extremities in response to pain
Access: Right tunnelled SC dialysis cath C/D/I, Left SC TLC
C/D/I.
Pertinent Results:
[**2162-4-6**] 03:21AM BLOOD WBC-12.4* RBC-3.29* Hgb-10.0* Hct-30.3*
MCV-92 MCH-30.5 MCHC-33.1 RDW-20.9* Plt Ct-276
[**2162-4-5**] 12:30AM BLOOD WBC-12.2* RBC-3.33* Hgb-10.2* Hct-29.9*
MCV-90 MCH-30.6 MCHC-34.1 RDW-19.8* Plt Ct-303
[**2162-4-4**] 03:00AM BLOOD WBC-9.6 RBC-3.04* Hgb-9.1* Hct-26.9*
MCV-89 MCH-30.0 MCHC-33.9 RDW-19.5* Plt Ct-310
[**2162-4-6**] 03:21AM BLOOD Plt Ct-276
[**2162-4-6**] 03:21AM BLOOD PT-13.9* PTT-29.2 INR(PT)-1.2
[**2162-4-5**] 12:30AM BLOOD Plt Ct-303
[**2162-4-5**] 12:30AM BLOOD PT-13.6 PTT-28.0 INR(PT)-1.2
[**2162-4-6**] 03:21AM BLOOD Glucose-128* UreaN-49* Creat-4.0* Na-142
K-4.0 Cl-101 HCO3-27 AnGap-18
[**2162-4-5**] 03:28PM BLOOD Glucose-123* UreaN-38* Creat-3.3*# Na-144
K-3.6 Cl-100 HCO3-28 AnGap-20
[**2162-4-5**] 12:30AM BLOOD Glucose-133* UreaN-89* Creat-6.0*# Na-139
K-4.9 Cl-96 HCO3-25 AnGap-23
[**2162-4-6**] 03:21AM BLOOD ALT-48* AST-134* LD(LDH)-479*
AlkPhos-351* Amylase-1015* TotBili-6.3* DirBili-4.9* IndBili-1.4
[**2162-4-5**] 12:30AM BLOOD ALT-25 AST-57* AlkPhos-286* Amylase-40
TotBili-5.5* DirBili-4.2* IndBili-1.3
[**2162-4-6**] 03:21AM BLOOD Lipase-2804*
[**2162-4-5**] 12:30AM BLOOD Lipase-27
[**2162-4-6**] 03:21AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.6 Mg-2.5
Iron-PND
[**2162-4-5**] 03:28PM BLOOD Calcium-8.9 Phos-4.0 Mg-1.8
[**2162-4-6**] 03:21AM BLOOD TSH-9.5*
[**2162-4-5**] 03:28PM BLOOD Vanco-18.5*
[**2162-4-5**] 03:10AM BLOOD HEPARIN DEPENDENT ANTIBODIES-PND
Micro
[**4-5**] MRSA screen pending
[**4-5**] VRE screen pending
[**4-3**] O&P (-)
[**4-2**] O&P, fecal cx (-), C. diff (-)
[**4-3**] right PICC tip cx (-)
[**4-2**] spcx moderate stenothrophomonas maltophilia (bactrim [**Last Name (un) 36**])
[**4-2**] bcx pending
Radiology
[**4-6**] renal U/S: Right kidney without
stones/hydronephrosis/masses. No left kidney viualized. (+)
gallstones/sludge, (+) left pleural effusion
[**4-6**] bilateral LENI: (-) DVT
[**4-4**] left wrist plain films: osteoarthritis
[**4-3**] Abd U/S: stones/sludge in GB, no GB
distension/thickening/edema, CBD upper limits of nl. No IHD
dilitation
[**4-3**] AP CXR: lg lucency at right lung base (bullous vs loculated
PTX), moderate left pleural effusion
Brief Hospital Course:
A: 85 yoM w/ CAD s/p recent CABG, HTN, AF admitted with
hyperbilirubinemia and fevers, now s/p ERCP.
P:
1) Hyperbilirubinemia: likely secondary to biliary obstruction
[**2-24**] sludge, although ischemic injury is also possible
2) Fevers: Most likely secondary to biliary obstruction,
possible cholangitis. DDx includes nosocomial pneumonia (sputum
from [**4-2**] growing Stenotrophomonas, although this may represent
colonization), empyema (although pleural effusion appears
chronic), line infection (had S. aureus line infection of temp
HD catheter in Fla.). Pt afebrile ~48 hrs since ERCP.NO
thoracentesis was done as pt has no tappable amount of fluid.
Fluid effusion likely fluid related. He will have bactrim for 7
more days and ampicillin/levofloxacin/flagyl for 7 more days for
presumed cholangitis.
3) Post-ERCP pancreatitis: He was clinically improving and
decreasing pancreatic enzyme as of [**4-7**] and [**4-8**]. He is to
restart on tube feed on [**4-8**]
4) Pleural effusion:THis was chronic and resolved with
hemodialysis yesterday on [**4-7**]. No plan to tap as minimal amount
on CXR.
5) Respiratory failure: c/b long respiratory wean. Was
tolerating trach collar at rehab prior to transfer.
6) Atrial fibrillation: Started post-CABG. Pacing wires placed
in Fla. were removed on admission.He was cntinued on admiodarone
and metoprol. He is to restart on coumadin on [**4-8**] w/ 2mg
initially and carefully titrate up w/ him on amiodarone
7) HTN: Stable. He is continued on metoprolol and hydralazine as
of [**4-8**].
8) Anemia: Likely [**2-24**] ESRD (had been on epogen). Lab panel
consistent with anemia of chronic inflammation.Hct is stable as
of [**4-8**].
9) HIT?: Intially there was a concern of HIT, but his HIT
antibody was negative as of [**4-8**]
10) CAD s/p CABG: His statin is held for LFT abnormalitis. He is
continued on aspirin and low dose b-blocker
11) F/E/N: NPO for now given post-ERCP pancreatitis.
- He is to restart on tube feed today on [**4-8**].
12) ESRD: CRF likely due to HTN and renovascular dz; renal U/S
[**4-6**] shows R kidney without hydronephrosis, stones, or masses.
No left kidney viualized. HD started post-CABG.
- He is continued on MWF dialysis
13) Access: R tunnelled SC dialysis cath, L SC TLC
14) Ppx: pneumoboots (no DVT on LENIs [**4-6**]), PPI
15) Code: Full Code
Medications on Admission:
Meds (on transfer)
1) Bactrim DS 3 tabs given following dialysis
2) Vancomycin 1 g IV prn vanco <15
3) levofloxacin 250 mg IV q48h
4) NTP q6h for sbp >150
5) RISS
6) acyclovir5% 6X/day
7) Lansoprazole 30 mg NG daily
8) morphine 2 mg IV q4h prn
9) Nephrocaps 1 cap PO daily
10) Albuterol neb q4h prn
11) Atrovent neb q6h prn
12) Levothyroxine 25 mg PO/NG daily
13) Amiodarone 200 mg NG daily
Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 6X/D (6
times a day).
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Three
(3) Tablet PO QHD (each hemodialysis) for 7 days.
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please check INR every day for [**Date range (1) 32718**] and every 3
days for 1 week, then every week afterward.
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: One (1)
Intravenous Q48H (every 48 hours) for 7 days.
12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 7 days.
13. Ampicillin 2 gm IV Q12H
14. Hydralazine HCl 20 mg IV Q6H
hold for SBP<120
15. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): please give 2 unit for FS
150-200; 4 unit for FS 201-250; 6 unit for FS251-300; 8 unit for
FS 301-350; 10 unit for FS 351-400; please give 10 units for
FS>401 and call house officer.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
cholethiasis
Discharge Condition:
stable
Discharge Instructions:
please call your doctor if you experience chest pain, shortness
of breath or abdominal pain.
Please take your medication
Followup Instructions:
need repeat ERCP in 3months (please have your primary care
provide call for appointment with GI at [**Hospital1 18**])
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 41197**]
ICD9 Codes: 5119, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2832
} | Medical Text: Admission Date: [**2126-9-17**] Discharge Date: [**2126-9-23**]
Date of Birth: [**2060-5-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vioxx
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting times three (left internal
mammary to left anterior descending, saphenous vein graft to
diagonal, saphenous vein graft to obtuse marginal) on [**2126-9-17**]
History of Present Illness:
Mr. [**Known lastname 69850**] is a 66 year old male who developed fatigue/chest
pain this past [**Month (only) **]/[**Month (only) 205**] while playing tennis. The symptoms were
similiar to those he experienced in [**2112**] prior to receiving an
left anterior descending artery stent. His symptoms resolved
with rest however he has noticed a progressive decline in his
aerobic capacity. A stress echocardiogram was obtained which was
positive for ischemia. A cardiac catheterization was
subsequently performed
which showed severe left main and single vessel disease. Given
the severity of his disease, he has been referred for surgical
management.
Past Medical History:
- Coronary artery disease
- Hypertension
- Hyperlipidemia
- Diverticulitis
- Arthritis
- GERD
- PCI/Stent to LAD [**2112**]
- Achilles tendon rupture with repair [**2106**]
- Right rotator cuff surgery in [**2122**] and [**2123**], right
- Arthroscopy of knee, left
Social History:
Mr. [**Known lastname 69850**] is a high school guidance counselor. He smoked
1-1.5 packs per day for ten years, quiting in his 20s. He
reports drinking less than one alcoholic beverage per week.
Family History:
Mr. [**Known lastname 69851**] brother has coronary artery disease and diabetes.
Physical Exam:
Pulse: 85 Resp: 16 O2 sat: 97%
B/P Right: 134/77 Left: 118/81
Height: 5'7" Weight: 207lbs
General: Well-developed male in no acute distress
Skin: Warm [X] Dry [X] intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema -
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: Right: - Left: -
Pertinent Results:
Intra-op TEE [**2126-9-17**]:
Conclusions
Pre-Bypass:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter with minimal atherosclerotic plaque. The
diameters of aorta at the sinus, ascending and arch levels are
normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
Post-Bypass:
The patient is A-Paced on a phenylephrine infusion s/p 3 vessel
CABG
Left ventricular function is preserved with EF-55%. No WMA.
Normal functioning aortic valve and trivial MR remain.
There is a small right pleural effusion.
There is no echocardiographic evidence of a aortic dissection
post de-cannulation.
.
[**2126-9-23**] 06:10AM BLOOD Hct-27.0*
[**2126-9-22**] 05:40AM BLOOD WBC-6.3 RBC-2.69* Hgb-8.8* Hct-26.2*
MCV-97 MCH-32.7* MCHC-33.7 RDW-13.6 Plt Ct-236
[**2126-9-21**] 04:54AM BLOOD WBC-7.2 RBC-2.50* Hgb-8.5* Hct-24.1*
MCV-97 MCH-33.9* MCHC-35.2* RDW-13.5 Plt Ct-165
[**2126-9-20**] 02:55PM BLOOD Hct-23.0*
[**2126-9-20**] 10:19AM BLOOD WBC-7.8 RBC-2.67* Hgb-8.8* Hct-25.9*
MCV-97 MCH-33.1* MCHC-34.1 RDW-12.8 Plt Ct-145*
[**2126-9-23**] 06:10AM BLOOD PT-20.0* INR(PT)-1.9*
[**2126-9-22**] 05:40AM BLOOD PT-13.1* INR(PT)-1.2*
[**2126-9-21**] 04:54AM BLOOD PT-12.0 INR(PT)-1.1
[**2126-9-22**] 05:40AM BLOOD Glucose-144* UreaN-19 Creat-0.8 Na-139
K-4.6 Cl-104 HCO3-29 AnGap-11
[**2126-9-21**] 04:54AM BLOOD Glucose-103* UreaN-23* Creat-0.9 Na-142
K-3.8 Cl-105 HCO3-31 AnGap-10
[**2126-9-20**] 10:19AM BLOOD Glucose-136* UreaN-22* Creat-0.9 Na-140
K-4.0 Cl-103 HCO3-34* AnGap-7*
Brief Hospital Course:
Mr. [**Known lastname 69850**] was brought to the Operating Room on [**2126-9-17**] where he
underwent coronary artery bypass grafting times three (left
internal mammary to left anterior descending, saphenous vein
graft to diagonal, saphenous vein graft to obtuse marginal).
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
Post-operative day one found the patient extubated, alert and
oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery. He experienced atrial fibrillation, which
converted to sinus rhythm with amiodarone. AFib returned and he
was started on coumadin. He remained in AFib/Flutter at
discharge. He received blood for a hct of 22%. The patient
developed a fever and blood was discontinued. Hematocrit rose
appropriately and remained stable. Stool guaiac was negative.
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 post-operative day 6 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home in good
condition with appropriate follow up instructions.
Medications on Admission:
Coreg 3.15mg twice daily
Lipitor 80mg daily
Diovan 80mg daily
Aspirin 81mg daily
Prevacid 30mg daily
Multivitamins
Fish oil
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Amiodarone 400 mg PO BID
400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then 200mg daily
RX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*56
Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Col-Rite] 100 mg 1 capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
6. Furosemide 20 mg PO DAILY Duration: 5 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet
Refills:*0
7. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days
Hold for K+ > 4.5
RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth daily
Disp #*5 Packet Refills:*0
8. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
RX *hydromorphone 2 mg [**1-14**] tablet(s) by mouth q3h Disp #*60
Tablet Refills:*0
9. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
12. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
13. Warfarin 2 mg PO DAILY16 Duration: 1 Doses
dose to change per Dr. [**First Name (STitle) 4223**] for goal INR 2-2.5
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease
PMH:
- Hypertension
- Hyperlipidemia
- Diverticulitis
- Arthritis
- GERD
Past Surgical History:
- PCI/Stent to LAD [**2112**]
- Achilles tendon rupture with repair [**2106**]
- Right rotator cuff surgery in [**2122**] and [**2123**], right
- Arthroscopy of knee, left
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
No edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] [**2126-9-26**]
10:45p
Surgeon Dr. [**Last Name (STitle) **] [**2126-10-16**] at 1:00p [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**Last Name (STitle) 6254**] [**2126-10-10**] at 11:20am
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 69852**] [**Name (STitle) 4223**] ([**Telephone/Fax (1) 69853**] in [**4-18**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for AFib
Goal INR 2-2.5
First draw [**2126-9-24**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**First Name (STitle) 4223**]
Results to phone [**Telephone/Fax (1) 69854**], fax [**Telephone/Fax (1) 69855**]
Completed by:[**2126-9-23**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2833
} | Medical Text: Admission Date: [**2119-5-8**] Discharge Date: [**2119-5-11**]
Date of Birth: [**2058-6-23**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 47645**] was a 60-year-old
gentleman who presented to [**Hospital6 3872**] on
[**2119-5-8**] with complaints of shortness of breath lasting
approximately a few hours prior to arrival. He had a
productive cough as well with no fever. He arrived to the
Emergency Department at [**Hospital3 1280**] pale and diaphoretic. The
patient had been previously healthy with no known cardiac
disease however upon interrogation at [**Hospital6 3874**] it was discovered that he had been having chest pain
for a number of days intermittently prior to admission to the
hospital. The morning of admission he awoke with significant
shortness of breath, chest pain and diaphoresis. On arrival
to the Emergency Department he was noted to be in sinus
tachycardia. He had ST elevations in the inferior leads as
well as ST depression in his anterior leads of his EKG.
Chest x-ray at that time revealed marked pulmonary edema.
His oxygen saturation was 84%. His blood pressure was 80/50
in atrial fibrillation with a heart rate of 110 per minute.
The patient ruled in by cardiac enzymes as well as EKG for an
inferior myocardial infarction with right ventricular
involvement. The patient also had hemoptysis upon admission
to the Emergency Department. The patient was emergently
transferred from [**Hospital6 3872**] to [**Hospital1 346**] early afternoon on [**2119-5-8**] where he
was taken emergently to the cardiac catheterization
laboratory.
PAST MEDICAL HISTORY: Deafness.
MEDICATIONS ON ADMISSION: He was taking no regular
medications prior to admission to the hospital.
ALLERGIES: The patient has no known drug allergies.
HOSPITAL COURSE: In the cardiac catheterization laboratory
the patient was found to have significant three-vessel
coronary artery disease as well as 4+ severe mitral
regurgitation with a left ventricular ejection fraction
estimated at 75%. He was hemodynamically unstable and in
cardiogenic shock with severe mitral regurgitation. An
intra-aortic balloon pump was placed emergently and the
patient was also emergently taken to the operating room for
mitral valve replacement and coronary artery bypass grafting.
The patient was emergently intubated in the cardiac
catheterization laboratory for oxygen saturation of about 60%
with pulmonary edema which was treated with Lasix, 100%
oxygen and PEEP.
The patient was taken to the operating room by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] where the patient underwent emergency coronary artery
bypass grafting x 2 with saphenous vein to the right
posterior descending coronary artery and saphenous vein to
the left anterior descending coronary artery. He also had a
mitral valve replacement with a #29 mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
valve. Postoperatively the patient was in profound hypoxic
state and pulmonary edema on epinephrine, Neo-Synephrine,
vasopressin and Levophed IV drips, with an intra-aortic
balloon pump in place. He was transported from the operating
room to the cardiac surgery recovery unit profoundly hypoxic.
Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] placed arterial and venous cannulas to
place the patient on ECMO in the intensive care unit, which
was initiated the night of surgery.
On [**2119-5-9**], postoperative day one the patient remained
critical. He remained profoundly fluid overloaded. His
pressors were weaned somewhat but remained on Levophed and
vasopressin at that time. The patient remained on full ECMO
support with ventilator and intra-aortic balloon pump in
place. The patient was kept paralyzed and sedated to
facilitate ventilation. Later in the day on [**2119-5-9**] the
patient was begun on CVVH due to massive fluid overload with
attempt to remove large volume of fluid in the hope that the
patient would be able to be weaned from the ECMO circuit and
be able to oxygenate adequately. The patient remained on
full support throughout the course of that night and on the
morning of [**2119-5-10**], remained on full ventilator support,
full ECMO support with CVVH for fluid removal. He remained
on cisatracurium IV drip for paralysis, fentanyl and Ativan
for sedation, Levophed, Neo-Synephrine and Pitressin drips to
maintain adequate blood pressure assistance.
The patient underwent bronchoscopy also on [**2119-5-10**] at
approximately 3 PM which was unremarkable. The patient's
intra-aortic balloon pump was removed on [**2119-5-10**] as well.
On the evening of [**2119-5-10**] the patient was taken to the
cardiac catheterization laboratory due to continued
hemodynamic instability, where he underwent an atrial
septostomy to decompress the left atrium. A transseptal
puncture was performed and the atrial septum was dilated and
there was successful left to right shunting after the
procedure. From the catheterization laboratory the patient
was transported again to the cardiac surgery recovery unit in
critical condition, remained on the previously mentioned
vasoactive drips and it was noted that the patient had an
ischemic left leg which is the leg that his ECMO cannulas had
been placed into.
The patient was take to the operating room in the evening of
[**2119-5-10**] where he underwent removal of the ECMO cannulas from
the left, replacement of those cannulas into the right,
repair of the common femoral artery with a graft on the
right, repair of the left femoral artery, left fasciotomy as
well. The patient was returned to the cardiac surgery
recovery unit early on the morning of [**2119-5-11**] where he
continued to decline from a hemodynamic standpoint. He also
had worsening metabolic acidosis treated with multiple amps
of sodium bicarbonate throughout the course of the night. He
was noted to have a severely distended abdomen which worsened
overnight as well as large volumes of guaiac positive watery
stool being expelled. His lactate had risen to the low 20s
at this time.
In the early morning of [**2119-5-11**] a discussion took place with
the patient's son and daughter-in-law who stated that they
felt the patient would not want any further surgical
procedures. They also stated that the patient would not want
to continue on the present amount of support that he remained
on at this time due to his worsening condition. After
discussion with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] he concurred with the
family's wishes and at 8:40 to 8:50 in the morning the
patient's vasoactive drips as well as ECMO were weaned to off
and the patient ceased spontaneous respirations as well as
heart rhythm at 8:55 this morning and was pronounced dead.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2119-5-11**] 09:26
T: [**2119-5-11**] 10:07
JOB#: [**Job Number 47646**]
ICD9 Codes: 4280, 4240, 2762, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2834
} | Medical Text: Admission Date: [**2145-8-24**] Discharge Date: [**2145-8-27**]
Date of Birth: [**2070-8-3**] Sex: M
Service: Neurosurgery
NOTE: The patient was admitted to the Trauma Service and
seen in consultation by the Neurosurgery Service.
HISTORY OF PRESENT ILLNESS: This is the first [**Hospital1 346**] admission for this 73-year-old white
male of Islamic origin, an Islamic and French-speaking
professor who was involved as a pedestrian when struck by a
low-speed motor vehicle.
The patient reportedly rolled onto and over the front [**Doctor Last Name **]
striking his head on the windshield with a positive
windshield fracture or "star sign" at the site of impact on
the windshield. There was no report of loss of
consciousness, and the patient was observed as alert at the
scene.
PAST MEDICAL HISTORY: His previous medical history includes
a history of hypertension, a history of diverticulitis, and a
history of arthritis.
PAST SURGICAL HISTORY: Previous surgical history includes a
colectomy secondary to diverticulitis.
MEDICATIONS ON ADMISSION: His current medications include
Prilosec, [**Doctor First Name **], and Hytrin.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: He is a nonsmoker, and no history of alcohol
use. He reports he is originally from [**Country **] and has been in
the United States for 17 years to 20 years. He teaches
Theology to postdoctoral students at [**University/College **]. He is married,
and his wife is a professor at the [**State 43840**]
which requires a [**State 5887**] address, and he commutes to his
work for a couple of days each week to [**Hospital1 8**],
[**State 350**].
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, his vital signs revealed temperature was 98.3,
blood pressure was 160/78, heart rate was 76, respiratory
was 18. Oxygen saturation was 97% on room air. He was awake
and alert, and spoke sufficient English to communicate
reasonably well with the examiner, but he did have an obvious
limitation to the English language. He was awake, alert, and
oriented to person, place, and time. He spoke with a heavy
middle-eastern accent but was conversant, and speech appeared
fluent; although, he did have an accent. His smile was
equal. The tongue was midline. Pupils were status post lens
implant on the right and nonreactive post surgically. On the
left there was a positive cataract but very minimal reaction
to bright light with pupils 2.5 mm to 2 mm reactive on the
left. Extraocular movements were intact. Head, eyes, ears,
nose, and throat was grossly within normal limits. His neck
at the time of admission in the Emergency Room was in a
cervical collar but was nontender. There was no drift of the
upper extremities and no clonus of the left extremities.
There was a small area of scalp abrasions and small evulsion
with approximately a 0.5-cm wedge shaped evulsion on the
superficial right posterior parietal occipital scalp. His
strength was intact in all muscle groups bilaterally in the
upper and lower extremities. Sensory examination was intact
to light touch. Deep tendon reflexes were within normal
limits bilaterally, 2+ and equal bilaterally in the upper
extremities, 2+ and equal at the knees, 1+ and equal at the
Achilles, and plantar response was downgoing. Gait was not
tested at the time of admission in the Emergency Department.
Finger-to-nose was within normal limits, and Romberg was not
tested.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
at the time of admission showed complete blood count,
coagulations, and Chemistry-7 all to be within normal limits.
RADIOLOGY/IMAGING: A CT scan of the head showed a roughly
1.5-cm small right posterior temporal parietal diffuse
intraparenchymal but otherwise was considered within normal
limits with no shift of midline structures. Normal sulci and
ventricles.
HOSPITAL COURSE: Therefore, the patient was admitted to the
Trauma Service for the first 24 hours of his hospitalization.
A repeat CT scan showed essentially no change in the right
posterior temporal parietal intraparenchymal hemorrhage, and
the patient was maintained in the Intensive Care Unit on the
Trauma Service for the first 24 hours of his hospitalization
and was subsequently transferred to the medical/surgical
floor and transferred to the Neurosurgery Service following
the first 24 hours of his hospitalization.
As stated above, a CT scan was felt to be without significant
change, and he was subsequently permitted to ambulate and
enjoy a regular diet.
DISCHARGE DISPOSITION: The remainder of his postoperative
hospitalization was essentially unremarkable, and he was
discharged to home on the morning of [**2145-8-27**] in
the accompaniment of his wife with plans to take the [**Name (NI) 44159**]
train back to his home in [**Location (un) 5622**], and arrangements were
to be made for him to call his primary care physician upon
return to [**Location (un) 5622**] to arrange for any followup.
[**Last Name (LF) **],[**First Name3 (LF) **] 02.205
Dictated By:[**Name8 (MD) 22907**]
MEDQUIST36
D: [**2145-8-27**] 10:06
T: [**2145-9-1**] 08:56
JOB#: [**Job Number 44160**]
cc:[**Telephone/Fax (1) 44161**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2835
} | Medical Text: Admission Date: [**2179-2-5**] Discharge Date: [**2179-2-13**]
Date of Birth: [**2100-4-8**] Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / Sulfa(Sulfonamide Antibiotics) / Penicillins /
Macrobid / Cleocin
Attending:[**Doctor First Name 3290**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
1. EGD [**2179-2-5**]
History of Present Illness:
Ms. [**Known lastname 19122**] is a 78F with PMH of cardiomyopathy (EF 45% per OSH
records), atrial fibrillation on coumadin, questionable liver
cirrhosis, recent ERCP [**2179-1-29**] with sphincterotomy given CBD,
discharged on [**2179-1-31**]. She said that after she was discharged to
home, she continued to feel poorly, weak, just not herself. She
wasn't eating much. Then, beginning yesterday, she felt very
short of breath in the morning. Her caretaker took her to her
[**Hospital 197**] clinic appt, where she was SOB and pale. From there she
was taken to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], where she was given lasix 40mg IV
x1, with 900cc urine output, with improvement in respiratory
status. She was tachycardic initially (not documented if sinus
or Afib with RVR), and given lopressor 5mg IV x1, with
improvement in rate to sinus 60s. She was then admitted for
further management with concern for acute on chronic systolic
heart failure exacerbation. where she was found to have Hct drop
from 28 to 21. She says that she had only taken one dose of the
Coumadin, and was taking Lovenox daily as a bridge. Then, at
[**Hospital3 **], she had [**2-19**] dark black stools. She denies any
chest pain, pressure, lightheadedness with this. Per [**Hospital1 **], these were guaiac positive and thought to be
melanotic.
.
After discharge on [**1-31**], she said her PCP had also discontinued
her Lasix. Therefore, in the last week, all of her
anti-hypertensives had been discontinued for low blood pressure.
She denies any recent NSAID use. She says that she had bright
blood in her underwear back in [**Month (only) 1096**]. At that time she
reports being evaluated at [**Hospital3 **]. She never had a
c-scope at that time.
.
She presented during the last admission from [**1-29**] to [**1-31**] for
elective ERCP based on obstructive picture with elevated Tbili
and mild transaminitis during admission at [**Hospital3 **] with
CT scan showing CBD at that time. She had an ERCP on [**1-29**] with
sphincterotomy.
.
On arrival to the ICU, VS T 96.5 HR 63 BP 102/49 RR 18 O2 sat
99%RA. She says that she feels tired from the long day. She
denies any abdominal pain, nausea or vomiting. She denies any
SOB, chest pain, chest pressure or lightheadedness.
.
Review of systems:
(+) Per HPI. Also positive for anorexia
(-) 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:
Past Medical History:
1. Cardiomyopathy: EF ~45% per pt and OSH record, "severely
dilated left atrium, mild global hypokinesis, mild septal
hypokinesis"
2. Paroxysmal atrial fibrillation
3. Anemia
4. Asthma
5. Hypertension, benign
6. GERD
7. Hypothyroidism
8. Hyperlipidemia
PSgHx:
1. vulva excision
2. dual chamber pacemaker
3. CCY
4. tonsillectomy
5. kyphoplasty
Social History:
She denies tobacco. She drinks 1 glass wine every few months.
She denies drugs. She lives at home alone, and has a 24 hour
caretaker since her broken elbow in [**2178-7-17**].
Family History:
Mother died at 59 of emphasema.
Father died at 76 of sudden cardiac death.
Physical Exam:
Admission Physical:
VS T 96.5 HR 63 BP 102/49 RR 18 O2 sat 99%RA.
General: Alert, oriented, no acute distress, appears mildly
fatigued
HEENT: EOMI, pale subjunctiva, sclera anicteric, dry MM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: no use of accessory muscles, clear to auscultation
bilaterally, no wheezes, rales, rhonchi
CV: RRR, normal S1 + S2, [**3-23**] holosystolic murmur, heard
throughout the precordium, no rubs, gallops
Abdomen: ecchymoses on abdomen (site of Lovenox), soft,
non-tender, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, appropriate, moving all extremities
Pertinent Results:
[**2179-2-6**] 03:14AM BLOOD WBC-7.2# RBC-2.24* Hgb-8.4* Hct-25.3*
MCV-113* MCH-37.5* MCHC-33.3 RDW-22.6* Plt Ct-101*
[**2179-2-12**] 07:30AM BLOOD WBC-8.9# RBC-3.23* Hgb-11.0* Hct-33.8*
MCV-105* MCH-34.0* MCHC-32.5 RDW-22.8* Plt Ct-109*
[**2179-2-9**] 07:18AM BLOOD PT-14.3* PTT-35.1 INR(PT)-1.3*
[**2179-2-12**] 07:30AM BLOOD Glucose-93 UreaN-19 Creat-0.9 Na-135
K-4.7 Cl-104 HCO3-27 AnGap-9
[**2179-2-5**] 07:44PM BLOOD calTIBC-257* Hapto-<5* Ferritn-201*
TRF-198*
[**2179-2-6**] 03:14AM BLOOD tTG-IgA-6
[**2179-2-5**] 07:44PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2179-2-5**] 07:44PM BLOOD HCV Ab-NEGATIVE
TEE REPORT: The left atrium is dilated. No atrial septal defect
is seen by 2D or color Doppler. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45 %). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 30 cm from the
incisors. The aortic valve leaflets are moderately thickened. No
masses or vegetations are seen on the aortic valve. No aortic
valve abscess is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**1-18**]+)
mitral regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetation, or pacemaker associated mass
or vegetation visualized. Mild to moderate mitral regurgitation.
Mildly depressed left ventricular systolic function.
Liver u/s
1. Limited evaluation demonstrating nodular hepatic contour with
increased
heterogeneous hepatic echogenicity, suggestive of cirrhosis.
2. Ascites.
3. Patent hepatic vasculature without evaluation of the right
posterior
portal vein due to patient body habitus and overlying gas.
Evaluation of the
hepatic arteries was also suboptimal due to patient difficulty
breath-holding.
Colonoscopy report:
Two 3mm sessile polyps of benign appearance were found in the
sigmoid colon. Single-piece polypectomies were performed using a
cold forceps in the sigmoid colon. The polyps were completely
removed.
Impression: Polyps in the sigmoid colon (polypectomy)
Otherwise normal colonoscopy to cecum
EGD report:
The ampulla was s/p previous sphincterotomy. There was oozing of
blood at 3 o'clock. The apexes and 3 o'clock were injected with
3 ml of epinephrine 1/[**Numeric Identifier 961**] with good hemostasis. Cauterization
with a gold probe was applied at 3 o'clock successfully.
Impression: The exam of the esophagus was normal.
There was minimal erythema at the distal antrum.
The ampulla was s/p previous sphincterotomy. There was oozing of
blood at 3 o'clock. The apexes and 3 o'clock were injected with
3 ml of epinephrine 1/[**Numeric Identifier 961**] with good hemostasis. Cauterization
with a gold probe was applied at 3 o'clock successfully.
Otherwise normal EGD to third part of the duodenum.
Capsule study pending
If clinical concern persists, repeat examination could be
attempted.
Brief Hospital Course:
Brief Course:
Ms. [**Known lastname 19122**] is a 78F with PMH of cardiomyopathy (EF 45% per OSH
records), atrial fibrillation on coumadin, questionable liver
cirrhosis, recent ERCP [**2179-1-29**] with sphincterotomy given CBD,
discharged on [**2179-1-31**], who was transferred for Hct drop and dark
stools. She was admitted to the ICU for EGD and monitoring. EGD
showed post-sphincterotomy bleed, which was injected with epi.
She had no recurrent bleeding.
.
# Anemia/GIB: She had acute GI bleeding on account of a post
sphincterotomy bleed. She had no further bleeding after
injection of the sphincterotomy site with epinephrine.
In discussion with her outpatient providers, we learned that she
had been admitted to [**Hospital3 3765**] in [**2178**] with a hematocrit
of 20 with guaiaic positive stool. To evaluate this previous
anemia she had an colonoscopy and capsule study. Two benign
appearing polyps were found during the colonoscopy, and these
were sent for evaluation by pathology. SHe had a capsule study,
and the preliminary report is negative, but final report not yet
available. Given that she had no recurrent bleeding, and that
no additional potential bleeding site was identified, she was
advised to resume coumadin with lovenox bridge at home on the
night of discharge. Hematocrit was 33. She will follow up with
her gastroenterologist. Evaluation with hematology would be a
next step.
.
# ? Cirrhosis: u/s showed nodular liver suggestive of
cirrhosis, but no mention of portal hypertension on that exam.
W/u for infectious hepatitis was negative. She will have follow
up with [**Hospital1 18**] liver specialists.
#. Atrial fibrillation: Pt was in sinus on admission and through
much of the hospitalization. On discharged, she is being paced
at 60 beats per minute.
# Chronic congestive heart failure EF at OSH 45% per report.
Patient did require a few doses of lasix during this
hospitalization. On discharge, patient has no rales on exam.
# LE edema: Patient with marked hyperpigmentation, suggestive
of venous stasis. She does have 1+ pitting edema on discharge
with a pressure blister over her left shin. LE edema likely
from venous stasis and prednisone use as her lungs are clear.
She has low dose lasix at home which she will take.
# Hypothyroidism: most recent TSH elevated at 15.66, free T4
1.11. Continued
Levothyroxine 150 mcg daily, and will need repeat TFT's with
outpatient PCP
# Hypertension: Bp meds held during admission b/c of initial
hypotension and GI bleed. Patient advised to restart diovan at
home, and to wait until PCP visit until resuming metoprolol.
# Asthma exacerbation: Patient had acute development of
wheezing while hospitalized. She required a five day course of
prednisone and bronchodilators.
# Bacteremia: Patinet had 2/2 bottles of coagulase negative
bacteremia. It likely developed after she had a picc line
placed in the right UE. PICC line was removed on discovering
bacteremia and she received seven days of IV vancomycin per the
ID team. She had a TTE and TEE that did not demonstrate
vegetation on heart valve or on pacemaker lead.
Medications on Admission:
- amiodarone 200mg daily
- Lovenox 70mcg q12hr
- Levothyroxine 125mcg daily
- Omeprazole 20mg [**Hospital1 **]
- Pravastatin 20mg qhs
- Warfarin 2mg daily
- ASA 81mg daily
- Ativan 1mg po qhs prn insomnia
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lovenox 80 mg/0.8 mL Syringe Sig: 70 mg Subcutaneous twice a
day: take 70mg every twelve hours until instructed to stop by
your coumadin clinic.
6. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
take as needed for leg swelling, or as otherwise specified by
your primary care doctor.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] home care
Discharge Diagnosis:
Post sphincterotomy bleed
Asthma exacerbation
Chronic systolic heart failure
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - walks with cane.
Discharge Instructions:
You were transferred to [**Hospital3 **] Hospital from [**Hospital1 4494**] for evaluation of bleeding. You had a procedure called
an ERCP and were found to have blood loss at the site of the
sphincterotomy which you had recently had. The
gastroenterologists injected the site so that it would not bleed
again, and you have not had any more bleeding. You received
blood, and your hematocrit is now 33.8, and you have not had any
additional blood loss.
You also had bacteria in your blood. You were evaluated by the
infectious disease team who advised that you have an ECHO, or
ultrasound of your heart. There were no infectious growths on
your heart valve as a consequence of having bacteria in your
blood. You received one week of IV antibiotics for this.
Subsequent blood cultures showed that the bacteria had been
cleared from your blood with this treatment.
You had a worsening of your asthma when you were here and
required a few days of prednisone and breathing treatments.
Your breathing is now much improved.
You were also seen by our gastroenterology team in evaluation of
anemia (low blood count) that your doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] were
evaluating. You had an endoscopy and colonoscopy that were not
revealing, and a capsule study to look at your small intestine.
We are awaiting final results on the capsule study, but it
appears not to show any source of blood loss.
You developed some swelling in your legs and a blister in your
legs. You likely held on to some fluid because of the
prednisone that you needed to receive. You may take the lasix
that you have at home.
Please keep the area of blistered skin clean and apply
bacitracin so that it does not become infected.
Since your blood count has been stable for several days, please
resume your lovenox and coumadin at home tonight. Call the
[**Hospital1 **] coumadin clinic on Monday to set up your next blood
check (INR).
In addition, there was some evidence that you may have
cirrhosis, or scarring of the liver. We have set up an
appointment for you to see one of our liver specialists after
you have been discharged.
Followup Instructions:
Please see Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **] next week. Call them to make
an appointment. I will fax each of them a copy of your
discharge summary.
Department: LIVER CENTER
When: THURSDAY [**2179-3-25**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 4254, 7907, 2851, 2449, 2724, 5715, 4280, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2836
} | Medical Text: Admission Date: [**2165-8-13**] Discharge Date: [**2165-8-19**]
Date of Birth: [**2148-4-14**] Sex: F
Service: TRAUMA [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 17 year old
female, four months pregnant, involved as the unrestrained
passenger of a single vehicle roll-over MVC at unknown speed,
prolonged extraction, vehicle was found upright. Driver
reportedly without significant injury. The patient was GCS
14 at the scene, but became combative and confused, was
intubated for airway protection and transferred to [**Hospital1 18**]
emergency department as hemodynamically stable, trauma plus,
intubated, on backboard, C-collar.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vitals temperature 94.3, heart rate
67, blood pressure 123/72, respiratory rate intubated, pulse
ox 99 percent. In general, intubated, sedated, C-collar,
backboard. HEENT pupils equal, round, reactive to light. OP
clear. ET tube at 24. Left scalp laceration with temporal
bone exposed without obvious fracture. No facial stepoff.
No rhinorrhea. Laceration on forehead approximately 20 to 30
cm. Lungs clear to auscultation bilaterally. Cardiovascular
regular rate and rhythm. Abdomen soft, nondistended,
nontender, no bruising noted. Pelvis stable. Extremities
bilateral lower extremities contusions, palpable pulses times
four. Rectal guaiac negative, no tone. Back no stepoff or
obvious injury.
LABORATORY DATA: White blood cell count 31.8, hematocrit
35.1, platelets 298. Chem-7 sodium 141, potassium 3.1.,
chloride 107, bicarb 22, BUN 7, creatinine 0.5, glucose 122.
[**Name (NI) 2591**] PT 13.5, PTT 28.4, INR 1.2, fibrinogen 315. UA
negative. Tox screen negative. ABG pH 7.33, PCO2 43, PO2
118. Chest x-ray negative, no pneumothorax, no hemothorax.
Pelvis no fracture. CT head left frontal epidural hematoma
measuring 2 cm with 5 mm midline shift. CT abdomen and
pelvis negative. CT face and C-spine held secondary to
emergent need for O.R.
HOSPITAL COURSE: In the emergency department the patient was
hemodynamically stable. The epidural hematoma was discovered
on head CT and the patient was taken emergently to the O.R.
for evacuation by neurosurgery after receiving 50 of mannitol
and then started on Dilantin for seizure prophylaxis and
labetalol for blood pressure control. After the operation,
the patient was transferred to the trauma SICU for further
management. On hospital day two the patient was taken to the
O.R. by OMFS for repair of the 20 cm, complex, full
thickness, degloving laceration on the left scalp. Repeat
head CT showed good resolution of the epidural hematoma
without midline shift.
A formal OB/GYN consult was obtained and the patient was
noted to have an intrauterine pregnancy with good fetal heart
tones and a viable fetus. The patient was deemed stable from
an OB standpoint and the OB team signed off with plans for
outpatient followup with the primary OB. Primary OB was
informed of the patient's progress information. Infectious
disease on was consulted on hospital day for antibiotic
recommendations and they recommended starting the patient on
clindamycin and aztreonam to complete a seven day course.
The patient continued steady improvement and was transferred
to the floor on [**2165-8-16**]. The patient was taking good p.o.
and was stable from a neurological standpoint. The patient's
hematocrit drifted into the low 20s, but the patient remained
asymptomatic and no transfusion was given. On [**2165-8-19**] the
patient was taking good p.o., having bowel movements,
ambulating well. OMFS removed the sutures on her forehead
and the neurosurgical service deemed the patient stable for
discharge. The patient was discharged home with followup
appointments as described below.
DISCHARGE DIAGNOSES:
1. Epidural hematoma.
2. Status post craniotomy with evacuation of epidural
hematoma.
3. Scalp laceration, status post debridement and primary
closure.
4. Status post motor vehicle collision.
5. Normal intrauterine pregnancy.
DISCHARGE MEDICATIONS:
1. Multivitamin one q.d.
2. Folic acid 1 mg q.d.
3. Pantoprazole 40 mg p.o. q.d.
4. Docusate 100 mg p.o. b.i.d. p.r.n.
5. Morphine sulfate 15 mg p.o. q.four to six hours p.r.n.
6. Acetaminophen 650 mg p.o. q.four to six hours p.r.n.
FOLLOWUP:
1. Follow up with neurosurgery in two weeks. Call Dr.[**Name (NI) 14510**]
office at [**Telephone/Fax (1) 1669**] for an appointment and to arrange
followup head CT prior to appointment.
2. Call neuro rehab at [**Telephone/Fax (1) 1690**] tomorrow to obtain an
appointment this week with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
3. Follow up with oral maxillofacial surgery on [**Last Name (LF) 2974**],
[**8-23**], at [**University/College **] Dental School. Call [**Telephone/Fax (1) 27823**] to
schedule an appointment. Ask them to remove sutures from the
back of the head as this has been approved by neurosurgery.
These sutures are to come out 10 days after their initial
insertion.
4. Follow up with OB/GYN physicians on [**2165-8-29**],
as originally scheduled.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. 2923
Dictated By:[**Name8 (MD) 17848**]
MEDQUIST36
D: [**2165-8-19**] 14:22
T: [**2165-8-19**] 15:34
JOB#: [**Job Number 48307**]
ICD9 Codes: 2851, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2837
} | Medical Text: Admission Date: [**2191-8-1**] Discharge Date: [**2191-8-8**]
Service: CARDIOTHORACIC SURGERY
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: Mr. [**Known lastname 10378**] is a 79 year-old
gentleman who has known mitral valve prolapse. He has been
treated medically, however, has had increasing symptoms of
shortness of breath as well as peripheral edema over the past
year. A follow up echocardiogram showed worsening mitral
regurgitation and decreasing left ventricular ejection
fraction. He was referred to Dr. [**Last Name (Prefixes) **] for mitral
valve replacement. Cardiac catheterization showed 80%
diagonal occlusion as well as a 50% left anterior descending
coronary artery. His other coronaries showed nonobstructive
disease. He had moderate mitral regurgitation and he had a
left ventricular ejection fraction of 25 to 30%.
PAST MEDICAL HISTORY: Hypothyroidism, hypertension, atrial
fibrillation, mitral valve prolapse, status post right
inguinal hernia repair in [**2189**] and he has a history of hard
of hearing.
MEDICATIONS:
1. Levoxyl 50 micrograms po q day.
2. Accupril 80 mg po q.d.
3. Lasix 40 mg po q.d.
4. Digitek 0.125 mg po q.d.
5. Potassium chloride.
6. Aspirin 81 mg po q.d.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: On [**2191-8-1**] the patient was admitted
to the Operating Room where he underwent a mitral valve
repair with an #26 mm Cosgrove anuloplasty band as well as [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] procedure by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. Postoperatively, he
was transported from the Operating Room to the cardiac
surgery recovery unit on milrinone, Levophed, Amiodarone and
Propofol intravenous drip. He was in normal sinus rhythm at
that time. The patient remained on ventilator support
overnight. He was placed on intravenous Vasopressin drip for
persistent hypotension. He remained with a cardiac index of
2.4 and was AV paced due to sinus bradycardia. Later on the
day of postoperative day one the patient was in normal sinus
rhythm and begun to wean from his vaso active drip. The
patient was weaned from mechanical ventilator and extubated
successfully. An electrophysiology consult was obtained on
the [**8-2**] on postoperative day one. It was their
recommendation to continue Amiodarone since he was in normal
sinus rhythm at this time. The patient continued in normal
sinus rhythm with first degree AV block. On postoperative
day two remains on Amiodarone and Milrinone drip. He was
started on Albuterol for respiratory secretion. His chest
tubes were removed and the patient was begun on diuretics.
The patient on postoperative day three had been weaned off of
his Milrinone. He remained on intravenous Amiodarone drip.
He began to progress with postoperative physical therapy.
Later that day was transferred from the Intensive Care Unit
to the telemetry floor where he continued to progress with
cardiac rehabilitation. On [**8-5**] postoperative day four
the patient remained in normal sinus rhythm, however, was
noted to have periods of atrial fibrillation, which were
nonsustained. The patient's creatinine had risen to about
the 1.5 range from his baseline of 1.2 or 1.3 and has
remained in the 1.5 to 1.6 range. His pacing wires were
discontinued. On postoperative day four the patient had
progressed well with ambulation. His sinus rate was in the
60s and he was begun on po Lopressor as well as his
Amiodarone. On postoperative day five the patient also
remained in normal sinus rhythm with a rate in the 60s. His
blood pressure was in the 140s and he was hemodynamically
stable and was continuing to progress with ambulation. He
was unsteady on his feet and did require a fair amount of
assistance at that time. The following day postoperative day
six the patient remained in normal sinus rhythm on Amiodarone
and Lopressor and was continuing with diuresis. His
creatinine was stable at 1.6. The following day the patient
was noted to have atrial fibrillation again, postoperative
day seven. His Lasix was increased. He remained on
Lopressor and Amiodarone and his rate is well controlled.
The patient remains in atrial fibrillation today, which is
postoperative day eight. His rate is well controlled in the
70s. His blood pressure is stable in the 130s/70s to 80s.
He is ready to be discharged to a rehabilitation facility.
There will be a continuation of this summary stating physical
examination and medications upon discharge.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2191-8-8**] 10:01
T: [**2191-8-8**] 10:18
JOB#: [**Job Number 48312**]
ICD9 Codes: 4240, 4254, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2838
} | Medical Text: Admission Date: [**2146-1-1**] Discharge Date: [**2146-1-19**]
Date of Birth: [**2094-7-30**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
s/p pedestrian vs. car with resultant polytrauma
Major Surgical or Invasive Procedure:
[**2146-1-1**]:
1. Irrigation and debridement of soft tissue, muscle
including bone of the right distal tibia open fracture.
2. Application of multiplanar external fixator to the right
lower extremity.
[**2146-1-5**]:
1. Inferior vena caval filter placed by the right
femoral route.
[**2146-1-5**]:
1. Open reduction, internal fixation left
supracondylar femur fracture.
[**2146-1-12**]:
1) Irrigation and debridement open right tibia
fracture
2) adjustment of external fixator with the addition of
calcaneal tibial pins and
3) closed reduction of the distal tibia fracture
and distal fibular fracture with traction and
manipulation.
History of Present Illness:
Mr. [**Known lastname 15273**] is a 51 year old gentleman who was struck by a car
while intoxicated. There was no LOC. He was transferred from an
OSH for further management of his injuries, which influded a
comminuted left femur fracture, an open right ankle fracture,
and right lateral 2nd and 3rd rib fractures.
Past Medical History:
none
Social History:
homeless
smokes cigarettes
drinks ~12 beers a day, long history of alcohol abuse
Family History:
not applicable
Physical Exam:
Upon Admission:
General Evaluation Exam
BP: 120/73 HR: 93 RR:14 Temp:97.3
Sensorium: Awake () Awake impaired (x) Unconscious ()
Airway: Intubated () Not intubated (x)
Breathing: Stable () Unstable (x)
Circulation: Stable (x) Unstable ()
Musculoskeletal Exam
Neck Normal () Abnormal () Comments: in C-collar
Spine Normal (x) Abnormal () Comments:
Clavicle
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Shoulder
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Arm
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Elbow
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Forearm
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Wrist
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Hand
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Pelvis
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Hip
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Thigh
R Normal (x) Abnormal () Comments:
L Normal () Abnormal (x) Comments: swelling distal
femur
Knee
R Normal () Abnormal (x) Comments:
L Normal () Abnormal (x) Comments:swelling/deformity
Leg
R Normal () Abnormal (x) Comments:
L Normal () Abnormal (x) Comments: Grade IIIa open fx
Ankle
R Normal () Abnormal (x) Comments: open distal tib/fib
L Normal (x) Abnormal () Comments:
Foot
R Normal (x) Abnormal () Comments:
L Normal (x) Abnormal () Comments:
Urethral Bleeding Yes () No (x)
Vascular:
Radial R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
DP R Palpable () Non-palpable () Doppler (x)
L Palpable () Non-palpable () Doppler (x)
PT R Palpable (x) Non-palpable () Doppler ()
L Palpable (x) Non-palpable () Doppler ()
Neuro: (not following commands)
Ant Tib R (weakly fires) L ()
[**Last Name (un) 938**] R (-) L (-)
Peroneal R (-) L (-)
GS R (-) L (-)
On discharge:
AVSS
NAD, A&O x3
CV: RRR
PULM: CTAB
ABD: soft, nt/nd
RLE: exfix in place, pin sites c/d/i, brisk capillary refill,
sensation intact to light touch, motor intact - moving all toes
LLE: knee immobilizer in place, incision c/d/i, brisk capillary
refill, sensation intact to light touch, [**6-1**] [**Last Name (un) 938**]/GS/TA
Pertinent Results:
[**2146-1-1**] 12:55AM BLOOD WBC-11.6* RBC-3.78* Hgb-11.8* Hct-35.9*
MCV-95 MCH-31.3 MCHC-33.0 RDW-14.7 Plt Ct-223
[**2146-1-1**] 04:17AM BLOOD WBC-8.9 RBC-3.71* Hgb-11.5* Hct-35.1*
MCV-95 MCH-31.0 MCHC-32.8 RDW-14.6 Plt Ct-204
[**2146-1-2**] 08:15AM BLOOD WBC-10.1 RBC-3.12* Hgb-9.6* Hct-28.8*
MCV-92 MCH-30.7 MCHC-33.3 RDW-14.6 Plt Ct-156
[**2146-1-3**] 04:50AM BLOOD WBC-9.3 RBC-2.79* Hgb-8.7* Hct-26.0*
MCV-93 MCH-31.3 MCHC-33.7 RDW-14.7 Plt Ct-152
[**2146-1-4**] 04:13AM BLOOD WBC-6.6 RBC-2.24* Hgb-7.0* Hct-21.3*
MCV-95 MCH-31.4 MCHC-33.0 RDW-14.1 Plt Ct-153
[**2146-1-4**] 11:04AM BLOOD WBC-8.3 RBC-2.74* Hgb-8.4* Hct-25.5*
MCV-93 MCH-30.8 MCHC-33.0 RDW-15.4 Plt Ct-164
[**2146-1-4**] 06:45PM BLOOD WBC-8.7 RBC-3.23* Hgb-9.8* Hct-29.5*
MCV-92 MCH-30.3 MCHC-33.1 RDW-16.2* Plt Ct-141*
[**2146-1-4**] 08:17PM BLOOD WBC-7.5 RBC-3.26* Hgb-9.7* Hct-29.8*
MCV-91 MCH-29.9 MCHC-32.8 RDW-16.3* Plt Ct-154
[**2146-1-5**] 02:17AM BLOOD WBC-8.7 RBC-3.20* Hgb-9.9* Hct-28.7*
MCV-90 MCH-31.0 MCHC-34.6 RDW-15.9* Plt Ct-169
[**2146-1-5**] 08:16PM BLOOD Hct-26.8*
[**2146-1-8**] 01:03AM BLOOD WBC-8.0 RBC-2.83* Hgb-8.7* Hct-25.8*
MCV-91 MCH-30.6 MCHC-33.6 RDW-15.1 Plt Ct-226
[**2146-1-8**] 05:00AM BLOOD WBC-8.1 RBC-2.92* Hgb-8.9* Hct-26.6*
MCV-91 MCH-30.4 MCHC-33.3 RDW-15.0 Plt Ct-259
[**2146-1-9**] 02:41AM BLOOD WBC-7.8 RBC-2.87* Hgb-8.7* Hct-25.4*
MCV-89 MCH-30.4 MCHC-34.3 RDW-14.9 Plt Ct-307
[**2146-1-10**] 01:53AM BLOOD WBC-7.1 RBC-2.95* Hgb-9.0* Hct-27.0*
MCV-91 MCH-30.4 MCHC-33.3 RDW-15.0 Plt Ct-327
[**2146-1-11**] 01:50AM BLOOD WBC-8.6 RBC-3.05* Hgb-9.1* Hct-27.7*
MCV-91 MCH-30.0 MCHC-33.0 RDW-15.0 Plt Ct-390
[**2146-1-12**] 10:58AM BLOOD WBC-12.3* RBC-3.31* Hgb-9.7* Hct-30.2*
MCV-91 MCH-29.5 MCHC-32.3 RDW-15.0 Plt Ct-455*
[**2146-1-13**] 02:30AM BLOOD WBC-9.6 RBC-2.92* Hgb-8.8* Hct-27.2*
MCV-93 MCH-30.2 MCHC-32.5 RDW-15.1 Plt Ct-433
[**2146-1-13**] 08:13AM BLOOD Hct-29.1*
[**2146-1-14**] 06:40AM BLOOD WBC-8.5 RBC-3.17* Hgb-9.5* Hct-28.6*
MCV-90 MCH-29.9 MCHC-33.2 RDW-14.9 Plt Ct-454*
[**2146-1-15**] 06:45AM BLOOD WBC-9.2 RBC-3.23* Hgb-9.8* Hct-29.2*
MCV-91 MCH-30.3 MCHC-33.4 RDW-14.4 Plt Ct-511*
[**2146-1-17**] 03:44AM BLOOD WBC-12.1* RBC-3.31* Hgb-9.8* Hct-29.8*
MCV-90 MCH-29.5 MCHC-32.8 RDW-14.7 Plt Ct-504*
[**2146-1-18**] 04:31AM BLOOD WBC-6.7 RBC-3.47* Hgb-10.1* Hct-30.6*
MCV-88 MCH-29.1 MCHC-32.9 RDW-14.5 Plt Ct-474*
[**2146-1-1**] 12:55AM BLOOD PT-13.3 PTT-24.2 INR(PT)-1.1
[**2146-1-2**] 08:15AM BLOOD PT-12.8 PTT-27.1 INR(PT)-1.1
[**2146-1-5**] 02:17AM BLOOD PT-12.0 PTT-26.5 INR(PT)-1.0
[**2146-1-1**] 04:17AM BLOOD Glucose-120* UreaN-11 Creat-0.6 Na-138
K-4.3 Cl-104 HCO3-26 AnGap-12
[**2146-1-2**] 08:15AM BLOOD Glucose-120* UreaN-10 Creat-0.8 Na-136
K-4.2 Cl-100 HCO3-28 AnGap-12
[**2146-1-3**] 04:50AM BLOOD Glucose-124* UreaN-9 Creat-0.7 Na-138
K-3.8 Cl-102 HCO3-28 AnGap-12
[**2146-1-4**] 04:13AM BLOOD Glucose-83 UreaN-13 Creat-0.6 Na-137
K-5.1 Cl-105 HCO3-28 AnGap-9
[**2146-1-5**] 02:17AM BLOOD Glucose-104 UreaN-9 Creat-0.7 Na-141
K-3.8 Cl-108 HCO3-27 AnGap-10
[**2146-1-6**] 01:55AM BLOOD Glucose-121* UreaN-9 Creat-0.6 Na-141
K-4.0 Cl-108 HCO3-28 AnGap-9
[**2146-1-8**] 05:00AM BLOOD Glucose-120* UreaN-9 Creat-0.5 Na-138
K-3.9 Cl-103 HCO3-28 AnGap-11
[**2146-1-10**] 01:53AM BLOOD Glucose-119* UreaN-13 Creat-0.6 Na-142
K-3.9 Cl-107 HCO3-26 AnGap-13
[**2146-1-12**] 10:58AM BLOOD Glucose-125* UreaN-16 Creat-0.8 Na-143
K-4.4 Cl-109* HCO3-25 AnGap-13
[**2146-1-17**] 03:44AM BLOOD Glucose-105 UreaN-14 Creat-0.8 Na-138
K-4.2 Cl-105 HCO3-23 AnGap-14
[**2146-1-18**] 04:31AM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-141
K-4.1 Cl-109* HCO3-24 AnGap-12
[**2146-1-1**] 04:17AM BLOOD ALT-55* AST-70* AlkPhos-78 Amylase-141*
TotBili-0.1
[**2146-1-2**] 07:11PM BLOOD CK(CPK)-569*
[**2146-1-3**] 04:50AM BLOOD ALT-25 AST-46* AlkPhos-60 Amylase-27
TotBili-1.0
[**2146-1-1**] 12:55AM BLOOD Lipase-427*
[**2146-1-1**] 04:17AM BLOOD Lipase-177*
[**2146-1-2**] 08:15AM BLOOD Lipase-17
[**2146-1-3**] 04:50AM BLOOD Lipase-15
[**2146-1-1**] 04:17AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.8
[**2146-1-5**] 02:17AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.0
[**2146-1-5**] 10:00PM BLOOD Calcium-7.6* Phos-3.4 Mg-1.7
[**2146-1-9**] 02:41AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.1
[**2146-1-10**] 01:53AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1
[**2146-1-10**] 01:53AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1
[**2146-1-11**] 01:50AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1
[**2146-1-12**] 10:58AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1
[**2146-1-17**] 03:44AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
[**2146-1-18**] 04:31AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.4
[**2146-1-9**] 02:41AM BLOOD T4-6.2
[**2146-1-9**] 02:41AM BLOOD TSH-4.0
[**2146-1-1**] 12:55AM BLOOD ASA-NEG Ethanol-275* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2146-1-1**] CT torso:
IMPRESSION:
1. Rib fractures, appearing both chronic and with acute rib
fractures seen at the second and third ribs on the right as well
as in the twelfth rib. There is no pneumothorax.
2. Bilateral spondylolysis, without spondylolisthesis at L5.
3. Bilateral dependent atelectasis as well as a poorly
marginated opacity in the right upper lobe. Considerations for
the latter finding include nodule or, less likely aspiration.
Followup is recommended to document
resolution/progression when clinically stable.
[**2146-1-1**] CT RLE:
IMPRESSION:
1. Comminuted displaced left distal femur fracture without
intra-articular
extension.
2. Segond fracture concerning for anterior cruciate ligament
injury.
3. Fracture through the fibular head which may signify
posterolateral corner injury. Further evaluation can be
performed with MRI if indicated.
[**2146-1-1**] Left tib/fib xray:
IMPRESSION: Comminuted fractures of the distal tibia and fibula
Brief Hospital Course:
The patient arrived in the [**Hospital1 18**] ED on [**2146-1-1**]. On primary and
secondary survey, the patient was intoxicated but was otherwise
hemodynamically stable and following commands with a GCS of 15.
Imaging studies ultimately revealed the following injuries:
Comminuted L femur fx
Open right ankle fx / near amputation
R lateral 2nd and 3rd rib fxs
The patient's admission labs also revealed pancreatitis with a
lipase of 427 and an alcohol level greater than 400.
The patient was admitted to the trauma service. The orthopedic
team was consulted and the patient was brought to the OR
[**2146-1-1**] for washout and ex fix placement of the R ankle. He was
started on lovenox. Ortho intended to take the patient back to
the OR for ORIF of his R tib/fib fractures. However, on POD1,
the patient was noted to have fevers and tachycardia. He was
also diaphoretic, agitated and disoriented. He was put on CIWA
protocol for alcohol withdrawal and later transferred to the ICU
on because he was developing delirium tremens.
While in the ICU, the patient required large amounts of valium.
He was also receiving haldol and dilaudid with little effect. An
NGT was used to decompress his stomach and reduce the risk of
aspiration. Because of his worsening progression and increased
somnolence, he was later intubated by the SICU team [**2146-1-3**]. He
was noted to have a Hct of 21 and was therefore received 4 units
of pRBCs.
On [**2146-1-5**], the patient was again brought to the OR for ORIF of
his left femur fracture. At the same time, an IVC filter was
placed by the trauma surgery service. Post-op, the patient was
left intubated and transferred back to the SICU. He was noted to
have fevers overnight and was therefore pancultured and started
on broad-spectrum antibiotics. His sputum eventually grew out
GNRs. His antibiotics were adjusted appropriately.
The patient was eventually started on tube feeds. His vent was
weaned and he was extubated [**2146-1-8**]. He continued to have
altered mental status, delirium and agitation, which was
controlled with Zyprexa. He was seen by physical therapy, who
recommended discharge to rehab.
On [**2146-1-12**], ortho again took the patient to the OR for washout
of the right ankle, adjustment of the ex fix, and closed
reduction of the tib fib fractures. He was intubated a few hours
prior to the OR for increased agitation. It was determined to
keep the patient intubated post-op and obtain a head CT to
assess for any potential etiology of his prolonged agitation and
delirium. This was ultimately negative. The patient was then
extubated and transferred to the floor. After this, the
patient's mental status was noted to improve markedly. He was
then transferred to the orthopedics service for continued
management.
On [**1-16**], he was confused and agitated for most of the day. He
received many doses of haldol, zyprexa, valium with no avail. He
tried to get OOB many times and despite mutiple restraints, he
fell onto his left side suffering a small left eyebrow abrasion.
Xrays were taken of his left femur. The hardware was intact,
with slighly more displacement compared to the fluoroscopic
images taken in the OR. He was transferred back to the SICU for
more close supervision an medical management of his
agitation/delirium.
He became stable and oriented thereafter. In the AM of [**1-18**] he
was alert and oriented to person, time, and place. All
antibiotics and IV medications were stopped prior to discharge.
He is being discharged to [**Hospital1 **] today in stable condition,
with a knee immoblizer on his left leg and an ex-fix to the
right. His staples from his left leg were removed just prior to
discharge.
Medications on Admission:
none
Discharge Medications:
1. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection [**Hospital1 **] (2 times a day).
7. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnosis
S/P pedestrian v. car
1. Comminuted left femur fracture
2. Open right ankle fracture/near amputation
3. Right lateral rib fractures 2&3
4. Delirium tremens
5. Acute blood loss anemia
Secondary diagnoses
1. ETOH abuse
2. Pancreatitis
Discharge Condition:
Stable. Ex-fix to RLE, KI to LLE
Discharge Instructions:
Do NOT drink alcohol. You had life threatening delirium tremens
during your hospitalization. A good addictions program will help
you to stay sober after your discharge, maybe AA.
You suffered a broken left leg which was surgically repaired and
you have a broken right ankle which needs surgery in a few
weeks. You can get up but do not bear weight on the right leg.
The left leg can be touch down weight bearing.
The Orthopedic service will re evaluate you in a few weeks.
Call Dr. [**Last Name (STitle) 1005**] if you have any fevers > 101 or increased
redness or swelling over the right leg.
Physical Therapy:
Activity: Bedrest
Right lower extremity: Non weight bearing
Left lower extremity: Touchdown weight bearing
Knee immobilizer: At all times
Treatments Frequency:
Site: RLE ex-fix
Type: Surgical
Comment: pin care - 50/50 mix of NS and peroxide [**Hospital1 **]
Site: R shin
Type: Surgical
Dressing: Nonadherent Dsg (Adaptic)
Comment: change daily, reinforce as needed with ABD
Site: left knee
Type: Surgical
Dressing: Gauze - dry
Comment: cover only for drainage
Followup Instructions:
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 6429**] for a follow up appointment in 2
weeks
Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up
appointment in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2146-1-19**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2839
} | Medical Text: Admission Date: [**2129-6-9**] Discharge Date: [**2129-6-15**]
Date of Birth: [**2050-1-29**] Sex: M
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
mental status changes
Major Surgical or Invasive Procedure:
EMG
History of Present Illness:
79 yo M with h/o recent four-month period of intermittent
hospitalizations at [**University/College **] hitchcock for respiratory
distress, critical AS, DM, A fib, transferred after two day stay
at [**Hospital1 **] for evaluation of chronic mental status changes. Pt
only able to communicate minimally. History obtained through
records and daughter. Pt was in USOH until [**2-2**] when he was in
an [**Month/Year (2) 8751**] w/ multiple traumas (rib fxs, pulm contusions, T9
compression fx. After [**Name (NI) 8751**] pt admitted DHMC [**Date range (1) 74054**]. DEtails of
this hospitalization unavailable. PT re-admitted [**Date range (1) 16803**] for
malnutrition. PEG placed during this admission. Pt received
diuresis for heart failure. O/w details unavailable. PT d/c'd to
[**Hospital **] [**Hospital 74055**] rehab then shortly transferred due to mental status
change/resp failure. Pt treated on BIPAP unsuccessfully,
developing worsenign hypercarbia and subsequently re-admitted
again to DHMC [**Date range (1) 74056**]. During this admission pt had recurrent
hypercarbic resp failure requiring intubation on three occaions.
Pt was ultimately trached on [**5-25**]. Other notable events during
this hospitalization included: On HD#2 pt intubated for
hypercarbic resp failure, and swanned. Intermittently bolused
for hypovolemia and placed on neo to maintain MAPs. TTE
demonstrated worsening aortic valve area (value unknown).
Valvuloiplasty/ temp PM placed ojn [**4-16**] HD#5: L heart cath:
non-obstructive CAD and nml EF (60%), severe AS, mod pulm htn.
Extubated HD#13, re-intubated HD#14 for hypercarbia. Repeat
valvuloplastytemp PM HD#18. Echo on HD# 26 demonstrated AV area
0.72 cm2. Also on HD#26 extubated, then re-intubated HD#26.
Trach'd HD#40. HD#51, successful off vent on trach trial X 24
hours. Throughout hospitalization multiple sputum cxs and
tracheal aspirates grew MRSA, most recently [**5-18**] (HD#32),
treated with course of vanc. CXR that day with RUL
consolidation. [**5-26**] MRI with small area of increased signal,
likely normal variant. On [**2129-6-8**], pt transferred to [**Hospital **]
rehab for further evaluation.
.
Pt evaluated by neurology at [**Hospital1 **]. Given dual upper and
lower neuron findings, neurology recommended pt be transferred
to [**Hospital1 18**] for admission to NICU and further evaluation.
.
At [**Hospital1 18**] ED, t97m hr 91, bp 135/83, rr 18, sat 98% on 50% trach
mask. In ED sats dropped to mid-80s, improved with increased o2
via venti-mask and suctioning. CT head in ED without acute
pathology. CXR ? pulm edema. Transferred to MICU for further
eval wiht plans for neuro eval in unit.
Past Medical History:
As above, multiple hospitlizations over 4 month period at DHMC,
trach placed [**5-25**]
TCP
CAD
chronically depressed mental status
critical AS valvuloplasty
A fib, on coumadin
chronic b/l pleural effusions
anemia
hypernatremia
MRSA PNA
Social History:
Lived at [**Hospital1 **] forthe past 2 days. Prior to that 14 weeks at
[**University/College **] Hitchcock. Has multiple children. Daughter [**First Name8 (NamePattern2) **] [**Name2 (NI) 74057**]
is a nurse and makes many of his health decisions.
Family History:
non-contributory
Physical Exam:
Temp 97.2
BP 119/83
Pulse 91
Resp 26
O2 sat 100 on 40% mask
Gen - nodding yes/no appropriately, attempting to mouth answers
to questions but appears weak
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - end exp grunt, o/w clear
CV - irreg irreg, 3/6 SEM aty lusb
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds,
G-tube in place
Back - No costovertebral angle tendernes
Extr - R>L UE pitting edema, trace pitting in LE
Neuro - as above, unable to cooperate otherwise, unable to
elicit reflexes, witnessed movement in LUE and both [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] - No rash
Pertinent Results:
[**2129-6-9**]
TYPE-ART O2-100 PO2-385* PCO2-54* PH-7.41 TOTAL CO2-35* BASE
XS-8 AADO2-285 REQ O2-53 COMMENTS-TRACH MASK
GLUCOSE-86 LACTATE-1.1 K+-4.4
GLUCOSE-76 UREA N-44* CREAT-0.7 SODIUM-146* POTASSIUM-4.3
CHLORIDE-108 TOTAL CO2-34* ANION GAP-8
ALT(SGPT)-27 AST(SGOT)-39 LD(LDH)-222 ALK PHOS-102 AMYLASE-21
TOT BILI-0.4
LIPASE-14
CALCIUM-8.9 PHOSPHATE-4.2 MAGNESIUM-2.4
WBC-7.3 RBC-3.08* HGB-9.1* HCT-28.2* MCV-92 MCH-29.6 MCHC-32.3
RDW-17.2*
NEUTS-81.9* BANDS-0 LYMPHS-12.1* MONOS-3.2 EOS-2.4 BASOS-0.4
HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+
MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
PLT SMR-NORMAL PLT COUNT-188
PT-31.4* PTT-54.5* INR(PT)-3.3*
COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0
([**2129-6-9**]) HEAD CT
IMPRESSION:
1. No acute intracranial abnormality.
2. Evidence of acute-on-chronic right maxillary and left
sphenoid sinusitis and right mastoiditis with small amount of
fluid in the left mastoid apex, which should be correlated with
clinical information.
([**2129-6-9**]) CHEST X-RAY
IMPRESSION: Limited examination, without comparisons, with
findings most suggestive of pulmonary edema, which should be
correlated clinically.
([**2129-6-10**]) UPPER EXTREMITY ULTRASOUND, BILATERAL
IMPRESSION: No evidence of DVT in either upper extremity.
([**2129-6-10**]) MRI SPINE
IMPRESSION: Limited study. Mild spinal stenosis at C6/7 without
evidence of spinal cord compression.
([**2129-6-10**]) MRI BRAIN
IMPRESSION:
1. No evidence of an acute infarction.
2. Small chronic lacunar infarction in the body of the right
caudate nucleus.
3. Mucosal thickening and air/fluid level of the right maxillary
sinus consistent with acute sinusitis.
4. No arterial occlusion or evidence of stenosis in the circle
of [**Location (un) 431**].
5. Possible fenestration of the proximal basilar artery.
([**2129-6-10**]) CHEST X-RAY
FINDINGS: Tracheostomy tube is unchanged. There are increased
alveolar opacities bilaterally which may be due to an increased
infectious process or increased pulmonary edema. The heart
continues to be moderately enlarged and there are right greater
than left moderate-sized pleural effusions.
([**2129-6-11**]) EEG:
IMPRESSION: Markedly abnormal EEG due to background slowing
consisting
both of bursts of higher voltage frontally predominant delta
rhythms
with a triphasic morphology followed by background suppression
as well
as more diffuse and persistent slowing. This tracing is
suggestive of
an encephalopathic process and comparison to previous tracing
would be
of interest with regard to progression and associated possible
clinical
diagnosis. Similarly, a repeat study if the patient's mental
status
worsens could be of further diagnostic benefit. No evidence of
epileptiform activity or non-convulsive status epilepticus was
seen
([**2129-6-11**]) ECG:
Atrial fibrillation with rapid ventricular response. Ventricular
ectopy. Left axis deviation. Non-specific intraventricular
conduction delay. There are Q waves in the inferior leads
consistent with prior infarction. There is a late transition
consistent with probable prior anterior wall myocardial
infarction. Diffuse non-specific ST-T wave changes which are
likely related to the intraventricular conduction delay.
Compared to the previous tracing there is no significant change.
Brief Hospital Course:
79 yo M s/p [**Month/Day/Year 8751**], admitted with impaired mental status with
completed neurological workup and in improved condition.
Mental status changes: appeared to be a chronic problem ongoing
since pt's [**Month/Day/Year 8751**]. Per daughter and grandson, no acute changes and
pt at post-[**Month/Day/Year 8751**] baseline. DDx included stroke vs. diffuse axonal
injury from [**Month/Day/Year 8751**] vs. infection vs. traumatic SC injury vs. ICU
neuropathy. Treated empirically with nutrition, MVI, B12,
folate, thiamine. Tests unrevealing to date, and mental status
continued to improve throughout his hospital stay. Neurology was
an active participant in care of this patient. Per their
recommendations, we performed an EEG which revealed changes
consistant with encephalopathy. EMG was also performed and
official [**Location (un) 1131**] will be available shortly.
.
Respiratory distress: Pt arrived in compensated resp acidosis,
trached. Did well using trach mask during day and PSV
overnights.
.
Positive blood cultures: coagulase negative Staph growing in 1
bottle. concern for PICC line infection, rechecked blood cx off
PICC.
.
Anemia: work-up showed Fe-deficiency anemia. gross hematuria
noted, UA sent. Pt started on Fe supplementation.
.
Hypernatremia: controlled with free water flushes while on tube
feeds.
.
Atrial fibrillation: controlled on beta-blocker, coumadin
initially held for elevated INR but re-started at home dose
without complications.
.
Critical AS: stable, no interventions during admission.
.
CAD: stable, on beta-blocker and ASA
.
DM2: Patient was kept on outpatient glargine regimen with good
glucose control.
.
C.diff: presumed given that pt arrived on PO Vanco, c-diff toxin
negative during hospitalization.
.
FEN/GI: During admission, tube feeds were continued and adjusted
per nutrition recommendation.
Prophylaxis: DVT prophylaxis with Heparin SC and pneumoboots. GI
prophylaxis maintained with H2 blocker.
Access: R PICC, Art line
Communication: Remained daughter [**Name (NI) **] [**Name (NI) 74057**] (h) [**Telephone/Fax (1) 74058**], (c)
[**Telephone/Fax (1) 74059**] throughout admission
Patient remained a Full Code throughout admission.
Medications on Admission:
ascorbic acid 500 mg [**Hospital1 **]
asa 325 mg daily
celexa 20 mg daily
lasix 20 mg daily
glargine 35 qhs
lansoprazole 30 mg daily
metoprolol 12.5 mg [**Hospital1 **]
KCL 40 meq [**Hospital1 **]
vanc 375 mg po qid
coumadin ? dose
zinc
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty Five (35)
Units Subcutaneous at bedtime.
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 4-6 Puffs
Inhalation Q6H (every 6 hours) as needed.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO 6AM
and 2PM.
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO 10 pm.
17. Acetaminophen 160 mg/5 mL Solution Sig: Two (2) mL PO Q6H
(every 6 hours) as needed.
18. Lasix 40 mg Tablet Sig: One (1) Tablet PO QAM.
19. Furosemide 10 mg/mL Solution Sig: Four (4) mL Injection QAM
(once a day (in the morning)).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
PRIMARY:
1. Delirium
2. Respiratory failure
SECONDARY:
1. Critical Aortic Stenosis
2. Diabetes Mellitus
3. Hypertension
4. Atrial fibrillation
Discharge Condition:
Stable, maintaining adequate oxygeneation on night-time pressure
support and daytime trach oxygen.
Discharge Instructions:
You were admitted to the hospital because of changes in your
mental status. During your hospitalization, we looked for signs
of infection or new vascular events affecting your brain and did
not find anything different from what was already known.
.
If you develop chest pain, shortness of breath, or those who
care for you find your are acting different or have any other
symptoms, please call your primary care doctor or come into the
emergency department.
Followup Instructions:
Please arrange for visit with your primary care doctor within 1
week.
ICD9 Codes: 4241, 5119, 2762, 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2840
} | Medical Text: Admission Date: [**2124-8-31**] Discharge Date: [**2124-9-2**]
Date of Birth: [**2074-6-20**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Brain Mass
Major Surgical or Invasive Procedure:
PRINCIPAL PROCEDURE:
1. Right-sided craniotomy for resection.
2. Intraoperative image guidance.
3. Microscopic dissection.
4. Duraplasty.
History of Present Illness:
50 yo M who experienced new onset seizures in [**Month (only) 205**] of this year,
found to have a right temporal brain mass, who presents today
for elective resection. He [**Month (only) 1834**] brain biopsy with Dr.
[**Last Name (STitle) **] on [**2124-8-2**] and pathology demonstrates oligodendroglioma
grade 2. He has been seen in Brain [**Hospital 341**] Clinic by Dr. [**Last Name (STitle) 6570**]
and will likely undergo chemotherapy with temozolomide
postoperatively. He is doing well, seizure free on Keppra
1000mg TID.
Past Medical History:
HTN, Right Temporal olidendroglioma grade 2
Social History:
He is divorced and lives alone. He is an air-conditioner
mechanic, and admits to some exposure to refrigerant fluid. He
has one sister and two brothers, all are healthy. He is a former
smoker, quit six years ago. He drinks regularly.
Family History:
Non contributory
Physical Exam:
On Admission: Nonfocal
He has no cognitive deficit in areas of alertness, orientation,
concentration, attention, memory, and language. On cranial nerve
examination, eye movements are full, pupils are equal and
reactive. Full visual fields. Face symmetric. Speech is intact
without dysarthria.
On motor examination, Strength is [**4-27**] in all muscle groups.
Coordination is normal. Fine movements are intact.
Sensation intact to light touch and vibration.
Reflexes are brisker on the right.
Normal Gait.
Pertinent Results:
[**2124-8-31**] Radiology MR HEAD W/ CONTRAST -- There is a
non-enhancing right temporal lobe mass. Previously noted focus
of enhancement is not seen. There is a burr hole in the right
parietotemporal region. No hydrocephalus.
[**2124-8-31**] Radiology CT HEAD W/O CONTRAST -- 1. Post-surgical
changes from right parietal craniotomy with minimal
frontoparietal pneumocephalus.
2. Sulcal effacement and mass effect in the operative bed with
minimal
subfalcine herniation towards the left. No new hemorrhage or
evidence of
acute large territorial infarction.
[**2124-9-1**] Radiology MR HEAD W & W/O CONTRAST --1. Status post
right craniectomy for a right parietal mass excision with a
small amount of hemorrhagic material within the post-surgical
cavity.
2. Minimal perilesional FLAIR signal abnormality which when
compared to the preoperative examination raises the possibility
of residual tumor both
anterior, and posterior to the surgical cavity. However, the
regions that
enhanced preoperatively do appear to have been resected.
3. Right hemispheric dural thickening and enhancement, likely
postoperative.
[**2124-8-31**] 04:10PM GLUCOSE-159* UREA N-24* CREAT-1.0 SODIUM-139
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-26 ANION GAP-16
[**2124-8-31**] 04:10PM estGFR-Using this
[**2124-8-31**] 04:10PM CALCIUM-9.0 PHOSPHATE-4.9*# MAGNESIUM-2.1
[**2124-8-31**] 12:31PM TYPE-ART RATES-14/ TIDAL VOL-600 O2-51
PO2-188* PCO2-33* PH-7.49* TOTAL CO2-26 BASE XS-3
INTUBATED-INTUBATED VENT-CONTROLLED
[**2124-8-31**] 12:31PM GLUCOSE-112* LACTATE-3.1* NA+-136 K+-3.7
CL--100
[**2124-8-31**] 12:31PM HGB-14.5 calcHCT-44 O2 SAT-98
[**2124-8-31**] 12:31PM freeCa-1.09*
Brief Hospital Course:
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a right craniotomy for resection of right
temporal tumor on [**2124-8-31**]. Postoperatively he was extubated and
transfered to the PACU for Q1 hour neurochecks and systolic
blood pressure controll less than 140. His dexamethasone was
increased to 4mg Q6 hours and will be tapered to 4mg daily over
10 days. Postop CT head demonstrated expected post-operative
change and he remained stable overngiht in the PACU. On the
mornign of [**9-1**] he was examined and felt to be stable for
trasnfer to the floor. He was awaiting post-op MRI scan and was
evaluated by PT and OT to establish a discharge plan. The
patient had an uneventful night without complaints. On [**2124-9-2**],
the patient was stable without complaints. Physical therapy
cleared the patient to be discharged to home without need of
services. The patient received instructions, prescriptions, and
was discharged home.
Medications on Admission:
Dexamethasone 4mg Daily, Keppra 1000mg TID
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: do no exceed 4g/day.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for heartburn.
8. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours for 1 days: start [**2124-9-2**].
Disp:*2 Tablet(s)* Refills:*0*
9. dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours for 1 days: start [**2124-9-3**].
Disp:*6 Tablet(s)* Refills:*0*
10. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 1 days: start [**2124-9-4**].
Disp:*2 Tablet(s)* Refills:*0*
11. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 1 days: start [**2124-9-5**].
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right-sided low-grade glioma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-2**] days (from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please make an appointment in the Brain [**Hospital 341**] Clinic. The
Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in
the [**Hospital Ward Name 23**] Building, [**Location (un) **]. If you do not receive a call
or email in 3 days please schedule an appointment, please call
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will need an MRI of the brain with/ or without gadolinium
contrast. If you are required to have a MRI, you may also
require a blood test to measure your BUN and Cr within 30 days
of your MRI. This can be measured by your PCP, [**Name10 (NameIs) **] please
make sure to have these results with you, when you come in for
your appointment.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2841
} | Medical Text: Admission Date: [**2180-12-3**] Discharge Date: [**2180-12-7**]
Date of Birth: [**2138-4-16**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Morphine / Demerol / Tape / Vicodin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
On [**2180-12-5**], she underwent pericardiocentesis with removal of
150cc and placement of a pericardial drain. Cytology sent. Right
8Fr FV removed in cath lab + compression with no issues.
History of Present Illness:
History per [**Hospital1 1516**] B noted dated [**2180-12-4**]. [**Known firstname **] [**Known lastname 12041**] is a
42F with a history of low grade follicular lymphoma being
followed off therapy, with a remote history of Hodgkin's disease
s/p splenectomy, chemotherapy (MOPP) and mantle irradiation who
presented to [**Hospital1 18**] on [**2180-12-4**] with chest pain and dyspnea with
exertion. Of note, she had a recent admission at [**Hospital1 18**] from
[**2180-11-15**] - [**2180-11-16**] for pleuritic chest pain and a fever to 102.
CTA during that admission did not show a pericardial effusion.
No source of her fever was identified and she was discharged to
complete a 7 day course of augmentin given her asplenia. She was
seen in follow up on [**2180-12-1**] at the [**Hospital 1944**] clinic,
during which time she reported that she felt well and that her
chest pain and shortness of breath had improved. However, she
was having ongoing fevers to 101.4 so plan was to repeat CT
torso this week for eval of lymphoma. At that visit, she was
found to have bacturia (no symptoms) and started on bactrim. On
the evening of [**2180-12-3**] she developed shortness of breath with
exertion and possible wheezing. She is [**Name8 (MD) **] NP and she listened to
her lungs and thought she heard a rub. On Sunday, at work she
had [**Name8 (MD) **] MD also listen and he also felt there was a rub. She
noted DOE that morning and was unable to walk short distance to
car. Normally, she can walk up 3 flights of stairs before
getting SOB.
.
In ED initial VS are 99.2 125 144/69 24 95% ra. She was not
given any medications in the ED, but she did receive 1L of NS.
Exam notable for rub. CXR with new bilateral effusions. TTE with
mild early tamponade physiology per Cardiology fellow. Pulsus
was 12-14 per fellow. VS prior to transfer, afebrile, HR down to
107 139/66 20 93% RA. Overnight the VS remained stable, however
while on the floor has developed SOB at rest requiring O2
supplementation and pulsus has widened to 16 mmHg.
Past Medical History:
CARDIAC RISK FACTORS: + Dyslipidemia
CARDIAC HISTORY:
#Radiation-induced aortic and tricuspid regurgitation.
OTHER PAST MEDICAL HISTORY:
# Hodgkin disease Stage IIb diagnosed [**2150**], s/p staging
laparotomy with splenectomy, mantle radiation with persistent
mediastinal adenopathy, followed by MOPP chemotherapy for six
cycles.
# Indolent follicular lymphoma, diagnosed 8 years ago
# Hypothyroidism
# GERD
# LE parasthesia
# Overactive bladder - due to ependymoma.
PSHx: T+A, ExLap/Splenectomy (staging), Excision of T8-T10
ependymoma, Bx L-groin, right clavicular fx s/p pinning
Social History:
Occupation: nurse [**First Name (Titles) 3639**]
[**Last Name (Titles) **]: none
Tobacco: previous
Alcohol: none
Family History:
PGF with sudden cardiac death at age 56.
FH positive for bladder cancer, diabetes and hypertension.
No family history of early MI, arrhythmia, or cardiomyopathies.
Physical Exam:
On Admission To CCU:
VS: T: 98.8 BP: 120/66 HR: 111 regular RR: 18 O2: 92%RA
Pulsus: 6 (126 --> 120)
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm, no carotid bruits
CARDIAC: S1, S2 increased rate, friction rub, pericardial drain
to gravity with minimal output
LUNGS: auscultated anteriorly, CTA bilaterally, unlabored
respirations
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: warm, distal pulses intact, right groin on
hematoma, no bruit, dressing C/D/I.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
On Discharge:
General: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: PERRL. Conjunctiva were pink, no pallor or cyanosis of
the oral mucosa.
Neck: Supple with JVP of 8 cm, unable to visualize above the
clavicles when sitting upwards
Cardiac: S1, S2 increased rate, no friction rub appreciated,
middle thorax incision with dressing ?????? c/d/i
Lungs: CTA bilaterally, decreased breath sounds in Left base
Abdomen: Soft, NTND. No HSM or tenderness.
Extremities: warm, distal pulses intact, right groin no hematoma
or ecchymosis.
Pertinent Results:
CBC: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2180-12-7**] 06:10 5.5 3.11* 9.8* 28.9* 93 31.5 33.9 14.8
580*
[**2180-12-6**] 05:00 7.4 3.34* 10.7* 31.5* 94 32.0 34.0 14.9
556*
[**2180-12-5**] 05:30 7.6 3.20* 9.9* 30.2* 94 30.8 32.7 14.6
532*
[**2180-12-4**] 16:44 7.8 3.29* 10.3* 30.7* 93 31.2 33.4 14.9
529*
[**2180-12-3**] 18:50 9.6 3.21* 10.1* 29.9* 93 31.5 33.9 14.7
510*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps
Metas
[**2180-12-5**] 05:30 67.8 21.6 5.8 4.0 0.8
[**2180-12-4**] 16:44 70.0 18.4 7.5 3.2 0.9
[**2180-12-3**] 18:50 76.7* 14.8* 5.5 2.4 0.6
BASIC COAGULATION PT PTT INR(PT) Plt Ct
[**2180-12-7**] 06:10 580*
[**2180-12-7**] 06:10 12.1 25.6 1.0
[**2180-12-6**] 05:00 556*
[**2180-12-6**] 05:00 12.7 25.7 1.1
[**2180-12-5**] 05:30 532*
[**2180-12-5**] 05:30 13.2 29.2 1.1
[**2180-12-4**] 16:44 529*
[**2180-12-4**] 16:44 13.2 26.4 1.1
[**2180-12-3**] 18:50 510*
[**2180-12-3**] 18:50 12.5 26.2 1.1
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2180-12-7**] 06:10 89 12 0.7 138 4.6 105 28
10
[**2180-12-6**] 05:00 81 12 0.7 141 4.4 103 30
12
[**2180-12-5**] 05:30 99 13 0.6 140 4.3 105 29
10
[**2180-12-4**] 16:44 104 9 0.6 138 4.3 104 26
12
[**2180-12-3**] 18:50 84 15 0.8 132* 4.7 98 26
13
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili
[**2180-12-3**] 18:50 38 33 205 117* 0.2
CPK ISOENZYMES proBNP
[**2180-12-3**] 18:50 337*
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg Uric Acid
[**2180-12-7**] 06:10
[**2180-12-6**] 05:00 9.1 4.1 2.3
[**2180-12-5**] 05:30 8.4 3.9 2.4
[**2180-12-4**] 16:44 8.8 3.4 2.1
[**2180-12-3**] 18:50 3.8 8.9 3.8 2.0 2.9
PERITOCARDIAL FLUID Analysis WBC RBC Polys Lymphs Monos
[**2180-12-4**] 09:45 [**2170**]* [**Numeric Identifier 5863**]* 27* 39* 34*
PERITOCARDIAL FLUID STAINS & FLOW CYTOMETRY CD23 CD45 HLA-DR
[**Last Name (STitle) 7736**]7 Kappa CD2 CD7 CD10 CD19 CD20 Lamba CD5: All completed, no
evidence of lymphoma per hematology/oncology
PERITOCARDIAL FLUID FOR IMMUNOPHENOTYPING T SUBSETS & CD34 CD3
[**2180-12-4**] 14:17 DONE
PERICARDIAL FLUID FOR IMMUNOPHENOTYPING FLOW CYTOMETRY IPT
[**2180-12-4**] 14:17 DONE1
PERITOCARDIAL FLUID CHEMISTRY TotProt Glucose LD(LDH) Amylase
Albumin
[**2180-12-4**] 09:45 4.7 83 557 19
2.9
Pathology report pericardial fluid: NEGATIVE FOR CARCINOMA.
Echo [**2180-12-3**] on admission: LVEF>55%. There is a small to
moderate sized pericardial effusion most prominent anterior to
the right atrium (1.5cm) and right ventricle (1.0cm with
prominent anterior fat pad. No right atrial or right ventricular
diastolic collapse is seen.
CXR AP/Lateral [**2180-12-3**]: Interval development of bilateral
effusions, with associated left basilar opacity, possibly
representing effusion and atelectasis, though associated
airspace consolidation is difficult to exclude radiographically.
Echo [**2180-12-4**]: LVEF>55. The right ventricular cavity is
unusually small. There is a small to moderate sized pericardial
effusion. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology. Compared
with the prior study (images reviewed) of [**2180-12-3**], the
effusion is slightly larger with impaired right ventricular
filling and smaller cavity. Tamponade physiology is now
suggested.
Cardiac Catherization [**2180-12-4**]:
Pericardiocentesis was performed under ultrasound guidance.
Right
heart catheterization revealed elevation of right and left heart
filling
pressures with equalization of diastolic pressures consistent
with
tamponade physiology. After drainiage of 140cc of fluid her left
and
right heart filling pressures remained elevated consistent with
effuso-constrictive physiology. Subxyphoid pericardial drain
sutured into position with drainage to gravity.
Post Cardiac Catherization Echo [**2180-12-4**]: LVEF>55%. RV cavity is
small. Initially, there is a small-moderate size pericardial
effusion, primarily anterior to the right atrium and right
ventricle. With injection of agitated saline, contrast is seen
in the pericardial space. After removal of 140ml of fluid, there
is minimal residual anterior pericardial fluid with expansion of
the right ventricular cavity. Biventricular systolic function
appears good/grossly normal.
Post Drain removal Echo:
LVEF>55%. Right ventricular chamber size and free wall motion
are normal. There is abnormal septal motion/position. There is a
very small pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
There are no echocardiographic signs of tamponade.
CXR [**2180-12-5**]: Interval increase in bilateral pleural effusions,
moderate on the left with associated atelectasis, and small on
the right.
CXR AP/Lateral [**2180-12-6**]: Large pleural effusions are again seen
bilaterally, more prominent on the left, where there is
substantial decrease in volume of the lower lobe. Mild
prominence of interstitial marking suggests some elevation of
pulmonary venous pressure.
Brief Hospital Course:
42 year old woman with a h/o low grade follicular lymphoma and
remote history of Hodgkin's disease s/p splenectomy,
chemotherapy (MOPP) and mantle irradiation who presented to
[**Hospital1 18**] on [**2180-12-3**] with dyspnea.
1. Pericardial Effusion with tamponade physiology by
Echocardiogram: The patient presented with a pericardial
effusion and was found to have constrictive and tamponade
physiology by echocardiogram on Day 2 of hospital stay. The
patient was taken to cardiac catherization and 140 cc of
pericardial fluid was drained and a pericardial drain was left
in place. A repeat echocardiogram showed minimal pericardial
effusion and no longer demonstrated tamponade physiology. The
patient was transferred to the CCU for monitoring. The
pericardial drain had little output over 24 hours and was
removed on [**2180-12-5**]. A repeat echocardiogram continued to show
minimal pericardial effusion and no longer demonstrated
tamponade physiology. The fluid was sent for cytology, flow
cytometry and culture. There is no evidence of lymphoma or
bacterial infection.
2. Bilateral Pleural Effusion: The patient presented with
dyspnea and decreased breath soudns at the bases. The patient
was found to have bilateral pleural effusions by chest x-ray.
The effusions increased in size from [**12-3**] - [**12-5**], but remained
stable after [**12-5**]. The patient originally required oxygen on
admission to the CCU, but no longer required it by discharge.
The patient maintained O2 saturation while ambulating on room
air. The effusions were thought to be secondary to a viral
pleuritis, and there was no clinical evidence for infection.
The hem/onc was not concerned for lymphoma.
3. Urinary Tract Infection: Patient was started on Bactrim DS as
an outpatient for an antibiotic course. This was continued
during the hospital admission has been completed.
4. Follicular Lymphoma: Hematology/Oncology was consulted during
admission. No evidence of active lymphoma causing symptoms
during admission. Patient will follow up as an outpatient. CT
of torso scheduled as an outpatient [**2180-12-8**].
Hematology/Oncology has requested only a CT of abdomen and
pelvis to evaluate for lymphadenopathy.
5. Hypothyroidism: The patient's home medication of
levothyroxine was continued during admission.
6. Bladder Instability: The patient's home medication of
oxybutynin was continued during admission.
Medications on Admission:
HOME MEDICATIONS:
- Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
- Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
- Omeprazole 20 mg Capsule, PO BID
- Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO DAILY
- Oxybutynin Chloride 10 mg Tablet Extended One Tablet PO once a
day.
- Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H as needed
for pain.
- Bactrim DS 1 tab PO BID x 7 days started [**2180-12-1**].
TRANSFER MEDICATIONS:
-tylenol 500-1000mg PO Q6hr PRN
-colase 100mg PO BID PRN
-senna 1 tab PO BID PRN
-bactrim DS 1 tab PO BID (duration 5 days)
-oxybutynin 10mg PO daily
-omeprazole 20mg PO BID
-levothyroxine 100mcg PO daily
Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Pericarditis
Pericardial Effusion
Pleural Effusions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for receiving your care at [**Hospital3 **]. You were
diagnosed with pericarditis, pericardial effusion, and bilateral
pleural effusions secondary to pleuritis. You had a pericardial
drain placed to remove pericardial fluid because you had signs
of cardiac tampanode by cardiac echo. The fluid drained from
the heart was not infected, and did not contain any malignant
cells. You will need an outpatient CT scan of your abdomen and
plevis to look for lymphadenopathy. You will also need to go
the following appointments listed below.
The following medications were changed to your regiment:
ADDED: None
STOPPED: Valacylovir, Bactrim, Ibuprofen
CHANGED: None
Followup Instructions:
PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) **], 8:30 am [**2180-12-13**]. [**Hospital Ward Name 23**] [**Location (un) **]. Central
Suite.
Cardiology: Dr. [**Last Name (STitle) 171**] 1:00 pm on [**2180-12-20**]. [**Location (un) 8661**] [**Location (un) **].
ICD9 Codes: 5119, 5990, 2449, 2724, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2842
} | Medical Text: Admission Date: [**2197-5-26**] Discharge Date: [**2197-6-12**]
Date of Birth: [**2137-10-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
pulmonary edema
Major Surgical or Invasive Procedure:
ERCP on [**5-31**]
AVR (23 mm CE tissue) on [**2197-6-2**]
History of Present Illness:
multiple CHF admissions, flash pulm. edema, adm. to [**Hospital1 **], diuresed and transferred to [**Hospital1 18**] for surgical eval.
Past Medical History:
- Schizophrenia
- Anxiety
Denies any other PMHx, including any cardiac history.
Social History:
Social history is significant for the current tobacco use, about
1 PPD, which he has used for about 44 years. There is no history
of alcohol abuse. He denies any intravenous drug abuse, but
states he has abused "motion sickness" medications in the past.
.
Patient lives independently in an assisted facility with a
roommate. He has no guardian, and makes all of his own
day-to-day decisions. The housing facility is supported by the
Department of Health. He has no known family in the area. At
baseline he walks about one flight of stairs or one block before
getting short of breath (until recently).
Family History:
He denies any family history of premature coronary artery
disease or sudden death.
Physical Exam:
labored breathing
dissuse skin rash
bilat crackles
3/6 systolic murmur
otherwise, unremarkable physical exam on admission
Pertinent Results:
[**2197-6-8**] 05:15AM BLOOD WBC-6.4 RBC-3.09* Hgb-8.9* Hct-26.7*
MCV-86 MCH-28.6 MCHC-33.2 RDW-14.9 Plt Ct-474*
[**2197-6-4**] 01:47AM BLOOD PT-14.8* PTT-32.9 INR(PT)-1.3*
[**2197-6-9**] 05:25AM BLOOD Glucose-90 UreaN-35* Creat-1.6* Na-140
K-4.2 Cl-110* HCO3-21* AnGap-13
[**2197-6-8**] 05:15AM BLOOD Glucose-90 UreaN-36* Creat-2.0* Na-139
K-4.1 Cl-109* HCO3-20* AnGap-14
[**2197-6-7**] 05:10AM BLOOD Glucose-87 UreaN-34* Creat-2.3* Na-137
K-4.1 Cl-107 HCO3-20* AnGap-14
[**2197-5-26**] 09:40PM BLOOD Glucose-111* UreaN-26* Creat-1.0 Na-144
K-4.2 Cl-111* HCO3-24 AnGap-13
CHEST (PA & LAT) [**2197-6-8**] 8:44 AM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
59 year old man s/p AVR
REASON FOR THIS EXAMINATION:
eval for pleural effusions
INDICATION: 59-year-old male status post AVR. Please evaluate
for pleural effusions.
FINDINGS: PA and lateral chest radiographs reviewed and compared
to [**2197-6-6**]. Post-operative cardiac silhouette is stable. Right
IJ central venous catheter has been removed. Pulmonary
vascularity is normal. Mild blunting at the left costophrenic
sulcus is now noted, and there is slightly worsening left
basilar atelectasis. Lungs are otherwise clear. There is no
pneumothorax.
IMPRESSION: Increasing left basilar atelectasis, and likely
small left pleural effusion.
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77286**] (Complete)
Done [**2197-6-2**] at 11:16:26 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2137-10-6**]
Age (years): 59 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for AVR
ICD-9 Codes: 402.90, 440.0, 424.1
Test Information
Date/Time: [**2197-6-2**] at 11:16 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 #: 2008AW4-: Machine: 1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *82 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 49 mm Hg
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *0.9 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Moderately dilated
LV cavity. Mild-moderate global left ventricular hypokinesis.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta. Focal calcifications in
ascending aorta. Simple atheroma in aortic arch. Mildly dilated
descending aorta. Complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Moderate-severe AS
(area 0.8-1.0cm2). Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Physiologic MR (within normal
limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
PERICARDIUM: Trivial/physiologic 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. Left pleural effusion.
Conclusions
PRE CPB No spontaneous echo contrast is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is mild to moderate global left
ventricular systolic dysfunction. Right ventricular chamber size
and free wall motion are normal. 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. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed, particularly the left and right
coronary cusps. There is moderate to severe aortic valve
stenosis (area 0.8-1.0cm2). Moderate (2+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
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.
POST CPB Normal right ventricular systolic function. Left
ventricle with continued mild to moderate global sytolic
dysfunction. A bioprosthesis is located in the aortic position.
It is well seated and displays normal leaflet function. There is
trace valvular aortic regurgitation. The maximum gradient across
the aortic valve is 54 mm Hg with a mean gradient of 36 mm Hg at
a cardiac output of 7.5 l/m. The effective orifice area of the
valve is 1.6 cm2. The thoracic aorta is intact. No other changes
from pre bypass study..
ERCP BILIARY&PANCREAS BY GI UNIT [**2197-5-30**] 2:40 PM
ERCP BILIARY&PANCREAS BY GI UN
Reason: Please review ERCP images done [**5-30**]
[**Hospital 93**] MEDICAL CONDITION:
Suspected bile ducts stone
REASON FOR THIS EXAMINATION:
Please review ERCP images done [**5-30**]
ERCP BY GI UNIT
INDICATION: 59-year-old man with suspicion for bile duct stone.
COMPARISON: MRCP from [**2197-5-29**].
FINDINGS: Six fluoroscopic images are submitted for evaluation
after ERCP by the Gastroenterologist. The radiologist was not
present at the time of study. There is some marked narrowing at
the distal CBD with some more proximal dilatation. However,
there is no filling defect definitively demonstrated on the
submitted images.
IMPRESSION: Markedly narrowed distal CBD without any evidence of
a filling defect. For further details, see the gastroenterology
report in CareWeb from the same day.
Brief Hospital Course:
59 y/o male presented to OSH in pulmonary edema, was treated
w/diuretics, and transferred to [**Hospital1 18**] on [**2197-5-26**] for surgical
evaluation.
He was admitted to the medical service where he was continued
with diuresis. A GI consult was obtained due to his history of
gallstone pancreatitis, and ongoing dull abdominal pain with
elevated LFT's. He underwent an ERCP on [**5-31**], and a CBD stone
had passed after the procedure. A dental consult was obtained
on [**5-31**], and it was recommended that tooth # 18 be removed.
This did not occur prior to surgery, and the patient was taken
to the OR on [**6-2**] where he underwent an AVR (#23mm CE
pericardial valve). Please see operative report for details of
surgical procedure.
On POD # 1, he was extubated, and hemodynamically stable, but he
was agitated and non-verbal. It was unclear at the time if this
was a neurologic problem vs. psychiatric. Both Neuro & psych
consults were obtained, his psych. meds were altered, and his
mental status improved significantly over the next few days.
His chest tubes and epicardial pacing wires were removed. Head
CT showed no acute process and carotid u/s was normal. He was
transfused for HCT 26. On POD # 4, she was transferred from the
ICU to the telemetry floor. He had returned to his baseline
psych status, and began to progress with physical therapy &
ambulation. He was ready for return to his group home on POD
#10. He will require Pen VK until he is seen by a dentist and
his tooth is extracted, and will need follow up with his
psychistrist as well as with GI for a repeat CT and colonoscopy.
Medications on Admission:
Lisinopril 5'
Colace 100"
Carafate
MVI
Zocor 40'
Folic Acid 1'
Iron 325"
Lasix 40'
ASA 81'
Toprol XL 25'
Nicotine patch
Benztropine 0.5 "'
Discharge Medications:
1. Simvastatin 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Folic Acid 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Fluphenazine HCl 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
4. Valproic Acid 250 mg Capsule [**Month/Year (2) **]: Three (3) Capsule PO Q12H
(every 12 hours).
Disp:*180 Capsule(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0*
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Norvasc 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Toprol XL 25 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
11. Penicillin V Potassium 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
four times a day: until tooth extraction.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Able VNA
Discharge Diagnosis:
AS
schizophrenia
chronic, systolic CHF
duodenitis
gallstone pancreatitis
HTN
hyperlipidemia
AS
schizophrenia
chronic, systolic CHF
duodenitis
gallstone pancreatitis
HTN
hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
shower daily, no bathing or swimming for 1 month
no creams, lotions, or powders to any incisions
no driving for 1 month
no lifting > 10 # for 10 weeks
Followup Instructions:
with Dr. [**Last Name (STitle) **] in [**4-15**]- weeks
with Dr. [**Last Name (STitle) **] in [**2-12**] weeks
with Dr. [**Last Name (STitle) **] in [**2-12**] weeks
Completed by:[**2197-6-12**]
ICD9 Codes: 4241, 4280, 4019, 2724, 2859, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2843
} | Medical Text: Admission Date: [**2116-6-18**] Discharge Date: [**2116-6-24**]
Date of Birth: [**2061-11-9**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
CODE STROKE/DIZZINESS, BLURRED VISION
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname 1743**] [**Known lastname 31603**] is a 54 yo right handed woman with a history of
hypertension, PVD s/p radiation to the pelvis for vaginal
cancer.
She presents today after waking at 6am with an unsteady gait and
feeling as though her vision was blurred. When walking, she felt
as if she was lurching back and forth and this prompted her to
seek medical attention. The patient states that she had a mild
UTI last week as well as a mild occiptal, thobbing headache
yesterday. Otherwise, she has been feeling in her usual state
of
health. She normally takes coumadin for her peripheral stents
but
had stopped this 3 days prior in preparation for a possible
dental proceedure. She denies ever having symptoms like this
before. She reports remote migraine headaches but her current
symptoms do not compare.
On neurologic review of systems, the patient reports the return
of a dull [**2-12**] denied headache, she reports blurred vision, but
debies diplopia, dysarthria, dysphagia, tinnitus or hearing
difficulty. She denied difficulties producing or comprehending
speech. She has no focal weakness, numbness, parasthesiae. She
straight caths several times daily as she has an umbilical
ostomy. She denied difficulty with gait.
On general review of systems, the patient reports a mild fever
with her URI symptoms last week (did not take her temperature
but
felt warm and then woke up in a sweat at night). She denies
cough or shortness of breath. Denied chest pain or tightness,
palpitations. She denies nausea, vomiting, diarrhea,
constipation or abdominal pain. All other ROS was negative.
Past Medical History:
-Vaginal cancer 10 years ago; s/p pelvic exeneration with
neovagina and neobladder
-Hypertension
-Vasovagal episodes
-s/p small bowel obstruction
-S/p R ilio-AKpop BPG w/vein ([**8-5**]), stents placed
-S/p left kidney surgery as a child, has left hydronephrosis
-Osteopenia
-Migraines- not in many years, no aura
Social History:
Married. Works as a neuroscience nurse [**First Name (Titles) **] [**Last Name (Titles) 112**]. Has a history
of
tobacco use, 1ppd x 20 years. Still smokes on occasion. Social
alcohol use. No drugs, no over the counter supplements.
Family History:
Hx of maternal hypertension. No history of cancer, stroke,
clotting disorders.
Physical Exam:
97.7 BP 145/72 HR 62 RR 16 O2%
General: Awake, cooperative, NAD.
Head and Neck: no cranial abnormailites, no scleral icterus
noted, mmm, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm, normal s1/s2. No murmurs,
rubs,
or gallops appreciated.
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or
organomegaly noted.
Extremities: 2+ radial, DP pulses bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Had difficulty [**Location (un) 1131**] (very slow, but reads
correctly) stated that her vision is blurrie, like parts of the
words are missing. Speech was not dysarthric. There was no
evidence of apraxia or neglect. Registered [**3-4**] and recalled [**1-5**]
at 5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. Visual fields full to
confrontation. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages. Visual acuity 20/25 +/- both eyes with
corrective lenses.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No rigidity. No adventitious movements, such as
tremors, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 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
double simultaneous stimuli.
-Deep tendon reflexes:
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on right, mute on left.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
mild dysmetria on FNF on the left, normal HKS bilaterally.
-Gait: deferred
Pertinent Results:
[**2116-6-23**] 03:25AM BLOOD WBC-6.9 RBC-4.64 Hgb-14.3 Hct-43.1 MCV-93
MCH-30.8 MCHC-33.2 RDW-13.9 Plt Ct-238
[**2116-6-22**] 03:45AM BLOOD WBC-6.7 RBC-4.56 Hgb-14.3 Hct-42.3 MCV-93
MCH-31.3 MCHC-33.8 RDW-13.7 Plt Ct-228
[**2116-6-21**] 05:01AM BLOOD WBC-6.8 RBC-4.70 Hgb-14.4 Hct-43.8 MCV-93
MCH-30.6 MCHC-32.8 RDW-14.0 Plt Ct-237
[**2116-6-23**] 03:25AM BLOOD Glucose-109* UreaN-24* Creat-1.1 Na-141
K-3.9 Cl-106 HCO3-25 AnGap-14
[**2116-6-23**] 03:25AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.1
Imaging:
Brief Hospital Course:
Ms. [**Known lastname 31603**] was admitted to neurology ICU after she presented to
ED for visual blurring and was evaluated initially as code
stroke.
Neuro
She underwent code stroke evaluation with CT scan of head as
well as CTA of head and neck which showed hypodense areas
within the right cerebellum and complete occlusion of right
vertebral artery. This suggested possible embolic source either
from heart or from the veins in legs travelling as paradoxical
emboli through a PFO or emboli from large vessels. This was
addressed by MRI with contrast to look for any underlying mass ,
given h/o vaginal cancer. The MRI showed
"multiple infarcts in bilateral posterior circulation territory
in the setting
of a very irregular distal right vertebral artery with a short
segment of
high-grade stenosis versus a short dissection. There appears to
have been
interval partial recanalization of the right vertebral artery
compared to the
CTA." She was closely monitered with neuro checks Q1H. She was
started on heparin IV with goal; PTT between 50-70. Coumadin was
added on day 2 with therapeutic goal INR [**2-5**]. The possibility of
neuro intervention such as clot retrieval was discussed but it
was felt that this may carry high risk and she did not have
significant deficits on exam, hence it was held off. Heparin
was stopped and she was discharged on coumadin with an INR
Cards
She was frequently monitored on telemetry for any arrthymia such
as fibrillation. The tele review was negative. She underwent
ECHO which showed mild left ventricular hypertrophy with normal
biventricular systolic function; mild mitral regurgitation. No
PFO/ASD were identified. Blood pressure goal initially was MAP
95-110 and pressors were used to increase cerebral perfusion,
however after 24-48 hrs, pressors were tapered off and Blood
pressure was allowed to autoregulate. Her BP mediations will be
slowly re-added as an outpatient.
Endo
RISS with gluocose checks. Fingerstick were normal and this was
discontinued
Renal
close watch over BUN CR and well as fluid status.
OT/PT/SS
She was seen by speech therapy who felt that she needed
outpatient therapy for her alexia.
Medications on Admission:
Coumadin 5mg/6mg QOD
Cardizem 240mg daily
Lisinopril 40mg daily
[**Month/Day (3) 25712**] XL 100mg daily
Discharge Medications:
1. Warfarin 6 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*6 Tablet(s)* Refills:*0*
2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
4. INR check Sig: One (1) on [**2116-6-26**].
Disp:*1 1* Refills:*0*
5. Speech therapy Sig: 10 every seventy-two (72) hours:
Speech therapy .
Disp:*1 1* Refills:*0*
These will be restarted by your PCP:
[**Name10 (NameIs) **] Succinate 100 mg Tablet Sustained Release 24 hr Sig:
One (1) Tablet Sustained Release 24 hr PO once a day.
Cardizem LA 240 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Right cerebellar stroke and complete occlusion of right
vertebral artery.
Discharge Condition:
She has mild dyslexia.
MS: intact
CN: 20/40 in R eye, 20/20 in L,
Motor: no deficits
[**Last Name (un) **]: no deficits
Gait: normal, narrow based.
Discharge Instructions:
You have had a stroke. You were placed on anticoagulation and
will need follow up with your PCP to check your INR levels.
You also had a UTI for which you were treated
Followup Instructions:
You will follow up with Dr. [**First Name (STitle) **] in the stroke clinic on [**7-17**] at noon ([**Hospital Ward Name 23**] building, [**Location (un) 442**]).
You will follow up with your PCP [**Last Name (NamePattern4) **] 48 h to check your INR.
You will receive speech therapy as prescribed
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2844
} | Medical Text: Admission Date: [**2143-1-12**] Discharge Date: [**2143-1-12**]
Date of Birth: [**2075-7-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aspirin
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Respiratory distress, rule-out wound infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64F with history of subglottic stenosis and chronic
tracheostomy. Was recently discharged from [**Hospital1 18**] on [**1-9**] after
sternotomy and thyroidectomy for a large goiter with
intrathoracic extension and tracheal compression. On [**1-11**] became
SOB, went to OSH where she underwent bronchoscopy and removal of
multiple mucous plugs with subsequent improvement of her
respiratory distress. By report, however, the staff were
concerned about questionable cellulitic changes and
purulent-appearing discharge from the inferior aspect of her
sternotomy incision.
Past Medical History:
Mild-to-moderate bronchomalacia
multi-nodule goiter
HTN
Morbid obesity
CAD
CHF
s/p small bowel resection and ileostomy for strangulated bowel
DM2
COPD
Stable angina
H/o resp. failure s/p tracheostomy
Right adrenal and liver lesions
pericardial effusion
Social History:
She lives at [**Hospital1 **]. She is a former silk mill worker. She
denies tobacco and alcohol.
Family History:
Noncontributory
Pertinent Results:
[**2143-1-12**] 02:13AM WBC-12.5* RBC-3.25* HGB-9.7* HCT-28.5* MCV-88
MCH-29.8 MCHC-33.9 RDW-14.9
[**2143-1-12**] 02:13AM URINE RBC-1 WBC-21-50* BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2143-1-12**] 02:13AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
Brief Hospital Course:
Ms. [**Known lastname **] was transferred to [**Hospital1 18**] in the early morning of
[**2143-1-12**] for concerns of respiratory distress and possibly
sternal wound infection/mediastinitis from an OSH. On arrival,
the the trauma SICU, the patient was afebrile with slight
bradycardia (55bpm) but otherwise stable and respiring well with
an oxygen saturation of 100% on 10L humidified oxygen via trach.
collar. The inferior aspect of her wound was draining a liquidy
clear yellow fluid which appeared more oily and was without
foul-smell (indeed, was without any odor). The area appeared
hyperemic but was without any evidence of fluctuation or frank
pus. A serum WBC count was 12,500 and consistent with those
from the past four days prior to her recent discharge (i.e.
11-12,000). A Gram stain of the sternal fluid showed 1+ PMNs
but no organisms; culture growth is still pending. A urinalysis
was consistent with her known UTI (which could possibly be
contributing to her leukocytosis) (for which she is to receive a
further 3 week course of ceftriaxone). lastly, a CXR showed
some slight volume loss on the left side but appeared improved
on the right with no change in the cardiac silhoutte or
mediastinal contours.
Ms. [**Known lastname **] was therefore deemed to be without sternal infection
and stable to return to her rehab facility. She is to continue
with her 3 week course of vancomycin (for MRSA bacteremia) and
ceftriaxone as previously decided. She is follow-up with Drs.
[**Name5 (PTitle) **] (Thoracic Surgery) in 2 weeks and [**Doctor Last Name **]
(Interventional Pulmonology) in [**5-17**] weeks. She is to maintain
her intravenous antibiotics for an additional 3 weeks and keep
her T-tube capped at all times, if possible. Lastly, a work-up
for her adrenal mass was negative to date for pheochromocytoma
but will be completed as an outpatient with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
(Endocrinology).
Medications on Admission:
1. Lidocaine HCl 0.5 % Solution Sig: 2 mL MLs Injection Q1H
(every hour) as needed for cough.
Disp:*QS ML(s)* Refills:*0*
2. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) as needed for copd.
Disp:*QS 1* Refills:*0*
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) as needed for dvt prophylaxis.
Disp:*qs 1* Refills:*0*
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for copd.
Disp:*qs 1* Refills:*0*
6. Albuterol Sulfate 0.083 % Solution Sig: [**2-12**] Inhalation Q4-6H
(every 4 to 6 hours) as needed.
Disp:*qs 1* Refills:*0*
7. Ipratropium Bromide 0.02 % Solution Sig: [**2-12**] Inhalation
Q4-6H (every 4 to 6 hours) as needed.
Disp:*qs 1* Refills:*0*
8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*qs 1* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 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. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QID PRN ().
Disp:*30 Tablet(s)* Refills:*2*
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
16. Hydroxyzine HCl 25 mg/mL Solution Sig: [**2-12**] Intramuscular
Q4-6H (every 4 to 6 hours) as needed.
Disp:*qs 1* Refills:*0*
17. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO TID (3
times a day) as needed for t-tube care.
Disp:*qs ML(s)* Refills:*0*
18. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for cough ONLY.
Disp:*qs Tablet(s)* Refills:*0*
19. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*qs Tablet(s)* Refills:*0*
20. Hydromorphone 2 mg/mL Syringe Sig: [**2-12**] Injection Q3-4H
(Every 3 to 4 Hours) as needed for breakthrough pain.
Disp:*qs 1* Refills:*0*
21. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*qs 1* Refills:*2*
22. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*qs 1* Refills:*2*
23. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
24. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 3 weeks.
Disp:*qs 1* Refills:*0*
25. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) Intravenous Q24H (every 24 hours) for 3 weeks.
Disp:*qs 1* Refills:*0*
26. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Disp:*qs ML(s)* Refills:*0*
Discharge Medications:
1. Lidocaine HCl 0.5 % Solution Sig: 2 mL MLs Injection Q1H
(every hour) as needed for cough.
Disp:*QS ML(s)* Refills:*0*
2. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) as needed for copd.
Disp:*QS 1* Refills:*0*
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) as needed for dvt prophylaxis.
Disp:*qs 1* Refills:*0*
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for copd.
Disp:*qs 1* Refills:*0*
6. Albuterol Sulfate 0.083 % Solution Sig: [**2-12**] Inhalation Q4-6H
(every 4 to 6 hours) as needed.
Disp:*qs 1* Refills:*0*
7. Ipratropium Bromide 0.02 % Solution Sig: [**2-12**] Inhalation
Q4-6H (every 4 to 6 hours) as needed.
Disp:*qs 1* Refills:*0*
8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*qs 1* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 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. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QID PRN ().
Disp:*30 Tablet(s)* Refills:*2*
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
16. Hydroxyzine HCl 25 mg/mL Solution Sig: [**2-12**] Intramuscular
Q4-6H (every 4 to 6 hours) as needed.
Disp:*qs 1* Refills:*0*
17. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO TID (3
times a day) as needed for t-tube care.
Disp:*qs ML(s)* Refills:*0*
18. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for cough ONLY.
Disp:*qs Tablet(s)* Refills:*0*
19. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*qs Tablet(s)* Refills:*0*
20. Hydromorphone 2 mg/mL Syringe Sig: [**2-12**] Injection Q3-4H
(Every 3 to 4 Hours) as needed for breakthrough pain.
Disp:*qs 1* Refills:*0*
21. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*qs 1* Refills:*2*
22. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*qs 1* Refills:*2*
23. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
24. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 3 weeks.
Disp:*qs 1* Refills:*0*
25. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) Intravenous Q24H (every 24 hours) for 3 weeks.
Disp:*qs 1* Refills:*0*
26. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Disp:*qs ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Commons
Discharge Diagnosis:
Respiratory Distress
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
Please take your antibiotics as prescribed. They shall be given
intravenously.
You may resume your diet as tolerated.
Take your medications as prescribed.
You may take showers.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in Thoracic Surgery in 2 weeks.
Call [**Telephone/Fax (1) 4741**] to schedule an appointment.
Please follow-up with Dr. [**First Name (STitle) **] in [**Hospital 1800**] clinic within 1
week of your discharge for your thyroid disease. Call
[**Telephone/Fax (1) 69423**] for an appointment.
Please follow-up with Dr. [**Name (NI) **] in Interventional
Pulmonology for your T-tube in [**5-17**] weeks. Please call
[**Telephone/Fax (1) 3020**] for an appointment.
ICD9 Codes: 4280, 496, 5990, 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2845
} | Medical Text: Admission Date: [**2141-7-3**] Discharge Date: [**2141-7-9**]
Date of Birth: [**2061-11-9**] Sex: F
Service: MEDICINE
Allergies:
Calcium Channel Blocking Agents-Benzothiazepines /
Statins-Hmg-Coa Reductase Inhibitors / Nexium / Amiodarone
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Increasing palpitations
Major Surgical or Invasive Procedure:
Pulmonary vein isolation
History of Present Illness:
79-year-old female with a longstanding history of paroxysmal
atrial fibrillation, HTN, and hyperlipidemia who was admitted
for afib ablation. Has had atrial fibrillation x39 years but
recently episodes have increased in frequency, requiring four
hospitalizations since [**2140-12-22**]. She is symptomatic with
these episodes, with rates in the 140s to 160s. She describes
palpitations with her atrial fibrillation, as well as having
severe chest pain and burning that makes her feel like she is
having a heart attack, severe fatigue and lightheadedness. She
states that these episodes are incapacitating. She was referred
for pulmonary vein isolation and ablation of afib on day of
admission.
.
Atrial fibrillation history is as follows: She has had
paroxysmal atrial fibrillation since the age of 40 and has been
managed on beta-blockers, calcium channel blockers, digoxin,
amiodarone and more recently sotalol, on escalating doses.
Currently on 160mg PO BID and continues having breakthrough
episodes on that dose. She was intolerant to amiodarone with
extreme tremors and was unable to tolerate calcium channel
blockers as well. She has had two prior DC cardioversions and
multiple hospital admissions for chemical conversions.
.
Patient had pulmonary vein isolated with all veins isolated.
Found to have atrial tachycardia, pt shocked out of AT. Sheath
pulled in lab after protamine was given. Case complicated by
large pelvic hematoma (12x 5 cm) without retroperitoneal bleed,
so patient transfused 2units pRBCs, transferred to CCU for
further observation.
.
On arrival to CCU, pt in sinus rhythm, stable hemodynamics.
denied chest pain, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope. Pt arrived on Neosynephrine drip, which was
subsequently weaned due to stable SBPs in the 130s--> 100s after
weaned. Finished her ordered 2 units of PRBC, rechecked Hct
q6hrs. Hct bumped appropriately from 29.4-->36.0. INR was
therapeutic at 2.8, coumadin held overnight. Controlled pain
with Tylenol #3.
.
Cardiac review of systems significant for no lower extremity
edema, orthopnea, syncope or presyncope. She has had no symptoms
consistent with stroke and/or TIA.
Past Medical History:
PAST MEDICAL HISTORY:
1.CARDIAC RISK FACTORS:(-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-atrial fibrillation x 39yrs
-PERCUTANEOUS CORONARY INTERVENTIONS:
-cardiac catheterization in [**2138**], complicated by femoral artery
either perforation or dissection.
-CABG: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Hyperlipidemia, not on statin due to intolerance/severe muscle
cramps
-Hypertension
-s/p 2 total right hip replacements and two additional right hip
surgeries
-GERD,
-[**2-26**]: emergent exploratory laparotomy after bowel perforation
from
swallowing part of a tooth pick
-s/p resection of skin cancers
-s/p appendectomy
-s/p resection of ovarian cyst
-s/p hemorrhoid surgery
Social History:
She is married and lives with her husband in [**Name (NI) 67742**],
[**State 2748**]. She has one 59 year old son.
[**Name (NI) 1139**]: She is a former smoker, quit 17 years ago
-ETOH: was a formal drinker but does not drink anymore due to
her
atrial fibrillation.
-Illicit drugs: Denies
Family History:
NC
Physical Exam:
VS: T=99.5 BP=131/64 HR=85 RR=12 O2 sat=99% on 2L NC
GENERAL: WDWN F 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 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. II/VI systolic murmur throughout
precordium, no rubs/gallops. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft but tender to palpation over Left lower abdomen to
midline, 3-4cm below umbilicus. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Femoral sites oozing.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Pertinent Results:
ECGs
Post-Intervention ECG, [**2141-7-3**]: Sinus rhythm, rate 74bpm, L
axis, atrial bigeminy, old LBBB.
ECG on arrival to CCU [**2141-7-3**]: Sinus rhythm, rate 81bpm, left
axis, old LBBB.
[**2141-6-9**]: sinus rhythm at a rate of 57 beats per minute with a PR
interval of 180 ms, a QRS interval of 142, and QTC of 477. She
notably has a left bundle-branch block.
CARDIAC CATH: [**2141-7-3**] - PVI procedure - wet read per EP fellow
note
s/p PVI. all veins isolated. AT (lower loop around IVC; ablated:
then reentry around CS os (confirmed by pacing R and l side);
burns around CS and within CS. Cs sheath got pulled back during
case: case terminated; pt shocked out of AT. sheath pulled in
lab after protamine was given. L hemipelvic hematoma
CT abd/pelvis [**7-3**]:
There is a large complex fluid collection in the left
hemipelvis, with several fluid levels, suggestive of acute
bleeding. The collection displaces urinary bladder, which
contains a Foley catheter. The collection extends along the left
iliac vessels and into the left inguinal region. The overall
measurements are approximate due to complex shape. The largest
dimensions are 12.5 x 5.5 cm in the axial plane. The rectum is
unremarkable, and the sigmoid colon is displaced by a
collection.
CT abd/pelvis [**7-4**]:
- Large extraperitoneal left pelvic hematoma has slightly
increased in size, measuring overall 14.7 x 6.8 cm in largest
axial dimensions, compared to 12.5 x 6.0 previously. There is
slightly greater superior extent of the hematoma which now
slightly expands the left psoas muscle. The hematoma continues
to displace and compress the urinary bladder as well as the
sigmoid colon.
ADMISSION LABS
[**2141-7-3**] 09:01PM HCT-36.0
[**2141-7-3**] 02:29PM HCT-29.4*#
[**2141-7-3**] 02:03PM PO2-72* PCO2-37 PH-7.37 TOTAL CO2-22 BASE
XS--3
[**2141-7-3**] 02:03PM HGB-11.2* calcHCT-34 O2 SAT-94
[**2141-7-3**] 08:53AM WBC-9.0# RBC-4.61 HGB-13.4 HCT-39.8 MCV-86
MCH-29.1 MCHC-33.7 RDW-13.0
[**2141-7-3**] 08:53AM PLT COUNT-284
[**2141-7-3**] 06:45AM GLUCOSE-112* UREA N-17 CREAT-0.8 SODIUM-140
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-16
[**2141-7-3**] 06:45AM PT-28.3* PTT-35.4* INR(PT)-2.8*
DISCHARGE LABS
INR=2.9
Hct=30.9
[**2141-7-9**] 05:18AM BLOOD Hct-30.9*
[**2141-7-8**] 07:39AM BLOOD WBC-8.2 RBC-3.72* Hgb-11.4* Hct-32.4*
MCV-87 MCH-30.5 MCHC-35.0 RDW-14.1 Plt Ct-210
[**2141-7-9**] 05:18AM BLOOD PT-29.0* PTT-32.9 INR(PT)-2.9*
[**2141-7-7**] 05:11AM BLOOD Glucose-114* UreaN-16 Creat-0.6 Na-136
K-4.0 Cl-101 HCO3-26 AnGap-13
Brief Hospital Course:
79-year-old female with a longstanding history of paroxysmal
atrial fibrillation, HTN, and hyperlipidemia with increasing
symptomatic afib presented for PVI which led to successful
conversion to normal sinus rhythm and was c/b large pelvic
hematoma.
RECURRENT AFIB s/p PVI: Patient s/p PVI for atrial fibrillation
on [**2141-7-3**]. All pulmonary veins were isolated, patient converted
to NSR post procedure. Patient asymptomatic post procedure.
Procedure complicated by large pelvic hematoma as below. Patient
continued on lower dose of sotalol 120 [**Hospital1 **] (home dose was 160mg
PO BID) and discharged on this lower dose. Initial INR was 2.8,
coumadin held in setting of bleed, and coumadin restarted
slowing as bleeding resolved. On discharge, patient was in sinus
rhythm, with INR of 2.9 on 5mg coumadin daily. She was
discharged back on her home dose of coumadin which 5mg PO daily
except for 2.5mg Tu, Fri. She should have INR and Hct rechecked
on Tuesday [**7-11**]. She was scheduled with f/u with Dr. [**Last Name (STitle) **]
as an outpatient.
PELVIC HEMATOMA: Had large pelvic hematoma as complication of
PVI procedure. Measured at 12x 6cm on initial CT, and repeat CT
was slightly increased at 14.7 x 6.8cm. Patient received total
of 7 units of pRBCs during her stay, coumadin was temporarily
held in setting of acute bleed, and by discharge, her Hct was
stable at 30.9 with decreased abdominal distension. Patient
should have Hct rechecked on [**7-11**] and faxed to PCP for followup.
She was discharged with instructions to limit activity to
moderate activity.
PUMP: Pt has preserved EF>60%. In setting of large blood volume
resuscitation, patient started having some symptoms of volume
overload on AM of [**7-6**], given 10mg IV lasix x 2 for diuresis.
After that, patient had autodiuresis and equilibration. She did
not need any ongoing lasix on discharge. Euvolemic at discharge.
CORONARIES: Status of coronaries not documented, no known h/o
CAD; had cath in past, but results unknown, no mention of CAD or
PCI. Risk factors include HTN and hyperlipidemia.
TRANSIENT HYPOTENSION: During PVI procedure had transient
hypotension requiring intra procedural neosynephrine, which was
weaned off within hours of arrival to CCU. No other issues with
BP, patient restarted on home doses of metoprolol and valsartan
and discharged on home BP medications.
GERD: Continued on ranitidine 150mg PO BID.
Hyperlipidemia: stable; not currently treated with statins.
COMM: [**Name (NI) **] [**Name (NI) 30864**] (husband): [**Telephone/Fax (1) 82167**]
Medications on Admission:
Folic acid 1 mg Tablet 1 Tablet(s) by mouth qpm
Losartan [Cozaar] 50 mg Tablet 1 Tablet(s) by mouth qpm
Metoprolol Tartrate 25 mg Tablet [**12-23**] Tablet(s) by mouth twice a
day
Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal 1
Tab(s) by mouth qpm
Ranitidine HCl 150 mg Tablet 1 Tablet(s) by mouth twice a day
Sotalol 160 mg Tablet 1 Tablet(s) by mouth twice a day
Warfarin 5 mg Tablet [**12-23**] Tablet(s) by mouth on Tuesdays and
Fridays, one tablet all other days
Magnesium Oxide 400 mg Tablet 1 Tablet(s) by mouth qpm
Multivitamin daily
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO at bedtime.
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please have your INR and Hematocrit checked on Tuesday [**7-11**] and
fax to your primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1124**] for adjustment of
your coumadin at ([**Telephone/Fax (1) 82168**]
9. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Recurrent atrial fibrillation
Secondary diagnosis
Pelvic hematoma
Hypertension
Hyperlipidemia
Gastroesophageal reflux
Discharge Condition:
Stable, walking around, abdominal pain and distension improved
Discharge Instructions:
You were admitted to the hospital for a procedure for your
recurrent abnormal heart rhythm called atrial fibrillation. You
developed a bleed in your pelvic area that we watched carefully
and gave you blood transfusions. While you were actively
bleeding, we temporarily held off on giving you your blood
thinner medication called coumadin but this was restarted and
you should continue taking coumadin daily on discharge.
Please continue taking all your home medications except for the
following additions and changes.
- Decrease your sotalol dosing from 160mg twice a day to 120mg
twice a day
- continue taking your 5mg coumadin pills - half tablet on
Tuesdays and Fridays, one tablet all other days. You will need
to check your INR at your appointment on [**7-20**] with Dr.
[**First Name (STitle) 1124**]
Please call your primary care physician or cardiologist if you
experience any dizziness, lightheadedness, palpitations,
shortness of breath, chest pain slurred speech, weakness, facial
droop, increased abdominal pain or distension, or any new or
worrisome symptoms.
Followup Instructions:
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on
Friday [**2141-8-18**] at 3:40pm. ([**Telephone/Fax (1) 2037**]
You have a follow up appointment with your primary care doctor,
[**Last Name (LF) **],[**First Name3 (LF) 13704**] P. on [**2141-7-20**] at 11:00am. ([**Telephone/Fax (1) 82169**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2846
} | Medical Text: Admission Date: [**2184-1-17**] Discharge Date: [**2184-1-21**]
Date of Birth: [**2125-8-3**] Sex: M
Service: MEDICINE
Allergies:
Byetta
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Hemodialysis Catheter Placement
History of Present Illness:
58-year-old man with HIV, pulmonary hypertension, hepatitis C
cirrhosis, OSA, DM, CHF with a few weeks of SOB. Patient was a
poor historian who seems to describe the gradual onset of
increasing DOE over the past 2-3 weeks. Per recent pulmonology
and cardiology notes this shortness of breath has been getting
gradually worse. He also noted a 30 lbs weight gain that he
reported over the last few weeks (from 330 to 360). Patient
reported that he felt like he couldn't breathe. He reported that
he had worsening leg edema, ascites. Complained of exertional
chest tightness, no pain. No recent fevers, no abdominal pain.
He described diarrhea x 2 days and some chills prior to
presentation. He had occasional palpitations. He described
chest pain that started on the right side of his chest one day
prior to admission. It was pleuritic in nature and ranges from
[**2184-3-15**].
In the ED, vitals were 97.8 89 123/64 24 96 on RA. He was given
an ASA. Pressure dropped to 80s, then responded to 90s after
given some fluids (500cc NS). Held lasix (takes 160 per day?).
CXR with ? some effusions. K elevated to 6.9 and received 1 amp
Ca gluconate, kayexelate and given 325 of ASA. No ECG changes.
On transfer to floor, 98/55, 84, 14 100% on CPAP 10/5. He was
placed on CPAP given his respiratory distress.
Past Medical History:
- HIV (last CD4 count 588 on [**2184-1-17**])
- Hepatitis C with stage IV cirrhosis, s/p antiviral tx
- Chronic kidney disease requiring several hospitalizations and
short-term dialysis
- Hypercholesterolemia
- Obstructive sleep apnea
- Depression
- CHF (last LVEF [**1-/2184**] >= 55%)
- GERD
- Obesity
- h/o C diff colitis ([**3-14**])
- Pancreatitis
- s/p Cholecystectomy
- s/p Appendectomy
Social History:
Patient lives with a female companion on [**Location (un) **]. He lost most
of his possessions, including property, when his bank when under
and recalled his loans which he could not pay and foreclosed his
home and other properties. This precipitated his psychiatric
admission for depression in [**Month (only) 116**]. Denies tobacco, alcohol or
current IV drug use. Has h/o IVDU.
Family History:
Depression and anxiety. Father with DM, CAD; Mother with CAD.
Brother was MI at age 46.
Physical Exam:
Vitals: 98/55, 84, 14 100% on CPAP 10/
General: Alert, oriented, mild respiratory distress. CPAP on.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Dificlt to assess JVP given neck girth
Lungs: Decreased BS b/l, Rhales at the bases b/l
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding.
GU: no foley
Ext: warm, well perfused, Pitting edema +1 b/l.
Pertinent Results:
[**1-17**] CXR: Opacity at the left base suggestive of pneumonia.
[**1-19**] Echo: The left 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. The estimated cardiac index is normal
(>=2.5L/min/m2). The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position and right ventricular pressure
overload. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
[**2184-1-17**] 06:41PM POTASSIUM-7.2*
[**2184-1-17**] 06:41PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-NEGATIVE
[**2184-1-17**] 05:08PM TYPE-ART PO2-79* PCO2-52* PH-7.28* TOTAL
CO2-25 BASE XS--2
[**2184-1-17**] 05:08PM LACTATE-1.2
[**2184-1-17**] 04:51PM GLUCOSE-128* UREA N-94* CREAT-3.3* SODIUM-138
POTASSIUM-6.4* CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2184-1-17**] 04:51PM CK(CPK)-114
[**2184-1-17**] 04:51PM CK-MB-2 cTropnT-<0.01
[**2184-1-17**] 04:51PM CALCIUM-10.0 PHOSPHATE-5.7* MAGNESIUM-2.3
[**2184-1-17**] 04:51PM HCT-27.1*
[**2184-1-17**] 03:59PM PT-13.4 PTT-38.7* INR(PT)-1.1
[**2184-1-17**] 03:25PM TYPE-ART PO2-112* PCO2-52* PH-7.26* TOTAL
CO2-24 BASE XS--4
[**2184-1-17**] 03:25PM K+-7.4*
[**2184-1-17**] 01:06PM CREAT-3.1* POTASSIUM-8.5*
[**2184-1-17**] 01:06PM URINE HOURS-RANDOM UREA N-682 CREAT-112
SODIUM-45
[**2184-1-17**] 01:06PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2184-1-17**] 01:06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2184-1-17**] 01:06PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2184-1-17**] 10:21AM GLUCOSE-136* UREA N-93* CREAT-3.1* SODIUM-137
POTASSIUM-8.0* CHLORIDE-105 TOTAL CO2-22 ANION GAP-18
[**2184-1-17**] 10:21AM CK(CPK)-129
[**2184-1-17**] 10:21AM CK-MB-3 cTropnT-0.02*
[**2184-1-17**] 10:21AM CALCIUM-8.4 PHOSPHATE-5.2* MAGNESIUM-2.1
[**2184-1-17**] 10:21AM WBC-5.2 RBC-3.52* HGB-8.3* HCT-27.7* MCV-79*
MCH-23.6* MCHC-30.0* RDW-15.3
[**2184-1-17**] 10:21AM PLT COUNT-205
[**2184-1-17**] 10:21AM PT-13.9* PTT-57.5* INR(PT)-1.2*
[**2184-1-17**] 10:21AM WBC-5.2 LYMPH-37 ABS LYMPH-[**2098**] CD3-89 ABS
CD3-1717 CD4-31 ABS CD4-588 CD8-56 ABS CD8-1074* CD4/CD8-0.6*
[**2184-1-17**] 08:05AM TYPE-ART PO2-94 PCO2-41 PH-7.33* TOTAL CO2-23
BASE XS--4
[**2184-1-17**] 08:05AM LACTATE-1.0
[**2184-1-17**] 04:17AM COMMENTS-GREEN TOP
[**2184-1-17**] 04:17AM K+-6.9*
[**2184-1-17**] 03:19AM PT-12.7 PTT-21.6* INR(PT)-1.1
[**2184-1-17**] 02:15AM GLUCOSE-115* UREA N-86* CREAT-2.3*#
SODIUM-136 POTASSIUM-6.9* CHLORIDE-105 TOTAL CO2-23 ANION GAP-15
[**2184-1-17**] 02:15AM estGFR-Using this
[**2184-1-17**] 02:15AM ALT(SGPT)-29 AST(SGOT)-32 LD(LDH)-197
CK(CPK)-149 ALK PHOS-43 TOT BILI-0.1
[**2184-1-17**] 02:15AM CK-MB-3 cTropnT-<0.01 proBNP-165
[**2184-1-17**] 02:15AM ALBUMIN-4.4
[**2184-1-17**] 02:15AM WBC-4.5 RBC-3.82* HGB-8.9* HCT-30.2* MCV-79*
MCH-23.2* MCHC-29.3* RDW-15.2
[**2184-1-17**] 02:15AM NEUTS-56.8 LYMPHS-36.9 MONOS-5.2 EOS-0.7
BASOS-0.4
[**2184-1-17**] 02:15AM PLT COUNT-212
Brief Hospital Course:
58 year old male with a history of long-standing HIV on HAART,
pulmonary hypertension, HCV (s/p successful interferon), stage
IV cirrhosis, dCHF, morbid obesity, DM, OSA, renal insufficiency
and previous hyperkalemia, who presented to the ED with weight
gain, chills, dyspnea and increasing edema, ARF. On the day of
admission he endorsed headache and myalgia.
Overall, major contributors to his presenting condition were
weight gain secondary to both increased ascites (cardiogenic and
hepatic), pulmonary hypertension and renal failure. BNP and
signs of volume overload were not marked, and venous pressure
was slightly up. Therefore there was likely some increased
interstitial fluid/intravascular fluid, with a possible large
contribution from ascites. This would have accounted for weight
gain and some increased difficulty walking before the admission.
Pulmonary hypertension and resulting fixed cardiac output with
slight fluid overload are likely contributors to dyspnea. We
need to also be mindful of HIV as a cause of pulmonary
hypertension and also for atypical infections, though CD4 counts
were reassuring.
# Dyspnea:
Likely multifactorial as mentioned. Pneumonia seemed less likely
given no constitutional signs of infection. Pulmonary
hypertension, slight fluid overload were most likely, while we
were mindful of unlikely pulmonary embolism (given rapid
recovery and likely little reserve given his underlying
physiology). Flu swab was negative and there was little concern
for CAP. Patient was diuresed while he was in the MICU with
good response. Sildenafil was continued while patient was
hospitalized and we also got in contact with patient's
pulmonologist, who recommended continuing sildenafil at the
current dose and regimen. Heparin gtt was initially started for
possible PE, but discontinued shortly thereafter.
After transfer to the floor, the patient was easily transitioned
back to room air with a resting oxygen saturation of 94-96%. He
continued to use his CPAP while sleeping.
His dyspnea most significantly responded to diuresis, and
patient was maintained on Lasix 40mg PO BID. Throughout the
hospitalization, he was down approximately 5 kg.
# Pulmonary HTN:
The patient and his pulmonologist have had difficulty treating
his pulmonary hypertension. The pulmonary hypertension is
presumed to be due to HIV and dCHF. Previously, he has not been
able to tolerate sildenafil as has feeling of being "drunk". We
discussed various treatments for PAH in addition to Sildenafil
and ultimately got in contact with patient's outpatient
pulmonologist as per above. Repeat echo demonstrated moderate
pulmonary artery systolic hypertension.
The patient was continued on sildenafil and did not have any
side effects. The patient was evaluated by the inpatient
pulmonology consult service while in the hospital.
# Hyperkalemia:
The patient's potassium appears to run in upper 5s and
occasionally lower 6. On admission his potassium was elevated
and reached a peak of 8.5 despite receiving calcium and
Kayexelate in the ED with no ECG changes. The patient received
additional kayexalate on the floor but when he peaked at 8.5
required emergent dialysis with placement of a temporary HD
catheter in his right IJ. After dialysis his potassium was
monitored twice a day and remained at an acceptable level
between [**4-12**].
The patient did not require any further dialysis during the
admission. He will have repeat laboratory studies on either
[**2184-1-23**] or [**2184-1-24**] to evaluate his potassium level.
# dCHF:
The patient has diastolic congestive heart failure based on
echocardiogram and right heart cath. It was unclear if his CHF
was worse given normal BNP and lack of true desaturation. We
did not suspect that dCHF was causing large component of his
dyspnea on exertion during this admission. Nonetheless, weight
gain was likely fluid. Despite low BNP likely small exacerbation
given improved renal function with diuresis. Lasix was continued
as tolerated by renal function and pressure.
# HIV: Last CD4 count in [**February 2183**] was 384. Patient currently on
ARVT. Repeat CD4 count was repeated and was found to be 588.
Patient was continued on his HAART regimen.
# Anemia:
Anemia, near-leukopenia, stable and likely attributable to HIV
and his other multiple medical co-morbidities. We continued to
trend Hct throughout admission and it was noted to be stable.
He did reach a nadir of 24.4 though repeat HCT testing returned
at 27.4. The patient had a digital rectal exam that was
hemeoccult negative.
The patient was found to have a microcytic anemia and
examination of iron studies releaved the patient to be iron
deficient. He was started on iron 325mg [**Hospital1 **] in the hospital and
will continue upon discharge.
He will have a repeat CBC and electrolytes on [**2184-1-23**] or [**2184-1-24**]
and will be followed up by his PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3535**].
# OSA:
Patient with history of noncompliance of CPAP in past. CPAP
seemed to improve his breathing and we continued CPAP use at
night. The patient tolerated CPAP well (with his home machine
and settings) and will continue with CPAP after discharge.
# Acute renal failure: Concern for poor renal perfusion given
possible fluid overload (BNP did not support) versus
over-diuresis with recent increase in Lasix at home. We
continued to trend Cr through hospitalization.
As above, he did require dialysis for hyperkalemia. The renal
consult service followed the patient throughout his
hospitalization and helped to maximize his renal function.
The patient's creatinine was 1.5 at the time of discharge and
will be checked on [**1-31**].
Medications on Admission:
Abacavir-Lamivudine
Citalopram 40 mg
Tricor 145 mg
Lasix 40 mg (1 in AM, 2 in PM)
Gabapentin 600mg tid
Novolog
Lantus
Lisinopril 20 mg
Kaletra 100 mg-25 mg
Omeprazole 20 mg
Pravastatin 40 mg
Trazodone 100 mg
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
Daily ().
3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
4. Lopinavir-Ritonavir 200-50 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insimia.
9. Metolazone 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/Fever.
11. Insulin Glargine 100 unit/mL Cartridge Sig: As previously
directed Subcutaneous once a day.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
18. Outpatient Lab Work
Please perform CBC and chem 7 on [**2184-1-23**] or [**2184-1-24**] and fax
results to primary care physician ([**Telephone/Fax (1) 3382**]). Thank You.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary:
(1) Dyspnea
(2) Pulmonary Hypertension
(3) Hyperkalemia
(4) Anemia
(5) Acute Renal Failure
Secondary:
(1) HIV
(2) Hepatitis C
(3) Cirrhosis
(4) Obstructive Sleep Apnea
(5) Diabetes Mellitus
(6) Congestive Heart Failure
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were seen and evaluated for difficulty breathing.
Initially, you were admitted into the intensive care unit. You
received medications to help remove fluid from your body. You
were found to have an extremely high potassium level, and you
required emergent dialysis.
On the floor, your breathing was markedly improved and the
dialysis catheter was removed.
Your hematocrit (or concentration of red blood cells in your
veins) was found to be low. This was monitored and was found to
be stable. You will need to have another lab test drawn on
[**2184-1-23**] in order to ensure this is stable.
Followup Instructions:
Provider: [**Name10 (NameIs) 191**] POST [**Hospital 894**] CLINIC Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2184-1-29**] 10:30
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2184-2-3**] 7:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2184-2-3**] 12:00
Completed by:[**2184-1-22**]
ICD9 Codes: 4168, 5849, 5856, 5715, 4280, 2767, 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2847
} | Medical Text: Admission Date: [**2164-9-30**] Discharge Date: [**2164-10-10**]
Date of Birth: [**2087-4-10**] Sex: M
Service: MED
Allergies:
Benzocaine
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation
Chest Tube Placement
History of Present Illness:
This is a 77 y.o. male smoker with h/o bullous emphysema (on 4
liters oxygen at home) who presents with acute dyspnea secondary
to spontaneous left pneumothorax initially admitted to thoracic
surgery service for chest tube placement. He was doing well on
the floor until [**10-2**] when he desated to 68% on 4L with BP:150/75
and HR:75. ABG: 7.2/89/92. He was placed on NRB with sats at
84% and taken to the MICU intubated.
Past Medical History:
1) Severe bullous COPD/Emphysema (on 3L home oxygen)
--[**5-13**]: FVC:33%, FEV1/FVC:49%, MMF:5%, looop with exp. coving
and reduced volume, DLCO (mod reduced in 03).
2) Multiple aspiration pneumonias with hemoptysis
3) BPH s/p TURP '[**62**] with trabeculated bladder with multiple
stones
4) Aflutter s/p cardioversion on amiodarone. (see by Dr.
[**Last Name (STitle) **]
5) Hep A on age 52
6) Depression
7) s/p Left inguinal hernia repair '[**62**]
8) Cataract Surgery
9) Peripheral Neuropathy
Social History:
50 pack-year tobacco. EtOH <1 week/day, Lives with brother.
Retired [**Name2 (NI) 68444**] worker
Family History:
Non-contributory
Physical Exam:
(@ admission)
T:98.0, 130/70, HR:77, RR:17, O2:100 NRB
Gen: NAD. A/O x3
HEENT: PEARLA, EOMI, VFI, OP: moist
CV: RR, S1>S2, No M/R/C/G
Pulm: Increased A-P. Distant b.s., absent breath sounds over
the left lung field
ABD: 3cm reducible umbilical hernia, S/NT/ND.
Ext: No c/c/e.
Neuro: A/O x 3. CN II-XII GI w/o sensory deficits
Pertinent Results:
[**2164-9-30**] 06:00PM GLUCOSE-131* UREA N-20 CREAT-1.1 SODIUM-140
POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-33* ANION GAP-15
[**2164-9-30**] 06:00PM CK(CPK)-61
[**2164-9-30**] 06:00PM CK-MB-3 cTropnT-<0.01
[**2164-9-30**] 06:00PM WBC-10.1 RBC-3.91* HGB-12.6* HCT-37.3* MCV-96
MCH-32.1* MCHC-33.6 RDW-14.7
[**2164-9-30**] 06:00PM CALCIUM-9.1 PHOSPHATE-3.8 MAGNESIUM-2.1
[**2164-9-30**] 06:00PM NEUTS-86.9* BANDS-0 LYMPHS-9.3* MONOS-2.8
EOS-0.4 BASOS-0.5
[**2164-9-30**] 06:00PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL TEARDROP-OCCASIONAL
[**2164-9-30**] 06:00PM PLT COUNT-318
CXR: Re-expanded left lung s/p chest tube placement
Brief Hospital Course:
The patient was initially admitted to the thoracic surgery
service, then transferred to the MICU, then called out to the
floor.
1) Respiratory Failure: The patient is on 3L nasal cannula at
home. He initially presented with dyspnea on [**9-30**]. A CXR
demonstrated a 75% Left Pneumothorax and a chest tube was placed
with subsequent resolution demonstrated on CXR. On [**10-1**], Chest
CT obtained:
--"Interval chest tube insertion. Increased opacity along the
left major
fissure with associated volume loss, suggestive of atelectasis.
A small
amount of residual loculated fluid is also noted in the major
fissure. This
has decreased compared to the two prior CT scans. There is also
extensive
subcutaneous air, and a small left anterobasilar pneumothorax.
-- Narrowing of the lingular bronchus. Considering distal
atelectasis,
correlation with bronchoscopy may be considered to exclude an
obstructing
lesion, if clinically indicated.
--Diffuse emphysematous changes, with bullous formation in the
right lung
base.
--Stable right renal cyst, and likely left adrenal adenoma."
The patient was doing well on the floor until [**10-2**] when he
vomited with aspiration and had a desaturation to 68% on 4L and
86% on NRB. He was intubated and transferred to the MICU. On
[**10-3**] a bronchoscopy demonstrated copious b/l secretions. RSBI
was 50 on [**10-4**], and he was weaned to face mask on with oxygen
sats in the 88-92% range on 4L. The Chest tube was D/C'd on
[**10-5**]. The patient did well on the floor with stable O2 sats on
3L N.C., albeit with persisent hemoptysis and productive cough.
The patient will need a CXR 1 month following D/C (prior to
follow-up with Thoracic Surgery). (See ID for details on
aspiration pneumonia)
2)COPD/Bronchospasm: He was continued on albuterol/atrovent nebs
standing. He was started on a slow prednisone taper of 60
mg/day on [**10-4**]. Placed on Ca, MVI, PPI, ISS while on steroids.
3)ID: He was initially treated with Levo/Flagyl for aspiration
RML and RLL pneumonia . Vancomycin was added on [**10-3**] given
presence of gram + cocci on expectorated [**Month/Year (2) **] sample on [**10-3**].
On [**10-6**] coverage was changed to ceftaz and vanco (for 14 day
course) given pseudomonas from the aforementioned [**Month/Year (2) **] sample.
Insulin control with sliding scale to optimize WBC function.
4)FEN: A Speech and swallow evaluation was obtained on [**10-6**]
which demonstrated that the patient could swallow all substances
but thin liquids were recommended.
5)Depression:Zoloft was continued per outpatient regimen.
6) Anemia: Thought to be secondary to hemoptysis. Guaiac (-)
black stool (?secondary to Fe supplements). Hct checked [**Hospital1 **] and
stable. Supplemented with Fe, eventhough MCV was 96 and Fe
studies were WNL.
7) EP: Patient is s/p cardioversion for afib. Maintained on
amiodarone (and continued inpatient with great caution given
underlying lung disease). Advised to reconsider this medication
as an outpatient.
8)Access: A Left subclavian line was placed to administer
sedatives and for central access during intubation. A PICC line
was placed on [**10-9**] and the Left subclavian line was
discontinued.
9)Proph: PPI, SC Heparin tid
10)Code/Comm: FULL CODE. Care discussed with brother.
Medications on Admission:
Zoloft 50 po qd
Lasix 40 po qd
Amiodarone 200 po bid
Flovent/Alb Nebs
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Aspiration Pneumonia
COPD
Emphysema
Depression
Discharge Condition:
stable
Discharge Instructions:
Please notify nurses or doctors [**First Name (Titles) **] [**Last Name (Titles) **] [**Name5 (PTitle) **], cough,
shortness of breath, chest pain, fevers, chills or any other
symptoms of concern.
Followup Instructions:
1. Please have an outpatient CXR in 1 month.
2. Follow up with Dr. [**Last Name (STitle) 14069**] after discharge from [**Hospital1 **].
3. You should also follow up with Dr. [**Last Name (STitle) **] (pulmonary) ([**Telephone/Fax (1) 92662**]and Dr. [**Last Name (STitle) **] (cardiology) ([**Telephone/Fax (2) 5862**]in the
next 1-2 months.
4. Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2164-10-16**] 1:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5070, 5180, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2848
} | Medical Text: Admission Date: [**2132-11-21**] Discharge Date: [**2132-11-28**]
Date of Birth: [**2064-4-19**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
unresponsive at skilled nursing facility
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 year old male with history of MS, neurogenic bladder with
suprapubic catheter and multiple drug resistant UTIs, with
recent admission for MRSA PNA, who presented with hypoxia and
unresponsiveness at nursing home requiring ICU admission for
sepsis, now transferred to medical floor. He was recently
admitted from [**10-28**] - [**2132-11-6**] with the same presentation, at
which time he was found to have a LLL infiltrate with sputum
culture growing MRSA. He was treated briefly with positive
pressure ventilation with improvement, and discharged back to
the nursing home with a PICC, to complete a 14 day course of
vancomycin and levofloxacin which would have finished on [**11-20**].
However, the patient was readmitted from [**11-15**] - [**2132-11-17**] when
his PICC line came out. He had the PICC line replaced by IR on
[**11-17**], and was discharged with orders to continue vancomycin
with end date as previously scheduled, as well as a 7 day course
of ciprofloxacin 500 mg [**Hospital1 **] for reasons that are unclear. Of
note, during this admission his creatinine was noted to be
elevated; urine lytes were not consistent with a pre-renal
etiology, it did not improve with hydration, and a renal
ultrasound was unrevealing. They did not investigate this
further, and discharged him with creatinine 1.5.
.
Per report, the patient was doing alright at the nursing home
until this morning when he was found to have an O2 sat of 86% on
RA, and unresponsive.
.
On arrival to the ED, T 101.8, HR 70s, BP 110/80 but with
occasional drops to the 80s systolic, 96-97% on NRB. He received
2 liters of IVF with eventual urine output, although initally
was anuric. Labs were notable for acute renal failure with
creatinine 2.5, up from 1.5 last week. He was given a dose of
linezolid and zosyn. DNR/DNI status was confirmed.
Past Medical History:
# Recent MRSA pneumonia ([**10/2132**])
# Progressive, relapsing, multiple sclerosis for the last 30
years. The patient is treated with monthly steroids, Solu-Medrol
and Avonex.
# Prostate cancer status post brachytherapy.
# Depression with multiple admissions in the past and history of
overdose of isopropyl alcohol.
# Neurogenic bladder with recurrent urinary tract infections.
The patient has a suprapubic foley.
# History of right elbow bursitis with MRSA.
# Hypertension.
# Chronic lower back pain with cervical and lumbar spinal
stenosis.
# Osteoarthritis.
# Impotence with penile prosthesis.
# Chronic polyps.
# History of peptic ulcer disease with upper GI bleed in the
setting of chronic NSAIDs use.
# History of alcohol abuse with history of generalized tonic
clonic seizures in the setting of alcohol (see neuro note
written in [**2130-3-6**]).
# Pemphigus
Social History:
Lives in [**Location **]. Denies alcohol or tobacco. [**Location **] involved in his
care.
Family History:
Non-contributory.
Physical Exam:
PHYSICAL EXAMINATION: 96.9, 80, 132/86, 20, 99% on 2l NC
GENERAL: Obese caucasian male, responds to questions
intermittently
HEENT: Dry mucous membranes.
NECK: Unable to locate JVP.
COR: nl rate, S1S2, no gmr
LUNGS: coarse BS anteriorly
ABDOMEN: obese abdomen, firm, +BS, unable to assess HSM.
PELVIS: Suprapubic catheter in place with surrounding bandage.
EXTR: 1+ non-pitting edema.
Pertinent Results:
PORTABLE AP: Heterogeneous opacification at the left lung base
is largely atelectasis, explaining the elevation of the left
hemidiaphragm. Right lung is low in volume but grossly clear.
Heart is not enlarged. Right PIC catheter tip projects over the
junction of the brachiocephalic veins. No pneumothorax.
.
CT HEAD: Bifrontal periventricular white matter hypodensities
unchanged from before. No hemorrhage.
.
MRI BRAIN WITH AND WITHOUT CONTRAST: A moderate to large amount
of foci of T2/FLAIR hyperintensity involving the deep central,
pericallosal, and periventricular white matter compatible with
multiple sclerosis plaques are essentially stable when compared
to [**2129-9-15**]. Prominence of the sulci and ventricles
compatible cortical atrophy is also unchanged. Post- gadolinium
administration, no areas of abnormal enhancement are identified
to suggest acute demyelination. Within the left frontal region,
a linear area of contrast enhancement is more compatible with a
developmental venous anomaly, rather than an enhancement of a
demyelinating plaque.
Within the region of the medullary pyramids, there is increased
T2-weighted signal, which is not well visualized on the previous
MRI. There is no abnormal enhancement or diffusion-weighted
imaging abnormality in this region. There is no evidence of
abnormal mass, shift of normally midline structures, or edema.
IMPRESSION: Aside from regions within the medullary pyramids of
T2/FLAIR hyperintensity, areas of demyelination compatible with
multiple sclerosis are unchanged dating back to [**2129-9-15**]. Thus, this medullary lesion could represent interval
development of an additional area of demyelination. No areas of
abnormal enhancement identified to indicate acute demyelination.
Brief Hospital Course:
68 year old male with MS, neurogenic bladder with suprapubic
catheter and multiple drug resistant UTIs, with recent admission
for MRSA PNA, who presented unresponsive possibly secondary to
infection.
.
# mental status change: had been alert enough to elope from
nursing home during the week prior to this hospitalization but
transferred here because minimally responsive. Head MRI showed
new focus of demyelination in the medulla, other areas of
demyelination essentially unchanged from [**2129**]; it is not clear
if this new medullary demyelination is contributing to current
symtpoms. Likely multifactorial, from hypercarbia, methadone use
in setting of decreasing renal function, and infection in
addition to MS. Improved with BiPAP in ICU, consistent with
combination of hypoxia and hypercarbia. Appreciate sleep
consult; will continue BiPAP 12/8 with back up rate 8 and 2L O2
flow by. Has recovered/woken up to what seems to be baseline
mental status, will continue to monitor. Avoiding all narcotis
and benzodiazepines.
.
# Recurrent PNA: recently treated with full course of vancomycin
for MRSA pneumonia with improvement of infiltrate on CXR.
However, febrile on admission and sputum did grow Proteus and
MRSA, so continuing with ceftriaxone and vancomycin through
[**2132-12-3**] as recommended by ID consult.
.
# Acute renal failure: Improving gradually from Cr 2.5 on
admission to 1.6, with good diuresis after lasix, probably also
autodiuresis.
.
# MS: Continue baclofen and gabapentin. PT/OT for LE
contractures
.
# Neurogenic bladder/autonomic instability?: Autonomic
instability causing labile blood pressures. Continue oxybutinin.
.
# Depression: Continue celexa and duloxetine.
.
# Microcytic Anemia: Cont iron. He does have a history of
esophagitis on EGD in [**2131**]. We have scheduled repeat EGD as
outpatient.
.
# HTN: BP trending up after sepsis resolved. Have added back
metoprolol, titrate up to 50mg tid and resumed home amlodipine
5mg daily.
.
# Decubitus ulcers: Wound care for pressure ulcers
.
# PPX: Continue PPI, SQ heparin, bowel regimen.
.
# Code: DNR/DNI, confirmed with HCP who is his [**Name (NI) **]. OK with
pressors, mask ventilation if necessary.
.
# Contact: [**Name (NI) **], HCP, [**Name (NI) 14573**] [**Name (NI) **].
Medications on Admission:
1. Baclofen 20 mg PO QID
2. Citalopram 40 mg PO DAILY
3. Gabapentin 200 mg PO TID
4. Pantoprazole 40 mg PO Q24H
5. Diazepam 5 mg PO HS
6. Vancomycin One (1) gram Intravenous Q18H
7. Duloxetine 40 mg PO HS
8. Heparin 5000 units Injection TID
9. Metoprolol Tartrate 50 mg PO TID
10. Ipratropium Bromide NEB Q6H for 3 days
11. Simethicone 80 mg PO QID PRN
12. Ferrous Sulfate 325 (65) mg PO DAILY
13. Albuterol Sulfate NEB Q6H for 3 days
14. Bisacodyl 10 mg PR DAILY
15. Trazodone 100 mg PO HS PRN
16. Senna 2 tabs PO BID
17. Oxybutinin SA 10 mg daily
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
6. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Multivitamin,Tx-Minerals 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 Q24H (every 24 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
13. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days: through [**12-1**].
14. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).
15. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
18. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q24H (every 24 hours) for 5 days: through
[**12-3**].
19. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 5 days: through
[**12-3**].
20. BiPAP
BiPAP 12/8 with back up rate 8 and 2L O2 flow by
21. PICC line
PICC line care per protocol
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
primary: recurrent MRSA and Proteus pneumonia
secondary: multiple sclerosis
Discharge Condition:
Stable. Wheelchair dependent. Discharge to acute level rehab
Discharge Instructions:
Take all medicines as prescribed.
.
Call your doctor for any medical concerns.
Followup Instructions:
Call your primary care doctor for an appointment in two weeks.
.
You should have a repeat endoscopy since you have a history of
esophagitis and anemia. We have scheduled this for you:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2133-1-15**] 10:00
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2133-1-15**] 10:00
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2849
} | Medical Text: Admission Date: [**2150-1-1**] Discharge Date: [**2150-1-8**]
Date of Birth: [**2071-7-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Diuretics / Shellfish
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2150-1-1**] Aortic valve replacement 21-mm Biocor Epic tissue valve
History of Present Illness:
78 year female with a history of aortic stenosis followed by
serial echocardiogram. Over the past several months, she has
noted worsening symptoms of dyspnea with exertion and lower
extremity swelling. He last echocardiogram in [**2149-3-7**]
revealed an LVEF of 55%, mild left ventricular hypertrophy and
moderate to severe aortic stenosis. Given the progression of her
symptoms and severity of her disease, she was referred for
surgical evaluation.
Past Medical History:
Severe aortic stenosis
Nonobstructive diffuse coronary artery disease on cardiac
catheterization in [**2147-8-8**]
Insulin-dependant diabetes
Hypertension
Hyperlipidemia
Chronic diastolic Congestive heart failure
Chronic low back pain
depression
Reactive airway disease
Face lift, cheek implants
Right cataract surgery
Cesarean sections
Social History:
Race: Caucasian
Last Dental Exam: Full dentures
Lives: Alone
Occupation: Retired
Tobacco use: Remote, quit more than 30 years ago
ETOH: occasional wine, one glass per week
Illicit drug use: denies
Family History:
Denies premature coronary artery disease
Physical Exam:
Pulse: 79 Resp: 18 O2 sat: 97%
B/P Right: 146/56 Left: 149/63
Height: 61 inches Weight: 190 lbs
General: Elderly female in no acute distress. Obese
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 4/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: trace
Varicosities: None
Neuro: Grossly intact
Pulses:
Femoral Right: 1 Left: 1
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 1 Left: 1
Carotid Bruit: transmitted murmurs bilaterally
Pertinent Results:
[**2150-1-1**] Echo: PRE-CPB: The left atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is severe mitral annular
calcification. Mild to moderate ([**12-8**]+) mitral regurgitation is
seen.
POST-CPB: There is a bioprothetic valve in the aortic position.
The valve appears well-seated with normally mobile leaflets.
There are no paravalvular leaks and no AI. The LV systolic
function remains normal, estimated EF>55%. There is no evidence
of dissection.
Chest X-Ray: PA and lateral chest compared to [**2150-1-4**]
Previous vascular congestion and borderline interstitial edema
have cleared. Cardiomediastinal silhouette has a normal
postoperative appearance. Lateral view shows small bilateral
pleural effusions and mild to moderately severe bibasilar
atelectasis. No pneumothorax.
[**2150-1-5**] WBC-9.9 RBC-2.94* Hgb-9.1* Hct-26.7* MCV-91 MCH-31.1
MCHC-34.3 RDW-16.1* Plt Ct-111*
[**2150-1-1**] WBC-5.5 RBC-2.90* Hgb-9.1* Hct-26.2* MCV-90 MCH-31.4
MCHC-34.7 RDW-16.2* Plt Ct-143*
[**2150-1-5**] UreaN-30* Creat-1.1 Na-135 K-4.6 Cl-98
[**2150-1-2**] Glucose-97 UreaN-13 Creat-1.0 Na-139 K-4.8 Cl-107
HCO3-27
[**2150-1-5**] Mg-2.6
Brief Hospital Course:
Mrs. [**Known lastname 95874**] was a same day admit and on [**2150-1-1**] was brought
directly to the operating room where she underwent an aortic
valve replacement. Please see operative note for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours she was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one she was started on beta-blockers and
diuretics and diuresed towards her pre-op weight. On post-op day
two she was transferred to the step-down floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. On post-op day three she had an episode of atrial
fibrillation which converted to sinus rhythm with beta-blockers
and Amiodarone. She was started on coumadin for her afib. she
was agressively diuresed toward her pre-op weight. She
experienced post-op confusion and all narcotics were
discontinued and her mental status claered. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility amd rehab was recommended. By the time of
discharge on POD #7 the patient was ambulating with assist, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to [**Hospital 1514**] rehab in good condition
with appropriate follow up instructions.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 1-2 puffs(s) by
mouth every four (4) to six (6) hours as needed for
cough/wheezing
ALENDRONATE - (Not Taking as Prescribed) - 70 mg Tablet - 1
tab(s) by mouth weekly in the AM with 6-8oz of plain water, do
not eat, drink or lie down for 30 mins
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth
once a day
GLYBURIDE - (Not Taking as Prescribed) - 5 mg Tablet - 2
Tablet(s) by mouth twice a day
INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin
Pen - 110 units sc once a day
SERTRALINE - 50 mg Tablet - 1 Tablet(s) by mouth once a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 puff po daily
TORSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth daily
TRIAMCINOLONE ACETONIDE - (chart conversion) - 0.025 % Cream -
Apply to affected area on back twice a day
VALSARTAN [DIOVAN] - (Not Taking as Prescribed) - 80 mg Tablet
- 1 Tablet(s) by mouth once a day
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [GLUCOCOM GLUCOSE] - (chart conversion) -
Strip - use as directed 1 time per day
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for
bronchospasm.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ranitidine HCl 150 mg Capsule Sig: One (1) Tablet PO once a
day for 2 weeks.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever or pain.
11. torsemide 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): home dose.
12. ipratropium bromide 0.02 % Solution Sig: One (1) neb IH
Inhalation Q6H (every 6 hours) as needed for wheezing.
13. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for SBP <90 or HR < 55.
15. insilin sliding scale and fixed dose ( see attached)
16. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: 400 mg [**Hospital1 **] through [**1-12**].
17. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks: 400 mg daily [**1-13**] through [**1-19**].
18. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
200 mg daily starting [**1-20**] ongoing.
19. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day: hold for K+ > 4.5;
please recheck potassium level in [**1-9**] days.
20. warfarin 1 mg Tablet Sig: daily dosing per rehab provider;
dose today [**1-8**] only is 4 mg; all further dosing per rehab;
target INR 2.0-2.5 for A Fib Tablets PO Once Daily at 4 PM: dose
today only [**1-8**] is 4 mg.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1514**] Health Care Center - [**Location (un) 1514**]
Discharge Diagnosis:
Severe aortic stenosis s/p Aortic valve replacement
Past medical history:
Nonobstructive diffuse coronary artery disease on cardiac
catheterization in [**2147-8-8**]
Insulin-dependant diabetes
Hypertension
Hyperlipidemia
Chronic diastolic Congestive heart failure
Chronic low back pain
depression
Reactive airway disease
Face lift, cheek implants
Right cataract surgery
Cesarean sections
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema BLE 2+
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 A Fib
Goal INR 2.0- 2.5
First draw [**1-9**]
***please arrange for coumadin followup prior to discharge from
rehab
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2150-2-4**] at 1:30PM
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] on [**2150-2-5**] at 11:00AM
Primary Care: Dr. [**First Name8 (NamePattern2) 4559**] [**Last Name (NamePattern1) 58**] on [**2150-3-4**] at 2:30PM
**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 A Fib
Goal INR 2.0- 2.5
First draw [**1-9**]
***please arrange for coumadin followup prior to discharge from
rehab
Completed by:[**2150-1-8**]
ICD9 Codes: 4241, 9971, 4019, 4280, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2850
} | Medical Text: Admission Date: [**2149-7-31**] Discharge Date: [**2149-8-4**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
CODE STROKE, ICH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 yo woman with dm, htn who presents as CODE STROKE from
[**Hospital3 **] facility where she had been eating dinner with
friends and suddenly complained of a R temporal headache. She
suddenly collapsed to the floor (no LOC) at 6:15PM and arrived
to the hospital at 7:00 PM (neurology arrived prior to pt
arrival). She provided additional hx that she felt shaky and
dizzy, which she could not specify as ltheaded vs vertigo, and
had nausea/vomiting after the event. She admits to problems
articulating, but had not noticed that the left side was weak
(noted by friends/ems not to be moving L side, and L facial
droop), and she complains of no visual changes (though she has R
gaze preference). She has had a stomach ache recently but
otherwise, her ROS for cp/f/c/sob/uri/gu/gi/msk sx was negative.
She still c/o HA in ER, which she says is at the R temple. Her
NIHSS score was 15 (below) and a stat head CT showed a very
large ICH that appears intraparenchymal in the R hemisphere
extending probably from caudate head to frontal lobe
(subcortical) and along falx, compressing ventricle, with mass
effect and shift. Neurosurgery was consulted STAT as well. Per
daughter, she has had periodic dizziness, which her daughter
wonders if representative of TIAs.
Past Medical History:
DM
HTN
OA
s/p vertebroplasty x 2
macular degeneration, s/p bilat eye surgeries
No hx afib, cad, or other medical problems to her knowledge
Social History:
Lives at [**Hospital3 **] facility, very independent, but walks
with walker b/c of OA; takes own meds, daughters involved with
care (one is pediatrician). No tob, no drugs.
Family History:
Noncontributory.
Physical Exam:
T 97.1 HR 82 201/76 RR 18 96%RA, 99%2L
General appearance: elderly woman, well dressed, some vomit,
gaze to R and neglects L side
HEENT: moist mucus membranes, vomit in op
Neck: supple, no bruits
Heart: regular rate and rhythm, no murmurs
Lungs: clear to auscultation anteriorly
Abdomen: soft, NT +BS
Extremities: warm, well-perfused
Mental Status: The patient is awake and mildly inattentive with
multiple times same question asked before response obtained;
however, provides appropriate response at that point, and
naming/language is intact with no errors (fluent though slow and
dysarthric). There is no hand or L/R agnosia.
Cranial Nerves: Visual acuity is intact for [**Location (un) 1131**]/pictures. L
dense hemianopsia. The optic discs are normal in appearance with
no papilledema. There is gaze preference for R, though pt can
move eyes to L with OCR and tracking finger, though does not
completely bury sclera on the L. Pupils react to light, though
L is sluggish and surgical 4->3, R is 4->2 brisk. Sensation on
the face is intact to light touch, pin prick per pt. L facial
droop UMN pattern. Hearing is intact to finger rub. Palate ML,
tongue protrudes in the midline. Dysarthria and slow speech.
Motor System: Appearance, power normal on the RUE
(delt/[**Hospital1 **]/tri/finger and wrist ext and flex) and RLE at quad,
ham, foot plantar/dorsiflex, [**2-26**] at R IP. Lower tone on L than
R. Periodically, there is rhythmic shaking of the R arm, which
pt says is involuntary.
Reflexes: The tendon reflexes are present, symmetric and normal.
The plantar reflexes are flexor on the R, extensor on the L.
Sensory: Sensation is intact to LT and PP per pt, reports no ext
to DSS, but often neglects L side stimuli.
Coordination: No ataxia or difficulty with foot tapping on the
R. Cannot perform on L.
Gait: deferred
Discharge exam: comfortable, speaking intermittently to family.
Pertinent Results:
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
UA: Prot 500 gluc
TransE: [**5-3**]
CastHy: [**1-26**]
o/w neg
[**2149-7-31**]
7:20p
Na:146 K:4.2 Cl:106 TCO2:23 Glu:152
Trop-*T*: <0.01
CK: 163 MB: 5
ALT: 36 AP: 153 Tbili: 0.9 Alb: 4.6
AST: 52
mcv 92
wbc 6.9 h/h 12.0/ 34.6 plt 201
PT: 11.9 PTT: 20.2 INR: 1.0
Imaging:
head CT showed a very large ICH that appears intraparenchymal in
the R hemisphere extending probably from caudate head to frontal
lobe(subcortical) and along falx, compressing ventricle, with
mass effect and shift
EKG: sinus tachycardia, st depressions V2-V4 1mm; no other
changes
Brief Hospital Course:
88 yo woman with dm, htn who presents as CODE STROKE from
[**Hospital3 **] facility where she had been eating dinner with
friends and suddenly complained of a R temporal headache, found
to have L hemiplegia, R gaze preference, neglect and dysarthria,
vomiting; by CT she had a large R hemisphere subcortical
hemorrhage with mass effect and shift. The family was not
interested in neurosurgical intervention, and she was DNR/DNI.
She was evaluated for possible enrollment in the Factor VII
trial. The most likely etiology of this spontaneous hemorrhage
was her hypertension, which her daughter says was not very well
controlled, despite being on multiple medications. She also was
having shaking of the right arm, which could have been focal
seizure activity. She was admitted to the neurology ICU for
blood pressure control and further monitoring. A repeat head CT
at 24 hours showed worsening hemorrhage and patient did not fit
criteria for the Factor VII trial. At meeting with family and
ICU team, family expressed that patient would not want to have
neurosurgical intervention (consistent with patient's wish
yesterday when she was being initally evaluated) and given low
likelihood of a signficant recovery to baseline, patient was
made comfort care measures only. Palliative care and social work
were consulted. The patient was comfortable at discharge.
Medications on Admission:
Nifedipine
Atenolol
Senakot
Lasix
Calcium
Mobic
Novolin 70/30 [**Hospital1 **]
Diovan
Ativan
indocin
celebrex
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4H (every 4 hours) as needed for fever or pain.
2. Ativan 0.5 mg Tablet Sig: 0.5-1 mg PO q2h as needed for
respiratory distress, anxiety, agitation, pain, nausea:
sublingual ativan please.
3. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
4. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1-2H
() as needed for pain.
5. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
6. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: [**11-25**]
tablets Sublingual every four (4) hours as needed for
respiratory secretions.
7. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Primary:
Right intracerebral hemorrhage
Secondary:
Hypertension
Diabetes mellitus
Discharge Condition:
Comfortable
Discharge Instructions:
Take medications as needed for comfort.
Call your doctor with any additional questions.
Followup Instructions:
None
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2851
} | Medical Text: Admission Date: [**2119-1-17**] Discharge Date: [**2119-1-21**]
Date of Birth: [**2087-4-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Mid scapular to lower back to RT testicular pain
beginning two says ago.
Major Surgical or Invasive Procedure:
none this admission
(Major Surgical or Invasive procedures: [**2119-1-9**] Replacement of
Ascending aorta with 28mm Gelweave graft)
History of Present Illness:
81yo white male who presented [**1-9**] to
RI VAH w/ acute onset upper back pain then radiating to
legs/testicles. CT revealed Type A dissection and transferred
here after diversion of LifeFlight from [**Hospital1 2025**]. He underwent
uneventful interposition tube graft repair and did well
postoperatively. The right kidney was not perfused from the true
lumen and was avascular on US as well after surgery. His admit
creatinine was 1.6 and 1.5 at discharge.
He had significant pain issues during his stay and called last
night w/ above pain but not taking meds. he had AF on transfer,
but stable Vital Signs. Non constrast CT at VA this AM shows
usual postop
changes. Toradol at VAH relieved his pain.
The aorta was abnormal appearing at surgery and Rheumatology and
ID were consulted. Cx were all negative and this was felt to
likely be Ehlos-Danler Type IV (also consistent w/ path report).
Past Medical History:
Remote stroke after rodding, no residual
Left deep vein thrombophlebitis
Chronic low back pain
Obstructive sleep apnea
Sinusitis- completed course antibiotics/prednisone
s/p Lumbar laminectomies
s/p femoral rodding
h/o tympanic membrane surgeries
Social History:
15pk year history (active smoker)
heavy ETOH until 2years ago
disabled from back pain
Family History:
noncontributory
Physical Exam:
Pulse: Resp:16 O2 sat: 98%
B/P Right: 120/70 Left:122/70
Height: Weight:
General:WDWN in NAD
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
Abdomen: Soft [x] non-distended [x] non-tender xbowel sounds +
[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:n Left:n
Pertinent Results:
[**2119-1-17**] 12:50PM GLUCOSE-94 UREA N-13 CREAT-1.3* SODIUM-135
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-11
[**2119-1-17**] 03:10AM PT-15.0* PTT-25.6 INR(PT)-1.3*
[**2119-1-17**] 12:50PM WBC-14.6* RBC-2.90* HGB-8.5* HCT-25.4* MCV-88
MCH-29.4 MCHC-33.6 RDW-14.5
[**2119-1-17**] CT chest abd pelvis
Wet Read: WWM [**First Name8 (NamePattern2) **] [**2119-1-17**] 9:02 AM
1. Type B (DeBakey III) Aortic dissection from just dist to LSCA
to bilat
CIAs. High attenuation small L pleural effusion with irregular
margins prox
desc thoracic aorta. Suspect leak, pre- rupture.
2. Thrombosed R renal artery resulting in right renal infarction
- stable c/w
[**2119-1-9**] CT. L kidney perfused, LRA supplied by true lumen and
patent. Remaining
major mesenteric vessels supplied by false lumen and well
opacified.
3. Significant fluid with minimal locules of air surround
ascending aorta -
presumed post op (reportedly 1 wk post repair), superinfection
not excluded.
Small focus of extravasation ~[**2-9**] o'clock at distal anastomosis
(se 2 im 29),
2nd focus posteriorly at 6 o'clock on se 2 im 28. Leak
suspected.
Scrotal ultra sound
IMPRESSION: No intratesticular mass and no signs of torsion.
Prominent left
spermatic cord with fatty component and possible mild left
varicocele;
however, these findings are not considered clinically
significant since the
patient complains of pain on the right.
[**2119-1-19**]
CTA chest abd pelvis
IMPRESSION:
1. Stable post-operative appearance of aortic repair with
contrast leak at
the distal anastomosis in the ascending arch as seen on prior.
2. Residual type B aortic dissection originating from just
distal to the left
subclavian artery, where it is fenestrated and extending
distally as far as
the bilateral common iliac arteries. There is associated
infarction of the
right kidney as seen on prior.
3. Cardiomegaly and bilateral simple pleural effusions without
evidence of
pulmonary congestion.
Brief Hospital Course:
Mr. [**Known lastname 48587**] was admitted to the CVICU for blood pressure
control and hemodynamic monitoring. The CTA x 2 showed stable
post-operative findings: 1. Stable post-operative appearance of
aortic repair with question of contrast leak at the distal
anastomosis in the ascending arch as seen on prior CTA. Vascular
surgery was also consulted and followed Mr. [**Known lastname 88053**] care
during his hospital course and he will be seen in follow up by
vascular surgery. Once blood pressure control was achieved with
oral agents, Mr. [**Known lastname 48587**] was transferred form the ICU to the
stepdown unit. At the time of discharge on HD5 his pain was
controlled with analgesics and his blood pressure was adequately
controlled. All discharge instructions and follow up
appointments were advised. He was cleared for discharge to home.
Medications on Admission:
Lopressor 37.5mg [**Hospital1 **],Percocet
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*45 Tablet(s)* Refills:*0*
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. losartan 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Type A Aortic dissection s/p Replacement of ascending aorta
Postop UTI
Past medical history:
Remote stroke
Chronic low back pain
Obstructive sleep apnea
s/p Lumbar laminectomies
s/p femoral rodding
h/o tympanic membrane surgeries
Discharge Condition:
alert and oriented x3
No testicular pain
gait steady
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**]
Keep your systolic (top number) blood pressure less than 130. If
your blood pressure is higher than 130, please call the cardaic
surgery office at [**Telephone/Fax (1) 170**] for instructions.
**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) **] ([**Telephone/Fax (1) 170**]) on Wednesday [**2-1**] at 1:00 ([**Hospital Ward Name **]
2A)
vascular surgery: Please call Dr.[**Name (NI) 7446**] office
[**Telephone/Fax (1) 1237**] to schedule a follow up appointment to be seen in
one month with a CT scan.
*** Cardiologist: Please ask Dr. [**Last Name (STitle) **] for a referral to a
cardiologist and make appt for 4 weeks
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office from genetic testing at [**Hospital1 11900**] of [**Location (un) 86**] will be calling you on Monday to arrange an
appointment. His office phone is ([**Telephone/Fax (1) 77621**].
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **] in [**4-11**] 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:[**2119-1-24**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2852
} | Medical Text: Admission Date: [**2142-10-12**] Discharge Date: [**2142-10-13**]
Date of Birth: [**2082-10-16**] Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
atrial flutter
Major Surgical or Invasive Procedure:
atrial flutter ablation, intubation
History of Present Illness:
This is a 59 year old patient with a PMH of DMII, HTN, MI
([**2135**])and history of persistent atrial fibrillation for several
years. He is s/p atrial fibrillation ablation in [**5-23**] and had
recurrent atrial flutter post procedure which required 2 DCCV??????s
in [**8-22**]. He again was seen by Dr. [**Last Name (STitle) 13177**] for an episode of
Atrial Flutter and was cardioverted in [**7-24**]. Although he feels
reletively well in atrial flutter he has noticed a decrease in
exercise tolerance due to shortness of breath. He used to be
able to walk one mile but in the last 2 months his exercise
tolerance has decreased to unable to climb 1 flight of stairs.
He also experiences lightheadedess when bending over when he is
in atrial flutter. Since the patient was becoming more
sympomatic he was scheduled to undergo elective ablation.
.
During the procedure, initial BP was 168/109 (baseline). He got
etomidate and succ for intubation, followed by fentanyl and
midazolam. The procedure went well and his atrial flutter
converted to NSR. Immediately after conversion, patient became
hypotensive to 70/50. Stat echo showed mildly depressed EF
without signs of tamponade. He was started on phenylephrine
briefly which was quickly weaned prior to arrival in CCU. He was
extubated without difficulty prior to transfer.
.
On arrival to the CCU patient is in NAD, alert and animated. No
SOB, CP, dizziness, or nausea and vomiting.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, or pulmonary embolism. He denies
exertional buttock or calf pain.
.
Cardiac review of systems is notable for dyspnea on exertion,
ankle edema, and palpatations. However there is absence of chest
pain.
Past Medical History:
-Atrial fibrillation s/p cardioversion x 2, followed by atrial
fib ablation [**5-23**] (Pulmonary Vein Isolation)
-Cardioversion x 2 post PVI for atrial flutter
-Hypothyroidism [**3-19**] to Amiodarone
-Rash on right shoulder [**7-24**]. Pt rested positive for Lyme
disease
treated with Doxycycline. Rash now resolved.
-IDDM (Type 2 DM on insulin pump)
-Asthma
-Bronchitis
-S/P Tonsillectomy
-Osteomyelitis right foot s/p surgery [**2134**]
-Neuropathy
-Cataract
-Anxiety
-? MI [**2135**] at [**Hospital1 34**] - had cath - no intervention - 50% occlusion
(pt not sure which vessel)
-Cardiac cath in [**2141**] per patient no intervention
(total of [**4-18**] caths since [**2135**])
-Basal cell carcinoma of the left forearm s/p surgical removal.
Social History:
-Tobacco history: None
-ETOH: Social
-Illicit drugs: None at present. During college years marijuana.
His HCP is his significant other [**Name (NI) 74545**] [**Name (NI) **] ([**Telephone/Fax (1) 78137**]).
Has one son age 30.
Family History:
Family history significant for brother age 66 with A. fib s/p
ablation. Father: DM, HTN died at age 55 of liver cancer.
Physical Exam:
VS: T= 96.9 BP= 124/65 HR= 72 RR= 18 O2 sat= 100% 6L NC Height:
6 feet 5 inches Weight: 293 lbs BMI 34.7
GENERAL: Obese white male in NAD. Oriented x3. Mood, affect
appropriate. Laying comfortably
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry oral mucosa.
No xanthalesma.
NECK: Supple. No LAD. No JVP appreciated. ?Left carotid bruit
CARDIAC: RRR, normal S1, S2. No m/r/g appreciated. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly and
midaxillary as well as no crackles, wheezes or rhonchi. (Pt
unable to sit up due to BL cath sites)
ABDOMEN: Soft, NTND. Obese. No HSM or tenderness. Unable to
access abdomial aorta. No abdominial bruits.
EXTREMITIES: left forearm 1.5cm x 1cm scab with erythematous
borders s/p BCC removal. Decreased sensation to pin prick BL
lower extremities. +1 edema at the ankles. No femoral bruits.
SKIN: Dry lower extremities. Well healed right toe ulcer.
Onychomycosis BL feet.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+
Left: Carotid 2+ Femoral 2+ DP 2+
Post-cath check 5:45pm
No evidence of hematoma, bruising or bruits at either site. Good
distal pulses. No mottling of the skin.
Pertinent Results:
Admission labs:
[**2142-10-12**] 12:10PM GLUCOSE-232* UREA N-18 CREAT-1.1 SODIUM-143
POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-28 ANION GAP-10
[**2142-10-12**] 12:10PM WBC-8.5 RBC-5.31 HGB-15.1 HCT-46.1 MCV-87
MCH-28.4 MCHC-32.7 RDW-14.3
[**2142-10-12**] 06:30AM PT-25.4* INR(PT)-2.4*
Brief Hospital Course:
This 59 year old patient with a PMH of DMII, HTN, ? MI ([**2135**])and
history of recurrent Atrial Fibrillation/ Atrial flutter
referred for elective Atrial flutter ablation on [**2142-10-12**], now
admitted to the CCU for management of his hypotension during
ablation requiring pressors.
.
# Rhythm: He was admitted for elective ablation. The procedure
went well from a rhythm standpoint and his atrial flutter
converted to NSR.
.
In the CCU, he was monitorred on telemetry overnight and
remained in NSR. Metoprolol was decreased to 50 mg [**Hospital1 **]. [**Doctor Last Name **] of
Hearts monitorring was arranged prior to discharge, and he was
instructed to follow up with his cardiologist in 5 days.
.
The patient was therapeutically anticoagulated upon admission
and will continue his outpatient dose of warfarin with INR
monitorring upon discharge.
.
# Hypotension: Patient chronically hypertensive. Baseline SBP
160s-180s. During the procedure, initial BP was 168/109
(baseline). He got etomidate and succinylcholine for intubation,
followed by fentanyl and midazolam. Immediately after reversion
to NSR, patient became hypotensive to 70/50. Stat echo showed
mildly depressed EF without signs of tamponade. He was started
on phenylephrine briefly which was quickly weaned. He was
extubated without difficulty and transferred to the CCU. He had
no further episodes of hypotension. In the CCU BPs were
100-140s systolic. His home ACEI and metoprolol were restarted.
# Coronaries: Patient experienced a questionable MI in [**2135**] for
which he was cath and demonstrated 50% occlusion of an unknown
vessel. Given that history, ASA was started. He will discuss
whether it is appropriate to continue this with his
cardiologist. ACEI and beta blocker were continued. He was
noted to have been unable to tolerate statins secondary to
myalgias.
.
# Pump: Unknown EF. Apparently euvolemic. Lasix was continued
at home dose.
.
# Type II DM: Last HBA1C was 8.3%. FS were initially 200s-300s
immediatley after procedure but well controlled subsequently.
Home insulin pump regimen was continued.
.
# Asthma: No active disease. Advair was continued
Medications on Admission:
Advair (250/50 mcg)
Albuterol PRN
Benazepril 30 mg twice a day
Coumadin regulated by Dr. [**Last Name (STitle) 13177**]
[**Name (STitle) **] oil 1,000mg daily
Lasix 40 mg once a day
Insulin pump
Metoprolol tartrate 100 mg twice a day
Multivitamin 1 tablet daily
Glucosamine 1,500 mg daily
Vitamin C 1,000mg
Alpha lipoic acid
Zetia 10 mg daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM: except 7 mg on Thursday.
6. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
7. Benazepril 20 mg Tablet Sig: 1.5 Tablets PO twice a day.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. insulin pump
Please continue your fingersticks and insulin pump as per home
regimen.
Discharge Disposition:
Home
Discharge Diagnosis:
primary: atrial flutter, hypotension
secondary: diabetes, hypothyroidism, asthma
Discharge Condition:
stable
Discharge Instructions:
You came to the hospital for a procedure to stop your atrial
flutter. The procedure was a success, but you briefly had low
blood pressure. This improved with medications.
The following medication changes were made:
1) metoprolol was decreased to 50 mg twice daily
2) aspirin 81 mg daily was started (Please discuss with Dr.
[**Last Name (STitle) 13177**] if you should continue this.)
You should resume your previous coumadin dosing and check your
levels as you have been doing.
Please follow up at [**Hospital3 **] Cardiology on Thursday,
[**10-18**]. The office will call you to arrange this. If you
do not hear from them, you need to call to schedule the
appointment: [**0-0-**].
Please wear the [**Doctor Last Name **] of Hearts monitor until you discuss it with
Dr. [**Last Name (STitle) 13177**] on Thursday. Instructions for this were provided.
Please call you doctor or return to the hospital for chest pain,
palpitations, shortness of breath, high fevers and chills, or
other symptoms that are concerning to you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 13177**] on Thursday, [**10-18**].
The office will call you to arrange this. If you do not hear
from them, you need to call to schedule the appointment:
[**0-0-**].
Completed by:[**2142-10-13**]
ICD9 Codes: 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2853
} | Medical Text: Admission Date: [**2151-3-24**] Discharge Date: [**2151-3-31**]
Date of Birth: [**2069-8-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
suboccipital craniotomy for evacuation of hemorrhage [**2151-3-24**]
History of Present Illness:
81 yom with history of HTN, HL, DM2, remote alcoholism and
cirrhosis, prior cerebellar hemorrhage in [**2149**], initially
admitted [**2151-3-24**] to Neurosurgery with new right cerebellar
hemorrhage, with hospital course c/b Afib with RVR,
thrombocytopenia, newly diagosed liver lesions concerning for
hepatocellular carcinoma (HCC) transferred to MICU in setting of
altered mental status and respiratoyr distress.
.
Patient has prior history of cerebellar hemorrhage in [**2149**], with
residual gait instability. On [**2151-3-24**], he developed a severe
headache, dizziness, and nausea, called EMS, and was brought to
OSH ED where CT head showed a large right cerebellar hemorrhage.
Patient was transferred to [**Hospital1 18**]. Was evaluated by Neurosurgery
and Neurology, and underwent emergent suboccipital decompression
for hemorrhage. He was transferred to SICU post-op, and
extubated [**2151-3-25**]. Cardiac monitor revealed frequent PVCs,
Cardiology was consulted, and home metoprolol was restarted. He
was called out to the floor [**2151-3-28**], and later developed Afib
with RVR to the 120s-130s prompting transfer to the Cardiology
service. He was initially treated with IV metoprolol and IV
diltiazem, and later transitioned from metoprolol to oral
diltiazem with improvement in HR control.
.
His course has also been notable for thrombocytopenia, which
prompted a Hematology consult. Work-up to assess for
splenomegaly/splenic sequestation as a possible etiology
included abdominal imaging that revealed hepatic cirrhosis with
portal hypertension, at least 3 liver lesions c/w HCC, portal
vein thrombosis, numerous varices, and mild splenomegaly. Was
also noted to have a cystic lesion adjacent to the uncinate
process of the pancreas and duodenal sweep, which could
represent a duplication cyst vs. cystic pancreatic lesion vs.
peripancreatic lymphangioma. This morning, he developed
progressively worsening mental status. As part of an infectious
work-up, UA had been sent [**3-29**] which suggested active infection
--> patient was started on empirical ceftriaxone while urine
culture pending. Was also concern for hepatic encephalopathy,
and lactulose was ordered. However, patient currently unable to
take PO medications secondary to mental status, and he has
pulled out a Dobhoff tube twice today. Per discussion with
family, decision was made to change code status to DNR/DNI and
not escalate care, though they still want to see if patient will
respond to lactulose and IVF for correction of hypernatremia.
Hepatology consulted, and felt that liver lesions were high
concerning for HCC. However, given cystic pancreatic lesion,
would also consider cholangiocarcinoma or pancreatic cancer with
metastases. Decision was made to transfer patient from
Cardiology to Medicine, with Hepatology following. On transfer,
patient tachypneic but denies dyspnea or chest pain. On arrival
to the floor patient demonstrated progressively altered mental
status and tachypneic.
ABG: 7.34 pCO2 43 pO2 60 HCO324. Due to high nursing requirement
patient transferred to the ICU.
.
On arrival to the MICU patient was somnulant, minimally
responsive or interactive.
.
Review of systems: As per HPI. Unable to obtain full ROS
secondary to patient's mental status.
.
Past Medical History:
HTN
HLD
DM
Cerebellar bleed [**2149**]
Psoriatic arthritis
Alcoholism in remote past
Cirrhosis
Thrombocytopenia with platlets 80-100 in [**5-/2149**]
Social History:
Lives with wife at home. Retired from retail. Independent in
ADLs: can pay [**Last Name (LF) 14994**], [**First Name3 (LF) **] taxes. Has been tired for years. Does
not walk much at home as calluses on feet and pedal
disfigurement make ambulation painful. Denied tobacco, Etoh and
drug use currently. Last EtOH 26 yrs ago.
Family History:
CNS bleeds (+), brain aneurisms (+): father, grandfather
Physical Exam:
Physical Exam on arrival to the MICU
General: somnolent, occasionally opens eyes to voice, minimally
responsive to noxious stimuli;
HEENT: sluggish but reactive and symmetric pupils. sclera
anicteric, slightly dry MM
Neck: supple
Lungs: coarse breath sounds bilaterally with transmitted upper
airway sounds, rales right base, no wheezing
CV: tacycardia with occassional ectopic beats, 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
Neuro: sommnulant, responseive to noxious stimulation, moving
all four extremities; not cooperative and not following commands
Pertinent Results:
Head CT [**2151-3-24**]
R cerebellar hemorrhage measuring 5cm with surrounding vasogenic
edema
NCHCT [**2151-3-24**] Post op
Right suboccipital craniectomy and partial cerebellar hematoma
evacuation. Residual cerebellar parenchymal, subdural, and
subarachnoid
hemorrhage. New intraventricular extension of blood. Increased
effacement of fourth ventricle, without hydrocephalus or
herniation.
CXR [**3-25**]
As compared to the previous radiograph, the signs of mild fluid
overload have increased in severity. There is mild pulmonary
edema. Borderline size of the cardiac silhouette. Low lung
volumes with areas of atelectasis at the lung bases. No larger
pleural effusions.
Echo [**3-29**]
Mildly dilated LA, RA; no significant valvular disease, EF >60%
CXR [**3-29**]
Bibasilar pneumonia vs atelectasis, small R subpneumonic pleural
effusion
Abd US [**3-29**]
Cirrhotic liver w/3 masses ?HCC, splenic varices suggestive of
portal HTN, borderline splenomegaly
Abd/Chest CT [**3-29**]
Multiple liver lesions c/w HCC, cirrhosis w/small volume
ascites, splenic/paraesophageal varices, thrombosed portal vein,
borderline splenomegaly, cystic lesion in/near pancreatic head,
possible calcified splenic artery aneurysm, b/l simple renal
cysts, diverticulosis
Brief Hospital Course:
81 y/o with history of cerebellar hemorrhage in [**2149**] presents
with complaint of headache found to have right cerebellar
hemorrhage s/p evacuation with hospital course complicated by
altered mental status, as well identification of hepatic lesions
consisent with malignancy (primary multifocal hepatocellular
carcinoma vs metastatic cholangiocarcinoma/pancreatic carcinoma)
ultimately transferred to MICU for increasing respiratory
distress.
In setting of altered mental status (toxic metabolic
encephalopathy) patient likely aspirated resulting in tachypnea,
hypoxia. Decision made to transfer to the MICU. In the MICU
patient aggresively diuresised for any potential contribution
from volume overload and antibiotics started for probable
aspiration. Despite interventions clincal status did not
improve. Extensive discussion with family members (including
HCP) ensued regarding goals of care and ultimately decision made
to transition to focus care on comfort, which was consistent
with patients previously expressed wishes. Patient was placed on
morphine gtt and passed away peacefully with family at the
bedside.
Medications on Admission:
Deceased
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2151-4-3**]
ICD9 Codes: 431, 2762, 2761, 5990, 4019, 2724, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2854
} | Medical Text: Admission Date: [**2169-10-11**] Discharge Date: [**2169-10-12**]
Service: MEDICINE
Allergies:
Aspirin / Percocet / Codeine / Ambien / Nutren Pulmonary
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is an 84 yo woman with h/o Steroid induced
hyperglycemia, COPD, MFAT, Asthma (recently on prednisone
taper), PVD, who presented to the GI suite as an outpt today for
colonoscopy to work up GI bleed. Prior to the procedure the
patient appeared confused and was difficult to [**Last Name (LF) 96592**], [**First Name3 (LF) **] her
FS was checked and was 19. Further questioning revealed that
although she had been NPO for her scope, she did receive her
full dose of lantus insulin last night at [**Hospital1 **]. Unclear if
she also received humalog this morning as well. In the GI suite
she was given 2 amps of D50 and was transferred to the ER. By
report her HR was 35 in the GI suite, however EKG performed
almost immediately thereafter revealed HR 70s; and in the ED she
was found to have HR of 80 with sinus rhythm and no ischemic
changes. On arrival to the ER her FS was 160. She had frequent
FS checks q1-2 hours and was found to have sporadic FS ranging
as high as 160 and as low as 52. In the ER she received a total
of 1.5 amps of D50 and was started on D5 1/2NS drip. On arrival
she was also found to be hypothermic with rectal temp of 32.5
degrees celsius. With a warming blanket this improved to 36.1
degrees. She was normotensive on arrival, however she had an
episode of hypotension in the ER to 80s/40s nad was started on
fluids immediately following which she was transferred to the
MICU. On arrival in the MICU and after one litre of NS and 500
cc bolus of D5 [**11-28**] she was still hypotense with sbp in the 80's.
Etiology unclear. She is admitted to the MICU for further
monitoring.
.
On arrival in the MICU, she was found to have a BP of 113/77,
and BG of 167, and appeared in NAD.
.
Called [**Hospital3 7**] and confirmed the following: pt. was
not given prednisone since [**10-9**] despite the fact that she was
due for this on taper schedule, furthermore: pt. was given
lantus eve of [**10-9**] then TF held at MN and prepped. At 1 am on
am [**10-11**], she had a BG of 45 and required a D 10 Gtt. This was
d/c'd prior to transfer to [**Hospital1 **].
Past Medical History:
1)Asthma > 5 hospitalization with no history of intubations. She
has been on steroids since the beginning of [**Month (only) 216**]. Prior to
this, she had been steroid free for the past 2 years. Recent
hospitalization with intubation complicated by MRSA pneumonia,
d/c on [**9-25**] to rehab.
2)Hypertension.
3)Steroid induced hyperglycemia. Discharged on insulin following
her [**Hospital1 **] admission.
4)Peripheral vascular disease, status post left fem-peroneal
bypass in [**2162**]
5)Multi-focal bacterial pneumonia.
6)Chronic obstructive pulmonary disease- PFT [**7-2**]- FVC 61% pred,
FEV1 56% pred, FEV1/FVC 92%, Reduced FVC related to gas
trapping, ~400 cc worse than PFT from one year ago.
7)Multi-focal atrial tachycardia.
8)Oral thrush.
9)Question left hilar mass.
10)Mult aspirations in past requiring now being on feeding tube
11)Hx. MRSA PNA
Social History:
Denies history of smoking. Only social alcohol, ~3 drinks /week.
No other drug use. Widowed, with 3 children and 8 grandchildren.
Family History:
Asthma in her father
Physical Exam:
97.1 92 SR 113/77 18 95% sat on 3 LPM
Asleep, NAD, [**Last Name (un) 96593**] arrousable
Dry MM
No JVD or LAD
RRR no MRG
CTA anteriorly
Soft, colostomy bag in place, NT, BS present
1+ LE edema with chronic venous stasis changes/scarring
Moves all four extremities
Pertinent Results:
[**2169-10-11**] 04:00PM PT-10.4 PTT-24.4 INR(PT)-0.9
[**2169-10-11**] 04:00PM PLT COUNT-253
[**2169-10-11**] 04:00PM WBC-5.8 RBC-3.01* HGB-9.8* HCT-29.3* MCV-97
MCH-32.5* MCHC-33.5 RDW-20.7*
[**2169-10-11**] 04:00PM cTropnT-0.01
[**2169-10-11**] 04:00PM ALT(SGPT)-16 AST(SGOT)-17 CK(CPK)-16* ALK
PHOS-67 TOT BILI-0.2
[**2169-10-11**] 04:00PM GLUCOSE-135* UREA N-56* CREAT-0.9 SODIUM-139
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
[**2169-10-11**] 05:14PM LACTATE-1.0
[**2169-10-11**] 06:29PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2169-10-11**] 06:29PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2169-10-12**] 04:00AM BLOOD WBC-5.3 RBC-2.84* Hgb-9.2* Hct-27.9*
MCV-98 MCH-32.5* MCHC-33.1 RDW-20.7* Plt Ct-259
[**2169-10-11**] 04:00PM BLOOD Neuts-88.1* Lymphs-7.8* Monos-3.5 Eos-0.4
Baso-0.2
[**2169-10-12**] 04:00AM BLOOD Plt Ct-259
[**2169-10-12**] 06:15AM BLOOD K-5.7*
[**2169-10-12**] 04:00AM BLOOD Glucose-230* UreaN-52* Creat-0.9 Na-134
K-5.8* Cl-102 HCO3-22 AnGap-16
[**2169-10-11**] 04:00PM BLOOD ALT-16 AST-17 CK(CPK)-16* AlkPhos-67
TotBili-0.2
1
CXR: IMPRESSION:
1) Slight improvement in right lower lobe atelectasis with
residual rounded opacity centrally. This is most likely due to a
rounded area of atelectasis given lack of mass on CT scan but
continued follow up recommended.
2) Persistent left lower lobe opacity, likely due to atelectasis
although underlying infection is not excluded.
3) Persistent small bilateral pleural effusions, slightly
improved on the right.
[**2168-12-12**] 04:00AM BLOOD Calcium-7.9* Phos-4.7*# Mg-2.5
Brief Hospital Course:
Ms. [**Known lastname **] is an 84 y/o woman with steroid dependent asthma
currently on prednisone taper who presented to outpatient
gastroenterology today for a colonoscopy to work up a past GI
bleed. Notably, she had not been given her prednisone doses for
the past two days despite her order for a slow taper. She
received her Lantus 22 units on the night prior to admission,
but was then NPO/tube feeds held for her colonoscopy. She had a
FS of 45 and was started on D10 at [**Hospital1 **], but this was
discontinued and the pt was sent to [**Hospital1 18**] where she was found to
have a FS of 19.
.
Hypoglycemia: She was transferred to the ER where she was
treated with D50 for a total of 3.5 amps. She was also put on a
D5 drip. Her fingersticks fluctuated in the ER between 52 and
160, however since arrival on the floor she had no fingersticks
below the 80s and on the day of discharge had fingersticks in
the 200s after we had held her lantus the night prior. We
restarted her tube feeds on arrival to the floor. She should be
covered with her insulin slide scale throughout the day on the
day of discharge, anticipating that she will likely run higher
than usual, and should be given her pm lanstus dose of 22 units
tonight. Please do not give the patient her full dose of lantus
if her tube feeds will be held in the future (consider halving
dose). Also please recall that the patient is not diabetic, but
her hyperglycemia is due to steroids, so as her steroids taper
(or if they are inappropriately held) she may require less
insulin.
.
Hypotension: The patient's hypotension in the ER was transient
and responded to fluids. This is likely in setting of her
completing a bowel prep and not taking tube feeds on the day
prior to admission, and may also reflect adrenal insufficiency
in the setting of a sudden d/c of her prednisone, which was
intended to be slowly tapered. The patient responded to fluid
boluses in the ICU and has had stable BP since arrival on the
floor. We restarted her prednisone at her home dose of 10mg po
qday and she should continue this dose until [**10-14**], at which
time she may decrease to 5mg po qday as directed.
-we held her usual diltiazem for HTN while she was in-house,
please monitor her BP throughout the day today and this can be
restarted today or toorrow as needed.
.
GIB: The patient has a hematocrit near her baseline at this
time. Colonoscopy to be scheduled again as an outpatient with
the patient's gastoenterologist to evaluate. Please be sure to
cut her lantus dose by about half when she has tube feeds held
for this procedure and confirm this with her gastroenterologist
prior to the procedure.
.
Asthma/COPD: Teh patient was continued on her outpt steroids and
inhalers and had no problems while in house.
.
The patient was discharged back to [**Hospital1 **] after staying
overnight in the [**Hospital1 18**] MICU. She was stable as described above
at the time of discharge.
Medications on Admission:
Allopurinol 100
Caldium/Vit D
Diltiazem 90 Q 6 hours
Docusate
[**Doctor First Name **]
Fluticasone/salmeterol 250/50 1 puff [**Hospital1 **]
Furosemide 40 daily
Gabapentin 600 mg 2200, 300 mg 0800 and 1400
Glargine insulin 22 U hs
RISS
Lansoprazole
Lidoderm patch (ant rt. thigh) Q O 12 h
Motelukast 10
MVI
Prednisone taper (was to have taken 10 mg this am, unclear if
she got this or not - was to take this [**10-11**] thru [**10-14**] then 5
mg for four days following this)
Tiotroprium
Discharge Medications:
Allopurinol 100
Caldium/Vit D
Diltiazem 90 Q 6 hours
Docusate
[**Doctor First Name **]
Fluticasone/salmeterol 250/50 1 puff [**Hospital1 **]
Furosemide 40 daily
Gabapentin 600 mg 2200, 300 mg 0800 and 1400
Glargine insulin 22 U hs
RISS
Lansoprazole
Lidoderm patch (ant rt. thigh) Q O 12 h
Motelukast 10
MVI
Prednisone taper 10mg [**10-12**] thru [**10-14**] then 5 mg for four days
following this)
Tiotroprium
Discharge Disposition:
Extended Care
Discharge Diagnosis:
hypoglycemia in setting of NPO, no steroids and given Lantus
dose
hypotension responsive to IV fluids
dehydration
Discharge Condition:
stable BP, stable (elevated) fingersticks.
Note pt did not receive her Lantus last night, so anticipate
that she will require her sliding scale insulin throughout the
day today [**2169-10-12**]. Please cover her fingersticks today and
restart her Lantus at its usual dose of 22u tonight [**2169-10-12**].
Discharge Instructions:
Please check patient's fingersticks at lunch, dinner and bedtime
today and treat with slide scale insulin. You can expect higher
FS than usual because we held her Lantus last night. Please
restart her Lantus tonight at her usual dose of 22units.
Please continue all medications as previously without changes.
Please call your gastroenterologist to reschedule your
colonoscopy to work up your gastrointestinal bleed. See below
for further instructions.
Followup Instructions:
Please call your gastroenterologist in the future to schedule
another colonoscopy. Please be sure that you take only half of
your Lantus dose if you are holding tube feeds for a
colonoscopy. Please note that patient only requires insulin
while on steroids, and discuss this with her gastroenterologist
if she is off steroids at the time her colonoscopy is
rescheduled.
ICD9 Codes: 5789, 4439, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2855
} | Medical Text: Admission Date: [**2113-3-19**] Discharge Date: [**2113-3-25**]
Date of Birth: [**2038-2-1**] Sex: M
Service: [**Doctor Last Name **]-INT M
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 5850**] is a 75 year old
male with a history of coronary artery disease, ischemic
cardiomyopathy, and atrial fibrillation, who presented to
[**Hospital 8641**] Hospital on [**2113-3-16**], complaining of five days of
melena and diffuse abdominal discomfort. His initial
hematocrit was 33 and on upper endoscopy he was found to have
Barrett's Grade I erosion. There were plans to do
colonoscopy for further evaluation of sources for
gastrointestinal bleeding and the patient was given a
GoLYTELY bowel prep at [**Hospital 8641**] Hospital. However, the patient
developed emesis and ten out of ten abdominal pain during
this time, with an episode bradycardia to 30 to 50s range and
decrease in blood pressure to systolic blood pressure in the
90s in the setting of having had a bowel movement and
getting up from the commode.
An arterial blood gas was done after this event and the
patient was found to have a serum pH of 7.24, pCO2 of 27 and
pAO2 of 100 on two liters nasal cannula. There was initial
concern for a possible colonic acute mesenteric ischemia
given the abdominal pain and hypotension and history of
melena, but abdominal CT scan done at the outside hospital
did not show any evidence of such.
A temporary pacer was placed secondary to the bradycardic
event. The patient was started on intravenous heparin given
concern for acute mesenteric ischemia with a history of
atrial fibrillation. The patient was transferred from the
outside hospital for further GI work-up and evaluation.
PAST MEDICAL HISTORY:
1. Duodenal ulcer treated with Pepcid; history of H. pylori,
treated.
2. History of colonic polyps/AVMs.
3. History of atrial fibrillation on Coumadin.
4. History of coronary artery disease with a history of
myocardial infarction in [**2098**]; status post coronary artery
bypass graft, left ventricular ejection fraction of 45%;
moderate mitral regurgitation and severe pulmonary
hypertension.
5. Spinal degenerative joint disease with right shoulder
contraction.
6. Type 2 diabetes mellitus, diet controlled.
7. Peripheral vascular disease.
8. Question of chronic obstructive pulmonary disease.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER:
1. Protonix 40 mg p.o. q. day.
2. Heparin 1000 units per hour.
3. Zocor 40 mg p.o. q. day.
4. Levofloxacin 500 mg p.o. q. day.
5. Flagyl 500 mg intravenous q. six.
6. Regular insulin sliding scale.
7. Isordil 40 mg p.o. three times a day.
8. Avapro 300 mg p.o. q. day.
9. Neurontin 100 mg p.o. three times a day.
OUTPATIENT MEDICATIONS:
1. Zocor 40 mg p.o. q. day.
2. Isordil.
3. Neurontin 100 mg p.o. three times a day.
4. Lasix 60 mg p.o. q. a.m.
5. Avapro.
6. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**].
7. Atenolol 50 mg p.o. twice a day.
SOCIAL HISTORY: Former smoker, quit since [**2079**]. Former
alcohol, quit [**2079**]. Lives in [**Hospital3 **] facility.
Daughter [**Name (NI) **] is in open care.
PHYSICAL EXAMINATION: In general, a pleasant male in no
acute distress. Vital signs with temperature 99.3 F.; heart
rate 75; blood pressure 128/88; respiratory rate 23;
saturation O2 98%. HEENT: Normocephalic, atraumatic. Dry
mucous membranes. Pupils are equal, round and reactive to
light. Extraocular movements intact. Neck: Left cordis in
place. Cardiac examination: Regular rate and rhythm, no
murmurs, rubs or gallops. Lung examination: Clear to
auscultation bilaterally. Abdomen soft, with suprapubic and
bilateral lower quadrant tenderness but no rebound.
Extremities with no cyanosis, clubbing or edema. Chronic
venous stasis changes. Neurological: Alert and oriented
times three. Cranial nerves intact, grossly non-focal.
LABORATORY: From [**3-19**] in the morning, white blood cell
count 6.0, hematocrit 28.0, platelets 98 down from 134, MCV
98 to 103. Chemistry panel with sodium 143, potasium 4.1,
chloride 109, bicarbonate 22, BUN 31, creatinine 1.8, glucose
104.
PT 22.8, PTT 42.3, fibrin 233, negative D-Dimer and negative
fibrin degradation products. CK 142, MB fraction 2.2,
troponin 0.5.
Chest x-ray showed cardiomegaly, no infiltrates, no effusion.
CT scan of the abdomen showed gallstones but no evidence of
cholecystitis. Right intestinal opacity/adhesions. Open
celiac supra-mesenteric and common iliac arteries.
SUMMARY OF HOSPITAL COURSE: The patient was initially
admitted to the Medical Intensive Care Unit for close
monitoring given history of bradycardia, placement of
temporary pacemaker and history of recent gastrointestinal
bleeding. Hospital course was notable for the following:
1. Gastrointestinal Bleeding: The patient had a known
history of arteriovenous malformations and polyps with
gastrointestinal bleeding in [**2111-3-23**]. EGD done at the
outside hospital showed Grade I esophagitis and CT scan of
the abdomen had already patent mesenteric vessels; no valve
thickening or obstruction. The patient had had hematocrits
checked after blood transfusion at the outside hospital (at
least one unit of packed red blood cells and two units of
fresh frozen plasma). The GI consultation service was
consulted for help in managing the patient's history of
gastrointestinal bleeding. The patient was placed on
intravenous Protonix, fluids and initially n.p.o. with serial
abdominal examinations.
After review of the data, history and CT scan, it was felt
that acute mesenteric ischemia was unlikely to have been
responsible and heparin was discontinued. On [**3-21**], the
patient underwent a colonoscopy and
esophagogastroduodenoscopy. The EGD showed medium hiatal
hernia; otherwise a normal EGD to second part of duodenum.
Erosions were seen inside the hernia. These erosions were
thought to have been the cause for patient's melena and the
GI Consult Service advised keeping patient on Protonix 40 mg
p.o. twice a day times one week, then 40 mg p.o. q. day for
60 days. The patient's colonoscopy on [**2113-3-21**], showed
polyps in the transverse colon, otherwise normal colonoscopy
to the cecum. Polypectomy was recommended at a future date
and follow-up when gastrointestinal bleeding and cardiac
issues resolved.
The patient was subsequently monitored with serial checks
with hematocrit which were stable with an initial trend
downward. He did have hematocrit of around 27 to 28 when
transferred from the Medical Intensive Care Unit to the
regular medical [**Hospital1 **] and given his history of coronary artery
disease, it was felt that he would benefit from blood
transfusion. He received one unit of packed red blood cells
and his subsequent hematocrits rose from 29 to 31 range and
have remained stable there since.
2. Cardiovascular: The patient has a known history of
coronary artery disease and atrial fibrillation. His serial
cardiac enzymes were sent to rule out myocardial infarction
given recent episode of hypotension and bradycardia. These
returned negative. He did have a temporary pacer placed at
the outside hospital for symptomatic bradycardia and
Cardiology consulted on this matter as well. After review of
the patient's history and hematocrit, it was felt that his
bradycardia was likely due to a combination of vasovagal
episode in the setting of bowel movement during bowel
preparation for colonoscopy and beta blockade with Atenolol
with the possibility of enhanced effects in the setting of
acute renal insufficiency. His beta blockers were initially
held and the patient had no further episodes of bradycardia.
His blood pressure remained stable and his temporary
pacemaker was discontinued. Because he did have a history of
atrial fibrillation and did need rate control, low dose beta
blockers were restarted with Metoprolol and have been
titrated up with good rate control and no further episodes of
bradycardia or hypotension.
His history of atrial fibrillation had prompted use of
anti-coagulants in the past, but given the acute episodes of
gastrointestinal bleeding his Coumadin was initially held,
but when his hematocrit stabilized, his Coumadin was
restarted and should be continued with goal INR of 2.0 to
3.0.
Also, his anti-hypertensive medications were held in the
setting of hypotensive event, however, when his blood
pressure stabilized and his renal function improved, his
angiotensin receptor blocker and Lasix were restarted.
3. Hypoxia: The patient developed an O2 requirement during
the course of his hospital stay. This was in the setting of
transfusion and intravenous fluid and holding of his Lasix.
His physical examination and chest x-ray findings were
consistent with congestive heart failure and the patient has
been restarted on his Lasix and his angiotensin receptor
blocker for treatment of this with subsequent improvement in
his hypoxia. It is anticipated that with further therapy,
his O2 requirements will resolve. He will need continued
monitoring of his daily weights and intakes and outputs until
his hypoxia resolved and his cardiovascular status becomes
stable.
4. Diabetes mellitus: The patient has a known history of
type 2 diabetes mellitus that was formerly controlled on
diet. He was started on Regular insulin sliding scale and
was on fingersticks while in the hospital and may benefit
from started an oral [**Doctor Last Name 360**] if he continues to have periodic
elevated blood sugars.
5. Deconditioning: After a prolonged hospital stay, the
patient was deconditioned and after Physical Therapy
evaluation was felt to be someone who could benefit from
Physical Therapy in a Rehabilitation setting.
DISPOSITION: The patient was subsequently stable fro
discharge and is awaiting transfer to Rehabilitation
facility.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleeding, likely secondary to esophageal
erosions, Barrett's Type I esophagus.
2. Bradycardic event; question vasovagal; question secondary
to enhanced effects of beta blocker in the setting of acute
renal insufficiency.
3. Acute renal insufficiency; prerenal etiology with
creatinine of 1.8 on presentation to [**Hospital1 190**] and improvement to baseline creatinine of 0.9
after intravenous fluid hydration.
4. Anemia secondary to gastrointestinal bleed.
5. History of coronary artery disease.
6. History of type 2 diabetes mellitus.
7. History of atrial fibrillation.
8. Colon polyps; needs GI follow-up for polypectomy once
gastrointestinal bleeding issues and cardiovascular status
stabilize.
9. Peripheral vascular disease.
10. History of spinal degenerative joint disease.
11. Questionable history of chronic obstructive pulmonary
disease.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. twice a day times two weeks, then
change to 40 mg p.o. q. day times 60 days.
2. Metoprolol 25 mg p.o. twice a day; continue to monitor
heart rate and blood pressure and adjust for rate control.
3. Ibesartan 300 mg p.o. q. day.
4. Atorvastatin 40 mg p.o. q. day.
5. Warfarin 4 mg p.o. q. day; adjust to goal INR of 2.0 to
3.0.
6. Lasix 60 mg p.o. q. a.m.
7. Potassium chloride 10 mEq p.o. q. day.
8. Neurontin 100 mg p.o. three times a day.
9. Isordil 10 mg p.o. three times a day.
DISCHARGE INSTRUCTIONS:
1. The patient will be discharged to Rehabilitation.
2. He will need follow-up with his primary care physician on
an ongoing basis.
3. He will INR checked two days following discharge and
adjust Coumadin to goal INR of 2.0 to 3.0.
4. The patient will also need to follow-up monitoring of his
hematocrit to insure stability, given history of
gastrointestinal bleeding.
5. The patient will also need follow-up colonoscopy for
polypectomy given findings of transverse colon polyps during
hospital stay.
6. Discharge diet, cardiac, two gram salt.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (NamePattern1) 6614**]
MEDQUIST36
D: [**2113-3-24**] 17:18
T: [**2113-3-24**] 23:14
JOB#: [**Job Number 40586**]
ICD9 Codes: 496, 4280, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2856
} | Medical Text: Admission Date: [**2128-3-11**] Discharge Date: [**2128-3-21**]
Date of Birth: [**2098-8-12**] Sex: M
Service: GU Surgery
BRIEF CLINICAL HISTORY: Patient is a 29-year-old white male
first seen by Dr. [**Last Name (STitle) **] in late [**Month (only) **] for irritated
bladder symptoms which had been developing for several
months. At that time he had been working in the Middle East
as a computer consultant, and his thinking was that perhaps
he had prostatitis and/or ureteral stone. Workup however,
eventually led to a TURB revealing an 18/18 positive cores
for signet ring adenocarcinoma including 2+ seminal vesicle
biopsies.
Subsequent workup to find the primary source for the cancer
included colonoscopy and gastroscopy were negative in
addition to body CT, MR of the pelvis indicated involvement
of a probable rectal duplicator cyst with the entire
posterior bladder and possible rectal wall involvement.
After careful consideration and treatment, plan was setup
whereby the patient wound undergo neoadjuvant 5FU and x-ray
therapy to the pelvis. This was completed by [**2128-1-19**], and
followed by plan for pelvic exeneration with reconstruction
depending on the intraoperative findings. The surgery would
be conducted in conjunction with Dr. [**Last Name (STitle) 1888**] of the General
Surgery team.
PAST MEDICAL HISTORY: Irritable bowel history.
PAST SURGICAL HISTORY: Surgery for fracture of the right
foot in [**2119**], multiple teeth extractions, no other.
MEDICATIONS: None.
ALLERGIES: None.
EXAMINATION: Examination on presentation on day of his
surgery finds the patient afebrile, vital signs stable. He
is 5 foot 11 inches, weighed 270 pounds. Pulse 78, blood
pressure 112/80, saturating 98% on room air. In general,
patient is a healthy-appearing gentleman of Middle Eastern
decent in no acute distress. He is alert and oriented times
three. HEENT examination shows cranial nerves II through XII
intact. Pupils are equal, round, and reactive to light.
Anterior and posterior lymph node chains show no evidence of
any tenderness or swelling. Cardiac examination is
unremarkable with regular rate and rhythm. Pulmonary
examination: Unremarkable with lungs are clear to
auscultation bilaterally. Abdomen is soft and nontender with
no evidence of any herniation.
OPERATIVE COURSE: On [**2128-3-24**], patient underwent surgery
jointly between the GU Surgical team and Dr.[**Name (NI) 4999**] [**Name (STitle) **]
Surgery team. Procedure included pelvic exeneration,
appendectomy, radical cystectomy, prostatectomy, creation of
colostomy and creation of a diverting urostomy. Procedures
reported to have undergone without complications, however,
involvement of the cancer was far more extensive than
originally had been thought, and procedure was changed
mid course from a potentially curative one to palliative
procedure. The intraoperative findings were immediately
communicated with both the patient's family and then later
with the patient himself.
Following the surgery, the patient was transferred to the
Surgical Intensive Care Unit still extubated. He had a
colostomy with appliance in place, urostomy with appliance in
place, and stents present. First postoperative night was
uneventful. The following morning he was extubated again
without problems. [**Name (NI) 1194**] control was adequate with a Morphine
PCA.
On hospital day two, postoperative day one, patient was
transferred to a normal surgical floor in stable condition.
On hospital day three, the patient began enterostomal
training with the enterostomy training nurse.
On hospital day three, postoperative day two, the patient had
the first of several temperatures to 102.2. These would
ultimately choose to become refractory to treatment. Over
the next several days, the fevers would peak to 104.2. As
part of the workup, the patient had a total of eight sets of
blood cultures drawn, none of which were shown to grow out
confirmed organisms. Likewise, patient's indwelling
catheters including a right internal jugular catheter and a
left Port-A-Cath, which had been placed several months
earlier were also removed. None of these effected the
fevers.
At no time, however, did the patient's white blood cell count
increase to reflect an active infection. A potential course
for the fevers were never found. Potential source of the
fevers were not pursued any further.
On postoperative day four, output from the patient's J-P
drains was sent for creatinine level confirming that this was
less than 1. Both J-Ps were pulled that same day.
On postoperative day five, patient had an appearance of
diffuse maculopapular rash across his back. Based on the
distribution of this rash, it appeared to be a contact
dermatitis, but nevertheless, a Dermatology consult was
requested given the patient's persistent fevers low-grade
tachycardia. Dermatology consult confirmed the presence that
this indeed was contact dermatitis. [**Name2 (NI) **] was started on
topical cortisone, which appeared to help.
On [**2128-3-16**], patient had another spike of fevers to 104.1,
and it was decided that his Permacath should indeed be
removed. After consulting with Dr. [**Last Name (STitle) **] of the General
Surgery service, this was organized for the following morning
and proceeded without complication. However, fevers did not
dissipate with this, and the patient continued to have fevers
albeit at lower peaks.
On postoperative day six, patient had first episode of
flatus. His p.o. intake was then advanced from sips through
clears, ultimate fulls and solids, which he tolerated
extremely well.
On postoperative day nine, patient had a final fever peak.
It was thought that it was necessary to work this up and
patient was sent for an abdomen CT with p.o. and IV contrast.
This showed no evidence of any fluid collections, abscesses,
or obvious causes for the fever spikes. Thereafter, the
[**Hospital 228**] hospital course was unremarkable. He was
discharged on [**2128-3-21**].
DISPOSITION: Patient is discharged to home. He will have
home nursing association followup with him to confirm that he
is able to care of his ostomy effectively.
DISCHARGE MEDICATIONS:
1. Percocet 1-2 tablets p.o. q.4-6h. prn pain.
2. Keflex for total of five more days.
FOLLOWUP: Patient will follow up with Dr. [**Last Name (STitle) **] in [**1-9**]
weeks and Dr. [**Last Name (STitle) 1888**] in [**1-9**] weeks.
DIAGNOSES:
1. Patient is status post cystectomy, prostatectomy, distal
colectomy, creation of diverting colostomy, creation of
diverting urostomy.
2. Fevers of unknown origin.
3. Postoperative anemia.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**]
Dictated By:[**Last Name (NamePattern1) 6825**]
MEDQUIST36
D: [**2128-3-25**] 10:59
T: [**2128-3-25**] 11:57
JOB#: [**Job Number 50516**]
(cclist)
ICD9 Codes: 5119, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2857
} | Medical Text: Admission Date: [**2100-10-2**] Discharge Date: [**2100-10-5**]
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
None
Past Medical History:
Pt is a 82 yo female with h/o CAD, CHF, HTN, AF on coumadin,
and left MCA stroke in past who was found on floor beside her
bed
at [**Hospital3 537**]. The last time she was seen in her USOH was
the
night before. The patient is intubated/sedated when I saw her,
so the history is from old notes and EMS sheets. She was
apparently awake when they found her but incomprehensible. She
has some aphasia and ? dementia after her old stroke, but the
severity is unknown. She was brought to the ED as a trauma
patient and MI was also a concern. She then had a head CT which
showed effacement of the sulci on the right in an MCA
distribution. Mild loss of G/W differentiation. No hyperdense
MCA
sign. It is difficult to tell exactly though given the changes
contralaterally from her old stroke. A code stroke was called,
but as she was last seen before bed and is on coumadin, she is
not a candidate for intervention. There is no record that she
was feling strangely before bed the night before. How she came
to be on the floor is unknown. She was intubated in the ED here
for airway protection, and was very agitated, so she was sedated
with propofol. She is DNR/DNI by report/notes, but was
intubated
before this was known. Her son is a physician and does wish to
leave the ET tube in for the time being. She was unable to get
an MRI due to metal in her ETT.
Patient is unable to answer a ROS.
Social History:
Patient lives at [**Hospital3 537**] and is undergoing rehab. Her
son is in the area. No smoking/EtOH.
Family History:
Unknown
Physical Exam:
Admission Exam(most immediate exam performed by Dr [**Last Name (STitle) 23608**]
Gen: 82 yo female intubated and sedated,wearing c-spine collar,
squirming intermittently
Heent: Normocephalic/atraumatic, conj clear, mmm
Resp: cta b/l
CV: irreg irreg, nl s1/s2, 3/6 sem at llsb
abd: +b s/nd
extr: w/wp
neuro:
Mental Status: does not respond to verbal commands to open eyes
or show thumb, but grasps with right hand and steps down with
right foot when instructed. no spontaneous eye-opening.
CN: Pupils equal and round 2mm, right non-reactive, left with
some hippus. Unable to assess oculocephalic reflex due to
c-spine collar. Unable to assess facial symmetry due to collar.
+Corneal reflex bilaterally. +Gag. No forced eye deviation.
Difficult to assess visual fields as blink-to-threat is
inconsistent.
Motor: grasps right hand on command with 4+/5 strength,
plantarflexes right foot with 5/5 strength; does not hold up any
extremities on command; spontaneously moves right arm and both
legs - seems to have left-sided neglect as she does not follow
commands to plantarflex left foot, but can spontaneously move it
Reflexes: dtr's absent in le's, 1+ and symmetric in ue's, toes
tonically upgoing bilaterally
Sensory: withdraws to pain with right arm, right leg, and left
leg, but left arm with decerebrate posturing in response to
pain.
(later, she was moving left leg spont, but still only posturing
her left arm)
Pertinent Results:
TECHNIQUE: Noncontrast head CT.
CT HEAD WITHOUT IV CONTRAST: Again seen is a large area of
decreased attenuation within the right cerebral hemisphere
consistent with an evolving right MCA infarct. Additionally,
there has been interval hemorrhage within this measuring 4.2 x
2.6 cm in maximum dimension, with increased mass effect and
obscuration of the frontal [**Doctor Last Name 534**] of the right lateral ventricle,
with focal increased shift of the midline adjacent to this.
Additionally, there is a tiny focus of increased density within
the posterior [**Doctor Last Name 534**] of the left lateral ventricle, which appears
to demonstrate layering, and likely represents intraventricular
hemorrhage suggesting a subarachnoid component. The caliber of
the occipital horns of the lateral ventricles is stable. Again
seen is an area of decreased attenuation within the left
parietal region consistent with prior left MCA infarct. There is
decreased attenuation of the white matter adjacent to the left
occipital [**Doctor Last Name 534**], which is stable in appearance. The basal
cisterns are stable in appearance. The Foramen of [**Doctor Last Name 23609**] is
patent. There appears to be some narrowing of the third
ventricle, however, this is patent. The soft tissue and osseous
structures are unchanged.
IMPRESSION: Again seen is evolving large right MCA infarct.
There has been interval hemorrhage within this, with compression
of the frontal [**Doctor Last Name 534**] of the right lateral ventricle, and
increased mass effect with slight shift of midline structures.
There is a focus of intraventricular hemorrhage
within the occipital [**Doctor Last Name 534**] of the left lateral ventricle. These
results were discussed with Dr. [**First Name4 (NamePattern1) 1104**] [**Last Name (NamePattern1) 4638**] at 12 p.m. on
[**2100-10-3**].
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2100-10-2**] 7:01 AM
CT HEAD W/O CONTRAST
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with ms changes s/p fall
HEAD CT WITHOUT IV CONTRAST: There is diffuse hypoattenuation
within the right frontal, parietal, and temporal regions with
narrowing of the sulci and loss of [**Doctor Last Name 352**]-white differentiation,
findings suggestive of an evolving infarction. Stable area of
hypodensity is again seen in the distribution of the left middle
cerebral artery with associated encephalomalacia changes and
exvacuo dilatation of the left lateral ventricle. There is no
intra- or extra-axial hemorrhage or shift of midline structures.
Configuration of the ventricles is stable since the prior
examination. Basal cisterns are within normal limits. Mild
mucosal thickening is seen involving the ethmoid air cells
anteriorly. Remaining visualized paranasal sinuses and mastoid
air cells are clear. Surrounding osseous and soft tissue
structures are unchanged.
IMPRESSION:
1. Area of hypoattenuation within the distribution of the right
middle cerebral artery with narrowing of the sulci and loss of
[**Doctor Last Name 352**] and white differentiation suggestive of an evolving
infarction.
2. Stable appearance of left cerebral middle artery territory
remote infarction.
3. No intracranial hemorrhage.
Brief Hospital Course:
The patient was admitted to the Neurology ICU for management of
her large right MCA stroke. Unfortunately, her clinical
condition worsened and repeat head imaging noted hemorrhageic
transformation of the stroke with interventricular extension.
After discussion with her family, the patient was extubated and
administered comfort measure level of care. She expired from
respiratory failure at 800AM [**2101-10-5**]
Discharge Disposition:
Expired
Discharge Diagnosis:
Right MCA stroke
Discharge Condition:
Expired
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 4280, 496, 5789, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2858
} | Medical Text: Admission Date: [**2187-11-26**] Discharge Date: [**2187-11-30**]
Date of Birth: [**2128-11-20**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 13252**]
Chief Complaint:
prolonged seizure
Major Surgical or Invasive Procedure:
EEG
History of Present Illness:
59yo woman with recently diagnosed renal cell cancer with brain
metastases diagnosed by MRI [**11-14**], presented with a prolonged
seizure at home. Per her husband, she has had no c/o recently
including f/c/cp/sob/gu/gi sx; she was supposed to have a
radiology study and mask fitting in preparation for cyberknife
procedure the morning of admission. Her husband woke up at 4am
and heard some commotion from living room - he walked in to find
the patient standing up, nodding her head up and to the right,
rhythmically, with eye deviation to the right, some blinking
(?rhythmic), not talking. He changed her clothes and helped her
into the car, then drove her to the hospital. Along the way, he
asked her if she could squeeze his hand, and she periodically
gave weak squeezes on command. When she arrived at [**Hospital1 **] (5AM) she
was not following commands, and rhythmic eye-blinking was noted,
with R eye deviation; she received 6mg total ativan, with some
effect (and was following commands again), and given 1gm PHT
load.
Past Medical History:
renal cell cancer diagnosed in [**8-26**] with a left renal mass,
presented with LE swelling. Now s/p L nephrectomy and
adrenalectomy [**9-26**], pathology showing renal cell. On [**2187-11-14**]
had MRI with a hemorrhagic metastasis L frontal, following with
Dr. [**Last Name (STitle) 4253**].
CHF with EF 40-55%
mitral valve regurgitation
HTN
anemia related to folate and iron defic
factor [**Last Name (STitle) **] deficiency
Social History:
Lives with husband and son, HS education; formerly worked at
[**Male First Name (un) 28447**] club/sales, quit tob 30 yrs ago, formerly smoked <1pd x 10
yrs, former etoh, no drugs, no toxic exposures
Family History:
son with sz d/o, father d. lung ca with mets to brain; mother d.
stroke, sister with cervical ca, brother with cad
Physical Exam:
Examination on admission:
Afeb HR 120 BP 144/97 RR 20 99%RA
General appearance: thin white female
HEENT: moist mucus membranes, clear oropharynx
Neck: supple
Heart: regular
Lungs: clear ant only
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Mental Status: The patient has her eyes open, blinking
spontaneously (not rhythmically at this point), staring
straight, but can track on command and follow commands to
squeeze hand wiggle toes, close eyes; no speech heard
Cranial Nerves: Blinks to threat bilat, optic discs are normal
in appearance, eye movements are normal with tracking and with
OCR (both vertical and horizontal), no nystagmus. Pupils
slightly anisocoric (<0.5mm difference, L>R) but both briskly
reactive to light; No obvious facial asymmetry with grimace,
intact corneals; Hearing is intact to voice. The palate elevates
in the midline. The tongue protrudes in the midline and is of
normal appearance.
Sensorimotor: Pt w/d vigorously all 4 ext to stim, squeezes
hands and wiggles toes, but did not raise legs off bed.
Reflexes: The tendon reflexes are brisk throughout, slightly
brisker on the right than the left. The plantar reflexes are
flexor.
Gait, coord could not be tested.
Pertinent Results:
Admission labs:
[**2187-11-26**] 05:16AM BLOOD WBC-7.6 RBC-3.40* Hgb-9.7* Hct-28.6*
MCV-84 MCH-28.7 MCHC-34.1 RDW-17.1* Plt Ct-539*
[**2187-11-26**] 05:16AM BLOOD Neuts-63.3 Lymphs-25.3 Monos-8.0 Eos-3.0
Baso-0.4
[**2187-11-26**] 05:16AM BLOOD PT-14.0* PTT-25.6 INR(PT)-1.2*
[**2187-11-26**] 05:16AM BLOOD Glucose-87 UreaN-15 Creat-0.6 Na-137
K-4.3 Cl-99 HCO3-26 AnGap-16
[**2187-11-26**] 05:16AM BLOOD ALT-61* AST-44* AlkPhos-324* Amylase-68
TotBili-0.3
[**2187-11-26**] 05:16AM BLOOD Albumin-3.2* Phos-3.9 Mg-2.0
[**2187-11-26**] 05:16AM BLOOD Lipase-101*
[**2187-11-26**] 05:16AM BLOOD Digoxin-0.5*
.
Imaging:
CXR: No evidence of pneumonia or CHF. Redemonstration of
numerous pulmonary lesions consistent with the patient's known
metastatic renal cell carcinoma.
.
Head CT [**11-26**]: There is a 14 mm ovoid hyperdense focus in the
left frontal lobe, consistent with hemorrhage at the site of the
patient's known metastatic lesion. This focus appears slightly
larger than on prior examination. There is also a significant
increase in hypodensity in the surrounding left frontal lobe
consistent with edema. This edema is compressing the frontal
[**Doctor Last Name 534**] of the left lateral ventricle. There is slight shift of
normally midline structures to the right, as shown by subfalcine
herniation. No new areas of hemorrhage are identified. There is
no hydrocephalus. The osseous and soft tissue structures are
unremarkable.
.
MRI Head [**11-26**]:
The metastasis in the superior left frontal lobe is again
demonstrated. It appears to have increased in size compared to
[**2187-11-14**]. For example, on the sagittal images, it has increased
from approximately 12 mm to 16 mm in oblique superior/inferior
dimension. There is more anterior extension of edema as well.
.
There is now a second punctate lesion in the left cerebellar
hemisphere with surrounding edema, as discussed by the radiology
residents with Dr. [**Last Name (STitle) 42460**] on [**11-27**].
.
The other small areas of FLAIR hyperintensity present on the
current study
were present previously and no underlying enhancing lesions are
seen, most
consistent with small vessel disease. There is new mass effect
on the left frontal [**Doctor Last Name 534**] from the left frontal metastasis and
edema. The cerebellar edema does not affect the fourth
ventricle. As seen previously, there is a degree of
ventriculomegaly. The craniovertebral junction is normal.
.
IMPRESSION:
1. There is a second punctate enhancing lesion in the left
cerebellum with surrounding edema, new since10/25 and most
consistent with a second
metastasis.
2. A left frontal lesion appears to have enlarged from
approximately 12 to approximately 16 mm since [**11-14**] and there is
slightly more surrounding edema with new mass effect on the left
frontal [**Doctor Last Name 534**].
.
EEG [**11-27**]:
ABNORMALITY #1: Sharp and slow wave complexes over the left
anterior quadrant occurred during wakefulness with a frequency
of 0.5-1 Hz. During these discharges, the patient was able to
follow simple commands, but was unable to state the date
appropriately.
BACKGROUND: A 9.5 Hz posterior predominant rhythm was recorded
in the waking state, which attenuated with eye opening. The
normal anterior to
posterior voltage gradient was observed.
HYPERVENTILATION: Contraindicated.
INTERMITTENT PHOTIC STIMULATION: Portable study precluded photic
testing.
SLEEP: The patient remained awake throughout the recording. No
state I or II sleep was recorded.
CARDIAC MONITOR: A generally regular rhythm was recorded, with
an average rate of 90 beats per minute.
IMPRESSION: This is an abnormal EEG in the waking state due to
the periodic sharp and slow wave complexes in the left anterior
quadrant occuring at a frequency of 0.5-1 Hz. No seizures were
recorded.
Brief Hospital Course:
Impression: 58yo woman with RCC with metastases to the brain,
who presented with a prolonged seizure likely to be focal motor
partial status. The seizure focus was felt to be her L frontal
lobe lesion, which was consistent with her symptoms and EEG
findings. She was given 6mg ativan and 1gm dilantin in the ED
with resolution of her symptoms. She was started on decadron in
the ED and continued on this throughout her hospital stay at 4
mg PO Q6. She was initially admitted to the ICU for close
monitoring. An EEG showed L frontal spikes occuring
approximately every 5 seconds. She slowly improved over the
course of the next several days, with persistent non-fluent
aphasia with preserved repetition. She was continued on dilantin
with keppra added for more long term seizure prophylaxis (goal
to wean pt of Dilantin and titrate up Keppra on an outpatient
basis). As her exam improved she was transferred to the floor.
.
She had an MRI by cyberknife protocol on [**11-26**], which showed a
new cerebellar lesion in addition to her frontal lesion. Her
radiation oncology, neurooncology, and neurosurgical teams were
notified of this. They decided that, due to potential impact of
the radiation on the edema surrounding the frontal lesion, it
would be advisable to proceed surgically with the anterior
frontal lesion, scheduled to happen in the week following
discharge by Dr. [**Last Name (STitle) **]. On [**11-28**], the patient was seen at the
radiation planning center for Cyberknife planning regarding the
cerebellar lesion and the lesion was radiated on [**11-29**]. Pt. was
monitored overnight with no clinical evidence of increased edema
or mass effect [**2-22**] radiation.
.
On discharge her exam was significant for a mild non-fluent
aphasia as above and mild R sided UMN pattern weakness and R NLF
flattening. She will be contact[**Name (NI) **] in the week following
discharge re: an appointment to come back into the hospital for
resection of her met, and Dr. [**Last Name (STitle) 4253**] will follow up with her
at that time.
Medications on Admission:
1. Ativan 0.5 mg q.8h. as needed for anxiety.
2. Digoxin 250 mcg a day.
3. Folinic acid 1 mg a day.
4. Ferrous sulfate 325 mg a day.
5. Lisinopril 10 mg a day.
6. Metoprolol 25 mg b.i.d.
Discharge Medications:
1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
8. 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*
9. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Renal Cell Carcinoma with metastases to Lung and Brain
L frontal and cerebellar brain mass
Status epilepticus, focal motor, likely [**2-22**] brain mass
Discharge Condition:
Stable, aphasia improved but present, no seizure activity for >
48 hours, able to walk without assistance, afebrile, no
confusion or lethargy
Discharge Instructions:
Please call your doctor or go to the ER if your speech gets
worse, you develop any headaches, vision changes, double vision,
nausea, vomiting, weakness in your arms or legs, unsteadiness or
trouble walking, confusion, excessive sleepiness, any further
seizures, or any other symptoms that concern you.
Please take all medications as prescribed.
Followup Instructions:
Neuro-Oncology: Dr. [**Last Name (STitle) 4253**] will see you in the hospital when
you come back to have your tumor resected. Please call her
office at [**Telephone/Fax (1) 44**] if you have any questions or problems
before that.
[**Doctor First Name **] from Dr.[**Name (NI) 9034**] office will be in contact with you on
[**Name (NI) 766**] about scheduling a date for your tumor resection by Dr.
[**Last Name (STitle) **]. Please call her office at [**Telephone/Fax (1) 2731**] if you have any
questions about this.
Previously scheduled appointments:
Cardiology: Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D.
Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2187-12-12**] 10:40
Oncology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-12-19**] 5:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Date/Time:[**2187-12-19**] 5:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 13255**]
Completed by:[**2187-11-30**]
ICD9 Codes: 4280, 4240, 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2859
} | Medical Text: Admission Date: [**2109-12-15**] Discharge Date: [**2109-12-20**]
Date of Birth: [**2028-4-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Abdominal pain and chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81M with history of CAD s/p MI x 4 per patient (no PCI or
interventions), CVA, presenting with two days of abdominal pain
and nausea without chest pain or dyspnea. Pain started 2 days
PTA, felt he had to go to BR. Took maalox for pain. Did not
take any of his medications that day and poor PO intake. Pain
returned on day prior to admission (?unclear if resolved in
interim); went into OSH. He went to OSH where had CXR showing ?
free air. Cardiac enzymes found to be high; also with renal
failure and hyperkalemia. Given ASA 325 mg PO and zosyn for
?infiltrate on CXR.
.
In the ED, initial vs were: T98.1 70 130/84 18 98%. CT
concerning for SBO. NGT placed. Cardiac enzymes positive.
Cards and surgery consulted. Patient was given plavix 300 mg,
and heparin gtt started.
.
On the floor, patient quite lethargic. Does arouse to loud
voice and tactile stimulation, but easily falling asleep.
Unclear if he is currently having pain.
Past Medical History:
- CAD s/p MI x 4 prior per patient/wife.
- CVA [**2109-10-6**] - residual deficits affects speech as well
as weakness; initially involved more one side than other.
Speech - when excited tends to slur speech together.
- HTN
- CHF (details unknown)
- CKD (creatinine 1.7 from [**2098**]-[**2101**] - last records)
- History of prostate surgery 8 years ago
Social History:
Lives with wife; had been at rehab after hospital stay for
stroke. She often has to push him to move around the house a
lot, take meds, eat. Balance poor since stroke (supposed to use
walker or cane).
- Tobacco: ? remote history
- Alcohol: none recent
- Illicits: none
Family History:
Non-contributory
Physical Exam:
General: Lethargic but arousable, seems to become more lethargic
with repeated stimulation; more awake and interactive when first
being awoken.
HEENT: Sclera anicteric, PERRL but somewhat resists opening of L
eye, MM slightly dry, oropharynx clear. NGT in place.
Neck: supple, JVD appears 2 cm ASA, no LAD, supple.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, S4 present, no
murmurs.
Abdomen: distended, slightly firm, minimal bowel sounds,
tympanic throughout. Mild to moderate diffuse tenderness to
palpation, no guarding ro rebound.
Ext: cool feet and hands, 2+ pitting edema of bilateral LEs,
some chronic venous stasis changes.
Neuro: Oriented to [**Hospital3 4107**], not able to specify date.
Very lethargic but arousable, though falling asleep easily.
Moves all extremities to command but unable to participate in
formal strength testing.
Pertinent Results:
Admission labs: [**2109-12-15**]
WBC-9.4 RBC-4.81 Hgb-14.2 Hct-43.4 MCV-90 MCH-29.5 MCHC-32.7
RDW-16.2* Plt Ct-221
PT-14.5* PTT-24.9 INR(PT)-1.3*
Glucose-108* UreaN-49* Creat-1.9* Na-145 K-5.4* Cl-107 HCO3-23
AnGap-20
ALT-38 AST-56* CK(CPK)-491* AlkPhos-77 TotBili-1.4
.
Other Pertinent labs:
[**2109-12-15**] 09:10PM BLOOD CK-MB-35* MB Indx-7.1*
[**2109-12-15**] 09:10PM BLOOD cTropnT-0.38*
[**2109-12-16**] 04:52AM BLOOD CK-MB-21* MB Indx-6.6* cTropnT-0.36*
[**2109-12-16**] 03:45PM BLOOD CK-MB-15* MB Indx-4.5 cTropnT-0.46*
.
Discharge Labs: [**2109-12-20**]
OD Glucose-67* UreaN-24* Creat-1.2 Na-144 K-3.7 Cl-105 HCO3-32
AnGap-11
WBC-5.1 RBC-4.42* Hgb-12.2* Hct-38.6* MCV-87 MCH-27.7 MCHC-31.7
RDW-16.3* Plt Ct-230
Phos-2.0* Mg-1.9
.
CT abd/pelvis: moderate R pleural effusion, small L effusion
with atelectasis. RLL ?aspirated barium. stomach dilated and
dilated small bowel loops, more distal loops decompressed -
concerning for SBO. no clear transition point. no free air
.
CT head: no hemorrhage, edema, mass effect. chronic small
vessel ischemic disease, old infarcts seen (R parietal lobe)
.
CXR: no lines/tubes. cardiomegaly. bilateral atelectasis.
dilated stomach and colon.
.
EKG: NSR at 84, LBBB with associated ST segment and T wave
changes. No significant change compared to priors from ED and
OSH ED. \
.
Echo: [**2109-12-16**]
Left ventricular cavity dilation with severe global dysfunction
c/w multivessel CAD or diffuse process (toxin, metabolic, etc.).
LVEF <20 %. The prominent trabeculations raises the possibility
of Non-compaction Syndrome. Right ventricular dilation with free
wall hypokinesis. Pulmonary artery systolic hypertension.
Dilated ascending aorta.
Brief Hospital Course:
81 yo M with history of CAD, CVA, admitted with NSTEMI, SBO, and
lethargy.
.
# NSTEMI/CAD. The patient was found to have elevaated troponins
prior to transfer. On arrival to [**Hospital1 18**] CD 419, MB index 7,
Troponin 0.36. ECG with LBBB, but did get documentation that
this is old (past ECG in chart). Cardiology was consulted while
patient was in the MICU and recommended to continue medical
management of CAD with ASA, plavix, ace-inhibitor, high dose
statin, b-blocker and also continuing heparing gtt for 48 hours.
They felt the elevated troponin leak was less likely to be from
ACS and more likely from demand. Heparin drip was stopped after
48 hours and he continued to be chest pain free on medical
management. TTE demonstrated an EF of 20%. His tropol XL was
increased to 75mg daily, he was started on lisinopril 10mg
daily, continued on atorvastatin 80mg. His aspirin was increased
to 325mg and plavix 75mg daily was started. The patient should
undergo cardiac rehabilitation upon discharge from [**Hospital1 1501**] as well
as continued physical therapy. During rehabilitation please
watch for symptoms of chest pain, shortness of breath, syncope,
palpitations. His work effort should be advanced slowly with
monitoring for the development of symptoms. He was restarted on
lasix and is being discharged on lasix 80mg twice daily (prior
home dose 40mg twice daily). His weight should be monitored
daily and consider dose increase with weight increase of 3lb.
Please check his chemistry on [**12-23**] and replete K if needed.
Please also monitor BUN/Cr on increased dose of lasix and
lisinopril.
.
# Abdominal pain/SBO. Unclear precipitant. No known surgical
history other than prostatectomy. No identified transition
point from CT, but does have distal decompressed bowel. Patient
with benign exam and CT only suggestive of SBO without other
process. General surgery followed patient during hospitalization
and recommended no acute surgical intervention along with serial
abdominal exams. Patient's abdominal pain resolved after having
a bowel movement. A NGT was also placed and put on intermittent
low suction. After low residuals were observed, the NG tube was
clamped and later removed. His diet was advanced to low
sodium/cardiac heart healthy. He tolerated solid foods well with
no abdominal pain prior to discharge. The patient was also
having normal bowel movements.
.
# Lethargy. Baseline per wife as above. Generally is able to
get up and ambulate; speech deficits and generalized weakness at
baseline. Also noted by wife to be intermittently lethargic and
falls asleep easily. Head CT negative for acute process.
.
# Renal failure. Possible mild acute component on chronic, but
unclear what actual baseline is. Was 1.7 in [**2101**]. The patient
was given IVF fluids and his Cr improved to 1.2 prior to
discharge.
.
# Acute systolic CHF: Echo done and shows EF of 20%. Patient
on appropriate CHF medications (see NSTEMI/CAD above). Due to
being fluid overload on exam, his lasix dose was increased once
his kidney function improved. He responded well to diuresis with
no increase in his Cr. His lasix dose has been increased to 80mg
po BID for continued lower extremity edema. Please check chem 7
on [**12-23**]
.
# O2 requirement: Initially required 2-3L NC. This is likely [**1-7**]
CHF. The patient was diuresed as indicated above. He was
discharged on room air.
.
# Communication: Patient and wife [**Telephone/Fax (1) 109246**]
Medications on Admission:
- ASA 81 mg daily
- Toprol XL 25 mg daily
- Lasix 40 mg [**Hospital1 **]
- NTG 0.2 mg/hr patch q24
- atorvastatin 80 mg daily.
- cozaar 50 mg daily
Discharge Medications:
1. Cardiac rehabilitation
Please refer to cardiac rehabilitation
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal once a day.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lasix 40 mg Tablet Sig: Two (2) Tablet PO twice a day.
9. Outpatient Lab Work
Please check chemistry 7 on [**2108-12-23**].
Discharge Disposition:
Extended Care
Facility:
[**Known lastname 13990**] Health Care
Discharge Diagnosis:
Primary Diagnosis:
Small bowel obstruction
NSTEMI
.
Secondary Diagnosis:
CAD
CVA
HTN
Chronic systolic CHF : EF < 20%
CKD
History of prostate surgery 8 years ago
Discharge Condition:
Stable. cooperative, needs assistance of ambulations.
Discharge Instructions:
You were admitted to the hospital with abdominal pain and a
heart attack. Your abdominal pain was due to a small bowel
obstruction which was treated with supportive care and resolved.
Cardiologists evaluated you while in the hospital. We treated
your heart attack with a blood thinner, heparin. Your cardiac
function has worsened and we have increased your cardiac
medications to help improve your heart's function. Please see
below. You should follow up with Dr. [**Last Name (STitle) **] after your
discharge. An appointment has been made for you.
Physical therapists worked with you and recommended that you go
to a rehabilitation facility.
We made the following changes to your medications:
1) Stop Cozaar
2) Start lisinopril 10mg by mouth once a day
3) Increase Aspirin to 325mg by mouth once a day
4) Start Plavix 75mg by mouth once a day
5) Increase Toprol XL to 75mg by mouth once a day
6) Increase lasix to 80mg twice daily - Your lasix has been
increased. You should be weighed daily and your dose of lasix
should be changed if your weight changes by more than 3 lbs.
Followup Instructions:
MD: [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Specialty: Internal Medicine/ Cardiovascular Disease
Date/ Time: [**Last Name (LF) 2974**], [**1-3**], 3:45pm
Location: [**Street Address(2) **], [**Hospital1 **] - [**Location (un) 470**]
Phone number: [**Telephone/Fax (1) 4475**]
Completed by:[**2109-12-20**]
ICD9 Codes: 5849, 4280, 2767, 4168, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2860
} | Medical Text: Admission Date: [**2155-12-23**] Discharge Date: [**2155-12-26**]
Date of Birth: [**2134-10-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 1148**]
Chief Complaint:
overdose, suicide attempt
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
21 yo F ingested tylenol PM, clonazepam, lorazepam, and alcohol
found with altered mental status. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69629**] of the Office of
Residential Life at [**University/College 14925**]placed a call to campus
police at 4:22PM. She found the patient on the bathroom of the
dorm semi-conscious, incoherent, unable to communicate. It
appeared that she had gone to the bathroom to vomit, but there
was no evidence of active vomiting. The patient had a sluggish
response to questions, and was unable to state her last name.
The patient stated that she had taken approximately [**6-21**] pills
around 3PM, but was very confused and lethargic. Ms. [**Name13 (STitle) 69629**]
found 2 empty Rx bottles of lorazepam and clonazepam, an empty
bottle of tylenol PM, an open bottle of advil, and an open
bottle of vodka approximately [**2-14**] full in the patient's dorm
room. The patient confirmed that she had consumed these items.
The bottles were left on site, so the dosages are unknown.
.
On arrival to the ED, the patient was tachypneic and dusky with
dilated pupils bilaterally per ED resident. She received anzemet
and propofol and was intubated for airway protection due to
depressed mental status. She got charcoal 100 mg via OG tube.
Toxicology was consulted. She received a loading dose of
N-acetyl-p-aminophenol in the ED.
Past Medical History:
Depression with 2 other attempts in the past, one of them an
ingestion. She was treated previously at [**Hospital3 1810**] by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Social History:
Her parents are from [**Country 3594**]. Is a student at BU, living in a
single, and has a work study job. She was doing well in school
and final exams are next week. She has been fighting with her
boyfriend lately. She drinks socially, and used to smoke
marijuana according to her father. She was prescribed ativan in
the past for a fear of flying.
She has supportive parents and a 17yo sister who live in the
area. She was sexually abused in the past.
Family History:
Denies any family history of psychiatric issues or substance
abuse
Physical Exam:
VS: 97.0 76 112/60 12 100% on AC TV 400 FiO2 40% RR 14 PEEP 5
Gen: appearing her stated age, intubated and sedated
HEENT: MMM, ET tube in place, PERRL, nonicteric
Cor: RRR no M/R/G
Pulm: CTAB no crackles bilaterally
Abd: +BS, soft NT ND. No hepatosplenomegaly. + umbilical ring
Ext: WWP, no edema, DP 2+ bilaterally
GU: clitoral ring
Skin: no rashes or jaundice, bilateral gluteal tattoos
Neuro: + gag on deep suction, downgoing toes bilaterally, moving
all 4 extremities
Pertinent Results:
[**2155-12-23**] 05:10PM ASA-NEG ETHANOL-90* ACETMNPHN-113.2*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2155-12-23**] 05:10PM WBC-5.6 RBC-4.65 HGB-14.4 HCT-39.6 MCV-85
MCH-31.1 MCHC-36.5* RDW-12.9
[**2155-12-23**] 05:10PM NEUTS-63.5 LYMPHS-28.2 MONOS-7.1 EOS-0.5
BASOS-0.6
[**2155-12-23**] 05:10PM PLT COUNT-379
[**2155-12-23**] 05:10PM PT-13.7* PTT-30.5 INR(PT)-1.2*
[**2155-12-23**] 05:10PM ALBUMIN-5.1*
[**2155-12-23**] 05:10PM LIPASE-38
[**2155-12-23**] 05:10PM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-61
AMYLASE-77 TOT BILI-0.3
[**2155-12-23**] 05:10PM estGFR-Using this
[**2155-12-23**] 05:10PM GLUCOSE-96 UREA N-8 CREAT-0.7 SODIUM-141
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-19
[**2155-12-23**] 05:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2155-12-23**] 08:16PM WBC-3.6* RBC-3.83* HGB-11.6* HCT-32.8* MCV-86
MCH-30.4 MCHC-35.5* RDW-13.0
[**2155-12-23**] 08:16PM ALT(SGPT)-10 AST(SGOT)-19 LD(LDH)-180
CK(CPK)-261* ALK PHOS-49 TOT BILI-0.3
[**12-23**] CXR: IMPRESSION:The ET tube tip is 2.5 cm above the
carina. The NG tube tip is within the stomach. The heart size
and the mediastinum are unremarkable. The lungs are clear. No
sizeable pleural effusion is identified.
[**12-25**] CXR: Heart size is normal. There is an ill-defined focal
opacity overlying left heart that likely represents atelectais
or possibly aspiration in L.L.L.
Brief Hospital Course:
This is a 21 y/o F w/hx of depression and prior suicide attempts
who presented to the ED on [**12-23**] after taking an unknown amount
of tylenol pm, clonazepam, ativan, and alcohol. She was
intubated in the ED for altered mental status and was admitted
to the [**Hospital Unit Name 153**]. Her initial tylenol level was 113, EtOH 90. She
was given NAC until her tylenol was zero. She was exutubated
the day after admission. She has been seen by psychiatry who
feel she warrants psychiatric admission now that her medical
issues have resolved.
#Overdose: Currently with negative acetaminophen level, benzo
intoxication has worn off.
.
# Fever: Had one post intubation. [**Month (only) 116**] have degree of chemical
pneumonitis from aspiration event. No prior sx suggestive of
influenza. Likely that sore throat [**2-13**] intubation and not strep
(no posterior pharyngeal exudate, no LAD). UA clean.
Leukocytosis resolved; no role for antibiotics at this time.
.
# Anemia: Unknown baseline. Likely due to aggressive IVF, vs
chronically low from menstruation. Iron studies suggestive of
anemia of chronic disease. Should get repeated at a later date.
.
# Tachycardia: Likely due to dehydration vs low-grade temp.
Improved with IV fluids.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1196**] - [**Location (un) 745**]
Discharge Diagnosis:
suicidal overdose, tylenol PM, clonazepam, alcohol
pneumonitis post intubation
anemia, likely from aggressive volume resuscitation
Discharge Condition:
Good
Discharge Instructions:
Please use the psychiatric facility.
Please follow up with a primary care doctor to get your
bloodwork checked to see that the anemia has resolved.
Followup Instructions:
Please make a follow up appointment with your primary care
doctor in the next 3-4 weeks.
ICD9 Codes: 5070, 2762, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2861
} | Medical Text: Admission Date: [**2199-7-24**] Discharge Date: [**2199-8-9**]
Date of Birth: [**2199-7-24**] Sex: M
Service: NB
NAME AFTER DISCHARGE: [**Known lastname **] [**Last Name (un) 69626**].
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] is the 2.235 kg
product of a 34 and [**5-29**] week gestation, born to a 35 year-
old, Gravida VI, Para V, now VI woman. Prenatal screens: B
positive, direct Coombs negative, hepatitis surface antigen
negative, RPR nonreactive, Rubella immune, GBS positive.
PAST MEDICAL HISTORY: Notable for chronic hypertension, not
currently treated with medications. This pregnancy was
notable for oligohydramnios of undetermined etiology.
Spontaneous onset of preterm labor, leading to spontaneous
vaginal delivery, under epidural and spinal anesthesia.
Rupture of membranes occurred at delivery and yielded clear
amniotic fluid. There was no intrapartum fever or other
clinical evidence of chorioamnionitis. Antepartum
antibacterial prophylaxis was administered beginning 14 hours
prior to delivery. Infant delivered vaginally with Apgars of
8 and 8.
PHYSICAL EXAMINATION: On admission, weight was 2.235 kg.
Head circumference 29.5 cm. Length 48.5 cm. Anterior
fontanel soft and flat, non dysmorphic. Palate intact. Neck
and mouth normal. No nasal flaring. Normocephalic. Chest:
No retractions, good breath sounds bilaterally, no
adventitial sounds. Cardiovascular: Well perfused, regular
rate and rhythm. Femoral pulses normal. S1 and S2 normal.
No murmur. Abdomen soft, nondistended, no organomegaly, no
masses. Bowel sounds active. Anus appears patent. Three
vessel umbilical cord. Genitourinary: Normal penis. Testes
palpable bilaterally. CNS: Active, alert, responds to
stimulation. Tone normal and symmetric. Moves all
extremities. Suck, root and gag intact. Facies symmetric.
Grasp symmetric. Musculoskeletal: Normal spine, limbs, hips
and clavicles.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Known lastname **]
was admitted to the newborn ICU in room air. He progressed
to have respiratory retractions, prompting placement on C-Pap
of 6. Chest x-ray was consistent with TPN. Infant weaned to
room air within 12 hours and has remained stable in room air
throughout the remainder of his hospital course. He has had
no clinical evidence of apnea or bradycardia of prematurity.
Cardiovascular: [**Known lastname **] has been stable. He did present with
a soft audible murmur on day of life 6. Chest x-ray, EKG and
pre and post ductal sats as well as 4 extremity blood
pressures were all within normal limits. Murmur considered
to be a flow murmuror a small VSD. Blood pressure most recently
was 81/39 with a mean of 53. Heart rates have been 130s to 160s.
Fluids, electrolytes and nutrition: Birth weight was 2,235
kg. Discharge weight is 2.5 kg. Infant was initially started
on 80 cc/kg/day of D-10-W. Enteral feedings were started on day
of life #1. Infant achieved full enteral feedings by day of
life #4. Infant has achieved full p.o. feedings by [**2199-8-3**]. He continues to demonstrate good weight gain. He is
currently feeding Similac 24 calorie or breast milk 24 calorie by
concentration. He demonstrated an immature feeding pattern and
would have some discordiation with feedings that resulted in some
bradycardia. His feeding pattern improved with time. Prior to
discharge, he had gone 72 hours without any immature feeding
patterns.
Gastrointestinal: Peak bilirubin was on day of life #3 of
6.4 over 0.4. Infant has not required any intervention.
Hematology: Hematocrit on admission was 46.7. He has not
required any blood products.
Infectious disease: CBC and blood culture were obtained on
admission. CBC was benign. Blood cultures remained negative
at 48 hours, at which time Ampicillin and Gentamycin were
discontinued. He developed a monilial rash and was treated with
nystatin to his diaper area.
GU: He had a circumcision prior to discharge with a good cosmetic
result.
Neurologic: Infant has been appropriate for gestational age.
Sensory: Hearing screen was performed with automated auditory
brain stem responses and the infant referred both ears.
Mother was given information to schedule a follow-up
appointment at [**Hospital6 **].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) 69627**], MD; telephone
number [**Telephone/Fax (1) 1260**] [**Location (un) 686**] House [**Location (un) **].
[**Location (un) 686**], [**Numeric Identifier **].
CARE RECOMMENDATIONS: Continue ad lib feeding, breast milk
or Similac 24 calorie.
Medications: Nystatin to the groin area.
Car seat position screening test was performed for a 90
minute screening and the infant passed.
State newborn screens have been sent for protocol, most
recently on [**2199-7-27**] and has been within normal limits.
The infant has received hepatitis B vaccine on [**2199-7-29**].
DISCHARGE DIAGNOSES:
1. Preterm male born at 34 and 6/7 weeks.
2. Rule out sepsis with antibiotics.
3. Mild respiratory distress syndrome.
4. Feeding immaturity, resolved
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2199-8-5**] 06:53:05
T: [**2199-8-5**] 07:23:03
Job#: [**Job Number 69628**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2862
} | Medical Text: Admission Date: [**2134-3-1**] Discharge Date: [**2134-3-7**]
Date of Birth: [**2083-10-23**] Sex: M
Service: UROLOGY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Kidney mass
Major Surgical or Invasive Procedure:
Left radical nephrectomy and adrenalectomy,
regional lymphadenectomy.
History of Present Illness:
Mr [**Known lastname 39818**] is a 50-year-old male, with a long
history of multiple medical problems which include aortic
valve replacement with a mechanical valve in [**2131**] on chronic
Coumadin therapy, heparin-induced thrombocytopenia from
intravenous heparin given in [**2133**], coronary disease status
post myocardial infarction at age 35, dilated cardiomyopathy
with ejection fraction of 25 percent, who was found to have
bilateral renal masses in [**2133-12-23**]. Six weeks ago,
he underwent right partial nephrectomy in preparation for
today's left radical nephrectomy. He has a previous biopsy
of the left renal mass that was done at an outside hospital,
which was confirmatory of renal cell carcinoma. He presents
now for surgical therapy.
Past Medical History:
CAD s/p MI [**2116**]
dilated cardiomyopathy c CHF (EF 25%) and global hypokinesis
AICD [**10-26**] (prophylactic for EF, no h/o arrythmias)
AVR s/p mechanical heart valve 00'
OSA
Social History:
Tob: 1 ppd x 35y until quit 3m ago. Married, lives with wife, 1
son. [**Name (NI) **] ETOH, no drugs. Retired [**Company **] employee.
Family History:
Father had kidney cancer and prostate cancer. Mother had breast
cancer.
Physical Exam:
GEN: NAD. WD, WN.
HEENT: NCAT, EOMI
NECK: no cervical, occipital, clavicular, axillary, or inguinal
LAD.
CV: RRR 3/6 SEM at RUSB, mechanical click
PULMO: CTAB
ABD: obese, soft, NT, ND, no CVA tenderness. no palpable masses.
R sided subcostal incision well-healed.
EXT: warm, no C/C/E, 2+ DP/PT.
GU: phallus nl.
Pertinent Results:
[**2134-3-1**] 11:58PM WBC-10.4 RBC-4.08* HGB-12.0* HCT-35.8* MCV-88
MCH-29.3 MCHC-33.4 RDW-13.5
[**2134-3-1**] 11:58PM PLT COUNT-187
[**2134-3-1**] 04:48PM PT-18.5* PTT-37.4* INR(PT)-2.2
[**2134-3-1**] 04:48PM GLUCOSE-155* UREA N-14 CREAT-1.1 SODIUM-138
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-25 ANION GAP-9
[**2134-3-1**] 04:48PM CALCIUM-7.6* MAGNESIUM-1.7
Brief Hospital Course:
Patient tolerated procedure well and was transferred to NSICU
d/t cardiac history. Post-op course was unremarkable. Patient
remained in NSICU for 2 days and was eventually transferred to
12Reisman. Pain was controlled with Dilaudid through
hospitalization.
On POD1, Chest tube was removed.
On POD2, NGT was removed.
On POD3, patient was transferred out of NSICU to 12R
On POD4, patient began regular diet after onset of flatus.
On POD5, patient was provided Toradol for pain. CT scan of
thorax was performed to rule out any source for pain; scan
revealed no hematoma/bleeding/fluid collection.
On POD6, patient was deemed stable and suitable for discharge.
On discharge patient remained therapeutic (INR 2.5-3.5) on
Warfarin.
Medications on Admission:
Toprol xl 50 qd
Lasix 40
Lipitor 40
Mavik 4
Coumadin 5/7.5
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
3. Hydromorphone HCl 4 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Tablet, Delayed Release (E.C.)(s)
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 1 doses: Alternate 5mg and 7.5mg qod.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left renal cancer
Discharge Condition:
Good.
Discharge Instructions:
Go to an Emergency Room if you experience symptoms including,
but not necessarily limited to: new and continuing nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Proceed to the ER/EW/ED if your wound becomes red, swollen,
warm, or produces pus.
You may remove your dressings 2 days after your surgery if they
were not removed in the hospital.
Leave the steri strips on until they begin to peel, then you may
remove them. Staples and stitches will remain until your
follow-up
appointment.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Continue taking your home medications unless otherwise
contraindicated and follow up with PCP. [**Name10 (NameIs) **] restarting
Mavik.
Recheck INR tomorrow.
Followup Instructions:
F/U with [**Doctor Last Name **]. Please call for appt.
F/U with PCP. [**Name10 (NameIs) **] restarting Mavik.
Completed by:[**2134-3-7**]
ICD9 Codes: 4254, 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2863
} | Medical Text: Admission Date: [**2189-7-29**] Discharge Date: [**2189-9-24**]
Date of Birth: [**2189-7-29**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 7931**] twin number one
was born at 30 and 4/7 weeks gestation to a 43 year-old
gravida 2 para 0 now 2 woman by cesarean section for maternal
pregnancy induced hypertension. This pregnancy was achieved
with invitro fertilization with a donor egg. This was
did receive magnesium sulfate for increased blood pressure
and she received a complete course of betamethasone prior to
delivery. Maternal history is remarkable for herpes simplex
virus treated with Valtrex six weeks prior to delivery. Twin
number one was noted to have oligohydramnios. The mother's
prenatal screens are blood type A positive, antibody
negative, Rubella immune, RPR nonreactive, hepatitis surface
emerged with spontaneous cry. Apgars were 8 at one minute
and 9 at five minutes. Birth weight was 1340 grams, birth
length 39 cm and birth head circumference 29.5 cm.
ADMISSION PHYSICAL EXAMINATION: Physical examination
revealed a premature infant, anterior fontanel open and flat.
Palette intact. Some grunting, flaring in intercostal
retractions, fair air exchange, soft abdomen. Liver edge 1
cm below the right costal margin. Testes palpable.
Appropriate tone for a premature infant.
HOSPITAL COURSE: 1. Respiratory status: The infant was
intubated soon after admission to the Neonatal Intensive Care
Unit. He received two doses of Surfactant and extubated to
continuous positive airway pressure on day of life number two
and then weaned to room air on day of life number four where
he has remained. He was treated with caffeine for apnea of
prematurity from day of life number one until day of life
twenty seven. His last episode of bradycardia occurred on
[**2189-9-18**].
2. Cardiovascular status: He has remained normotensive
throughout his Neonatal Intensive Care Unit stay. He had
some premature ventricular beats on the bedside monitor
prompting an electrocardiogram on [**2189-7-27**] that was read by
[**Hospital3 1810**] cardiology as normal sinus rhythm with
occasional ventricular premature beats. On examination he
has an intermittent grade 1/6 systolic ejection murmur
consistent with peripheral pulmonic stenosis.
3. Fluid, electrolyte and nutrition status: Enteral feeds
are begun on day of life number two and advanced without
difficulty to full volume feeding by day of life number
eight. He was then advanced to an enhanced calories of 30
calories per ounce with added ProMod. At the time of
discharge his feedings are Enfamil 24 calories per ounce. At
discharge his weight is 2990 grams, length 49.8 cm and head
circumference 34.5 cm.
4. Gastrointestinal status: He was treated with
phototherapy for physiologic hyperbilirubinemia on day of
life number one until day of life number ten. His peak
bilirubin occurred on day of life number eight and was total
6.5 direct 0.2.
5. Genitourinary status: The infant was circumcised on
[**2189-9-22**]. There was some oozing from the site necessitating
application of silver nitrate with resolution of the
bleeding. The site is currently healing nicely with
granulation tissue.
6. Hematological status: His last hematocrit on [**2189-9-9**] was
29.3 with reticulocyte count of 6.3%. He has received no
blood product transfusions during his Neonatal Intensive Care
Unit stay.
7. Infectious disease status: [**Known lastname **] was started on
Ampicillin and Gentamycin at the time of admission for sepsis
risk factors. The antibiotics were discontinued after 48
hours when the blood cultures were negative and the infant
was clinically well. On day of life number eight he had a
clinical presentation of sepsis and was treated for seven
days with Vancomycin and Gentamycin for presumed sepsis. His
blood cultures and cerebral spinal fluid did remain negative.
He has remained off antibiotics since that time.
8. Neurological status: Head ultrasound on [**8-5**] and [**2189-8-28**]
were both within normal limits. Hearing screen was performed
with automated auditory brain stem responses and he passed in
both ears on [**2189-8-27**]. Ophthalmology, his eyes were examined
most recently on [**2189-9-9**] and revealing mature retinal vessels.
Follow up examination is recommended in eight months.
9. Psycho/social: The parents are married. They have been
very involved in the infant's care throughout his Neonatal
Intensive Care Unit stay.
DISCHARGE CONDITION: The infant is being discharged in good
condition. He is being discharged home with is parents.
Primary pediatric care will be provided by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
of [**Hospital6 1129**], telephone number
[**Telephone/Fax (1) 36947**].
CARE AND RECOMMENDATIONS: 1. Feedings, 24 calories per
ounce of Enfamil made with biconcentration with Enfamil
powder on an ad lib schedule. 2. Medications Fer-In-[**Male First Name (un) **] 0.3
cc po q.d. to provide 7.5 mg of elemental iron. 3. The
infant passed a car seat position screening test on [**2189-9-23**].
4. State newborn screens were sent on [**8-14**] and [**2189-9-9**].
5. Immunizations the infant received a hepatitis C vaccine
on [**2189-8-31**].
FOLLOW UP APPOINTMENTS: 1. Early Intervention from [**Hospital1 **]
Area early intervention program, telephone number
[**Telephone/Fax (1) 43005**]. 2. [**Location (un) 86**] [**Hospital6 407**],
telephone number [**Telephone/Fax (1) 37525**].
DISCHARGE DIAGNOSES:
1. Status post prematurity 30 and 4/7 weeks gestation.
2. Twin number one.
3. Status post respiratory distress syndrome.
4. Sepsis ruled out.
5. Status post presumed sepsis.
6. Status post physiologic hyperbilirubinemia.
7. Status post apnea of prematurity.
8. Anemia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 43006**]
MEDQUIST36
D: [**2189-9-24**] 04:41
T: [**2189-9-24**] 07:35
JOB#: [**Job Number 43007**]
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2864
} | Medical Text: Admission Date: [**2119-7-17**] Discharge Date: [**2119-7-26**]
Date of Birth: [**2058-11-22**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Penicillins / Tetracyclines / Erythromycin Base / Codeine
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
The patient is a 60-year-old female who has
been found to have a moderately differentiated squamous cell
carcinoma involving predominantly the right anterior floor of
the mouth, but extending over the midline and into the
lateral floor of the mouth somewhat. Patient presented to [**Hospital1 18**]
for treatment.
Major Surgical or Invasive Procedure:
ENT:
PROCEDURE:
1. Laryngoscopy.
2. Rigid esophagoscopy.
3. Bilateral modified neck dissection.
4. Transoral resection of anterior floor of mouth tumor.
5. Tracheostomy.
Plastic Surgery:
PROCEDURE PERFORMED:
1. Split-thickness skin grafting, 2 inches x 10 cm to the
floor mouth and ventral surface of the tongue.
2. Local tissue rearrangement of the upper lip for closure,
status post removal basal cell carcinoma.
3. Closure of neck wound.
History of Present Illness:
The patient is a 60-year-old female with a hx of a lesion of the
floor of the mouth. She noted an irritation and a lumpy
sensation in the right floor of the mouth, no bleeding or pain.
No limitation of tongue movement. She has a history of
70-pack-year history of tobacco use.
Past Medical History:
Past medical history includes arthritis, basal cell cancer, high
blood pressure, fibromyalgia, and allergies.
Past surgical history includes tonsillectomy, appendectomy, foot
bone spur, and complete hysterectomy in [**2110**].
Medications include Nasonex, Astelin, Premarin, enalapril,
nortriptyline, Skelaxin, Wellbutrin.
Social History:
Social History: Does not smoke currently and drinks two times a
week, is retired from the Federal Government from project
management of Mass Transit.
Family History:
Family history is significant for high blood pressure, heart
disease, diabetes.
Physical Exam:
Vitals: 96.4 114/90 102 17 98% RA
Exam: NAD, pt ambulating, tolerating liquid diet, voiding, +BM,
pain well controlled on 4 mg dilauded / day.
GEN: well dressed, standing in room waiting to go home
HEENT:symetric smile, Crainial nerve II-XII grossly intact,
hypoglossal midline, mouth/ tongue: graph pink, healing well.
incision: Four sugical sites: mouth/ tongue, left side neck,
tracheal area, or left thigh. All three healing well, no calor,
tubor, dolor, rubor. No drainage. Steri strips on neck, dressing
on trach site, xeroform on [**Last Name (un) **] graph site on leg. Dressings
dry.
CVS: Tachy but no mumor or rubs, S1, S2 regular rhythm
LUNGS: CTAB
ABD:soft non tender
EXT:no edema
Neuro: grossly intact.
Psych: mood positive, cheerful excited to go home.
Pertinent Results:
[**2119-7-19**] 03:09AM BLOOD WBC-9.1 RBC-3.26* Hgb-9.7* Hct-29.4*
MCV-90 MCH-29.6 MCHC-32.8 RDW-13.8 Plt Ct-217
[**2119-7-18**] 03:44AM BLOOD WBC-10.9 RBC-3.78* Hgb-11.1* Hct-33.0*
MCV-87 MCH-29.3 MCHC-33.5 RDW-14.3 Plt Ct-266
[**2119-7-17**] 07:27PM BLOOD WBC-8.7 RBC-3.74* Hgb-11.3* Hct-32.3*
MCV-86 MCH-30.2 MCHC-35.0 RDW-13.5 Plt Ct-224
[**2119-7-17**] 07:27PM BLOOD Neuts-82.8* Lymphs-13.4* Monos-3.0
Eos-0.6 Baso-0.3
[**2119-7-19**] 03:09AM BLOOD Plt Ct-217
[**2119-7-18**] 03:44AM BLOOD Plt Ct-266
[**2119-7-17**] 07:27PM BLOOD Plt Ct-224
[**2119-7-17**] 07:27PM BLOOD PT-11.8 PTT-26.1 INR(PT)-1.0
[**2119-7-25**] 06:10AM BLOOD Glucose-129* UreaN-20 Creat-0.9 Na-137
K-4.9 Cl-98 HCO3-24 AnGap-20
[**2119-7-25**] 06:10AM BLOOD Calcium-9.8 Phos-5.1*# Mg-2.3
Brief Hospital Course:
Patient is a 60 yo female with a hx of Squamous cell carcinoma
of the right
anterior floor of mouth. Patient presented to the [**Hospital1 18**] and
underwent a Laryngoscopy, Rigid esophagoscopy, Bilateral
modified neck dissection, Transoral resection of anterior floor
of mouth tumor, Tracheostomy, skin graft and closure of the
floor of the mouth. Please see Dr.[**Name (NI) 20390**] op note for
details of the procedure. Patient tolerated the procedure well
and was admitted to the SICU for observation. Rest of the
[**Hospital 228**] hospital course will be on systems:
Neuro: Patient on propofol for sedation and was weaned of of
sedation POD1. Patient placed on dilaudid PCA post operatively
and weaned of of PCA to Q4 oxycodone. Patient given Skelaxin
and TCA for fibromyalgia.
Cardiovascular: Patient placed on metoprolol in SICU and
switched to enalapril and hydralazine for htn. Patient
continously tachycardic throughout hospital stay. Patient
claims to have tachycardia as an outpatient for years. Pt to see
PCP as [**Name9 (PRE) **] for work up of chronic tachycardia.
Pulmonary: Patient s/p trach and weaned off of vent on POD1 in
SICU. Patient with generalized trach care and placed on trach
mask. Trach down sized and capped on POD#6. She was
Decannulized on POD#8 ([**7-25**])
Gastrointestinal: Patient given pepcid for GI prophylaxis.
Patient placed on Tube feeds via dobhoff. [**7-24**] pt [**Last Name (un) 32019**] was
removed by plastics. Speech and Swallow cleared pt [**7-25**] for full
liquid diet/ puree diet. Donhoff d/c on [**7-25**]. Pt placed on full
liquid diet on [**7-25**] tolerating well.
Nutrition: Patient place on repleate with fiber at a goal of
55cc. [**7-25**] pt switched to full liquid diet.
Infectious disease: Patient placed on Clindamycin post
operative for prophylaxis ([**Date range (1) 32020**]). Pt remained afebrile.
incisions: left neck: healing well, stiches removed on [**7-25**],
steri strips placed. no erythema no edema, no calor or dolor. No
discharge.
Mouth/tongue: healing well, graft pink healthy. No erythema no
edema, no calor or dolor. No discharge.
Left thigh: healing well, xeroform, scabbing underneath. No
erythema no edema, no calor or dolor. No discharge.
General Care: [**7-24**] pt cleared by PT for discharge to home.
Ambulating well.
Medications on Admission:
Medications
AZELASTINE [ASTELIN]
BUPROPION HCL [WELLBUTRIN]
CONJUGATED ESTROGENS [PREMARIN]
ENALAPRIL MALEATE
IMIQUIMOD [ALDARA]
METAXALONE [SKELAXIN]
MOM[**Name (NI) **] [NASONEX]
NORTRIPTYLINE
Discharge Medications:
1. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. Nortriptyline 10 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
3. Enalapril Maleate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Conjugated Estrogens 0.3 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Skelaxin 800 mg Tablet Sig: One (1) Tablet PO qam ().
8. Skelaxin 800 mg Tablet Sig: One (1) Tablet PO qhs ().
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane twice a day as needed for mouth rinse.
Disp:*500 ML(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Moderately differentiated squamous cell carcinoma of floor of
the mouth
Discharge Condition:
Stable
Discharge Instructions:
GENERAL RECOVERY:
- You should continue on all medications you were prescribed or
started on in the hospital
- Physical Activity:
o For the first 1-2 months, you need to avoid any vigorous
activity that places strain and pressure on your neck; no
racquetball, tennis, basketball, weight lifting
o Routine, non-contact, low impact exercise is good ?????? walking is
excellent
- Swelling after surgery is common. Different people have
different amounts of swelling. Please call if you are concerned
about it
- No driving until after your first post-op visit
- You may be more comfortable sleeping with the head of the bed
elevated or with an extra pillow or two
- For the next year, avoid prolonged sun exposure ?????? use either a
scarf or zinc oxide to protect the incision
WOUND / HEALING:
- Minor seepage or crusting is not cause for alarm
- Avoid immersion of the incision under water or in the direct
path of the shower
- You can cover the incision with a light, non-abrasive dressing
or scarf if you wish
- Your sutures will be removed at your post op visit
PAIN AND STIFFNESS:
- Your neck / shoulder will be stiff after the surgery ?????? when
you come in for your post op visit, we will have you start
stretching exercises which will help
- If you continue to have pain or movement issues, we will refer
you to physical therapy
- You should continue to take your pain medication as you need
it. With time, we expect pain to resolve
- If you are on narcotic pain medication, you also need to be on
a stool softener / laxative
- You may have a sore throat after surgery ?????? this is expected
and will improve
COME TO THE HOSPITAL OR CONTACT PCP IF FEELING SHORT OF BREATH,
FEVER, YOUR WOUND HAS BECOME RED, YOU HAVE DRAINAGE FROM YOUR
WOUND, YOU HAVE ANY NEW CONCERNING SYMPTOMS INCLUDING NEW PAIN.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 32021**] at 11:20 am on Friday
[**220-8-3**] [**Doctor First Name **] [**Location (un) **]. Please call the office to
confirm your appointment. [**Telephone/Fax (1) 41**]
Please follow up with your Oncologist Dr/ Mohadivan. Please call
them on Monday [**7-31**] at [**Telephone/Fax (1) 9710**] to make the follow up
apt.
Please follow up with Dr. [**First Name (STitle) **] Plastic Surgery on [**8-8**] at
14:15. Go to 110 [**Doctor First Name **] [**Location (un) 442**] 5a. Please call [**Telephone/Fax (1) 6742**]
to confirm the apt.
Follow up with speech and swallow on thursday [**7-28**].
Scheduled Appointments : Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 32022**], MS SLP
Phone:[**Telephone/Fax (1) 3731**] Date/Time:[**2119-7-28**] 10:30
Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 32023**] Wed [**8-2**] at 1445 regarding your elevated heart rate
during your stay. Call to confirm at [**Telephone/Fax (1) 32024**].
ICD9 Codes: 3051, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2865
} | Medical Text: Admission Date: [**2125-12-11**] Discharge Date:
Date of Birth: [**2097-9-9**] Sex: M
Service: [**Last Name (un) 26755**] ICU
REASON FOR ADMISSION: Hypoxic respiratory distress.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26756**] is a 28-year-old
gentlemen with a history of type 1 diabetes and hypertension
who presented on [**2125-12-21**] to the [**Hospital1 **] Emergency Department with a three day history of
total body myalgias, a one day history of fever to 102
associated with rigors, and a productive cough without
hemoptysis times three days alongside worsening dyspnea at
rest and exertional dyspnea. The patient denied chest pain
or pleurisy at the time of admission. He had had no recent
nasal congestion, headache, swollen glands, but he did report
a sick contact seen over the [**Holiday 1451**] weekend one week
prior to admission. There was no recent travel. No pets at
home. No chronic steroid use or history of opportunistic
infections or insect bites.
When the patient presented to the Emergency Department, he
was diagnosed with a right lower lobe pneumonia and started
on levofloxacin and volume resuscitated with two liters of
normal saline. His initial oxygen saturation was 95% on room
air at the time of arrival to the Emergency Department. By
the time of arrival to the floor, 18 hours later, his oxygen
saturation was 94% on four liters nasal cannula with a normal
respiratory rate.
Upon arrival to the floor, he had the acute onset of hypoxia
with tachypnea with an oxygen saturation of 91% on 100%
nonrebreather and respiratory rate into the 40s. An arterial
blood gas at the time was 742, 33 and 62. A chest x-ray
showed blossomed left upper lobe infiltrated in addition to
the right lower lobe and the patient's clinical status
resolved quickly with chest physical therapy. It was felt
that he had developed a mucus plus. The patient was
clinically stable until [**2125-12-23**] when he developed a
similar episode of acute onset hypoxemic respiratory distress
which was nonresponsive to chest physical therapy. He was
intubated semiurgently and brought to the Intensive Care Unit
for further evaluation and management.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes times 25 years followed at the
[**Last Name (un) **].
2. Diabetic retinopathy status post laser photocoagulation.
3. Hypertension.
MEDICATIONS ON ADMISSION:
1. Insulin Humalog 12 units q.a.m., 12 units q.p.m. and NPH
32 units q.a.m. and 24 units q.p.m.
2. Zestril, dose unknown.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco, no intravenous drug use, mild
alcohol consumption. Patient is sexually active with a
longtime female partner at times unprotected. He lives with
multiple roommates. He is physically very active.
FAMILY HISTORY: Father with diabetes otherwise unremarkable.
ADMISSION PHYSICAL EXAMINATION: Physical examination at time
of admission to Intensive Care Unit: Temperature 100.2.
Heart rate 129. Blood pressure 128/72. Respiratory rate 43.
Oxygen saturation 94% on six liters nasal cannula. General:
A young white male in moderate respiratory distress. Head,
eyes, ears, nose and throat: Pupils equal, round and
reactive to light. Extraocular movements intact. Sclerae
are anicteric. Oropharynx clear. No nystagmus. Mucous
membranes were dry. Neck: Jugular veins were flat. No
thyromegaly, no thyroid tenderness to palpation. Chest:
Inspiratory crackles halfway up on the right. Patient
talking in full sentences, using expiratory muscles, no
wheezes were auscultated. Cardiac: Tachycardic, no murmurs,
rubs or gallops. Abdomen: Soft, nontender, no
hepatosplenomegaly, normal active bowel sounds. Extremities:
Trace bilateral lower extremity edema. No clubbing, no
cyanosis, no intertriginal rash. Neurological: Alert and
oriented times two. Cranial nerves II through XII are
intact. Strength 5/5 in all four extremities.
LABORATORIES: White blood cell count 9.9, hematocrit 40.6,
platelets 216,000. SMA-7: Sodium 134, potassium 3.8,
chloride 98, bicarbonate 23, BUN 15, creatinine 1.0, glucose
246. Arterial blood gas 742, 30, 80 on six liters nasal
cannula oxygen. Chest x-ray: Bilateral diffuse infiltrates
with sparing of the apices and bases. No effusions. Normal
cardiac silhouette. Urinalysis: 1.07 large blood, 8 red
blood cells, 2 white blood cells, greater than 1000 glucose,
trace ketones. Electrocardiogram: Sinus tachycardia at 130,
axis is 100 degrees, normal intervals, T wave inversions in
II, III and aVF. Q waves in II, III and aVF.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for management of hypoxic respiratory
distress. The following will outline his Medical Intensive
Care Unit course from [**2125-12-13**] to [**2125-12-29**]
by systems:
1. Neurological: The patient had no acute neurological
issues. He had an escalating sedation requirement
additionally managed on Ativan and Fentanyl drips. Ativan
was switched over to midazolam on [**2125-12-29**] for
prophylaxis against crystal induced acute renal failure.
2. Respiratory: The patient was originally admitted to the
[**Hospital6 733**] Service with atypical community
acquired pneumonia. He was initially started on levofloxacin
after being admitted to the unit and intubated Ceftriaxone
was added on [**2125-12-13**]. Bronchoscopy was done which
was unremarkable except for friable mucosa. BAL studies were
negative for PCP. [**Name10 (NameIs) 26757**] caused her acid fast bacilli
smear viral and >.....<virilized and culture. The patient
appeared to have developed adult respiratory distress
syndrome and was management with a long protective strategy.
He was aggressively volume resusitated to a wedge of 29 which
corrected to 24 with discounting of a PEEP of 20. He was
ruled out for PE by CT angio and a normal echocardiogram on
[**2125-12-13**].
In addition to atypical community acquired pneumonia, adult
respiratory distress syndrome and volume overload, it
appeared that the patient had developed a vent associated
pneumonia as evidenced by a new retrocardiac opacity and
increased purulence secretions; vancomycin was added on
[**2125-12-24**]. Ceftazidime was subsequently added on
[**2125-12-26**] for persistent fevers to cover gram
negative pathogens. At the time of this dictation, the
patient is on assist controlled ventilation with PEEP of 14
and FIO2 of 50%.
3. Cardiac: In pursuit of the patient's concerning
electrocardiogram, there were no prior electrocardiograms for
comparison and the clinical suspicion was high for RV strain
in the setting of multiple PEs. However, an echocardiogram
showed a normal ejection fraction, normal RV size and
function and a normal left ventricular ejection fraction and
normal left ventricular size. There were no significant
valvular abnormalities and no vegetations on transfer
>.....<ultrasound. For the first five days of the [**Hospital 228**]
hospital course, he was noted to be on a high cardiac output
low SVR state. During that, he never developed hypotension
or oliguria. He was eventually volume resusitated to a wedge
pressure of 29.
4. Renal: The patient came to the unit originally in renal
failure with a creatinine of 2 over a baseline of 1.0. After
aggressive volume recessitation, his creatinine returned to
[**Location 213**]. FeNA obtained was consistent with previous azotemia.
Since [**2125-12-25**], the patient has been on a Lasix drip
to achieve diuresis to help resolve respiratory failure,
which he has tolerated well from a renal and hemodynamic
standpoint.
5. Gastrointestinal: The patient has had stabilely elevated
liver biochemistries including an alkaline phosphatase of
roughly 400 and T bilirubin that had risen from .2 to 1.1. A
gallbladder ultrasound obtained on [**2125-12-26**] showed
mild gallbladder distention with a normal gallbladder wall
thickness and question of pericholecystic fluid. Subsequent
HIDA scan to evaluate for a calculus cholecystitis showed
equivocal results. The results of a repeat ultrasound of the
gallbladder on [**2125-12-29**] are pending. The patient is
currently being ruled out for C. difficile and is negative
times one.
6. Infectious Disease: The patient was initially managed on
levofloxacin for community acquired pneumonia started on
[**2125-12-31**]. Ceftriaxone was added to that on [**2126-1-2**]. Levofloxacin was added to that on [**2125-12-24**]
for suspicion of vent associated pneumonia. Ceftriaxone was
replaced by ceftazidime on [**2125-12-26**] to cover for
possible gram negative pulmonary pathogens. The patient has
had persistent fevers since [**2125-12-26**]. [**Doctor First Name **], ANCA and
HIV antibody were all negative obtained during this
hospitalization. Urine legionella antigen is negative. PCP
immunofluorescent on BAL is negative. His right internal
jugular and right arterial line were both changed to a left
subclavian and a left-sided radial arterial line on [**2125-12-28**] with tip sent. Gallbladder evaluation for a
calculus cholecystitis was underway. The patient was being
ruled out for C. difficile. Drug fever may be the culprit
here with likely pathogens including ceftazidime and Lasix.
The patient does have eosinophilia with an absolute
eosinophils count of 800 on [**2125-12-28**] and a truncal
rash has developed from [**2125-12-28**] to [**2125-12-29**]. At the current time, ceftazidime is on, but may be
discontinued with patient observation should the rest of his
Infectious Disease work-up be negative. The patient has had
no positive culture date including multiple blood cultures,
sputum cultures and BAL cultures.
7. Endocrine: The patient had a high dose ACTH stimulation
test which was normal. The patient's diabetes has been
managed with an insulin drip.
8. Nutrition: The patient is currently on hyperalimentation
with tube feds being titrated up as tolerated.
9. Prophylaxis: Patient on subcutaneous heparin and proton
pump inhibitor along with tube feds.
10. Access: Left subclavian placed on [**2125-12-28**].
Left radial arterial line placed on [**2125-12-28**].
DIAGNOSES AT THE TIME OF THIS DISCHARGE SUMMARY:
1. Atypical community acquired pneumonia.
2. Adult respiratory distress syndrome.
3. Vent associated pneumonia.
4. Volume overload.
5. Persistent fevers.
6. Right axis deviation of unclear etiology and duration.
7. Status post peripheral compartment syndrome from tense
peripheral edema.
8. Diabetes mellitus.
9. Possible drug fever.
10. Possible a calculus cholecystitis.
MEDICATIONS AT TIME OF DISCHARGE:
1. Vancomycin 1 gram q. 12 hours.
2. Levofloxacin 500 mg q. 24 hours.
3. Ceftazidime 2 grams q. 8 hours.
4. Insulin drip.
5. Midazolam drip.
6. Fentanyl drip.
7. Lasix drip.
8. Insulin drip.
9. Protonix.
10. Subcutaneous heparin.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Name8 (MD) 2653**]
MEDQUIST36
D: [**2125-12-29**] 17:21
T: [**2125-12-28**] 22:52
JOB#: [**Job Number 26758**]
ICD9 Codes: 5849, 5990, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2866
} | Medical Text: Admission Date: [**2197-12-1**] Discharge Date: [**2197-12-4**]
Date of Birth: [**2136-3-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
STEMI now s/p stents in LCx (100% - culprit lesion) and OM1
(70%) with temp wire in for pre-cath brady in ED and with
post-cath hypotension on dopa drip.
Major Surgical or Invasive Procedure:
Coronary catheterization with stenting of the LCx and OM1.
History of Present Illness:
61 yo male smoker h/o hypercholesterolemia p/w CP and found to
have STEMI at [**Hospital1 18**]. Pain was substernal, heavy and crushing,
[**11-13**] and different than any other pain he has had. Works as
mechanic -initially attributed pain to lifting, but not as it
increased in intensity. Developed diaphoresis, SOB, lay on
ground and lost consciousness. Awoke and called EMS - got NTG
in ambulance without relief. EKG showed 4mm STE in III, aVF and
ST depressions in V1-V4. In the ED a temp wire was placed for
brady in the 20's. Pain to balloon time roughly 2.5 hours.
After cath the pt was hypotensive and put on a dopa drip.
Currently being weaned. In unit after procedure, pain free and
no groin or back pain.
.
Post-cath the patient had N/V x 1 with ? dark emesis. No guaiac
was done. HCT decreased 41 -> 34 but was then stable at 33.
Past Medical History:
hyperlipidemia
Social History:
Married with three children (35, 32, 25) who live in area.
Works as mechanic (heavy lifting). Weekend social etoh of a few
drinks. Smokes PPD x 20yrs. No illicits
Family History:
No CAD, MI, Sudden Death, DM
Physical Exam:
V: 95/51 (dopa at 3), 69, 16, 95% RA
G: NAD, lying flat, interactive
H: EOMI, PERRL, neck supple, no LAD, OP clear, no JVD, no bruits
C: RRR, no murmurs, physiologic split S2, good distal pulses
L: Clear bilaterally
A: Soft, NT, ND, nml BS
E: R groin with sheath in place, no hematoma, no ecchymosis.
Distal pulses symm. Feet WWP bilat
N: AandOx3, CN II-XII intact, MAE, sensation intact, no drift
Pertinent Results:
EKG: prior to cath: ST elevations III, aVF. ST depr V1-3, 5.
after cath: nsr with no ST/TW changes
.
[**2197-12-1**] Hct-41.3
[**2197-12-1**] 02:01PM Hct-34.6*
[**2197-12-1**] 05:26PM Hct-33.3*
[**2197-12-2**] 01:19AM Hct-32.6*
[**2197-12-2**] 06:28AM Hct-32.8* Plt Ct-302
[**2197-12-3**] 07:00AM Hct-38.8*
.
[**2197-12-4**] 06:10AM BLOOD Glucose-98 UreaN-10 Creat-0.9 Na-143
K-4.4 Cl-108 HCO3-25 AnGap-14
.
[**2197-12-1**] 09:50AM BLOOD CK(CPK)-199*
[**2197-12-1**] 02:01PM BLOOD CK(CPK)-330*
[**2197-12-1**] 05:26PM BLOOD ALT-29 AST-61* LD(LDH)-203 CK(CPK)-609*
AlkPhos-70 TotBili-0.4
[**2197-12-2**] 01:19AM BLOOD CK(CPK)-652*
[**2197-12-2**] 06:28AM BLOOD CK(CPK)-632*
[**2197-12-3**] 07:00AM BLOOD CK(CPK)-283*
.
[**2197-12-1**] 09:50AM BLOOD CK-MB-3
[**2197-12-1**] 09:50AM BLOOD cTropnT-<0.01
[**2197-12-1**] 02:01PM BLOOD CK-MB-33* MB Indx-10.0*
[**2197-12-1**] 05:26PM BLOOD CK-MB-49* MB Indx-8.0* cTropnT-1.88*
[**2197-12-2**] 01:19AM BLOOD CK-MB-38* MB Indx-5.8 cTropnT-1.53*
[**2197-12-2**] 06:28AM BLOOD CK-MB-30* MB Indx-4.7
[**2197-12-3**] 07:00AM BLOOD CK-MB-8
.
Coronary Cath
COMMENTS:
1. Selective coornary angiography of this codominant system
revealed
single vessel coronary artery disease. Te LMCA had no
angiographically
apparent flow limiting lesions. The LAD had mild diffuse
disease. The
LCX was a large vessel and was codominant. The LCX was totally
occluded
after the OM2. The OM1 was a large branch with an 80% proximal
stenosis.
The RCA was a codominant vessel with no angiographically
apparent flow
limiting stenosis.
2. Resting hemodyncamics revealed elevated right snd left sided
pressures with a PA pressure of 50mmHgand a PCWP of 25mmHg. The
cardiac
output was 3.41l/min and the cardiac index was 1.91l/min/m2.
3. Left ventriculography was deferred.
4. Successful predilation using a 2.0 X 15 Voyager balloon,
stenting
using a 2.5 X 28 Cypher stent of the acutely occluded CX with
lesion
reduction from 100% to 0%. The final angiogram showed TIMI III
flow with
no dissection and no embolisation. There was jailing of the OM2
with
<50% residual stenosis.
5. Successful direct stenting of the proximal OM1 stenosis using
a 2.5 X
18 Cypher stent with lesion reduction from 80% to 0%. The final
angiogram showed TIMI III flow with no dissection and no
embolisation.
( see PTCA comments)
FINAL DIAGNOSIS:
1. Angiographic evidience of single vessel coronary artery
disease.
2. Elevated right and left sided pressures.
3. Acute inferior myocardial infarction PCI with drug-eluting
stenting
of the mid co-dominant LCx.
4 Successful drug-eluting stenting of the OM1
.
[**2197-12-4**] Echo Conclusions: EF > 55%
1.The left atrium is mildly dilated.
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
6.There is borderline pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Brief Hospital Course:
BRIEF OVERVIEW: 61 yo smoker with dyslipidemia presented with
STEMI stented x2 in LCX (culprit 100-0%) and OM1 (70% - 0%) with
a pacer wire placed in cath lab for bradycardia from CHB that
resolved after cath. Hypotensive post-cath and put on dopamine
for 12 hours then weaned with good pressure. Also had a HCT
drop post cath, which then stabilized and increased. He
remained symptom free and had no arrhythmias on telemetry. He
was placed on BB, acei, plavix, aspirin, high-dose statin and
discharged home in stable condition.
## CV:
-CAD: The patient had 3 risks (age, lipid, smoker) and was found
to have 2VD on coronary catheterization. LCx was the culprit
lesion and was stented open with a DES. In addition, OM1 was
stented. In the ED the patient was bradycardic to 20bpm and a
temporary pacer wire was placed in the cath lab. Post-stenting,
ST changes resolved and the pt's bradycardia also resolved.
CE's trended down. However, the patient remained hypotensive and
he received a dopamine drip for 12 hours. Thereafter his BP
climbed and he was weaned off pressors and started on both
metoprolol and captopril (followed by lisinopril prior to
discharge). Toprol was not used in this patient as he chews his
pills prior to swallowing them.
.
-Pump: The patient had a post-even echocardiogram that showed an
EF of 55% that was suggestive of little decrease in stroke
volume/CO.
.
-Rhythm: The patient was brady in ED with temp wire placed at
the cath lab. Had CHB, but resolved with stenting. The patient
continued to be mildly bradycardic after the MI initially,
however there was no evidence of a bundle block or AV slowing or
continued CHB.
.
##Anemia - drop in HCT after procedure not uncommon - will tx
for <30. Would continue to monitor HCT [**Hospital1 **] or qd. Could be
dilutional. No hematoma, only small amt oozing at groin site
that cleared by the second day post-MI.
##Smoking - The patient was encouraged to quit. Initially there
was no nicotine patch as he was recently stented. However, he
was counselled to use assistive devices PRN at home. He
suggested that he would do everything he could to stop smoking.
The pt was counselled on this topic foer at least 30 minutes.
.
## Dispo - the patient was discharged home after being cleared
by PT with good follow-up.
Medications on Admission:
Atorvastatin 10mg
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take EVERY DAY as directed to prevent stent closure.
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take daily to decrease cholesterol and prevent coronary
artery narrowing.
Disp:*30 Tablet(s)* Refills:*0*
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for angina: Take
one tablet for Chest Pain and wait 5 minutes. If the pain does
not resolve, repeat up to 2 times.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day:
Take daily for blood pressure control and heart protection.
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
twice a day: Take as prescribed for Blood Pressure control and
to protect your heart.
Disp:*180 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Myocardial infarction
Hypercholesterolemia
Hypotension
Discharge Condition:
Stable
Stable
Stable
Stable
Discharge Instructions:
You were admitted to the hospital because of a myocardial
infarction, also called "MI," or "heart attack." You were taken
to catheterization, which opened the artery in your heart that
had clogged.
You are now going home. You will need to follow up with your
Dr. [**Last Name (STitle) 11679**], your primary care doctor/cardiologist within 1
week. Please call him for an appointment [**Telephone/Fax (1) 2394**].
You will be taking some new medications because of your MI.
Because you had stents placed in your heart during the
catheterization, you will need to take aspirin and plavix EVERY
DAY. Be sure not to miss a day.
If you have any medical problems including chest pain, groin
pain, groin bleeding, cold leg, lightheadedness, feeling like
you are going to pass out, or any other worrisome symptoms,
please seek immediate medical attention.
Followup Instructions:
Dr. [**Last Name (STitle) 11679**] in one week - pt to call for appointment. Will need
K and Cr checked as he has recently been started on an ACEI.
Cardiac rehab to start in appx 6 weeks. (Will need to be
arranged through Dr. [**Last Name (STitle) 11679**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
Completed by:[**2197-12-6**]
ICD9 Codes: 2720, 3051, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2867
} | Medical Text: Admission Date: [**2185-10-29**] Discharge Date: [**2185-11-4**]
Date of Birth: [**2149-2-12**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old
female with ethanol abuse, status post a motor vehicle
accident. The patient was a pedestrian who was struck three
days ago and had refused treatment at that time.
The patient's mother brought the patient to an outside
hospital from mental status changes. While in the Emergency
Department, the patient developed a seizure. A head computed
tomography showed a left subdural hematoma with a midline
shift. The patient was transferred to [**Hospital1 190**] for acute management.
PAST MEDICAL HISTORY:
1. Anorexia.
2. Depression.
3. Borderline diabetes.
4. Ethanol abuse.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient's blood pressure was 130/73, her
heart rate was 96, and her oxygen saturation was 100%, and
her respiratory rate was 18, and her temperature was 98.2
degrees Fahrenheit. The patient was intubated and sedated.
The patient's pupils were constricted bilaterally.
Cardiovascular examination revealed a regular rate and
rhythm. Pulmonary examination revealed the lungs were clear
to auscultation. The abdomen was soft, nontender, and
nondistended. There were positive bowel sounds. Extremity
examination revealed no edema.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was taken
emergently to the operating room for an evacuation of the
left subdural hematoma. There were no intraoperative
complications.
Postoperatively, the patient's condition revealed the pupils
were 3 mm down to 2 mm and equally reactive. She was still
intubated and sedated with a drain in place. The patient was
awake and opened eyes. She was following commands. Two
fingers on the left with squeezing. She withdrew briskly
with all extremities. A postoperative computed tomography
scan showed a continued left subdural hematoma of
approximately 1.5 cm at the greatest width with 7 mm of
midline shift. There was decreased effacement of the right
lateral ventricle compared with the preoperative head
computed tomography.
On [**2185-10-30**] the patient was moving all extremities.
She was following commands in the left upper extremities.
Squeezing on the right. The patient was somewhat stable.
The drain continued to be in place. The patient was to get a
repeat head computed tomography. The head computed
tomography showed no change with the continued presence of
recurrent subdural hematoma.
Therefore, the patient was take back to the operating room on
[**2185-11-1**] for a second evacuation of what turned out
to be an epidural hematoma. A postoperative head computed
tomography after the second surgery showed a significant
reduction of the epidural hematoma and midline shift. The
patient was opening eyes to stimulation purposefully with
bilateral upper extremities showing exophthalmia on the left.
There was good motor function in the bilateral upper
extremities. The patient was extubated and remained
neurologically stable.
The patient was extubated status post the second surgery
without difficulties. She was transferred to the regular
floor on [**2185-11-3**]. The remainder of her
postoperative course was uneventful. She was discharged to
home after being cleared by the Physical Therapy Service with
a home safety evaluation.
DISCHARGE DISPOSITION: The patient was discharged on
[**2185-11-4**] in stable condition with followup with Dr.
[**First Name (STitle) **] [**Name (STitle) 739**] in one month with a repeat head
computed tomography and followup for staple removal in 10
days.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D.
[**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2186-1-26**] 13:04
T: [**2186-1-28**] 10:03
JOB#: [**Job Number 52127**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2868
} | Medical Text: Admission Date: [**2142-10-16**] Discharge Date: Interim
Summary ([**10-16**] - [**10-24**])
Date of Birth: [**2142-10-16**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: This delightful boy is now 7
days old. He was born at 33 weeks gestation, weighing 2115
gm to a 37 year old gravida 1, now para 2 mother. [**Name (NI) **]
prenatal laboratory data were 0 positive, antibody negative,
Group B Streptotoccus unknown, hepatitis B surface antigen
negative. RPR nonresponsive. Her prenatal course was
remarkable for an invitro fertilization conception with
dichorionic-diamniotic twins. She went into preterm labor,
ultimately requiring hospitalization between [**2142-8-28**]
and [**2142-9-28**]. She was treated with magnesium
sulfate. She received one course of Betamethasone and was
discharged home on Terbutaline. She was readmitted on the
day of delivery in unstoppable preterm labor with cervical
dilatation. She underwent cesarean section under spinal
anesthesia from vertex/breech presentation. The infant
emerged with a good cry. He was bulb suctioned and dried and
required PPV for 20 to 30 seconds as well as blow-by oxygen.
His Apgars were 4, 7 and 9.
PHYSICAL EXAMINATION: Birthweight 2115, length 46, head
circumference 32.5. This infant was nondysmorphic. He was
noted to be in mild respiratory distress. His palate was
intact. His heart rate was regular in rate and rhythm.
Heart sounds were normal with no audible murmurs. His
femoral pulses were easily palpable. He was noted to have
nasal flaring with mild to moderate subcostal, intercostal
retractions. He has fair air entry bilaterally. His abdomen
is soft, nontender, nondistended without any organomegaly.
He had normal premature external genitalia with testes
descended bilaterally in the scrotum. His anus was patent.
He had stable hips. He was warm and well perfused and moving
all extremities. His tone and power were appropriate for his
gestational age. His anterior fontanelle was open, flat and
soft.
HOSPITAL COURSE: He was admitted to Neonatal Intensive Care
Unit in view of his prematurity, respiratory distress and for
evaluation of sepsis.
Respiratory - This infant had hyaline membrane disease both
clinically and radiographically. He initially was supported
with nasal CPAP and subsequently went on to require
intubation and ventilation. He received 2 doses of
Surfactant. He was eventually extubated on CPAP on [**2142-10-21**], and went onto nasal cannula on [**2142-10-22**].
He currently remains on nasal cannula, FIO2 1.0 at 25 cc per
minute flow with no apneas or prematurity.
Cardiovascular - As mentioned before, this infant was
intubated on the ventilator for hyaline membrane disease. He
did not wean off of his ventilation as expected following his
two doses of Surfactants. In view of this a chest x-ray was
repeated on [**2142-10-19**] which showed evidence of mild
cardiomegaly and wet-looking lung fields. An echocardiogram
was performed which showed evidence of a moderate patent
ductus arteriosus. Following this, he received a course of
Indomethacin and weaned successfully off of the ventilator.
He has remained hemodynamically stable throughout and has not
required any inotropic support.
Fluids, electrolytes and nutrition - He was initially NPO and
was not initiated on enteral feeding until after his patent
ductus arteriosus had successfully been closed following
medical therapy. Feeds were initiated on day of life #5. He
is currently advancing with enteral feedings and is on PE20 at
45 cc/kg/day advancing 15 cc/kg b.i.d. His full fluid intake
is 150 cc/kg/day. He has had good urine output throughout.
His weight on [**2142-10-23**] was [**2074**] gm which was still
below his birthweight.
Gastrointestinal - He developed hyperbilirubinemia of
prematurity and required phototherapy from day of life four
to five. His rebound bilirubin was 6.4 on [**2142-10-22**].
Infectious disease - In view of his prematurity, maternal
unknown Group B Streptotoccus status and respiratory distress
he underwent an initial sepsis evaluation. His blood
cultures were negative. There was no left shift in his
complete blood count and his antibiotics were discontinued
after 48 hours.
Neurology - He has had no issues during this admission.
INTERIM SUMMARY DIAGNOSIS:
1. Prematurity
2. Diamniotic-Dichorionic twin, Twin II
3. Hyaline membrane disease
4. Sepsis evaluation
5. Patent ductus arteriosus
6. Hyperbilirubinemia of prematurity
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2142-10-25**] 13:28
T: [**2142-10-25**] 16:27
JOB#: [**Job Number 50197**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2869
} | Medical Text: Admission Date: [**2197-8-6**] Discharge Date: [**2197-8-8**]
Date of Birth: [**2144-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
NG tube, EGD
History of Present Illness:
Mrs. [**Known lastname **] is a 53 year old woman with a history of HCV
cirrhosis c/b varices s/p banding now presents with hematemesis
x 5 at home. The patient was in her usual state of health and
had just had food at a barbeque with one glass of wine when she
suddenly noted nausea. She ran to the bathroom and vomitted,
with bright red blood x 5. She estimates approximately 2 cups
worth of emesis. She reported some associated nausea, dizziness,
and diarrhea. This presentation seems similar to her prior
presentations of variceal bleeds. She denies any black, bloody
stools, or abdominal pain.
.
In the ED, she had the following vital signs: 97.6 110/78 120 16
100%2LNC. An NG tube was placed which yielded bright red blood
that cleared to clear pink fluid after 500cc of NS. An 18 and 20
gauge IV was placed and she was bolused with pantoprazole 80mg
IV ONCE then 8mg/hr, octreotide 25mcg/hr, zofran 4mg IV ONCE for
nausea, and 2L of NS. Her last set of vitals were 98 107 110 16
100%RA.
.
ROS: Denies any recent fevers, chills, cough, dysuria, chest
pain, shortness of breath, abdominal pain, black, bloody stools.
She reports drinking 3 glasses of wine on Friday and 1 glass of
wine on Saturday. She reports taking 2 advils on Friday for
pain.
Past Medical History:
- Hepatitis C; diagnosed 2 years prior (per patient, no h/o IVDU
but may have contracted through transfusion of sexual
transmission with IVDU in past), no current treatment,
complicated by varices s/p banding in [**5-14**]
- h/o PUD and antral erosions in past s/p H. pylori treatment in
[**9-/2194**]
- Iron deficiency anemia (recent baseline around 27) undergoing
on IV Fe and occasional blood transfusions
- GERD
- Hypertension
Social History:
She lives alone, does marketing. She reports drinking 3 glasses
of wine on Friday and 1 glass of wine on Saturday. Denies
tobacco, recreational drugs or IVDA.
Family History:
No family history of liver disease.
Physical Exam:
VS: Temp: 98 BP: 123/83 HR: 103 RR: 21 O2sat 97%RA
GEN: pleasant, comfortable, NAD, NGT in place with black/maroon
residue
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd,
CV: Tachycardic, RR, S1 and S2 wnl, no m/r/g
RESP: CTA b/l with good air movement throughout
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, no
flank dullness
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Moving all four extremities, no asterixus.
Pertinent Results:
[**2197-8-6**] 01:35PM BLOOD WBC-8.4# RBC-3.03*# Hgb-8.8*# Hct-29.7*#
MCV-98# MCH-29.2 MCHC-29.7* RDW-23.5* Plt Ct-257#
[**2197-8-7**] 06:24AM BLOOD WBC-4.1# RBC-3.35* Hgb-10.2* Hct-30.5*
MCV-91# MCH-30.6 MCHC-33.6# RDW-22.0* Plt Ct-101*#
[**2197-8-7**] 09:00PM BLOOD WBC-4.0 RBC-3.28* Hgb-10.0* Hct-30.1*
MCV-92 MCH-30.5 MCHC-33.2 RDW-22.3* Plt Ct-91*
[**2197-8-8**] 07:15AM BLOOD WBC-2.6* RBC-3.25* Hgb-9.6* Hct-29.9*
MCV-92 MCH-29.5 MCHC-32.0 RDW-23.0* Plt Ct-66*
[**2197-8-6**] 01:35PM BLOOD Neuts-65.7 Lymphs-25.9 Monos-6.8 Eos-0.7
Baso-0.9
[**2197-8-6**] 02:12PM BLOOD PT-19.2* PTT-24.4 INR(PT)-1.7*
[**2197-8-7**] 06:24AM BLOOD PT-18.3* PTT-27.2 INR(PT)-1.6*
[**2197-8-8**] 07:15AM BLOOD PT-17.7* PTT-26.1 INR(PT)-1.6*
[**2197-8-6**] 01:35PM BLOOD Glucose-164* UreaN-27* Creat-0.7 Na-140
K-4.0 Cl-103 HCO3-17* AnGap-24*
[**2197-8-7**] 06:24AM BLOOD Glucose-154* UreaN-18 Creat-0.6 Na-138
K-3.3 Cl-107 HCO3-23 AnGap-11
[**2197-8-7**] 11:41AM BLOOD Glucose-209* UreaN-16 Creat-0.7 Na-136
K-3.8 Cl-106 HCO3-26 AnGap-8
[**2197-8-8**] 07:15AM BLOOD Glucose-125* UreaN-9 Creat-0.5 Na-137
K-3.9 Cl-110* HCO3-22 AnGap-9
[**2197-8-6**] 01:35PM BLOOD ALT-51* AST-114* AlkPhos-78 TotBili-1.1
[**2197-8-7**] 06:24AM BLOOD ALT-43* AST-101* LD(LDH)-204 AlkPhos-55
TotBili-3.4* DirBili-1.9* IndBili-1.5
[**2197-8-8**] 07:15AM BLOOD ALT-74* AST-166* AlkPhos-56 TotBili-2.2*
[**2197-8-6**] 01:35PM BLOOD Albumin-3.4* Calcium-8.5 Phos-3.5 Mg-1.7
[**2197-8-7**] 06:24AM BLOOD Albumin-2.7* Calcium-7.0* Phos-2.3*
Mg-1.5*
[**2197-8-7**] 11:41AM BLOOD Calcium-7.6* Phos-1.9* Mg-3.1*
[**2197-8-8**] 07:15AM BLOOD Calcium-7.3* Phos-2.6* Mg-2.1
[**2197-8-7**] 06:24AM BLOOD Hapto-30
[**2197-8-6**] 01:35PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2197-8-6**] 07:33PM BLOOD Ethanol-NEG
[**2197-8-6**] 01:55PM BLOOD Glucose-161* Lactate-3.9* Na-139 K-3.8
Cl-102 calHCO3-23
[**2197-8-6**] 08:22PM BLOOD Lactate-2.2*
REPORTS:
[**2197-8-7**] CXR:
Low inspiratory volumes. Allowing for this, no definite
cardiomegaly. No
CHF, focal infiltrate, or effusion is identified. Within the
limits of plain film radiography, no hilar or mediastinal
lymphadenopathy is detected.
EGD [**2197-8-6**]
Impression: Obliterated varices seen in the esophagus.
Portal hypertensive gastropathy
Clot in the stomach. No source of bleeding seen- possibilities
are portal hypertensive gastropathy, gastric ulcer, vs. small
gastric varix underlying clot.
Recommendations: IV PPI and octreotide.
Serial Hct.
Repeat EGD on [**2197-8-8**].
[**2197-8-7**] RUQ U/S: IMPRESSION:
1. Cirrhotic liver.
2. Doppler assessment of the hepatic vasculature and splenic
vein shows
patency and appropriate directionality of flow.
3. Trace perihepatic ascites.
[**2197-8-8**] EGD:
Impression: Evidence of obliterated varices in the distal
esophagus.
Erythema and congestion with mosaic pattern in the fundus and
stomach body compatible with portal hypertensive gastropathy
Punctate erythema in the fundus compatible with gastritis
Nodularity in the antrum compatible with hyperplastic polyps
Otherwise normal EGD to third part of the duodenum
MICRO:
Blood culture [**2197-8-6**] PENDING
[**2197-8-7**] 2:41 pm URINE Source: CVS.
URINE CULTURE (Final [**2197-8-8**]): <10,000 organisms/ml.
Brief Hospital Course:
Presentation:
53 year old woman with a history of HCV cirrhosis c/b varices
s/p banding now presents with hematemesis x 5 at home concerning
for an acute GI bleed.
.
Active Issues:
#) GI bleed: Pt was tachycardic in the ED but not hypotensive.
Pt was started on Octreotide gtt and PPI gtt. An EGD was
performed which showed an antral clot and evidence of portal
gastropathy. Although she had no varices seen on this and prior
EGD [**2-14**], a small varix underneath the clot could not be
excluded. We believe her recent alcohol and NSAID use may have
contributed to this presentation and we counseled her to avoid
these behaviors. The patient received a total of 4 units of
PRBCs and her Hct responded appropriately and remained stable.
Pt was also given Ceftriaxone 2gm IV Q24H for SBP prophylaxis.
Pt was also give vitamin K 2mg PO once. A repeat EGD was
performed on [**2197-8-8**] and it was also negative for any clear
source of bleeding. Pt was then discharged home on home PPI [**Hospital1 **]
and 4 more days of abx (PO Cefpodoxime). Pt's home Nadolol was
initially held but then restarted on day of discharge as pt's
BPs remained stable.
.
#. HCV cirrhosis: Patient with a MELD of 13 and currently
compensated. Patient's liver function was near baseline with
normal bili and INR of 1.7 (baseline 1.7). Serum tox negative.
Urine tox was positive for benzos (which she received during
hospitalization). RUQ U/S with dopplers was obtained which
showed cirrhosis, patent vessels. Pt needs close outpt GI follow
up, and liver transplant could be considered given GI bleed.
.
#. Anion gap acidosis: Pt had a anion gap of 20 with no
delta/delta, which was most likely secondary to lactate
elevation due to acute blood loss and/or liver dysfunction.
Sepsis is a possible cause of lactate elevation, however,
patient was without focal signs of infection. Did not suspect
DKA given glucose in 160s. Infectious work up with CXR, U/A,
blood cx were all negative. Lactate normalized, as did the gap.
.
#. Alcohol use: Likely contributed to this presentation. No
signs of abuse/withdrawal. Counseled patient on abstinence. Pt
was maintained on a CIWA scale however did not score on it. Pt
was started on folate, thiamine, MTV.
.
# Thrombocytopenia: Plts were 257 on admission, then trended
down slowly to 101, 91 and 66. No evidence of acute bleeding or
spontaneous bleeding, no petechia/purpura/ecchymoses on exam.
Most likely consumption or destruction vs. dilutional in setting
of blood transfusions. There was no evidence of HIT, no exposure
to heparin products on this admission. Does not meet nadir for
drug induced and other more likely possibilities. Sequestration
high on differential, given known liver disease. Pt's plts need
to be followed closely as outpatient.
.
Inactive Issues:
#. HTN: Home Nadolol was initially held in the setting of acute
bleed, then restarted on day of discharge since pt's BPs
remained stable.
.
#. GERD: Pt was maintained on a PPI gtt then transitioned back
to her home PPI by the time of discharge.
.
#. Iron defeciency anemia: Pt needs outpt follow-up for this.
Hct rose appropriately to transfusions and remained stable.
.
Transitional Issues:
1. Urine and blood cultures are still pending at time of
discharge.
2. Platelets were trending down and need to be closely monitored
as outpt.
3. Given pt's GI bleed, pt may be considered for a liver
transplant in the future.
Medications on Admission:
1. Nadolol 20 mg po BID
2. Omeprazole 40 mg PO BID
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: hematemesis
Secondary: HCV cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you here at [**Hospital1 18**]. You were
admitted because you had bloody vomit. You were given IV
medications to control the bleeding. You were also given blood
transfusions. The gastroenterologists evaluated you and
performed an upper endoscopy which revealed no obvious source of
bleeding. Your blood counts remained stable and a repeat
endocscopy was performed which again showed no source of
bleeding. You were maintained on antibiotics to prevent an
abdominal infection. You were then discharged home.
Please make the following changes to your medications:
1. START Cefpodoxime for 4 days
2. START Multivitamin daily
3. START Folic acid daily
4. START Thiamine daily
Please continue to take all your home medications as before.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Appointment: Thursday [**8-10**] at 3:40PM
You should have blood work done at this visit.
Name: [**Last Name (LF) 26390**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: [**8-24**] at 12:40PM
Discuss with your hepatologist the possibility of transplant
given recent bleeding episodes.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2197-8-9**]
ICD9 Codes: 2762, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2870
} | Medical Text: Admission Date: [**2180-2-24**] Discharge Date: [**2180-2-26**]
Service: MEDICINE
Allergies:
Diovan
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Right- and left- heart catheterization:
1. Coronary arteries are normal.
2. Moderate aortic stenosis.
3. Severe diastolic ventricular dysfunction.
4. Severe systemic hypetension.
.
History of Present Illness:
88 yo [**Location 7972**] F with hypertension, hypercholesterolemia,
known AAA (4.4x4.1cm), AV nodal disease s/p pacer placement, PVD
and AS with valve area 0.81 who presents after diagnostic right
and left heart cath with a hypotensive episode.
.
The patient presented today from home for diagnostic right and
left heart cath. Prior to the procedure, the patient was noted
to be hypertensive to 145/110. She received 5mg IV lopressor.
During the procedure, the patient was noted to be hypertensive
to >200/100. She received heparin 1000U, nitroglycerin gtt at
40mcg/min and then 80mcg/min during the procedure with some bp
response to 180/90. In the post-cath holding area after the
procedure, the patient was again hypertensive to 224/94. She
received hydralazine 10mg IV. Approximately 3 hours after the
procedure at 1:15PM the patient complained of left leg pain
described as cramping, contralateral to her groin access site on
the right. She also complained of nausea and vomiting. She was
noted at this time to have over 2L urine output in her foley
bag. Her BP was 70/palp from 162/60. She received NS bolus of
1L, zofran 4mg IV, dopamine at 5 and then 12mcg/kg/min with
improvement in her bp to 108/52. She was noted to have no
hematoma or at her right groin site and dopplerable pulses in
the distal extremities bilaterally.
.
On presentation to the ICU, the patient was noted to have a bp
141/74 off of dopamine. She complained of some mild epigastric
discomfort. She denies experiencing this pain in the past
however notes in OMR and verbal report from other physicians
describes frequent complaints of abdominal pain.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. She endorses DOE after 3
flights of stairs in a recent cardiovascular clinic note though
denies this currently. ROS otherwise negative in detail with the
exception of some calf cramping occurring with activity and
relieved with rest.
.
Past Medical History:
Hypertension
Hyperlipidemia
Aortic stenosis
AV nodal disease s/p pacemaker placement in [**1-/2180**]
AAA (4.3cm) and ascending thoracic aneurysm (3.5cm)
PVD s/p bilateral lower extremity revascularization
Right proximal popliteal aneurysm
S/p left arterectomy PFA [**2-/2177**], R SFA angioplasty [**3-/2177**]
S/p Wharthin gland excision
Neurocystercircosis s/p VP shunt >14years ago for hydrocephalus
.
Social History:
Lives with husband and daughter. [**Name (NI) **] tobacco, EtOH or drug use.
Family History:
No family history of premature CAD or sudden death.
Physical Exam:
VS: 78 101/47 12 100% facemask
Gen: Elderly woman. NAD.
CV: Loud AS murmur. Normal rhythm.
Pulm: CTA bilaterally.
Abd: Soft, nontender, no masses.
Ext: No edema. No palpable pulses on the distal right and no
palpable dorsalis pedis on the left. Palpable posterior tibial
pulse on the left.
.
Pertinent Results:
[**2180-2-24**] 04:08PM WBC-11.8*# RBC-3.96* HGB-11.6* HCT-35.8*
MCV-91 MCH-29.3 MCHC-32.4 RDW-13.4
[**2180-2-24**] 04:08PM PLT COUNT-142*
[**2180-2-24**] 04:08PM PT-12.8 PTT-25.4 INR(PT)-1.1
[**2180-2-24**] 04:08PM GLUCOSE-104 UREA N-14 CREAT-0.7 SODIUM-141
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2180-2-24**] 04:08PM CALCIUM-9.3 PHOSPHATE-4.1 MAGNESIUM-1.9
[**2180-2-24**] 09:54AM TYPE-ART PO2-225* PCO2-54* PH-7.34* TOTAL
CO2-30 BASE XS-2 INTUBATED-NOT INTUBA
.
.
Right- and Left- Heart Catheterization:
1. Selective coronary angiography revealed a right dominant
system with
patent LMCA. The LAD had no demonstrable stenosis. LCX was
non-dominant
with no significant obstructive disease. The RCA was dominant
without
critical lesions.
2. Left ventriculography showed preserved ejection fraction of
55% and
normal wall motion with small cavity suggestive of diastolic
dysfunction.
3. Abdominal aortography showed an aneurysm of about 4 cm in
size.
4. Hemodynamic assessment revealed markedly elevated systemic
pressures
of above 200 mm Hg. There was a 30 mm Hg gradient across the
aortic
valve with calculated valve are of 0.8 cm2 which was unchanged
from
prior exam. Left and right sided filling pressures were normal
and
cardiac index was preserved. Administration of intravenous
nitroglycerine did not increase PCWP and decreased systemic
blood pressure to 185 mm Hg with brisk diuresis in the lab.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Moderate aortic stenosis.
3. Severe diastolic ventricular dysfunction.
4. Severe systemic hypetension.
.
.
ECG ([**2180-2-24**]): Atrial pacing. Left axis deviation. Left
anterior fascicular block.
Non-specific lateral and anterolateral ST-T wave changes.
Compared to the
previous tracing ventricular pacing is no longer present.
.
.
2D-[**Year (4 digits) **] ([**2180-2-17**]): The left atrium is normal in size.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets are
severely thickened/deformed. There is moderate to severe aortic
valve stenosis (area 0.8-1.0cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2179-12-16**],
aortic gradients and pulmonary pressures are lower but there is
still significant aortic stenosis
.
P-MIBI ([**2178-2-16**]): No anginal symptoms or ECG changes from
baseline. 1. Normal myocardial perfusion. 2. Normal left
ventricular cavity
size and function. EF 66%.
.
CT abd/pelvis ([**2179-12-21**]): 1. 44 x 41 mm abdominal aortic
aneurysm as described above with extensive atherosclerosis in
the branches of the abdominal aorta as well as ectasia of the
iliac arteries. 2. Bilateral renal cortical thinning and
bilateral renal hypodensities likely represent cysts. 3.
Uterine calcifications likely represent fibroids.
.
Brief Hospital Course:
The patient is an 88-year-old [**Location 7972**] woman with
hypertension, hypercholesterolemia, known AAA (4.4x4.1cm), AV
nodal disease s/p pacemaker placement, PVD and AS with valve
area 0.81, who presents after diagnostic right- and left- heart
catheterization with a hypotensive episode in the setting of
multiple antihypertensive agents, 2 liter autodiuresis, and
severe abdominal pain.
.
#. Hypotensive episode - The patient experienced hypotension
post-catheterization, likely from a combination of receiving
multiple anti-hypertensives within a short amount of time
(metoprolol, nitroglycerin, and hydralazine), with a
large-volume auto-diuresis, and likely a component of vasovagal
response in the setting of severe abdominal pain. She received
approx 1.5L of volume resuscitation and her anti-hypertensives
were held. She did well clinically thereafter, with good
response in her blood pressure. Her beta-blocker was resumed at
home dose on [**2180-2-26**], which she tolerated well, and she was
started on a low-dose ACE-inhibitor as well, which she also
tolerated well. Her HCTZ was held and was not restarted. She was
discharged on [**2180-2-26**] with follow-up planned with Dr. [**First Name (STitle) **]
in 2 weeks.
.
#. Coronary Artery Disease (ischemia) - The patient had no
significant CAD on her left-heart catheterization, and she had
no signs of active ischemia. She was maintained on her home baby
aspirin for primary prophylaxis.
.
#. Pump - The patient has a preserved EF on her most recent TTE,
with no signs of CHF currenty. She is pre-load dependent given
her valvular disease.
.
#. Rhythm - The patient has a history of high-degree AV nodal
disease s/p recent pacemaker placement. She currently has a
paced rhythm.
.
#. Valves - The patient has known severe AS with valve area 0.8.
She will have outpatient follow-up with Dr. [**First Name (STitle) **] for further
management of her valvular disease.
.
#. Hypertension - The patient's home anti-hypertensives, HCTZ
and metoprolol, were initially held given her hypotensive
episode above. The metoprolol was re-instituted as the patient's
blood pressures improved, and she was also started on an
ACE-inhibitor prior to discharge. Her HCTZ was discontinued.
.
#. Hyperlipidemia - The patient was continued on her home
cholestyramine and Lescol.
.
#. Vascular Aneurysms - The patient has known AAA (4.3cm),
ascending thoracic aneurysm (3.5cm), and right proximal
popliteal aneurysm, all of which are followed as an outpatient.
.
#. Peripheral Vascular Disease - The patient has PVD s/p
bilateral lower extremity revascularization. She was continued
on her home baby aspirin.
.
Medications on Admission:
Aspirin 81 mg Daily
Docusate Sodium 100 mg Twice daily
Fluticasone 50 mcg/Actuation Daily
Hydrochlorothiazide 25 mg Daily
Imipramine HCl 10 mg QHS
Metoprolol Tartrate 25 mg Twice daily
Oxycodone 5 mg Twice daily
Protonix 40 mg Daily
Lescol XL 80 mg QHS
Cholestyramine One tsp twice a day
Meclizine 12.5 mg twice daily
Tylenol Arthritis Pain 650 mg twice a day as needed
.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Fluticasone 50 mcg/Actuation Disk with Device Sig: One (1)
puff Inhalation once a day.
4. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Lescol XL 80 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO at bedtime.
9. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
10. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
12. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Hypotensive episode
Secondary Diagnosis:
- high-degree AV nodal disease s/p permanent pacemaker
- severe Aortic Stenosis (valve area 0.8)
- hypertension
- hyperlipidemia
.
Discharge Condition:
afebrile, vital signs stable, tolerating anti-hypertensive
medications.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for diagnostic right and left heart
catheterization, which was complicated by hypotension in the
setting of receiving many medications during the
catheterization. You were treated with IV fluid boluses for
hypotension, and your blood pressure normalized by [**2180-2-26**].
You were restarted on your home metoprolol, which you tolerated
well, and you were then started on a new medication, lisinopril,
which you also tolerated well. You HCTZ was held and you should
stop taking this medication.
.
You should continue to take your medications as prescribed
below. You should call the office of Dr. [**First Name (STitle) **], your
cardiologist, to schedule an appointment in 2 weeks time.
.
If you experience any chest pain, shortness of breath,
lightheadedness, or feelings of fainting, you should call your
doctor or return to the Emergency Room for evaluation.
.
Followup Instructions:
You should call Dr. [**First Name (STitle) **], your cardiologist, at [**Telephone/Fax (1) 920**]
to schedule an appointment to see him within 2 weeks.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2180-3-2**] 10:15
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2180-3-23**]
4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2180-4-12**] 2:30
.
ICD9 Codes: 4241, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2871
} | Medical Text: Admission Date: [**2194-5-30**] Discharge Date: [**2194-6-6**]
Date of Birth: [**2133-10-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
S/p emergent tracheostomy
History of Present Illness:
Mr. [**Known lastname 86057**] is a 60 year old male w/ h/o COPD who presented with
sore throat for several days and stridor for 3 hours. No
vomiting, no CP, no abd pain. + Fever, chills.
.
In ED, vitals were, Temp:102.8 HR:90 BP:1421/P Resp:26-28
O(2)Sat:98 normal. Pt was dyspneic and noted to have biphasic
stridor. ENT was consulted was who upon examination of the
patients oropharynx with fiberoptic scope, noted significant
supraglottic and epiglottic swelling with a 2 mm airway.
Preparations were made for emergent transfer to the OR. The pt
received IV ceftriaxone and unasyn as well as 10 mg IV
dexamethasone and nebulized racemic epi as a temporizing measure
in the ED. The patient was noted to have increasing respiratory
distress on arrival to the OR. Fiberoptic intubation was
attempted but unable to visualize arytenoids or pass a bougie.
Perc cric was then attempted with puncture of the airway through
the thyroid cartilage. The patients sats dropped to 70s,
unclear if pt aspirated while in extremis. A temporary airway
was established and then converted to a formal tracheostomy.
The pt was then transferred to the MICU.
Past Medical History:
COPD
GERD
Frequent URI's
Social History:
- Tobacco: ++, [**3-5**] ppd x45 yrs, currently at 2 ppd
- Alcohol:
- Illicits:
High school teacher lives with wife who is a nurse.
Family History:
NC
Physical Exam:
PE AFTER ADMISION TO THE FLOOR:
Vitals: 99.5, 144/80, 57, 18, 95% on 2L NC
Gen: Well appearing male in NAD, speaking in full senteces
CV: RRR, no murmurs
LUngs: diminished BS at bases, ronchi on upper airway clearing
with cough. NO SOB, trach is capped.
ABD: soft, NT/ND, + BS x 4 quads. NG tube with feeds.
Ext: no edema and + pulses
Neuro: A+Ox3
Pertinent Results:
ADMISSION LABS:
===============
[**2194-5-29**] 11:45PM BLOOD WBC-20.1* RBC-5.78 Hgb-17.3 Hct-52.3*
MCV-90 MCH-29.9 MCHC-33.1 RDW-14.3 Plt Ct-239
[**2194-5-29**] 11:45PM BLOOD PT-12.3 PTT-25.3 INR(PT)-1.0
[**2194-5-29**] 11:45PM BLOOD Glucose-110* UreaN-12 Creat-0.9 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
[**2194-5-30**] 04:22AM BLOOD Calcium-7.2* Phos-3.5 Mg-1.9
[**2194-5-30**] 04:40AM BLOOD Type-ART Temp-37.4 PEEP-8 O2 Flow-100
pO2-109* pCO2-53* pH-7.28* calTCO2-26 Base XS--2
Intubat-INTUBATED
[**2194-5-29**] 11:53PM BLOOD Lactate-1.2 K-3.7
[**2194-5-30**] 10:19PM BLOOD freeCa-1.10*
MICROBIOLOGY:
.
[**2194-5-30**] 8:56 am BLOOD CULTURE Source: Line-tlcl.
Blood Culture, Routine (Final [**2194-6-5**]): NO GROWTH.
.
[**2194-5-30**] 8:57 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2194-5-30**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2194-6-1**]):
RARE GROWTH Commensal Respiratory Flora.
.
[**2194-5-30**] 8:57 am URINE Source: Catheter.
URINE CULTURE (Final [**2194-5-31**]): NO GROWTH.
.
[**2194-5-29**] 11:45 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2194-6-4**]): NO GROWTH.
DISCHARGE LABS:
================
[**2194-6-6**] 05:50AM BLOOD WBC-11.4* RBC-4.80 Hgb-14.0 Hct-41.7
MCV-87 MCH-29.2 MCHC-33.6 RDW-13.7 Plt Ct-295
[**2194-6-6**] 05:50AM BLOOD Glucose-94 UreaN-13 Creat-0.6 Na-142
K-4.1 Cl-105 HCO3-27 AnGap-14
[**2194-6-6**] 05:50AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2
IMAGING/STUDIES:
# ECG ON [**2194-5-29**]:
Baseline artifact. Sinus rhythm. Left axis deviation. Late R
wave
progression. No previous tracing available for comparison.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
91 152 94 352/406 71 -43 28
.
# CXRAY [**2194-5-29**]:
SINGLE FRONTAL VIEW OF THE CHEST: Vascular engorgement and
minimal basal
interstitial abnormality could be due to cardiac decompensation,
although
heart size is only top normal. No pneumonia.
The laryngeal and subglottic airway looks diffusely narrowed and
should be
evaluated with conventional or CT radiography. Leftward
displacement of normal calibre trachea below the thoracic inlet
could be due to tortuous vasculature.
IMPRESSION:
1. Possible narrowing larnyngeal and subglottic airway should be
imaged
further.
2. Borderline cardiac decompensation.
.
#NECK SOFT TISSUE [**2194-5-29**]:
PORTABLE SINGLE LATERAL VIEW OF THE NECK: Only C1 through C4 is
visualized on this lateral view. The visualized prevertebral
soft tissues are within normal limits. The epiglottis is largely
obscured by overlying patient's shoulders. Degenerative changes
are noted throughout the visualized cervical spine.
IMPRESSION: Limited evaluation. Apparent soft tissue swelling of
the
anterior neck.
.
#PATHOLOGY Tracheal cartilage:
Respiratory mucosa with mild acute and chronic inflammation,
bone, and cartilage.
Clinical: Acute epiglottitis.
Gross:
The specimen is received fresh in a container labeled the
patient's name, "[**Known lastname 86057**], [**Known firstname **]", the medical record number and
"tracheal cartilage". It consists of two fragments of pink-tan
cartilage measuring 1.5 x 0.7 x 0.7 cm in aggregate. The
specimen is entirely submitted in cassette A.
#CXRAY ON [**2194-6-1**]:
One portable view. Comparison with [**2194-5-31**]. There is persistent
asymmetric
density at the right lung base suspicious for pneumonia. The
left lung
appears relatively clear on the current study. The heart and
mediastinal
structures are unchanged. A right subclavian catheter,
tracheostomy tube and nasogastric tube remain in place.
IMPRESSION: Persistent asymmetric density at the right base
suspicious for
pneumonia.
.
#UGI SGL CONTRAST W/ KUB Study Date of [**2194-6-5**] 4:25 PM
FINDINGS: The initial scout radiograph of mediastinal area was
performed.
Limited visualization of the lung bases. However, the previously
noted
asymmetric opacity in the right lung base is improved. No
pneumothorax or
subcutaneous emphysema is identified in the lower neck and
chest.
A barium swallow study was performed with thin liquid barium. On
administration of thin liquid barium, there was normal free
passage of barium through the oropharynx and the esophagus. No
definite leak is identified in the oropharynx or the esophagus.
There is no evidence of obstruction with contrast passing freely
into the stomach. Detailed evaluation of the motility of the
esophagus was not performed at this time.
IMPRESSION: Limited upper GI study, did not reveal contrast leak
from the
oropharynx or the esophagus.
Brief Hospital Course:
60 yo M w/ h/o COPD here with ST for several days, fever,
stridor with epiglottitis seen on fiberoptic scope s/p emergent
trach in OR prior to transfer to the MICU.
.
# Epiglottitis- Confirmed by fiberoptic scope by ENT in the ED
then again during emergent trach in the OR. The trach was left
in place, with the balloon inflated x5d post admission for
airway protection while supraglottic and glottic edema resolved.
The patient received high dose dexamethasone in the first 24
hours in the ICU to speed improvement in the airway edema. He
was given IV unasyn x5d as well as IV vancomycin x4d (for
presumed aspiration during emergent airway procedure) with plan
to transition to orals once pt passed barium swallow. The
oropharynx was visualized again on HD6 with moderate but
resolving supraglottic edema seen. His antibiotics were changed
to Augmentin 875mg twice daily for total of 14 days (Day 1 was
on [**2194-6-4**]). On [**2194-6-5**] he had oropharynx was visualized and
supraglottic edema was improved. He had both tracheotosmy and NG
tube removed. Patient had Barium swallow study wich showed no
aspiration and no leakage. He was advanced to regular soft diet
which he tolerated well, he no difficulty swallowing. Patient
denies having any shortness of breath and his o2 sats have been
in mid 90s% while walking and while resting. Patient and family
wanted to leave today and drive to [**Location (un) 7349**]. He was given instruction
to follow-up with a ENT doctor early next week. His wife is a
nursse and is trying to arrange the appointment.
.
#Hypotension- The patient was hypotensive with SBPs in the 70s
initially on arrival to the ICU. DDX included volume depletion
vs. sepsis [**3-4**] epiglottitis or aspiration pneumonitis. The pt
required dopamine then levophed gtts initially in addition to
IVF resuscitation to support BPs but were weaned within the
first 24 hours. BP was stable in the normal range since.
.
#Tracheostomy, crash airway- Pt converted to formal trach in OR.
Reportedly the thyroid cartilage was punctured during the
emergent procedure, which required ENT to be more cautious with
trach removal. Cuff was left inflated for 5 days then deflated
by ENT, the trach was downsized on HD6 and it was decannulazed
on the following day. The pt was advanced to po's once he
passed a barium swallow study demonstrating no persistent injury
to the hypopharynx caused by the crash procedure.
.
#COPD- Albuterol and ipratropium MDIs given per trach q6h
scheduled for pts known COPD. He denies having any shortness of
breath and was sating in mid 90s% at time of discharge.
.
GERD- IV PPI daily.
.
# FEN: tolerating soft diet well with no complains and no
difficulty swallowing.
# Prophylaxis: He was given Subcutaneous heparin
# Access: peripherals.
# Communication: Patient.
# Code: Full
# Disposition: going home to [**Location (un) 7349**]
Medications on Admission:
azithromycin 500 mg x1 dose yest. am
advair prn
albuterol prn
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
[**Last Name (STitle) **]:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0*
2. Nicotine 14 mg/24 hr Patch 24 hr [**Last Name (STitle) **]: One (1) Patch 24 hr
Transdermal DAILY (Daily): You should use the 14mg patch for a
total of 6 weeks then change to 7mg for 2 weeks and then stop.
You will need to follow-up with your primary care doctor.
[**Last Name (Titles) **]:*30 Patch 24 hr(s)* Refills:*0*
3. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (Titles) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*2 Inhalers* Refills:*1*
4. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution [**Hospital1 **]: One (1) PO BID (2 times a day) for 10 days.
[**Hospital1 **]:*20 Tablets* Refills:*0*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing, SOB.
[**Hospital1 **]:*2 inhalers* Refills:*1*
6. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation Q6H (every 6 hours).
[**Hospital1 **]:*2 inhalers* Refills:*1*
7. Oxycodone 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every four (4)
hours as needed for pain: This medication may cause drowsiness.
You should not drive,operate heavy machenary or do anything that
may require allertness while taking this medication.
[**Hospital1 **]:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Epiglotitis, s/p emergent tracheostomy
Secondary:
COPD
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital1 18**] for shortness of breath. You were
found to have epiglotitis, swelling and infection of your
throat. Unfortunately your throat closed completely and you
needed to have an emergent tracheostomy. You were then taken to
the ICU and you have overall improved. Your tracheostomy was
removed and you have done very well. You had a swallow
evaluation and you have been eating soft diet without any
difficulty. You will need to follow-up with an ENT (Ear, Nose
and Throat) doctor [**First Name (Titles) **] [**Last Name (Titles) **] early next week. Please let us know if
you have any difficulty in arranging for this appointment.
We have added the following medications to your regimen:
- Augumentin 875 mg twice per day for another 10 more days. It
is very important that you take this medication as prescribed
and do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**].
- Albuterol 2 puffs every 4 hours as need for SOB and wheezing
- Fluticasone Propionate 110mcg 2 PUFF twice daily
- Ipratropium Bromide MDI 2 PUFFs every 6 hours
- Nicotine Patch 14 mg TD DAILY
- Prevacid disintergrating tablets daily (gastric reflux)
- Oxycodone 5mg 1-2 tablets as needed every 6 hours for pain.
This medication may cause drowsiness and you should not drive,
operate heavy machenary or do anything that requires alertness
while taking this medication
Followup Instructions:
You wife is arranging an appointment with an ENT doctor in [**Location (un) 5426**]. You should see someone early next week or sooner if you
have any other concerns. Please call Dr. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
at [**Telephone/Fax (1) 2756**] and ask operator to page [**Numeric Identifier 86058**] if you have any
questions or concerns or if you can't get an ENT doctor.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5070, 3051, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2872
} | Medical Text: Admission Date: [**2139-4-20**] Discharge Date: [**2139-4-24**]
Date of Birth: [**2070-5-7**] Sex: M
Service: CSU
PREOPERATIVE DIAGNOSES:
1. Mitral regurgitation/mitral valve prolapse.
2. Hypercholesterolemia.
3. Gastroesophageal reflux disease.
4. Peptic ulcer disease.
5. Status post right total knee replacement.
6. Hiatal hernia status post repair.
7. Status post orchidopexy.
8. Status post transurethral resection of the prostate.
DISCHARGE DIAGNOSES:
1. Mitral regurgitation/mitral valve prolapse - status post
mitral valve replacement with 33-mm mosaic porcine valve.
2. Maze procedure for atrial fibrillation.
3. Hypercholesterolemia.
4. Gastroesophageal reflux disease.
5. Peptic ulcer disease.
6. Status post right total knee replacement.
7. Hiatal hernia status post repair.
8. Status post orchidopexy.
9. Status post transurethral resection of the prostate.
ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname 110983**] is a generally
healthy 68-year-old male who had been noticing some
increasing symptoms of palpitations and shortness of breath.
He was found on echocardiogram to have [**1-29**]+ mitral
regurgitation and was admitted electively for mitral valve
repair/replacement. His transesophageal echocardiogram at the
start of the procedure noted myxomatous degeneration of both
the anterior and posterior leaflets and prolapse at both
leaflets necessitating replacement of the valve.
His preoperative physical examination was notable for a mild
systolic murmur, but his lungs were otherwise clear. Abdomen
was soft. Pulse exam was within normal limits, and he had no
peripheral edema.
His preoperative labs include a hematocrit of 38.3, and BUN
and creatinine of 16 and 0.7.
HOSPITAL COURSE: Patient was admitted on [**2139-4-20**], and
on that same day underwent a minimally invasive mitral valve
replacement with a 33-mm mosaic porcine valve.
Intraoperatively, the patient experienced some atrial
fibrillation and a maze procedure was performed. Patient
tolerated the procedure well, and was taken to the cardiac
surgery recovery unit postoperatively.
He was extubated on postoperative day 0. His hospital course
was relatively unremarkable. He did quite well aside from
requirement for Neo-Synephrine to maintain his mean arterial
blood pressure above 60 for 2 days. His hypotension was fully
evaluated, not felt to be secondary to any sort of
cardiogenic etiology or secondary to hypovolemia, and as
noted by postoperative day 2, he was able to wean off the Neo-
Synephrine without any adverse effect on his blood pressure.
He was otherwise, as noted, extubated on postoperative day 0.
His chest tubes were removed on postoperative day 2 without
incident, and the patient was transferred to the regular
floor on postoperative day 2. He did require diuresis with
Lasix postoperatively for a 9 kilogram weight differential
from his preoperative and postoperative weight. He otherwise
remained afebrile and hemodynamically normal throughout the
rest of hospitalization. He was started on amiodarone and
Coumadin on postoperative day 3 for his atrial fibrillation
and without incident. He remained in sinus rhythm throughout
the rest of his hospitalization.
It is felt that by postoperative day 4, as the patient had
been afebrile, hemodynamically normal with oxygen saturations
in the high 90s and on room air, that he can be discharged to
home safely. At the time of his discharge, the patient's
lungs were slightly decreased at the bases, but otherwise
clear. His heart was regular in sinus rhythm, and he had
about a 1+ peripheral edema.
His labs were notable for a hematocrit of 27.4 and a BUN and
creatinine of 15 and 0.8. His final x-ray prior to discharge
was just notable for a little atelectasis at the bases, but
otherwise unremarkable.
He was sent home on the following medications: Lopressor 12.5
mg p.o. b.i.d., Lasix 20 mg p.o. b.i.d. for 10 days,
potassium chloride 20 mEq p.o. b.i.d. for 10 days, Zantac 150
mg p.o. b.i.d. for 2 weeks, aspirin 81 mg once a day, Colace
as needed, Percocet 5/325 one to two tablets every 4-6 hours
as needed, amiodarone taper starting 400 mg p.o. t.i.d. to
complete a 1 week course, followed by 400 mg p.o. b.i.d. for
1 week, followed by 400 mg once a day for 1 week, followed by
200 mg once daily or as adjusted by his cardiologist.
Th[**Last Name (STitle) 1050**] was advised to followup with Dr. [**Last Name (Prefixes) **] in
clinic in 4 weeks. He was also advised to followup with Dr.
[**Known firstname **] [**Last Name (NamePattern1) **] from the electrophysiology service for
management of his atrial fibrillation as he had seen Dr.
[**Last Name (STitle) **] preoperatively. Patient was unsure about this and
felt he may wanted another cardiologist, the name of which he
would let Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office know. He was also advised
to followup with his primary care physician within the next 7-
10 days.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2139-4-24**] 10:38:07
T: [**2139-4-24**] 11:14:43
Job#: [**Job Number 110984**]
ICD9 Codes: 4240, 9971, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2873
} | Medical Text: Admission Date: [**2128-11-18**] Discharge Date: [**2128-11-24**]
Date of Birth: [**2058-10-8**] Sex: F
Service: NEUROSURGERY
Allergies:
Amoxicillin / Latex
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Right frontal traumatic subarachnoid hemorrhage and
intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 year old female presents after having some left sided
weakness this morning. She then fell and hit the front of her
head after going down the stairs. No LOC. She was plegic when
she
arrived to the OSH and her head CT showed IPH. The patient was
transferred to [**Hospital1 18**] for a neurosurgical evaluation. Currently
the patient reports a headache and dizziness. She vomited in the
ER. She has no visual changes. She does report some decreased
sensation that started in the left side and is now in the RLE.
The patient has no SOB or chest pain. She does not take coumadin
but does take 81 mg of aspirin every other day.
Past Medical History:
Diverticulitis, breast cancer. She has
had four pregnancies and three vaginal deliveries
Social History:
She drinks two alcoholic drinks per day. She
denies tobacco. She is retired. She currently lives in [**Location **],
[**State 350**].
Family History:
She has several first and second degree relatives who have had
breast cancer. There is no history of ovarian or uterine
cancer.
Physical Exam:
Exam upon admission:
T:96.5 BP:134/50 HR: 51 RR:17 O2Sats:100% 4L NC
Gen: Somewhat cachectic appearing
HEENT: Pupils: left pupil [**3-11**], right [**2-8**] EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils - left [**3-11**], right 3-2 mm. 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: Strength 5/5 RUE, RLE. Left side plegic.
Not able to test pronator drift.
Sensation: Grossly intact to light touch bilaterally.
Toes downgoing bilaterally
Exam upon discharge:
Pt is A+O x3, opens eyes to voice, PERRL, has left sided
neglect, eyes do not cross midline otherwise EOMI. tongue is
midline, left facial droop noted. Full motor strength on RUE
and RLE, no movement noted on LUE and LLE. Toes upgoing on left,
down on right.
Pertinent Results:
[**2128-11-18**] 06:20PM GLUCOSE-150* UREA N-12 CREAT-0.6 SODIUM-135
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-25 ANION GAP-12
[**2128-11-18**] 06:20PM CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-1.9
[**2128-11-18**] 06:20PM WBC-10.0 RBC-3.41* HGB-11.1* HCT-30.8* MCV-91
MCH-32.4* MCHC-35.8* RDW-12.8
[**2128-11-18**] 06:20PM PLT COUNT-270
[**2128-11-18**] 06:20PM PT-12.1 PTT-21.5* INR(PT)-1.0
[**2128-11-18**] 10:50AM GLUCOSE-144* UREA N-15 CREAT-0.8 SODIUM-138
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
[**2128-11-18**] 10:50AM CK(CPK)-183*
[**2128-11-18**] 10:50AM cTropnT-0.04*
[**2128-11-18**] 10:50AM CK-MB-3
[**2128-11-18**] 10:50AM CALCIUM-9.0 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2128-11-18**] 10:50AM WBC-10.4# RBC-3.78* HGB-12.0 HCT-34.2* MCV-91
MCH-31.8 MCHC-35.1* RDW-12.9
[**2128-11-18**] 10:50AM NEUTS-78.5* LYMPHS-16.1* MONOS-3.9 EOS-1.3
BASOS-0.3
[**2128-11-18**] 10:50AM PLT COUNT-293
[**2128-11-24**] 05:57AM BLOOD WBC-6.3 RBC-3.39* Hgb-10.9* Hct-30.5*
MCV-90 MCH-32.1* MCHC-35.7* RDW-12.5 Plt Ct-317
[**2128-11-24**] 05:57AM BLOOD Plt Ct-317
[**2128-11-24**] 05:57AM BLOOD Plt Ct-317
[**2128-11-24**] 05:57AM BLOOD Glucose-116* UreaN-7 Creat-0.5 Na-140
K-3.3 Cl-103 HCO3-26 AnGap-14
[**2128-11-24**] 05:57AM BLOOD Albumin-3.8 Calcium-8.6 Phos-2.5* Mg-1.8
[**2128-11-24**] 05:57AM BLOOD Phenyto-2.5*
CT head [**11-20**]:
FINDINGS: There is a large left subarachnoid and frontal
intraparenchymal
hemorrhage, relatively unchanged in extent compared to prior
study. There is persistent peri-hemorrhagic edema, again
comparable to yesterday. There is mild mass effect causing
effacement of the adjacent sulci and approximately 5-mm leftward
subfalcine herniation, unchanged since the prior study. There
continues to be compression of the anterior and occipital horns
of the right lateral ventricle. However, there is no
hydrocephalus or intraventricular extension of the hemorrhage.
The quadrigeminal plate cistern and perimesencephalic cisterns
are relatively preserved, suggesting no significant downward
transtentorial herniation. There are no new hemorrhagic foci.
There are areas of low attenuation in the left cerebral white
matter, which could reflect chronic ischemic changes, overall
unchanged. Unchanged extent of subdural hematoma layering along
the right tentorium. No major vascular territorial infarcts are
evident.
Osseous and soft tissue structures are unremarkable. Opacified
left lens is incidentally noted.
IMPRESSION: Unchanged appearance of the right subarachnoid,
intraparenchymal, subdural hemorrhage as described above with
associated peri-hemorrhagic edema and 5-mm leftward subfalcine
herniation. No significant interval changes.
CT Head [**11-19**]:
FINDINGS: There is further evolution of large region of
parenchymal
hemorrhage within the right frontal lobe with associated
subarachnoid
hemorrhage and edema. Effacement of the subjacent sulci within
the right
cerebral hemisphere again noted. There is no appreciable change
to 4 mm
leftward shift of normally midline structures. There is little
if any
transtentorial herniation with preservation of the quadrigeminal
and
suprasellar cisterns. Similar degree of subdural hemorrhage
layers along the right tentorium. There is no evidence of new
intracranial hemorrhage.
Moderate chronic small vessel ischemic change is noted.
Extracalvarial soft tissues appear within normal limits. There
has been a
right lens replacement. Possible osteomas are again noted within
the
maxillary sinuses. Otherwise the visualized paranasal sinuses
and mastoid air cells are clear.
There is no hydrocephalus or evidence of intraventricular
migration of
hemorrhagic products.
IMPRESSION: Interval evolution of intracranial hemorrhage
without evidence of new hemorrhage or mass effect.
CT/CTA Head [**11-18**]:
FINDINGS:
CT HEAD: There is unchanged massive right hemispheric
hemorrhage, most
evidenced in the right frontal intraparenchymal hemorrhage with
perihemorrhagic edema. There is also right- sided subdural
hematoma tracking along the falx and tentorium. There is
persistent mass effect, with a 4-mm leftward shift of midline
structures. Please refer to the non-contrast CT head performed
at an earlier time on the same day. There is periventricular
white matter hypodensities suggesting chronic microvascular
ischemic disease.
HEAD CTA: The carotid and vertebral arteries and their major
branches are
patent without evidence of stenosis. There is a small right
vertebral artery with a dominant left vertebral artery. The
distal cervical internal carotid artery measures 4 mm in
diameter bilaterally. There is no evidence of aneurysm formation
or other vascular anomaly.
IMPRESSION:
1. No intracranial aneurysm or vascular anomaly.
2. Large right hemispheric intraparenchymal hemorrhage, subdural
hematoma and mass effect as described above.
Brief Hospital Course:
Patient admitted to SICU on [**11-19**]. Pt noted to be hemiplegic on
L, full on R with stable head CT. [**11-20**] no interval change on
CT noted in the extent or distribution of the right SAH, IPH and
SDH. The patient was transferred to the neuro stepdown unit
[**11-20**]. On [**11-22**] she had speech and swallow evaluation, Dobhoff
recommended for periods of lethargy. A Dobhoff was placed [**11-22**],
which pt pulled out that night. Patient re-evaluated by speech
on [**11-23**] who recommend advancing to thin liquids and soft
solids. She opens eyes to examiner, however she has some
difficulty opening them, and they are slit-like at times.
Patient was evaluated by physical and occupational therapy, who
recommended rehab for this person. On [**11-24**], the patient is
neurologically stable and ready for discharge to a rehab
facility.
Medications on Admission:
81 mg aspirin every other day
multivitamins
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain, headache.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 650 mg Suppository Sig: [**12-10**] Suppositorys Rectal
Q6H (every 6 hours) as needed for headache.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Right frontal traumatic subarachnoid hemorrhage and
intraparenchymal hemorrhage
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2128-11-24**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2874
} | Medical Text: Admission Date: [**2180-2-8**] Discharge Date: [**2180-3-8**]
Date of Birth: [**2109-4-8**] Sex: F
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
Portugese female with chronic enterocutaneous fistula
requiring multiple admissions in the past. The patient
originally presented to the outside hospital with small bowel
obstruction in [**2176**], and underwent small bowel resection. It
was complicated by enterocutaneous fistula. She then
underwent multiple attempts at closure but developed recent
fistula reformation. In [**2179-5-10**], she underwent a
diverting loop colostomy proximal to the fistula. In [**2179-8-9**], she underwent colostomy take-down. However, the
postoperative course was complicated by reopening of the
fistula. The patient was consequently referred to [**Hospital1 1444**] with cellulitis of her
abdominal wall. After stabilization, culture and treatment
of her abdominal wall cellulitis, she underwent another
attempt at closure of her enterocutaneous fistula.
PAST MEDICAL HISTORY:
1. Enterocutaneous fistula in [**2176-12-9**], status post
exploratory laparotomy, small bowel resection in [**2176-12-9**], at [**Hospital 8**] Hospital.
2. Diverting loop colostomy in [**2179-5-10**].
3. Take-down colostomy [**2179-8-9**].
4. Take-down fistula attempt in [**2179-8-9**].
5. Noninsulin dependent diabetes mellitus.
6. Stroke with right hemiparesis in [**2170**].
7. Occipital stroke in [**2168**].
8. Myocardial infarction in [**2162**].
9. Open cholecystectomy in [**2173**].
10. History of cholangitis.
11. History of angina.
12. History of perforated gastric ulcer with a
gastrointestinal bleed.
13. Hypercholesterolemia.
14. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
15. Glaucoma.
MEDICATIONS ON ADMISSION:
1. Timoptic 0.5 one drop in both eyes q.h.s.
2. Lipitor 10 mg p.o. once daily.
3. Celexa 40 mg p.o. once daily.
4. Protonix 40 mg p.o. once daily.
5. Oxycontin p.r.n.
6. Ativan 0.75 mg twice a day.
7. Metamucil two tablespoons in water twice a day.
8. Fioricet for headaches as needed.
ALLERGIES: Aspirin gives hives. Nonsteroidal
anti-inflammatory drugs.
PHYSICAL EXAMINATION: Temperature is 97.2, blood pressure
110/60, heart rate 74, respiratory rate 18, oxygen saturation
98% in room air. In general, the patient is a pleasant
elderly female in no apparent distress. Head, eyes, ears,
nose and throat examination is anicteric, no jugular venous
distention, no bruits. Cardiovascular examination is regular
rate and rhythm, no murmurs. Pulmonary examination is clear
to auscultation bilaterally. Abdominal examination reveals
multiple surgical scars, enterocutaneous fistula evident,
mildly tender throughout. Extremities are warm and well
perfused.
HOSPITAL COURSE: The patient received appropriate bowel
preparation preoperatively. Prophylactic antibiotics were
given. The patient remained afebrile with stable vital signs
prior to the operation. On [**2180-2-10**], the patient underwent
exploratory laparotomy, lysis of adhesions, coloproctostomy,
mobilization of splenic flexure, repair of the bladder and
placement of feeding jejunostomy. The patient tolerated the
procedure well. There were no complications. Please see the
full operative note for details. The central line was placed
in the operating room and the patient spent the night in the
Intensive Care Unit. Her hematocrit remained stable. The
urine output remained adequate. The patient was maintained
on intravenous hydration. The patient was originally placed
on Vancomycin, Fluconazole and Flagyl. The patient remained
intubated overnight and extubated the following day without
any problems. Intraoperative cultures were obtained which
grew gram negative rods, Staphylococcus aureus, as well as
Enterococcus with sensitivities. The patient remained on
Ampicillin, Gentamicin. Flagyl, Fluconazole as well as
Nystatin. The patient remained stable. She complained of
some vague abdominal pain postoperatively, but her pain was
well controlled with Demerol. She originally remained NPO.
Four [**Location (un) 1661**]-[**Location (un) 1662**] drains remained in place. The
subcutaneous drains produced the murky colored discharge at
some point during the hospitalization. The deep pelvic drains
remained to produce serosanguinous fluid. The nasogastric
tube was originally placed and eventually removed. The
patient remained without nausea. She was started on TPN and
also tube feedings which consisted of Impact with fiber. The
tube feedings were gradually advanced. Physical therapy was
consulted which followed the patient during her
hospitalization. The electrolytes were repleted as needed.
The heart rate was controlled with Lopressor. Her diet was
eventually advanced from sips to clears to regular diet which
she tolerated well. The antibiotics were eventually
discontinued. The patient remained afebrile.
The patient did have one episode of nausea and vomiting on
postoperative day twelve and tube feeds were held and then
restarted without any further episodes of vomiting. The
Foley catheter remained in place for approximately two weeks
given the repair of the bladder wall that happened during the
surgery. It was eventually removed. The tube feeds were
advanced and cycled at night with regular diet during the
day. The patient was ambulating without difficulty. The
decision was made to discharge her to home with visiting
nurse services.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with VNA services.
DISCHARGE DIAGNOSES: Enterocutaneous fistula, status post
exploratory laparotomy, lysis of adhesions, coloproctostomy,
feeding jejunostomy, and repair of the bladder wall.
MEDICATIONS ON DISCHARGE:
1. Fibercon two tablets p.o. twice a day.
2. Tube feeds consisting of Impact with fiber two thirds
strength cycled twelve hours overnight at 70 cc/hour.
3. Demerol 25 to 50 mg p.o. q4-6hours p.r.n. pain.
4. Iron 325 mg p.o. once daily.
5. Multivitamins one tablet p.o. once daily.
6. Sucralfate one gram p.o. four times a day.
7. Protonix 40 mg p.o. once daily.
8. Celexa 40 mg p.o. once daily.
9. Lopressor 25 mg p.o. twice a day.
10. Insulin NPH 10 units twice a day subcutaneously.
11. Insulin sliding scale.
DISCHARGE INSTRUCTIONS:
1. The patient is to continue on tube feedings as instructed
above cycled for twelve hours at night.
2. The patient is to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**] in approximately
one to two weeks as instructed.
3. The patient is to see her primary care physician in one
to two weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2180-3-10**] 21:18
T: [**2180-3-12**] 13:15
JOB#: [**Job Number 104738**]
ICD9 Codes: 412, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2875
} | Medical Text: Admission Date: [**2185-7-10**] Discharge Date: [**2185-7-12**]
Date of Birth: [**2156-1-30**] Sex: M
Service: x
CHIEF COMPLAINT: Hematemesis.
HISTORY OF PRESENT ILLNESS: This is a 29 year old male with
a history of congenital esophageal atresia status post
reconstruction and esophagitis, who presents with bright red
blood in his vomit. The patient was doing well until the day
prior to admission when he began having episodes of nausea
and vomiting. Initially this was clear, but then progressed
to bright red blood and then to coffee grounds. He then
noted a diffuse abdominal pain. He did note that this
episode occurred after drinking three rum & cokes and not
having eaten breakfast secondary to nausea. He thereafter
presented to the outside hospital with a hematocrit of "58"
and a white blood cell count of 20, with a low grade
temperature. He did not have the coffee ground emesis at
that institution. He was transferred to [**Hospital1 346**] for further evaluation.
He denied any fevers, chills, diarrhea, constipation, melena,
bright red blood per rectum, chest pain, shortness of breath
or cough. He did note some dysphagia with solids which had
prompted an Emergency Department visit back in [**Month (only) 116**].
In the Emergency Department, vital signs were 100.5 F.;
138/75; 110; 98% on room air. He was given two liters of
normal saline, Phenergan, Demerol and Zofran. His hematocrit
then decreased to 40.8 after two lites of intravenous fluids.
He was then admitted to the Medical Intensive Care Unit per
Gastrointestinal request for observation and a possible plan of
esophagogastroduodenoscopy.
PAST MEDICAL HISTORY:
1. Congenital esophageal atresia status post reconstruction
with bowel.
2. Esophageal polyps, stricture, esophagitis and gastritis;
last esophagogastroduodenoscopy in [**6-/2185**] demonstrated Grade
4 esophagitis with stigmata of bleeding in the lower and
middle third of the esophagus. [**Known lastname 15532**]'s esophagus
associated with ulcerative mucosa and a stricture; a single
nodule was biopsied. Stomach demonstrated gastritis with a
nonbleeding polyp. Esophageal stricture was dilated and he
was started on Protonix 40 mg p.o. q. day at that time.
Pathology negative for malignancy.
3. Carpal tunnel syndrome on the left.
4. Small bowel obstruction.
MEDICATIONS:
1. Protonix 40 mg p.o. q. day.
ALLERGIES: Penicillin causes hives.
SOCIAL HISTORY: The patient works with computers. He drinks
about three rum & cokes on occasion. He smokes one pack of
cigarettes per day for the last 12 years. Denies any history of
intravenous drug use. He lives with his girlfriend.
FAMILY HISTORY: Peptic ulcer disease, gastric carcinoma in his
father.
PHYSICAL EXAMINATION: Vital signs are 100.0 F.; 107;
136/85; 29; 95% on room air. Generally, this is a thin man
in mild distress but pleasant, speaking in full sentences.
He is alert and oriented times three. HEENT: Normocephalic,
atraumatic. Pupils are equal, round and reactive to light;
anicteric. Oropharynx clear. Neck with flat jugular venous
pressure, supple. Cardiovascular: Tachycardia but regular;
no murmurs, rubs or gallops. Lungs clear to auscultation
bilaterally. Abdomen soft, nontender, multiple well healed
scars diffusely in the mostly epigastric area. No rebound or
guarding. There is a 1 by 1 firm centimeter mass in the
epigastrium, no hepatosplenomegaly. No caput medusa. Rectal
is heme negative by Emergency Department. Extremities with
no cyanosis, clubbing or edema. Congenital deformity of the
right hand. Skin without spiders, jaundice, or palmar
erythema.
LABORATORY: White blood cell count 17.8, hematocrit of 40.8,
platelets 221.
Chest x-ray with no infiltrates. KUB with no obstruction or
free fluid.
HOSPITAL COURSE:
1. UPPER GASTROINTESTINAL BLEED: The patient was admitted
to the Medical Intensive Care Unit for evaluation. He had
serial hematocrits which remained stable between 38 and 40.
He did not require any units of packed red blood cells. He
was maintained on Protonix 40 mg intravenously twice a day
and then transitioned to p.o.
He was transferred to the Floor. He did not have any
additional episodes of nausea, vomiting or hematemesis. His
blood counts remained stable.
Gastrointestinal decided to defer scope at this time given
recent scope in [**Month (only) 116**]. H. pylori antibody was sent which was
negative. He will follow-up with Dr. [**Last Name (STitle) **] as an
outpatient and will continue on Protonix 40 mg p.o. twice a
day until that time.
2. FEVER: The patient had a low grade temperature on
admission and slightly decreased oxygen saturation. Chest
x-ray demonstrated a left lower lobe pneumonia with some
diffuse infiltrates; question aspiration versus atypical
pneumonia. The patient was started on Levofloxacin and was
doing well on discharge; he will complete a ten day course.
3. ELEVATED INR: The patient's most likely elevated INR
secondary to poor p.o. intake. He was given Vitamin K
subcutaneously in the Medical Intensive Care Unit.
4. ETOH: The patient was placed on CIWA scale given three
drinks per night, although he was not felt to be high risk
for withdrawal. He did not demonstrate any withdrawal
symptoms and did not require any Ativan. It was felt that
the patient was well and ready for discharge.
DISCHARGE DISPOSITION: Discharged home.
DISCHARGE INSTRUCTIONS:
1. Outpatient follow-up with Dr. [**Last Name (STitle) **]. Follow-up with
Dr. [**Last Name (STitle) 9006**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed.
2. Pneumonia.
3. Congenital atresia of the esophagus status post
reconstruction.
4. Small bowel obstruction.
5. Esophageal stricture and ulceration.
6. [**Known lastname 15532**]'s esophagus.
7. Alcohol use.
8. Smoking.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. twice a day.
2. Levofloxacin 500 mg p.o. q. day times seven days to complete
a total of a ten day course.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 10885**]
Dictated By: [**Name6 (MD) **] [**Name8 (MD) **], M.D.
MEDQUIST36
D: [**2185-7-12**] 13:59
T: [**2185-7-15**] 22:41
JOB#: [**Job Number 23583**]
ICD9 Codes: 5789, 5070, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2876
} | Medical Text: Admission Date: [**2130-4-12**] Discharge Date: [**2130-4-19**]
Date of Birth: [**2075-3-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
CABG X 2 (LIMA to LAD, SVG to PDA) on [**2130-4-12**]
History of Present Illness:
55 y/o female who was hospitalized on [**2-1**] for DOE diagnosed
with CHF/CAD. Pt. saw Dr. [**Last Name (STitle) **] and had cardiac cath done at that
time. Cardiac cath revealed stenosis of 100% of RCA, 75% LAD,
and an EF of 15%. Pt. was then referred for CABG.
Past Medical History:
CAD
HTN
IDDM
^ Chol
CHF
Thyroid Nodules
OA
Obesity
RLE Varicose Veins
s/p C-section [**2110**]
s/p fibroidectomy [**2105**]
Social History:
Occupation: hairdresser; Tobacco: Quit 20 yrs ago after 40 pk/yr
hx. ETOH: none
Family History:
Father died from CHF at 54
Physical Exam:
Ht: 5'4" Wt: 216 lbs HR 80 RR 16 BPR 116/82 L 120/78
General: Obese women in NAD
Skin: Unremarkable
HEENT: Unremarkable, EOMI, PERRLA
Chest: CTAB
Heart: RRR +S1S2, -c/r/m/g
Abd: Soft, NT/ND, +BS, -r/r/g
Ext: Warm, well-perfused, -c/c/e, RLE varicosities
Neuro: Non-focal, A&O x 3, [**6-1**] strengths
Pulses: RFem 1+, LFem 2+, BDP 1+, BPT 1+
Pertinent Results:
Carotid U/S: Bilat. < 40% stenosis, Bilat thyroid nodules
Vein Mapping: Patent bilateral greater saphenous veins. Mild
reflux involving the right greater saphenous vein below the
knee. Dimensions on the right are 0.29 cm at the ankle, which
gradually increase to 0.57 cm at the saphenofemoral junction.
Similar values on the left are 0.28 and 0.38 cm.
Pre-op CXR: Normal chest x-ray, with recent CHF resolved. No
consolidation
or effusion.
[**2130-4-12**] 11:31AM BLOOD WBC-11.2*# RBC-3.61* Hgb-9.5* Hct-28.6*
MCV-79* MCH-26.3* MCHC-33.1 RDW-16.5* Plt Ct-290
[**2130-4-18**] 10:05AM BLOOD WBC-7.9 RBC-3.65* Hgb-9.7* Hct-29.1*
MCV-80* MCH-26.5* MCHC-33.3 RDW-16.8* Plt Ct-515*#
[**2130-4-12**] 11:31AM BLOOD PT-16.7* PTT-37.5* INR(PT)-1.8
[**2130-4-12**] 11:31AM BLOOD Plt Ct-290
[**2130-4-18**] 10:05AM BLOOD Plt Ct-515*#
[**2130-4-12**] 12:07PM BLOOD UreaN-29* Creat-0.6 Cl-106 HCO3-28
[**2130-4-18**] 10:05AM BLOOD Glucose-154* UreaN-16 Creat-0.7 Na-136
K-4.6 Cl-94* HCO3-32* AnGap-15
Brief Hospital Course:
Pt. was previously seen in clinic and was a same day admission
following surgery. On [**2130-4-12**] pt. was brought into the operating
and after general anesthesia, a coronary artery bypass graft
surgery was performed. Please see operative note for full
surgical details. Pt. tolerated the procedure well with a CPB
time of 45 min and XCT of 26 min. Pt was transferred to CSRU in
stable condition with a HR of 89 NSR, MAP 72, CVP 8, PAD 9, [**Doctor First Name 1052**]
19 and being titrated on propofol and epinephrine. Later on op
day, pt's propofol was weaned, pt. became less sedated, NMB
reversed, and once pt. was adequately breathing on her own she
was extubated without incidence. She was awake, alert and
neurologically intact.
POD #1 - Pt. was hemodynamically stable. Epinephrine was being
weaned down for BP support. Swan Ganz catheter was removed.
Along with chest tubes. Lasix and Lopressor were started per
protocol. [**Last Name (un) **] consult was initiated for tight DM management.
POD #2 - Epicardial pacing wires and Foley were removed. Pt. was
doing well and transferred from CSRU to telemetry floor.
POD #3 - Pt. hemodynamically stable. Continues to improve,
encouraged pt to get OOB, ambulate, and pulm. toilet.
POD #[**5-3**] - Pt. cont. to slowly improve. Lasix was gradually
increased. Pt. had Echo on POD #6 which showed [**1-29**]+MR [**First Name (Titles) **] [**Last Name (Titles) 58964**]s of basal half of Inf. wall.
POD #7 - Pt. improved considerably, at level 5, and was
discharged home today with VNA services. During her entire
hospital stay pt. was seen by [**Last Name (un) **] for DM management. Also
seen by PT throughout hospital course. D/C PE:
97.9 78SR 124/67 20
Neuro: Alert, oriented, non-focal
Pulm: CTAB -w/r/r
Cardiac: RRR -c/r/m/g
Sternum: Stable, Inc. C/D/I, -drainage/erythema
Abd: Soft, NT/ND, +BS
Ext: Warm, [**1-29**]+ edema, Inc. C/D/I
Medications on Admission:
1. ASA 325 mg QD
2. Lasix 40 mg [**Hospital1 **]
3. Metformin 500 mg QD
4. Lisinopril 15 mg QD
5. Toprol XL 75 mg QD
6. Lescol XL 80 mg QD
7. NPH 20 units qAM, 10 units qPM
8. Humalin SSI
9. NTG SL prn
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily) for 2 weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Pravastatin Sodium 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Insulin Lispro (Human) 100 unit/mL Solution Sig: SSRI vial
Subcutaneous four times a day: sliding scale as pre-operatively.
Disp:*1 vial* Refills:*2*
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 20 AM,
10PM Units Subcutaneous twice a day: 20 Units sc Q AM
10 Units sc q PM.
Disp:*1 vial* Refills:*2*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CAD s/p Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to
PDA)
HTN
IDDM
^ Chol
CHF
Thyroid Nodules
OA
Obesity
RLE Varicose Veins
s/p C-section [**2110**]
s/p fibroidectomy [**2105**]
Discharge Condition:
good
Discharge Instructions:
no driving or lifting > 10# for 1 month
no creams, lotions or powders to any incisions
may shower, no bathing or swimming for 1 month
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
with Dr. [**Last Name (STitle) 70**] in 6 weeks
with Dr. [**Last Name (STitle) **] in [**3-2**] weeks
with Dr. [**Last Name (STitle) **] in [**3-2**] weeks
Completed by:[**2130-5-3**]
ICD9 Codes: 4240, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2877
} | Medical Text: Admission Date: [**2132-8-3**] Discharge Date: [**2132-8-15**]
Date of Birth: [**2063-10-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Penicillins / Tetracyclines / Erythromycin Base /
Ciprofloxacin
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Hypotension, ARF
Major Surgical or Invasive Procedure:
Intubation, Arterial Line Placement, Central Veinous Access
History of Present Illness:
MICU HPI:
Reverend [**Known lastname 13469**] is a 68 year old homeless man with DM, HTN,
seizure disorder, chronic pain, recently admitted [**Date range (1) 94315**] for
presumed aspiration PNA c/b rhabdo and ARF discharged on
Clindamycin and Amlodipine for elevated BP now re-presenting to
ED with initially vague complaints of SOB, ongoing productive
cough of green sputum, and weakness as well as decreased UOP.
Also had reported 60 lb weight loss over last 4 months and
constipation x 1 month.
On initial ED triage, VS 97.9 116/96 75 14 99%RA but when
brought back to room SBP 50s-60s with HR 70s. Per report, pt
mentating normally with bounding pulses at the time. BP taken
manually in all 4 extremities and persistently low despite 5L
IVF. Pt complained of CP and EKG with ST depressions precordial
leads, I, AVL, STE III so Cardiology was consulted who felt
changes were likely reflective of demand ischemia related to
hypotension. He received rectal ASA 325mg and had normal bedside
echo with preserved EF. He was started on peripheral dopa for
hypotension with SBP up to 100s-110s but was subsequently
tachycardic to 120 with more pronounced ST depressions so RIJ
placed as well as A line and he was swicthed to levophed with
decreased HR to 70s and resolution of ST changes. He was
intubated for airway protection in setting of progressive
obtundation, reportedly was never hypoxic, and recieved
vancomycin and meropenem for ? sepsis due to history of PCN
allergy. Labs significant for WBC 10.5 with 12% bands, normal
lactate, ARF with Cr 4.8 from 1.1 [**7-30**], CK 698 (from peak [**2123**]),
trop 0.05. CT head for progressive obtundation was unremarkable
and CT torso with bibasilar infiltrates consistent with
aspiration.
.
At time of transfer, patient on 0.06 levophed, fentnayl, versed
with BP 135/57 HR 68.
Past Medical History:
1. Seizure history - describes as "[**Doctor Last Name 11332**] mal" but was previously
described as "tonic-clonic" with bilateral arm shaking, no LOC.
Was on Trileptal in the past, but was weaned off due to
associated hyponatremia, now on Keppra. Followed by Dr. [**First Name (STitle) 3322**]
[**Name (STitle) **] (EEG negative 2/[**2132**]).
2. Headaches - taken multiple narcotics in the past to
treat this, in addition to advil and tylenol. It was described
in
prior notes as starting on the left side of his head and
radiating anteriorly and down his back. He also has had
documented left face pain.
3. Type II DM
4. Peripheral neuropathy
5. Hypertension
6. Hypercholesterolemia
7. Diastolic Dysfunction (EF 60-70% on recent echo with LVH)
8. GERD
9. Depression/Anxiety
10. Lumbar spinal stenosis w/ history C3/C7 fractures
11. Degenerative joint disease
12. Neurogenic bladder
13. s/p left cataract surgery
[**37**]. Vitamin B12 deficiency
15. Atypical CP (last MIBI negative [**3-10**])
16. Hyponatremia (baseline 128-131)
17. h/o multiple falls due to multifactorial gait ataxia, also
followed by Dr. [**First Name (STitle) 3322**] [**Name (STitle) **]
18. 8-mm thecal mass, stable over several years, consistent with
nerve sheath tumor.
19. Likely prior left temporal infarct (per atrophy on head MRI)
Social History:
Homeless, retired Operating Room nurse, Buddhist monk, sister
living in
[**Name (NI) **] as only family but who has declined to take him in.
Tobacco: former smoker, ~45 pack year history (quit 30 years
ago)
.
Also, per records:
Pt has been living on the street for 3-4 months. Was engaged to
a woman many years ago but broke it off. He states he had many
relationships, and used to be bisexual. Now he is "celibate"
since becoming a priest and is not in any relationship.
Graduated from high school. College graduate. Worked on Masters.
Attended nursing school. Buddhist priest x 25 years. Was working
to counsel AIDS patients prior to becoming homeless (x 10
years). No social supports in [**Location (un) 86**]. All of his friends have
passed away.
.
Pt has a history of sexual abuse by his father's brother at age
[**6-8**]. Never told anybody, no treatment. Was also physically
abused by his father growing up.
Family History:
Mother died of esophageal cancer, ?EtOH abuse and depression.
Father died suddenly of heart attack.
.
Multiple family members with CAD including father, sister [**Name (NI) **] at
58 yo), all 4 grandparents
Type 2 DM (paternal grandfather)
Esophageal cancer (mother)
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: BP 70/40 initially, improving to 110/60 with levophed.
HR
70-80, sats 98% on 2L, RR 14
GEN: Intubated, sedated, responds to sternal rub only
HEENT: Moist mucus membranes, unable to appreciated JVP
CVS: S1,S2, no murmurs or rubs
RESP: CTA BL anteriorly
EXT: no edema, cool to touch
ABD: soft, nontender, nondistended, 2 ecchymoses on abdomen, no
ascites or organomegaly
NEURO: As above. Somnolent. Left surgical pupil. Right pupil 3mm
reactive.
SKIN: Ecchymoses abdomen. No rash.
Pulses: DP/PT 2+ BL
DISCHARGE PHYSICAL EXAM
T: 98.6 HR: 54 (54-76) BP: 116/78 RR: 18 O2: 95% RA - ambulatory
sat of 97% today
GEN: NAD, lying comfortably in his bed
HEENT: MMM, OP clear, no JVD
CV: RRR, no murmurs/clicks/rubs appreciated
PULM: CTA on left, slight crackles at right base - much
improved
ABD: protuberant, +BS, soft, NT/ND
EXT: L shoulder TTP at baseline, 2+ pulses
NEURO: alert, oriented, no focal defecits
Pertinent Results:
MICU LABS
[**2132-8-3**] 02:00PM PT-12.5 PTT-25.1 INR(PT)-1.1
[**2132-8-3**] 02:00PM PLT SMR-NORMAL PLT COUNT-256
[**2132-8-3**] 02:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2132-8-3**] 02:00PM NEUTS-50 BANDS-12* LYMPHS-21 MONOS-7 EOS-10*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2132-8-3**] 02:00PM WBC-10.5# RBC-4.39* HGB-12.5* HCT-37.6*
MCV-86 MCH-28.6 MCHC-33.3 RDW-15.8*
[**2132-8-3**] 02:00PM CK-MB-16* MB INDX-2.3
[**2132-8-3**] 02:00PM LIPASE-55
[**2132-8-3**] 02:00PM ALT(SGPT)-18 AST(SGOT)-36 CK(CPK)-698* ALK
PHOS-53 TOT BILI-0.4
[**2132-8-3**] 02:00PM estGFR-Using this
[**2132-8-3**] 02:00PM GLUCOSE-110* UREA N-48* CREAT-4.8*#
SODIUM-140 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-18* ANION GAP-25
[**2132-8-3**] 02:17PM LACTATE-1.6 K+-4.3
[**2132-8-3**] 02:45PM URINE GR HOLD-HOLD
[**2132-8-3**] 02:45PM URINE UHOLD-HOLD
[**2132-8-3**] 02:45PM URINE HOURS-RANDOM
[**2132-8-3**] 02:45PM URINE HOURS-RANDOM
[**2132-8-3**] 02:50PM URINE RBC-0-2 WBC-[**3-6**] BACTERIA-OCC YEAST-NONE
EPI-[**3-6**]
[**2132-8-3**] 02:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2132-8-3**] 02:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2132-8-3**] 03:16PM cTropnT-0.05*
[**2132-8-3**] 08:39PM PT-12.6 PTT-27.1 INR(PT)-1.1
[**2132-8-3**] 08:39PM PLT COUNT-188
[**2132-8-3**] 08:39PM NEUTS-85.9* LYMPHS-9.3* MONOS-2.5 EOS-2.2
BASOS-0.2
[**2132-8-3**] 08:39PM WBC-11.8* RBC-4.20* HGB-11.3* HCT-36.8*
MCV-88 MCH-26.9* MCHC-30.7* RDW-14.9
[**2132-8-3**] 08:39PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2132-8-3**] 08:39PM OSMOLAL-308
[**2132-8-3**] 08:39PM ALBUMIN-3.8 CALCIUM-7.4* PHOSPHATE-4.8*#
MAGNESIUM-2.2
[**2132-8-3**] 08:39PM CK-MB-19* MB INDX-2.3 cTropnT-0.01
[**2132-8-3**] 08:39PM CK(CPK)-815*
[**2132-8-3**] 08:39PM GLUCOSE-150* UREA N-37* CREAT-2.8*#
SODIUM-143 POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-19* ANION
GAP-15
[**2132-8-3**] 08:40PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2132-8-3**] 08:40PM URINE OSMOLAL-430
[**2132-8-3**] 08:40PM URINE HOURS-RANDOM CREAT-83 SODIUM-73
POTASSIUM-15 CHLORIDE-37
[**2132-8-3**] 08:56PM freeCa-1.10*
[**2132-8-3**] 08:56PM O2 SAT-98
[**2132-8-3**] 08:56PM LACTATE-0.6
[**2132-8-3**] 08:56PM TYPE-ART TEMP-36.2 RATES-14/ TIDAL VOL-550
PEEP-5 O2-70 PO2-134* PCO2-44 PH-7.24* TOTAL CO2-20* BASE XS--8
-ASSIST/CON INTUBATED-INTUBATED
[**2132-8-3**] 10:08PM TYPE-MIX TEMP-36.2 RATES-16/0 TIDAL VOL-550
PEEP-5 O2-60 PO2-160* PCO2-43 PH-7.25* TOTAL CO2-20* BASE XS--8
-ASSIST/CON INTUBATED-INTUBATED
[**2132-8-3**] 10:11PM URINE EOS-NEGATIVE
REPEAT CXR [**2132-8-7**]:
IMPRESSION: Resolution of multifocal pneumonia. Small right
lower lobe
pulmonary nodule which has been evaluated on several prior CT
scans.
CXR [**2132-8-12**]
IMPRESSION:
No evidence of consolidation. Cardiomediastinal silhouette is
unchanged,
satisfactory position of new left-sided PICC line with minor
left lower lobe
atelectasis.
REPEAT EKG:
Sinus bradycardia. Compared to the previous tracing of [**2132-8-5**]
there is no
longer evidence for prior inferior myocardial infarction,
although it is still
probable.
DISCHARGE LABS: [**2132-8-15**]
Na: 140
K:4.0
Cl:109
Bicarb: 28
BUN: 12
Cr: 1.1
Hgb: 11.0
Hct: 34.6
Brief Hospital Course:
Pt arrived in the MICU intubated with arterial line and central
line for presumed sepsis and PNA since he was recently
discharged for aspiration PNA.
Overnight in the MICU he had no acute events, and was weaned
down on his ventilatory requirement. He was extubated the next
morning and restarted on his home seizure and HTN medications.
He was observed one more night in the ICU, and then determined
to be stable enough for transfer to the floor.
Problems addressed During Admission:
# Hypotension: Pt. was initially hypotensive and intubated,
given IVF, and treated with empiric antibiotics for presumed
sepsis. His sputum cx eventually showed MRSA and he was
continued on Vancomycin (Meropenem was DC'd). His hypotension
improved on hospital day 2 and once he was transferred to the
floor, his BP was monitored and home meds eventually restarted.
#. EKG changes: Likely demand related ischemia. Pt. complained
of some chest pain after being moved to the floor - repeat EKGs
were done which did not show any concerning changes from prior
and his cardiaac enzymes remained normal. CK trended down to
normal as well.
# Acidemia: Pt had combined anion gap metabolic and respiratory
acidosis on admission which resolved with administration of IVF.
His Cr was within normal limits for the rest of his hospital
stay.
# ARF: Likely prerenal in addition to ATN given hypotension. [**Month (only) 116**]
have been partly precipitated by increased antihypertensive
regimen +/- rhabdo as described in the MICU notes. Within 48
hours, baseline Cr normalized and it was 1.1 on the day of
discharge out of the hospital.
# PNA: Pt recently discharged on [**7-30**] with aspiration PNA on
Clindamycin and returned with persistent infiltrates. He was
originally started on Vanco/[**Last Name (un) **] and once sputum culture showed
MRSA the meropenem was DC'd and vanco continued for a total
course of 11 days. He had remarkable clinical improvement and
his repeat CXR after PICC line placement showed resolution of
prior infiltrates.
# Rhabdomyolysis: CK trended up to 800 from 600s on admission
but overall down since last admission peak of [**2123**]. CK continued
to trend down and was within normal limits on [**2132-8-6**]: level was
142.
# TYPE 2 DM: Was kept on NPH and ISS while admitted - typically
on NPH.
# Chronic Pain: Pt on chronic narcotics (Oxycontin 20mg [**Hospital1 **] and
Percocet for breathrough), although he was not discharged on
oxycontin from previous admission. He received percocet as
needed for back and shoulder pain. As described below, pt. was
discharged on [**2132-7-30**] with a script for 84 percocet. He was
readmitted on [**2132-8-3**] and on inspection of his home med bottles
before discharged, he only has 2 pills left. This was brought
to his attention and he was told that percocet would only be
prescribed for enough over the weekend until his appt. with Dr.
[**Last Name (STitle) **] on [**Last Name (STitle) 766**] at 12:30. No oxycontin was given.
# Hx of Seizure Disorder: Pt. was kept on his Keppra and
gabapentin was restarted on the floor.
# Depression: Per last DC summary, patient was on Paxil which
was again resumed. However, after confirming with Dr. [**Name (NI) **], pt.
should have been on Celexa. This was prescribed. Pt. insisted
he was on Cymbalta and in fact had some Cymbalta with his home
meds prescribed by another physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 5404**]. It was
explained AT LENGTH the importance of not taking both Cymbalta
and Celexa. The patient was asked to throw away the Cymbalta
which he refused to do.
# Social: The patient is a homeless Reverend/retired OR nurse.
Social worker [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) **] spent multiple hours with Mr. [**Known lastname 13469**]
attempting to get him into a shelter or facility. He claimed
during the admission that his wallet and glucometer were stolen.
Putting his belongings in the safe was offered on multiple
occasions by case management prior to this alleged theft, but
the patient refused this service. As described by social work,
Mr. [**Known lastname 13469**] [**Last Name (Titles) 23156**] both help-seeking and help-rejecting
behavior throughout his admission, making his disposition
difficult in terms of finding him placement as many shelters and
SNFs refused to take him.
*************Pt. had Cymbalta in his bag of medications
prescribed by Dr. [**First Name (STitle) **] [**Name (STitle) 5404**]. We did not continue this and
wrote him a prescription for the Celexa which Dr. [**Last Name (STitle) **] had
prescribed. Additionally, he was prescribed 84 percocet on
[**2132-7-30**] when he was discharged from the hospital. He only has 2
pills left in his pill bottle and he was readmitted on [**8-3**]. He received percocet here for pain and was prescribed 20
pills to give him for pain until he sees Dr. [**Last Name (STitle) **] on [**Last Name (STitle) 766**].
He was not discharged from his last hospitalization on
Oxycontin and therefore he was not prescribed any after this
admission.
Medications on Admission:
1. Aspirin 81 mg Tablet PO DAILY
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID
3. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
4. Pantoprazole 40 mg Tablet, One Tablet PO Q24H
5. Oxybutynin Chloride 5 mg Tablet 1 Tablet PO BID
6. Albuterol Sulfate 1 neb inhaled q6 hours
7. Metoprolol Succinate 25 mg Tablet PO daily
8. Isosorbide Mononitrate 60 mg Tablet 1 tablet PO daily
9. Nitroglycerin 0.3 mg Tablet SL prn chest pain
10. Atorvastatin 40 mg Tablet PO DAILY
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO every six (6) hours as needed for pain
13. Paroxetine 40 mg Tablet 1 tab PO daily
14. Toprol XL 25 mg Tablet 1 tab PO daily
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous qAM: 6-9units qPM.
17. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO every twelve (12) hours as
needed for pain.
18. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO every
six (6) hours for 5 days.
Disp:*48 Capsule(s)* Refills:*0*
19. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
20. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
21. Gabapentin 600 mg Tablet Sig: Two (2) Tablet PO twice a day.
22. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*84 Tablet(s)* Refills:*0*
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: [**1-4**] Tablet PO twice a
day.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
12. Gabapentin 600 mg Tablet Sig: Two (2) Tablet PO twice a day.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual PRN as needed for chest pain: take one tab for chest
pain every 5 minutes if pain persists - not to exceed 3 tabs in
15 minutes. Call 911 for chest pain .
15. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
18. Glucometer
Please dispense one glucometer.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pneumonia - Sputum positive for methicillin resistant staph
aureus
Secondary:
Acute Renal Failure
Altered Mental Status
Rhabdomyolysis
Hypertension
Depression
Seizure Disorder
headaches
Peripheral Neuropathy
Hypercholesterolemia
GERD
Discharge Condition:
Stable, Ambulatory, at his baseline level of function
Discharge Instructions:
You were admitted to the hospital after you came in with some
confusion, low blood pressure, and renal failure. You went to
the medical ICU and a breathing tube was placed to help you
breath for about 24 hours. You were given fluids and
antibiotics and continued to improve. Your EKGs initially
showed some concerning changes which improved with treatment of
your acute problems.
PLEASE FOLLOW THE BELOW INSTRUCTIONS ON YOUR MEDICATIONS:
1. Your metoprolol was decreased from 25mg twice daily to 12.5
mg twice daily - take [**1-4**] tablet twice daily.
2. Stop taking Cymbalta - Dr. [**Last Name (STitle) **] has said you should be on
Celexa (Citalopram) 20mg daily.
3. You should no longer take any Clindamycin or levaquin.
4. You were prescribed 84 percocet on [**2132-7-30**] only 4 days
before you were brought back to the hospital. You only have 2
left and we are unable to prescribe you any more than enough to
get you to your appointment with Dr. [**Last Name (STitle) **] on [**Last Name (STitle) 766**]. You
should discuss this on [**Last Name (STitle) 766**] at your follow up appointment.
5. When you were discharged from the hospital on your last
admission, you were not discharged on any oxycontin
You can resume your other home medications as prescribed from
your recent discharge from the hospital.
You stopped the paxil and went back on your prior regimen of
Celexa - discuss this further with your primary care doctor.
You should call your doctor or return to the hospital if you
develop any fevers, chills, worsening pain, chest pain,
shortness of breath, nausea, vomiting, diarrhea, abdominal pain,
or anything else that concerns you.
Followup Instructions:
Please follow up with your Primary Care Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: PCP
Date and time: [**Last Name (LF) 766**], [**8-18**] at 12:30PM
Location: [**Location (un) **], [**Location (un) 86**], [**Numeric Identifier 718**]
Phone number: ([**Telephone/Fax (1) 10757**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
ICD9 Codes: 5845, 2761, 4280, 5859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2878
} | Medical Text: Admission Date: [**2162-4-8**] Discharge Date: [**2162-4-13**]
Date of Birth: [**2096-5-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation via trach
History of Present Illness:
65M with severe COPD p/w tachypnea. He was at home and sneezed
and his trach cap flew off. He initially had difficulty finding
it and called [**Company 191**] who referred him to 911. When EMS arrived he
had found it but was tachypneic so they brought him to ED. He
has been short of breath lately but he denies feeling SOB except
when he is moving too fast, he says that doctors [**Name5 (PTitle) **] telling
[**Name5 (PTitle) **] to move slower. Got trach placed in [**Month (only) **]. EKG in ED was
sinus tach. Was tachypneic to 50 in ED so put on [**6-10**] and then
appeared comfortable. His trach was changed. VS prior to
transfer: 87, 109/59, 95% on [**6-10**] 35% FIO2. Was satting 87-88 Got
4L IVF for borderline high 80s pressures after being put on the
vent, he had a similar reaction after intubation in [**Month (only) **].
Got cefepime/vanc in addition to azithromycin and
methylprednisolon in the ED. Norepinephrine was about to be
started but his pressure came up and it was immediately stopped.
He denies any worsening cough, progressive SOB, fevers,
rhinorrhea, N/V/D, chest pain. He says that he has been
compliant with all of his medications including his advair,
tiotropium and albuterol.
Past Medical History:
- COPD: FEV1 23% predicted, home 1.5-2L O2 at night only
- Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO
[**2159-9-18**])
- Schizophrenia
- Hx GI bleeding
- Mental Retardation
- Pulmonary Hypertension
- s/p tonsillectomy
- s/p trach
Social History:
Lives in [**Location **], unknown if alone. On disability since [**2149**]
for mental health issues. Has home nurse visit every morning and
evening. Reports ~50 pack-year smoking denies current smoking.
Denies any ETOH/drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 98.7 BP: 108/62 P: 74 R: 40 O2: 91% on 2L NC
General: Alert, oriented, no acute distress, able to speak w/
trach cap on.
[**Year (4 digits) 4459**]: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Significantly decreased bilaterally with extremely
prolonged expiratory phase and scattered wheezing.
CV: Regular, distant heart sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Passing
flatulence on exam.
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, mild cyanosis,
no edema
Pertinent Results:
Admission Labs:
[**2162-4-8**] 08:20AM BLOOD WBC-12.3* RBC-4.86 Hgb-14.3 Hct-45.6
MCV-94 MCH-29.4 MCHC-31.3 RDW-12.9 Plt Ct-354
[**2162-4-8**] 08:20AM BLOOD Neuts-85.6* Lymphs-10.0* Monos-3.0
Eos-1.0 Baso-0.4
[**2162-4-8**] 08:20AM BLOOD PT-13.3 PTT-31.6 INR(PT)-1.1
[**2162-4-8**] 08:20AM BLOOD Glucose-145* UreaN-14 Creat-1.0 Na-140
K-4.5 Cl-96 HCO3-38* AnGap-11
[**2162-4-8**] 08:35AM BLOOD Type-ART O2 Flow-4 pO2-57* pCO2-58*
pH-7.38 calTCO2-36* Base XS-6 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
Cardiac Biomarkers:
[**2162-4-8**] 08:20AM BLOOD cTropnT-<0.01
[**2162-4-8**] 05:26PM BLOOD CK-MB-2 cTropnT-<0.01
Studies:
CHEST (PORTABLE AP) Study Date of [**2162-4-8**] 8:09 AM
FINDINGS:
The lung volumes are normal. There is no pleural effusion,
pneumothorax, or focal consolidation. The hilar and mediastinal
silhouettes are unchanged. The heart is of normal size. The
pulmonary vasculature appears prominent. Left basal scarring and
atelectasis appears unchanged.
In comparison to [**2162-4-5**] exam, there is increased retrocardiac
opacity. The trachostomy tube terminates 8.5 cm above the
carina.
IMPRESSION:
Interval increase of the retrocardiac opacity, which may
represent atelectasis. However, superimposed infection cannot be
entirely excluded. Lateral views may aid in further evaluation,
if clinically indicated.
Microbiology:
[**2162-4-8**] 9:30 am SPUTUM TRACHEOSTOMY.
GRAM STAIN (Final [**2162-4-8**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS
AND CHAINS.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH Commensal Respiratory Flora.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
Respiratory Viral Antigen Screen (Final [**2162-4-8**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further information.
Respiratory Viral Culture (Final [**2162-4-10**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will only
be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Brief Hospital Course:
65 yo M w/ severe COPD s/p trach p/w hypoxia and respiratory
distress.
1. Hypoxia: At presentation his sats were in the low 90s on home
O2 of 2L. In the ED his ABG did not suggest acute worsening of
hypoventilation. His worsening respiratory status was thought to
be secondary to a COPD exacerbation given his improved
oxygenation with pressure support initially. While on pressure
support he was hypotensive and was resuscitated with 4L of NS.
He was initially tachycardic and it resolved after resuscitation
and was normotensive prior to off of positive pressure. He had a
flu swab sent, which returned negative, with a culture sent from
the same sample. On chest x-ray, he had a retrocardiac opacity,
and in the setting of his hypoxia and tachypnea, he was started
on Levofloxacin and Ceftiaxone for pneumonia. When he arrived in
the ICU, he was on PS and pulling tidal volumes of 150. He was
switched to AC 450 with a PEEP of 10 and FiO2 of 30%. He was
started on solumedrol 60mg IV Q8H and written for Tamiflu which
was discontinued when his flu came back negative. He was also
given nebulizers and continued on inhaled steroids. Because of
his history of MRSA he was started on vanco, which was DC'd when
his cultures came back positive for Strep pneumoniae. He was
treated with levofloxacin for a 5 day course which he finished
and Ceftriaxone/Cefpodoxime for a 7 day course. His steroids
were tapered from Solumedrol to prednisone. Calcium and vitamin
D were started on the day of discharge.
Follow-up:
- Finish Cefpodoxime 200mg PO BID until [**2162-4-14**]
- Steroid taper: Prednisone 40mg until [**4-17**], then 30mg until
[**4-22**], then 20mg until [**4-27**], then 10mg until [**5-2**].
2. Apnea: While here, the patient had apneic episodes while in
house which was thought to be central in nature. He will not
tolerate a CPAP mask at night, and would likely need to be
ventilated at night for these episodes.
Follow-up:
- Please perform a sleep study to assess for central sleep apnea
- Please arrange for home ventillation if necessary at night
based on the sleep study results for central apnea
3. Hypotension: Initially hypotensive and tachycardic. However
this resolved with fluids as above as well as removal of
positive airway pressure. He remained hemodynamically stable and
normotensive for the remainder of his stay.
4. ARF: His baseline creatinine appeared to be around 0.6-0.7
and was 1.0 on admission to the ICU. This was likely a pre-renal
azotemia secondary to dehydration. He was fluid resucitated with
4L NS as above.
5. Schizophrenia: Olanzapine was held initially for his
inability to tolerate being off the vent to take POs and was
added back to his regimen when he tolerated PO medications.
6. Diarrhea: Patient began experiencing diarrhea on the day of
discharge. He was afebrile, without an increase in his WBC. A C.
Diff was sent.
- Follow-up on C. Diff toxin
Transition issues: C. Diff toxin was pending at the time of
discharge. Mr. [**Known lastname 79627**] needs a sleep study to evaluate for
central sleep apnea, and may require further intervention based
on the results of that study.
Medications on Admission:
1. Zyprexa 7.5 mg Tab 1 Tablet(s) by mouth once a day
2. Multivitamins with Minerals Tab 1 Tablet(s) by mouth once a
day
3. Advair Diskus 500 mcg-50 mcg/Dose for Inhalation 1 puff(s)
inhaled twice a day
4. Spiriva with HandiHaler 18 mcg & inhalation Caps 1 capsule
inhaled once a day
5. Aspirin 81 mg Tab, Delayed Release1 Tablet(s) by mouth once a
day
6. Tylenol 325 mg Tab 1 Tablet(s) by mouth every four (4) hours
as needed for fever or pain
7. ProAir HFA 90 mcg/Actuation Aerosol Inhaler
2 puffs(s) inhaled twice a day and q 4 hours prn wheeze
8. Famotidine 20 mg Tab 1 Tablet(s) by mouth every twelve (12)
hours
9. Prednisone 20 mg Tab 2 Tablet(s) by mouth DAILY (Daily) .
Taper as directed.
10. Colace 100 mg Cap 1 Capsule(s) by mouth once a day
Discharge Medications:
1. olanzapine 7.5 mg Tablet [**Known lastname **]: One (1) Tablet PO once a day.
2. multivitamin Tablet [**Known lastname **]: One (1) Tablet PO once a day.
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device [**Known lastname **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation every four (4) hours as needed for
wheezing.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q2H (every 2 hours) as
needed for wheezing for 10 days.
6. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob/wheeze for 10
days.
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
8. aspirin 81 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
9. Tylenol 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six (6)
hours as needed for pain.
10. cefpodoxime 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q12H (every
12 hours) for 3 doses.
11. prednisone 10 mg Tablet [**Hospital1 **]: Four (4) Tablet PO As directed
per taper below: Take 40mg (4 tabs) until [**3-20**], take 30mg (3
tabs) until [**3-25**], take 20mg (2 tabs) until [**3-30**], and take 10mg
(1 tab) until [**4-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Pneumonia
COPD exascerbation
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:
Mr. [**Known lastname 79627**],
It was a pleasure taking part in your care. You were admitted to
[**Hospital1 18**] for difficulty breathing, low oxygen, and low blood
pressure. You were found to have pneumonia with a bacteria
called Streptococcus pneumoniae, and were treated with
antibiotics. You were also given IV fluids because you were
dehydrated.
You were admitted to the medical intensive care unit, and you
required mechanical ventilation through your trach to help rest
you as well as to keep your oxygen level appropriate.
Throughout your stay, your oxygen level improved and you were
able to be kept off the ventilator for long periods of time.
The following changes were made to your medications:
- Continue Cefpodoxime 200mg by mouth twice a day through [**2162-4-14**]
- Continue Prednisone according to the following taper:
40mg until [**4-17**]
30mg until [**4-22**]
20mg until [**4-27**]
10mg until [**5-2**]
- Use ipratropium and albuterol neublizers as needed for
shortness of breath, and wheezing
Please take all medications as prescribed.
Please follow-up at your appointments below.
Followup Instructions:
Please arrange to follow-up with your primary care doctor at the
appointment below.
Department: [**Hospital3 249**]
When: TUESDAY [**2162-4-27**] at 10:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2162-4-13**]
ICD9 Codes: 5849, 4168, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2879
} | Medical Text: Admission Date: [**2159-2-21**] Discharge Date: [**2159-2-23**]
Date of Birth: [**2112-5-19**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: This is a 46-year-old white
male patient with a known history of aortic regurgitation
which has been followed over the past few years by serial
echocardiography. The most recent one showed worsening
aortic regurgitation and the patient was referred for aortic
valve replacement. The patient had a cardiac catheterization
which revealed a normal left ventricular ejection fraction,
normal coronary arteries, and severe aortic regurgitation.
PAST MEDICAL HISTORY:
1. Aortic regurgitation, per HPI.
2. GERD.
3. Intermittent hematuria with negative cystoscopy.
PAST SURGICAL HISTORY:
1. Wisdom teeth extraction.
2. Skin lesion removal.
ADMISSION MEDICATIONS:
1. Prilosec 20 mg p.o. q.d.
2. Ibuprofen p.r.n.
ALLERGIES: Penicillin, unknown reaction.
PHYSICAL EXAMINATION ON ADMISSION: Unremarkable.
LABORATORY/RADIOLOGIC DATA: The preoperative laboratory
values were unremarkable.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2159-2-21**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] where he underwent a
limited access aortic valve replacement with a #29
[**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. Postoperatively, he
was transported from the operating room to the cardiac
surgery recovery unit in good condition.
On the day of surgery, he was weaned from mechanical
ventilation and extubated. On postoperative day number one,
he remained hemodynamically stable and his chest tube/[**Doctor Last Name 406**]
drain was discontinued and he was transferred from the
Intensive Care Unit to the telemetry floor, at which point
the patient began to progress with physical therapy and
ambulation and cardiac rehabilitation.
Today, postoperative day number two, the patient remains
hemodynamically stable. His epicardial pacing wires were
removed this morning. He remained in normal sinus rhythm
with a heart rate of 69, blood pressure of 116/59, and he is
ready to be discharged home today. He has progressed to
physical therapy level V, ambulating without any difficulty.
PHYSICAL CONDITION UPON DISCHARGE: Neurologically, the
patient has no apparent deficits. The patient's lung
examination is clear to auscultation bilaterally. His
cardiac examination revealed a regular rate and rhythm. His
wounds were clean, dry, and intact. The most recent chest
x-ray was from [**2159-2-21**] which showed no pneumothorax
and no pleural effusion. The most recent laboratory values
are from today, [**2159-2-23**], which include a white blood
cell count of 10, hematocrit 27.8, platelet count 120,000.
Sodium 138, potassium 5.1, chloride 102, C02 32, BUN 23,
creatinine 0.9, glucose 103.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg p.o. q.d.
2. Metoprolol 25 mg p.o. b.i.d.
3. Colace 100 mg p.o. b.i.d.
4. Lasix 20 mg p.o. q. 12 hours times seven days.
5. Potassium chloride 20 mEq p.o. q. 12 hours times seven
days.
6. Ibuprofen 400 mg p.o. q. six hours p.r.n. pain.
7. Percocet 5/325 one to two tablets p.o. q. four to six
hours p.r.n. pain.
FOLLOW-UP: The patient is to follow-up with his primary care
physician in two to three weeks. He is to follow-up in the
Cardiac Surgery office in four weeks for postoperative check.
DISCHARGE DIAGNOSIS: Aortic regurgitation, status post
aortic valve replacement.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2159-2-23**] 12:21
T: [**2159-2-23**] 14:45
JOB#: [**Job Number 50380**]
ICD9 Codes: 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2880
} | Medical Text: Admission Date: [**2199-9-15**] Discharge Date: [**2199-9-19**]
Date of Birth: [**2124-8-6**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 75 year-old male with
cardiac risk factors of hypercholesterolemia, tobacco
smoking, his age, who is known to have coronary artery
disease in the past status post question of a myocardial
infarction in [**2183**] at which time he underwent cardiac
catheterization, but was managed medically and reportedly had
episodes of pericarditis in [**2192**]. He also has a history of a
abdominal aortic aneurysm repair in [**2180**], who has been
relatively asymptomatic with the exception of the occasional
arm weakness during golfing. This all changed the day prior
to admission when he was helping his son with [**Name2 (NI) **] work when
he suddenly developed left arm/elbow pain that radiated
across his shoulders and was associated with mild shortness
of breath (this is his anginal equivalent of left elbow
pain). He had no chest pain, no nausea or vomiting. He
presented to an outside hospital at approximately 3:00 p.m.
(the onset of his elbow pain was at 2:30 p.m.) where an
electrocardiogram revealed anterior [**Street Address(2) 4793**] elevations with
inferior reciprocal depressions. Initially these were
unrecognized and the patient was admitted for rule out
myocardial infarction without additional treatment. At
midnight his CKs were positive for myocardial infarction.
The electrocardiogram still had residual ST elevations so he
was transferred to [**Hospital1 69**] for
further management.
The patient had continued to have 6 out of 10 arm pain
throughout midnight, which decreased to 2 out of 10 after the
institution of aspirin, nitroglycerin, morphine, and heparin
drip. He arrives at [**Hospital1 69**]
complaining of 1 to 2 out of 10 arm pain, his anginal
equivalent. He had no shortness of breath, no palpitations,
no nausea, vomiting or chest pain. He denies recent illness.
He has no recent fevers or chills. His review of systems was
otherwise negative. He was taken immediately to the Cardiac
Catheterization Laboratory where hemodynamically he had mild
elevation of his left ventricular and diastolic pressure as
well as his pulmonary capillary wedge pressure with a mean
wedge of 19. He also notably had a normal cardiac index at
2.74. A left ventriculogram was performed that demonstrated
trace mitral regurgitation and left ventricular ejection
fraction of 40% with severe hypokinesis of the anterior wall,
and akinesis of the apex. He had a hyperdynamic high
anterior wall with preserved motion of the inferior wall.
His coronary angiograph demonstrated a right dominant system.
His left main coronary artery had mild irregularities. His
left anterior descending artery showed a total occlusion at
the second septal junction after a high small diagonal. TIMI
0 flow was noted. This vessel was stented with 0% residual.
TIMI 3 flow was demonstrated. He also notably had a left
circumflex artery of 80% proximal lesion, into a single huge
marginal. The right coronary artery was 100% mid right
coronary artery with [**Doctor First Name **] right to right and left to right
collaterals. A large posterior descending coronary artery
and post left ventricular branches were seen. Otherwise his
catheterization was notable for a previously repaired
abdominal aortic aneurysm.
In summary his catheterization was notable for multivessel
disease including a chronic occlusion of the right coronary
artery and moderate to severe lesion of the proximal left
circumflex. The left anterior descending coronary artery was
occluded and managed with primary percutaneous transluminal
coronary angioplasty from TIMI 0 to TIMI 3 flow post stent.
PAST MEDICAL HISTORY: As above.
FAMILY HISTORY: He has a brother who died of heart disease
at 69. He has a father who died of a cerebrovascular
accident at age 55.
SOCIAL HISTORY: He has 80 pack year smoking of tobacco. He
quit in [**2181-4-17**]. He denies any intravenous drug use. He
is married, retired. He drinks one glass of alcohol/wine per
night.
ALLERGIES: The patient has no known drug allergies, however,
on this admission appears to be allergic to betadine
ointment, which causes a maculopapular rash.
MEDICATIONS: His cardiac medications on admission were
Lipitor, Imdur and aspirin.
PHYSICAL EXAMINATION ON ADMISSION: Heart rate 67, blood
pressure 117/65. Respiratory rate 12. He was sating 98% on
room air. In general, he was pleasant and in no acute
distress. His mucous membranes are moist. His oropharynx
was clear. He had anicteric sclera. He had no JVD, no
carotid bruits. His heart examination was regular rate and
rhythm with distant S1 and S2 sounds. No murmurs or rubs or
gallops were appreciated. His lungs were clear to
auscultation. His abdomen was soft, nontender, nondistended.
He had a small reducible soft hernia and a clean and dry
abdominal aortic aneurysm scar. His extremities were without
edema. His pedals were palpable. He had no femoral bruits
bilaterally. He was guaiac negative.
LABORATORY FINDINGS ON ADMISSION: White blood cell count was
11.5, hematocrit 44.2, platelets 154, sodium 139, potassium
4.1, BUN 22, creatinine 1.1, INR was 1.2. An
electrocardiogram on admission, he was in normal sinus rhythm
at a rate of 74. His PR interval was 304 milliseconds, left
axis deviation was noted. He had ST elevations in leads V1
through V3 with T wave inversions in leads 3 and AVF. This
electrocardiogram was his presenting electrocardiogram from
the outside hospital.
HOSPITAL COURSE: 1. Cardiac: Ischemia; the patient had an
anterior ST elevation myocardial infarction with a cardiac
catheterization notable for three vessel disease. He is
status post a proximal left anterior descending coronary
artery stent. The patient did well post catheterization. He
was maintained on aspirin and Plavix to complete a thirty day
course of Plavix. His CKs peaked at 1432, his peak index was
14.2. He had no further dynamic electrocardiogram changes.
His lipid panel revealed a total cholesterol of 153, LDL of
88, HDL 43, triglycerides of 108. He was maintained on
Lipitor for his dyslipidemia. Regarding his ischemia, the
plan was to medically manage him presently and bring him back
for an elective coronary artery bypass graft in four to six
weeks following completion of a thirty day course of Plavix.
Pump; on [**2199-9-16**] a transthoracic echocardiogram
was obtained. It demonstrated a left ventricular ejection
fraction of 30% with left ventricular systolic function
moderately to severely depressed secondary to severe
hypokinesis of the anterior septum and anterior free wall.
Apical akinesis was also noted (no thrombus was seen). Also
there was mid ventricular plus apical segments and inferior
plus posterior wall hypokinesis. There was 1+ mitral
regurgitation. The patient was maintained on beta blockers
and ace inhibitors as his blood pressure and heart rate
tolerated. He was continued on heparin following his
catheterization for his apical akinesis. He was slowly
transitioned to Coumadin for discharge. Coumadin will resume
until a week prior to surgery.
Rhythm; the patient had a few runs of nonsustained
ventricular tachycardia following his anterior ST elevation
myocardial infarction. the longest of these runs were
approximately seven beats in the immediate post
catheterization. He had no further episodes noted on
telemetry for the rest of his hospitalization. The patient
also had a signal average electrocardiogram performed by Dr.
[**Last Name (STitle) 45512**]. He will follow up with a T wave alternans study
following his coronary artery bypass graft. The decision was
made not to stress him with T wave alternans study
preoperatively given his three vessel disease. From a rhythm
standpoint, there will be consideration of ICD placement post
coronary artery bypass graft given his EF of 30%. Again this
consideration will be post coronary artery bypass graft.
The patient was evaluated by physical therapy during this
admission and deemed to have return to his baseline level of
function and safe to go home.
MEDICATIONS ON DISCHARGE: 1. Lopresor 75 mg po b.i.d. 2.
Captopril 25 mg po t.i.d. 3. Aspirin 325 mg po q.d. 4.
Lipitor 10 mg po q day. 5. Protonix 40 mg po q.d. 6.
Coumadin 5 mg po q.h.s. 7. Plavix 75 mg po q.d. to complete
a thirty day course.
FOLLOW UP: The patient will have his cardiology follow up
per Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. He was formally followed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 45513**] at [**Hospital3 45514**] Center. The patient, however,
expressed his wishes to be followed primarily at [**Hospital1 346**]. He will follow up with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 45515**]
Dr.[**Name (NI) 9388**] nurse practitioner [**First Name (Titles) **] [**2199-10-4**] at 11:30
a.m. The patient will be discharged on Coumadin and his INR
will be drawn by nurse [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 41978**] and the results will be
forwarded to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 45516**] office who will titrate his
Coumadin appropriately to a therapeutic level. The patient
will also be seen in the [**Hospital **] Clinic on [**2199-10-7**] at
1:00 p.m. on the [**Hospital1 **] [**Location (un) **] [**Apartment Address(1) 45517**]. He will
also follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] of cardiac surgery on
[**10-8**] at 1:30 p.m. at [**Last Name (NamePattern1) 439**]. The patient
will complete a thirty day course of Plavix prior to coronary
artery bypass graft. The plan will be to undergo coronary
artery bypass graft per Dr. [**Last Name (STitle) 70**]. The patient's
Coumadin will likely be discontinued a week prior to surgery.
The patient will follow up a T wave alternans study and
consideration of ICD placement following his surgery.
Arrangements for said follow up will be per Dr. [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) **].
ALLERGIES ON DISCHARGE: The patient has an allergy to
betadine ointment, which gave him a rash.
CONDITION ON DISCHARGE: Stable.
PRINCIPAL DIAGNOSES:
1. Anterior ST elevation myocardial infarction, status post
a proximal left anterior descending coronary artery stent.
2. Three vessel disease, plan for elective coronary artery
bypass graft in four to six weeks following discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name (STitle) 45071**]
MEDQUIST36
D: [**2199-10-8**] 16:26
T: [**2199-10-11**] 07:36
JOB#: [**Job Number **]
ICD9 Codes: 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2881
} | Medical Text: Admission Date: [**2136-1-5**] Discharge Date: [**2136-1-19**]
Date of Birth: [**2066-5-29**] Sex: F
Service: CARDIOTHORACIC
CHIEF COMPLAINT: The patient was admitted to the hospital
with a chief complaint of chest pressure.
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 68941**] is a 68 year-old
woman with a past medical history significant for diabetes
mellitus, hypertension and end stage renal disease on
peritoneal dialysis presented to the Emergency Room with
chest pressure and shortness of breath times 24 hours. The
night prior to admission the patient developed shortness of
breath and chest pain with a pressure like sensation that was
episodic in nature with no radiation to the neck or arm. No
nausea, vomiting, lightheadedness. On the arrival to the
Emergency Room the patient was pain free, but she was noted
to have systolic blood pressure from 240 to 250. She was
treated with Hydralazine and intravenous nitroglycerin.
Additionally she was noted to have inferolateral ST
depressions and the troponin one came back at 2.8. Therefore
she was given Lopresor and started on intravenous heparin and
nitroglycerin and the decision was made to admit her to the
Coronary Care Unit.
PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus times
twenty years requiring insulin. 2. Hypercholesterolemia.
3. Hypertension. 4. Uterine fibroids leading to a total
abdominal hysterectomy. 5. End stage renal disease
currently on peritoneal dialysis. 6. Cerebrovascular
accident with slightly residual right arm weakness. 7.
Seizure disorder. 8. Bladder diverticula. 9. Multi
infarct dementia. 10. Fall in [**2133-10-26**] leading to a
tibial fracture.
MEDICATIONS ON ADMISSION: Amlodipine 10 mg q.d., Clonidine
patch 0.2 mg q week, Diltiazem CD 360 mg q day, Losartan 50
mg q day, Senna tab one q.h.s., Nephrocaps one q.h.s., NPH
insulin 14 units q.a.m., Percocet one to two tabs q 4 hours
prn and Phos-Lo one tab t.i.d.
ALLERGIES: Penicillin, which causes pruritus.
SOCIAL HISTORY: The patient is retired, formerly worked as
an employment counselor. She lives at home and is able to
take care of herself. She denies any alcohol or drug use.
She has ninety pack year history of smoking, stopped in [**2118**].
PHYSICAL EXAMINATION ON ADMISSION: Vital signs, temperature
98.6. Heart rate 83. Respiratory rate 29. Blood pressure
174/64. O2 sat 100% on 2 liters. HEENT anicteric. Neck is
supple. No LAD. No JVD. Chest is clear to auscultation
bilaterally. Cardiovascular normal S1 and S2 with 3/6
systolic ejection murmur heard at apex. Abdomen is soft,
nontender with positive bowel sounds. Extremities no
clubbing, cyanosis or edema. Neurological examination is
nonfocal.
LABORATORIES ON ADMISSION: White blood cell count 6.1,
hematocrit 29.5, platelets 202, PT 12.3, PTT 25, glucose 202,
BUN 49, sodium 142, potassium 3.3, chloride 99, CO2 27, BUN
49, creatinine 13.9, CK 222, troponin 2.8. Electrocardiogram
normal sinus rhythm iwth ST depressions and T wave inversions
in V4 through 5 as well as 2, 3 and F. The patient continued
to have intermittent chest pain. She was therefore brought
to the Cardiac Catheterization laboratory. Please see
catheterization report for full details. In summary, the
catheterization showed 95% left main, 95% right coronary
artery, 90% left circumflex, 70% obtuse marginal one.
HOSPITAL COURSE: An intra-aortic balloon pump was placed and
the patient was returned to the Coronary Care Unit.
Cardiothoracic Surgery was consulted at that time. The
patient was accepted for cardiac surgery, however, initially
refused surgery. It was found post cardiac catheterization
that the patient's peritoneal dialysis catheter was no longer
functioning. A hemodialysis catheter was placed and the
patient was begun on hemodialysis. Over the next several
days the patient was treated by the Medical Service and
followed by the Renal Service. She was at that time thought
to have peritonitis a one of the cultures from her peritoneal
catheter had grown out staph of non aureus species. She was
treated with Vancomycin and Levofloxacin. She did on her
third day after admission agree to undergo coronary artery
bypass grafting. CT Surgery was again consulted and she was
scheduled for coronary artery bypass grafting once the
peritonitis issue had been resolved.
On [**1-11**] the patient was brought to the Operating Room
at which time she underwent an off pump coronary artery
bypass graft times one. Please see the operative report for
full details. In summary, she had an off pump coronary
artery bypass graft times one with a left internal mammary
coronary artery to the left anterior descending coronary
artery. She tolerated the surgery well and was transferred
from the Operating Room to the Cardiothoracic Intensive Care
Unit. The patient was kept intubated and sedated throughout
the night of her operative day. Her balloon pump was
maintained at one to one. During that time she remained
hemodynamically stable. On postoperative day one the patient
was weaned from the intra-aortic balloon pump and the balloon
pump was discontinued late in the afternoon on postoperative
day one. Also on postoperative day one the patient's
sedation was discontinued. She awoke from her sedation and
was weaned from the ventilator. However, she remained
intubated throughout the remainder of postoperative day one.
Additionally, the patient's chest tube was discontinued on
postoperative day one. On postoperative day two the patient
remained intubated in the morning. She underwent dialysis
early in the morning and following her dialysis she was
extubated. Following extubation the patient was noted to be
tachypneic. A chest x-ray was done. At that time the
patient was noted to have bilateral pleural effusions for
which bilateral chest tubes were placed. The patient
remained in the Cardiothoracic Intensive Care Unit until
postoperative day five. At that point she was felt to be
stable from a hemodynamic as well as a respiratory point and
she was transferred to the floor for continuing postoperative
care and cardiac rehabilitation. Over the next several days
the patient continued to make slow progress with her cardiac
rehabilitation.
On postoperative day six the patient was returned to the
Operating Room with the Transplant Surgery Service. At that
time she underwent removal of her peritoneal dialysis
catheter and insertion of a Perm-A-Cath in the right
subclavian vein. This procedure was tolerated well and she
was returned to the floor for continuing postoperative care.
The patient continued to make slow progress over the next two
postoperative days and on postoperative day eight she was
deemed stable and ready for transfer to rehabilitation for
continuing care.
At the time of transfer the patient's physical examination is
as follows: Vital signs temperature 98.6. Heart rate 78
sinus rhythm. Blood pressure 150/71. Respiratory rate 18.
O2 sat 98%. Weight preoperatively is 49 kilograms. At
discharge is 46.6 kilograms. Laboratory data at the time of
discharge: White count had been 23,000 the day prior to
discharge. Red blood cell count 28.2, platelets 101, sodium
139, potassium 4.1, chloride 101, CO2 26, BUN 32, creatinine
4.2, glucose 60. Physical examination, neurological alert
and conversant. Respiratory clear to auscultation
bilaterally. Heart sounds regular rate and rhythm with a 3/6
systolic ejection murmur heard best at the left sternal
border. Sternum is stable. Incision with Steri-Strips open
to air clean and dry. Abdomen is soft, nondistended.
Positive bowel sounds. Midline tenderness at incision site.
Abdominal incision with dry sterile dressing. No drainage.
Lower extremities are warm with no edema. Right upper arm
has positive edema with a hematoma from the mid forearm to
the mid bicep that was noted prior to surgery. This hematoma
appears to be slowly resolving and may be the source of her
elevated white blood cell count.
MEDICATIONS ON DISCHARGE: Norvasc 10 mg q.d., Losartan 50 mg
q.d., Nephrocaps one q.h.s., Metoprolol 50 mg b.i.d., enteric
coated aspirin 325 mg q.d, Plavix 75 mg q.d., Colace 100 mg
b.i.d., Ranitidine 150 mg q.d., Catapres patch 0.2 mg q week,
Levaquin 500 mg q.o.d., Vancomycin 500 mg intravenous prn
when the trough level is less then 15 to be given during
hemodialysis. Percocet 5/325 one to two tabs q 4 hours prn,
NPH insulin 7 units q.a.m., regular insulin sliding scale
q.a.c. and h.s. The Levaquin and the Vancomycin are due to
be discontinued on [**1-23**].
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post off pump coronary
artery bypass grafting times one with a left internal mammary
coronary artery to the left anterior descending coronary
artery.
2. Diabetes mellitus type 2.
3. Hypertension.
4. End stage renal disease status post Perm-A-Cath placement
currently on hemodialysis.
5. Hypercholesterolemia.
6. Status post cerebrovascular accident with right sided
weakness.
7. Seizure disorder.
8. Multi infarct dementia.
9. Bladder diverticula.
10. Status post total abdominal hysterectomy.
The patient is to be discharged to rehabilitation. She is to
have follow up with her primary care physician in two weeks.
She is to have follow up with renal. She is due for
hemodialysis on [**1-20**] and she is to have follow up with
Dr. [**Last Name (STitle) 1537**] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2136-1-19**] 10:32
T: [**2136-1-19**] 10:57
JOB#: [**Job Number **]
ICD9 Codes: 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2882
} | Medical Text: Admission Date: [**2110-2-10**] Discharge Date: [**2110-2-14**]
Date of Birth: [**2062-11-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
Abnormal Labs
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
47yo M with h/o HIV not on HAART presnted to PCP's office and
then to our ED with non-productive cough, hiccups, jaundice, and
icterus x 4 days. Had "flu" about four weeks ago with
predominant symptom rhinorrha. This resolved on its own and
patient has not felt sweaty at night or febrile.
4 days ago developed a cough and presented initially to PCP's
office who noted the jaundice, SaO2=97% RA, no desaturation with
ambulation and hepatomegaly on exam. Labs at PCP notable for
WBC [**Numeric Identifier 43204**] (3060 bands), Hb/HCT 11.8/35.7 ESR 119, Na 120, Cl 86,
Ca 7.7, Alb 2.7, TB 10.2, DB 6.6, SGOT 294, SGPT 225. PCP
referred him to ED.
Of note patient was admitted to [**Hospital1 18**] in [**2108**] with FUO. Had a
multitude of tests sent including EBV (IgM non-reactive, one IGG
reactive and the other negative), CMV (negative), RMSF
(negative) and HIV which returned positive. He has since been
followed at [**Hospital1 778**] Health and is not treated with HAART per his
PCP.
In the ED Initial Vitals: T:100.1 HR:140 BP:117/82 18 O2Sat:94%.
Jaundice on exam but feels fine and wouldnt have come to ED
withotu PCP's advice. LLL PNA on CXR. given 2 DS Bactrim tablet
to cover PCP and [**Name9 (PRE) 14990**] 750mg PO. abd US shows splenomegaly
but no acute thrombus. LFTs elevated. Lactate trended down with
2L NS. Has also spiked fever to 102.2 and receiving toradol for
the fever.
EKG: sinus tachy and non specific TW changes and persistent
tachycardia to 130s with 3L NS so admission changed from floor
to ICU.
On arrival to the floor patient c/o feeling hot and slightly
short of breath. Otherwise denied abdominal pain, dysuria,
frequency, chest pain, shoulder pain, rash, sick contacts,
palpitations. Did endorse dark colored urine X 1 day at home.
Past Medical History:
HIV not on HAART
Hospitalized for recurrent abcess on his buttocks x 1 night,
MRSA cellulitis of arm.
Immune to HBV and HAV in [**2108**]. HCV negative in [**2108**].
Social History:
Single, MSM, works at [**Company **] (no exposures to dust
particles), lives with roommate and cats that he has had for a
long time. Previously drank one beer weekly but quit 2 months
ago. non-smoker. Denies illicit drug use.
Family History:
Mother died at age 67-DM,CAD. Father alive & well. 7 brothers, 8
sisters a & w
Physical Exam:
Afebrile, VSS
GEN: pleasant
HEENT: PERRL, icteric sclera, op without lesions or thrush, flat
jvd,
RESP: Decreased breath sounds at bases, egophany left middle
lobe
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses.
EXT: no c/c/e
SKIN: no rashes/no splinters
NEURO: AAOx3. Slow in answering some questions.
Pertinent Results:
Admission labs:
Labs from this admission:
Lactate 4.0-> 2.3 with 3L NS
120 / 84 / 17
--------------
4.0 \ 22 \ 1.0
Glucose 117
Ca: 8.3 Mg: 2.3 P: 3.1
ALT: 253 AP: 134 Tbili: 12.7 Alb: 3.0
AST: 329 LDH: 435 Dbili: 9.8 TProt:
[**Doctor First Name **]: Lip: 61
Tox negative (serum)
WBC 23 85N, 10 band, 2L, 1Meta, 0eos
INR 1.3, PTT 26.3
.
Previous labs from [**2109-3-22**] CD4 count 257/22%, WBC 3800
HIV VL [**Numeric Identifier **]
Hep A Ab reactive
HBsAg non-reactive
HBsAb reactive
HBcAb reactive
HCV Ab non-reactive
EKG: Sinus tachycardia at 130bpm. No ST/TW changes
Imaging:
CXR: Patchy right upper and left lower lobe opacities raise
concern for multi-focal pneumonia.
CXR [**2-13**]: FINDINGS: As compared to the previous radiograph, there
is no relevant
change. Evidence of a left basal opacity with air bronchograms,
extending
both behind the heart and in the left lateral and perihilar lung
areas.
Minimal additional overhydration cannot be excluded. Borderline
size of the
cardiac silhouette. No evidence of pleural effusions. No newly
appeared
parenchymal opacities.
CXR [**2-14**]: Tip of the new left PIC line is in the low SVC. There
is no pneumothorax,
pleural effusion or mediastinal widening. Heart size is normal.
Consolidation in the left lower lobe has been present since
[**2-12**] and
could represent either atelectasis or pneumonia. Lungs are
otherwise clear
and there is no appreciable pleural effusion.
Abd U/S:
IMPRESSION: Prominence of the portal triads may be due to acute
hepatitis. Recommend correlation with serum LFTs. Splenomegaly.
No ascites. Patent portal vein.
Legionella Urinary Antigen (Final [**2110-2-11**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN
Blood Culture, Routine (Final [**2110-2-13**]):
STREPTOCOCCUS PNEUMONIAE. FINAL SENSITIVITIES.
Note: For treatment of meningitis, penicillin G MIC
breakpoints
are <=0.06 ug/ml (S) and >=0.12 ug/ml (R).
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R).
For treatment with oral penicillin, the MIC break
points are
<=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE-----------<=0.06 S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- <=0.5 S
PENICILLIN G----------<=0.06 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
Mycolytic blood cultures/Acid fast cultures pending
Blood cultures negative
[**2110-2-14**] 08:05AM BLOOD WBC-8.7 RBC-3.88* Hgb-10.7* Hct-31.6*
MCV-81* MCH-27.6 MCHC-33.9 RDW-14.9 Plt Ct-422
[**2110-2-14**] 08:05AM BLOOD WBC-8.7 RBC-3.88* Hgb-10.7* Hct-31.6*
MCV-81* MCH-27.6 MCHC-33.9 RDW-14.9 Plt Ct-422
[**2110-2-14**] 08:05AM BLOOD PT-13.9* PTT-26.1 INR(PT)-1.2*
[**2110-2-11**] 04:43AM BLOOD WBC-12.3* Lymph-6* Abs [**Last Name (un) **]-738 CD3%-69
Abs CD3-511* CD4%-17 Abs CD4-123* CD8%-45 Abs CD8-335
CD4/CD8-0.4*
[**2110-2-14**] 03:35PM BLOOD Na-132* K-4.2 Cl-101
[**2110-2-14**] 08:05AM BLOOD Glucose-83 UreaN-10 Creat-0.6 Na-131*
K-4.1 Cl-102 HCO3-23 AnGap-10
[**2110-2-14**] 08:05AM BLOOD ALT-161* AST-164* TotBili-2.5*
[**2110-2-13**] 05:14AM BLOOD ALT-114* AST-114* AlkPhos-95 TotBili-3.0*
[**2110-2-14**] 08:05AM BLOOD Calcium-7.7* Phos-4.1 Mg-2.2
[**2110-2-11**] 04:43AM BLOOD calTIBC-88* Ferritn-2182* TRF-68*
[**2110-2-14**] 08:05AM BLOOD Osmolal-273*
[**2110-2-11**] 04:43AM BLOOD IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2110-2-11**] 02:51PM BLOOD AMA-NEGATIVE
[**2110-2-13**] 05:14AM BLOOD AFP-<1.0
[**2110-2-11**] 02:51PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2110-2-11**] 04:43AM BLOOD IgG-1512 IgA-220 IgM-158
Brief Hospital Course:
47yo M with h/o HIV not on HAART admitted to the MICU with a
multifocal PNA and with liver injury likely secondary to sepsis,
also with bacteremia.
# Hypoxia/multifocal pneumonia/gram positive cocci bactermia:
The patient's presentation of fever, leukocytosis, and
tachycardia along with the CXR showing a multifocal PNA point
towards a lung infection as his underlying process. Blood
cultures grew out gram postive cocci, later speciated to
pansensitive strep pneumo. Initially he was broadly treated
with vanc, cefepime, levofloxacin (for legionella/atypicals),
and bactrim (for PCP). ID was consulted and recommended
starting steroids, even though PCP was less likely until sputum
culture ruled out PCP. [**Name Initial (NameIs) **] he steroids were discontinued when
strep pneumo was speciated from the blood. He had no recent CD4
count so this was repeated and returned at 71. Once the blood
cultures came back his antibiotics were tailored to CTX only.
He will need to complete a 14 day course.
# Hepatocellular injury: Patient with acutely elevated
bilirubin and INR with a moderate transaminitis. With the
preceding viral-like illness would consider
EBV/CMV/VZV/influenza as well as bacterial infection with
legionella most likely. Abdominal ultrasound was consistent
with acute hepatitis. Liver was consulted and felt his findings
were likely from liver-induced injury due to sepsis. Several
viral serologies, acute hepatitis serologies, autoimmune workup,
and iron studies/ceroplasmin were sent for additional workup and
did not reveal any cause of liver injury. LFTs trended down
during stay, although did have a slight bump on the day of
discharge. This should be followed as an outpatient to ensure
continued resolution.
# HIV/AIDS: Last CD4 count in [**3-20**] was 257. VL:[**Numeric Identifier **]. CD4 count
checked at [**Hospital1 778**] before admission returned at 71. He will need
follow up with his PCP after discharge for initiation of HAART.
A CMV was also checked and returned with CMV IgG positive, but
viral load was negative.
.
# Hyponatremia: Patient was initally hyponatremic with a Na of
120 which improved with volume resuscitation. Most likely was
hypovolemic hyponatremia.
Comm: with patient and [**Name (NI) 65032**] (roommate) [**Telephone/Fax (1) 65033**]
Code: Confirmed full
Medications on Admission:
None
Discharge Medications:
1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. ceftriaxone 2 gram Recon Soln Sig: Two (2) gram Intravenous
every twenty-four(24) hours for 10 days: Last day [**2-24**].
Disp:*qs * Refills:*0*
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
Primary: Pneumococcal pneumonia, pneumococcal bacteremia, HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1538**],
It was a pleasure taking care of you during your
hospitalization. You were admitted with cough and jaundice and
found out to have a pneumococcal pneumonia, as well as positive
blood cultures for strep pneumoniae. You were treated in the
ICU with IV antibiotics, and these were continued on the floor.
We checked your CD4 count and it came back at 123, so you were
continued on a prophylactic dose of bactrim for pneumocystis
carinii pneumonia. You need to follow-up with your primary care
physician and talk to him about starting antiretrovirals to
treat your HIV infection.
We made the following changes to your medications:
STARTED
Ceftriaxone 2gm IV every 24 hours for a total of 14 days - last
day on [**2-24**].
Albuterol MDI 1-2 puffs every 4-6 hours as needed for wheeze,
shortness of breath
Please follow up with your PCP as scheduled. You will need to
have labs drawn in 1 week after your discharge.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R.
Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
When: Tuesday, [**2-18**], 2:30PM
Please have a CBC with differential and a creatinine and BUN
drawn at your visit. Dr. [**Last Name (STitle) 6420**] will follow up with these
labs. He should also follow up with the pending liver serology
labs. You had a positive CMV (cytomegalovirus) test as an
inpatient, the viral load is still pending and Dr. [**Last Name (STitle) 6420**]
should follow this up.
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
Completed by:[**2110-2-18**]
ICD9 Codes: 2761, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2883
} | Medical Text: Admission Date: [**2168-9-12**] Discharge Date: [**2168-9-17**]
Date of Birth: [**2094-7-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic with positive nuclear stress test that showed a
fixed inferior prefusion defect
Major Surgical or Invasive Procedure:
[**2168-9-12**] coronary bypass grafting x2 with left internal mamary
artery to left anterior descending artery and reverse saphenous
vein graft to obtuse marginal artery
History of Present Illness:
74 year old spanish speaking male who has severe peripheral
vascilar disease. He has 1.5 block intermittent claudication and
recent peripheral angiogram that
demonstrated multiple areas of stenosis that requires surgery.
In reparation for this he underwent a nuclear stress test that
showed a fixed inferior prefusion defect. He then underwent a
cardiac cath which revealed 50% left main lesion, 70% LAD and
100% RCA lesion. He is now referred for surgical
revasclarization
Past Medical History:
Hypertension, Hyperlipidemia, Diabetes Mellitus, Peripheral
vascular disease s/p left common iliac stent, Right leg
fracture, Right hip surgery for foreign body
Social History:
Race: Hispanic
Last Dental Exam: N/A
Lives with: Wife and son
Contact: [**Name (NI) 91624**] [**Name (NI) 4890**] - wife Phone #[**Telephone/Fax (1) 91625**]
[**Name2 (NI) 27057**]tion: Retired
Cigarettes: Smoked [X] last cigarette 5yrs Hx: 1ppd x
50 yrs Other Tobacco use: none
ETOH: < 1 drink/week [X]
Illicit drug use none
Family History:
No premature coronary artery disease
Physical Exam:
Pulse: 55 Resp: 16 O2 sat: 100%
B/P Right: 176/75 Left: 172/65
Height: 66" Weight: 150 lbs
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 [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] +BS [X]
Extremities: Warm [X], well-perfused [X] Edema [-]
Varicosities: mild right
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
Admission labs:
[**2168-9-12**] 12:07PM HGB-13.1* calcHCT-39
[**2168-9-12**] 12:07PM GLUCOSE-89 LACTATE-1.3 NA+-135 K+-4.2 CL--103
[**2168-9-12**] 03:07PM FIBRINOGE-148*
[**2168-9-12**] 03:07PM PLT COUNT-134*
[**2168-9-12**] 03:07PM WBC-13.5*# RBC-2.84*# HGB-8.7*# HCT-25.3*#
MCV-89 MCH-30.7 MCHC-34.4 RDW-12.7
[**2168-9-12**] 04:11PM UREA N-14 CREAT-0.8 SODIUM-138 POTASSIUM-4.8
CHLORIDE-108 TOTAL CO2-26 ANION GAP-9
[**2168-9-15**] 04:59AM BLOOD WBC-16.2* RBC-3.74* Hgb-11.2* Hct-32.6*
MCV-87 MCH-29.9 MCHC-34.3 RDW-12.8 Plt Ct-193
[**2168-9-15**] 04:59AM BLOOD Glucose-137* UreaN-22* Creat-0.9 Na-140
K-3.9 Cl-103 HCO3-27 AnGap-14
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Conclusions
PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular free wall is hypertrophied
with normal free wall contractility. There are simple atheroma
in the ascending aorta. There are complex (>4mm) atheroma in the
aortic arch. The descending thoracic aorta is mildly dilated.
There are complex (>4mm) atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. The left coronary cusp is
immobilized. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is 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.
POST-BYPASS: There is normal biventricular systolic function.
The mitral regurgitation is slightly worse - now mild-moderate.
The thoracic aorta is intact after decannulation.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2168-9-13**]
12:56 PM
Final Report: Bilateral lung volumes are low. Following left
chest tube removal, there is no evidence of pneumothorax. Right
internal jugular line ends at upper SVC. Right lower lung
atelectasis and elevation of the right
hemidiaphragm have improved. Nodular opacity in the left lower
lung near the apex is likely residual edema from the previous
chest tube placement.
Bilateral lower lung atelectasis is unchanged. The patient is
status post
median sternotomy with intact sternotomy sutures. Mediastinal
and hilar
contours are stable.
[**2168-9-16**] 05:58AM BLOOD WBC-10.1 RBC-3.35* Hgb-10.1* Hct-29.3*
MCV-87 MCH-30.1 MCHC-34.4 RDW-12.7 Plt Ct-201
[**2168-9-17**] 06:55AM BLOOD UreaN-23* Creat-1.0 Na-138 K-4.3 Cl-101
Brief Hospital Course:
Mr. [**Known lastname 91626**] [**Last Name (Titles) 91627**] is a 74 year old male who was a direct
admission to the operating room for coronary bypass grafting on
[**9-12**]. Please see the operative report for details, in summary he
had a coronary bypass grafting x2 with left internal mammary
artery to left anterior descending artery and reverse saphenous
vein graft to obtuse marginal artery. His bypass time was 63
minutes with a cross clamp of 36 minutes. He tolerated the
operation well and was transferred from the operating room to
the cardiac surgery ICU in stable condition. He remained
hemodynamically stable in the immediate post-op period,
anesthesia was reversed he woke neurologically intact and was
extubated. All tubes lines and drains were removed per cardiac
surgery protocol. He remained hemodynamically stable and on post
operative day one was transferred from the ICU to the cardiac
surgery step-down floor. Once on the floor he worked with
nursing and physical therapy to increase his strength and
mobility. His antihypertensives were titrated up and additional
medications were added for better blood pressure control. The
remainder of his hospital course was uneventful and on post
operative day five he was discharged home with visiting nurse
services in stable condition. All follow up appointments were
advised.
Medications on Admission:
Medications at home:
Plavix 75mg daily
Hydrochlorothiazide 25mg daily - stopped
Enalapril 20mg daily
Aspirin 325mg daily
Metformin 500mg
Amlodipine 5mg daily
Lipitor 10mg 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. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
8. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*2*
10. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*2*
11. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
s/p CABGx2(LIMA-LAD,SVG-OM)
PMH:
Hypertension, Hyperlipidemia, Diabetes Mellitus, Peripheral
vascular disease s/p left common iliac stent, Right leg
fracture, ?Right hip surgery for foreign body
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] [**2168-10-19**] @1:15P
[**Hospital 409**] Clinic: Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2168-9-27**] @10:45A
Cardiologist: [**Doctor First Name 29069**] Kvaternick on [**10-4**] at 1:15pm
Please call to schedule appointments with your
Vascular: Mark Iafrati
Primary Care Dr.[**Last Name (STitle) 91628**],[**First Name3 (LF) 58427**] [**Telephone/Fax (1) 63099**] in [**3-29**] 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:[**2168-9-17**]
ICD9 Codes: 4111, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2884
} | Medical Text: Admission Date: [**2133-2-18**] Discharge Date: [**2133-3-1**]
Date of Birth: [**2051-11-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Bactrim / Morphine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Recurrent right pneumothorax
Major Surgical or Invasive Procedure:
[**2133-2-20**]: Video-assisted thoracoscopic right apical
blebectomy and mechanical and chemical (1 gram doxycycline)
pleurodesis.
[**2133-2-25**]: Right 4gram talc pleurodiesis.
History of Present Illness:
Mr. [**Known lastname 25501**] is a 81 year-old male with COPD. He presented to [**Hospital 25502**] Hospital, [**Location (un) 8117**] NH on [**2132-2-11**] for increased shortness of
breath. A chest film revealed a right pneumothorax, a chest tube
was placed to suction, on [**2133-2-11**] pleurodesis with 1 gm Doxy was
done, resolution of pneumothorax by chest film, RLL infiltrates
were also seen, sputum culture grew pseudomonas treated with
Zosyn changed to Fortaz. He was discharged on [**2133-2-13**]. He
returned to the ED on [**2-17**] with decreased oxygen saturation and
increased respiratory effort. He was admitted, chest film today
showed recurrent right apical pneumothorax a chest tube was
placed and he transferred to [**Hospital1 18**] for further management.
Past Medical History:
Right Lower lobe lung nodule s/p R VATs wedge for Squamous cell
[**7-/2128**]
Left pneumothorax s/p L VATs blebectomy pleurodesis [**7-/2129**]
Severe chronic obstructive pulmonary disease on home 02 3L
Parkinson's disease
Hypertension
Diverticulosis
Associated lower GI Bleed
Right lower lobe pneumonia
PSH: R VATS wedge resection [**7-/2128**], L VATS
blebectomy/pleurodesis
[**2129**], Bowel perforation [**2100**], right inguinal hernia repair,
right
shoulder dislocation
Social History:
heavy smoking history-quit in 25 yrs ago
married, lives in [**Location 8117**], works in financial services
Family History:
Lung and cardiac disease
Physical Exam:
VS: 67.2 90 111/61 20 91%4L
General: 81 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur/gallop or rub
Resp: decreased breath sounds with bibasilar crackles no wheezes
GI: bowel sounds positive, abdomen soft
non-tender/non-distended.
Extr: warm no edema
Incision: Right VATs site clean dry intact. no erythema or
discharge
Skin: bilateral earlobes 1 cm x 1 cm stage II. Coccyx Stage I
Neuro: awake, alert, oriented, slurred speech
Pertinent Results:
[**2133-2-27**] 07:25AM BLOOD WBC-8.3 RBC-3.31* Hgb-10.4* Hct-30.4*
MCV-92 MCH-31.5 MCHC-34.3 RDW-14.3 Plt Ct-267
[**2133-2-26**] 07:45AM BLOOD WBC-7.4 RBC-3.48* Hgb-11.2* Hct-32.6*
MCV-94 MCH-32.2* MCHC-34.4 RDW-14.1 Plt Ct-299
[**2133-2-18**] 05:13PM BLOOD WBC-10.7 RBC-4.03* Hgb-12.9* Hct-37.3*
MCV-93# MCH-31.9 MCHC-34.5 RDW-14.1 Plt Ct-337
[**2133-2-27**] 03:05PM BLOOD Glucose-107* UreaN-18 Creat-0.7 Na-131*
K-4.0 Cl-95* HCO3-28 AnGap-12
[**2133-2-27**] 07:25AM BLOOD Glucose-103* UreaN-16 Creat-0.6 Na-131*
K-4.0 Cl-95* HCO3-28 AnGap-12
[**2133-2-23**] 01:58AM BLOOD Glucose-109* UreaN-24* Creat-0.6 Na-135
K-3.8 Cl-98 HCO3-31 AnGap-10
[**2133-2-18**] 05:13PM BLOOD Glucose-110* UreaN-25* Creat-0.7 Na-132*
K-4.7 Cl-94* HCO3-33* AnGap-10
[**2133-2-27**] 03:05PM BLOOD Mg-2.1
CXR:
[**2133-2-27**]: There is a minimal right basal air collection in the
pleural
space. No clear apical pneumothorax is identified. Unchanged
opacities at
the left lung base and the entire right lung, but both lungs
show signs of
improved aeration. No newly occurred parenchymal opacities.
Normal size of
the cardiac silhouette.
[**2133-2-26**]: Unchanged appearance of parenchymal opacity at the
bases of the right upper lobe and the atelectasis at both lung
bases. Minimal right pleural effusion cannot be excluded.
Unchanged size of the cardiac
silhouette. No interval appearance of new parenchymal opacities.
[**2133-2-25**]: 1. Very small right-sided hydropneumothorax with chest
tube in unchanged position.
2. Heterogeneous opacification of the right lung with focal
opacity in the right upper lobe. It is difficult to entirely
exclude pneumonia but the
appearance could be seen with post-operative changes including
atelectasis.
3. Severe emphysema.
[**2133-2-19**]: FINDINGS: Very small right apical pneumothorax is
present with a basilar right chest tube in place. Postoperative
changes are present within the right mid lung with surgical
chain sutures. Upper lobe bullous emphysema is present as well
as a mid and lower lung predominant interstitial process,
possibly representing acute interstitial edema superimposed on
underlying emphysema.
Chest CT:
[**2133-2-26**]: No pulmonary embolus seen. Extensive distortion of the
pulmonary
architecture consistent with the patient's known emphysema.
Areas of
consolidation along suture lines within the dependent lungs are
likely
atelectasis secondary to recent surgery.
[**2133-2-18**]: 1. Right-sided chest tube with minimal anterior
right-sided pneumothorax.
2. Right middle lobe solid, ground-glass nodules, new since the
prior
examination. Given the patient's underlying severe diffuse
emphysematous
disease, these nodules warrant followup in three months.
3. Severe atherosclerotic disease of the aorta, and coronary
vessels.
4. Gallstones. Ventral mesh, intact.
Brief Hospital Course:
Mr. [**Known lastname 25501**] was admitted for right recurrent apical pneumothorax
on [**2133-2-18**]. He was taken to the operating room by Dr.
[**Last Name (STitle) **] on [**2133-2-20**] for a right Video-assisted thoracoscopic
right apical blebectomy and mechanical and chemical (1 gram
doxycycline) pleurodesis. He was extubated in the operating
room and transferred to the PACU. While in the PACU he
desaturated to the mid 80's his PCO2 was 77%. He transferred to
the intensive care unit for observation. He was slightly
confused, with two chest tubes to wall suction for over 48
hours. The patient was transferred to the floor on [**2133-2-23**].
Below is a systems review of his hospital course.
Neuro: The patient's Parkinson's medications were continued. His
PCP and geriatrics followed him while in house. He developed
delirium in the ICU. Geriatrics was consulted followed him
throughout his hospital course and recommended, continue his
home dose of Ativan 0.5 [**Hospital1 **] and Seroquel 12.5 for acute
agitation. No Haldol since would make his Parkinson worse.
Ultram and acetaminophen, Lidoderm patch for pain. No morphine
secondary to confusion with this narcotics. His delirium
improved.
Pulmonary: Pulmonary toilet with incentive spirometry,
nebulizers, and mucolytics were continued. The patient had a
good productive yellow cough. The patient's oxygen saturations
were kept in the low 90's initially with shovel mask transition
ed to 4 L Nasal cannula. On [**2133-2-26**] his saturations decreased
a Chest CT was negative for Pulmonary Embolism.
Chest-tubes: On POD 3, the anterior chest tube was discontinued
with posterior chest tube kept to water seal. CXR was stable,
however small leak persisted. gram right talc pleurodesis and
chest tubes to wall suction for 48 hours. The chest tube was
clamped on [**2133-2-27**] follow-up chest film showed no pneumothorax.
The chest tube was removed.
Serial chest films: see above report.
CV: He was found to tachycardic in the ICU and low-dose
beta-blocker was started. He converted to PO with HR 70-90's.
Once stabilized the beta-blocker was titrated off given his
history of severe COPD. His home dose of felodipine of 5 mg was
continue on admission but decreased to 2.5 mg to allow BP
greater than 110 for cerebral perfusion.
Abd: Stool softeners were given throughout his stay. The
patients diet was advanced and tolerated, however he had poor
appetite. Ensure supplemental shakes were continued. The patient
had adequate bowel movements.
GU/renal: Foley was removed following surgery. Initially he had
low urine output responded to fluid bolus. Hyponatremia with
Na+ 131. monitored closely.
ID: no fevers or leukocytosis.
Heme: HCT stable 30-33.
Prophylaxis: SCD's and SQ heparin were instituted for VTE
prophylaxis.
Disposition: he was followed by physical therapy who recommended
rehab. He was discharged to [**Hospital 11729**] Hospital Rehab in [**Location (un) 8117**]
NH on [**2133-3-1**]. He will follow-up with Dr. [**Last Name (STitle) **] as an
outpatient.
Medications on Admission:
Symbicort 160/4.5 2 puffs twice daily
Guaifenesin 600 mg [**Hospital1 **]
Carbidopa/levodopa 25-250 twice daily
Omeprazole 40 mg daily
Tiotropium bromide 1 capsule daily
Felodipine 5 mg daily
Naprosyn 500 twice daily
Acetylcysteine & albuterol nebs QID
PRN: Senna, Ativan 0.5 Q6, MSO4 0.5 SL Q4, [**2-27**] IV Q4, bisacodyl
10
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) SQ
Injection TID (3 times a day).
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO BID (2 times a
day) as needed for SOB.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
6. carbidopa-levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous Q6H (every 6 hours) as needed for wheezing: mix
with albuterol to prevent bronchospasm.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q4H (every 4 hours) as
needed for wheezing/SOB.
11. felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO DAILY (Daily): increase to
5 mg as BP tolerates.
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
13. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
15. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: Right shoulder.
Discharge Disposition:
Extended Care
Facility:
St. [**Hospital **] Hospital Rehabilitation Unit
Discharge Diagnosis:
Right apical recurrent pneumothorax s/p right apical blebectomy
with pleurodiesis.
Right Lower lobe lung nodule s/p R VATs wedge for Squamous cell
[**7-/2128**]
Left pneumothorax s/p L VATs blebectomy pleurodesis [**7-/2129**]
Severe chronic obstructive pulmonary disease on home 02 3L
Parkinson's disease
Hypertension
Diverticulosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office at [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101.5, chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
-Chest tube site remove dressing Saturday and cover with a
bandaid until healed.
-Should site drain cover with a clean dry dressing and change as
needed
-Shower daily. Wash incision with mild soap, rinse, pat dry
-Oxygen titrate to maintain saturations 88-90%
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2133-3-17**] 2:00 [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **].
Chest X-ray [**Location (un) **] radiology 30 minutes prior to your
appointment.
Completed by:[**2133-3-1**]
ICD9 Codes: 2761, 2762, 2930, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2885
} | Medical Text: Admission Date: [**2103-8-23**] Discharge Date: [**2103-9-4**]
Date of Birth: [**2055-8-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2103-8-28**]:
Mitral valve replacement, [**Street Address(2) 7163**]. [**Hospital 923**] Medical mechanical
valve.
Tricuspid valve repair with a 28 mm [**Company 1543**] Contour
annuloplasty ring.
History of Present Illness:
47 year old Spanish speaking male who was admitted to an OSH on
[**2103-7-17**] with progressive dyspnea on exertion and lower extremity
edema. Clinically and
radiographically he was treated for congestive heart failure
with
diuresis and BIPAP and admitted to the OSH ICU. He denies chest
pain, palpitations or dizziness. Cardiac echo was performed
which revealed severe Mitral Stenosis. He was transferred to
[**Hospital1 18**] for evaluation of surgical correction.
Past Medical History:
Rheumatic fever
Social History:
Last Dental Exam:UPPER DENTAL IMPLANTS-LAST SAW DENTIST 2 YO
Lives with:MOM,BROTHER
Contact: Phone #
Occupation:unemployed
Cigarettes: Smoked no [] yes [x] last cigarette -1 month ago Hx:
Other Tobacco use:
ETOH: < 1 drink/week [] [**12-25**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
noncontributory
Physical Exam:
Physical Exam
Pulse: 90 Resp:18 O2 sat:
B/P Right: Left: 100% RA
Height:5'7" Weight:66.7 KG
General:A&Ox3, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade _SEM 4/6_____
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: Left:
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right: Left:
Carotid Bruit -none Right:2+ Left:2+
Pertinent Results:
[**2103-9-4**] 05:30AM BLOOD WBC-7.7 RBC-3.76* Hgb-9.4* Hct-28.8*
MCV-77* MCH-25.0* MCHC-32.6 RDW-19.2* Plt Ct-362
[**2103-9-2**] 04:55AM BLOOD WBC-10.2 RBC-4.11* Hgb-10.1* Hct-31.0*
MCV-76* MCH-24.6* MCHC-32.6 RDW-19.2* Plt Ct-277
[**2103-9-1**] 10:12AM BLOOD WBC-10.7 RBC-4.24* Hgb-10.4* Hct-32.2*
MCV-76* MCH-24.4* MCHC-32.2 RDW-18.7* Plt Ct-216
[**2103-9-4**] 05:30AM BLOOD PT-37.4* PTT-33.7 INR(PT)-3.8*
[**2103-9-3**] 10:00PM BLOOD PT-37.4* PTT-49.9* INR(PT)-3.8*
[**2103-9-3**] 01:00PM BLOOD PT-34.5* PTT-39.0* INR(PT)-3.4*
[**2103-9-3**] 04:55AM BLOOD PT-31.6* PTT-31.6 INR(PT)-3.1*
[**2103-9-2**] 02:44PM BLOOD PT-27.5* PTT-54.8* INR(PT)-2.6*
[**2103-9-2**] 04:55AM BLOOD PT-24.9* PTT-58.8* INR(PT)-2.4*
[**2103-9-1**] 10:12AM BLOOD PT-18.2* PTT-31.2 INR(PT)-1.6*
[**2103-8-31**] 04:28AM BLOOD PT-15.9* PTT-29.6 INR(PT)-1.4*
[**2103-9-4**] 05:30AM BLOOD Glucose-82 UreaN-14 Creat-1.0 Na-133
K-4.6 Cl-95* HCO3-28 AnGap-15
[**2103-9-3**] 04:55AM BLOOD UreaN-16 Creat-1.0 Na-134 K-4.0 Cl-96
[**2103-9-2**] 04:55AM BLOOD Glucose-131* UreaN-15 Creat-0.9 Na-135
K-4.0 Cl-97 HCO3-27 AnGap-15
[**2103-9-1**] 10:12AM BLOOD Glucose-147* UreaN-14 Creat-0.9 Na-134
K-4.1 Cl-96 HCO3-28 AnGap-1410/07/11 10:00AM BLOOD WBC-3.4*
RBC-4.87 Hgb-10.9* Hct-35.9* MCV-74* MCH-22.3* MCHC-30.2*
RDW-17.7* Plt Ct-287
[**2103-8-24**] 10:00AM BLOOD PT-18.0* INR(PT)-1.6*
[**2103-8-24**] 10:00AM BLOOD Glucose-118* UreaN-28* Creat-1.2 Na-130*
K-4.0 Cl-94* HCO3-26 AnGap-14
[**2103-8-23**] 04:52PM BLOOD ALT-20 AST-28 LD(LDH)-378* AlkPhos-105
Amylase-72 TotBili-1.3
[**2103-8-28**] TTE
PRE-BYPASS: The left atrium is dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. Mild
spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No thrombus is seen in the left atrial
appendage. The right atrium is dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque
to 45 cm from the incisors. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve shows characteristic rheumatic deformity. There
is severe valvular mitral stenosis (area <1.0cm2). Severe (4+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. The tricuspid annulus is mildly dilated
(4.1 mm). There is no pericardial effusion.
POST-BYPASS: The patient is A-paced. The patient is on no
inotropes. There is a well-seated, well-functioning mechanical
valve in the mitral position. There is no mitral stenosis. No
mitral regurgitation is seen. No paravalvular leak is seen.
Bileaflet mechanical valve washing jets are present. There is a
tricuspid annuloplasty ring in place. There is trace tricuspid
regurgitation. There is no tricuspid stenosis (mean gradient of
2 mmHg). Aortic regurgitation is unchanged. Biventricular
function is unchanged. The aorta is intact post-decannulation.
Brief Hospital Course:
47 year old Spanish speaking male who was admitted to an OSH on
[**2103-7-17**] with progressive dyspnea on exertion,lower extremity
edema, and was treated for congestive heart failure with
diuresis and BIPAP. Cardiac echo was performed which revealed
severe Mitral Stenosis/ Mitral regurgitation and pulmonary
artery hypertension. Mr.[**Known lastname 77892**] was transferred to [**Hospital1 18**] for
evaluation of surgical correction. [**2103-8-24**] cardiac cath was done
and revealed no coronary disease. He was worked up for surgery
and diuresed for several days. He was taken to the operating
room on [**2103-8-28**] where he underwent mitral valve replacement, [**Street Address(2) 90956**]. [**Hospital 923**] Medical
mechanical valve and tricuspid valve repair with a 28 mm
[**Company 1543**] Contour annuloplasty ring. See operative note for
full details. He was brought out of the OR on multiple
vasoactive medications, including Vasopressin and Milrinone,
with high pulmonary artery pressures initially. He was weaned
from vasoactive medications and extubated on POD #2 without
incidence. He was started on Coumadin for mechanical valve and
Heparin was started on POD#3 until INR>3.5. Pacing wires and
chest tubes were removed per cardiac surgery protocol. He went
into atrial fibrillation post op day 4 and converted to sinus
rhythm on Amiodarone. Coreg and Lisinopril were started for
blood pressure control with low EF and these are to be titrated
by outpatient cardiologist. He was ambulating without
difficulty, tolerating a full oral diet and his incisions were
healing well on POD#7. He was given prescriptions for free care
medications and he is to have his INR checked at [**Hospital 487**]
Hospital with results called into the cardiac surgery office for
Coumadin dosing instructions until follow-up with his
cardiologist on [**9-20**]. His INR at discharge was 3.8. He was
discharged home in stable condition. All follow up appointments
were advised.
Medications on Admission:
None
Discharge Medications:
1. Outpatient [**Name (NI) **] Work
PT/INR as needed for coumadin dosing - results to cardiac
surgery office phone # [**Telephone/Fax (1) 170**]
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take 400 mg [**Hospital1 **] x 1 week then 200 mg [**Hospital1 **] x 2 weeks then
200 mg daily x 1 month then as directed by cardiologist.
Disp:*100 Tablet(s)* Refills:*0*
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Coumadin 2 mg Tablet Sig: 1-2 Tablets PO once a day: Take as
directed for INR goal 3.5 for mech MVR/ Atrial fibrillation.
Disp:*100 Tablet(s)* Refills:*0*
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Severe Mitral Stenosis/MR/severe PA HTN.
Rheumatic fever
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg 1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**10-3**] at 1:30pm
Wound check - [**9-11**] at 10:45am [**Hospital Unit Name **] [**Last Name (NamePattern1) **]
[**Hospital Unit Name **]
Cardiology - [**Doctor Last Name 4922**], [**Name8 (MD) **] MD [**First Name (Titles) 16337**] [**9-20**] at 3 pm
**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 Mech MVR/ A fib
Goal INR 3.5
First draw [**2103-9-5**] at [**Hospital 487**] Hospital
Results to phone cardiac surgery office until follow up with
cardiologist # [**Telephone/Fax (1) 170**]
Completed by:[**2103-9-4**]
ICD9 Codes: 2851, 9971, 4168, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2886
} | Medical Text: Admission Date: [**2167-11-18**] Discharge Date: [**2167-11-23**]
Date of Birth: [**2094-9-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Erythromycin
Base
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Palpitations/dizziness/Dyspnea on exertion
Major Surgical or Invasive Procedure:
Replacement of ascending aorta with a Vascutek Dacron 28
mm tube graft using deep hypothermic circulatory arrest.
History of Present Illness:
73 year old female with occassional dizziness and palpitations
which began about 6 weeks ago. She underwent an echocardiogram
which revealed an ascending aortic aneurysm measuring 4.9cm. A
CT
scan was obtained which showed the ascending aorta to measure
5.7cm. Given the above findings, she has been referred for
surgical evalutation.
Past Medical History:
Bilateral renal calculi
Urinary frequency with urge incontinence
Breast cancer x2
Hypertension
Glaucoma
Depression
Subdural bleed bilaterally from trauma. Closed head injury.
Social History:
Lives with: Son in [**Name2 (NI) 87591**]
Occupation: Retired
Tobacco: Denies
ETOH: Rare use
Family History:
Non contributory
Physical Exam:
Pulse: 85 Resp: 18 O2 sat: 98%
B/P Right: 130/82 Left: 114/83
Height: 60" Weight: 144lb
General: WDWN in NAD
Skin: Warm[X] Dry [X] intact [X] No C/C/E
HEENT: NCAT[X] PERRLA [X] EOMI [X] Anicteric sclera, OP benign.
Teeth appear in good repair
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]Bilateral mastectomy scars.
Prominent right clavicle.
Heart: RRR, NlS1-S2, No M/R/G appreciated
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Grossly intact. Mild facial asymmetry
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 None
Pertinent Results:
Admission Labs:
[**2167-11-18**] 09:37AM GLUCOSE-114* LACTATE-2.3* NA+-138 K+-3.5
CL--96*
[**2167-11-18**] 01:11PM GLUCOSE-154* LACTATE-4.1* NA+-133* K+-3.1*
CL--105
[**2167-11-18**] 01:13PM PT-14.5* PTT-28.7 INR(PT)-1.3*
[**2167-11-18**] 01:13PM PLT COUNT-213
[**2167-11-18**] 01:13PM WBC-16.3*# RBC-2.67*# HGB-8.0*# HCT-23.0*#
MCV-86 MCH-29.9 MCHC-34.6 RDW-14.1
[**2167-11-18**] 03:06PM UREA N-14 CREAT-0.7 SODIUM-140 POTASSIUM-3.1*
CHLORIDE-111* TOTAL CO2-22 ANION GAP-10
Discharge Labs:
[**2167-11-23**] 06:00AM BLOOD WBC-7.8 RBC-2.76* Hgb-8.5* Hct-24.2*
MCV-88 MCH-30.7 MCHC-35.0 RDW-14.5 Plt Ct-322
[**2167-11-23**] 06:00AM BLOOD Plt Ct-322
[**2167-11-20**] 01:34AM BLOOD PT-15.3* PTT-27.0 INR(PT)-1.3*
[**2167-11-23**] 06:00AM BLOOD Glucose-94 UreaN-19 Creat-1.0 Na-142
K-3.7 Cl-107 HCO3-26 AnGap-13
Radiology Report CHEST (PA & LAT) Study Date of [**2167-11-21**] 1:30 PM
[**Hospital 93**] MEDICAL CONDITION: 73 year old woman with POD #3 s/p
hemiarch with increased SOB, please evaluate for incresed
pleural effusions.
Final Report: In comparison with study of [**11-20**], the patient has
taken a better inspiration. However, there is increased
opacification at the right base with an oblique configuration,
consistent with volume loss in the right lower lung.
Retrocardiac opacification persists, consistent with pleural
fluid and volume loss in the left lower lobe.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Left Ventricle - Stroke Volume: 6 ml/beat
Aorta - Annulus: 1.9 cm <= 3.0 cm
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.1 cm <= 3.0 cm
Aorta - Ascending: *5.2 cm <= 3.4 cm
Aorta - Arch: *3.9 cm <= 3.0 cm
Aorta - Descending Thoracic: *3.7 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 2
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *1.9 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Normal LV cavity size. Normal regional LV systolic
function. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque. Normal aortic diameter at
the sinus level. Moderately dilated ascending aorta
AORTIC VALVE: Normal aortic valve leaflets (3). Mild to moderate
([**12-20**]+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Left ventricular wall thicknesses and cavity size are normal.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 45 cm from the
incisors. The ascending aorta is moderately dilated,with
preserved aortic root diameters.The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. Mild to
moderate ([**12-20**]+) aortic regurgitation is seen.The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.There is a PFO Visualized by 2D
and CFD.
Post Bypass
Patient is now s/p Ascending aortic replacement with a Dacron
Graft
The proximal end of the Dacron graft is visualized just distal
to the Sinotubular junction with the distal end proximal to the
innominate
Currently on a Neosynephrine drip at 1.6 mcg/kg/min
The LV function is preserved with an EF of >55%
There is persistent [**12-20**]+ Central Aortic regurgitation.
There are no dissection flaps visualized in the ascending aorta
.
All finding Pre and Post Bypass communicated to Dr [**Last Name (STitle) 914**]
Electronically signed by [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2167-11-19**] 11:18
Brief Hospital Course:
The patient was brought to the operating room on [**2167-11-18**] where
the patient underwent replacement of the ascending aorta with a
Vascutek Dacron 28mm tube graft using deep hypothermic
circulatory arrest. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes were discontinued on post-operative day number one
without complication and the epicardial pacing wires were
discontinued on post-operative day number 3 without
complications. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD five the patient was ambulating with [**Year (4 digits) **],
the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home with visiting
nursed in good condition with appropriate follow up
instructions.
Medications on Admission:
ANASTROZOLE [ARIMIDEX] - (Prescribed by Other Provider) - 1 mg
Tablet - 1 Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth once a day
POTASSIUM CITRATE - (Prescribed by Other Provider) - 10 mEq
(1,080 mg) Tablet Sustained Release - 1 Tablet(s) by mouth four
times a day
SERTRALINE [ZOLOFT] - (Prescribed by Other Provider) - 100 mg
Tablet - 1 Tablet(s) by mouth once a day
TIMOLOL - (Prescribed by Other Provider) - Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (Prescribed by
Other Provider) - 400 unit Capsule - 1 Capsule(s) by mouth once
a
day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
5. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
8. anastrozole 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Ascending aortic aneurysm extending into the aortic arch s/p
replacement
Bilateral renal calculi
Urinary frequency with urge incontinence
Breast cancer
Hypertension
Glaucoma
Depression
Subdural bleed bilaterally from trauma. Closed head injury.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 83786**] pain managed with tylenol
[**Last Name (NamePattern1) 83786**] Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] :[**2167-12-8**] @
1:30
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 10381**] in [**3-23**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] in 4 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:[**2167-11-23**]
ICD9 Codes: 5185, 2851, 4241, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2887
} | Medical Text: Admission Date: [**2133-10-28**] Discharge Date: [**2133-11-9**]
Service: MEDICINE
Allergies:
Hydrochlorothiazide
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Coronary catheterization
History of Present Illness:
89 yo F with no prior h/o known CAD who presents with inferior
STEMI.
.
Per home aid pt was sitting at home with friend when the friend
noted a change in her demeaner, when home aid came to se her she
was unresponsive and her eyes were rolling back and so pt's son
was called. After hanging up she noted pt to be diaphoretic and
nauseous. Since she seemed to improve somewhat after a few
minutes without an intervention the family decided to wait
initially but then shortly thereafter pt was holding her chest
and said "call an ambulance".
.
Per EMS, when they arrived, EKG tracings were significant for an
inferior STEMI and a code STEMI was activated. She was
reportedly hypotensive with SBPs in the 60s while in route to
the ED. Initial vitals in the ED were BP 129/80, HR 88, and O2
sat 100% NRB. An EKG confirmed an inferoposterior STEMI. She was
given ASA 325 mg po X 1, metoprolol 2.5 mg IV X 1, plavix 600 mg
po X 1, and started on heparin and integrillin gtts. A total of
1.5 L of IVFs were given prior to arrival to the cath lab. In
the cath lab, the pt was started on a dopamine gtt at 5
mcg/kg/min for hypotension. A cardiac cath was significant for 3
vessel disease with total occlusion and thrombus in the prox
RCA, total occlusion of the mid LCx, 80% prox and diffuse mid
70% of the LAD, and 40% prox occlusion of the LMCA. A CI was
depressed at 1.77 with mixed venous oxygen saturation of 51%. A
IABP was unable to be placed [**1-16**] tight R iliac lesion. She was
then transferred to the CCU for further care with a Swan-Ganz
catheter in place and off integrillin and heparin gtts.
.
When seen in the CCU, she denied any chest pain, or shortness of
breath. Her only complaint was that she was cold.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
# Arthritis, knees
# s/p kidney removal as child
# Anxiety/Depression
# s/p cataract surgery
- R eye 2 weeks ago, L eye several years ago
# Dementia
# GERD
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
(on admission)
VS: T 95.0 , BP 117/72, HR 97, RR 19, O2 93% on 11L NRB
Gen: Elderly female in NAD, appearing anxious. Oriented x3.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP 7
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: Resp were unlabored, no accessory muscle use. Mild
crackles at bases L>R. No wheezes, rhonchi.
Abd: soft, NTND, No HSM or tenderness.
Ext: No c/c/e.
Skin: feet cold
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
CARDIAC CATH performed on [**10-28**] demonstrated:
1. Selective coronary angiography of this right dominant system
revealed severe three vessel coronary artery disease. The LMCA
had diffuse disease with a 40% proximal lesion. The LAD was
also diffusely diseased with an 80% proximal lesion and a
diffuse 70% lesion. The LCX was totally occluded at the mid
vessel. The RCA was totally occluded proximally with an acute
thrombus.
2. Resting hemodynamics revealed elevated left and right sided
filling pressures with RVEDP of 19 mm Hg and PCWP mean of 25 mm
Hg. Cardiac index was depressed at 1.8 l/min/m2.
3. Distal aortagram revealed diffuse aortoiliac disease.
.
TTE ([**10-29**]): The left atrium is mildly dilated (4.5x5.6)
moderate regional left ventricular systolic dysfunction with
akinesis of the inferior and inferolateral walls.
The remaining segments contract normally (LVEF = 30-35%).
focal hypokinesis of the apical two thirds of the right
ventricular free wall
mild AR and AS
Moderate (2+) mitral regurgitation is seen.
.
Renal U/S and duplex ([**11-4**]):
The patient is status post left nephrectomy. The right
kidney measures 9.2 cm. The renal cortex is markedly echogenic
consistent
with medical renal disease. A 1.3 cm simple cyst is seen within
the mid pole of the right kidney. There are no stones or
hydronephrosis. The renal artery and vein are patent, although
detailed assessment is limited. There are small bilateral
pleural effusions.
IMPRESSION:
1. Echogenic renal parenchyma consistent with medical renal
disease. Simple right renal cyst.
.
CXR (AP, [**10-28**]):There is moderate cardiomegaly. The aorta is
elongated. Swan-Ganz catheter tip is in the right main
pulmonary artery. There is moderate interstitial pulmonary
edema with no pneumothorax or sizable pleural effusions.
.
CXR ([**11-3**]): Substantial enlargement of the cardiac silhouette
with bilateral pleural effusions and some indistinctness of
pulmonary vessels consistent with elevated pulmonary venous
pressure. No evidence of acute pneumonia. Some prominence in
the azygos region raises the possibility of right-heart failure
.
------------- LABS -------------------
[**2133-10-28**] 08:46PM TYPE-MIX RATES-/28 PO2-30* PCO2-40 PH-7.30*
TOTAL CO2-20* BASE XS--6 INTUBATED-NOT INTUBA
[**2133-10-28**] 08:46PM LACTATE-1.5
[**2133-10-28**] 06:39PM TYPE-ART PO2-123* PCO2-34* PH-7.30* TOTAL
CO2-17* BASE XS--8
[**2133-10-28**] 06:39PM O2 SAT-97
[**2133-10-28**] 06:20PM GLUCOSE-190* UREA N-29* CREAT-1.5* SODIUM-134
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-16* ANION GAP-17
[**2133-10-28**] 06:20PM CK(CPK)-284*
[**2133-10-28**] 06:20PM CK-MB-50* MB INDX-17.6* cTropnT-0.90*
[**2133-10-28**] 03:15PM CK-MB-NotDone cTropnT-0.41*
[**2133-10-28**] 03:05PM CK(CPK)-82
[**2133-10-28**] 03:05PM CK-MB-NotDone
[**2133-10-28**] 03:05PM cTropnT-0.43*
[**2133-10-28**] 06:20PM CALCIUM-8.5 PHOSPHATE-4.0 MAGNESIUM-2.2
[**2133-10-28**] 06:20PM WBC-16.2*# RBC-3.69* HGB-11.5* HCT-35.0*
MCV-95 MCH-31.1 MCHC-32.8 RDW-14.2
[**2133-10-28**] 06:20PM PT-14.5* PTT-76.7* INR(PT)-1.3*
[**2133-10-28**] 03:15PM GLUCOSE-138* UREA N-30* CREAT-1.5* SODIUM-140
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-16* ANION GAP-20
[**2133-10-28**] 03:15PM ALT(SGPT)-11 AST(SGOT)-19 CK(CPK)-71 ALK
PHOS-92 AMYLASE-90 TOT BILI-0.3
[**2133-10-28**] 03:15PM ALBUMIN-3.6 CHOLEST-225*
[**2133-10-28**] 03:15PM %HbA1c-5.7
[**2133-10-28**] 03:15PM TRIGLYCER-101 HDL CHOL-85 CHOL/HDL-2.6
LDL(CALC)-120
[**2133-10-28**] 03:15PM WBC-9.2 RBC-3.67* HGB-11.3* HCT-34.5* MCV-94
MCH-30.8 MCHC-32.7 RDW-14.0
[**2133-10-28**] 03:15PM NEUTS-80.7* LYMPHS-15.7* MONOS-2.7 EOS-0.9
BASOS-0
[**2133-10-28**] 03:15PM PLT COUNT-243
[**2133-10-28**] 03:15PM PT-14.8* INR(PT)-1.3*
[**2133-10-28**] 03:05PM UREA N-30* CREAT-1.6*
Brief Hospital Course:
As mentioned above, when the pt was seen in the ED at [**Hospital1 18**] EKG
confirmed an inferoposterior STEMI. She was given ASA 325 mg po
X 1, metoprolol 2.5 mg IV X 1, plavix 600 mg po X 1, and started
on heparin and integrillin gtts. A total of 1.5 L of IVFs were
given prior to arrival to the cath lab. In the cath lab, the pt
was started on a dopamine gtt at 5 mcg/kg/min for hypotension. A
cardiac cath was significant for 3 vessel disease with total
occlusion and thrombus in the prox RCA, total occlusion of the
mid LCx, 80% prox and diffuse mid 70% of the LAD, and 40% prox
occlusion of the LMCA. A CI was depressed at 1.77 with mixed
venous oxygen saturation of 51%. A IABP was unable to be placed
[**1-16**] tight R iliac lesion. She was then transferred to the CCU
for further care with a Swan-Ganz catheter in place and off
integrillin and heparin gtts. When seen in the CCU, she denied
any chest pain, or shortness of breath. Her only complaint was
that she was cold.
In the CCU and later on the floor the following problems were
[**Name2 (NI) 13744**] ad follows;
Cardiac
Ischemia:
- Cath was significant for severe 3 vessel disease with BMS X 3
to RCA for IMI
- On arrival to CCU, heparin and integrillin gtts were off
- CK peaked 1698, MB 123, MBI 11.5
- ASA, plavix, atorvastatin (80mg) were starteda and continued
- On HOD#2 the pt was weaned off dopamine
- On HOD#3 the Swan-Ganz was discontinued since CI>2 after
starting low dose BB
- An attempt to start on ACE-I was done on HOD#3 but d/c'd on
HOD#5 due to SBPs in 70s and due to increasing creatinine
- HgA1c was tested and returned at 5.7%
- Chol panel: total 225, LDL 120, HDL 85, trig 101
.
Pump:
- Initially with cardiogenic shock s/p STEMI. CI 1.7 with mixed
venous O2 sat 51%.
- Required pressors for hypotension during cath.
- On presentation to CCU, dopamine gtt running at 5 mcg/kg/min.
- RN weaned off dopamine gtt entirely in less than 24hrs with
SBPs holding in 120s, HR 70-80s.
- On HOD#3 the Swan-Ganz was discontinued since CI>2 after
starting low dose BB
- TTE [**10-29**] with LVEF 30-35%, akinesis of inferior and
inferolateral walls, hypokinesis of apical [**1-17**] of RV free wall,
mild AS, 2+ MR, mild PA systolic HTN, trivial pericardial
effusion.
- Although LVEF = 30-35%, it was thought that pt likely will
recover some of this function --> should get an echo 4-6 weeks
out to establish new EF
- continued to have significant pulmonary effusions with
continued oxygen requirment despite low dose lasix in the
setting of a rising creatinine; therefore renal was consulted to
thought ATN from dye load and hypotension at cath; their
recommnedation was IV lasix with goal of 1L per day
-Patient was diuresed with lasix IV and switched to a stable
regimen of Lasix 100mg po daily on which she was sating well and
Creatinine was improving.
.
Rhythm: Pt in and out of a-fib during hospital course.
Reportedly had palpitations at home for past few weeks. Decision
made to not anticoagulate with coumadin given other
co-morbidities and fall risk (family and PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] all
agreed). Metoprolol was titrated up during the hospital stay
and despite this pt kep entering afb with RVR into 130-140s. On
HOD#10, the decision was ade to start amiodarone for rhythm
control- she should continue amiodarone loading at 400mg po bid
for a total of 2 weeks (begun [**11-6**]) and then decreased to 200mg
po bid. In the future she should have LFTs and TFTs checked for
amiodarone toxicity.
.
# Renal Insufficiency:
- Pt with only 1 kidney s/p surgery as child for unknown reasons
(R kidney remaining). Cr here 1.6 on admission prior to cath
which is what the pt's baseline was.
- Received HCO3 drip post cath for total of 1L
- pt had rising creatinine with a peak at 2.9; therefore renal
was consulted to thought ATN from dye load and hypotension at
cath (and the ACEI was stopped). Discharge Cr 2.7.
.
# Pulm
- O2 requirement likely [**1-16**] pulm edema from acute systolic heart
failure after MI and 2+MR; diuresed as above
- intermittent hyperventilation with resp alkalosis likely [**1-16**]
anxiety since pt not hyperventilating when asleep
-100% on room air the morning of discharge.
.
# Neuro/Psych
- dementia and depression/anxiety at baseline; worsening in hosp
likely related to new environment and disrupted sleep/wake cycle
and UTI found on day#3
- cont. strattera, and melatonin qhs, and lower dose benzo
- finished 10 day treatment of UTI with levofloxacin
- pt with increased delerium on terazosin (so was only tired
once)
.
# MSK/Arthritis - cont tylenol. no nsaids
# GI/GERD - cont PPI
# s/p cataract surgery - cont home eye drop meds
# FEN/GI - cardiac healthy diet, replete lytes prn.
# Ppx - bowel regimen, heparin sq
# Dispo - d/c to nursing home
Medications on Admission:
Strattera 20mg qam
Namenda 10mg qam
Lorazepam 0.5mg-1mg qhs
Prilosec 20mg qday
Rozerem (melatonin) 8mg qpm
Tylenol 325-625mg q6hrs prn
Advil 200mg with meals
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Vigamox Ophthalmic
5. Strattera 10 mg Capsule Sig: Two (2) Capsule PO qam ().
6. Rozerem 8 mg Tablet Sig: One (1) Tablet PO q HS ().
7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO qam ().
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed.
9. Amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): Please take 2 tablets twice a day for 12 days,
then one tablet twice a day for 14 days then once daily after
that until directed by a physician to stop taking.
Disp:*60 Tablet(s)* Refills:*2*
10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Lasix 40 mg Tablet Sig: 2.5 Tablets PO once a day.
13. Nevanac 0.1 % Drops, Suspension Sig: One (1) Ophthalmic [**Hospital1 **]
(): OU.
14. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnosis:
ST elevation myocardial infarction
Cardiogenic shock [**1-16**] MI
Acute congestive heart failure
Acute on chronic renal failure s/p kidney removal as child
Paroxysmal atrial fibrillation
Anxiety/Depression
Urinary tract infection
Dementia
s/p cataract surgery
.
Secondary diagnosis:
Arthritis, knees
GERD
Discharge Condition:
stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] with an ST elevation myocardial
infarction.
Please take your previous medications as prescribed including
the following medications:
- please start taking aspirin 325mg daily for secondary
cardiovascular prevention (to prevent another heart attack)
- Please start taking atorvastatin 80mg daily for your heart and
for your cholesterol
- Please start taking Toprol XL 100mg daily for your heart and
blood pressure
- Please start taking clopidogrel (Plavix) 75 mg daily to keep
stents open
- Please start taking amiodarone as directed to prevent your
heart from going into an abnormal rhythm
- Please start taking lasix as directed to prevent fluid from
accumulating in your lungs.
If you develop chest pain, jaw pain, or chest pressure with pain
radiating into arm, or if you for any reason become concerned
about your medical condition please call 911 or present to
nearest ED.
- We also gave you Nitroglycerin tablets to take if you
experience chest pain, please call 911 or your doctor if chest
pain recurs even if it dissapears with nitroglycerine
**DO NOT STOP TAKING THE ASPIRIN OR PLAVIX UNLESS INSTRUCTED TO
DO SO BY YOUR CARDIOLOGIST EVEN IF ANOTHER DOCTOR TELLS YOU TO**
We strongly recommend you stop smoking as discussed
Followup Instructions:
You should follow up with your primary care physician [**Name Initial (PRE) 176**] [**1-18**]
weeks of your discharge from the hospital. You should have your
primary care physician set you up with a cardiologist who you
should try to see within 2 weeks of your discharge. Also have
your primary care physician set you up with a kidney doctor
(nephrologist) to see within 4-6 weeks of your discharge from
the hospital.
ICD9 Codes: 5845, 5990, 4280, 5859, 311, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2888
} | Medical Text: Admission Date: [**2166-2-26**] Discharge Date: [**2166-3-7**]
Date of Birth: [**2114-1-15**] Sex: M
Service: MEDICINE
Allergies:
Pegasys ProClick / Penicillins
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Elective resection of L temporal mass.
Major Surgical or Invasive Procedure:
[**2166-2-26**] Left temporal craniotomy for mass resection.
[**2166-3-3**] Right inguinal lymph node biopsy.
[**2166-3-4**] Bone marrow biopsy.
History of Present Illness:
52 yo Right handed man diagnosed with a left temporal lesion in
[**Month (only) 404**], found on workup of right sided arm and leg numbness,
speech arrest, episodes of disorientation, memory difficulties
and involuntary movements of his righ hand. He was started on
Keppra and the dose has been titrated up by Dr. [**Last Name (STitle) 724**] for control
of these symptoms with good effect. Since the increase in
Keppra to 1000mg [**Hospital1 **] the patient has not experienced any
numbness, tingling, difficulies with speech or episodes of
disorientation. He presents with his wife today for surgical
consultation. He reports Headaches in the form of pressure at
the back of his head.
Past Medical History:
1. Histocytosis X, dx [**2147**] by CT imaging, no biopsy.
2. Diabetes insipidus, dx [**2144**].
3. Hypertension.
4. Seizure.
5. Osteoarthritis.
6. Sleep disorder.
7. Right hip replacement.
8. Chronic hepatitis B.
9. Positive PPD due to BCG vaccination, TB exposure from mother.
Social History:
Married, children, from [**Country 10363**], works as an engineer. His wife
is a psychiatrist.
Family History:
Mother had disseminated TB.
Physical Exam:
ADMISSION EXAM:
AF VSS
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**2-22**] EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-22**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-26**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right [**1-23**]
Left [**1-23**]
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
ADMISSION LABS:
[**2166-2-27**] 01:01AM BLOOD WBC-9.1# RBC-4.04* Hgb-12.8* Hct-35.3*
MCV-87 MCH-31.5 MCHC-36.1* RDW-12.1 Plt Ct-258
[**2166-2-27**] 01:01AM BLOOD PT-11.9 INR(PT)-1.1
[**2166-2-26**] 06:39PM BLOOD Na-126* K-4.0 Cl-96
[**2166-2-27**] 01:01AM BLOOD Glucose-156* UreaN-7 Creat-0.8 Na-125*
K-4.5 Cl-95* HCO3-20* AnGap-15
[**2166-2-27**] 01:01AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.8
.
[**2166-1-17**] CT TORSO: IMPRESSION:
1. Biapical reticular and cystic changes consistent with
patient's known history of histiocytosis X.
2. Subcentimeter subpleural pulmonary nodules for which a follow
up CT chest in 12 months or attention on follow up imaging is
recommended.
2. Bilateral axillary adenopathy which is stable since [**Month (only) **]
[**2160**].
3. Left adrenal adenoma.
4. Multiple enlarged retroperitoneal and pelvic lymph nodes. A
right
external iliac lymph node may be amenable to ultrasound-guided
biopsy if required.
.
[**2166-2-26**] MRI HEAD: IMPRESSION: Surgical planning study
demonstrates increase in size (3cm) in irregular pattern of
enhancement of left temporal and periatrial mass. The mass has
considerably increased in size compared with the MRI [**2166-1-17**].
Given the rapid change in size, an aggressive neoplasm such as
glioma is suspected.
.
[**2166-2-27**] ECHO: IMPRESSION: Normal global and regional
biventricular systolic function.
.
[**2166-3-1**] CTA CHEST: IMPRESSION:
1. Post-contrast images are motion degraded, limiting evaluation
for
pulmonary embolism in segmental and subsegmental branches. No
central
pulmonary embolism identified.
2. Chronic reticular and cystic changes within the upper lungs
in this patient with history of Langerhans' cell histiocytosis.
No new focal consolidation within the lungs.
.
DISCHARGE LABS:
[**2166-3-7**] 12:54AM BLOOD WBC-5.7 RBC-3.68* Hgb-12.1* Hct-33.9*
MCV-92 MCH-32.9* MCHC-35.7* RDW-12.1 Plt Ct-309
[**2166-3-3**] 05:18AM BLOOD PT-11.6 PTT-27.3 INR(PT)-1.1
[**2166-3-7**] 12:54AM BLOOD Glucose-113* UreaN-12 Creat-0.8 Na-127*
K-4.1 Cl-95* HCO3-25 AnGap-11
[**2166-3-7**] 12:54AM BLOOD ALT-51* AST-16 LD(LDH)-162 AlkPhos-45
TotBili-0.7
[**2166-3-1**] 04:00AM BLOOD CK(CPK)-407*
[**2166-3-3**] 05:18AM BLOOD ALT-43* AST-14 LD(LDH)-152 CK(CPK)-248
AlkPhos-51 TotBili-0.8
[**2166-3-1**] 04:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2166-3-7**] 12:54AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.3 UricAcd-2.8*
[**2166-2-28**] 01:08PM BLOOD Osmolal-273*
[**2166-3-5**] 05:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2166-3-5**] 05:00AM BLOOD HIV Ab-NEGATIVE
[**2166-3-5**] 05:00AM BLOOD HCV Ab-NEGATIVE
[**2166-3-6**] 05:21PM BLOOD mthotrx-0.43
[**2166-3-7**] 12:54AM BLOOD mthotrx-0.10
Brief Hospital Course:
52yo man with histiocytosis and diabetes insipidus admitted for
left temporal mass resection, preliminary pathology suspicious
for lymphoma. He was having right ear fullness, headaches,
numbness on the right side, and involuntary RUE movements
(?seizure) x3 months. Seen in Brain [**Hospital 341**] Clinic [**2166-1-17**] and
scheduled for resection [**2166-2-26**]. MRI prior to rescetion showed
increase in size compared to [**Month (only) 404**]. CT torso [**2166-1-17**]
significant for enlarged retroperitoenal and iliac LNs. He was
admitted to the Neurosurgery service for elective bx and
resection of temporal mass. He was transferred to the ICU for
SBP control and q1 neurochecks. He tolerated the procedure
well, but post-operatively he showed marked word finding
difficulty. A head CT showed no hemorrhage or hydrocephalus.
He was given NaCl tabs for hyponatremia. Neuro-oncology was
consulted for further management and he was then transferred to
the Oncology service.
.
# Left temporal lesion: Craniotomy [**2166-2-26**] confirmed high-grade
B-cell lymphoma. High-dose methotrexate delayed for iliac lymph
node biopsy and bone marrow biopsy to exclude systemic lymphoma.
Pelvic LN biopsy done [**2166-3-3**], results pending, but early
review showed abundance of lymphocytes, not appearing aggressive
like CNS lesion. Case discussed at HemePath Conference. Cycle
#1 high-dose methotrexate 6g/m2 (dose reduced for 1st cycle with
plan to increase dose if tolerated) given [**2166-3-5**]. HIV
negative. Continued dexamethasone. Sodium bicarb by IV and PO
to aid excretion of MTX. Followed MTX levels daily starting
24hrs after MTX. Leucovorin (or levoleucovorin) rescue started
24hrs post-chemo. Anti-emetics PRN. He tolerated chemotherapy
very well and the expressive aphasia resolved over days.
- PENDING final pathology of pelvic LN and bone marrow.
- PENDING EBV serologies.
.
# Seizures: Continued levetiracetam 1000 mg [**Hospital1 **].
.
# Anxiety and sleep disorder: Added clonazepam 0.5mg qNOON for
anxiety. Continued clonazepam 1mg QHS for insomnia.
.
# Aphasia: Speech therapy following with services at discharge.
.
# Hyponatremia: Likely SIADH + HCTZ. HCTZ stopped and NaCl tabs
were given in ICU, then stopped. Hyponatremia resolved, so
DDAVP restarted [**2166-3-2**]. Followed serum sodium [**Hospital1 **].
.
# Diabetes insipidus: Controlled on DDAVP. Endocrine consulted.
Restarted DDAVP, initially held due to hyponatremia/SIADH.
Followed sodium levels [**Hospital1 **]. Followed daily urine Na, osm, and
specific gravity.
.
# Chronic hepatitis B: Hepatitis serologies negative. Hep B
viral load negative; lamivudine not given.
.
# Chest pain: Troponin negative, CTA negative. Unclear
etiology. Tender right upper chest wall suggested
musculoskeletal cause, no resolved. Repeat CK normalized.
.
# HTN: Continued lisinopril. HCTZ stopped due to hyponatremia.
.
# FEN: Regular MTX diet (no citrate, vitamin C, or carbonated
beverages).
.
# PPX: Heparin SC, H2 blocker, bowel regimen.
.
# Access: Triple lumen central line from craniotomy d/c'd at
discharge.
.
# Code: Full.
Medications on Admission:
CLONAZEPAM 1 mg PO at bedtime
DESMOPRESSIN [DDAVP] 2 sprays times a day
HYDROCHLOROTHIAZIDE 25 mg PO once a day
LEVETIRACETAM 1,000 mg PO BID
LISINOPRIL 10 mg PO once a day
ASPIRIN 81 mg PO once a day
DIPHENHYDRAMINE-ACETAMINOPHEN [TYLENOL PM]
Discharge Medications:
1. clonazepam 1 mg PO QHS.
2. clonazepam 0.5 mg PO NOON.
Disp:*30 Tablet(s)* Refills:*0*
3. levetiracetam 1000 mg PO BID.
Disp:*120 Tablet(s)* Refills:*2*
4. lisinopril 10 mg PO HS.
5. dexamethasone 4 mg PO Q6H.
Disp:*120 Tablet(s)* Refills:*1*
6. famotidine 20 mg PO Q12H.
Disp:*60 Tablet(s)* Refills:*2*
7. desmopressin 10 mcg/spray Aerosol, Spray Sig: Two (2) Spray
Nasal [**Hospital1 **]: Take at 6:00AM and qHS.
8. desmopressin 10 mcg/spray Aerosol, Spray Sig: One (1) Spray
Nasal NOON.
9. acetaminophen 325-650 mg PO Q6H PRN Pain.
10. oxycodone 5-10 mg PO Q4H Pain.
Disp:*20 Tablet(s)* Refills:*0*
11. docusate sodium 100 mg PO BID.
12. senna 8.6 mg PO BID PRN constipation.
13. leucovorin calcium 5 mg Tablet Sig: 4 Tablets PO Q6H x1
days.
Disp:*16 Tablet(s)* Refills:*0*
14. sodium bicarbonate 1300 mg PO Q6H x1 days.
Disp:*8 Tablet(s)* Refills:*0*
15. prochlorperazine maleate 5-10mg PO Q6H PRN Nausea.
Disp:*20 Tablet(s)* Refills:*3*
16. Outpatient Speech/Swallowing Therapy
Speech therapy for resolving expressive aphasia post-craniotomy.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Left temporal mass.
2. CNS (central nervous system) lymphoma.
3. Pelvic adenopathy (enlarge lymph nodes).
4. Expressive aphasia (difficulty speaking).
5. Cycle #1 high-dose methotrexate chemotherapy.
6. Hyponatremia (low sodium level).
7. SIADH (syndrome of inappropriate anti-diuretic hormone) makes
sodium levels low.
8. Diabetes insipidus - makes sodium levels high.
Discharge Condition:
Activity as tolerated. No lifting greater than 10 pounds.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a craniotomy and resection
of a brain mass in the left temporal region. Pathology showed
this to be an aggressive lymphoma, so you were transferred to
the Oncology service to start chemotherapy. The surgery was
complicated by a severe word finding difficulty, which markedly
improved over several days. Before you were given chemotherapy,
a pelvic lymph node biopsy was done because a CT scan had shown
enlarged lymph nodes in the pelvis and abdomen. A bone marrow
biopsy was also done to complete staging. High-dose
methotrexate chemotherapy was given [**2166-3-5**] and you tolerated
this well, but will need to take an additional day of sodium
bicarbonate and leucovorin to help the kidneys continue
excreting the chemotherapy. You were also followed by
Endocrinology for diabetes insipidus and SIADH (syndrome of
inappropriate antidiuretic hormone) causing high and low sodium
levels. This was treated with DDAVP and careful monitoring of
sodium levels.
.
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound was closed with dissolvable sutures; you can wash
your hair since three days after surgery.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
.
MEDICATION CHANGES:
1. Dexamethasone 4mg every six hours.
2. Sodium bicarbonate 1300mg every six hours for one day.
3. Leucovorin every six hours for one day.
4. STOP HCTZ (hydrochlorothiazide).
Followup Instructions:
RETURN TO 11-[**Hospital Ward Name **], [**Hospital Ward Name **], [**Hospital1 **], ON
WEDNESDAY, [**3-19**] FOR CYCLE #2 HIGH-DOSE METHOTREXATE
CHEMOTHERAPY.
.
PLEASE CALL DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] THIS WEEK TO ARRANGE FOLLOW-UP.
Follow-Up Appointment Instructions
?????? Please return to the office in [**7-1**] days (from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
?????? The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**],
in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call to make an appointment, or require
additional directions.
.
Department: HEMATOLOGY/BMT
When: WEDNESDAY [**2166-3-12**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2166-3-12**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2889
} | Medical Text: Admission Date: [**2142-1-12**] Discharge Date: [**2142-1-24**]
Date of Birth: [**2082-8-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Atorvastatin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Sternal wound drainage and pain with associated fever to 102
Major Surgical or Invasive Procedure:
sternal debridement([**1-17**]) with plate/pec flap closure([**1-19**])
PICC line placement, 4F single lumen [**1-23**]
History of Present Illness:
Pt s/p CABG/MVR/ASD closure on [**2141-12-25**] discharged home [**2142-1-1**].
Returned on [**1-12**] with sternal drainage. She was admitted for
further management.
Past Medical History:
MI [**2138**]
PCI to LAD and LCX [**2138**]
HTN
lipids
obesity
MVA [**2140**]
s/p bilat knee arthroscopy
s/p deviated septum repair
Social History:
Denies tobacco, ETOH, drug use
Family History:
Mother with DM. Denies CAD.
Physical Exam:
Admission:
VS T 98.3 HR 82 BP 120/76 RR 20 O2sat 96%RA
Gen NAD
Neuro A&Ox3, nonfocal exam
CV RRR no murmur. Sternal wound w/purulent drainage and
surrouding erythema
Pulm CTA bilat
Abdm obese, NT/ND/NABS
Ext trace edema, palpable pulses bilat
Discharge
VS T 99.1 HR 86SR BP 117/52 RR 20 O2sat 93%RA
Neuro A&Ox3, nonfocal exam
Pulm CTA-bilat
CV RRR no MRG. Sternal incision CDI. JP drains x3 w/serosang
drainage
Abdm soft, NT/NABS
Ext warm, well perfused 1+ pedal edema bilat
Pertinent Results:
[**2142-1-12**] 07:15PM GLUCOSE-114* UREA N-12 CREAT-0.9 SODIUM-142
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17
[**2142-1-12**] 07:15PM WBC-7.1 RBC-2.81* HGB-8.6* HCT-25.6* MCV-91
MCH-30.7 MCHC-33.7 RDW-13.5
[**2142-1-12**] 07:15PM PLT COUNT-359
[**2142-1-12**] 07:15PM PT-13.2* PTT-31.6 INR(PT)-1.1
[**2142-1-23**] 05:30PM BLOOD WBC-10.9 RBC-3.26* Hgb-9.5* Hct-28.6*
MCV-88 MCH-29.0 MCHC-33.1 RDW-14.5 Plt Ct-402
[**2142-1-23**] 05:30PM BLOOD Plt Ct-402
[**2142-1-21**] 03:31AM BLOOD PT-14.9* PTT-32.1 INR(PT)-1.3*
[**2142-1-23**] 05:30PM BLOOD Glucose-125* UreaN-17 Creat-0.7 Na-135
K-4.2 Cl-98 HCO3-30 AnGap-11
[**2142-1-23**] 05:30PM BLOOD ALT-215* AST-203* LD(LDH)-318*
AlkPhos-150* TotBili-0.5
RADIOLOGY Final Report
CHEST (PA & LAT) [**2142-1-23**] 3:29 PM
CHEST (PA & LAT)
Reason: pleural effusion
[**Hospital 93**] MEDICAL CONDITION:
59 year old man s/p sternal debridement flap closure
REASON FOR THIS EXAMINATION:
pleural effusion
INDICATION: Assess for pleural effusion.
COMPARISON: Comparison is made to study performed one hour
earlier.
FRONTAL AND LATERAL CHEST RADIOGRAPHS.
Multiple plates and screws again seen overlying the mediastinum.
Right-sided PICC seen at least to the level of the distal SVC,
tip not well evaluated on this study. Other linear densities
overlying the chest possibly represent pacing wires. Cardiac and
mediastinal contours appear stable. Right sided atelectasis
again seen. No new focal consolidations seen within the lungs.
No evidence of pleural effusion.
IMPRESSION: No evidence of pleural effusion. Otherwise, little
change from prior.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2142-1-15**] 6:21 PM
CT CHEST W/CONTRAST
Reason: evaluate for fluid collection
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with s/p CABG mv repair with sternal wound
infection
REASON FOR THIS EXAMINATION:
evaluate for fluid collection
CONTRAINDICATIONS for IV CONTRAST: None.
CT CHEST
REASON FOR EXAM: Evaluate for fluid collection. Patient post
CABG with sternal wound infection.
TECHNIQUE: Multidetector CT through the chest following
administration of IV contrast. 5, 1.25-mm collimation images and
coronal reformations were reviewed.
FINDINGS: Retrosternal fluid collection located in the anterior
mediastinum at the level of the superior sternum body / aortic
arc, measures 53 x 39 mm with high density (37 Hounsfield
units). It is probably partially hemorrhagic. It continues
inferiorly with a small precardial collection. There is no
pericardial effusion. Cardiac size is slightly enlarged, patient
is post CABG. Wide dehiscense of the soft tissues anterior to
the sternum extends several cm, 3.5 cm below the xiphoid
process. It is not associated with fluid, though a small
fistulous connection to the prevascular space could be present
but not visible.
The sternum is apposed with no bone destruction to suggest
osteomyelitis.
The airways are patent to segmental level. There are few
subcentimeter paratracheal lymph nodes. The lungs are clear.
Left pleural effusion is small.
The upper abdomen showed no abnormalities.
IMPRESSION:
Upper retrosternal fluid collection probably partially
hemorrhagic, free of definite connection to the wide soft tissue
dehiscence anterior to the sternotomy inferiorly, though a small
sinus tract is not excluded. No evidence of osteopmyelitis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 3901**] [**Name (STitle) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Brief Hospital Course:
Patient was admitted with sternal wound drainage on [**1-12**]. His
wound was opened and packed with normal saline wet to dry
dressing. Plastic surgery and infectious disease consults were
obtained. A CT of chest showed substernal fluid collection and
on [**1-17**] he was taken to the OR for sternal debridement and wire
removal. The chest was left open and Mr. [**Known lastname **] was chemically
paralyzed and sedated for 48 hours. He was then returned to OR
on [**1-19**] for sternal plating and pectoral flap closure by the
plastic surgery serrvice. Please see OR reports for details.
After closure pt returned to cardiac surgery ICU. His sedation
was weaned and he was extubated on POD1. He continued to
progress and was transferred to the step down floors on POD2.
Mr. [**Known lastname **] continued to do well and on [**2142-1-24**] it was decided
the patient was stable and ready for discharge home with
visiting nurses and home infusion service. He will follow-up
with the plastic surgery service, Dr. [**First Name (STitle) **] and his
cardiologist as an outpatient.
Medications on Admission:
Lisinopril 5'
Toprol XL 100'
Plavix 75'
Pravachol 80'
ASA325'
Darvocet-prn
Percocet-prn
Ibuprofen-prn
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. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks: 20mEq [**Hospital1 **] for 1 week then 20mEq QD x 2 weeks.
Disp:*56 Capsule, Sustained Release(s)* Refills:*0*
6. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) grams Intravenous Q24H (every 24 hours) for 2 weeks.
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous Q 8H (Every 8 Hours) for 6 weeks.
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 40mg [**Hospital1 **] x1 week then 40mg QD x2 weeks.
Disp:*60 Tablet(s)* Refills:*2*
14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: start
on [**1-26**].
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
s/p sternal debridement([**1-17**])
s/p plate/pec flap closure([**1-19**])
PMH: s/p CABG/MVR [**12-10**], ^chol, HTN, obesity, OA, bilat knee
arthroscopy,
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. No bathing or swimming
for 1 month. Use sunscreen on incision if exposed to sun.
5)No lifting greater then 10 pounds for 10 weeks.
6)No driving for 1 month.
Followup Instructions:
Plastic Surgery - Dr [**First Name (STitle) **] ([**Telephone/Fax (1) 57665**] please call for follow
up appointment
Dr [**First Name (STitle) **] in [**2-4**] weeks ([**Telephone/Fax (1) 11763**] please call for appointment
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2142-2-16**] 10:30
Labs: weekly Vancomycin trough, CBC with diff, ESR, CRP, Cr, LFT
with results to Dr [**Last Name (STitle) **] ([**Hospital **] clinic) [**Telephone/Fax (1) 432**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2142-1-24**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2890
} | Medical Text: Admission Date: [**2115-8-7**] Discharge Date: [**2115-9-6**]
Date of Birth: [**2037-6-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
resiratory failure
Major Surgical or Invasive Procedure:
--VATS
--chest tube placement
History of Present Illness:
Source: Family, olds notes (pt non-verbal).
.
CC: Dyspnea
.
HPI: Ms. [**Known lastname 108496**] 78 yo F w/ end stage Parkinsons-like syndrome
presenting to the [**Hospital1 18**] ED with SOB/tachypnea. Her daughter
reports that the patient was in her usual state of health until
the day of presentation when according to her regular VNA she
was found in her wheelchair with sob/tachypnea. Her daughter was
called and came and gave her Lasix 20mg with little improvement.
Over the next 2 hours, the daughter describes the patient as
becoming increasingly anxious, which is reportedly similar to
her behaviour when experiencing pain. Pt has limited mobility at
baseline, with Parkinsonian cogwheel rigidity, and is in a
wheelchair. Per her daughter, she is able to respond to verbal
commands/questions, and can focus on the speaker, though in the
ED she was agitated and noncommunicative. Her daughter reports
that she has had a cough x 1day, though nonproductive. She has a
suction machine at home that the family uses occasional, as she
is s/p removal of her bottom teeth in [**12-22**].
.
In the ED, the patient was started on Ceftriaxone and
Azithromycin for pneumonia, and was diuresed with Lasix for
possible CHF. She was also sent for CT head given h/o recent
fall and inability to communicate. While waiting for admission
her BP dropped to 70s/30s and temp rose to 103.5F. She was given
4 liters of normal saline with recovery of her blood pressure to
the high 90's / 40's. The sepsis protocol was initiated but the
family refused placement of a central line.
.
ROS: + for limited mobility, with fall from wheelchair 6 days
ago, hitting head, no residual symptoms per family. She has also
had a right foot ulcer on heel x 3months, increased lethargy in
afternoon post Parkinson meds (by family report, pt sleeps for
up to 6 hours after receiving meds, they were concerned for
overmedication and held her afternoon doses today, she received
them in the ED).
.
Past Medical History:
PMH:
1) Cortico-basal degeneration (treated as Parkinson's) - [**2107**]
2) PE - bilateral, [**2113-6-16**], w/ NSTEMI
3) L hip replacement - [**2112**]
4) HTN - well-controlled on lisinopril
5) Kaposi's sarcome - patient has received 3 rounds of Doxil
chemotx in [**2111**], [**2113**], and [**2114**] (last [**4-21**])
6) Hyperthyroidism
7) h/o Afib - during last hospital admission, currently not
rate-controlled, no other episodes per family
Social History:
Greek. Denies EtOH or tobacco. Patient is non-verbal at baseline
and lives with her son. She has a VNA at home.
Family History:
NC
Physical Exam:
PE: 100.2 105 78/32 20 98%NC
Gen: lying in bed, rigid with arms flexed and legs extended,
anxious, diaphoretic
HEENT: MMM, PERRL
Neck: No LAD
Chest: pt unable to cooperate, anterior exam w/ good air mvmt,
no crackles
CV: RRR, nl S1 S2, III/VI HSM at apex.
Abd: Soft, NT, ND +BS.
Skin: red macular and nodular lesions on hands, feet, forearms.
Ulcer on R heel, without purulent drainage or fluctuance.
Dressing moist
Pertinent Results:
[**2115-8-6**] 04:00PM PT-17.3* PTT-24.4 INR(PT)-2.1
[**2115-8-6**] 04:00PM PLT COUNT-235
[**2115-8-6**] 04:00PM NEUTS-91.7* LYMPHS-5.1* MONOS-2.9 EOS-0.3
BASOS-0
[**2115-8-6**] 04:00PM WBC-16.0* RBC-4.11* HGB-12.3 HCT-36.3 MCV-88
MCH-29.9 MCHC-33.8 RDW-13.3
[**2115-8-6**] 04:00PM CK-MB-2 cTropnT-0.10*
[**2115-8-6**] 04:00PM CK(CPK)-257*
[**2115-8-6**] 04:27PM LACTATE-2.5*
[**2115-8-6**] 07:05PM GLUCOSE-156* UREA N-33* CREAT-1.3* SODIUM-137
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
[**2115-8-6**] 09:00PM URINE RBC-[**4-26**]* WBC-[**4-26**]* BACTERIA-FEW
YEAST-NONE EPI-[**4-26**]
[**2115-8-6**] 09:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2115-8-6**] 11:00PM CK-MB-2 cTropnT-0.10*
[**2115-8-6**] 11:00PM CK(CPK)-169*
[**2115-8-6**] 11:21PM LACTATE-3.1*
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
CT HEAD [**8-6**]: No evidence of intracranial hemorrhage.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
CXR [**8-6**]: No change since [**2115-1-13**]. Elevated left
hemidiaphragm with associated minimal left basilar atelectasis
and a small right pleural effusion/thickening.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
LE U/S [**8-8**]: No evidence of right lower extremity DVT.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
UE U/S [**8-11**]: Patent internal jugular and subclavian veins
bilaterally.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
TTE [**8-13**]: The left atrium is mildly dilated. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. There is moderate/severe mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
CT [**8-24**]: 1. Moderate-sized left pleural effusion, containing
heterogeneous increased signal throughout. Findings suspicious
for hemothorax. This could be related to the chest tube, as
there is increased density fluid surrounding the chest tube tip.
No evidence of abdominal or retroperitoneal hematoma. 2.
Probable left renal cyst
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
RENAL U/S [**8-31**]: Atrophic right kidney. Simple left renal cyst.
No evidence of hydronephrosis
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
CXR [**9-5**]: Moderate sized bilateral pleural effusion with mild
pulmonary edema. More intense opacification in the lower lungs
could be a combination of edema and atelectasis as well as a
fissural and costodiaphragmatic pleural effusion, but pneumonia
cannot be excluded. No central venous line is seen. Tracheostomy
tube is in standard placement. There is no appreciable
pneumothorax, but a small pleural air collection might not be
appreciated, particularly since the patient is supine.
Brief Hospital Course:
MICU Course:
Patient [**Hospital 32805**] transferred to MICU for hypoxia secondary to
aspiration PNA which was treated but still difficult to wean
patient off ventilator. Patient then developed a presumed VAP
and was treated with a 14 day course of Zosyn/vancomycin. After
treatment of PNA patient initially improved on ventilator and
felt that respiratory distress was secondary to pulmonary
congestion. Patient was started on lasix gtt to remove fluid.
Patient was extubated however after extubation patient did not
look good from respiratory standpoint. Chest xray showed left
pleural effusion which was felt could be contributing to
patient'd respiratory distress. Patient underwent thoracentesis
under U/S which drew back 20cc of blood and was aborted. After
thoracentesis patient became very tachypneic and decision made
to re-intubate after only 2 days s/p extubation. Later that day
after thoracentesis patient became hypotensive and was found to
have 10 point Hct drop and increased left lung opacity on CXR.
Thoracic surgery called and chest tube placed which produced
about 1L of serosanginous fluid. Patient required total 9 units
of PRBC and Hct stabalized after 3 days. CT scan showed that
blood was still present in pleural space even with chest tube in
place so patient underwent trial of TPA through chest tube to
break up any clots in pleural space. After 3 rounds of TPA and
repeat CT scan decision made for patient to undergo VATS to
remove any hematomas found in pleural space. During VATS
patient was almost 3 weeks with ventilator support and family
agreed to have tracheostomy and PEG tube placed as it was felt
that patient would most likely need long term rehab to have any
possible change to come off vent. After first chest tube placed
patient started to spike temps and cx data positive for VRE from
pleural fluid and [**11-24**] bld cx bottles. Patient was started on
course of Linezolid. Chest tubes were removed after no further
drainage was present, Hct stable 26-28 and CXR improvement.
Respiratory failure thought to also have a possible CHF
component, thus more aggressive diuresis was initiated. Pt has
been maintained on pressure support setting with attempts to
slowly wean her PS down (25 at discharge), PEEP 5, Vts 350-450,
FiO2 40%. Her coumadin was reinitiated at time of discharge.
Linezolid was day 11 of 14 at time of discharge. She has a
persistent right pleural effusion. She has an elevated left
hemidiaphragm. She has persistent papular lesions on her arms
and legs.
Medications on Admission:
Lasix 60mg qAM
Methimazol 5mg qd
Mirapex 0.5mg [**Hospital1 **]
Sinemet 25/100 1.5 tab PO tid
Lisinopril 5mg PO qd
Warfarin 1mg x 2 days/wk (Wed and Sat), 2mg x 5days/wk
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED): sliding scale.
9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO BID (2 times a day).
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours).
11. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO TID
(3 times a day).
12. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO bid ().
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): x 4 days.
16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,TH,FR).
17. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS (WE,SA).
18. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Furosemide 10 mg/mL Solution Sig: [**12-21**] ml Injection [**Hospital1 **] (2
times a day): base dose on volume status and urine output, goal
is euvolemic.
20. Lorazepam 2 mg/mL Syringe Sig: 0.5-2 ml Injection Q6H (every
6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
Shaunessey-[**Hospital1 656**]
Discharge Diagnosis:
PRIMARY:
--Respiratory failure
--hemothorax
--elevated left hemidiaphragm
--persistent right pleural effusion
--mrsa and VRE pleural infection
SECONDARY:
--Cortico-basal degeneration
--HTN
--Kaposi's sarcoma Doxil chemotx in [**2111**], [**2113**], and [**2114**] (last
[**4-21**])
--Hypothyroidism
--AFIB
Discharge Condition:
intubated
Discharge Instructions:
see page 1
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 1144**] call for an appointment when
extubated and rehabilitated
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
Completed by:[**2115-9-6**]
ICD9 Codes: 0389, 4280, 5849, 2762, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2891
} | Medical Text: Admission Date: [**2196-7-18**] Discharge Date: [**2196-8-21**]
Date of Birth: [**2138-1-19**] Sex: F
Service: OMED
HISTORY OF ILLNESS: This patient is a 58-year-old woman with
a complicated hospitalization originally admitted for
debulking nephrectomy of the right kidney on [**2196-7-18**]. She
was diagnosed with renal cell carcinoma in [**1-/2196**] after
having shortness of breath and anemia refractory to
intravenous iron. MBS was found on bone marrow biopsy. The
patient developed congestive heart failure at that time
through idiopathic dilated cardiomyopathy, and
hepatosplenomegaly was found back on a CT scan that was done
in 02/[**2195**]. During that CT scan a right renal mass was
located. Biopsy revealed renal cell carcinoma. Patient was
also noted to have lung metastases, but a clear report of
this diagnosis is not well elucidated.
POST SURGICAL CARE AFTER HER NEPHRECTOMY ON [**2196-7-18**]:
1. Was complicated by congestive heart failure and a 15
liter fluid overload.
2. A left IJ clot after line placing requiring
anticoagulation and leading to hematoma at nephrectomy site
that required a 10-unit transfusion until stable.
3. A 21-day intubation with multiple failed attempts
secondary to pulmonary edema.
4. Recurrent hypertension urgency after extubation.
5. Profound anxiety that was difficult to control as the
patient is intolerant, having paradoxical reactions to
benzodiazepines.
Patient recently had mental status changes in the Critical
Care Unit and had a head CT through which new brain
metastases were diagnosed.
Patient was admitted to the Oncology Medicine service on
[**2196-8-17**]. Prior to the admission, 29 days prior to this,
patient could ambulate well while walking for 30 minutes
without shortness of breath, dyspnea on exertion, or pain.
She had normal coronary arteries per catheterization at [**Hospital 336**]
Hospital in [**1-/2196**], and she had lost 30 pounds within six
months, and had presented with hypoalbuminemia.
On transfer to the Oncology Medicine service the patient was
on 4 liters of oxygen nasal cannula, had sats in the high 90s
but desaturated frequently overnight, requiring BIPAP, which
she often refused. Her most recent ejection fraction was
documented as 55% improved from the 25% noted three weeks
ago, requiring a CCU stay. She could not ambulate secondary
to weakness, and she spoke softly, if at all, due to vocal
cord dysfunction status post extubation. She tolerated only
honey nectar diet and was on aspiration precautions. She was
also being treated for a urinary tract infection.
VITALS ON ADMISSION TO THE ONCOLOGY MEDICINE SERVICE:
Temperature 96.6, blood pressure 119/58, pulse of 114,
respirations 28, and a 97% saturation on 4 liters of nasal
cannula. She is obese, pale, and has atrophic arms and legs.
She is sitting up, awake, and alert, writing down on paper
that she is frustrated being a mute. Pupils are equal and
reactive to light. Her conjunctivae are anicteric. She has
no appreciable jugular venous distention. Cardiovascular
exam: She has a regular rate and rhythm; normal S1 and S2
and a positive S3 with no murmurs, rubs, or gallops. Radial
and dorsalis pedis pulses are 1+ bilaterally. Respiratory:
She has poor effort and better air movement on the left
versus the right without crackles or wheezes. Abdomen is
obese, soft, mildly distended without tympany or tenderness.
Extremities are pale, dry, and have edema to the knees 2+.
IMPRESSION:
1. The impression was that she was an unfortunate
58-year-old woman with right renal cell carcinoma and
metastases to her lung and newly diagnosed metastases to her
brain status post nephrectomy for 29 days, severely
malnourished, and deconditioned.
2. Her oncologic issues were renal cell carcinoma in which
treatment options were discussed with Dr. [**Last Name (STitle) **]. Neurosurgery
was considering stereotactic surgery for the metastases, and
Radiation Oncology was following the patient through the CCU
stay into the OMED stay.
3. Her CHF was compensated, but she has hypervolemic, but
diuresis was continued with Lasix and well maintained.
Respiratory status: She had clear lungs and a known history
of chronic obstructive pulmonary disease and asthma, and the
hypoxia was thought to be multifactorial. She had large
metastases as well as CHF. She was maintained on BIPAP every
evening and nasal cannula throughout the day.
4. Endocrine: The patient was hypothyroid, and
Levothyroxine was continued. For renal her creatinine was
1.8; at baseline, was 0.8 on admission. She had one kidney
and was expected to have compensation by that point. It was
felt that she was intervascularly dry, and she was given
fluids occasionally in order to mobilize the edema that was
present and perfuse her kidneys better.
5. Per Infectious Diseases she had a urinary tract
infection. She was on Ciprofloxacin.
6. For Hematology she had anemia present since [**94**]/[**2195**]. Her
hematocrit was stable. She was maintained on iron every day
and was given only prophylactic doses of Heparin subq given
her risk of bleeding at her nephrectomy site.
7. For gastrointestinal she had no acute concerns, but she
was covered with a bowel and nausea regimen and Protonix
prophylaxis. She was given tube feeds to improve her
nutrition and was tolerating these well.
8. For deconditioning Physical Therapy and Occupational
Therapy were consulted to improve her status and set up home
services for when she was ready for discharge. All these
plans were discussed with the family as well as with Dr.[**Name (NI) 47540**]
team.
As her diuresis was maintained and she was preparing for
discharge, the patient was continuing to receive tube feeds,
and on the evening of [**2196-8-20**] she was found, by the nurse,
unresponsive in her room. A code was called. Patient was
found to have vomited on her tube feeds. She was
resuscitated and intubated and taken to the [**Hospital Unit Name 153**]. She was
maintained on pressors and mechanical ventilation until her
family arrived, at which time a plan of care was discussed
with them and the medical time. The family felt that it was
best to extubate her and to provide comfort measures. The
patient was pronounced dead at 9:26 a.m. on [**2196-9-10**] with
her family at her side. Dr. [**Last Name (STitle) **] and primary team were made
aware.
[**Name6 (MD) 6337**] [**Name8 (MD) **], M.D. [**MD Number(1) 6342**]
Dictated By:[**Last Name (NamePattern1) 47889**]
MEDQUIST36
D: [**2196-10-26**] 18:08
T: [**2196-10-27**] 20:27
JOB#: [**Job Number 51537**]
ICD9 Codes: 496, 4254, 4280, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2892
} | Medical Text: Admission Date: [**2126-12-7**] Discharge Date: [**2126-12-8**]
Date of Birth: [**2049-5-4**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Quinolones
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
abdominal pain, marroon colored stools
Major Surgical or Invasive Procedure:
ERCP
IR attempt at embolization of bleeding gastroduodenal artery
Intubation
Trauma line insertion
History of Present Illness:
77 yo M with history of coronary artery disease s/p CABG [**2116**],
PCI native left circumflex [**2124**], systolic heart failure, and
multiple sclerosis, presents with melena from [**Hospital3 **]. Of note, patient had a recent admission to [**Hospital1 18**] from
[**2126-9-2**] to [**2126-9-4**] for elective ERCP during which he had
removal of CBD stones as well as a biliary stent placed. That
hospital course was complicated by atrial fibrillation with RVR.
He then presented on [**2126-11-19**] to [**Hospital6 5016**] for
additional ERCP to have his previously placed biliary stent
removed. At time of that procedure, [**Hospital3 **] ERCP team
reported some [**Hospital3 **] from around the stent at the ampulla, which
they cauterized to gain hemostasis. Patient was discharged from
[**Hospital3 **] and reports that he was not feeling like he ws back
to his baseline at any point in [**Month (only) 1096**]. This morning at 0600,
he awoke with severe mid-abdominal pain and then had urgency to
have bowel movement, which was described as "mahagony-colored".
He then proceeded to Holy [**Hospital 81777**] hospital, where he received
one unit of [**Hospital **] and ~1 L IVF. Due to poor respiratory status,
he received furosemide. He was then urgently transferred to
[**Hospital1 18**] for suspected upper GI bleed related to his history of
multiple ERCPs.
.
Of note, patient has had upper respiratory sypmtoms for the last
3 to 4 weeks and presented to his primary care physician several
days prior to coming in for his acute complaint at this
admission. He was prescribed an antibiotic of which he does not
recall the name. Regardless, he never filled the prescription.
He notes his breathing is a bit labored and though denies acute
complaints, later admits that he has had increased cough and
sputum production in last week.
.
Vitals upon presentation to the ED were: T 98, HR 120, BP
100/74, RR 16, O2Sat 100% on NRB. Once arriving at [**Hospital1 18**], ED
obtained NG lavage, which failed to clear of [**Hospital1 **] and noted
large amounts of melena. Additionally, U/A which showed moderate
bacteria and positive nitrite, but was without WBCs. Urine
culture and [**Hospital1 **] cultures are pending. Patient was given
pantoprazole IV as only medical intervention. Patient was
maintained on a non-rebreather throughout his stay in the ED and
sats were 100%. He was noted to be in atrial fibrillation with
RVR and HR was in the 110s to 120s throughout his ED stay with
no intervention performed. GI, hepatology, and ERCP were
consulted. GI attending in ED felt that source of bleed was
likely to be sphincterotomy site as patient had an ERCP in
[**8-/2126**], which was complicated by ulcerative bleed around stent.
Surgery deferred managment decisions to GI and ERCP team.
Patient was then transferred to the [**Hospital Unit Name 153**] prior to signout of the
patient to the admitting medicine ICU team due to need for
emergent ERCP.
.
Patient originally came to [**Hospital Unit Name 153**] and went urgently to ERCP, where
was quickly noted to be exanguinating from duodenum, though
bleeding was too brisk to localize further as several units of
[**Hospital Unit Name **] were reported to be seen in stomach as well as in the
small bowel. ERCP was aborted and trauma line was plaed by
anesthesia in ERCP suite prior to patient being transferred back
to [**Hospital Unit Name 153**] for stabilization. Massive transfusion protocol was
activated and paitent was transfused 5 units PRBC and 2 units
FFP prior to transfer to the [**Hospital Ward Name **] MICU [**Location (un) 2452**] for
stabilization prior to IR attempted angio and embolization.
.
REVIEW OF SYSTEMS:
(+)ve: fatigue, hematochezia, melena, focal weakness
(-)ve: fever, chills, night sweats, loss of appetite, chest
pain, palpitations, rhinorrhea, nasal congestion, cough, sputum
production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, nausea, vomiting, diarrhea, constipation, dysuria,
urinary frequency, urinary urgency, focal numbness, myalgias,
arthralgias
Past Medical History:
1) Multiple sclerosis with left hemiparesis/neurogenic bladder
2) CAD s/p 2 vessel CABG [**2116**], PCI LCX [**2124**]
3) Chronic systolic heart failure (EF 45-50% with mild
hypokinesis of the basal to mid inferior and inferolateral
segments)
4) Atrial fibrillation (complicated by RVR at prior admissions,
not on anticoagulation)
5) 15 x 7 mm spiculated left upper lobe pulmonary nodule ([**2124**])
6) Diabetes mellitus type II
7) COPD, on 2L home 02 at night and while ambulatory in summer,
no current pulmonologist
8) Recurrent pseudomonal urinary tract infections
9) Recurrent aspiration pneumonia ([**12-28**] and [**2-25**])
10) Chronic left ankle fracture c/b non-healing malleolar ulcer
11) MRSA colonization
12) Hypertension
13) Trigeminal neuralgia
14) Benign prostatic hypertrophy
15) GERD
Social History:
Home: Lives with wife and daughter in [**Name (NI) 8072**], NH
Occupation: retired electronics tester.
EtOH: Denies
Drugs: Denies
Tobacco: roughly 120 PPY history (3 PPD x 40 y)
Family History:
Non contributory
Physical Exam:
VS: T 97.5, HR 119, BP 119/62, RR 20, O2Sat 99% NRB
GEN: NAD
HEENT: PERRL, EOMI, oral mucosa dry, NG tube in place, patient
on non-rebreather
NECK: Supple, no [**Doctor First Name **]
PULM: CTAB
CARD: Irregular, nl S1, nl S2, II/VI sys murmur RUSB
ABD: obese, BS+, soft, non-tender, non-distended
EXT: 1+ BLE edema to level of knees
SKIN: No rashes
NEURO: Oriented to self, month, year, location. Can not name
specific day of week. CN II-XII grossly intact. BLE weakness.
PSYCH: Restricted affect appropriate for clinical situation
Pertinent Results:
[**2126-12-7**] 02:25PM [**Month/Day/Year 3143**] WBC-6.6 RBC-3.46* Hgb-9.7* Hct-29.2*
MCV-85# MCH-28.2 MCHC-33.3 RDW-17.2* Plt Ct-245#
[**2126-12-7**] 02:25PM [**Month/Day/Year 3143**] PT-14.4* PTT-24.2 INR(PT)-1.3*
[**2126-12-7**] 02:25PM [**Month/Day/Year 3143**] Glucose-151* UreaN-22* Creat-0.7 Na-139
K-4.1 Cl-100 HCO3-31 AnGap-12
[**2126-12-7**] 02:25PM [**Month/Day/Year 3143**] ALT-47* AST-80* CK(CPK)-11* AlkPhos-554*
TotBili-2.7* DirBili-2.3* IndBili-0.4
[**2126-12-7**] 09:38PM [**Month/Day/Year 3143**] Albumin-2.4* Calcium-7.3* Phos-5.1*#
Mg-1.8
[**2126-12-8**] 01:08AM [**Month/Day/Year 3143**] WBC-10.3 RBC-3.74* Hgb-11.2* Hct-32.1*
MCV-86 MCH-30.0 MCHC-34.9 RDW-15.8* Plt Ct-230
[**2126-12-8**] 01:08AM [**Month/Day/Year 3143**] PT-15.3* PTT-25.8 INR(PT)-1.3*
[**2126-12-8**] 01:08AM [**Month/Day/Year 3143**] Glucose-123* UreaN-26* Creat-0.8 Na-141
K-3.7 Cl-106 HCO3-30 AnGap-9
[**2126-12-8**] 01:08AM [**Month/Day/Year 3143**] ALT-36 AST-54* LD(LDH)-145 AlkPhos-289*
TotBili-9.1*
Brief Hospital Course:
77 yo M with history of coronary artery disease s/p CABG [**2116**],
PCI native left circumflex [**2124**], systolic heart failure, and
multiple sclerosis, presented with melena from [**Hospital3 **]. Found to be having massive upper GI bleed as well as
cholangitis and pneumonia. Suspected source of bleeding was from
recent biliary stenting where he had bled in the past. He
urgently went to ERCP where he was seen to be bleeding near the
duodenal papilla at the site of a prior spincterotomy and bleed.
Sclerosis and ligation were unsuccessful at ERCP. IR was called
and he went to angio. At angio the gastroduodenal artery was
identified as the bleeding source. Embolization was
unsuccessful. Surgery was following throughout. After IR could
not embolize the source of bleeding, surgery was urgently called
to the bedside. Surgery felt the patient was an extremely high
operative risk given his CHF, PNA, Afib, MS, and cholangitis on
top of his GI bleed. His wife was [**Name (NI) 653**] by surgery and she
agreed to defer surgery. The patient was made DNR at that point.
He continued to massively hemorrhage. Again his wife was
[**Name (NI) 653**] and he was made [**Name (NI) 3225**]. He expired shortly thereafter
from exsanguination.
Medications on Admission:
1) Carbamazepine 200 mg PO QID
2) Simvastatin 10 mg PO DAILY
3) Zonisamide 100 mg PO DAILY
4) Albuterol Sulfate 90 mcg 2 puffs Q6H:PRN dyspnea
5) Furosemide 20 mg PO DAILY
6) Tamsulosin 0.4 mg PO HS
7) Fluticasone-Salmeterol 250-50 mcg/Dose 1 inhalation [**Hospital1 **]
8) Metformin 500 mg PO BID
9) Sertraline 50 mg Tablet PO DAILY
10) Hydromorphone 2 mg PO Q4H:PRN pain
11) Carvedilol 3.125 mg PO BID (at 8AM and 10PM)
12) Pantoprazole 40 mg PO Q12H
13) Glyburide 2.5 mg PO DAILY
14) Gabapentin 600 mg PO QID
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
upper GI bleed
Discharge Condition:
death
Discharge Instructions:
death
Followup Instructions:
death
Completed by:[**2126-12-11**]
ICD9 Codes: 5789, 486, 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2893
} | Medical Text: Admission Date: [**2196-4-13**] Discharge Date: [**2196-4-16**]
Date of Birth: [**2124-6-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / clindamycin / Nickel / Sulfa(Sulfonamide
Antibiotics) / mycins
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
"s/p esophageal stent placement with HTN urgency."
Major Surgical or Invasive Procedure:
EGD with esophageal stent placement
History of Present Illness:
71 yo female with history of multiple malignancies (Breast,
Ovarian, Colon) and recent diagnosis of esophageal mass([**3-30**])
who presented to [**Hospital1 18**] for esophageal stent placement.
Patient notes approx one week of dysphagia/odynophagia prior to
evaluation at [**Hospital3 **] where EGD was performed on [**2-24**] and
esophageal stricture was dilated. Symptoms recurred and patient
eventually presented to [**First Name5 (NamePattern1) 46**] [**Last Name (NamePattern1) **] again on [**3-30**] where EGD
revealed poorly diff malignancy involving the stomach/esophagus.
CT chest was performed and revealed likely metastases. PET scan
performed approx one week aggo revealed lung, liver, brain mets.
MRI of brain with left temporal lobe (1.2cm) brain met. Started
on decadron and met with radiation onc. Got one dose of XRT to
brain. She has not started chemotherapy though port is placed
in anticipation.
She was transferred to [**Hospital1 18**] for esophageal stent placement on
[**4-13**]. After stent placement she has continued to have upper
abdominal pain which is acute on chronic but worse since stent
placement. PO intake makes pain worse. She has lost approx 40
lbs since the start of these symptoms.
Patient has been noted to be chronically aspirating and CXR was
performed during admission which identified changes consistent
with chronic aspiration. Patient had low grade temperature on
[**4-14**] and started on levofloxacin. No bowel movement in the last
3 days. Passing gas. KUB with evidence of mild small bowel
distention. Patient has intermittently been hypertensive
requiring IV hydralazine.
Morning of transfer to ICU patient was noted to be tachycardic.
EKG showed atrial fibrillation with lateral ST depressions at
rate of 158. Patient was given metoprolol IV 5mg x4 and
metoprolol 25mg daily with improvement in rates to 120s. Patient
was given full strength aspirin. Troponin was checked and
negative. Blood pressure transiently decreased to systolic of
100s. During this time patient was asymptomatic. Patient was
transfered to the ICU given potential need for diltiazem gtt as
patient unable to tolerate PO currently.
On arrival to the MICU, patient's VS 129/61, 140, 20, 96 2L
(93RA). Tmax 99.9 last 24 hours. Patient notes no chest pain or
shortness of breath, no dizziness. She continues to not some
abdominal discomfort in the center of the belly which has been
present for the last month.
Past Medical History:
-h/o CVA at age 38 yo-[**1-21**] to HTN per patient-no residual
deficits
-HTN
-HLD
-h/o tachycardia
-asthma
-COPD, no on home oxygen
-h/o aspiration pna [**2196-3-13**]
-GERD
-history of congenital kidney dysfunction (congenital solitary
kidney) and renal biopsy
-colon adenocarcinoma s/p resection-[**2145**]
-uterine cancer s/p oopherectomy and fallopian tube removal-[**2146**]
-right breast cancer s/p mastectomy-[**2168**]
-esophageal carcinoma-diagnosed 1 week ago, also s/p port
placement [**2196-4-1**] for anticipated chemotherapy
-h/o anemia
-DJD
-constipation
Social History:
etoh-none
tobacco-quit in [**2186**], 50 PY history
ADL's-independent
Living situation-had lived with sister in [**Name (NI) 3320**] prior to her
admission, was at [**Hospital1 1501**] for 5 days prior to her admission here
Family History:
father-h/o suicide
mother-CHF, DM
[**Name (NI) 110452**]
Physical Exam:
Admission PE
VS
162/76 68 20 100 RA
General: AAOX3, in nad but does retch multiple times during
exam, appears older then stated age
HEENT: OP clear, MM somewhat dry
Endocrine/Lymph: no lad, no obvious thyroid masses
CV: distant HS, RRR, no RMG
Lungs: CTAB, no WRR
Abdomen: TTP in epigastrum and suprapubic area, active BS, no
HSM, no rebound
Extremities: BUE are cool to touch (patient reports this is
chronic), pulses 1+ and equal, no edema
Neuro: CN and MS, strength and sensation wnl
Derm: no obvious rashes
Psyc: mood and affect wnl
Discharge PE:
156/71, 93, 20, 96% on 3Liters
General: AAOX3, NAD
HEENT: OP clear, MM dry
Endocrine/Lymph: no lad, no obvious thyroid masses
CV: RRR, no MRG
Lungs: Rhonchi at bilateral bases
Abdomen: TTP in epigastrum and suprapubic area, active BS, no
HSM, no rebound
Extremities: BUE are cool to touch (patient reports this is
chronic), pulses 1+ and equal, no edema
Neuro: CN and MS, strength and sensation wnl
Derm: no obvious rashes
Psyc: mood and affect wnl
Pertinent Results:
Labs:
CBC:
[**2196-4-13**] 08:45PM BLOOD WBC-11.6* RBC-4.59 Hgb-12.5 Hct-39.7
MCV-86 MCH-27.3 MCHC-31.6 RDW-15.3 Plt Ct-220
[**2196-4-14**] 06:25AM BLOOD WBC-11.2* RBC-4.60 Hgb-12.4 Hct-39.2
MCV-85 MCH-27.1 MCHC-31.7 RDW-14.3 Plt Ct-227
[**2196-4-15**] 06:33AM BLOOD WBC-15.6* RBC-4.30 Hgb-12.0 Hct-36.1
MCV-84 MCH-28.0 MCHC-33.3 RDW-15.3 Plt Ct-259
[**2196-4-16**] 04:21AM BLOOD WBC-11.4* RBC-3.78* Hgb-10.4* Hct-32.0*
MCV-85 MCH-27.4 MCHC-32.4 RDW-15.0 Plt Ct-227
Coags:
[**2196-4-14**] 06:25AM BLOOD PT-12.0 PTT-19.5* INR(PT)-1.1
[**2196-4-15**] 06:33AM BLOOD PT-15.9* PTT-28.6 INR(PT)-1.5*
[**2196-4-13**] 08:45PM BLOOD Glucose-107* UreaN-12 Creat-0.6 Na-136
K-3.0* Cl-102 HCO3-22 AnGap-15
Electrolytes:
[**2196-4-14**] 06:25AM BLOOD Glucose-96 UreaN-10 Creat-0.6 Na-136
K-3.1* Cl-99 HCO3-22 AnGap-18
[**2196-4-14**] 07:30PM BLOOD Glucose-95 UreaN-12 Creat-0.6 Na-138
K-3.8 Cl-102 HCO3-24 AnGap-16
[**2196-4-15**] 06:33AM BLOOD Glucose-93 UreaN-13 Creat-0.6 Na-138
K-3.1* Cl-100 HCO3-21* AnGap-20
[**2196-4-15**] 02:44PM BLOOD Glucose-238* UreaN-16 Creat-0.6 Na-134
K-3.5 Cl-101 HCO3-19* AnGap-18
[**2196-4-16**] 04:21AM BLOOD Glucose-122* UreaN-20 Creat-0.6 Na-140
K-3.2* Cl-108 HCO3-20* AnGap-15
[**2196-4-13**] 08:45PM BLOOD Calcium-8.9 Phos-3.0 Mg-1.6
[**2196-4-14**] 06:25AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.6
[**2196-4-14**] 07:30PM BLOOD Calcium-8.3* Phos-2.7 Mg-1.8
[**2196-4-15**] 06:33AM BLOOD Calcium-8.4 Phos-1.9* Mg-2.1
[**2196-4-15**] 02:44PM BLOOD Albumin-2.8* Calcium-7.6* Phos-1.8*
Mg-2.0
[**2196-4-16**] 04:21AM BLOOD Calcium-7.8* Phos-1.6* Mg-1.9
[**2196-4-15**] 03:20PM BLOOD Lactate-1.2
.
CXR ([**4-14**]):The patient obviously has received an esophageal
stent. The proximal part of the stent projects over the middle
third of the esophagus, the distal part of the stent is at the
gastroesophageal junction. There is no evidence of
pneumomediastinum. Left pectoral Port-A-Cath in situ. Relatively
widespread bilateral parenchymal opacities, left more than
right, presumably being the result of chronic aspiration. No
pulmonary edema. Mild cardiomegaly. No pleural effusions.
KUB ([**4-14**]): IMPRESSION: Mild small bowel dilatation, suggestive
of ileus. No evidence of pneumoperitoneum.
EGD:
--A very narrow malignant appearing stricture was noted in the
distal esophagus about 30 cm. The scope could not traverse the
lesion.
--A 450 JAG wire was passed under fluoroscopic vision through
the stricture into the stomach.
--A 125mm by 23mm WallFlex TM Esophageal fully covered metal
stent (REF: 1674, LOT: [**Numeric Identifier 110453**]) was placed successfully under
fluoroscopic vision.
--Otherwise normal EGD to esophagus
EKG:
[**4-13**]: Sinus 93, NA, borderline PR prolongation, Q wave III,
withou concerning ST-T wave changes
[**4-15**]: Atrial fibrillation 158, St depressions v4-v6
[**4-15**] -6:48: Atrial fibrillation 124, interval resolution of ST
depressions
[**2196-4-15**] 02:44PM BLOOD TSH-2.0
Brief Hospital Course:
71 yo female with history of multiple malignancies (Breast,
Ovarian, Colon) and recent diagnosis of esophageal mass([**3-30**])
who presented to [**Hospital1 18**] for esophageal stent placement. Found to
have aspiration pneumonia and small bowel illeus. Started on
Levofloxacin/Metronidazole. Transferred to ICU on [**2-15**] for
atrial fibrillation with RVR. Patient is now rate controlled and
will be transferred to [**Hospital3 3583**] (Dr. [**Last Name (STitle) 69038**] for continued
oncology care.
#. Atrial Fibrillation with RVR: Patient developed atrial
fibrillation with RVR on [**7-15**]. Despite IV and PO metoprolol
patient was unable to be rate controlled. Patient was briefly
placed on a diltiazem gtt before returning to sinus rhythm. She
was continued on oral diltiazem. She remained in sinus rhythm
for the remaining time in the intensive care unit.
Anticoagulation was not started given brain mets and likelihood
for further procedures in the near future. TSH was within normal
range. Cardiac enzymes were cycled and negative.
#. Metastatic CA, unknown primary: Mass identified in esophagus
creating a stricture. Patient transferred to [**Hospital1 18**] for
esophageal stent which was placed. PET scan with known lung,
liver, brain mets. Patient was continued on decadron during
hospitalization given brain met and associated edema. Patient
will be transferred back to Dr. [**Last Name (STitle) 69038**] at [**Hospital3 3583**] for
ongoing treatment.
#. Aspiration Pneumonia: Patient appears to be chronically
aspirating which is likely secondary to esophageal obstruction.
Recent low grade fever and rise in white blood cell count
concerning for pneumonia. Patient started on
levofloxacin/metronidazole. At [**Hospital3 3583**] patient should
have a speech and swallow evaluation.
#. Small Bowel dilation suggestive of illeus: Currently passing
gas however has not moved bowels in several days. Patient was
continued on clears/sips as tolerated and abdomen was serially
examined. Bowel regimen was continued however at the time of
discharge patient had not yet moved her bowels. Management of
this should be continued at the time of discharge.
#. COPD: Continued advair, albuterol, tiotroprium
#. HLD: Continued simvastatin once tolerating POs
#. HO CVA: Continued Aspirin 81mg
Code Status: DNR/DNI
Transitional Issues:
1. Continued Oncology Care: [**Hospital1 46**] oncologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69038**]
2. Telemetry Monitoring for recurrent atrial fibrillation
3. Complete 10 day course of Levofloxacin/Metronidazole for
aspiration pneumonia
4. Monitoring/Treatment of mild small bowel illeus and
constipation
5. Nutrition assessment and discussion of feeding tube
6. Speech and Swallow evaluation given concern for chronic
aspiration
Dispo: Plan for transfer to [**Hospital3 **] in am for continued
treatment for ileus, start of brain radiation.
Medications on Admission:
List acquired from [**Company **] Pharmacy [**Telephone/Fax (1) 110454**]
advair 250/50
amlodipine 5 QD
carafate 1 g [**Hospital1 **]
simvastatin 80 QHS
meloxicam 15 QD
lisinopril 10 QD
proair prn
spiriva QD
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. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. dexamethasone sodium phosphate 4 mg/mL Solution Sig: Two (2)
Injection twice a day: 2 mg iv bid.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. meloxicam 7.5 mg/5 mL Suspension Sig: Fifteen (15) mg PO QD
().
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Levofloxacin 750 mg IV Q24H
13. Morphine Sulfate 1-8 mg IV Q4H:PRN pain
hold for sedation
14. Ondansetron 8 mg IV Q8H:PRN nausea
15. Promethazine 6.25 mg IV Q6H:PRN nausea
may repeat times one, hold for sedation
16. Pantoprazole 40 mg IV Q24H
17. 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.
18. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
19. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Esophageal Mass with stricture, s/p stent placement
Atrial Fibrillation
Hypertension
Ileus
COPD
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:
Ms. [**Known lastname 13712**],
You were admitted to [**Hospital3 **] Hospital for placement of a
stent in your esophagus to open up the blockage caused by your
cancer. While here, we found that you had an ileus, or that
your gut was not moving and propelling food and contents
forward. This somtimes happens when people take pain
medications. You found to have a aspiration pneumonia and were
started on IV antibiotics. Finally, you were found to have
atrial fibrillation (a fast irregular heart rate) which was
controlled with a new medication called diltiazem. You are being
transferred to [**Hospital3 3583**] for further oncology care.
When you are discharged from [**Hospital3 3583**] you will be
provided with a updated list of medications you should take at
home.
It was a pleasure caring for you.
Followup Instructions:
Follow up will be arranged at the time of discharge from [**Hospital1 3325**].
ICD9 Codes: 4019, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2894
} | Medical Text: Admission Date: [**2185-5-6**] Discharge Date: [**2185-5-25**]
Date of Birth: [**2117-3-14**] Sex: F
Service: MEDICINE
Allergies:
Tylenol/Codeine No.3 / Percocet
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath, lower extremity swelling
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
Ms. [**Known lastname 7072**] is a 68 year old woman with history of CAD (s/p
stent of mid-LAD in [**2177**]) who presents with weeks of gradually
worsening dyspnea on exertion and lower extremity edema to the
thighs. Approximately two weeks ago, she started noticing that
she felt "worse". Her legs started to [**Last Name (LF) **], [**First Name3 (LF) **] she went to see
her PCP (Dr. [**Last Name (STitle) 1789**]. He examined her and felt that she needed
emergent evaluation, so he sent her to the ED. She denies
current chest pain, shortness of breath ("much better"), and
palpitations. She complains of intermittent chest pain with
walking, especially when she takes a deep breath. She has a
non-productive cough which is worse with exercise. She reports
3-pillow orthopnea but denies PND.
In the ED, she was initially satting 80% on room air and was
tachypneic. EKG showed no acute changes. Her first set of
cardiac biomarkers was negative. Her chest x-ray showed severe
pulmonary edema. She was initially placed on a nitro drip, which
was subsequently discontinued to enable furosemide diuresis.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
- Stage II breast cancer. Diagnosed [**2172**] with 5cm infiltrating
ductal carcinoma of left breast, histologic grade III with LVI.
15 positive axillary lymph nodes. ER neg. Treated with radical
mastectomy, post-mastectomy wall XRT, four cycles of AC.
- CAD(s/p PTCA to mLAD)
- Breast CA (s/p R. mastectomy and chemo and XRT c/b ILD)
- Asthma
- Chronic bilateral arm pain/cyanosis
- Hypertension, although not on any heart meds
Social History:
Social history is significant for current tobacco use (1 pack
per week, with > 50 pack-year history). There is no history of
alcohol abuse. She lives alone in [**Location (un) 669**] and works as a hotel
desk coordinator at the [**Location (un) 7073**] [**Last Name (un) 28893**].
Family History:
There is family history of premature coronary artery disease
(brother), but no history of sudden death.
Physical Exam:
VS: Temperature 97.4F, BP 97/65, HR 93, RR 33, O2 100% on 2L NC
Gen: WDWN older female in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP at level of ear at 60 degrees.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. S3 audible. III/VI systolic murmur loudest at
apex.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse crackles
throughout lung fields.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No clubbing or cyanosis. 2+ pitting edema to above the
knees bilaterally.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Chemistries:
[**2185-5-5**] 08:24PM BLOOD Glucose-123* UreaN-23* Creat-0.6 Na-130*
K-4.0 Cl-96 HCO3-27 AnGap-11
[**2185-5-6**] 08:40AM BLOOD ALT-27 AST-52* LD(LDH)-309* CK(CPK)-44
AlkPhos-180* TotBili-1.2
[**2185-5-6**] 08:40AM BLOOD Albumin-2.6* Calcium-8.2* Phos-3.4 Mg-1.6
[**2185-5-5**] 08:24PM BLOOD proBNP-3775*
Hematology:
[**2185-5-5**] 08:24PM BLOOD WBC-5.7# RBC-3.74* Hgb-10.4* Hct-34.3*
MCV-92 MCH-27.9 MCHC-30.4* RDW-14.8 Plt Ct-180#
[**2185-5-5**] 08:24PM BLOOD Neuts-85.5* Lymphs-8.5* Monos-5.4 Eos-0.4
Baso-0.3
[**2185-5-5**] 08:30PM BLOOD PT-15.0* PTT-32.7 INR(PT)-1.3*
Cardiac Enzymes:
[**2185-5-5**] 08:24PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-3775*
EKG demonstrated normal sinus rhythm at 99bpm with Q in II, II,
aVF, TWI in I, aVL, isolated ST elevation in V2, poor R wave
progression (which is new from previous, dated [**2181-10-30**]).
CHEST (PORTABLE AP) [**2185-5-5**] 9:09 PM
There is significant engorgement of the vascular pedicle,
pulmonary vascular indistinctness and interlobular septal lines
consistent with severe pulmonary edema. The cardiac silhouette
remains markedly enlarged. There are bilateral pleural
effusions. The left effusion is loculated over the lung apex. A
markedly tortuous aorta is again noted. The bones are diffusely
osteopenic.
CHEST (PA & LAT) [**2185-5-6**] 2:31 AM
The heart is abnormally enlarged. Persistent pulmonary edema
that has not changed since the last examination along with
persistent small bilateral pleural effusion. The azygos vein is
abnormally distended. The unilateral opacity seen projecting
over the left mid lung region hasn't progressed.
Echocardiogram [**2185-5-6**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-20mmHg. The coronary sinus is dilated (diameter >15mm). There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild to moderate
regional left ventricular systolic dysfunction with hypokinesis
of the anterior, anteroseptal, distal inferior and apical severe
hypokinesis/akinesis. The right ventricular cavity is moderately
dilated with mild global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened. There are filamentous strands
on the aortic leaflets consistent with Lambl's excresences
(normal variant). There is also a focal echodensity associated
with the left coronary cusp, for which the differential
diagnosis includes calcification, healed vegetation, or a valve
tumor. Mild (1+) aortic regurgitation is seen. There is no
aortic stenosis. The mitral valve leaflets are mildly thickened.
Moderate (2+) mitral regurgitation is seen. Severe [4+]
tricuspid regurgitation is seen. There is at least mild
pulmonary artery systolic hypertension (may be underestimated
given severity of tricuspid regurgitation). There is no
pericardial effusion.
Echocardiogram [**2185-5-20**]
Findings
This study was compared to the prior study of [**2185-5-6**].
LEFT ATRIUM: Elongated LA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild
regional LV systolic dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV
free wall hypokinesis. [Intrinsic RV systolic function likely
more depressed given the severity of TR].
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Focal calcifications in aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild to moderate ([**12-15**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Frequent atrial premature beats. Left pleural
effusion.
.
Conclusions:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the distal anterior wall and apex. The remaining segments
contract normally (LVEF = 50 %). Right ventricular chamber size
is moderately increased with mild free wall hypokinesis.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] 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. There is no mitral
valve prolapse. Mild to moderate ([**12-15**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. At
least moderate [2+] tricuspid regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2185-5-6**],
left ventricular systolic function is improved, the severity of
tricuspid regurgitation is reduced and the estimated pulmonary
artery systolic pressure is higher.
.
Transabdominal and Transvaginal Ultrasound [**2185-5-14**]:
FINDINGS: Transabdominal and transvaginal examinations were
performed, the latter to better assess the endometrium.
Uterus is anteverted, measuring 9.9 x 4.7 x 5.3 cm, normal in
appearance. Endometrium is heterogeneously hyperechoic and
thickened measuring up to 11 mm in diameter. There appears to be
some associated vascularity to this thickened endometrium though
this may be technical. There is a tiny focal area of rounded
hypoechogenicity posteriorly, which may represent a small area
of cystic change or focal fluid.
Ascites is seen throughout the abdomen and pelvis, consistent
with known decompensated congestive heart failure. There is no
hydronephrosis. Ovaries are not visualized.
IMPRESSION:
1. Abnormal thickened and heterogeneous endometrium. Correlation
with endometrial biopsy is strongly recommended.
Brief Hospital Course:
Patient is a 68 year old female with history of coronary artery
disease status-post PCI to LAD ([**2177**]) and breast cancer status
post chemo with Adriamycin/Cytoxan ([**2173-6-14**]) who presented with
lower extremity edema and worsening shortness of breath.
#) Acute on Chronic Systolic Heart Failure: The patient
presented with shortness of breath and lower extremity edema.
Her BNP was elevated, and chest x-ray was consistent with
pulmonary edema. Her EKG did not show signs of ischemia. Her
initial cardiac enzymes were negative. She had an
echocardiogram which showed findings consistent with coronary
artery disease including mild to moderate systolic dysfunction,
severe tricuspid regurgitation, mild pulmonary hypertension and
an ejection fraction of 40%. She was treated with aggressive
diuresis with lasix drip and subsuently IV lasix and metolazone
with improvement in her symptoms. She underwent cardiac
catheterization which showed CTO of the mid LAD with
collaterals, as well as elevated filling pressures. Attempts at
diuresis were limited by her hypotension, her SBPs ran 80-100s,
on [**2185-5-12**] her blood pressure dropped to low 70s. She was
symptomatic during this time and received a 250 cc bolus. The
congestive heart failure service consulted, and patient was
transfered to the cardiac intensive care unit for further
diuresis.
It was felt that her valvular pathology was likely secondary to
radiation injury and would not be amenable to surgical
intervention. She was placed on a lasix drip as well as a
dopamine drip to maintain her blood pressure with diuresis. She
continued on this regimen with steady diuresis. She was
eventually transitioned to turosemide and acetazolamide.
Attempts to wean her off of the dopamine drip were unsuccessful
due to hypotension and lethargy. Initially, arrangements were
made to continue the dopamine drip at home. Her volume status
improved, but her energy level and functional status declined
markedly.
As plans for this were being made for home dopamine, however,
the [**Hospital 228**] clinic status continued to deteroirate, and she
became more lethargic and less responsive. Based on the
patient's and family's wishes, and in conjunction with Hospice
services and the palliative care team, arrangements were made
for the patient to be transported home. Upon arrival to her
home, her dopamine infusion was stopped, and hospice nurses were
available to treat her symptoms. Goals of care became focused
on more comfort-oriented measures.
#) Coronary Artery Disease: The patient has a history of one
vessel coronary disease. On catheterization in [**2177**] she had a
totally occluded LAD which was treated with PTCA. On this
admission she denied chest pain. She had negative cardiac
enzymes. Her EKG was not consistent with acute ischemia. As
above, her echocardiogram was concerning for coronary artery
disease and she underwent repeat catheterization which showed
CTO of the mid LAD with collaterals, as well as elevated filling
pressures. She was continued on aspirin 325 mg daily. She was
started on simvastatin 40 mg daily.
#) Hypertension: Patient was not currently on any medications.
On admission her blood pressures were in the 90s systolic. She
tolerated diuresis with some asympotomatic hypotension as
discussed above, and did not show any signs of hypertension
during this admission.
#) Urinary tract infection: Patient completed a course of
treatment for an e. coli urinary tract infection with
ciprofloxacin.
#) Vaginal bleeding: Initially, bleeding was noted that was felt
to be due to foley trauma, but upon further questioning the
patient reported abnormal vaginal bleeding for the previous 2
months. Gynecology was consulted and recommended a pelvic
ultrasound. This was completed and demonstrated a thickened
endometrial stripe, concerning for pathology such as endometrial
cancer. Patient had no further bleeding during her stay.
Arrangements were made for follow up with gynecology for further
work-up and management (even if patient is not a surgical
candidate for any pathology found, symptomatic control of
bleeding could be acheived via Mirena IUD or other treatments).
As her discharge date approached, based on discussions with the
gynecology department, it was felt that given her current state
of health, there would be no interventions planned. If her
health status improved, she may follow up with the gynecology
clinic at [**Telephone/Fax (1) 2664**].
#) Code: Family meetings and goals of care were addressed during
her stay. She was clear regarding her wishes to have a DNR/DNI
code status. Arrangements were made for the patient to return
home with Hospice services given the marked decline in her
health. Focus of care became more oriented towards comfort.
Medications on Admission:
Aspirin 325 mg daily
Celexa 10 mg daily
Levothyroxine 0.25 mg daily
Lorazepam 0.5 mg [**Hospital1 **]
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO q2-4 hr as
needed.
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Hospital Bed
Pt needs hospital bed. Thank you.
4. Morphine Concentrate 20 mg/mL Solution Sig: 5-20mg PO q1hr
as needed for pain.
Disp:*30 ml* Refills:*0*
5. Torsemide 20 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day): may take for shortness of breath.
Disp:*60 Tablet(s)* Refills:*2*
6. Oxygen
Supplemental Oxygen -- titrate to comfort
7. Bedside Commode
Use as needed
8. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours as needed for secretions.
Disp:*4 patches* Refills:*0*
9. Levsin/SL 0.125 mg Tablet, Sublingual Sig: [**12-15**] Sublingual
every four (4) hours as needed for excess secretions.
Disp:*30 tablets* Refills:*2*
10. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a
day.
Disp:*60 packets* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Primary:
Acute on Chronic Systolic Heart Failure
Coronary Artery Disease
Discharge Condition:
Terminally ill.
Discharge Instructions:
You were treated for severe congestive heart failure.
You were treated with diuretics and blood pressure supporting
medications. You underwent cardaic catheterization. You were
transferred to the cardiac intensive care unit for treatment
with medications that help increase your blood pressure.
Your goals of care were addressed and you desired to return
home. Arrangements were made for this to occur.
Many of your medications have been discontinued. We have
prescribed only those that may make you comfortable.
Please contact your hospice nurse, primary care physician, [**Name10 (NameIs) **]
cardiologist if you experience any worsening pain, shortness of
breath, or other concerns.
Followup Instructions:
The hospice service will be caring for you at home.
ICD9 Codes: 5990, 5180, 4280, 4240, 4168, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2895
} | Medical Text: Admission Date: [**2170-9-6**] Discharge Date: [**2170-9-8**]
Date of Birth: [**2117-10-26**] Sex: M
Service: MEDICINE
Allergies:
Integrilin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Here for elective cath of L iliac artery for poss stenting.
Major Surgical or Invasive Procedure:
Catheterization of L iliac from R side.
History of Present Illness:
: Pt is a 52 yo male with history of diabetes, HTN, depression,
anxiety disorder,CAD s/p MI in [**2160**] PTCA [**2161**] to RPL, cypher
stenting RCA [**2168**] (repeat cath in [**7-/2168**] with no flow limiting
disease), and PVD complaining of worsening LLE pain. Reported
that he could only walk [**1-28**] block without severe pain. He was
seen in Dr.[**Name (NI) 5452**] office found to have ABI of 0.5 on the left
with blunted waveforms and was cheduled for LE angiography. On
arrival to the hospital he was found to be hypotensive to the
60s but was asymptomatic. It was decided to proceed with the
procedure and he was given 5 liters of NS during the procedure
with BPs in high 70's to 90's but asymptomatic. Cath showed 100%
occlusion of L external iliacStress Echo on [**9-3**] showed EF 50 %
which is unchanged from previous. Of note patient was seen in
the ED on [**9-2**] with chest pain at which time he had a CTA chest
was negative and troponins were flat. He said that the chest
pain lasted only a few seconds, was sharp and was in center to
left chest. Denied SOB, N/V or diaphoresis at this time. It was
also noticed that his HCT on [**9-2**] was 46.2 and on admission 36.3.
He was transferred to the CCU as he was hypotensive and had
decreased HCT.
Denies melana, BRBPR, hematemesis, hemoptysis, recent illness,
CP on exertion, SOB, change in bowel habits. Has had some
decreased po intake as he has not been thirsty but has had good
UOP. Currently has no symptoms.
Past Medical History:
1. Coronary artery disease, status post MI in [**2160**], status
post stent in [**2168-5-26**] to the right coronary artery.
[**2168-8-16**] cardiac catheterization: LM and Cx free of disease. LAD
with an 80% ostial stenosis of the D1. RCA with diffuse disease
of the proximal and mid segment with a maximal stenosis of 50%.
The distal RCA stent was widely patent. FFR of mid RCA was 0.88.
[**2169-3-1**] echo: EF 50%, trivial MR, 1+ TR
[**2170-4-18**] Cardiolite stress test: Negative for ischemia.
.
2. Hypertension.
3. Anxiety disorder.
4. PVD with claudication.
5. Major Depressive disorder.
6. Diabetes.
7. Appendectomy
8. Asthma
Social History:
Social History: Has history of smokingPatient is separated and
lives with his 12 year- old son and his mother. [**Name (NI) **] currently
does not work. He was born in [**Country 5881**] and grew up in South
[**Country 480**]. He came to the US in [**2153**].
Family History:
Family History: (+ ) FHx CAD: Mother had MI at the age of 81.
His
60 year-old brother has "problems with his heart".
Physical Exam:
Vitals: BP 98/70 HR 79 R 15 O2 sats 95% RA
General: middle aged male lying in bed in NAD
HEENT: MMM, no JVD, no LAD
CV:nl S1 S2, 2/6 systolic murmur heard best at the apex
Pulm: CTA anteriorly
Abd: Normal BS, soft, NT/ND
Guaiac: negative
Ext: warm, 1+ DP pulse on right, no palpable DP pulse on left,
no edema
Groin: cath site C/D/I with
Neuro: AAox 3, 5/5 strength in upper and lower extremities,
senastion to light touch intact
Labs: see end of note
EKG: NSR, Rate 75, normal intervals, Q wave in III, no st
changes, poor R wave progression
.
Pertinent Results:
[**2170-9-6**] 10:01PM GLUCOSE-128* UREA N-16 CREAT-0.9 SODIUM-144
POTASSIUM-4.0 CHLORIDE-114* TOTAL CO2-21* ANION GAP-13
[**2170-9-6**] 10:01PM CK(CPK)-47 TOT BILI-0.2
[**2170-9-6**] 10:01PM CK-MB-NotDone cTropnT-<0.01
[**2170-9-6**] 10:01PM CALCIUM-9.0 PHOSPHATE-2.6*# MAGNESIUM-1.7
IRON-56
[**2170-9-6**] 10:01PM calTIBC-268 HAPTOGLOB-229* FERRITIN-171
TRF-206
[**2170-9-6**] 10:01PM OSMOLAL-302
[**2170-9-6**] 10:01PM WBC-5.7 RBC-3.99* HGB-13.5* HCT-37.3* MCV-93
MCH-33.9* MCHC-36.3* RDW-15.8*
[**2170-9-6**] 10:01PM NEUTS-55.4 LYMPHS-37.2 MONOS-6.4 EOS-0.9
BASOS-0.2
[**2170-9-6**] 10:01PM MACROCYT-1+
[**2170-9-6**] 10:01PM PLT COUNT-148*
[**2170-9-6**] 10:01PM PT-12.9 PTT-34.1 INR(PT)-1.1
[**2170-9-6**] 03:05PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-139
POTASSIUM-3.9 CHLORIDE-113* TOTAL CO2-19* ANION GAP-11
[**2170-9-6**] 03:05PM ALT(SGPT)-17 AST(SGOT)-13 CK(CPK)-36* ALK
PHOS-34* AMYLASE-60
[**2170-9-6**] 03:05PM ALBUMIN-3.1*
[**2170-9-6**] 03:05PM PLT COUNT-137*
[**2170-9-6**] 03:05PM WBC-7.4 RBC-3.83* HGB-12.6*# HCT-36.3* MCV-95
MCH-32.9* MCHC-34.7 RDW-15.9*
[**2170-9-6**] 03:05PM PT-13.6* PTT-36.8* INR(PT)-1.2
[**2170-9-7**] 05:47AM BLOOD Cortsol-6.6
[**2170-9-6**] 10:01PM BLOOD Osmolal-302
[**2170-9-6**] 10:01PM BLOOD calTIBC-268 Hapto-229* Ferritn-171
TRF-206
[**2170-9-7**] 05:47AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2170-9-6**] 10:01PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2170-9-7**] 05:47AM BLOOD CK(CPK)-47
[**2170-9-6**] 10:01PM BLOOD CK(CPK)-47 TotBili-0.2
[**2170-9-6**] 03:05PM BLOOD ALT-17 AST-13 CK(CPK)-36* AlkPhos-34*
Amylase-60
.
.
Cath [**9-6**]:
COMMENTS:
1. Access was obtained via the right CFA in a retrograde
fashion.
2. Resting hemodynamics showed normal central aortic pressures.
3. The abdominal aorta had minimal disease.
4. Right lower extremity: patent CIA/EIA as well as the
proximal SFA
and profunda artery.
5. Left lower extremity: the CIA was patent. The EIA had a long
occlusion into the CFA, which reconstituted via collaterals. The
proximal SFA and profunda were patent.
6. Unsuccessful PTA of the left EIA (see PTA comments).
FINAL DIAGNOSIS:
1. Occluded left EIA.
.
.
CXR on admit:IMPRESSION: No evidence of acute cardiopulmonary
process.
Brief Hospital Course:
BRIEF OVERVIEW:
52 yo male with h/o diabetes, HTN, depression, anxiety
disorder,CAD s/p MI in [**2160**] PTCA [**2161**] to RPL, cypher stenting
RCA [**2168**] (repeat cath in [**7-/2168**] with no flow limiting disease),
and PVD complaining of worsening LLE pain. Pt was admitted for
cath for possible stenting of the L iliac artery. He was found
to have a SBP in the 60's on presentation to the cath [**Year (4 digits) **]. The
catheterization was conducted, and the L iliac was totally
occluded. No intervention was performed. S/p LE cath he was
tx'd to the CCU for monitoring. His BP returned to the low
100's and he was tx'd to the floor. He was stable overnight on
the floor and was restarted on a small dose of his home BB and
discharged in good condition.
.
HOSPITAL COURSE BY SYSTEM:
1. Hypotension: The pt was hypotensive in the cath [**Year (4 digits) **]
presenting from home. It was thought that this was most likely
[**2-28**] dehydration as patient said he has been taking decreased PO
and had been NPO after MN for the procedure. However, after
vigorous hydration in the [**Month/Day (2) **] with 5L of saline, he remained
hypotensive. Blood cultures, U/A, urine culture were negative.
Cortisol in AM was 6.6, which is not diagnostic, so a cortisol
stim test was conducted, which revealed a normal response. HCT
remained stable. Iron studies and hemolysis labs revealed no
abnormalities. CE's remained flat. In the CCU, all
antihypertensives were held. Seroquel was also held as it has
been implicated in orthostatic hypotension. No definitive
determination of the cause of the hypotension was revealed, but
the BP was stable and was tx'd to the floor overnight. His BP
remained stable and his metoprolol was restarted at 12.5 [**Hospital1 **], a
much lower dose. It was thought that he was likely dehydrated
when he presented, as well as having taken all of his BP meds
just prior to presentation. F/U was arranged for close
monitoring of his BP and the pt was discharged in good
condition.
.
2. PVD - The pt was brought in for cath of the L iliac via the R
iliac. He was tx'd to the CCU s/p cath with total occlusion of
L ext iliac, no intervention. The pt was continued on ASA,
plavix. At the time of this hospitalization, there was no plan
for OR.
.
3. DM: Hypoglycemics were held post-cath to prevent
hypoglycemia and/or lactic acidosis. The pt was continued on a
RISS and fingersticks were followed.
.
4. Psych: There were no issues at this hospitalization.
Seroquel was held initially and restarted after the first night
in the hospital. He tolerated his home dose well from a BP
point of view. Of note, the pt was noted to have a bilateral
UE/LE tremor throughout his body. This was thought to represent
an EPS. It has been constant and unchanged for years per the
pt.
.
5. Seizure disorder: Anti-epileptics were continued and there
were no issues at this hospitalization.
.
6.Anemia: There was a significant acute decrease in HCT after
the cath [**Last Name (LF) **], [**First Name3 (LF) **] recheck and get hemolysis labs and iron
studies. There were no obvious sites of acute blood loss, and
the patient was guaiac negative. He did not require any
transfusions. It was later thought that this drop in HCT
represented a significant dilutional anemia due to the 5L of
fluid the pt received in the cath [**First Name3 (LF) **].
.
7. Ppx: The patient received mucomyst after his procedure for
kidney protection.
9. Codae status: The patient remained full code during the
course of this hospitalization.
Medications on Admission:
Metformin 500mg [**Hospital1 **]
Glipizide 10mg [**Hospital1 **].
Actos 30mg daily.
Aspirin 325mg daily.
Cardizem CD 240mg daily.
Plavix 75mg daily.
Zestril 10mg daily.
Lorazepam 1mg tid.
Metoprolol 100mg [**Hospital1 **].
Isosorbide 20mg [**Hospital1 **].
Pletal 100mg [**Hospital1 **].
Depakote 1000mg qAM, 1500mg qPM.
Niaspan 1000mg daily.
Folic acid 1mg [**Hospital1 **].
Crestor 10mg daily.
Seroquel 200mg qHS.
Oxycodone 5mg qid.
Zonegran 200mg daily.
Advair diskus 1 puff [**Hospital1 **].
Albuterol 1 puff tid.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Divalproex Sodium 500 mg Tablet, Delayed Release (E.C.) Sig:
Two (2) Tablet, Delayed Release (E.C.) PO QAM (once a day (in
the morning)).
4. Divalproex Sodium 500 mg Tablet, Delayed Release (E.C.) Sig:
Three (3) Tablet, Delayed Release (E.C.) PO QPM (once a day (in
the evening)).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Rosuvastatin Calcium 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Pioglitazone 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Quetiapine Fumarate 200 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
13. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
16. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day.
18. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO twice a day. Capsule, Sustained
Release(s)
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
L Internal Iliac Occlusion
DM
Bipolar
Discharge Condition:
Good
Discharge Instructions:
Your blood pressure was low, likely because you were dehydrated.
Your blood pressure medications may be too high, as well. We
have reduced the number and amount of BP medications at this
hospitalization.
.
You should call Dr. [**Last Name (STitle) **] early next week for an appointment.
([**Telephone/Fax (1) 5455**]
.
You should call Dr. [**First Name (STitle) **] for an appointment, as well.
[**Telephone/Fax (1) 11144**]
They will need to measure your blood pressure and check your
basic labs.
.
Be sure to drink plenty of fluids.
.
If you develop lightheadedness, lose consciousness, have chest
pain or shortness of breath, please seek medical attention
immediately.
Followup Instructions:
Dr. [**Name (NI) **] - pt to call for appt.
Dr. [**Name (NI) **] - pt to call for appt.
Completed by:[**2170-9-11**]
ICD9 Codes: 2765, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2896
} | Medical Text: Admission Date: [**2118-2-6**] Discharge Date: [**2118-6-25**]
Date of Birth: [**2118-2-6**] Sex: F
Service: NEONATOLOGY
This patient's post discharge name is [**Name (NI) 76980**] [**Name (NI) 76981**]. Her
[**Hospital3 1810**] medical record number is [**Numeric Identifier 76982**].
HISTORY OF PRESENT ILLNESS: This is the former 670 gram
product of a 25-4/7 weeks' gestation pregnancy born to a 39-
year-old primiparous mother. The pregnancy was unremarkable
except for maternal hypothyroidism which was treated with
Synthroid. The mother presented on [**2118-1-25**] to [**Hospital6 **] with premature rupture of the membranes and
premature labor. She was treated with betamethasone,
tocolysis and transferred to the [**Hospital1 190**]. She completed her course of betamethasone and
was monitored on the antepartum floor. On the day of delivery
there was concerns for fetal bradycardia prompting delivery
by cesarean section. There were no sepsis risk factors except
for the premature rupture of membranes. Prenatal screens:
Blood type O+, antibody negative, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group beta
strep status unknown.
At delivery, the infant emerged with decreased tone and
respiratory effort. She had a low heart rate with immediate
response to bagged mask ventilation. She was intubated with a
2.0 endotracheal tube after attempts to pass a 2.5
endotracheal tube below the cords was unsuccessful. Apgars
were 4 at one minute, 6 at five minutes and 7 at ten minutes.
She was admitted to the neonatal intensive care unit for
treatment of prematurity. Anthropometric measurements upon
admission to the neonatal intensive care unit: Weight 670
grams--10th-25th percentile, length 28.5 cm--less than the
10th percentile, head circumference 23 cm--25th percentile.
PHYSICAL EXAM AT DISCHARGE: Weight 3.9 kg--50th percentile
for corrected age of 1 month, length 52 cm--25th percentile
for corrected age 1 month, head circumference 37 cm--50th
percentile for corrected age of 1 month. General: Alert,
active infant, pink on nasal cannula O2 at 250 cc/min flow,
alert gaze, conjugate and fixated following gaze. Head, ears,
eyes, nose and throat: Anterior fontanel open and flat,
sutures apposed, positive red reflex bilaterally, normal ears
and nose, palate intact. Neck supple without masses. Skin
warm and dry. Color pink, well-perfused, healed scar on the
left chest status post patent ductus arteriosus ligation.
Chest: Breath sounds clear, equal, well-aerated, baseline
subcostal retractions. Cardiovascular: Regular rate and
rhythm, no murmur, normal S1, S2. Femoral pulses +2, well-
perfused. Abdomen soft, nontender, nondistended, no masses,
no organomegaly, cord healed, small umbilical hernia, soft
and easily reduced. GU: Normal female. Spine straight, normal
sacrum. Musculoskeletal: Normal digits, nails and creases,
hips stable, clavicles intact. Neuro: Alert, positive suck,
positive grasp, symmetric tone.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. RESPIRATORY: This infant was placed on the conventional
ventilator upon admission to the neonatal intensive care
unit. She was treated with three doses of surfactant. On
day of life #5, with the onset of her patent ductus
arteriosus, she required transition to the high-
frequency oscillating ventilator. Her peak airway
pressure requirement was 9 cmH2O. She was transitioned
back to the conventional ventilator on day of life #13.
She continued on moderate ventilatory support through
day of life #55 when she was successfully extubated to
continue with positive airway pressure. She remained on
the continuous positive airway pressure through day of
life 100 when she transitioned to nasal cannula O2 at 1
liter/min. She was able to wean to 250 cc/min flow and
has been stable on that flow since [**2118-5-31**]. Her chest
x-ray is consistent with evolving chronic lung disease.
At the time of discharge, she is breathing comfortably
with a respiratory rate of 40-60 breaths/min with
baseline subcostal retractions. This infant required
treatment for apnea of prematurity with caffeine
citrate. The caffeine was discontinued on day of life
#71, [**2118-4-18**]. She continued to have intermittent
episodes of spontaneous apnea and bradycardia. On
[**2118-6-17**], a 24-hour pneumogram was performed showing
no central apnea, no reflux and spontaneous bradycardic
drops to 70-80 beats per minute. On the day of
discharge, she has been without any episodes of
spontaneous apnea or bradycardia for five days. This
infant will be followed in the Pulmonary Clinic at
[**Hospital3 1810**] by Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] and she has a
follow-up appointment scheduled for [**2118-7-8**] at 9:15
a.m. Her baseline arterial blood gas at discharge is 7.38,
pCO2 56, pO2 103 HCO3 34 in NC flow as described above. She
has benefited from administration of albuterol at
times.
1. CARDIOVASCULAR: This infant has maintained normal heart
rates and blood pressures during her neonatal intensive
care unit admission. A murmur was noted on day of life
#5 and the infant was treated with a course of
indomethacin. An echocardiogram performed on day of life
#7 after the second course of indomethacin showed no
patent ductus arteriosus with good biventricular
function. The infant then had a murmur noted again and
on [**2118-2-24**] was noted to have a moderate patent ductus
arteriosus with continuous left-to-right flow. She was
taken to patent ductus arteriosus ligation on
[**2118-2-25**]. She had an echocardiogram repeated on
[**2118-6-14**] which showed no right ventricular
hypertension, a patent foramen ovale with left-to-right
flow. At the time of discharge, she has an intermittent
murmur noted with a baseline heart rate of 110-130 beats
per minute, recent blood pressure of 78/33 mmHg, mean
arterial pressure 49 mmHg.
1. FLUIDS, ELECTROLYTES AND NUTRITION: This infant
initially had umbilical arterial and venous catheters
placed. She received total parenteral nutrition. Enteral
feeds were initiated on day of life #10 and gradually
advanced to full volume. She was made n.p.o. for her
patent ductus arteriosus ligation and feeds were resumed
three days postoperatively and again advanced to full
volume. She had a percutaneously inserted central
catheter for approximately two weeks. Her maximum
caloric density was breast milk fortified to 30 cal/oz
with additional Beneprotein. This infant had difficulty
transitioning to all oral feeds. The pediatric feeding
team from [**Hospital3 1810**] was consulted and had no
additional suggestions and felt that the infant was
advancing normally. They remained available for
consultation with the [**Hospital3 **] after discharge should any
feeding issues arise. The infant was started on Prilosec
and Reglan for symptoms of gastroesophageal reflux.
Weight on the day of discharge is 3.9 kg. Her discharge
formula is EnfaCare fortified to 28 cal/oz by
concentration. Serum electrolytes were checked
frequently during admission and were within normal
limits.
1. INFECTIOUS DISEASE: Due to the premature rupture of
membranes and her prematurity, this infant was evaluated
for sepsis upon admission to the neonatal intensive care
unit. A complete blood count and differential were
within normal limits. A blood culture was obtained prior
to starting intravenous ampicillin and gentamicin. The
blood culture was no growth and the antibiotics were
discontinued at 48 hours. On day of life #5, with the
onset of her patent ductus arteriosus and clinical
instability, this infant was reevaluated for sepsis with
a complete blood count and blood culture. She was
started on vancomycin and gentamicin. That second blood
culture was no growth and the antibiotics were
discontinued 48 hours later. At two other episodes
during her neonatal intensive care unit admission, the
infant was concerning for possible sepsis. Blood
cultures on both of those occasions were no growth.
1. HEMATOLOGICAL: This infant is blood type O+, direct
antibody test negative. She required seven transfusions
of packed red cells during her neonatal intensive care
unit admission. Her most recent hematocrit was 33% with
a reticulocyte count of 2.9% performed on [**2118-6-14**].
She is being discharged home on supplemental iron.
1. GASTROINTESTINAL: This infant required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life 2 at 4 mg/dL.
She was treated with phototherapy for approximately
three weeks. Her final serum bilirubin on day of life 23
was 3.1 mg/dL. As previously noted, she is being treated
for gastroesophageal reflux with Prilosec and Reglan.
1. RENAL: This infant had onset of hematuria on [**2118-5-18**].
A renal ultrasound performed on [**5-19**] showed bilateral
renal calculi. The infant was evaluated by the
Nephrology service at [**Hospital3 1810**]. A repeat
renal ultrasound on [**2118-6-2**] showed increase in the
number and size of the renal calculi especially on the
left side. At the recommendation of the nephrology team.
She was started on Diuril p.o. b.i.d. Repeat ultrasound
on [**2118-6-10**] showed decrease number and size of the
renal calculi with significant improvement. She is being
discharged home on Diuril and would be followed up by
the nephrology team with an appointment scheduled for
[**2118-8-10**] at 1:00 p.m.
1. ENDOCRINE: This infant was noted to have low T4 levels.
She was evaluated by the Endocrinology service at
[**Hospital3 1810**] and was felt to have sick euthyroid
syndrome. She was not treated and the thyroid levels
normalized.
1. NEUROLOGICAL: The initial head ultrasound performed on
this infant on day of life #1 showed absence of the
cavum septum pellucidum. There was no intraventricular
hemorrhage or other abnormalities noted. Repeat head
ultrasounds on [**2-15**] and [**3-10**] were without change. The
infant was evaluated by the Neonatal Neurology service
for [**Hospital3 1810**] who recommend a magnetic
resonance imaging test to be done as an outpatient. She
will be followed in the Neonatal Neurology Program at
[**Hospital3 1810**]. The referral has been made and they
will contact the [**Name2 (NI) **] with the appointment. The
infant's neurological exam has been within normal limits
with some mildly increased tone noted in the lower
extremities.
1. SENSORY:
a. AUDIOLOGY: Hearing screening was performed with
automated auditory brainstem responses. This infant
passed in both ears on [**2118-6-12**].
b. OPHTHALMOLOGY: The first initial eye exams were
concerning for fixed and dilated pupils versus
aniridia. Due to the finding of the absence cavum
septum pellucidum on the head ultrasound there was
concern for potential absence of the optic nerves. The
optic nerves were finally visualized on [**2118-3-16**] and
at that time she was noted to have immature retinal
vessels. She proceeded to advance to stage 1
retinopathy of prematurity to zone III. The retinopathy
resolved and she was noted to have mature retinas on
[**5-23**]/4008. She will require ophthalmology follow-up at
age 9 months.
c. PSYCHOSOCIAL: [**Hospital1 69**]
Social Work has been involved with this family. The
contact social worker is [**Name (NI) 4457**] [**Name (NI) 36244**] and she can be
reached at ([**Telephone/Fax (1) 24237**]. [**Telephone/Fax (1) 6961**] have been vigilant
and very involved during their daughter's neonatal
intensive care unit admission.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with the [**Telephone/Fax (1) **].
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 8771**] [**Last Name (NamePattern1) 76983**], [**Apartment Address(1) 76984**], [**Hospital1 8**], [**Numeric Identifier 53049**], phone number
([**Telephone/Fax (1) 76985**], fax number ([**Telephone/Fax (1) 59810**].
CARE AND RECOMMENDATIONS ON DISCHARGE:
1. Oxygen by nasal cannula at 250 cc/min.
2. Feeding: Ad lib feeding a minimum of 130 mL/kg/D of
breast milk or EnfaCare 28 cal/oz formula.
3. Medications: Reglan 0.3 mg p.o. q.8h., Prilosec 4 mg
p.o. once daily, chlorothiazide or Diuril 38 mg p.o.
q.12h., Goldline baby vitamins 1 mL p.o. once daily,
ferrous sulfate 25 mg/mL dilution 0.6 mL p.o. once
daily.
4. Iron and vitamin D supplementation:
a. Iron supplementation is recommended for preterm
and low birthweight infants until 12 months corrected
age.
b. All infants fed predominantly breast milk should
received vitamin D supplementation at 200 international
unit (may be provided as a multivitamin preparation)
daily until 12 months corrected age.
5. Car seat position screening was performed. This infant
was observed in her car seat for 90 minutes without any
episodes of oxygen desaturation or bradycardia.
6. State newborn screens were sent on [**12-3**] and
[**2118-3-12**]. There was hypothyroidism noted on the
initial screens which resolved.
7. Immunizations: Hepatitis B vaccine was administered on
[**2118-3-8**]. Pediarix was administered on [**3-/2039**] and
[**2118-6-7**]. Haemophilus influenza B was administered on
[**4-9**] and [**2118-6-7**]. Pneumococcal 7-[**Last Name (un) **] Conjugate
vaccine was administered on [**3-/2039**]/ and [**2118-6-7**].
8. Immunizations recommended:
a. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criteria: 1) Born at less than or equal to
32 weeks; 2) Born between 32 and 35-0/7 weeks with 2 of
the following: Daycare during RSV season, a smoker in
the household, neuromuscular disease, airway
abnormalities or school-aged siblings; 3) Chronic lung
disease; or 4) Hemodynamically significant congenital
heart disease.
After discussion with the patient's primary pediatrician who
noted continued cases of RSV being seen in their practice
currently and requested treatment with Synagis. The possibility
of Synagis was considered with the [**Month (only) **]. Current AAP criteria
were reviewed. Afetr consideration of these and patient's
situation it was decided to administer a dose of Synagis prior to
disacharge.
b. Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of
age. Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
c. This infant has not received rotavirus vaccine.
The American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable and at least 6 weeks but fewer than 12 weeks of
age.
9. Follow-up appointments:
a. Appointment with Dr. [**Last Name (STitle) 76983**], primary
pediatrician, on [**2118-6-27**] at 10:00 a.m.
b. Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**], pediatric pulmonology, [**Doctor Last Name 37393**]
Four at [**Hospital3 1810**], [**Location (un) 86**], ([**Telephone/Fax (1) 76986**],
[**2118-7-8**] at 9:15 a.m.
c. Infant Followup Program [**Hospital3 1810**], ([**Telephone/Fax (1) 76987**], appointment for [**2118-11-29**] at 8:00 a.m.
d. Pediatric Nephrology, [**Hospital3 1810**], [**Last Name (un) 9795**]
Five, [**2118-8-10**] at 1:00 p.m.
e. Neonatology Neurology Program, ([**Telephone/Fax (1) 56746**],
[**Last Name (un) 9795**] Eleven, [**Hospital3 1810**], appointment to be
determined.
f. Genetics, [**Hospital3 1810**], [**Location (un) 86**], [**Last Name (un) 9795**] Ten,
([**Telephone/Fax (1) 46984**], appointment to be determined.
g. Pediatric Ophthalmology at 9 months of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 25-4/7 weeks' gestation.
2. Respiratory distress syndrome secondary to surfactant
deficiency.
3. Chronic lung disease.
4. Suspicion for sepsis ruled out x2.
5. Patent ductus arteriosus status post two courses of
indomethacin.
6. Status post patent ductus arteriosus ligation.
7. Apnea of prematurity.
8. Anemia of prematurity.
9. Retinopathy of prematurity Stage 1, resolved.
10.Bilateral renal calculi.
11.Transient hypothyroidism secondary to sick euthyroid
syndrome.
12.Unconjugated hyperbilirubinemia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Name8 (MD) 75740**]
MEDQUIST36
D: [**2118-6-25**] 02:24:47
T: [**2118-6-25**] 08:50:00
Job#: [**Job Number 76988**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2897
} | Medical Text: Admission Date: [**2129-8-26**] Discharge Date: [**2129-10-7**]
Date of Birth: [**2078-1-17**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: This is a 51 year old man who
was recently evaluated by his primary care physician for
complaints of atypical left upper quadrant abdominal pain. A
CT scan was obtained which detected a large right common
iliac aneurysm 4.5 by 4.5, along with a small left common
iliac aneurysm. The patient had a cardiac work-up which
revealed an essentially normal echocardiogram with an
ejection fraction of 60 to 70% along with no ischemic
symptoms by exercise tolerance.
The patient underwent an arteriogram by Dr. [**Last Name (STitle) **] on [**7-28**]
which demonstrated a right pseudo-iliac aneurysm and a left
common iliac aneurysm. The patient now is admitted
electively for repair.
PAST MEDICAL HISTORY:
1. Hay fever.
2. No previous surgeries.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient is not on any medications at the
present time.
SOCIAL HISTORY: He is married; he is self-employed as a
tile installer. He lives with his wife. [**Name (NI) **] ambulates
independently.
DISCHARGE LABORATORY: PT 12.8, INR 1.1, PTT 32.7. CBC with
white blood cell count of 9.9, hematocrit 31.0, platelets
745k.
Electrolytes were sodium 134, potassium 4.9, chloride 97,
carbon dioxide 24, BUN 28, creatinine 0.7, glucose 103,
calcium 8.5, phosphorus 5.7, magnesium 1.9.
A video swallow done on [**2129-6-3**], demonstrated decreased
bolus control with premature spillage. There was poor
epiglottic dysflexion throughout the entire study. Residue
remained in the panniculi with nectar liquids and there was
trace penetration during swallowing of nectar liquids. With
thin liquids there was aspiration; the patient could not
transfer or swallow a barium tablet.
Bilateral venous studies for deep vein thrombosis were
obtained on [**2129-9-20**], which showed no evidence of deep vein
thrombosis in the left lower extremity from the inguinal to
popliteal region as well as the right common femoral vein.
A CT scan of the chest attained on [**2129-8-31**] for persistent
fevers demonstrated heart and pericardium were unremarkable.
Anterior mediastinum was clear. The great vessels were
intact. There was no significant hilum or spinal, axillary
lymphadenopathy. There are bilateral pleural effusions which
are moderate sized. There is bilateral apical patchy
infiltrates seen greater on the right than on the left.
There is a left subclavicular and jugular line in the
inferior aspect of the superior vena cava. The trachea is
midline with an ET in place and a nasogastric tube in place.
Abdominal CT scan: The liver, spleen, liver and pancreas
were unremarkable. There were small gallstones in the
dependent portion of the gallbladder, however, there was no
wall thickening or pericholecystic fluid collection. The
left kidney showed an inferior simple cyst. There was free
fluid in the abdomen and that has not changed significantly
in amount compared to previous study. There is no free air
in the abdomen.
CT scan of the pelvis: Large and small bowels are normal
caliber and course. Fluid throughout the pelvis which
measures approximately 16 hounds filled units, unchanged from
previous. Post-surgical changes were seen in the mesentery
on the left side.
The infraradial aorta-[**Hospital1 **]-iliac bypass was seen with a small
amount of hematoma around the graft, but no extravasation,
but there is a peri-aortic collection which has expanded
since the previous study of [**8-31**]. There is no change in the
retroperitoneum hematoma on the left.
Preoperative chest x-ray was unremarkable. Chest x-ray,
single view only, done on [**2129-9-24**], did demonstrate low
lung volumes with subsequent atelectasis in the left lower
zones. No evidence of pulmonary edema.
HOSPITAL COURSE: The patient was admitted to the
Preoperative Holding Area on [**2129-8-26**]. He underwent
bilateral iliac aneurysm repair with an aorta-bifemoral
bypass. Interoperatively, the iliac vein was injured with
repair. The patient had open bedside laparotomy on [**8-26**],
later that day and returned to the Operating Room for
intra-abdominal sepsis and bleeding of the iliac vein. The
patient remained in the SICU intubated during this time.
On [**9-4**], the patient had bilateral chest tubes placed
secondary to moderate pleural effusions bilaterally and
underwent an exploratory laparotomy which was unremarkable.
On [**9-9**], he underwent abdominal washout with fascial partial
closure and then returned to the Operating Room on [**9-12**] for
exploratory laparotomy, abdominal washout and repair of a
serosal small bowel tear and fascial closing with Silastic.
During his hospitalization, he required total parenteral
nutrition and nasogastric tube feeds secondary to aspiration.
He was initially evaluated by Speech Therapy on [**9-22**], and
then a repeat video swallow was done on [**10-3**], which
continued to show aspiration with thin liquids.
Recommendations were soft solid ground foods and thickened
liquids.
The patient underwent, on [**9-23**], a venogram with IVC filter
placement. He was begun on anti-coagulation. A repeat MRV
was recommended which the patient refused to have done.
The remaining hospital course was unremarkable. The patient
was discharged to rehabilitation in stable condition.
DISCHARGE INSTRUCTIONS:
1. He is to follow-up with Dr. [**Last Name (STitle) **] in one weeks time.
2. Coumadin 2.5 mg q. day. This should be adjusted for a
goal INR of 2.0 to 2.5.
3. His diet will be regular soft solids with thickened
liquids. His tube feeds were discontinued on [**2129-10-5**] by
the patient.
4. The patient should have INR drawn on Saturday and this
should be called to Dr.[**Name (NI) 5695**] office at [**Telephone/Fax (1) 3121**].
DISCHARGE MEDICATIONS:
1. Tomoxiprole 40 mg subcutaneously q. 12 hours.
2. Protonix 40 mg q. day.
3. Reglan 10 mg a.c. and h.s.
4. Lopressor 50 mg three times a day; hold for systolic
blood pressure less than 100 and heart rate less than 60.
5. Dazolicine 60 mg four times a day, hold for heart rate
less than 60, systolic blood pressure less than 115.
6. Enalapril 5 mg q. day.
7. Miconazole Powder to affected areas four times a day and
p.r.n.
8. Artificial Tears one to two drops o.u. p.r.n.
9. Albuterol multi-dose inhalers, puffs four to eight p.r.n.
10. Insulin sliding scale, discontinued.
11. Lorazepam intravenous q. h.s. p.r.n.; if discharged to
home this will be discontinued.
DISCHARGE DIAGNOSES:
1. Bilateral iliac aneurysm status post aorta-bifemoral
graft with right iliac vein injury status post repair.
2. Status post open laparotomy times three.
3. Bilateral pleural effusions, status post chest tubes.
4. Aspiration status post video swallow.
5. Questionable iliac thrombus status post IVC filter
placement.
6. Blood loss anemia, corrected.
7. Hypertension, stable.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2129-10-7**] 14:12
T: [**2129-10-7**] 16:52
JOB#: [**Job Number 33438**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2898
} | Medical Text: Admission Date: [**2118-12-11**] Discharge Date: [**2118-12-16**]
Date of Birth: [**2033-5-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
hematemesis, melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
85 y/o male with h/o bladder cancer s/p urostomy, HTN, HLD, and
h/o GIB who presents from [**Hospital **] Hospital ED with concern for
upper GI bleed in the setting of dark-colored stools and
hematemesis. Three days prior to admission, the patient
developed the sudden onset of dark-colored stools. He gradually
developed nausea and vomiting with four episodes of
coffee-ground emesis. With regards to his prior GIB, the source
is unknown as the family is unaware of whether the patient had
an EGD or colonoscopy. He was recently started on an NSAID [**3-11**]
weeks ago for a joint effusion. He developed GI upset and the
dosing was decreased from daily to [**Hospital1 **]. He was also started on
aspirin 81 mg po daily one week ago. He has no history of
alcohol abuse, liver disorders and is not on any
anti-coagulation. Patient reports ongoing nausea but denies any
fevers, chills, abdominal pain, chest pain, SOB, or dysuria. He
denies any dizziness or presyncope.
.
The patient initially presented to [**Hospital **] Hospital ED. He was
given an Octreotide bolus, Protonix bolus and was started on a
Protonix drip. An NGT was placed which revealed coffee-ground
emesis which cleared with NG lavage. His hemoglobin at [**Hospital **]
Hospital was 10.1, which is noted to be his baseline. On arrival
to the [**Hospital3 **] ED, his initial VS were 96.4, 60 113/49, 14,
99% RA. His repeat CBC revealed a hemoglobin of 9.6 and a
leukocytosis of 15.6 with a left-shift (PMNs 84.9%) with no
bands. A CXR did not reveal any evidence of aspiration and was
otherwise clear, and NGT was noted to be appropriately placed.
He was continued on the Protonix gtt and given 2 L NS. He was
T&S for 2 units. A GI consult was called prior to transfer to
the MICU and they plan on EGD in the am. VS on transfer were
96.4, P: 65, BP: 105/36, RR: 20, 99% on 2L NC.
.
Currently, he is without complaint and states he is feeling
better.
Past Medical History:
1. Bladder CA s/p urostomy
2. Hypertension
3. Hyperlipidemia
4. SIADH
Social History:
Patient lives by himself with the help of 2 home health aides.
He denies ever drinking alcohol, smoking or using illicit drugs.
Family History:
patient unsure but denies a history of cancer.
Physical Exam:
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, sl dry MM, OP
clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - crackles at RLL, otherwise CTAB, no r/rh/wh, good air
movement, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - urostomy in place in RLQ, NABS, soft/NT/ND, no masses
or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-12**] throughout, sensation grossly intact throughout, gait
deferred
Pertinent Results:
[**2118-12-11**] 08:45PM BLOOD WBC-15.9* RBC-2.92* Hgb-9.6* Hct-28.2*
MCV-97 MCH-32.8* MCHC-33.9 RDW-12.5 Plt Ct-338
[**2118-12-12**] 05:25AM BLOOD WBC-9.9 RBC-2.85* Hgb-9.0* Hct-27.3*
MCV-96 MCH-31.5 MCHC-32.9 RDW-14.7 Plt Ct-288
[**2118-12-13**] 10:14AM BLOOD WBC-7.5 RBC-2.85* Hgb-8.9* Hct-26.3*
MCV-92 MCH-31.2 MCHC-33.8 RDW-15.9* Plt Ct-235
[**2118-12-11**] 08:45PM BLOOD Neuts-84.9* Lymphs-12.8* Monos-1.7*
Eos-0.2 Baso-0.4
[**2118-12-13**] 04:32AM BLOOD PT-12.3 PTT-72.5* INR(PT)-1.1
[**2118-12-13**] 04:32AM BLOOD Glucose-80 UreaN-41* Creat-1.6* Na-141
K-3.4 Cl-111* HCO3-24 AnGap-9
[**2118-12-11**] 08:45PM BLOOD ALT-26 AST-31 LD(LDH)-231 AlkPhos-74
TotBili-0.4
Brief Hospital Course:
Patient is a 85 y/o male with h/o bladder cancer s/p urostomy,
HTN, HLD, SIADH who presents with upper GI bleed in the setting
of recent NSAID use.
.
#. Upper GI bleed: Patient admitted with hematemesis and melena
consistent with upper GI bleed. Given his recent use of NSAIDS
and aspirin, gastritis or ulcer were the most likely etiology.
He remained hemodynamically stable. He was initally placed on a
PPI drip and transitioned to high dose PPI IV BID. He underwent
EGD; a peptic ulcer was found in the distal bulb, and this was
clipped. He was transferred to the floor and remained stable.
His PPI was made PO and his home medicines were restarted. We
held his Aspirin and his NSAID pain medicine. He should avoid
NSAIDs in the future. He will need to have his ASA started at
the discretion of his PCP.
.
#. Leukocytosis: UA suggestive of UTI, although he has chronic
indwelling urostomy and no symptoms of infection. [**Month (only) 116**] also be
secondary to stress reaction in setting of probable GIB. CXR
without infiltrate c/f pneumonia. Urine culture was negative.
Leukocytosis resolved and was likley due to acute bleed.
. .
#. Positive Urinalysis/Asymptomatic Bacteriuria: Patient s/p
bladder cancer with urostomy so has chronic indwelling biofilm
so UA likely to be persistently positive. Culture was negative.
No antibiotics were given.
.
#. Hypertension, benign: amlodipine and nadolol were held on
admission. His BP normalized and his home anti-hypertensives
were restarted.
.
# Night time oxygen desaturations; Patient had several nighttime
SaO2 values of 75% while sleeping. He was asymptomatic during
these events. He did not endorse symptoms to suggest sleep
apnea. Sleep was consulted and felt he did have evidence however
an urgent inptaint sleep study was not warrented. He will be
discharged on night time home oxygen therapy and will follow up
with the sleep clinic in early [**Month (only) 404**]. In the mean time he will
need assistence in setting up an outpatient sleep study. His PCP
was called and this was communicated to him directly.
.
+++++++++++++++++
Transitional issues:
1) Consider restarting Aspirin 81 after follow up visit with
PCP, [**Name10 (NameIs) **] there is no recurrent bleeding.
2) Will need CBC and Chem 7 checked on Monday following
discharge by PCP (office aware). Hct 29.3 and Creatinine 1.6 on
last check here.
3) Will need to have Outpatient sleep study set up, preferably
at [**Hospital **] hospital.
4) He was advised to avoid NSAIDs.
.
Medications on Admission:
demeclocycline 150 mg po BID
simvastatin 10 mg po daily
nadolol 20 mg po once a daily
amlodipine 10 mg po daily
Aricept 10 mg Once Daily
Aspirin- 81 mg po daily (started 1 week ago)
Arthrotec 75/200 1 tab [**Hospital1 **] (diclofenac/ misoprostol)
Discharge Medications:
1. Home O2
Patient requires night time home oxygen. Documented
desaturations to <78% on room air while sleeping. Corrects fully
with oxygen. Saturations remain above 90% on RA while awake.
Please start at 2L/min nasal cannula and titrate to SaO2 >95%
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. demeclocycline 150 mg Tablet Sig: One (1) Tablet PO bid ().
5. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
8. Outpatient Lab Work
please draw CBC, Sodium, Potassium, Chloride, Bicarb, BUN and Cr
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6549**] Medical
Discharge Diagnosis:
Duodenal ulcer
Sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] because you had a bleeding ulcer in
your stomach. This was a result of the anti-inflammatory
medications you were taking for your knee. The GI doctors placed
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] across the bleeding and it has stopped. You will need to
follow up with your PCP as listed below.
.
You also were found to have a condition known as sleep apnea.
You will need to have a sleep study soon after being discharged
from the hospital. You will need to discuss this with your PCP
and have this set up at [**Hospital **] hospital when you see him in
follow up. In the meantime you will need to wear Oxygen while
you sleep.
.
While you were here we made the following changes to yoru
medications.
We STOPPED your arthrotec
We STOPPED your aspirin - you will need to talk about when to
restart this with your PCP
We STARTED you on Pantoprazole
We STARTED you on Senna
We STARTED you on colace
.
You should continue to take your other emdications as directed.
Followup Instructions:
You will have need to have your blood drawn this monday at Dr. [**Name (NI) 92610**] office. You will be given an oreder to take with you
that will let them know what tests to order.
.
You will be called by Dr.[**Name (NI) 92611**] office to have a follow up
appointment sheduled. If you have not heard from them in 1 week
you shoudl call them ASAP to set up a follow up appointment.
.
You will need to see the sleep physicians for a follow up
appointment on Tuesday [**2119-1-17**] at 9am. Please call ([**Telephone/Fax (1) 514**] to set up the details of your appointment. They will
help to schedule your sleep study for you.
ICD9 Codes: 5849, 2851, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2899
} | Medical Text: Admission Date: [**2123-4-23**] Discharge Date: [**2123-5-3**]
Date of Birth: [**2039-12-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
worsening shortness of breath and fatigue
Major Surgical or Invasive Procedure:
1) PPM: [**2123-4-23**]
Implant of Pacemaker for AV block second degree, Mobitz II
([**Company 1543**] Model# ADDRL1, Serial#[**Serial Number 88600**])
2) TAVI: [**2123-4-27**]
-Transfemoral transcatheter aortic valve replacement with a
31-mm [**Company 1543**] core valve.
-Balloon valvuloplasty with a 22 mm XiMED balloon.
-Thoracic and abdominal aortography.
History of Present Illness:
Patient is an 83yo caucasian male with history of CAD s/p
CABG x 6 in [**2114**], and known symptomatic aortic stenosis. He
reports worsening shortness of breath over the last 2 years.
Cardiac cath revealed occluded SVG to the RCA with collaterals
and otherwise patent grafts. He was referred for screening for
Corevalve/TAVI 8 months ago and was excluded due to large
annular
size. Since that time a new 31mm Corevalve has been made
available. Since prior visit, patient reports decreased exercise
tolerance with ability to walk less that half a block with out
stopping due to shortness of breath. He reports worsening
fatigue, and 10 lb weight loss. Family members report a decline
in his functional status though he remains independent. He
admits
to frequent episodes of lightheadedness and dizziness though
this
is also in the setting of baseline vertigo disease. In addition,
he has known second degree heart block. It has been determined
that he would likely need a permanent pacemaker if having either
surgical AVR or TAVI.
Informed consent was obtained for the High Risk cohort for
the Corevalve/TAVI study. He met all inclusion criteria and did
not meet any exclusion criteria. He was screened and accepted
and has been randomized to the Corevalve procedure.
NYHA Class: III
CARDIAC CATHETERIZATION [**2122-7-23**]. Three vessel coronary
artery disease with 100% occlusion of the SVG to the RCA with
prominent left to right collaterals to the PDA, Patent
sequential
SVG to the proximal LAD and mid LAD; Patent LIMA to the diagonal
branch; Patent graft to OMB1 (that provides collaterals to the
PDA). The only area of potential ischemia in the inferior wall
is supplied by collaterals from the LCA.
ECHOCARDIOGRAM TTE (Complete) Done [**2123-3-10**] at 11:00:00
Echocardiographic Measurements
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. RV function
depressed.
AORTA: Mildy dilated aortic root. Focal calcifications in aortic
root.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2).
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
Normal tricuspid valve supporting structures. No TS.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function
is normal (LVEF 65%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
depressed free wall contractility. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area 0.7 cm2). The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined with
certainty or precision (due to the absence of a reliable
tricuspid regurgitation Doppler spectrum) but appears to be at
least moderately elevated. There is no pericardial effusion.
Compared with the findings of the prior study (images
reviewed)
of [**2122-9-4**], the calculated aortic valve orifice area is
reduced. This is most likely the result of technical factors
(LVOT diameter measurement was 0.1 cm larger on prior study, and
LVOT flow velocity was 0.2 m/sec higher on prior study) rather
than a major change in the aortic valve itself.
EKG: Study Date of [**2123-3-10**] 11:44:18 AM
Intervals Axes
Rate PR QRS QT/QTc P QRS T
41 262 98 524/490 118 -21 95
CT: CARDIAC STRUCTURE/MORPH, 3D, FUNCTION Study Date of [**2122-9-4**]
FINDINGS:
CT CHEST: Airways are patent to the level of subsegmental
bronchi bilaterally. Extensive interstitial changes are noted
throughout the lungs, with subpleural predominance as well as
apical-basal gradient, consistent most likely with nonspecific
interstitial pneumonia. No focal consolidation worrisome for
infection or neoplasm is noted. Focal areas of airtrapping are
present.
No pathologically enlarged mediastinal, hilar, or axillary
lymph nodes are present. Post-sternotomy wires in a patient
after
CABG are unremarkable.
Main pulmonary artery is dilated up to 3.8 cm, right main
pulmonary artery is 2.8 cm and left main pulmonary artery is 2.7
cm, findings consistent with pulmonary hypertension.
CT ABDOMEN: Liver, spleen, adrenals, kidneys are unremarkable.
Questionable gallstones are noted, but no evidence of
cholecystitis is present.
No bowel wall thickening or bowel wall dilatation is present.
There is no intraperitoneal air or fluid. No lymphadenopathy is
seen.
CT PELVIS: Diverticulosis of the sigmoid with no evidence of
diverticulitis is present. Bladder is unremarkable. No
lymphadenopathy, free fluid, or air is noted.
Extensive degenerative changes are present in the imaged
portion of the skeleton, but no lytic or sclerotic lesions
worrisome for infection or neoplasm demonstrated.
CTA:
AORTA: No pathologic aortic dilatation is noted throughout the
entire aorta. Mild tortuosity of the abdominal aorta is present.
Extensive calcifications at the origin of the SMA are noted with
potentially substantial narrowing. Renal arteries are calcified
at their origins but no substantial narrowing is present.
Aorta bifurcates unremarkably. Minimal focal dissection/mural
thrombus at the proximal portion of the common iliac artery is
present, 7:180. Measurements of iliac and femoral arteries will
be added separately.
SUBCLAVIAN ARTERIES: Both subclavian arteries are
unremarkable.
The aortic valve is calcified, consistent with known aortic
stenosis. The patient is after bypass surgery. Extensive
calcifications of native coronary arteries are present. Right
bypass is occluded with aneurysmatic dilatation at the mid
portion.
IMPRESSION:
1. Evidence of interstitial lung fibrosis, consistent with
nonspecific interstitial lung disease.
2. No evidence of aneurysmatic dilatation of the aorta.
3. Pulmonary hypertension.
PFT's: Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study
Date
of [**2122-9-4**] 2:16 PM
SPIROMETRY 2:16 PM Pre drug
Actual Pred %Pred
FVC 2.94 3.85 76
FEV1 2.56 2.41 106
MMF 3.87 2.04 189
FEV1/FVC 87 63 139
LUNG VOLUMES 2:16 PM Pre drug
Actual Pred %Pred
TLC 4.26 6.50 66
FRC 2.24 3.75 60
RV 1.69 2.65 64
VC 2.78 3.85 72
IC 2.02 2.75 73
ERV 0.56 1.10 50
RV/TLC 40 41 97
He Mix Time 2.13
DLCO 2:16 PM
Actual Pred %Pred
DSB 12.26 22.54 54
VA(sb) 4.17 6.50 64
HB 14.60
DSB(HB) 12.26 22.54 54
DL/VA 2.94 3.47 85
Impression:
Mild restrictive ventilatory defect with a moderate gas
exchange defect.
The DLCO is reduced out of proportion to the reduction in TLC
which is consistent with an interstitial process. There are no
prior studies available for comparison.
Carotid dopplers: [**2122-7-22**] < 50% stenosis of both carotids
Past Medical History:
- severe aortic stenosis
- CAD s/p CABG x 6 ([**2114**])
- Hypertension, controlled
- Hyperlipidemia, on simvastatin
- Peripheral vascular disease (poor circulation in the legs)
- Stomach ulcers
- Right ear surgery leading to vertigo.
- Possible dementia
- Second degree AV block without syncope
- Diabetes mellitus, Type II with diabetic neuropathy
- Chronic kidney disease Stage III
- Prostate disease
- History of CVA
- vertigo x 8 years
- hearing loss right
- right ear surgery
- multiple skin lesions to all extremities (mult. frozen
removals)
- Right palm/thumb trauma
- low back pain (bimonthly injections)
LV diastolic dysfunction
Grade: [ ] None [ ] I [ ] II [ ] III [ ] IV
Chest wall deformity Yes [ ] No [x]
History of IE Yes [ ] No [x]
Peripheral vascular disease Yes [ ] No [x]
Cirrhosis of Liver Yes [ ] No [x]
If yes, Child [**Doctor Last Name 14477**] Score A [ ] B [ ] C [ ]
History of anemia req transfusion Yes [ ] No [ ]?
Ulcer disease Yes [x] No [ ]
Connective tissue disease Yes [ ] No [x]
Hostile mediastinum Yes [ ] No [x]
Immunosuppressive therapy Yes [ ] No [x]
Previous Cardiac Surgery?: CABG x 6 ([**2114**])- Sextuple coronary
artery bypass grafting with left internal mammmary artery to the
diagonal, aorto sequential saphenous vein to the proximal and
distal left anterior descending, aortosequential saphenous vein
to the first and second obtuse marginal, aortosaphenous vein to
the RPDA.
Previous Balloon Valvuloplasty?: NO
Permanent Pacemaker/ICD in-situ?: NO
Social History:
The patient is a widower and lives alone. He does not smoke and
has not in the past. He has a glass of wine per week. He
exercises with PT and maintains a low sugar diet. Four stairs to
enter his home. One level home. Neice lives 15min
away. [**Telephone/Fax (1) 88601**] (NIECE)[**Doctor First Name **] [**Doctor Last Name **]
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
Race: caucasian
Last Dental Exam: none recent
Lives with: alone
Occupation: retired heavy machine operator
Tobacco: none
ETOH: 1/week
Family History:
There is a family history of hypertension, diabetes
mellitus,heart disease, and strokes. His mother died at [**Age over 90 **]
years old age; his father died at 86 years. All 14 of his
siblings are deceased.
Physical Exam:
ADMISSION:
General: Weight changes - 12 lb wt loss/6 months
Skin: Eczema [ ] Psoriasis [ ] Skin cancer [ ] Other [ ]
Denies [ ] - skin lesions, dry
HEENT: Hearing aid [ ] Glasses [ ] Other [ ]- HOH right
Respiratory: Asthma [ ] COPD [ ] Pneumonia [ ] Cough [ ]
Sputum [ ] Other : Denies [x]
Cardiac: Chest pain [ ] SOB [x] DOE [x] Orthopnea [ ] PND
[
]
GI: Nausea [ ] Vomiting [ ] Diarrhea [ ] Constipation [ ]
Heartburn/GERD [ ] Other:-stomach ulcers Denies [ ]
GU: Dysuria [ ] Frequency [ ] Prostate [x] GYN [ ] Other:
Denies [ ]
Musculoskeletal: Arthritis [ ] Other: Denies [x]
Peripheral vascular: Claudication [x] Other: Denies [ ]
Psych: Anxiety [ ] Depression [ ] Other: Denies [x]
Endocrine: Diabetes [ ] Thyroid [ ] Other: Denies [x]
Heme/ID: Denies [x]
Neuro: TIA [ ] CVA x ] Neuropathy [ ] Seizures [ ]
Other: Denies [ ]
PHYSICAL EXAMINATION:
Pulse: 65
B/P: 133/67
Resp: 18
O2 Sat: 98% (RA)
Temp: 97.6
Height: 69 inchaes Weight: 185 lbs
General: Alert, pleasant male in NAD seated in chair.
Skin: Multiple red skin lesions upper and lower extremities.
Turgor fair. Hair growth to ankles. Well healed sternal
incision.
HEENT: Normocephalic, anicteric. Upper dentures, lower dentition
intact. Oropharynx moist. Conjunctiva pink.
Neck: Supple, trachea midline, bilateral carotid bruit vs
murmer.
Chest: Irreg. Murmer III/VI RSB throughout. No heaves/thrills.
Abdomen: Soft, nontender, nondistended. (+)BS x 4 quadrants.
Extremities: Trace pedal edema RLE, 1+ edema LLE.
Neuro: A+O x 3, HOH, asking questions approp. Gross FROM.
Limited
ROM right thumb secondary to prior trauma.
Pulses: palpable peripheral pulses.
DISCHARGE:
General: Alert, pleasant male lying in bed, NAD.
Skin: Heels intact. left torso/axilla echymosis improved,
yellowing. Left chest incision clean and dry, no erythema, mild
echymosis, edema decreasing, steristrips intact.
Turgor fair. Hair growth to ankles. Well healed sternal scar.
HEENT: Normocephalic, anicteric. Upper dentures, lower dentition
intact. Oropharynx moist. Conjunctiva pink.
Neck: Supple, trachea midline.
Chest: II/VI murmer RSB, no radiation to carotids. No
heaves/thrills.
Abdomen: Soft, nontender, nondistended. (+)BS x 4 quadrants. (BM
x2)
Extremities: No edema. Groin sites clean and dry, trace
echymosis, right groin palp ridge.
Neuro: A+O x 3, HOH, asking questions approp. Gross FROM.
Limited
ROM right thumb secondary to prior trauma. Ambulated with
rolling walker,gait fairly steady.
Pulses: palpable peripheral pulses.
Pertinent Results:
LABS ON ADMIT:
[**2123-4-23**] 11:00AM BLOOD WBC-6.8 RBC-4.24* Hgb-14.5 Hct-42.2
MCV-99* MCH-34.1* MCHC-34.3 RDW-14.0 Plt Ct-215
[**2123-4-23**] 11:00AM BLOOD Neuts-73.8* Lymphs-19.4 Monos-5.2 Eos-0.8
Baso-0.8
[**2123-4-23**] 11:00AM BLOOD PT-10.3 INR(PT)-0.9
[**2123-4-23**] 11:00AM BLOOD Glucose-153* UreaN-53* Creat-2.0* Na-137
K-4.3 Cl-99 HCO3-28 AnGap-14
[**2123-4-26**] 06:30AM BLOOD ALT-22 AST-34 CK(CPK)-79 AlkPhos-80
TotBili-0.4
[**2123-4-25**] 07:17AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1
[**2123-4-26**] 06:30AM BLOOD %HbA1c-6.1* eAG-128*
LABS ON DC:
[**2123-5-3**] 07:25AM BLOOD WBC-5.4 RBC-3.24* Hgb-10.9* Hct-33.5*
MCV-103* MCH-33.5* MCHC-32.4 RDW-13.8 Plt Ct-278
[**2123-5-3**] 07:25AM BLOOD PT-10.7 PTT-25.6 INR(PT)-1.0
[**2123-5-3**] 07:25AM BLOOD Glucose-107* UreaN-41* Creat-1.6* Na-142
K-4.2 Cl-102 HCO3-31 AnGap-13
[**2123-5-3**] 07:25AM BLOOD ALT-33 AST-42* CK(CPK)-66 AlkPhos-87
TotBili-0.4
INTRAOP TEE [**2123-4-27**]:
Prevalve Implant
No atrial septal defect is seen by 2D or color Doppler. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). with mild global
RV free wall hypokinesis. There are simple atheroma in the
ascending aorta. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. Mild
to moderate ([**2-15**]+) mitral regurgitation is seen. There is no
pericardial effusion. Drs [**Last Name (STitle) **] , [**Name5 (PTitle) **] and [**Name5 (PTitle) 914**] notified in
person of the results on [**2123-4-27**] at 915 am.
Post valve implant
Corevalve seen in the aortic position. Appears seated a little
high for postion. Two mild perivalvular leaks seen. Rest of the
examination is unchanged.
TTE [**2123-5-3**]:
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
The estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
An aortic CoreValve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Well seated, normal functioning CoreValve aortic
prosthesis. Trace aortic regurgitation. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Mild mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2123-4-28**],
the findings are similar.
Brief Hospital Course:
HOSPITAL COURSE: 83yo caucasian male who got a Corevalve for
severe symptomatic aortic stensois, and a PPM for second degree
heart block.
Problem [**Name (NI) **]:
#. Symptomatic Severe Aortic Stenosis: on dc pt is POD#6
Corevalve/TAVI. Access was obtained with 18 Fr in right leg with
perclose. He got angioseal to left groin.
Pacer was used during the procedure. The first valve popped out,
placed 2nd valve, and had 1+ perivalvular leak after procedure.
He got 450 cc of contrast. He will need to be on dual
antiplatelet therapy x minimum 3 mos ([**Last Name (LF) 88602**], [**First Name3 (LF) **]). We
decreased his [**First Name3 (LF) **] to 81mg daily and the pt was ambulating
regularly s/p core valve.
#. Diastolic heart failure: we gently diuresed the pt, initally
with IV and then later with Lasix 40mg po which we decreased to
20mg daily post discharge as patient was back to preop weight.
We continued lisinopril at 10mg which may need to be increased
after dc. We discontinued patients home amlodipine and htz.
#. Arrythmia: pt had second degree heart block and was POD 10
s/p placement of [**Company 1543**] Adapta PM. No events occurred and the
pt remained stable.
#. CAD: pt is s/p CABG x6. SVG to the PDA is occluded. All
other grafts were patent. We continued ezetimibe/simvastatin,
Metoprolol Succinate XL 12.5 mg PO DAILY and Aspirin 81 mg PO
DAILY
#. CKD-stage III. The pt was tolerating ACE-I low dose. His Cr
was at baseline on dc.
#. HTN. We continued beta blocker and lisinipril 10mg daily.
#. diabetes: We managed with insulin s/s
# obstructive sleep apnea: pt used CPAP mask at night
# anemia: Pt remained hemodynamically stable, incisions sites
were clean and dry and there were no signs of active bleeding.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - one
Tablet(s) by mouth daily
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - 50,000 unit Capsule - one Capsule(s) by mouth three
times weekly
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other Provider)
- 40 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth
daily
EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg
Tablet - one Tablet(s) by mouth daily
GLIMEPIRIDE - (Prescribed by Other Provider) - 2 mg Tablet - one
Tablet(s) orally daily
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - one Tablet(s) by mouth daily
HYDROCODONE-ACETAMINOPHEN [VICODIN] - (Prescribed by Other
Provider) - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth four times
a day
LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet -
one Tablet(s) by mouth daily
Medications - OTC
ASPIRIN, BUFFERED - (Prescribed by Other Provider) - 325 mg
Tablet - one Tablet(s) by mouth daily
MULTIVIT WITH MIN-FA-LYCOPENE [ONE-A-DAY MEN'S] - (Prescribed by
Other Provider) - Dosage uncertain
VITAMINS-LIPOTROPICS [LIPO-FLAVONOID PLUS] - (Prescribed by
Other Provider) - Dosage uncertain
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) as needed for constipation.
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. glimepiride 2 mg Tablet Sig: One (1) Tablet PO daily ().
9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
16. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-15**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for nasal dryness.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 81223**]Nusing Care and Rehab
Discharge Diagnosis:
1. Aortic stenosis - POD#6 s/p Corevalve/TAVI
2. diastolic heart failure
3. Arrythmia-AV block second degree, Mobitz II - POD#10 s/p
[**Company 1543**] Adapta ADDRL1 DDD pacemaker placement
4. CAD s/p CAGB x 6 (SVG to the PDA is occluded, all other
grafts patent)
5. CKD- Stage III (Baseline Cr 1.6)
6. HTN
7. Diabetes
8. Obstructive Sleep apnea (uses CPap machine at night)
9. Meniere's disease/vertigo
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:
Mr [**Known lastname 6608**],
It has been a pleasure caring for you here at [**Hospital1 18**]
throughout your stay from [**2123-4-23**] through [**2123-5-3**]. You were
admitted for severe symptomatic aortic stenosis for which you
were extremely short of breath with increasing fatigue,
diastolic heart failure for which you were retaining fluid, and
an irregular heart rythm of second degree heart block which put
you at risk for progressing to a more dangerous heart rythm. For
this, you received a permanent pacemaker to prevent your heart
from skipping beats. For your severe symptomatic aortic stenosis
you had a transcatheter percutaneous aortic valve replacement
with a Corevalve 31mm device. You did not receive any blood
products. You did not have any major post procedure
complications. You have continued to progress in your recovery
and are ready for discharge to a rehab facility for further
monitoring and strengthening.
Several changes have been made to your medications:
1. DISCONTINUE amlodipine
2. DISCONTINUE hydrochlorothiazide (HCTZ)
3. REDUCE your aspirin to 81mg daily
4. REDUCE your lisinopril to 10mg daily (this may need to be
increased at a later date as your blood pressure increases)
5. ADD furosemide 20mg daily
6. ADD [**Year (4 digits) 88602**] 75mg daily
7. ADD metropolol succinate 12.5mg daily
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2123-5-26**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2123-5-26**] at 1 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2123-5-26**] at 1 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2123-5-26**] at 2:00 PM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: Dr. [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) **]
Location: CMC-[**Location (un) **] HEART INSTITUTE
Address: [**Location (un) **], [**Apartment Address(1) 88603**], [**Location (un) **],[**Numeric Identifier 86371**]
Phone: [**Telephone/Fax (1) **]
Appointment: Tuesday [**2123-5-11**] 1:40pm
*This is a follow up appointment for your hospitalization you
will be reconnected with your primary cardiologist after this
visit.
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
ICD9 Codes: 4241, 4280, 3572, 2724, 2859 |
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