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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2900
} | Medical Text: Admission Date: [**2169-10-25**] Discharge Date: [**2169-12-4**]
Date of Birth: [**2116-10-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7760**]
Chief Complaint:
coffee-ground emesis
Major Surgical or Invasive Procedure:
1) Ex-lap, ileocecectomy [**10-25**]
2) Return to OR for washout and ileostomy creation [**10-27**]
3) CVVHD [**10-26**] - [**11-6**]
4) Ex-lap, washout, resection of transverse and limited
descending colon for ischemic segment of splenic flexure [**10-30**]
5) IVC filter placement [**10-31**] (for prophylaxis, h/o L
subsegmental PE and multiple)
6) Abdominal closing at bedside (sutured [**Location (un) 5701**] bag to reduce
abdominal opening by ~50%)
7) Ex-lap, washout, omentectomy, GJ tube placement, open
tracheostomy, abdominal wall closure [**2169-11-3**]
History of Present Illness:
53M with multiple medical problems, transported from nursing
home to [**Hospital1 18**] ED for coffee-ground emesis, hypotension, and
tachycardia noted after dialysis. He was found to have an upper
GI bleed in the setting of fevers and sepsis. The upper GI
bleeding resolved. Once stabilized, a CT scan was obtained
which revealed free air and a dilated thickened cecum. Because
of this, he was taken emergently to the operating room for
exploration.
Past Medical History:
ESRD on HD, left AV fistula clotted
DM
Dementia
Anemia
Seizure disorder
HTN
Depression
Pneumonias
Social History:
per daughter - no ETOH, "a lot" cigarettes
Family History:
noncontributory
Physical Exam:
On admission:
T 96.1 HR 135 BP 79/52 RR 17 O2sat 88%
Gen: intubated and sedated
CV: reg rhythm, tachycardic
Lungs: CTAB
Abd: soft, mildly distended, no tenderness elicited, no masses
Rectal: no tenderness elicited, no masses noted, heme neg
.
ON DISCHARGE:
T: 98.1 HR: 81 BP: 149/63 RR: 19 Sat: 97% trach mask
NAD, alert and awake
RRR
coarse bilateral breath sounds
soft, mildly distended, wound healing well with grannulation
tissue, clean
no edema of extremities
Pertinent Results:
[**2169-10-25**] 05:19AM WBC-5.9 RBC-3.56* Hgb-12.6* Hct-38.8* MCV-109*
MCH-35.5* MCHC-32.6 RDW-21.0* Plt Ct-457*
[**2169-10-25**] 05:19AM Neuts-74* Bands-7* Lymphs-16* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-2*
[**2169-10-25**] 05:19AM PT-14.6* PTT-24.1 INR(PT)-1.3*
[**2169-10-25**] 08:10PM Fibrino-449* D-Dimer-3084*
[**2169-10-25**] 05:19AM Glucose-194* UreaN-29* Creat-5.1* Na-137 K-4.8
Cl-93* HCO3-21* AnGap-28*
[**2169-10-25**] 07:21PM ALT-17 AST-59* AlkPhos-77 TotBili-0.2
[**2169-10-25**] 05:19AM CK(CPK)-184 CK-MB-4 cTropnT-0.08*
[**2169-10-25**] 11:21AM CK(CPK)-404 CK-MB-6 cTropnT-0.06*
[**2169-10-25**] 11:21AM ALT-17 AST-48*
[**2169-10-25**] 11:21AM Calcium-7.8* Phos-1.1* Mg-1.8
[**2169-10-25**] 05:12AM Lactate-10.8*
.
ON DISCHARGE:
[**2169-12-4**] 02:55AM BLOOD WBC-12.4* RBC-3.12* Hgb-9.2* Hct-28.5*
MCV-91 MCH-29.5 MCHC-32.3 RDW-19.4* Plt Ct-501*
[**2169-12-2**] 01:30AM BLOOD PT-14.7* PTT-30.6 INR(PT)-1.3*
[**2169-12-4**] 02:55AM BLOOD Glucose-102 UreaN-92* Creat-7.5*# Na-141
K-4.4 Cl-98 HCO3-22 AnGap-25*
[**2169-12-4**] 02:55AM BLOOD ALT-48* AST-63* AlkPhos-607* Amylase-221*
TotBili-1.2
[**2169-12-4**] 02:55AM BLOOD Lipase-160*
[**2169-12-4**] 02:55AM BLOOD Calcium-11.0* Phos-9.1*# Mg-2.5
.
Brief Hospital Course:
53M with ESRD and multiple medical problems was transported from
nursing home to [**Hospital1 18**] ED on [**10-25**] for coffee-ground emesis,
hypotension to 70's, and tachycardia to 130's. NGT was placed,
which returned coffee-ground colored liquid. He was intubated
and sedated in ED for airway protection, and given 6U PRBC, 2U
FFP, 2L crystalloid for presumed GI bleed. GI was consulted for
possible EGD and intervention. Post-transfusion Hct was 38.
Cultures were sent, and Vanc/Zosyn were started empirically. CT
scan of the abdomen/pelvis was done, which showed free
intraperitoneal air and fluid suggestive of perforation, and
markedly dilated colon with a sharp transition in the region of
the splenic flexure. Of note, he was also found to have LLL
pulmonary emboli with bilateral ultrasound negative for DVTs.
He was taken urgently to the OR for ex-lap, and ileocecectomy
was performed, with plans to return to OR for washout and
closure/maturing of ostomy at later date.
.
Postoperatively, he remained stable in the TICU - on CVVH, BP
supported with pressors, Vanc/Zosyn continued, Fluc was added
for broader coverage, PPI [**Hospital1 **] for prophylaxis.
.
On [**10-27**], he was taken back to the OR for exploratory
laparotomy, removal of
[**Location (un) 5701**] bag, ascending colectomy, abdominal wash-out, ileostomy
maturation and reclosure with [**Location (un) 5701**] bag. Post-operatively, he
became tachycardic to 200's, and was cardioverted. An ECHO was
performed which demonstrated LVEF > 55% wuth grossly normal
biventricular systolic function. A repeat ECHO on [**10-30**] showed
similar findings. On [**10-29**], platelets were noted to be
significantly decreased, so all heparin products were stopped,
and HIT antibody was sent, which was ultimately came back
negative.
.
On [**10-30**], he underwent ex-lap, washout, resection of transverse
and limited descending colon for ischemic segment of splenic
flexure. Exploratory laparotomy, washout, transverse colectomy,
closure with a [**Location (un) 5701**] bag and left groin dialysis
catheter placement.
.
On [**2169-10-31**] he had a IVC filter placed by Dr. [**Last Name (STitle) **] for
prophylaxis, h/o L subsegmental PE. He underwent abdominal
closure at the bedside (sutured [**Location (un) 5701**] bag to reduce abdominal
opening by ~50%). He continued to have elevated LFTs and a RUQ
ultrasound was performed for possible cholecystitis on [**2169-11-2**],
it showed sludge without evidence of cholecystitis. On [**2169-11-3**],
he returned to the OR for exploratory laparotomy, abdominal
washout, abdominal wall closure with retention sutures,
gastrostomy tube and tracheostomy. Infectious disease was
consulted on [**2169-11-7**] for tailoring of his antibiotics towards
[**Female First Name (un) 564**], Enterococcus, and Basteroides grown from his cultures.
He continued on CVVH until [**2169-11-7**] whe he was transitioned to
hemodialysis.
.
On [**2169-11-9**] A CT scan of his abdomen for persistent fevers found
an 11 cm thick-walled fluid collection in the mid lower pelvis
just beneath the intralesional scar, most likely representing
abscess in this setting of cecal perforation and fever and he
underwent drainage and placement of a pigtail catheter under CT
guidance. The placement of the drain was complicated by a
postop bleed with a decrease of his hematocrit to 23.6. He was
managed conservatively with transfusions for the pelivc hematoma
and was transfused a total of 10 units of PRBC and 2 units FFP
up to [**2169-11-19**] when he finally stablized his hematocrit in the
27-30 range. Repeat CT scan on [**2169-11-13**] demonstrated stable
size of the hematoma. A repeat ultrasound on [**2169-11-17**] for
possible drainage found the large predominantly solidified
pelvic hematoma not amenable to drainage. He continued to have
fevers daily and his lines were changed. All cultures, except
for his initial cultures from his OR swab, were negative.
During the period of management of his pelvic hematoma, he also
developed an ileus with decreased output from his ostomy and was
provided nutrition via TPN. He stopped having fevers and his
antibiotics(zosyn, flagyl, fluconazole, and daptomycin) were
finally stopped on [**2169-11-27**]. His ileus resolved and he was
restarted on tube feeds, slowly advanced to goal. His right
subclavian quentin catheter used for dialysis was removed and a
tunneled catheter was placed by interventional radiology on
[**2169-11-30**] in the right internal jugular vein.
.
His retiention sutures were removed on [**2169-12-2**] with his wound
healing well by secondary intention and essentially closed at
the skin. His JP drain from his initial operation was also
discontinued with minimal output. His pain has been
well-controlled with Dilaudid prn. He has remained
hemodynamically stable since his last operation on [**2169-11-3**]. His
respiratory status has slowly improved with the ability to
tolerate trach mask for the majority of the day, occasionally
becoming tachypnic and diaphoretic when he tires. He continues
to tolerate TF via his J-tube and his G-tube clamped. He
received dialysis via his tunnel right IJ catheter on Monday,
Wednesday, and Friday. He has been afebrile since [**2169-12-1**] and
his hematocrit stable in the 27-28 range. He was deemed stable
for discharge to an extended care facility and will follow-up
with Dr. [**Last Name (STitle) **].
Medications on Admission:
ASA, Lanthanum, Prozac, Lisinopril, Lopressor, Kayexalate,
Nephrocap, Lopid, Estraderm
Discharge Medications:
1. Metoprolol Tartrate 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1)
Intravenous Q4H (every 4 hours): SBP > 160.
2. Hydromorphone 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) Injection Q3H
(every 3 hours) as needed for pain.
3. Hydralazine 20 mg/mL Solution [**Last Name (STitle) **]: One (1) dose Injection Q6H
(every 6 hours) as needed for SBP>160.
4. Acetaminophen 650 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
5. Influenza Tri-Split [**2169**] Vac Intramuscular
6. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Year (4 digits) **]: One (1)
ML Intravenous DAILY (Daily) as needed.
7. Metoprolol Tartrate 25 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO TID
(3 times a day): Hold for SBP < 100 or HR < 60.
8. Heparin (Porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1)
Injection TID (3 times a day).
9. Gemfibrozil 600 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times
a day).
10. Levothyroxine 125 mcg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
(Daily).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Aluminum Hydroxide Gel 600 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty
(30) ML PO TID (3 times a day).
13. Insulin sliding scale
NPH 14 units Q12H
.
Scale
Glucose Insulin Dose Regular
0-60 mg/dL [**1-3**] amp D50
61-120 mg/dL 0 Units
121-140 mg/dL 5 Units
141-160 mg/dL 8 Units
161-180 mg/dL 11 Units
181-200 mg/dL 14 Units
201-220 mg/dL 17 Units
221-240 mg/dL 20 Units
241-260 mg/dL 23 Units
261-280 mg/dL 26 Units
281-300 mg/dL 29 Units
301-320 mg/dL 32 Units
321-340 mg/dL 35 Units
341-360 mg/dL 38 Units
> 361 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Cecal perforation
LLL Pulmonary emboli
Pelvic Hematoma
Anemia
ESRD on HD
HTN
DM
Discharge Condition:
Stable, to extended care facility.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
.
Diet:
Please continue your tube feeds.
.
Medication Instructions:
Please take all medications as prescribed.
.
Activity:
No heavy activity until directed. Please continue physical
therapy.
.
Renal:
Please continue hemodialysis per renal.
.
Please follow-up as directed.
ICD9 Codes: 5789, 5856, 0389, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2901
} | Medical Text: Admission Date: [**2165-2-2**] Discharge Date: [**2165-2-7**]
Date of Birth: [**2165-2-2**] Sex: M
Service: NEONATOLOG
HISTORY OF THE PRESENT ILLNESS: The baby is a 36 week
gestation male, twin A, delivered by cesarean section with no
labor due to poor growth of a discordant twin B girl admitted
to the NICU with respiratory distress.
PRENATAL HISTORY: The mother is 40-years-old, gravida I,
para 0 now II, EDC [**2165-3-2**]. Prenatal screens: O positive,
AB negative, RPR nonreactive, rubella immune, hepatitis B
surface antigen negative, Group B Streptococcus unknown.
This was an IVF conception. The pregnancy was complicated by
preterm labor at 26 weeks, treated with terbutaline. Twin B
fell to less than the tenth percentile on the most recent
ultrasound. Therefore, the decision to deliver by cesarean
section was made.
Rupture of membranes was at delivery. Twin A emerged with
spontaneous cry, required only blow-by oxygen, and developed
progressive respiratory distress and, therefore, was
transferred to the NICU for evaluation and admission.
ADMISSION PHYSICAL EXAMINATION: Weight 3.020 kilograms, AGA,
heart rate 180, respiratory rate 42, pulse 71/42, mean 47,
temperature 98.7, oxygen 100% on blow-by oxygen. The baby
was [**Name2 (NI) 43619**] with overall appearance consistent with
known gestational age. AFSOF, positive grunting and flaring,
palate was intact, marked intercostal and subcostal
retractions, diminished air entry, regular rate and rhythm
without murmur. The abdomen was benign without HSM. No
masses, normal male genitalia with testes in lower canal
bilaterally. Normal back and stable hips. The skin was pink
and well perfused. The baby was [**Name2 (NI) 3584**] and responsive with
appropriate tone and strength.
LABORATORY DATA: The D stick was 40. The CBC included a
hematocrit of 47.5, platelets 279,000, I/T was benign.
ASSESSMENT AND PLAN: The assessment and plan at that time
was that of a 36 week gestation male delivered preterm via
cesarean section with respiratory distress and borderline
hypoglycemia. Respiratory symptoms were likely due to
combination of Surfactant deficiency and retained fetal lung
fluid. No perinatal risk factors for sepsis. Cannot rule
out pneumonia. Hypoglycemia likely due to poor glycogen
stores in the setting of stress.
1. CPAP. If symptoms persist, consider chest x-ray, blood
gas, Surfactant.
2. Nothing by mouth until respiratory symptoms normalize,
D10 bolus, maintenance IV fluids, D10 water at 60 cc per
kilogram per day.
3. Follow blood cultures, ampicillin and gentamicin pending
clinical course, 48 hour blood culture rule out.
4. I spoke with the parents in the Delivery Room. We will
keep the parents updated.
HOSPITAL COURSE:
1. RESPIRATORY: The baby was weaned off CPAP by day of life
number one and remained on room air throughout. The baby was
transferred to the normal nursery on hospital day number two.
There the baby was noted to have a cyanotic episode with a
bottle feed during an evaluation with lactation therapy. An
oxygen saturation was not obtained. The patient recieved BBO2
and was transferred back up to the NICU for evaluation.
Upon arrival to the NICU, the patient had sats in the high
90s and was comfortable. A chest x-ray was obtained at that
time that was normal. The patient remained on room air with
one witnessed "dusky episode" while bottle feeding on
hospital day number three that did not correlate with a low
saturation. Saturations remained in the high 90s during
this episode.
The patient was started on Decadron ophthalmic drops infused
in the nares for nasal stuffiness thought to be secondary to
CPAP inflammation from the previous admission. The patient
remained on Decadron nasal drops for a period of 24 hours and
then was watched for an additional 36 hours off of the
Decadron nasal drops for desaturations and the patient had no
desaturations in the 48-60 hours prior to discharge and had
been able to maintain his saturations well into the high 90s
with all of his feeds.
The patient had no episodes of central appearing apnea. The
patient is comfortable and stable from a respiratory
standpoint on discharge.
2. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient had
mild hypoglycemia that resolved with one D10 bolus on day of
life number zero. The baby was started on breast feeding and
bottle feeds and worked up to full feeds. The mother had
decided to discontinue breast feeds and the baby continued on
[**Name (NI) 37112**] 20 where he has remained since day of life number
three on ad lib on demand taking greater than 100 cc per
kilogram per day.
Baby [**Known lastname 46596**] birth weight was 3,020 and the discharge
weight was 2,760.
3. GASTROINTESTINAL: The baby [**Name (NI) 46597**]. The patient had an
indirect hyperbilirubinemia with a total bilirubinemia of
9.5/0.3 that seemed to resolve clinically as his p.o. feeds
were progressing.
4. HEMATOLOGY: The patient had a stable hematocrit of 47
and that was not rechecked.
5. INFECTIOUS DISEASE: The patient's blood cultures were
negative at 48 hours and the ampicillin and gentamicin were
discontinued at 48 hours. The patient was stable off
antibiotics for three days.
6. NEUROLOGIC: The patient had no neurologic issues this
admission.
7. HEARING SCREEN: A hearing screen was done and passed
prior to discharge.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: [**Hospital **] Pediatrics.
FEEDS AT DISCHARGE: [**Hospital 37112**] p.o. ad lib on demand.
DISCHARGE MEDICATIONS: The baby was on no medications.
CAR SEAT TEST: The baby passed his car seat test.
STATE SCREEN: The baby had a state screen sent and is
pending.
IMMUNIZATIONS: The mother deferred hepatitis B vaccine to the
pediatrician's office. The baby does not qualify for [**Name (NI) 38801**]
at this point.
DISCHARGE DIAGNOSIS:
1. Intermittent desaturation thought to be secondary to
nasal passage trauma, resolved.
2. Prematurity.
3. Transient tachypnea of the newborn
4. Sepsis ruled out
5. Hypoglycemia, resolved
6. Physiologic Jaundice
Thank you for allowing us to take care of baby boy [**Name (NI) **].
We wish him the best of luck.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**]
Dictated By:[**Name8 (MD) 43626**]
MEDQUIST36
D: [**2165-2-7**] 11:09
T: [**2165-2-7**] 11:14
JOB#: [**Job Number 46598**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2902
} | Medical Text: Admission Date: [**2175-8-19**] Discharge Date: [**2175-9-12**]
Service: SURGERY
Allergies:
Aspirin / Azithromycin / Codeine
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
traumatic brain injury/stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87M with a history of hypertension and renal insufficiency not
anticoagulated who presents from an outside hospital after a
fall from standing. The patient was at a wedding when he
reportedly fell without breaking his fall. He was transferred to
[**Hospital **] Hospital where he was intubated for a GCS 8. Head CT at
the OSH reveals bilateral subarachnoid hemorrhages with
associated intraventricular hemorrhage.
Past Medical History:
PMH: HTN, hx TIA, CRI
PSH: IHR, lap ccy
Social History:
Retired Professor [**First Name (Titles) **] [**Last Name (Titles) 75591**]. Works around the house, recently
did some gardening. Only uses etoh socially and does not smoke.
Family History:
noncontributory
Physical Exam:
P/E at Discharge:
EXPIRED
Pertinent Results:
LABORATORIES:
Admit:
[**2175-8-19**] 09:35PM BLOOD WBC-7.8 RBC-3.94* Hgb-12.7* Hct-33.7*
MCV-86 MCH-32.1* MCHC-37.5* RDW-15.2 Plt Ct-180
[**2175-8-19**] 09:35PM BLOOD PT-13.6* PTT-20.3* INR(PT)-1.2*
[**2175-8-20**] 12:29AM BLOOD Glucose-162* UreaN-39* Creat-2.3* Na-135
K-3.6 Cl-107 HCO3-18* AnGap-14
[**2175-8-20**] 12:29AM BLOOD ALT-18 AST-30 CK(CPK)-108 AlkPhos-164*
Amylase-202* TotBili-0.6
[**2175-8-20**] 12:29AM BLOOD Albumin-3.7 Calcium-9.0 Phos-4.2 Mg-2.0
IMAGING:
CT Head [**8-19**]: 1. Stable bilateral subdural hematomas without
associated mass effect and small focus of extra-axial hemorrhage
adjacent to the left cerebellar hemisphere. 2. Bilateral
subarachnoid hemorrhages extending into sylvian fissures, which
appear slightly increased in the interval. 3. Minimally
displaced right parieto-temporal bone fracture.
MR [**Name13 (STitle) 430**] [**8-20**]: 1. Acute infarction in the right temporal and
inferior parietal lobes, in the right middle cerebral artery
territory. The right middle cerebral artery and its proximal
branches are patent, but smaller in caliber compared to the
left. This appearance is compatible with vasospasm, but onset of
vasospasm one day following subarachnoid hemorrhage is highly
unusual. 2. Bilateral subdural, subarachnoid, and
intraventricular hemorrhage, as seen on the preceding CT scan.
The parafalcine and paratentorial extent of the subdural
hemorrhage is new since [**2175-8-19**]. 3. Small right superior medial
frontal hemorrhagic contusion and a small left inferior
cerebellar hemisphere parenchymal hemorrhage, as seen on the
preceding CT scan, but newly evident since [**2175-8-19**].
TTE [**8-22**]: No cardiac source of embolus identified (cannot
definitively exclude).
TTE [**8-24**] (Bubble study): No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers.
[**8-28**]: Renal U/S: neg for obstruction
EEG [**8-29**]: IMPRESSION: Abnormal EEG due to the slowing of the
background with bursts of generalized slowing, indicating a
widespread encephalopathy
and due to a lower voltage background on the right side,
indicating a
widespread cortical dysfunction on that side or material
interposed
between the brain surface and recording electrodes, e.g.
subdural fluid.
There were no clearly epileptiform features though much of the
recording
was degraded by lead artifact. An abnormal cardiac rhythm was
noted.
CT C/A/P [**9-1**]: 1. Asymmetrically enlarged right thyroid lobe
without discrete nodule, possibly due to goiter, if clinically
indicated, could be evaluated with thyroid ultrasound. 2.
Bilateral trace pleural effusions with adjacent compressive
atelectasis, cannot exclude superimposed infection in the larger
left consolidation. 3. NG tube in place. 4. Extensive
diverticulosis without diverticulitis. 5. Pagetoid bony changes.
6. Fat-containing left inguinal hernia.
MICROBIOLOGY:
[**8-19**] MRSA: neg
[**8-21**] MRSA: pending
[**8-23**] BCx: GNR's x 2 bottles
[**8-23**] UCx: NGTD
[**8-23**] UCx (anaerobic): NGTD
[**8-23**] U/A: large leuk, >182 WBC, mod bacteria, neg nitrites, few
WBC clumps
[**8-24**] BAL: 2+ GRAM POSITIVE COCCI (IN PAIRS AND CLUSTERS). 1+
GRAM POSITIVE ROD(S).
PATHOLOGY: None
Brief Hospital Course:
The patient was transferred from OSH to [**Hospital1 18**] ED having been
intubated for GCS 8. Trauma protocol was initiated on arrival
with evaluation by ACS and ED teams. Patient was
hemodynamically stable. Appropriate trauma scans were obtained
as per above. Patient was transferred to the TSICU for further
management under care of the ACS team.
Neuro: Initial CT head obtained in trauma bay demonstrated
traumatic brain injury. Dilantin loaded and maintained on
seizure prophylaxis per neurosurgery as no other NSurg
intervention was warranted. Repeat CT head [**8-20**] demonstrated
stable TBI. MRI obtained [**8-20**] demonstrated R MCA stroke.
Mental status [**8-20**] improved to support extubation though patient
patient was agitated post extubation. Agitation well managed
with medication. Neuro stroke team consulted [**8-21**]. Head CT was
repeated [**8-22**] with redistribution of traumatic bleed but overall
stable. Patient showed improved mental status and was OOB to
chair and appropriately interactive. CT head was again repeated
[**8-25**] for altered mental status and found to be largely stable.
Per neuro, EEG obtained [**2081-8-24**] to assess for occult seizure
activity though none was evident on EEG. Mental status
continued to be poor with minimal interaction [**8-30**]. Overall
activity level continued to decline. Agitation regimen was
titrated appropriately. Neurology evaluation [**9-6**] noted overall
very poor prognosis for recovery of meaningful function.
CV: Patient was hemodyamically stable on arrival. Following
diagnosis of stroke, vascular workup was undertaken including
carotid US [**8-22**] (40% stenosis bilaterally) and TTE with no
evidence of embolic source. Repeat TTE w bubble study [**8-24**] was
negative for PFO. Lopressor started [**8-25**] for persistent
tachycardia. PACS/PVCs seen on telemetry [**8-27**] though remained
hemodynamically stable. [**8-30**] demonstrated
tachycardia/hypotension in setting possible sepsis. Cardiology
consulted for paroxysmal afib in setting likely sepsis.
Amiodarone was started per cardiology. TEE performed [**9-6**]
showing preserved EF and no thrombus.
Pulmonary: Patient arrived to [**Hospital1 18**] intubated. Met criteria for
vent wean [**8-20**] and successfully extubated. Patient did well w
floor transfer [**8-23**]. Transferred back to ICU [**8-23**] PM w
respiratory distress following aspiration. Pulmonary function
worsened requiring re-intubation [**8-23**] PM with bronchoscopy
showing significant secretions. Patient extubated when meeting
criteria. Continued with labored breathing though ABGs and CXRs
without significant abnormality. Re-intubated [**8-30**] for
respiratory distress and bronchoscopy showed copious secretions.
IP consulted and repeated bronch [**9-1**] with no new findings
evident. Patient continued ventilatory support with poor
performance on CPAP.
GI/GU: On admission patient was maintained on IVF and was NPO
related to intubation. Speech and swallow evaluated patient
[**8-21**] and was cleared for supervised diet with thin liquids and
pureed solids. Fluids were discontinued [**8-22**] and patient
tolerated regular diet well. Patient was transferred to floor
[**8-23**] but likely had aspiration event with feeding. Dobhoff tube
placed [**8-24**] and TFs initiated. TFs continued with intermittent
interruptions [**1-11**] loss of enteral access. Bowel regimen was
maintained throughout admission.
Patient arrived to [**Hospital1 18**] with foley in place. Has baseline of
known CKI. Made good urine and foley removed [**8-23**] with
improvement in mental status. Diuresis with lasix initiated
[**8-22**] with good response. Finasteride and terazosin were resumed
9/14 per home regimen. Lasix gtt started [**8-28**] for fluid
overload and this had good effect. Renal US [**8-28**] for rising
creatinine showed no evidence of obstruction or renal artery
stenosis. Renal consult obtained [**8-29**]. Fluid balance managed
with albumin/lasix in combination. Recommendations from renal
followed.
ID: Patient transferred back to ICU [**8-23**] with respiratory
distress as above. Pan cultures obtained. Fever and
leukocytosis increased. UA showed likely UTI and cipro
initiated. ID was consulted [**8-24**] and patient started on
vancomycin/zosyn for presumed VAP. Febrile [**8-29**] with further
cultures obtained. ID continued to follow and antibiotics were
tailored to evolving culture data. Antibiotics discontinued
[**9-7**] as patient afebrile.
Prophylaxis: The patient received subcutaneous heparin during
this stay when cleared by neuro stroke and neurosurgery.
HEME: B/L UE swelling prompted US [**8-28**] showing B/L UE
superficial thrombophlebitis with clot surrounding RUE PICC.
PICC removed and LIJ placed. B/L LENIs were negative for DVT.
RHEUM: Concern for gout [**8-28**] prompted allopurinol therapy though
uric acid level WNL.
DISPO: Patient admitted to ICU for management. Family present
at time of arrival to [**Hospital1 18**]. Family meeting held [**8-27**] to
discuss goals of care with outcome of continued full code. In
accordance with family wishes, patient made CMO [**9-11**] in light of
poor prognosis and failure to progress.
Patient expired [**2175-9-12**].
Medications on Admission:
[**Last Name (un) 1724**]: Allopurinol 300, Atenolol 25, Desonide 0.05% top'',
Doxercalciferol 1.5, Finasteride 5, Fluticasone 50'', Furosemide
40, Hydrocortisone top 2.5%'', Ranitidine 300, Terazosin 20,
Timolol maleate (dose unknown), Triamcinolone acetonide top
0.1%'', Acetaminophen 500prn
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Right middle cerebral artery cerebrovascular accident
2. Traumatic brain injury
3. Right temporoparietal fracture
4. Aspiration pneumonia
5. Urinary tract infection
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
Completed by:[**2175-9-12**]
ICD9 Codes: 5070, 5849, 2760, 5990, 2859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2903
} | Medical Text: Admission Date: [**2174-9-8**] Discharge Date: [**2174-9-11**]
Date of Birth: [**2119-3-4**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
acute L leg ischemia
Major Surgical or Invasive Procedure:
Left femoral embolectomy and vein patch angioplasty.
History of Present Illness:
This 55-year-old gentleman presented to our emergency room last
night with an acutely ischemic left foot which had been present
for several hours. He was placed on heparin with significant
improvement in symptoms. He had absent pulses distal to the
groin on the left with intact pulses throughout on the right. He
is now being explored for possible embolectomy.
Past Medical History:
PMH:
MI,
HIV,
HTN
Social History:
He denies any use of alcohol or IV drugs. He has smoked [**1-30**]
packs of cigarettes per day for the last 30 years.
Family History:
non contributary
Physical Exam:
HEENT:
No thrush. Neck is supple.
Full range of motion. No lymphadenopathy.
CHEST:
is clear to auscultation bilaterally.
HEART:
regular rate and rhythm without gallops or rubs noted. There is
a III/VI murmur noted at the left lower sternal border to the
left upper sternal border.
ABDOMEN:
is soft, nontender, nondistended. There were
bowel sounds noted.
RECTAL:
There is no stool in the vault. The fluid in the vault is occult
blood negative.
EXTREMITIES:
without clubbing, cyanosis or edema.
NUEROLOGICAL EXAMINATION:
Awake, alert and oriented x3.
Cranial nerves, motor examination and sensory examination were
normal.
The toes were down-going bilaterally.
Pertinent Results:
[**2174-9-11**]
WBC-6.0 RBC-2.66* Hgb-11.9* Hct-31.4* MCV-118* MCH-44.7*
MCHC-37.8* RDW-13.4 Plt Ct-184
[**2174-9-11**]
Plt Ct-184
[**2174-9-11**]
PT-12.4 PTT-27.7 INR(PT)-1.0
[**2174-9-11**]
Glucose-93 UreaN-15 Creat-0.9 Na-141 K-4.1 Cl-107 HCO3-27
AnGap-11
[**2174-9-8**]
CK(CPK)-409*
[**2174-9-11**]
Calcium-8.9 Phos-2.9 Mg-1.7
Cardiology Report ECG Study Date of [**2174-9-8**] 11:30:44 AM
Baseline artifact. Sinus rhythm. Q waves in the anterior leads
consistent with prior infarction. Probable left atrial
abnormality. Compared to the previous tracing of [**2169-3-14**] the
rate is faster.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 168 96 [**Telephone/Fax (2) 5693**] 57
[**2174-9-8**] 2:07 PM
CHEST (PRE-OP PA & LAT)
Reason: pt preop vascular surgery
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with new onset pain L leg/blanching and pulses
diminished. Arterial clot
REASON FOR THIS EXAMINATION:
pt preop vascular surgery
INDICATION: Left leg blanching and decreased pulses,
preoperative study for vascular surgery.
No studies are available for comparison on PACs.
AP UPRIGHT AND LATERAL VIEWS OF THE CHEST: The heart size is
normal. The mediastinal and hilar contours are normal. The lungs
are clear. There is no pleural effusion or pneumothorax. The
osseous structures are unremarkable.
IMPRESSION: No evidence of acute cardiopulmonary process.
GENERAL URINE INFORMATION
Type Color Appear Sp [**Last Name (un) **]
Straw Clear 1.008
Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks
SM NEG NEG NEG NEG NEG NEG 6.5 NEG
RBC WBC Bacteri Yeast Epi
0-2 0-2 NONE NONE 0-2
Brief Hospital Course:
Pt admitted on [**2174-9-11**]
Stared on heparin.
Pt undergoes a Left femoral embolectomy and vein patch
angioplasty. Pt tolerates the procedure well. There were no
complications. Flow was re-established into
the profunda femoris first and then into the superficial femoral
artery. Doppler interrogation demonstrated good flow in both
branches and there was a strongly palpable dorsalis pedis pulse.
Pt extubated in the OR. Pt transfered to the PACU in stable
condition.
Once recovered from anesthesia. Pt transfered to the PACU in
stable condition.
Once recovered from anesthesia pt transfered to the VICU
instable condition.
IV Heparin started / coumadin started.
[**2174-9-12**]
Pt delined, diet was advanced as tolerated.
PT consult was obtained. Pt was allowed to get OOB to chair.
[**2174-9-13**] - Discharge
Pt stable PTT was monitered / On Discharge pt INR not at desired
level. Pt [**Name (NI) 1788**] on lovenox for bridge over to couamdin.
On discharge pt is stable / taking PO / ambulating / pos BM /
urinating without difficulty.
Medications on Admission:
lopressor 25',
combivir,
viramune,
lisinopril,
lipitor,
aspirin
Discharge Medications:
1. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous once a day: Continue lovenox daily until INR is at
least 2.0.
Disp:*30 syringes* Refills:*0*
2. Outpatient [**Name (NI) **] Work
PT, INR labs every other day until INR is at least 2.0. Please
have the [**Name (NI) **] fax the results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD.
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*40 Tablet(s)* Refills:*0*
4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*6*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis
1) Thromboembolism s/p embolectomy and vein patch angioplasty.
secondary diagnosis
2) HIV
3) HTN
4) h/o MI
Discharge Condition:
good
Discharge Instructions:
Please resume all your home medications as before as well as the
ones prescribed to you upon discharge from the hospital. If you
experience fevers, chills, leg pain, or severe bleeding from
your incisions, please report to the emergency department.
Please do not drive for one week. Please keep your dressing on
till Monday. You may take a shower on Monday. Please do not
soak in baths or swim in pools.
Please be careful with falls and bumps because of increased risk
of bleeding with lovenox and coumadin.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one week to follow
up your blood coagulation times (PT/INR). Please call ([**Telephone/Fax (1) 5694**] to make an appointment. Dr. [**Last Name (STitle) **] will also set up
a TTE to evaluate your heart. Thank you.
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks. Please
call [**Telephone/Fax (1) 3121**] to make an appointment.
Completed by:[**2174-11-1**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2904
} | Medical Text: Admission Date: [**2104-8-5**] Discharge Date: [**2104-8-8**]
Date of Birth: [**2025-1-13**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
bleeding per rectum
Major Surgical or Invasive Procedure:
1.Colonoscopy
2.Right femoral line placement/removal
History of Present Illness:
Ms. [**Known lastname 4223**] is a pleasant 79 year-old female with severe PVD
(s/p right BKA in [**2-/2104**] and [**6-/2104**] left great toe amputation),
hemorrhoids, complicated diabetes mellitus, HTN, hyperlipidemia,
diabetic related nephropathy and neuropathy and pulmonary emboli
diagnosed in [**4-/2104**] ([**Hospital1 2025**]) who had been on combination of
ASA/Plavix/Coumadin when she presented on this admission
complaining of bright red blood per rectum for 1.5 weeks before
transfer for evaluation.
On arrival to ED, outside facility reported that patient's last
INR was 7.1 a week before and Coumadin was held temporarily. Per
the patient, she had bright red blood with bowel movements for a
little over a week that the nursing home staff were monitoring.
She notes her BM's have most recently been diarrhea which she
attributes to stool softeners at the NH and reportedly just
finished a course of Flagyl in recent weeks for suspected
C.Difficile. She had 5-10 episodes of BRBPR the past week that
were painless, definitely bright red without melena, mixed in
with the stool (not necessarily streaked), and there was blood
on the toilet paper as well. No episodes of dizziness, chest
pains, dyspnea, presyncope, weakness, blood loss anywhere else.
Of note, had a negative screening colonoscopy in [**2101**] here at
[**Hospital1 18**].
.
On [**2104-8-5**] she was brought into the ED, initial VS: [**Age over 90 **]F, HR 72
BP 118/49, RR 16 and 100%RA. Labs significant for Hct 25.3, INR
2.7, and normal Plts. GI was consulted in the ED. K was also 6.2
so she was given Ca gluconate, insulin/D50. She had BRB on
rectal exam and NG lavage was negative. Access was an issue and
she was unable to get secure peripherals, so after failed
bilateral central line (IJ) attempts, she got a triple lumen in
her right femoral region, then got 1L NS IVFs, 1u PRBC's, 2u
FFP, and Vitamin K.
.
ROS was negative for any associated abdominal pains, nausea,
emesis, vision changes, HEENT problems, headaches, poor PO
intake, dysphagia, odynophagia, SOB, cough, palpitations,
dysuria or problems with urination, skin changes.
Vitals before transfer to the ICU were HR 75, BP 148/60, RR 20
and O2 sat 100%RA. She has very stable blood pressures despite
GIB and her HCT was also stable in the 24-25 ranges in the ICU
so she was sent to the general medical floor on [**8-6**] where was
followed until time of discharge with a fairly unremarkable
course. The GI consult service followed patient closely and she
had colonoscopy performed on [**8-7**] with notable AVMs in lower GI
tract/sigmoid area that were treated with argon coagulation.
.
Past Medical History:
- Peripheral arterial disease: s/p R BKA in [**2-/2104**]; L anterior
tibial artery angioplasty then L toe amputation in [**6-/2104**]
- PE in [**4-/2104**] (diagnosed at [**Hospital1 2025**]) and placed on Coumadin
- HTN
- Hyperlipidemia
- Diabetes Mellitus type II with nephropathy and neuropathy
- diastolic CHF
- Thyroid nodules (benign)
- Transient diplopia and left leg weakness with negative MRI
[**2096**]
.
Past Surgical History: Hemorrhoidectomy, [**2104-2-25**] Right BKA and
left great toe amputation in 6/[**2104**].
.
Social History:
Patient was a music teacher and was living in the same apartment
for 22 years. From [**State 5170**] and has limited family in the area.
She had been quite independent before her leg amputation [**2-/2104**]
and has been living in rehabilitation facilities/nursing homes
for the past 6 months after R BKA and toe amputation, most
recently at [**Hospital1 **] Lights. Distant history of tobacco use for 4
yrs, quit 20yrs ago, rare alcohol use. No IVDU.
Family History:
Father died at 76yo from MI, mother died at [**Age over 90 **]yo, sister and
maternal grandfather with DM.
Physical Exam:
Temp 97, HR 81, BP 137/79, RR15-16, 100%RA
.
Pleasant, well appearing F in no distress, fair historian.
HEENT: EOMI, sclera clear, no icterus, no pallor. Mouth moist,
normal appearing.
Neck: No JVD, supple
Lungs : CTAB no w/c/r, good air movement, no adventitious sounds
Cardiac : RRR without murmurs, rubs or gallops
Abd: obese and soft, NT/ND, benign
EXT /Skin: Right femoral line in place (c/d/i). R BKA noted,
surgical scar well healed. Several stitches present in left
great toe, with crusting over healing scabs. Left heel with
healing over ulcer, neither appear infected. L pitting edema to
mid shin
Neuro: CN 2-12 grossly intact, able to move around in bed,
spontaneously moving all extremities
Pertinent Results:
ADMISSION Labs :
135 106 43
------------------< 224
6.2 24 1.6
WBC 8.0 E4.1 o/w normal
Hct 25.3
Plts 317
Coags 28.4 / 35.0 / 2.7
.
.
[**8-6**] EKG: Sinus rhythm. Low precordial lead voltage. Compared to
the previous tracing of [**2104-6-27**] there is variation in precordial
lead placement which may relate to misattached leads. No
apparent diagnostic interim change.
.
[**8-7**] Colonscopy Report:
Findings:
Contents: Poor prep was noted throughout the whole colon,
however there were no obvious massess visualized. Significant
amount of stool was found in the right colon limiting the view.
Mucosa: Abnormal vascularity typical of AVMs with spontaneous
bleeding. There were associated pale/white mucosal plaques also
noted in the rectum, and distal sigmoid colon. They were not
able to be washed off. Cold forceps biopsies were performed for
histology.
Other
procedures: An Argon-Plasma Coagulator was applied for
hemostasis successfully in the rectum and distal sigmoid colon.
Cold forceps biopsies were performed for histology of the white
musosal lesions at the distal sigmoid colon.
Impression: Abnormal vascularity in the rectum, and distal
sigmoid colon (biopsy)
Stool in the whole colon
(thermal therapy, biopsy)
Otherwise normal colonoscopy to cecum
.
***GI Biopsies : pending
.
LABS AT DISCHARGE :
[**2104-8-8**] 06:40AM BLOOD WBC-7.5 RBC-2.85* Hgb-8.5* Hct-24.3*
MCV-85 MCH-29.8 MCHC-35.0 RDW-15.2 Plt Ct-225
[**2104-8-8**] 06:40AM BLOOD Plt Ct-225
[**2104-8-8**] 06:40AM BLOOD Glucose-126* UreaN-18 Creat-1.1 Na-139
K-4.4 Cl-109* HCO3-23 AnGap-11
.
Brief Hospital Course:
79 year old female with h/o PVD s/p R BKA in [**2-/2104**] and [**6-/2104**] L
toe amp; HTN/HL/DM with nephropathy and neuropathy; PE in [**4-/2104**]
and currently on ASA/Plavix/Coumadin, and h/o hemorrhoid surgery
who presents with blood per rectum x1 week.
1. GIB: Given history of bright red blood and negative NG
lavage, mostly suspected lower GIB. Given h/o hemorrhoidal
surgery and Hct being fairly within her baseline, this seems
high the differential. However, other common causes of LGIB were
considered such as diverticular bleed and AVM's. Given normal
colonoscopy in [**2101**], lower suspicion for malignancy. Lack of
pain, fevers, WBC count makes infectious vs ischemic colitis
less likely. She had very stable HCTs in the 24-25 range and
only required one unit of blood on entire admission as no
excessive bleeding noted. She never had any concerning
hypotension or tachycardia which was also reassuring. GI scoped
the patient on hospital day 3 after preparation with Moviprep
overnight. Reports revealed abnormal vascularity typical of AVMs
with spontaneous bleeding. There were associated pale/white
mucosal plaques also noted in the rectum, and distal sigmoid
colon. Biopsies were performed for histology. Biopsies are
pending now. An Argon-Plasma Coagulator was applied for
hemostasis successfully in the rectum and distal sigmoid colon.
Bleeding was blamed on LGI AVMs that were noted.
She had all of her anti-HTN medications held and her aspirin,
plavix and coumadin all held for 3 days. Team opted to hold her
usual home Plavix at time of discharge and she will discuss
restart with her new PCP and her vascular surgeon at upcoming
appointment in a few weeks. She will plan to still continue her
coumadin for her known PE and her ASA 81mg daily with close
monitoring of her coags/INR at her facility. She was tolerating
a regular (diabetic/cardiac healthy) diet at time of discharge.
Recheck HCT level tomorrow and on Monday [**8-11**] with additional
labs.
.
2. Pulmonary Emboli: Patient explained she had shortness of
breath complaints when she was living at [**Hospital1 **] Center in [**2104-4-11**] and was sent to [**Hospital3 2576**]
Hospital for evaluation and was then diagnosed with a pulmonary
emboli and placed on Coumadin. During this hospitalization she
was saturating well on RA, no tachycardia, no respiratory
distress. Supratherapeutic INR just prior to admission in the 7
range and she needed 2 Units FFP and Vitamin K in ED and INR
settled down to 2 range and drifted to 1.5 range for colonoscopy
to be done safely and then she was restarted on 5mg daily
coumadin prior to discharge with plans for close INR follow-ups
at [**Hospital1 **] Lights to be followed by [**Initials (NamePattern4) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 98438**] over the
coming weeks with possible transition to [**Hospital1 18**] anticoagulation
management through PCP if patient prefers this option in the
near future. Specific dates outlined for lab draws and enclosed
in nursing instruction page. .
.
3. Diabetes: Well controlled during hospital course. Patient had
glargine decreased to 6 units while NPO and then placed back on
usual 8 units qhs along with a Humalog sliding scale.
.
4. Hypertension: Well controlled and even off of her anti-HTN
medications her SBPs ranged in the 120-140s ranges. She had her
amlodipine discontinued at time of discharge but can plan to
continue her usual dose of valsartan, [**Hospital1 **] metoprolol and her low
dose 20mg lasix daily. Please have dose held if her blood
pressures fall below 100 systolic.
.
5. Peripheral vascular disease: Severe disease and known
hyperlipidemia, smoking history. She underwent a right BKA in
[**2-/2104**] followed by a left great toe amputation 6/[**2104**]. She will
continue her 20mg daily simvastatin, 81mg aspirin and plans to
restart her Plavix at a later date once her GI bleeding has been
stable for several weeks. Patient was set up for outpatient
vascular follow-up appointment with Dr. [**Last Name (STitle) 98439**] on [**2104-8-22**].
.
6. Hyperkalemia: This was felt to be from worse renal
dysfunction and medication effects may have also played a role.
She may need some dose adjustments in her Valsartan medication
as an outpatient as this medication can increase K. She no
longer takes lisinopril which was recently discontinued. At time
of discharge, her K was back in the 4 range with plans for
recheck at [**Hospital1 **] Lights within a few days of discharge on [**8-11**]
lab recheck.
Medications on Admission:
1. warfarin 5 mg Tablet PO once a day: INR
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
6. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: hold for hr<55 sbp<100.
7. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
8. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day:
hold for sbp<100.
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
12. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
15. insulin glargine 100 unit/mL Solution Sig: Eight (8) units
subcutaneous at bedtime.
16. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous
four times a day.
17. sliding scale Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose
0-70mg/dL Proceed with hypoglycemia protocol
71-100mg/dL 0Units 0Units 0Units 0Units
101-150mg/dL 4Units 4Units 4Units 0Units
151-200mg/dL 7Units 7Units 7Units 0Units
201-250mg/dL 9Units 9Units 9Units 2Units
251-300mg/dL 11Units 11Units 11Units 4Units
301-350mg/dL 13Units 13Units 13Units 6Units
351-400mg/dL 15Units 15Units 15Units 8Units
> 400mg/dL Notify M.D.
.
-
Discharge Medications:
1. Insulin Instructions
Continue insulin glargine 100 unit/mL Solution Sig: Eight (8)
units subcutaneous at bedtime.
.
Also continue Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
.
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose
0-70mg/dL Proceed with hypoglycemia protocol
71-100mg/dL 0Units 0Units 0Units 0Units
101-150mg/dL 4Units 4Units 4Units 0Units
151-200mg/dL 7Units 7Units 7Units 0Units
201-250mg/dL 9Units 9Units 9Units 2Units
251-300mg/dL 11Units 11Units 11Units 4Units
301-350mg/dL 13Units 13Units 13Units 6Units
351-400mg/dL 15Units 15Units 15Units 8Units
> 400mg/dL Notify M.D.
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for AS
DIRECTED weeks: Please have INR levels checked at facility on
[**6-15**], [**8-12**] and then q3-5 days as needed until stable INR [**2-14**]
range, then qweekly. .
3. INR Monitoring
Please have INR levels checked at facility on [**6-15**], [**8-12**] and
then q3-5 days as needed until stable INR 2-3 range, then
qweekly. Please have nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) 98438**] check
your lab results at [**Hospital1 **] Lights. Once you have been evaluated
by your new PCP at [**Hospital3 **] ([**Company 191**])you can discuss
transitioning your Coumadin monitoring to the [**Hospital 191**] [**Hospital 197**]
Clinic if you prefer this option.
4. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
7. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
8. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day:
please hold for SBP <100.
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. medication
ferrous sulfate 300mg (60mg) tablet once daily
11. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. multivitamin Capsule Sig: One (1) Capsule PO once a day.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
14. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**4-16**]
hours as needed for pain: hold if systolic BP <100.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 23095**] Rehabilitation & Nursing Center - [**Location 8391**]
Discharge Diagnosis:
Primary Diagnoses:
1. Lower gastrointestinal bleeding / arteriovenous malformations
2. Hyperkalemia
3. Peripheral vascular disease with recent amputation left great
toe, status post right below the knee amputation
.
Secondary Diagnoses:
1. Pulmonary Emboli
2. Hypertension
3. Hyperlipidemia
4. diastolic CHF
5. Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 4223**],
.
It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted after complaints of
bright red blood noticed in your stools. This was concerning for
a gastrointestinal bleed so you were admitted to the intensive
care unit for overnight monitoring of your red blood cell counts
and to watch your blood pressures closely. Your bleeding was
likely partly due to several blood thinning medications
(Aspirin, Plavix and Coumadin)that you have been taking for
cardiac reasons and for your recently diagnosed pulmonary
embolism. Fortunately, you remained stable and the bleeding
tapered over the first few hours after admission. You were seen
and evaluated by the GI consult team who performed a colonoscopy
on [**2104-8-7**]. This colonoscopy revealed
some abnormal blood vessels with spontaneous bleeding. There
were associated pale/white mucosal plaques also noted in the
rectum, and distal sigmoid colon and biopsies were performed. An
Argon-Plasma Coagulator was applied as a tool to help stop some
of the smaller bleeding vessels with excellent results.
.
You have been set up for an outpatient gastroenterology
appointment in 2 weeks to review the results of your biopsies.
See appointment details below.
.
You also had some elevated potassium levels that corrected after
you were given IV medications.
.
Several of you blood pressure medications were initially held
and then restarted and adjusted at time of discharge. Please see
below for current medication instructions.
.
.
MEDICATION CHANGES:
1.Please HOLD your Plavix (clopidogrel) medication until your
next vascular surgery follow-up
2.Please DISCONTINUE your amlodipine blood pressure medications
as your blood pressure was near normal ranges (and you are on
several other BP lowering medications)
.
*Otherwise, continue all of your other usual home medications as
prescribed
.
*Your INR levels will need to be checked at [**Hospital1 **] Lights
Rehabilitation Center as outlined below.
.
Followup Instructions:
.
1) Primary Care Appointment:
Please follow-up with your new primary care physician at
[**Hospital3 **] -
Department: [**Hospital3 249**]
When: WEDNESDAY [**2104-9-10**] at 2:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 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
.
2) Vascular Medicine Appointment
Department: VASCULAR SURGERY
When: FRIDAY [**2104-8-22**] at 12:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20205**], MD [**Telephone/Fax (1) 20206**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
3) Gastroenterology Appointment:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2104-8-20**] at 2:00 PM
With: [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
Completed by:[**2104-8-9**]
ICD9 Codes: 2767, 3572, 5859, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2905
} | Medical Text: Admission Date: [**2197-3-23**] Discharge Date: [**2197-3-29**]
Date of Birth: [**2120-8-17**] Sex: M
Service: [**Company 191**]
HISTORY OF THE PRESENT ILLNESS: This is a 76-year-old male
who was found to be rigoring after getting out of the pool on
the day of admission. The patient was overall feeling fine
and did not complain of a fever, cough, or general malaise.
The patient went to the Emergency Department and was found to
have a temperature of 101.1. During the patient's visit in
the Emergency Department, the patient's blood pressure fell
from a systolic blood pressure of 110 down to a systolic
blood pressure of 68. The patient was resuscitated with IV
fluids and pressors.
A workup of fever in the Emergency Department did not reveal
a source of fever. Chest x-ray was negative. Blood cultures
and urine cultures were collected. The patient was
empirically begun on levofloxacin and Flagyl. The patient
was stabilized and admitted to the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. CAD, status post CABG in [**2192**] with an EF of 30-40%.
2. Atrial fibrillation, currently taking Coumadin.
3. Depression.
4. Status post hernia repair.
5. Seizure disorder.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
101, blood pressure 110/80, heart rate 100, respiratory rate
15, breathing 98% on room air. General: The patient was an
ill-appearing male in no apparent distress. Skin: No
rashes. The membranes were moist. Neck: Supple with no
lymphadenopathy. Cardiac: Irregularly/irregular pulse with
a normal S1 and S2. There was a grade II/VI systolic murmur
best heard at the apex. Lungs: Clear to auscultation
bilaterally. Abdomen: Soft, nondistended, with no
tenderness. Extremities: The left extremity was very mildly
erythematous. Pulses were palpable bilaterally.
HOSPITAL COURSE: On the second day of the [**Hospital 228**] hospital
stay, the patient developed a cellulitis of his left lower
extremity. The cellulitis was felt to be the etiology of his
fevers and rigors. The patient was begun on oxacillin 2
grams IV q. six hours for the cellulitis. The cellulitis
improved dramatically over the next several days.
While in the ICU, the patient was mildly volume overloaded.
Diuretic therapy with Lasix and good results were achieved.
The patient became euvolemic and was transferred to the floor
for observation.
On the floor, the patient complained of a mild cough since
aspirating a small amount of water in the ICU. A chest x-ray
was performed and revealed pneumonitis secondary to
aspiration. The patient's cough resolved within a day.
The patient's chemistries on admission were a sodium of 140,
potassium 4.5, chloride 101, bicarbonate 26, BUN 20,
creatinine 1.0, glucose 98. Calcium was 7.5, phosphate 2.5,
magnesium 1.7. The patient's white count was 15 with a left
shift.
DISCHARGE CONDITION: The patient was discharged in good
condition.
DISCHARGE DIAGNOSIS:
1. Cellulitis.
2. Sepsis.
3. Congestive heart failure.
DISPOSITION: The patient was discharged home.
DISCHARGE MEDICATIONS:
1. Oxacillin p.o. to be taken for 14 days.
2. The patient was instructed to take all of the medications
he was taking previously before admission.
FOLLOW-UP: The patient is to follow-up with his primary care
physician within two weeks to monitor the compression and
resolution of his cellulitis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. [**MD Number(1) 101646**]
Dictated By:[**Last Name (NamePattern1) 104024**]
MEDQUIST36
D: [**2197-4-3**] 12:01
T: [**2197-4-4**] 09:07
JOB#: [**Job Number 45493**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2906
} | Medical Text: Admission Date: [**2142-3-8**] Discharge Date:
Date of Birth: [**2068-12-26**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 73-year-old gentlemen
with a past medical history of three vessel coronary artery
disease, status post a coronary bypass graft in [**2112**] with a
saphenous vein graft to left anterior descending along with
an saphenous vein graft to an OM and an saphenous vein graft
at that time was not used. Patient was in his usual state of
health until the morning of admission when he presented to an
outside hospital with severe substernal chest pain that
failed to radiate to the extremities, the jaw, or back. He
did complain, however, of some shortness of breath, nausea,
and diaphoresis. He states that his symptoms had been
increasing in intensity for about one to two weeks, but the
most intense he had experienced since his coronary artery
bypass graft 20 years ago. He rates the pain as a 9 on a
scale of [**2-2**]. The patient attempted to relieve his chest
pain with an antacid along with sublingual nitroglycerin. He
was rushed to the Emergency Room. Electrocardiogram failed
to show any ST changes, however, his troponin was 1.9 and his
CK was 16.9. He was then transferred to [**Hospital3 **] for
further evaluation. A catheterization on the [**9-5**] revealed severely elevated filling pressures with a
wedge of 25 and a left ventricular end-diastolic pressure of
30. Cardiac output was 5.6 liters with a cardiac index of
2.5 liters/minutes/meters squared. The left ventriculography
revealed a moderately depressed ejection fraction of about
41% along with global hypokinesis and a more severe inferior
hypo-akinesis with 2+ MR. The coronary angiography revealed the
left anterior descending totally occluded proximally. The left
circumflex was a diffusely diseased vessel. The OMs were
completely occluded. The right coronary artery was also
completely occluded proximally and was filling by
collaterals. The graft angiography revealed a 95% ostial
stenosis of the saphenous vein graft to the left anterior
descending. The saphenous vein graft to the OM had a 90%
ostial stenosis along with an 80% mid stenosis and a 40%
touchdown stenosis. The saphenous vein graft to the
posterior descending artery was known to be occluded. A
intraaortic balloon pump was placed and the patient was
returned to the Coronary Care Unit for further management.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post a coronary artery
bypass graft in [**2122**]. It was a three vessel coronary artery
bypass graft with an saphenous vein graft to the left
anterior descending, an saphenous vein graft to the OM and
saphenous vein graft to the right coronary artery.
2. Diabetes mellitus.
3. Peripheral vascular disease.
4. Hyperlipidemia.
5. Hypertension.
6. Hypothyroidism.
7. Peptic ulcer disease.
8. Gastroesophageal reflux disease.
9. Gout.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg po q.d.
2. Heparin.
3. Metoprolol 12.5 mg b.i.d.
4. Simvastatin 80 mg q.d.
5. Losartan 50 mg q.d.
6. Regular insulin sliding scale.
7. Zoloft 200 q.d.
8. Allopurinol 300 q.d.
9. Pantoprazole 40 q.d.
10. Synthroid 150 mcg q.d.
ALLERGIES: Patient reports no known drug allergies.
SOCIAL HISTORY: He is retired. He lives with his wife. [**Name (NI) **]
reports a 40 pack year history. He quit at the time of his
coronary artery bypass graft 20 years ago. He denies any
alcohol or intravenous drug use.
FAMILY HISTORY: Significant for a mother who had coronary
artery disease.
PHYSICAL EXAMINATION: The patient was afebrile. A blood
pressure of 102/64. Heart rate of 92 beats per minute.
Respiratory rate of 24 breaths per minute. An oxygen
saturation of 94% on six liters of nasal cannula. In
general, this is an obese elderly gentlemen who was in no
apparent distress. His pupils equal, round and reactive to
light and his extraocular movements were intact. His mucous
membranes was moist and his oropharynx was clear. Patient
had an extremely thick neck and jugular venous pressure and
lymphadenopathy could not be appreciated. His heart was
regular rate and rhythm with distant heart sounds. There was
a faint systolic ejection murmur at the right upper sternal
border. His lungs showed diffuse crackles, predominantly in
the lower half of both lungs. He had decreased breath sounds
in the apexes of both lungs. His abdomen was obese,
nontender, slightly distended, but not firm. He had positive
bowel sounds. His extremities had chronic venous stasis changes
along with +2 pedal edema bilaterally. Dorsalis pedis pulses
were appreciated.
LABORATORIES UPON ADMISSION: Revealed a white blood cell
count of 9.45, a hematocrit of 28.9, a platelet count of
248,000. Sodium of 140, potassium 4.3, chloride 102,
bicarbonate 27, BUN of 31, creatinine of 1.2 and a glucose of
268. His calcium was 8.8, magnesium of 1.6, phosphate of
2.7. His INR was 1.2.
Electrocardiogram showed sinus rhythm. A first degree AV
block, left axis deviation, right bundle branch block, left
atria was slightly enlarged. There were Q waves in the
inferior leads. There was also Q waves in the anterior
lateral leads.
HOSPITAL COURSE: This is a 73-year-old gentlemen with known
coronary artery disease, status post a three vessel coronary
artery bypass graft in [**2122**] who presented with severe
saphenous vein graft occlusion. His problem list includes
the following:
1. Cardiac: The patient was evaluated by the Cardiothoracic
Surgery Team who felt that the patient was not a surgical
candidate given the lack of touchdown sites and severely
elevated procedureal risk. He was then referred to the
Interventional Cardiology Service for possible PCI intervention
on femoral-femoral bypass support. After reviewing the
films, the Interventional Cardiology Service felt that his
two grafts were stentable but with severely elevated risk that
was lower than redo CABG. He went to the laboratory and was
placed on the bypass machine and successfully had his two
occluded saphenous venous grafts stented. He was then
returned to the floor. The intraaortic balloon pump was
removed and the [**Hospital 228**] medical regimen was optimized. He had
no evidence of post-procedure myocardial infarction.
This included placing the patient on an aspirin, Plavix, a
low dose beta-[**Last Name (LF) 7005**], [**First Name3 (LF) **] angiotensin receptor [**First Name3 (LF) 7005**] and a
statin. An echocardiogram was performed which revealed that
he had a left ventricular ejection fraction of about 40%. It
also showed severe akinetic and hypokinetic left ventricle.
The echocardiogram also estimated the patient to have +2
mitral regurgitation. During the patient's stay, he had no
chest pain or other myocardial infarction symptoms. He
remained in sinus rhythm with limited ectopy on telemetry.
2. Pulmonary: The patient was electively intubated for
agitation. During his time, he appears to have developed a
possible aspiration pneumonia for which he was treated with
levofloxacin, vancomycin, and Flagyl. He was also
aggressively diuresed secondary to pulmonary edema. He was
successfully weaned from the ventilator and remained on nasal
cannula oxygen at the time of this dictation.
3. Renal: The patient's baseline creatinine was estimated
at about 1.3. Following the dye load that he received during
his two procedures, he developed acute renal failure with a
creatinine that bumped to 2.2. His medications were renally
dosed and nephrotoxins were avoided. At the time of this
discharge summary, his creatinine had decreased from 2.2 to
1.4.
4. Hematology: Following return of the catheterization
laboratory, the patient started to have some bright red blood
by the nasogastric tube. The Integrilin was discontinued and
his hematocrit was followed. He did receive two units of
packed red blood cells during his stay and his hematocrit
bumped appropriately. He remained on a proton pump inhibitor
throughout his stay. The patient's blood was cleared very
rapidly after discontinuing the Integrilin and his hematocrit
remained stable and he had no signs of hemodynamic
instability.
5. Endocrine: Patient with a history of diabetes. His
sugars were extremely elevated and the patient was placed on
an insulin drip for better control. Gradually, the insulin
drip was weaned off and the patient was placed back on his
home insulin dose. Patient also has a history of
hypothyroidism. He remained on his home dose of
levothyroxine.
6. Infectious Disease: The patient had several fevers along
with an elevated white blood cell count. Multiple cultures
were drawn. He showed that he had gram positive organisms
growing out of [**3-27**] blood cultures. These were later
identified as a staphylococcus which was coag negative. He
was treated with vancomycin. The patient also had a
respiratory culture which grew out H. influenza. He was
treated with levofloxacin.
THIS CONCLUDES THE DISCHARGE SUMMARY FOR [**Known firstname **] [**Known lastname 47272**] FROM
[**3-8**] UNTIL [**2142-3-18**]. THERE WILL BE ANOTHER
ADDENDUM WHICH WILL COVER HIS DISCHARGE MEDICATIONS AND
DISCHARGE PLANNING ALONG WITH HIS TIME COURSE FROM THIS
PERIOD ON.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**First Name3 (LF) 47273**]
MEDQUIST36
D: [**2142-3-17**] 01:58
T: [**2142-3-17**] 14:32
JOB#: [**Job Number 47274**]
ICD9 Codes: 5070, 7907, 5849, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2907
} | Medical Text: Admission Date: [**2109-9-27**] Discharge Date: [**2109-10-25**]
Date of Birth: [**2053-7-14**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 56-year-old woman with
non-insulin dependent diabetes mellitus, coronary artery
disease, status post three vessel coronary artery bypass
graft in [**8-3**], end stage renal disease on hemodialysis,
rushed to the [**Hospital1 69**] Emergency
Room with fever for three days, shortness of breath and right
sided chest pain. She has been meanwhile at home receiving
visiting nurse care. She states the fever at home was as
high as 101.4 degrees. She was previously admitted to CT
surgery service for median sternotomy wound drainage which
required IV antibiotics and wound debridement. At home she
denies any productive cough, wheezing or wound drainage. The
symptoms were first noticed by the patient two days ago and
have worsened over the past several days.
PAST MEDICAL HISTORY: As described in history and physical.
MEDICATIONS: On admission, Aspirin 81 mg po q day, Premarin
0.625 mg po q day, Norvasc 5 mg po bid, Trazodone,
Hydroxyprogesterone, Neurontin 300 mg po bid, Ultram 50 mg po
q day, Lipitor 10 mg po q day, Pravachol 0.25 mg po q day,
Lopressor 12.5 mg po bid.
ALLERGIES: No allergies.
PAST SURGICAL HISTORY: Status post CABG times three on
[**2109-8-8**].
PHYSICAL EXAMINATION: On admission, T max 101.5, blood
pressure 106/70, pulse 88, respirations 16, FAO2 90% on five
liters. In general, alert and oriented times three,
conversant, pulmonary clear to auscultation left, decreased
breath sounds at the right base. CV, regular rate and
rhythm. Chest wall, sternotomy wound, the bottom half of the
midline sternotomy incision is opened with fibrinous exudate
and 0 drainage. There is a click appreciated when the
patient coughs. Abdomen soft, nontender, non distended.
Right saphenectomy site, small area of erythema and a large
amount of scab. Both feet are warm. There is trace edema in
the right lower extremity.
Pertinent studies: Chest x-ray, bilateral pleural effusion,
no evidence of CHF, effusion is greater on the right side vs
the left. Chest, no pulmonary embolism, no infiltrate or
consolidation, some modest right effusion with right lower
lobe atelectasis, small left effusion, small amount of fluid
in the anterior mediastinum, no pneumomediastinum.
Labs, CBC with white count 14.0, hematocrit 27.2, platelet
count 330,000, differential of 95% neutrophils, 0% bands.
Chemistries, sodium 135, potassium 5.2, chloride 93, CO2 28,
BUN 54, creatinine 6.7, glucose 264.
HOSPITAL COURSE: The night of admission a thoracentesis was
performed in the right posterior thorax. Approximately 500
cc of fluid was removed. Also on the night of admission the
saphenectomy wound was sharply debrided, the bleeding tissue
impacted with wet to dry dressing and normal saline and the
sternal wound was sharply debrided. The granulation tissue
was packed with wet to dry dressings and normal saline. The
patient was empirically started on Piperacillin and
Vancomycin. Plastic surgery was consulted, they recommended
conservative management as was being performed by general
surgery. The patient was also seen by the renal service who
managed the patient's dialysis and electrolyte management
during the hospitalization. PICC line was placed in
anticipation of a long course of IV antibiotics. On [**9-30**] a
VAC dressing was first placed in the wound. The patient was
doing well on intravenous antibiotics and VAC dressing
changes.
The [**Hospital 228**] hospital course faltered when at hemodialysis,
increased venous pressures were noticed on [**10-1**]. On [**10-2**]
fistulogram revealed a clotted fistula and the patient was
unable to receive her normal dialysis on [**2109-10-3**]. Transplant
surgery saw the patient and scheduled her for revision.
During the interim, Quinton catheter was placed in the
patient's right groin for dialysis. On the evening of
[**2109-10-4**], the patient fell getting out of bed. When the house
officer arrived, the patient was confused in bed and somewhat
difficult to arouse. CT scan of the head performed on an
emergent basis demonstrated no intracranial pathology.
Initially the skull was intact. The next morning the patient
was difficult to arouse and her labs reflected the fact that
she had not been dialyzed in several days with a rising BUN,
creatinine and potassium. The patient was given Kayexalate
for the rising potassium. A repeat CT scan of the head was
similar to the previous CT scan in that there was no evidence
of intracranial pathology. At this point the patient had an
episode of bradycardia with wide QRS complexes. She lost
consciousness. After receiving an amp of D50 insulin and
Calcium Gluconate, the patient was transferred to the
Intensive Care Unit. At this point her hematocrit was found
to be 13. The patient vomited a large amount of guaiac
positive material.
In the Intensive Care Unit the patient was transfused four
units of packed red cells and 4 units of FFP. The patient
was intubated and an NG tube was placed. Large amount of
bloody material was aspirated from the stomach. GI service
was consulted for an emergent EGD which revealed an enormous
amount of clot protruding from the pylorus and bright red
blood was seeping around it. The gastroduodenal artery was
visualized in the posterior wall of the duodenum. The
patient was given blood and FFP to maintain hematocrit and to
combat an ongoing coagulopathy. On [**10-4**] the patient went to
the interventional radiology suite and had an
angioembolization of the gastroduodenal artery. At this
point patient was placed on Protonix and started on a course
of Amoxicillin and Clarithromycin in addition to the
Piperacillin and Vancomycin.
The patient received her dialysis in the ICU beginning on
[**2109-10-5**]. During this course in the Intensive Care Unit, the
patient remained intubated and was repeatedly transfused to
keep her hematocrit above 30. By [**2109-10-7**] the patient's
mechanics were good enough to begin a wean from the
ventilator and by [**10-18**] she was extubated. By [**10-11**] the
patient was transferred to the patient care floor. The
patient continued to do well on the floor, the VAC dressing
changes to the sternum were continued and the size of the
sternal wound had decreased with time. Additionally, the
saphenectomy sites were cared for with wet to dry dressings
which were changed over to santyl dressings twice a day.
Both wounds were intermittently debrided to reveal viable
tissue.
On [**2109-10-15**] the transplant surgery service deemed the patient
an operable candidate and brought her to the operating room
for fistular revision. Please see previously dictated
operative note for more details.
After the fistula revision the patient was able to use her
fistula for hemodialysis and the Quinton catheter was
removed. The VAC dressing changes continued. The [**Hospital 228**]
hospital course was complicated further by a brief episode of
C. difficile colitis. For this, the patient was treated with
Flagyl for 10 days and remained on Piperacillin and
Vancomycin. By [**2109-10-26**] the patient was accepted to
[**Hospital3 **]. At this point patient's wounds were stable,
she had a PICC line in place, was tolerating po and was ready
to go to rehabilitation.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To rehab.
DISCHARGE MEDICATIONS: Regular insulin sliding scale as
follows: Glucose 150-200 gets 2 units, 201-250 gets 4 units,
251-300 gets 6 units, 301-150 8 units, Epogen 14,000 units q
hemodialysis, Vitamin A, D, Zinc ointment to affected area
tid, Vancomycin 500 mg IV after hemodialysis times 6 weeks,
Neurontin 500 mg po bid, Norvasc 5 mg po bid, Trazodone 100
mg po q h.s., Lopressor 25 mg po bid, Lipitor 10 mg po q
h.s., Piperacillin 3 gm IV q 8 hours for 6 more weeks,
Captopril 12.5 mg po q 8 hours, Protonix 40 mg po q day,
Miconazole powder applied to affected areas prn, Morphine
Sulfate 2 mg IV before dressing changes.
DISCHARGE DIAGNOSIS:
1. Sternal wound infection.
2. Infection of saphenectomy site.
3. Gastrointestinal bleed, status post embolization.
4. C. difficile colitis.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 4722**]
MEDQUIST36
D: [**2109-10-25**] 19:17
T: [**2109-10-25**] 19:31
JOB#: [**Job Number 4723**]
ICD9 Codes: 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2908
} | Medical Text: Admission Date: [**2167-4-18**] Discharge Date: [**2167-5-4**]
Date of Birth: [**2167-4-18**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname **] is a 34 and [**11-26**]
week gestational age, 2480 gram, female who was born to a 27-
year-old gravida 1, para 0 (now 1) woman.
Serologies revealed O positive, antibody negative, hepatitis
B surface antigen negative, rapid plasma reagin nonreactive,
Rubella unknown, group B strep status screening unknown.
[**Hospital 37544**] medical history notable for asthma - treated with
albuterol as needed.
The pregnancy was reportedly uncomplicated. Mother presented
to Labor and Delivery on the day of admission with preterm
spontaneous rupture of membranes. No maternal fever. No
maternal intrapartum antibiotics given. Because of breech
position, the infant was delivered via a cesarean section.
Agars were 8 at 1 minute and 8 at 5 minutes.
PHYSICAL EXAMINATION ON ADMISSION: Weight was 2480 grams
(75th percentile), head circumference was 32.5 cm (75th
percentile), and length was 42 cm (25th percentile). General
appearance revealed the infant was resting comfortably on
heated radiant warmer, pink color, stable vital signs. Head,
eyes, ears, nose, and throat examination revealed anterior
fontanel was soft and flat. Ears were normal. Red reflexes
were visualized bilaterally. The palate was intact. Chest
revealed clavicles intact. The lungs were clear to
auscultation and equal. Cardiovascular examination revealed
a regular rate and rhythm. No murmurs. Femoral pulses were
2 plus. The abdomen was soft, positive bowel sounds, no
hepatosplenomegaly or masses. A 3-vessel cord.
Genitourinary examination revealed normal preterm female,
patent anus, no sacral anomalies. Normal hip examination.
Extremities were warm, pink and well perfused, full range of
motion in all four extremities. Skin revealed bruising on
the right fingertips, right knee, on the lateral groin areas,
and left buttocks.
SUMMARY OF HOSPITAL COURSE:
RESPIRATORY: The infant has remained in room air during the
entire hospitalization. She had occasional mild
apnea and bradycardia of prematurity which did not require
therapy with caffeine. Her last A&B event was [**4-21**].
CARDIOVASCULAR: The infant has been stable from a
cardiovascular stand point. On day of life 12, a [**12-26**] murmur
was noted in the precordial area at the left lower sternal
border. This murmur radiated to both axillae and the back.
Four extremity blood pressures were normal. The infant has
remained hemodynamically stable, and it is our initial
perception that this murmur is consistent with peripheral
pulmonary stenosis. However, we would recommend close
followup as a ventricular septal defect cannot be excluded.
FLUIDS, ELECTROLYTES, AND NUTRITION: [**Known lastname 1356**] was initially
maintained on intravenous fluids, and then transitioned to
full enteral feedings; initially via gavage feedings and
eventually to full oral feedings. She currently feeds breast
milk 24 calories per ounce enriched with Enfamil powder. She
also breast feeds ad lib. Because mom wishes to primarily
breast feed, iron supplementation and multivitamin were added
to her nutritional regimen.
Her discharge weight was 2755 gms.
On day of life four, [**Known lastname 1356**] was noted to have a guaiac-
positive stool. Her abdomen was slightly distended. A KUB
was reassuring, and feedings were continued without any
further complications.
HEMATOLOGY: On day of life three, [**Known lastname 30613**] total bilirubin
level had risen to 12.8 mg/dL with a direct bilirubin
component of 0.4 mg/dL. We therefore initiated phototherapy
treatment until [**4-27**]. Her rebound bilirubin level on [**4-28**] was 7.2 mg/dL with a direct component of 0.2; essentially
unchanged from the previous day. The infant's blood type is
A positive and antibody negative.
INFECTIOUS DISEASE: Because of premature labor, the infant
was initially started on antibiotic therapy with ampicillin
and gentamicin. These antibiotics were discontinued after
cultures had remained negative for 48 hours.
SENSORY: A hearing screen was performed with automated
auditory brain stem responses. [**Known lastname 1356**] passed on both ears.
CONDITION ON DISCHARGE: Well appearing. In no acute
distress. Physical examination remarkable for a persistent
[**12-26**] murmur radiating to both axillae and the back. A left
hip click noted on Ortolani maneuver. No hip asymmetry, no
limitation to adduction.
DISCHARGE DISPOSITION: Discharged to home.
PRIMARY CARE PROVIDER: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Hospital1 **] (telephone
number [**Telephone/Fax (1) 40499**]).
CARE RECOMMENDATIONS: Feedings at discharge: Breast feed ad
lib and breast milk 24 calories enriched with 4 calories per
ounce of Enfamil powder by mouth ad lib.
Medications: Ferrous sulfate 2 mg/kilogram by mouth once per
day (Fer-In-[**Male First Name (un) **] 25mg/ml concentration at 0.2 cc by mouth once
per day), Tri-Vi-[**Male First Name (un) **] 1 cc by mouth every day.
Car seat screening performed on [**2167-5-3**] and passed.
Newborn screening performed on [**2167-4-22**] as well as [**2167-5-3**].
IMMUNIZATIONS: Hepatitis B vaccination on [**2167-4-21**].
IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) born at less than 32 weeks gestation; (2) born
between 32 and 35 weeks gestation with 2/3 of the following:
Plans for day care during respiratory syncytial virus season,
a smoker in the household, neuromuscular disease, airway
abnormalities, or with school-age siblings; or (3) with
chronic lung disease.
Influenza immunization should be considered annually in the
Fall for preterm infants once they reach six months of age.
Before this age, and for the first 24 months of the child's
life, immunization against influenza is recommended for
household contacts and out of home caregivers.
DISCHARGE FOLLOW UP: Follow-up appointment with primary care
physician [**Name Initial (PRE) 176**] 48 hours after discharge.
Followup for cardiac murmur.
Followup for left hip click. A screening ultrasound was
recommended at six weeks of life per AAP recommendations for
this preterm infant delivered by cesarean section for in-utero
breech positioning.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks.
2. Mild apnea and bradycardia of prematurity.
3. Hyperbilirubinemia.
4. Rule out sepsis.
5. Feeding dysmaturity of the premature.
6. Heart murmur.
7. Left hip click.
DR.[**First Name (STitle) **],[**First Name3 (LF) 36400**] 50-595
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2167-5-4**] 08:32:44
T: [**2167-5-4**] 09:36:42
Job#: [**Job Number 55506**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2909
} | Medical Text: Admission Date: [**2153-10-1**] Discharge Date: [**2153-10-9**]
Date of Birth: [**2099-12-25**] Sex: F
Service: NEUROLOGY
Allergies:
Augmentin / Doxycycline / Trazamine / Ambien
Attending:[**First Name3 (LF) 5341**]
Chief Complaint:
Tx from neurosurgical service s/p placement of [**Last Name (un) **] catheter
for intrathecal chemotherapy.
Major Surgical or Invasive Procedure:
[**10-2**]: Rickham Catheter Placement
History of Present Illness:
[**Known lastname 14537**] is a 53 year-old woman with h/o metastatic breast CA
to liver and brain, chronic LE weakness, ?chronic dyspnea who is
being transferred from the neurosurgical service for spinal XRT.
.
She is well known to this service from her previous
hospitalization, when she presented with urinary retention, back
pain, and worsening shortness of breath. She was started on
dexamethasone, treated for UTI, and her symptoms improved until
discharge, when she was voiding on her own and without any more
back pain. [**Known lastname 4338**] of her C-T-L spine during that hospital course
showed no cord compression, but there were three distinct
lesions noted in the thoracic cord, likely representing
metastatic disease; there was question of leptomeningeal
involvement of the tumor. Radiation oncology had been consulted
and believed the thoracic lesions were unlikely the cause of her
symptoms. They believed there was no emergent need for XRT at
the time. LP was done prior to discharge and the cytology
report is negative for malignant cells.
.
She was discharged five days ago and reports that the following
day she experienced dyspnea. She describes the sensation as
"difficulty taking a deep breath." She felt uncomfortable,
called her boyfriend, and decided to come to the emergency room.
She denies any associated symptoms, including chest pain,
palpitations, lightheadedness, or dizziness. She was admitted
to the neurosurgical service for placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
catheter.
.
On admission her neuro exam showed A&Ox3, general weakness, no
focal deficits. Placement of Rickham catheter occurred on [**10-2**].
Post-op CT looked good. She was transferred to the [**Hospital Ward Name **]
today for radiation therapy, and now she is admitted to OMED.
Past Medical History:
Past Medical History (adapted from previous admission note):
# Breast cancer metastatic to liver and brain
- HER-2 positive
- s/p mastectomy
- s/p whole brain radiation
# HTN
# h/o Cat scratch disease at 8 years old
# s/p Left groin lump excision at age 8
# s/p 2.5 liter right thoracentesis on [**2151-9-28**]
# h/o R thigh subjective weakness for ~4 years, thought to be
due to proximal muscles
# ?baseline SOB
Social History:
Currently lives in [**Location 4628**] with her boyfriend, [**Name (NI) 122**], who is
very supportive. Used to work as LNA at a rehab, but is now on
disability. Smoked 1ppd x 3 years until [**2149**] (when she moved out
of a house owned by a smoker). No EtOH currently, was previously
a social drinker. No IVDU. Divorced, one daughter (age 26).
Family History:
Mother died in 70's of lung problems, DM, HTN. Father died at 74
of Parkinson's Disease, stroke. Two brothers with obesity and
hypertension. One 26 year old daughter with cervical
abnormalities (but no cancer) since age 19. No family history of
breast, ovarian, colon cancer.
Physical Exam:
Physical Exam at Admission
Vitals T 95.5, BP 133/89, RR 16, HR 94, O2 sat 99% RA
General WDWN, NAD, breathing comfortably on RA, hoarse voice
(unchanged from prior hospitalization)
HEENT PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck supple, no thyromegaly or masses, no LAD
Cardiac RRR, s1s2 normal, no m/r/g, no JVD
Pulmonary: CTAB
Abdomen: hypoactive bowel sounds, soft, nontender
Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves
all extremities; strength is [**3-26**] upper and lower extremities,
although there is slight weakness of hip flexion on the LLE; her
sensation is normal; her heel-to-shin and finger-to-nose are
normal.
.
Physical Exam at Discharge
Pertinent Results:
Labs at Admission
.
[**2153-10-1**] 05:16AM PT-12.6 PTT-71.0* INR(PT)-1.1
[**2153-10-1**] 04:55AM GLUCOSE-98 UREA N-12 CREAT-0.5 SODIUM-140
POTASSIUM-3.0* CHLORIDE-102 TOTAL CO2-30 ANION GAP-11
[**2153-10-1**] 04:55AM CK(CPK)-29
[**2153-10-1**] 04:55AM CK-MB-NotDone cTropnT-<0.01
[**2153-10-1**] 04:55AM WBC-5.2 RBC-3.83* HGB-11.4* HCT-33.2* MCV-87
MCH-29.8 MCHC-34.3 RDW-13.7
[**2153-10-1**] 04:55AM NEUTS-65.2 LYMPHS-25.8 MONOS-8.3 EOS-0.6
BASOS-0.1
[**2153-10-1**] 04:55AM PLT COUNT-292
.
Studies
.
CTA Chest ([**2153-10-1**])
1. No evidence of pulmonary embolism or acute aortic process.
2. Status post right mastectomy with stable appearance of
multifocal lung
nodules and scarring within the lungs.
.
Cytology from LP ([**2153-10-1**])
ATYPICAL. A few isolated atypical cells with a moderate amount
of cytoplasm - histiocytes versus astrocytes. Small fragment of
glial tissue. Scant background lymphocytes and macrophages.
.
CT Head without contrast ([**2153-10-3**])
1. Status post placement of a ventriculostomy drain with the tip
terminating in the right lateral ventricle.
2. No evidence of increasing hydrocephalus.
3. No interval development of hemorrhage, increasing edema, mass
effect, or shift of midline structures.
4. Metastatic involvement is better evaluated on previous MR
examination.
.
[**Month/Day/Year 4338**] Brain ([**2153-10-4**])
1. Unchanged size and appearance of multiple intracranial
metastases. No new metastases identified.
2. Interval placement of a right ventriculostomy catheter with
slight interval improvement of prominence of the bilateral
ventricles.
Brief Hospital Course:
53 year-old woman with history of metastatic breast cancer to
liver and brain, transferred from neurosurgical service status
post [**Last Name (un) **] catheter (ventriculostomy tube) placement for XRT
to C7-T3 and T8-L2.
.
METASTATIC BREAST CANCER
She was transferred to the oncologic medicine service from
neurosurgery after venticulostomy tube had been placed. She
underwent follow-up LP and cytology showed atypical cells. [**Last Name (un) 4338**]
of her brain showed diffuse cerbral metastatic disease that was
unchanged from prior. She began receiving XRT to her cervical
and thoracolumbar spine. The treatment was without
complications.
.
She will receive a total of 10 radiation treatments to her
spinal cord after which she will receive intrathecal
chemotherapy. Dr. [**Last Name (STitle) 4253**] is her neuro-oncologist and will
decide on the timing of chemo. She should return to [**Hospital1 18**] for
five more radiation treatments. The directions are outlined in
the discharge orders.
.
HISTORY OF URINARY RETENTION
She has a history of urinary retention that started about three
weeks ago. The symptoms transiently resolved after steroids
were increased during her previous hospitalization. However,
she has required foley cath placement intermittently during this
admission, and her post-void residuals have been as high as 450
cc. At time of discharge foley has been replaced; her most
recent PVR was 350 cc. We are hoping that her symptoms may
improve as her metastatic CNS disease is treated.
.
HYPERTENSION
We uptitrated her home HCTZ from 25 mg to 50 mg once daily. We
also added nifedipine and uptitrated the dose to 60 mg once
daily to achieve BP goal of <130/80.
.
ANXIETY
We continued her home lorazepam dose.
.
NIGHT-TIME INSOMNIA / DAYTIME SOMNULENCE
We continued her home Ambien CR.
.
SOCIAL / HOME ISSUES
We asked social work to meet with patient to discuss home-care
issues. The consensus is that she will need home services,
including VNA and potentially meals-on-wheels and homemaker
services. In the immediate-post radiation course, she will be
discharged to rehab.
.
She was kept on a normal diet. Due to her metastatic
intracranial disease, pneumoboots rather than subcutaneous
heparin were used for venous thrombosis prophylaxis. Her code
status is full code.
Medications on Admission:
Baclofen 5 mg PO TID PRN
Lorazepam 1 mg PO every 4-6 hours as needed for anxiety.
Docusate Sodium 200 mg PO BID
Senna 1 Tablet PO DAILY
Methylphenidate 10 mg QAM
Oxycodone 5 mg po q4h prn pain (takes only rarely)
Ambien CR 12.5 mg po qhs prn insomnia
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
6. Ambien CR 12.5 mg Tablet, Multiphasic Release Sig: One (1)
Tablet, Multiphasic Release PO HS (at bedtime).
7. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
8. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO three times a day as
needed for pain.
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for anxiety/ insomnia.
10. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
11. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
13. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush.
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2251**] Rehab
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Metastatic breast cancer to the central nervous system
.
SECONDARY DIAGNOSIS
Hypertension
Discharge Condition:
Vital signs stable. Afebrile.
Discharge Instructions:
You were hospitalized for treatment of breast cancer that had
spread to your spinal cord. You underwent a neurosurgical
procedure that will allow us access to administer chemotherapy
more easily to your central nervous system. You also underwent
radiation therapy to the spinal cord.
.
There have been several changes to your medicines. We have
added a new medicine to help control your blood pressure, and we
have changed the dose of your steroids. Your full medication
list is printed out below.
.
The neurosurgeons have given you detailed instructions regarding
the catheter that they placed during this hospitalization.
Please read the following instructions very carefully:
.
??????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.
??????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 an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing in one
week. Please have results faxed to [**Telephone/Fax (1) 87**].
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????New onset of tremors or seizures.
??????Any confusion or change in mental status.
??????Any numbness, tingling, weakness in your extremities.
??????Pain or headache that is continually increasing, or not
relieved by pain medication.
??????Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????Fever greater than or equal to 101?????? F.
Followup Instructions:
Please return to [**Hospital1 18**] for radiation treatment. You have 5 more
radiation treatments remaining. You should have transportation
coordinated so that you arrive at the [**Hospital Ward Name 332**] basement radiation
oncology department in the [**Hospital Ward Name 516**] at [**Hospital **] [**Hospital 1225**] Medical
Center on [**Location (un) **] at 9:15 AM. You will need to return
for five more treatments Wednesday thru Friday of this week and
Monday and Tuesday of next week.
Completed by:[**2153-10-9**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2910
} | Medical Text: Admission Date: [**2115-10-28**] Discharge Date: [**2115-11-4**]
Date of Birth: [**2046-1-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
recurrent rt. carotid stenosis
Major Surgical or Invasive Procedure:
redo right carotid endartectomy [**2115-10-24**]
cardiac [**Last Name (un) **] with PCI/stenting of OM1 x2 stents, Left
lateralcx x1,significant LMT disease
History of Present Illness:
Patient well known to Dr. [**Last Name (STitle) **] who prsent with recurrent
carotid stenosis on rt. s/p CEA x2 with totaly occluded left
carotid. Now ;for redo carotid
endarectomy.
Past Medical History:
history of PVd,s/p rt. fem-[**Doctor Last Name **]
history of hypertension
histoy of ischemic heart disease, stable angina, s/p CABG's [**2104**]
history of caroitd disease with occluded [**Doctor First Name 3098**] and s/p Rt. CEA
history of tobacco use, current 1ppd
history of + stress with fixed inferolateral wall defect, no
ischemia [**8-17**]
history of arthritis
history of gout-uses colchicine prn
histroy of postoperative delerium
history of gastric reflux disease
history of hyperlipdemia
history of recent URi, resolving [**10-19**]
history of dysrythmia
history of renal artery stenoisi s/p renal stenting with chronic
renal disease stg [**12-12**]
Social History:
married, lives with spouse
tobacco, 1ppd, current
ETOH +
Family History:
unknown
Physical Exam:
Vital signs:b/p 136/63 O2 sat 99% room air
GEN: AAOx3, no acute distress
Lungs: clear to auscultatiojn
Heart:RRR, no mumur,gallop or rub
Abd: bengin
EXT: femorals 1+, rt. DP/PT/dopperable,lt dp dopp/left Pt absent
Neuro: grossly intact.
Pertinent Results:
[**2115-10-28**] 04:18PM WBC-10.5 RBC-3.03*# HGB-10.0*# HCT-28.6*#
MCV-94 MCH-33.0* MCHC-34.9 RDW-13.5
[**2115-10-28**] 04:18PM PLT COUNT-209
[**2115-10-28**] 12:44PM TYPE-ART TEMP-36.6 O2-60 PO2-228* PCO2-34*
PH-7.45 TOTAL CO2-24 BASE XS-0
[**2115-10-28**] 12:44PM GLUCOSE-129* LACTATE-1.8 NA+-139 K+-4.3
CL--104
[**2115-10-28**] 12:44PM freeCa-1.07*
Brief Hospital Course:
[**2115-10-28**] rti carotid endartectomy,redo #3transfered to PACU
stable and neurologically intact.Requiring IV ntg gtt for
systolic hypertension.
[**2115-10-29**] POD#1 onset of headache-frontal with rt. lower
extremity wakness and paresis. Non-contrast head CT was
obtained.
IMPRESSION: There is no intracranial hemorrhage. Foci of low
attenuation of
the right posterior occipitoparietal lobe are stable in
comparison to [**9-16**].
[**Doctor Last Name **] white matter differentiation is otherwise normally
preserved.
There is no mass effect, edema or shift of normally midline
structures.
Prominence of the cerebral sulci is compatible with age-related
involutional
change. Areas of periventricular and deep white matter low
attenuation are
compatible with microvascular ischemic change. Dense
atherosclerotic
calcifications are noted on the carotid arteries.
There is opacification of scattered ethmoid air cells
bilaterally, and mild
mucosal thickening of the maxillary sinuses. No suspicious lytic
or blastic
osseous lesion is identified.
MRI and MRA of the brain.IMPRESSION:
1. Multiple areas of acute infarction most prominent at the left
frontal
para-centrilobular and also multiple punctate areas of
infarction at the
convexity bilaterally. This distribution is worrisome for acute
infarction
secondary to embolic events.
2. Complete occlusion of the left internal carotid artery with
collateral
flow from the anterior communicating and posterior communicating
arteries.
Significant segmental narrowing at the left middle cerebral
artery.
Recommend a perfusion study either CT perfusion or MR perfusion
for further
evaluation of possible areas of ischemia.
ECHO: Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
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.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Compared with the prior study (images reviewed) of [**2113-10-10**],
an interatrial shunt is not identified. The findings are
otherwise unchanged.
Neuro consulted.Continue with IV heparinization untli source
detrmined for stroke. maintain patient normotensive and
euvolenmic.continue antiplatlet and statin meds.
Cardology consulted for onset of chest pain, EKG with
inferolateral ST depressions and ST elevations in Avr.cardiac
enzymes trended CK 119-363, CK MB [**1-/2036**] MBI 0-8,troponin
0.01-0.18-0.77-0.82
recommendations were to continue current managment and plavix if
neuro is agreeable.
underwent angioplasty with stenting of LMT and OM1. [**2115-10-30**]
Transfered to CCU for post interventional montering and care.
Transfused for hct 24.8 Iv nitro gtt required for b/p managment.
developement of small neck hematoma which was serially montered.
[**2115-10-31**] IV heparin discontinued. [**Last Name (un) **] transfusion hct 27.4
neck hematoma stable.
mmild wheezing on exam: CXR mmild volume overload, diuresesd.
nitro gtt weaned.main tain b/p 120-140. diet advanced. Neuro
exam unchanged. No chest pain.Remined in CCU secondary to no
VICU beds.
[**2115-11-1**] Transfered to
VIUC for continued monitering.
ECHO:Conclusions
A small secundum atrial septal defect is present. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF 50%) secondary to hypokinesis of
the basal inferior and posterior walls. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2115-10-29**], no major change is evident.
OT evaluation completed.PT evaluation completed will require
rehab.
[**Date range (1) 32519**] patient without cardiac symptoms. neuro exam
stable. awaiting rehab bed.
[**2115-11-4**] REhab bed availble. Patient stable. neck skin clips
removed.discharged
.
Medications on Admission:
simvistatin 20mgm
zetia 10mg
norvasc 10mg
plavix 75mg
atenolol 50mg daily
asa 81mgm
citropram 20mg daily
colchicine 0.6mg prn
multi vitamin tab
omega 3
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Discharge Worksheet-Discharge Diagnosis-Finalized:[**Last Name (LF) **],[**First Name3 (LF) **],
PA on [**2115-11-4**] @ 1220
recurrent carotid stenosis right,s/p cea x2(previous)
history of left ICA occlusion with visual field defect
history of gastric reflux
history of hypertension
history of dysrythmia, type unknown
history of recebntURI, resolving
histroy of ischemic heart disease s /p CABG's x3 [**2104**]
history of renal artery disease, s/p renal artery stenting,
chronic renal disease stag [**12-12**]
history of perpheral vascular disease s/p rt. fem-[**Doctor Last Name **] bpg
history of arthritis, gout
history of current tobacco use
postoperative stroke
postoperative myocardial infract
postoperative acute blood loss anemia, transfused
Discharge Condition:
stable
Discharge Instructions:
please continue all medications as directed.
please call if you develope any signs of stroke, and go to
nearset ER
please call if you develope any chest pain, SOB and go to
nearest ER
Followup Instructions:
2 weeks Dr. [**Last Name (STitle) 1391**], call for an appointment, [**Telephone/Fax (1) 1393**]
followup with his cardologist upon d/c from rehab.for continue
cardiac care.(Dr.[**Name (NI) 32520**] office/[**First Name4 (NamePattern1) 803**] [**Last Name (NamePattern1) **] Np)
Completed by:[**2115-11-4**]
ICD9 Codes: 9971, 2851, 4439, 3051, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2911
} | Medical Text: Admission Date: [**2169-11-8**] Discharge Date: [**2169-11-9**]
Date of Birth: [**2087-4-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
cardiac catheterization with BMS to circumflex artery
History of Present Illness:
Mr. [**Known lastname 26442**] is a 82M with history of CAD s/p CABG (LIMA to LAD,
SVG to diagonal), HTN, HL presents transferred from [**Location (un) **] with
an NSTEMI. He had a recent hospital stay at [**Hospital3 **] for
hip pain that had a negative workup for fracture 1 week prior
and discharged to rehab. The patient states that he has been
having "indigestion" over the last week that was relieved with
Alka-Seltzer. The patient reports that on the day of admission
to the OSH he had epigastric/substernal, non-radiation
pressure/burning sensation. He rated the pain [**2170-7-2**] and notice
some diaphoresis, but no other associated symptoms of
N/V/SOB/palpitations. Vitals at OSH were 98 163/64 73 95% on
55% venti mask. CXR showed left lower lobe infiltrate. The
patient denied F/C and reported a chronic productive cough that
was unchanged. WBC of 12.1 HCT of 35.3. BUN 67 CR: 2.2 CK 277,
CK-MB 33.2 Trop 2.3. He was given plavix 300mg, aspirin 325mg,
solumedrol 125mg IV, lopressor 50mg, norvasc 10mg. He was
transferred on heparin drip and nitro drip. No antibiotics were
given.
The patient underwent cardiac cath that showed: native LMCA and
3 vessel CAD with known chronic total occlusion of the RCA with
progression with another subtotal occlusion in the distal AV
groove CX with successfull BMS. The patient had a patent
LIMA-LAD with a 75% stenosis in the mid-distal LAD downstream of
the anastomosis that was not intervened on. He had occluded
SVG-diagonal. The patient had an end LV pressure of 44mmHg and
given 40mg IV lasix. He received a total of 270ml of dye and was
started on a bicarb gtt. The patient had worsening hypoxia
during the case and required non-rebreather and ABG during the
case was 7.34/30/71/17.
The patient was transferred to the CCU for further management.
On arrive he was 99% on a non-rebreather. He diuresed 700cc to
the lasix. Denied chest pain or SOB. He stated he was tired and
wanted to sleep.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of c paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS::
- Hyperlipideima
- Hypertension
2. CARDIAC HISTORY:
-CABG ([**2164-1-18**]) LIMA to LAD, SVG to diagonal
- Dx Cath([**2164-1-17**]): LMCA 60% stenosis, LAD 60% stenosis
proximally and diffusely diseased distally, D1 90% stenosis
proximally, LCX had 90% stenosis in proximal vessel, RCA
occluded - filled collaterals
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Benign prostatic hypertrophy.
- s/p prostatectomy
- Bell's palsy.
- Peripheral vascular disease.
- Blindness in the right eye due to cataracts.
- Meniere's disease.
Social History:
Patient came from [**Location (un) **] House Rehab Center
-Tobacco history: Quit 15yrs prior (1.5ppd since 18yrs old)
-ETOH: denied
-Illicit drugs: denied
Family History:
Father MI at 78
No other family history of early MI, otherwise non-contributory.
Physical Exam:
VS: T=97.7...BP=150/56...HR=73...RR=20...O2 sat=95% NRB
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. right eye blind and with cataract. Sclera
anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa. dry MM No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. diminished breathe
sounds and crackles at the bases, other clear anteriorly. no
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/ trace edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Pertinent Results:
ADMISSION LABS [**2169-11-8**]:
[**2169-11-8**] 07:48PM WBC-14.1* Hgb-11.6* Hct-34.8* Plt Ct-317
[**2169-11-8**] 07:48PM Neuts-91.6* Lymphs-6.6* Monos-1.6* Eos-0.1
Baso-0.1
[**2169-11-8**] 07:48PM PT-16.0* PTT-150* INR(PT)-1.4*
[**2169-11-8**] 07:48PM Glucose-189* UreaN-70* Creat-2.1* Na-144 K-4.1
Cl-105 HCO3-26 AnGap-17
[**2169-11-8**] 07:48PM ALT-17 AST-44* LD(LDH)-224 AlkPhos-57
TotBili-0.2
[**2169-11-8**] 07:48PM Albumin-3.8 Calcium-9.4 Phos-4.9* Mg-2.6
[**2169-11-8**] 04:55PM Type-ART pO2-71* pCO2-30* pH-7.34* calTCO2-17*
Base XS--8 Intubat-NOT INTUBA
[**2169-11-8**] 04:55PM Hgb-12.4* calcHCT-37 O2 Sat-94
Urinalysis:
[**2169-11-9**] 12:33AM Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022
[**2169-11-9**] 12:33AM Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2169-11-9**] 12:33AM RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0
[**2169-11-9**] 12:33AM Hours-RANDOM UreaN-403 Creat-35 Na-73
CE TREND:
[**2169-11-9**] 01:41AM CK-365 CK-MB-21 MBI-5.8
[**2169-11-9**] 07:56AM CK-340 CK-MB-14 MBI-4.1 TropT-0.62
MICRO:
[**Last Name (un) **] Legionella - negative
[**11-8**] BCx - pending
STUDIES:
[**11-8**] Cardiac cath:
COMMENTS:
1. Selective coronary angiography in this co-dominant system
demonstrated 3 vessel disease. The LMCA was a moderately
calcified
vessel with a distal 50% stenosis. The LAD was a heavily
calcified
vessel. There was an ostial 60% stenosis immediately before D1,
after D1
there was a 70% proximal LAD stenosis. The mid LAD has difuse
70%
stenosis and showed competitive flow. The 1st septal branch had
a
proximal 50% stenosis. The D1 had a proximal 70% stenosis before
a
bifurcation in the vessel and a 40% stenosis in the small branch
of
vessel immediately after the bifurcation. The Cx had diffuse
disease
throughout. There was 60% stenosis in the proximal LAD prior to
the OM1.
There was 50% stenosis between OM1 and OM2 and 60% stenosis
between OM2
and OM3. There is a series of heavily calcified 90% stenosies in
the
distal AV groove Cx. The distal AV groove Cx supplies a long
LPL1 branch
and a small LPDA. The LPL has only TIMI2 flow. The RCA had a
proximal
70% stenosis prior to the atrial branch as well as a mid total
occlusion
after the acute marginal. The distal RCA and distal acute
marginal
filled via right to right collaterals.
2. Arterial conduit angiography revealed the origin of the LIMA
to have
a 35% stenosis which improved to 20% after intra-atrerial
nitroglycerine. The LIMA was patent therafter to the mid LAD.
There wasa
75% stenosis in the mid-distal LAD downstream of the LIMA
touchdown and
diffuse 60% stenosis of the apical LAD. The LAD provided septal
collaterals to the RPDA. The SVG to D1 was occluded at the
origin.
3. The left subclavian artery had a proximal 30% stenosis with
midl
plaquing throughout.
4. Limited resting hemodynamics revelaed severely elevated left
sided
filling pressures with an LVEDP of 44 mmHg. The central aortic
pressure
was 165/56 mmHg. There was no transaortic valve gradient on
pullback of
the catheter from the LV to the aorta.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe left ventricular diastolic dysfunction.
ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
CXR: Retrocardiac density seen on 2view CXR, final read pending.
DISCHARGE LABS [**2169-11-9**]:
[**2169-11-9**] 01:41AM WBC-16.9* Hgb-11.4* Hct-34.5* Plt Ct-263
[**2169-11-9**] 01:41AM BUN-74 Cr-2.3 K-4.2
Brief Hospital Course:
Mr. [**Known lastname 26442**] is a 82M with history of CAD s/p CABG (LIMA to LAD,
SVG to diagonal), HTN, [**Hospital **] transferred from [**Location (un) **] with an
NSTEMI s/p BMS to the LCx.
#NSTEMI: Pt underwent cath s/p BMS to the distal AV groove Cx.
Pt with 75% stenosis to the mid-distal LAD downstream to the
LIMA-LAD anastomosis that was not intervened on. Pt with CK 277,
CK-MB 33.2, Trop-I 2.30 at OSH. CK peaked at 365. The patient is
currently on ASA, Plavix, Lipitor, Labetalol. He has been weaned
off nitro gtt prior to transfer to [**Location (un) **]. He was started on
Imdur 30mg. He has had no further chest discomfort.
# PUMP: Pt with elevated end LV pressure (44mmHg) and pulm edema
on CXR. Pt also hypoxic during procedure and received 40mg IV
lasix to which he responded well. TTE was performed prior to
transfer (see attached report).
# RHYTHM: NSR. The patient had no events on telemetry overnight.
#. Hypoxia: Pt with hypoxia requiring NRB initially. CXR at OSH
showed ?LLL pna vs pulm edema. CXR here was inconclusive. Pt no
fevers, chills, but with chronic productive cough. Leukocytosis
of 14.1 on admission here, but received IV steroids at OSH. No
bands. Likely pulm edema from CHF, but started on antibiotics
(Vanc/Cefepime for HAP as patient was previously at rehab)
overnight given hypoxia. 2 view CXR showed retrocardiac opacity,
and antibiotics were initiated to complete an 8 day course.
#. Leukocytosis: Pt with elevated WBC of 14.1 up to 16.9. At OSH
WBC count was 8.8 on transfer. Pt did receive IV solumedrol
prior to transfer and likely cause of leukocytosis as well as
reactive secondary to NSTEMI. CXR was also consistent with LLL
PNA. He was started on Vanc/Cefepime as above.
# Acute on Chonic RF: Pt with Cr of 2.1 on admission, up to 2.3
on discharge with diuresis. Prior records from [**2163**] indicate Cr
1.2-1.5. Unclear baseline, but likely secondary to chronic HTN
and poor forward flow from ishemia.
# HTN: Pt with SBP 150's on admission. Pt also with elevated BP
at the OSH. Pt is on Labetalol 300mg [**Hospital1 **], Norvasc 10mg daily,
and started on Imdur 30mg daily.
Medications on Admission:
HOME MEDICATIONS:
(Per OSH records)
Labetolol 200mg qam/ 150mg qpm
Norvasc 10mg daily
Tylenol prn
Dulcolax
Caltrate 600 + VitD
Immodium prn
MOM
Percocet q6prn
[**Name2 (NI) 10687**]
Fleet Enema
Visine eye drops prn
OSH Medications given:
[**2169-11-8**] am plavix 300mg
--12pm norvasc 10mg, 50mg lopressor, caltrate 600mg, colace
100mg, aspirin 325mg, solumedoral 125mg.
--heparin at 1100units/hr up at 12pm ntg at 6.6 mg/kg/min.
--NS at 75cc/hr
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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Labetalol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units
units Injection TID (3 times a day).
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-25**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO DAILY (Daily).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
13. [**Month/Day (2) 10687**] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
14. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q48H (every 48 hours) for 6 days.
15. Cefepime 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day for 6 days.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
NSTEMI s/p BMS to left circumflex
healthcare associated pneumonia
acute on chronic congestive heart failure
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Mr. [**Known lastname 26442**],
You were admitted with chest discomfort due to a heart attack.
You had a cardiac catheterization which showed a blockage in one
of the arteries in your heart. A bare metal stent was placed in
this blockage to allow blood flow and limit ongoing injury to
your heart muscle. You need to take plavix, a blood thinner,
for at least 1 month and if you suffer no bleeding complications
you should ideally continue this medication for one year.
We also started you on treatment for a suspected healthcare-
associated pneumonia with the antibiotics, vancomycin and
cefepime which were started on [**11-8**], and should be continued
for total of 8 day course.
You are being discharged to [**Hospital3 **] for continuation of
your care.
Followup Instructions:
Please follow up with your primary cardiologist about further
testing and/or intervention that may be necessary in the future
Completed by:[**2169-11-9**]
ICD9 Codes: 486, 5849, 4280, 5859, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2912
} | Medical Text: Admission Date: [**2193-12-25**] Discharge Date: [**2193-12-31**]
Date of Birth: [**2193-12-25**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**First Name8 (NamePattern2) 50434**] [**Known lastname **] is the
former 2.535 kg product of a 33 and 3/7 weeks gestation
pregnancy born to a 21 year-old, G3, P1 now 2 woman.
Prenatal screens: Blood type 0 positive, antibody negative,
Rubella immune, RPR nonreactive, hepatitis B surface antigen
negative, GBS status unknown. The mother's medical history
is non contributory. This pregnancy was notable for an
echogenic focus noted in the amniotic fluid and amniocentesis
performed at [**Hospital 1474**] Hospital. It showed meconium
particulate material. The mother was transferred to [**Hospital1 1444**] for further evaluation. The
fetus was noted to have a flat tracing and she was therefore
taken to Cesarean section. The infant emerged with meconium
staining. He was warmed, dried and stimulated. He had
spontaneous vigorous respirations. Apgars were 8 at 1 minute
and 9 at 5 minutes. He was admitted to the NICU for treatment
of prematurity. The mother was treated with betamethasone,
one dose prior to the delivery of the infant.
Anthropometric measurements upon admission to the NICU:
Weight 2.535 kg, greater than the 90th percentile. Length 46
cm, 75th percentile. Head circumference 31 cm 50th
percentile, all for 33 weeks.
PHYSICAL EXAM AT DISCHARGE: Weight 2.290 kg, length 46 cm,
head circumference 30.5 cm. General: Pink non distressed,
preterm male in room air. Head, eyes, ears, nose and throat:
Anterior fontanel open and flat, normal facies. Palate
intact. Positive red reflex bilaterally. Neck supple. Chest:
Breath sounds clear and equal, no distress. Cardiovascular:
Regular rate and rhythm, no murmur. Normal S1 and S2.
Femoral pulses +2. Abdomen soft, nontender, nondistended. No
hepatosplenomegaly. Genitourinary: Normal phallus. Testes in
the scrotum. Musculoskeletal: Stable hips, spine straight,
normal sacrum. Skin: Pink, intact, no rashes. Neuro:
Alert, symmetric tone and reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: System 1. Respiratory: This infant required brief
blow-by oxygen upon admission to the Neonatal Intensive Care
Unit and then stabilized in room air. He has had intermittent
episodes of spontaneous apnea and bradycardia. At the time of
discharge, he is breathing comfortably in room air with a
respiratory rate of 30 to 60 breaths per minute and oxygen
saturations greater than or equal to 95%.
System 2. Cardiovascular. This infant has maintained normal
heart rates and blood pressures. No murmurs have been noted.
Baseline heart rate is 130 to 150 beats per minute with a
recent blood pressure of 77 over 44 mmHg. Mean arterial
pressure of 54 mmHg.
System 3. Fluids, electrolytes and nutrition. This infant
was initially n.p.o. and maintained on IV fluids. Initial
whole blood glucose was 30 and he was treated with D-10-W
with normalization of the glucose levels. Enteral feeds were
started on day of life one and gradually advanced to full
volume. At the time of discharge, he is taking 150 ml/kg per
day of breast milk or preemie Enfamil 24 calorie per ounce
formula. He is also attempting to breast feed. Serum glucoses
have remained stable on enteral feeds. Serum electrolytes
were normal at day of life one.
System 4. Infectious disease. Due to his prematurity,
unknown group B strep status of his mother, this infant was
evaluated for sepsis upon admission to the NICU. A complete
blood count showed a white count of 13,200 with a
differential of 41% polymorphonuclear cells, 1% band
neutrophils, 3 metamyelocytes and 5 myelocytes. I to T ratio
was 0.18. A blood culture was obtained prior to starting IV
ampicillin and gentamycin. Blood culture was no growth at 48
hours and the antibiotics were discontinued.
System 5. Hematologic. Hematocrit at birth was 37%. This
infant did not receive any transfusions of blood products.
System 6. Gastrointestinal. This infant required treatment
for unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life 3. Total 10.9 mg/dl.
He received approximately 48 hours of phototherapy. Serum
bilirubin on the day of discharge is .
System 7. Neurologic. This infant has maintained a normal
neurologic exam. During admission, there were no neurologic
concerns at the time of discharge.
System 8. Sensory.
Audiology: Hearing screening not yet completed--recommend prior
to discharge home.
System 9. Psychosocial. This is in intact couple. The baby's
surname after discharge will be Damestoire. [**Hospital1 346**] 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) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital 1474**] Hospital for continuing
level II care. The eventual primary pediatrician is Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 233**], phone number [**Telephone/Fax (1) 50563**].
CARE AND RECOMMENDATIONS AT THE TIME OF TRANSFER:
1. Feeding: 150 ml/kg per day of preemie Enfamil 20
calorie per ounce or expressed breast milk.
2. No medications.
3. Iron and vitamin D supplementation: Iron
supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age. All
infants fed predominantly breast milk should receive
Vitamin D supplementation at 200 i.u. (may be provided
as a multi-vitamin preparation) daily until 12 months
corrected age.
4. Car seat position screening is recommended prior to
discharge.
5. State newborn screens have been sent on [**12-28**] and
[**2193-12-31**] with no notification of abnormal results to
date.
6. Hepatitis B vaccine was administered on [**2193-12-31**].
7. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease or (4) hemodynamically significant
congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 33 and 3/7 weeks gestation.
2. Transitional respiratory distress.
3. Suspicion for sepsis ruled out.
4. Apnea of prematurity.
5. Unconjugated hyperbilirubinemia.
[**First Name8 (NamePattern2) 73452**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 73453**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2193-12-31**] 01:57:27
T: [**2193-12-31**] 04:41:04
Job#: [**Job Number 76205**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2913
} | Medical Text: Admission Date: [**2153-2-8**] Discharge Date: [**2153-2-19**]
Date of Birth: [**2109-1-1**] Sex: M
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: This is a 48-year-old male with
pulmonary alveolar proteinosis secondary to occupation silica
dust exposure, status post whole lung lavage on [**2150-1-31**] who is admitted for elective repeat lavage. Patient
also found to have a positive acid fast bacilli alveolar
lavage, but negative mycobacterium. Had state laboratory
that was started on oral drug tuberculosis therapy.
Patient's symptoms significantly improved post previous
lavage. He resumed work at his previous job as a stone
crusher and has since been having worsening dyspnea on
exertion over the last months to years.
Currently he is unable to walk less than one block prior to
getting short of breath. No chest pain with exertion, no
orthopnea or paroxysmal nocturnal dyspnea. He does have a
cough with clear fluid and no sputum or hemoptysis, no
wheezes. Patient recently finished a course of Bactrim and
prednisone taper for pneumonia last month. He has self-
discontinued all medications except for Serevent. No
over-the-counter medications. Currently still smoking two
packs per day, greater than ten alcoholic beverages per
night. Longest sobriety three weeks, years ago.
PAST MEDICAL HISTORY:
1. Pulmonary alveolar proteinosis, diagnosed in [**2150-1-16**]. Complicated by pneumothorax and intubations, status
post whole lung lavage.
2. Anxiety disorder with a question of bipolar disorder.
3. History of alcohol abuse.
4. Negative PPD in [**2149**], but alveolar lavage with acid fast
bacilli. He was treated with a four drug regimen for three
to four months.
5. HIV negative in [**2150-1-16**].
SOCIAL HISTORY: Works as a stone cutter. Tobacco: Greater
than 40 pack years. Currently two packs per day. Drug use:
Ten years of crack cocaine, quit in [**2145**]. Alcohol greater
then ten liquor drinks per night. Divorced with two kids.
FAMILY HISTORY: Alcoholism in brother, asthma in niece,
brother with coronary artery disease at 61.
MEDICATIONS: He is currently only on Serevent. He
discontinued Paxil, Prozac, Depakote. He also finished
prednisone, Bactrim taper. He takes over-the-counter folate.
PHYSICAL EXAMINATION: Temperature 95.8. Blood pressure
159/109. Heart rate 95. Respiratory rate 14. Oxygen
saturation 96% on room air. General: Anxious, tremulous,
alcohol on breath. Head, eyes, ears, nose and throat:
Anicteric. Pupils equal, round and reactive to light.
Extraocular movements intact. Chest: End inspiratory
crackles, right greater than left. Heart: Tachycardic with
no murmur. Abdomen: Soft, nontender, nondistended with no
hepatosplenomegaly. Extremities: 2+ peripheral pulses, no
edema. Neurological: Alert and oriented times three,
tremulous.
LABORATORIES: White blood cell count 14.6, hematocrit 52.5,
platelet count 430,000. Electrolytes were unremarkable.
HOSPITAL COURSE:
1. Pulmonary: The patient underwent a pulmonary alveolar
lavage secondary to his increasing dyspnea on exertion
similar to the bilateral lung lavage that appeared in [**2149**].
The patient was on the ventilator for a prolonged period of
time and had a change in mental status. This was believed
secondary to medication effect. Perhaps it was secondary to
the fact that he has a high alcohol intake. The patient was
then extubated and removed from the Medical Intensive Care
Unit and was transferred to the floor and his breathing
improved each day.
2. Alcohol history: The patient was placed on a CIWA scale
and also received thiamine and folate and multivitamins
throughout his period of course. Ativan was also used as
needed.
3. Fever: The patient developed perhaps a clostridium
difficile by [**Doctor First Name **] testing. HE also grew out 1/4 bottles
with coagulation negative Staph which was felt to be
secondary to a contaminant. He received vancomycin which was
then discontinued. Patient was discharged on a 14 day course
of Flagyl.
4. Change in mental status: The patient had a right
deviation with his right eye, but this improved along with
his alertness once the Ativan and propofol were discontinued.
Therefore, an MRI and lumbar puncture were not performed.
DISCHARGE STATUS: To home.
DISCHARGE CONDITION: Patient able to ambulate and required
no oxygen.
DISCHARGE MEDICATIONS:
1. Folate 1 mg q.d.
2. Flagyl 500 mg t.i.d. times 12 days.
3. Multivitamin.
FOLLOW-UP: The patient is to follow-up with his
pulmonologist, Dr. ............, pulmonary specialist of [**Hospital3 15516**], [**Last Name (un) 34839**], [**Hospital1 1562**], [**Numeric Identifier 34840**].
Phone number: [**Telephone/Fax (1) 34841**]. He does not have any primary
care physician and this is the physician caring for him.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 26705**]
MEDQUIST36
D: [**2153-2-19**] 02:05
T: [**2153-2-19**] 14:40
JOB#: [**Job Number 34842**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2914
} | Medical Text: Admission Date: [**2178-5-31**] Discharge Date: [**2178-6-7**]
Date of Birth: [**2159-12-26**] Sex: M
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: This is a [**Hospital1 190**] admission for this 18-year-old male who was
occasioned by a high-speed accident when the front wheel of a
motor bike lifted off the road and ran head-on into a car in
the opposite [**Male First Name (un) **]. The patient's helmet flew off on impact,
and then he hit the windshield of the car. He was found to
have decorticate positioning. He was taken to an outside
hospital, [**Hospital3 417**], where he was intubated, and he was
sent to the [**Hospital1 69**].
PAST MEDICAL HISTORY: He has an unknown past medical
history.
PAST SURGICAL HISTORY: He has an unknown past surgical
history.
MEDICATIONS ON ADMISSION: He has unknown medications.
ALLERGIES: He has unknown allergies.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, his temperature was 99 rectally, pulse was 108,
blood pressure was 118/62. He had blood in both external ear
canals. He had 4-mm fixed pupil on the right, and a regular
rate and rhythm. His chest was clear to auscultation
bilaterally without any deformities. His abdomen was soft
and not distended. His pelvis was stable. He had a
degloving injury in the left anterior shoulder. He had
decreased rectal tone on rectal examination.
HOSPITAL COURSE: The patient was admitted and taken to the
Trauma Intensive Care Unit. A right chest tube was placed in
the right pneumothorax, and he was kept sedated and
intubated. A head CT showed a subarachnoid hemorrhage and
basal skull fractures with diffuse edema. A neck CT showed
no fracture. A chest CT showed bilateral atelectasis in the
left lower lobe, left lower lobe collapse, right
pneumothorax, a grade I liver laceration was found on
abdominal CT. He also had air in his spinal canal most
likely secondary to the basilar skull fracture. He also had
a pubic symphysis fracture and sacral fracture, and a
clavicular fracture, and a left forearm evulsion injury.
Plastic Surgery was consulted as well. His intracranial
pressures rose, and the CT scan showed ventricular collapse
around the drain that was placed in the ventricle, and he was
transfused, and supportive care continued. On [**6-4**], he
had an angiogram that showed an intracranial left internal
carotid artery dissection and diffuse intracranial vasospasm.
He had an inferior vena cava filter placed, and he continued
to have increased intracranial pressure which necessitated a
head CT scan which showed herniation.
On [**6-7**], after fulfilling the criteria for brain death,
death was declared.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern4) 12891**]
MEDQUIST36
D: [**2178-8-21**] 09:28
T: [**2178-8-24**] 07:13
JOB#: [**Job Number 36073**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2915
} | Medical Text: Admission Date: [**2146-8-1**] Discharge Date: [**2146-8-22**]
Date of Birth: [**2093-9-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Chronic nonhealing rt. foot wound
Major Surgical or Invasive Procedure:
Right BKA [**2146-8-18**]
rt. tma [**2146-8-8**]
rt. angioplasty of graft and PT [**2146-8-4**]
History of Present Illness:
52y/o male with known PVD s/p rt. fem-pr bpg with 3rd toe
amputation7/08 , discharged to rehab [**2146-6-17**] but rehospitalized
for Mi and underwent cardiac catherization witch was negative
for significant coronary artery diseas.He presents now [**2146-8-1**]
with low grade fever(99)[**8-1**] /08. Had [**Month/Year (2) 269**] servicces for wound
care.The [**Name8 (MD) 269**] RN note wound erythema two days prior to [**8-1**],
increasing foot drainage and pain brought patient to seek
medical care. Patient transfered here for further care.
Past Medical History:
history of Dm2 with neuropathy, insulin dependant, uncontrolled
hisitory of coronary artery disease s/p MI1998,S/p CABG"sx4
'[**38**],s/p PCI w stenting '[**35**]
history of PVD s/p rt. fem-pt bpg with #3 toe amputation [**5-24**]
historyof HTN
historyof systolic/dastolic CHF, chronic, compensated
historyof dyslipdemia
history of COPD/emphysema-inhalers
history of depression/anxiety
history of Bell's palsey? side
historoy of tonsillectomy
history of
Social History:
lives alone
former ETOH abuse, none x 7 yrs
Denies tobacco use
Family History:
noncontributory
Physical Exam:
Vital signs: 99.5-100-22 B/P 120/62 O2 sat 95% Room Air
Gen: AAOx3
Lungs: clear to A
Heart: RRR
abd: bengin
EXt: palpable rt. femoral and graft pulse, dopperable DP, PT.
Rt. foot plantar ulceration with fibrinous base, toe amp site
necrotic no purulance noted
left pedal pulses dopperable.
Neuro: nonfocal
Pertinent Results:
Rt. foot film;
1. Regional progressive erosive change involving the second
through fourth
proximal phalanges is concerning for infection/osteomyelitis.
2. New planter ulcer, remote from the bony changes described
above.
arterial studies:
IMPRESSION: Low velocity, high resistance flow within the
femoral posterior
tibial bypass. There appears to be a flow-limiting stenosis in
the area of
the upper calf portion of the graft. This has the appearance of
a failing
bypass. Further imaging and angiography is recommended.
Brief Hospital Course:
[**2146-8-2**] Admitted Iv Vanco, cipro started, flagyl began wound c/s
obtained.
[**2146-8-3**] Podiatry consulted. fore foot PVR flat. Duplex of graft
with mid graft stenosis.
[**2146-8-4**] angiogram: right graft PT angioplasty.
[**2146-8-8**] Rt. TMA complicated by hypotension requiring neo.Gtt.
IV.Transfused 4units PRBC'sTransfered to ICU from PACU
[**2146-8-9**] POD#1,PPD#6. Neo gtt weaned. intermitted agitiation
which responds to lorazepam. Hemodynamically stable and
transfered to VICU.
[**2146-8-10**] POD#2/PPD#7 Evaluated by PT will [**Hospital **] rehab at d/c.PCA
converted to po pain meds.
9/25-26/08 POD#[**1-18**],PPD#[**6-25**] PCA reatarted, failed po medication
pain control.Being followed by psychiatry.
Patient ambulating against surigal services advice. TMA wound
with masseration and cyanosis.
9/26-28/08 POD#5/6/7,PPD#[**2150-8-27**] amp site not improving despite
IV antibiotics
and encouragment to main tain NWB. Ampuitation discussed with
patinet.
[**2146-8-15**] POD#8,PPD#13 accepting need of rt. BKA.Followed by psych
and social service.
Antibiotics continued.
[**2146-8-16**] POD#9,PPD#14 scheled for BKA defered secondary to
surgical emergency.and reschedualed.
[**2146-8-18**] POD#11,PPD#16 Right BKA without complication.
[**2146-8-19**] POD#[**11-27**],PPD#17 delined diet advanced. patient pain
controlled on diludid PCA.
Patient will be transfered to rehab when bed avaible and
converted to po painmedication with adequate pain control.
Medications on Admission:
plavix 75mgm daily
digoxin 250mcg daily
tramadol 50mgm [**Hospital1 **]
ntg sl 0.3mgm prn
niacin 500mgm [**Hospital1 **]
fenofibrinate micronized 48mg [**Hospital1 **]
percocet tabs [**11-17**] q4h prn
senna tabs 8.6mgm [**Hospital1 **]
gabapentin 100mgm tid
glargine 25units [**Hospital1 **]
humalog ss
mirtazapine 15mgm HS
lasix 40mg [**Hospital1 **]
ntg patch 0.4mg.hr q24h,omeprazol 20mgm daily
lisinopril20mgm [**Hospital1 **]
rosuvastatin 20mgm daily
spirolactone/meprolol xl 150mgm daily
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
15. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
16. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
17. Fenofibrate Micronized 48 mg Tablet Sig: Two (2) Tablet PO
QAM (once a day (in the morning)).
18. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
19. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
Discharge Disposition:
Extended Care
Facility:
LIBERTY COMMONS
Discharge Diagnosis:
chroinc rt. foot wounds
historoy of PVD, s/p rt. fem-pt bpg and rt. toe 3 amputation
[**5-24**]
history of DM2, uncontrolled
histroy of DM neuropathy
historoy of coronary artery disease,s/p MI [**2135**],s/p CABG'sx4 '[**38**]
history of HTN
history of COPD/emphysema on inhalers
history of Bell's Palsey side unknown
history of tonsillectomy
history of chronic systloic/diastoic CHF, compensated EF 20%
postoperative hypotension,resolved
postoperative acute blood loss anemia s/p transfusion, corrected
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
no stump shrinkers
leave skin clips of BK stump in place until seen in followup
with Dr. [**Last Name (STitle) 1391**]
call if wound develope swelling ,redness or drainage
call if developes fever >101.5
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2146-9-8**] 11:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 81677**] 3-4 weeks,call for an appointment,[**Telephone/Fax (1) 1393**]
Completed by:[**2146-8-19**]
ICD9 Codes: 4280, 4019, 2724, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2916
} | Medical Text: Admission Date: [**2123-7-13**] Discharge Date: [**2123-7-28**]
Date of Birth: [**2042-4-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
tachypnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 year-old female with CAD s/p CABG x 3 and mitral valve repair
(bioprosthetic) at [**Hospital1 756**] [**2122-5-12**], CHF, CAD, prior C. difficile
infection admitted from [**Location (un) 583**] House rehab with increasing
oxygen requirement and tachpnea. Per rehab call-in, baseline
oxygen saturation mid-90s on 2L nasal canula; takes torsemide
50mg PO daily. Today noted to have increased dyspnea at rest
with increased oxygen requirement (mid-90s oxygen saturation on
5L NC); minimal improvement with nebulizer treatments,
additional torsemide 20mg PO daily. CXR at rehab showed
"moderate congestion."
.
Of note, she recently completed a long, slow taper of vancomycin
PO for C. difficile infection. She continues on cholestyramine.
Has had some loose stools today, but staff note dtr has been
giving her MOM at times. She was also recently discharged on
[**2123-5-24**] after an admission for CHF. Since then, she has seen her
cardiologist who changed her lasix to torsemide 100mg daily (of
note rehab call-in reported 50mg daily).
.
In the ED, 100.7 89 122/91 32 100%. Physical examination noted
for tachypnea, significant peripheral edema. Laboratory data
significant for creatinine 1.5, WBC 8.5 with left shift, first
set cardiac markers with normal limits. ABG 7.45/44/96. UA
nitrite positive and with many bacteria. Lactate 2.2. CXR 1V
with fluid overload, no clear infiltrate. EKG reportedly
unremarkable. Blood cultures, urine culture sent. Received Lasix
40mg IV, nitro gtt. Was briefly on BiPap, now doing well off
BiPap (stopped approximately 1 hour ago). SBP dropped to 80s,
nitro gtt was stopped and BP improved. On transfer to MICU, 100%
on NRB. Pt also given Vanc, Clindamycin and and Levoquin.
.
On arrival to the CCU, FS was 40. She received 1amp D50. She
was not communicative with [**Date Range 595**] phone interpreter. Patient
frequently taking off BiPAP mask.
.
Patient unable to answer review of systems.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: s/p CABG x 3 and mitral valve repair (bioprosthetic) at
[**Hospital1 756**] [**2122-5-12**] ([**Last Name (un) 12397**]/[**Doctor Last Name 1537**])
[**2122-2-26**] Cath showed a 3-vessel coronary artery disease.
LAD had 60% mid vessel stenosis and 60% stenosis of a small
diagonal.
Her left circumflex had 90% ostial OM 1 stenosis and the mid RCA
was occluded with left to right collaterals. Her resting
hemodynamics demonstrated elevated right and left sided filling
pressures with a mean RA pressure of 16 mmHg, RVEDP of 19 mmHg,
mean pulmonary capillary wedge pressure of 24 mmHg, and a PCWV
of
33 mmHg, and an LVEDP of 22 mmHg.
-PERCUTANEOUS CORONARY INTERVENTIONS: Cath see above
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
.
#. Coronary artery disease - s/p CABG x 3 and mitral valve
repair
(bioprosthetic) at [**Hospital1 756**] [**2122-5-12**] ([**Last Name (un) 12397**]/[**Doctor Last Name 1537**])
post-operative course complicated by prolonged mechanical
ventilation requiring tracheostomy and PEG tube placement, C.
diff colitis, and upper GI bleed
#. History of type B thrombosed aortic dissection (seen on chest
CTA [**2122-2-23**])
# Postoperative AF, unable to tolerate warfarin (GIB).
#. h/o recurrent Clostridium difficile colitis X8-9 times,
treated with flagyl PO, flagyl IV, vanco PO with taper in
past--usually in setting of ABx for UTIs
#. h/o Upper GI Bleed
#. Gallstones diagnosed 30 years prior.
#. Type II diabetes
#. Hypertension.
#. Status post hysterectomy.
#. History of benign mastitis and lumpectomy.
#. History of paroxysmal atrial fibrillation not on AC (?)
#. T11 Vertebral Compression fx ([**1-/2123**])
#. Diastolic CHF (EF > 65% [**2123-3-3**])
#. History of multiple urinary tract infections
After spending 1.5 months ([**4-/2122**]) at [**Hospital1 112**] ICU -> [**Hospital1 **] for
vented unit -> rehab ([**Location (un) 745**] where the PEG was removed) -> home
[**2122-6-12**] where she developed Cdiff colitis -> [**Hospital1 18**] -> MACU in
[**Hospital1 5595**] ([**2122-8-12**])->[**Hospital3 2558**] ( [**Month (only) 205**] - [**Month (only) 359**]) -> home for
1.5 months with husband and [**Name (NI) 269**] -> lower back pain and slid off
bed-> wound in leg -> [**Hospital1 18**] [**2123-2-12**] -> [**Hospital1 5595**] MACU ->
[**Hospital3 2558**] (admitted [**2123-4-14**]).
Social History:
Home: [**Month/Day/Year 595**]-speaking only. Lived with husband prior to heart
surgery. Had prolonged hospitalization and rehab course after
CABG and MVR in [**4-20**]. At rehab after most recent discharge. See
outline below.
Tobacco: Never smoked.
Occupation: Retired physician
[**Name Initial (PRE) **]: Denies
Drugs: Denies
Very hard of hearing and her husband takes her hearing aides
home at night. Prior to her heart surgery she walked without a
walker or cane. Prior to coming in in [**2123-2-12**] at home she
was able to walk with a walker outside with her husband and
climb 7 steps. At baseline she did not have noticeable memory
deficits.
Family History:
She is an only child. Mother died of heart disease in her 70s.
Father died in the war.
Physical Exam:
VS: T= 98.1 BP=109/56 HR=84 RR=89 O2 sat= 99% FIO2 35%
GENERAL: Elderly patient laying in bed, removing BiPAP mask
frequently. Not answering questions with phone interpreter
though shakes her head to questions.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP elevated to ear lobe.
CARDIAC: PMI laterally displaced. Irregular, normal S1, S2. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
labored with accessory muscle use. Lung sounds notable for
rhonchi and reduced breath sounds at bases.
ABDOMEN: Soft. Patient appears uncomfortable with palpation,
though in general appears to be uncomfortable with palpation of
any part of her body. No HSM. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES: +3 edema to the thighs bilaterally. No femoral
bruits.
SKIN: venous ulcers on LE bl wrapped with gauze.
PULSES: distal pulses difficult to appreciate given edema.
Pertinent Results:
[**2123-7-13**] 03:50PM PT-12.9 PTT-23.1 INR(PT)-1.1
[**2123-7-13**] 03:50PM PLT COUNT-281
[**2123-7-13**] 03:50PM NEUTS-86.4* LYMPHS-4.7* MONOS-7.5 EOS-1.0
BASOS-0.4
[**2123-7-13**] 03:50PM WBC-8.5 RBC-4.60 HGB-11.4* HCT-37.1 MCV-81*
MCH-24.9* MCHC-30.8* RDW-16.8*
[**2123-7-13**] 03:50PM proBNP-9626*
[**2123-7-13**] 03:50PM cTropnT-<0.01
[**2123-7-13**] 03:50PM estGFR-Using this
[**2123-7-13**] 03:50PM GLUCOSE-241* UREA N-48* CREAT-1.5* SODIUM-136
POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-30 ANION GAP-17
[**2123-7-13**] 04:07PM TYPE-ART PO2-96 PCO2-44 PH-7.45 TOTAL CO2-32*
BASE XS-5
[**2123-7-13**] 04:18PM URINE HYALINE-[**4-16**]*
[**2123-7-13**] 04:18PM URINE RBC-0 WBC-0-2 BACTERIA-MANY YEAST-NONE
EPI-0
[**2123-7-13**] 04:18PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2123-7-13**] 04:18PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2123-7-13**] 04:18PM URINE UHOLD-HOLD
[**2123-7-13**] 04:18PM URINE HOURS-RANDOM
[**2123-7-13**] 05:19PM LACTATE-2.2*
[**2123-7-13**] 05:19PM COMMENTS-GREEN TOP
[**2123-7-13**] 11:41PM LACTATE-1.0
[**2123-7-13**] 11:41PM TYPE-ART PO2-63* PCO2-46* PH-7.47* TOTAL
CO2-34* BASE XS-8
Brief Hospital Course:
SUMMARY
81 year-old female with CHF, CAD, prior C. difficile infection
admitted with tachypnea and dyspnea with evidence of volume
overload on exam and on CXR. She responded to aggressive
diuresis but refused laboratories and had [**Last Name (un) **] compounded by
severe C.Diff colitis. She also continued to chronically
aspirate.
MICU COURSE [**7-19**] to [**7-21**]
Patient was transferred to the MICU from the CCU service [**7-19**]
through [**7-21**] for altered mental status and hypotension. Patient
had not had labs for several days and was found to be in acute
on chronic renal failure to Cr of 3.7, which was likely from
over agressive diuresis with torsemide. Cr improved with gentle
IV hydration from 2.6 to 1.7 whil in the MICU. Mental status
improved with improved renal function. Cdiff was managed with
oral vancomycin 250 mg QID with Flagyl 500 mg IV Q8H, and
patient was kept NPO. Surgery and ID remained involved during
this care. KUB revealed colonic ileus, but patient continued to
have [**2-14**] stools per day and abdominal exam was benign.
BY PROBLEM.
1. Diastolic Heart Failure, Severe and Acute on Chronic
On arrival to the CCU, patient was tachypneic and very short
of breath. Her symptoms were thought to be secondary to acute on
Chronic diastolic heart failure (elevated BNP and evidence of
pulmonary edema on CXR). ECG notable for atrial flutter,
exacerbating her heart failure symptoms. She was briefly placed
on BiPAP, but became very agitated and removed the bipap. She
was diuresed with lasix drip and given morphine. Patient was
volume overloaded on exam, with . She was initially diuresed
with a lasix drip and metolazone. Her creatine increased after
diuresis and lasix drip was briedly held. She was subsequently
started on 100mg PO torsemide. This was complicated by [**Last Name (un) **] (see
below). She was ultimately discharged on alternating doses of 30
and 40mg of torsemide. We are tolerating a creatinine of [**2-13**],
aiming toward 1.5.
2. [**Last Name (un) **]
Patient over diuresed in the setting of refusing lab draws.
This, in the setting of hypotension, prompted a brief MICU
transfer. It resolved with IVF. In the name of euvolemia, it was
resolved to tolerate a creatinine of [**2-13**].
3. Severe C. Diff Colitis
Patient had recently finished long vancomycin taper. PO vanc
was started prophylactically while she was treated for her UTI
using cipro. Cholestyramine was held given patient's complaints
of constipation on admission. This became markedly worse. She
came under control with higher doses of PO vanc and IV flagyl.
On discharge she was kept on a taper of vanc po and later
rifaximin.
4. Aspiration
Comfort Eating
DNR/DNI
Patient is known chronic aspirator. Video swallow revealed
[**Month/Day (2) **] aspiration. Speech and swallow reccommended NPO. Patient
has had PEG in past, family recognized that patient prefers to
eat for comfort and pleasure. Patient allowed to eat and drink
and made DNR/DNI with no MICU transfers. At the time of
discharge, the family was considering a do-not-hospitalize
policy.
5. Atrial flutter
Admission ECG notable for atrial flutter. Amiodarone was
discontinued. She was continued on metoprolol 37.5mg tid and
subsequently switched to metoprolol succinate 100mg daily. Due
to blood pressure limitations, her dose was titrated to safety.
She was discharged on Metoprolol 25 mg TID. Patient not
anticoagulated given significant history of GI bleed, though she
was kept on aspirin 325mg.
6. CAD
Patient has history of 3 vessel disease s/p multivessel CABG
and MVR in [**2122**]. She denied any symptoms of chest pain. Her ECG
was without ischemic changes. Her cardiac markers were
elevated, in the setting of CHF and renal insufficiency. She
was continued on aspirin, metoprolol and simvastatin.
7. UTI
Urine notable for ecoli sensitive to cipro. Patient was
febrile in the ED, but defervesced upon arrival. She was
treated with cipro for her UTI and started on vanc
prophylactically given her significant history of c diff. This
failed. The patient has asymptomatic bacteriuria. She should
never be treated with Cipro. She can receive cranberry juice.
Consider intravaginal estriol for treatment of atrophic
vaginitis and therefore UTI ppx.
8. Hypoglycemia/Diabetes:
Patient was hypoglycemic on arrival to the ICU and responded
well to 1 amp D50 with appropriate response to blood sugar. Her
insulin regimen was initially held and restarted at a lower dose
of glargine 6U (previously on 10 U) once blood sugars stable.
9. Hypothyroid: Patient continued on her synthroid. TSH was
checked and was within normal limits.
.
#. HTN: Metoprolol
.
#. HLD: Continued home statin.
SPECIAL NOTES
1. Please check Na, K, HCO3, Cr and BUN every 3 days. This
information is crucial to the management of her heart failure.
It is appropriate and encouraged to keep her Creatinine at 1-2
(~1.5)
2. Physical Therapy: Please work on strength and stamina. Keep
Out of bed for meals.
3. Telemetry. Patient in atrial fibrillation. Tachycardia > 110
can be a sign of overdiuresis.
4. Diuretics:
a. Weigh patient daily. If increase in > 3lb, must contact MD
and increase diuretic
b. Must tolerate creatinine between 1 and 2. Effective diuresis
causes mild renal failure. If creatinine > 2, then reduce
torsemide dose. If cr < 1.3, then increase torsemide dose.
Consult with MD. Consider changing dose by 10 mg.
c. Patient is resistent to oral lasix
5. UTIs
a. Do not give patient antibiotics for UTI unless positive that
it is causing symptoms. Cipro causes C.Diff
b. Encourage cranberry juice consumption
c. Consider Intravaginal estriol for atrophic vaginitis and
prevention of bacteriuria
6. Aspiration
Patient chronically aspirates. Her family is aware of this. She
was allowed to eat for comfort.
7. DNR/DNI
Patient was made DNR/DNI this hospitalization
Medications on Admission:
Aspirin 81 mg/day
Amiodarone 200 mg/day
Synthroid 150 mcg/day (per rehab note)
Prilosec 20 mg/day
Spironolactone 12.5 mg/day
Lidocaine patch
Simvastatin 40 mg/day
Calcium 600 mg b.i.d.,
Metoprolol 37.5 mg t.i.d.
Torsemide 50mg by mouth daily
Vancomycin 125 mg p.o. b.i.d. (completed)
vitamin D
Colace
Iron 325 mg daily
Cholestyramine-Sucrose 4 gram Packet tid
Glargine Insulin 10 Units QHS (not on rehab list)
Humolog Sliding Scale Insulin (not on rehab list)
Combivent
Calcium 500 + D 500 mg(1,250mg) -400 unit [**Hospital1 **]
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): On for
12 hours during day.
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for back pain.
4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days: last day is [**8-3**].
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
6. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
8. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO
once a day.
9. Cholestyramine-Aspartame 4 gram Packet Sig: One (1) packet PO
three times a day.
10. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
11. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
13. Torsemide 20 mg Tablet Sig: 1.5-2 Tablets PO once a day:
Give 30mg and 40mg on alternating days. hold if cr > 2.0. If Cr
falls below 1.3, or patient short of breath, increase dose of
torsemide.
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
three times a day.
15. Xifaxan 200 mg Tablet Sig: Two (2) Tablet PO twice a day for
2 weeks: Start on [**8-3**] and continue for 2 weeks.
16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
17. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
18. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
19. 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.
20. 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.
21. Outpatient Lab Work
Please check Na, K, HCO3, Cr and BUN every 3 days.
22. Outpatient Physical Therapy
Please work on strength and stamina. Keep Out of bed for meals.
23. Telemetry
Please monitor on telemetry. Patient in atrial fibrillation.
Tachycardia > 110 can be a sign of overdiuresis.
24. Diuretics
1. Weigh patient daily. If increase in > 3lb, must contact MD
and increase diuretic
2. Must tolerate creatinine between 1 and 2. Effective diuresis
causes mild renal failure. If creatinine > 2, then reduce
torsemide dose. If cr < 1.3, then increase torsemide dose.
Consult with MD. Consider changing dose by 10 mg.
3. Patient is resistent to oral lasix
25. UTIs
1. Do not give patient antibiotics for UTI unless positive that
it is causing symptoms. Cipro causes C.Diff
2. Encourage cranberry juice consumption
3. Consider Intravaginal estriol for atrophic vaginitis and
prevention of bacteriuria
26. Aspiration
Patient chronically aspirates. Her family is aware of this. She
was allowed to eat for comfort.
27. DNR/DNI
Patient was made DNR/DNI this hospitalization
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Acute on chronic Diastolic congestive Heart Failure
Acute on Chronic Kidney Disease
Urinary Tract infection
C-Difficile infection
Chronic Aspiration
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 had an episode of congestive heart failure and needed to
receive medicine to take off the extra fluid. You need to weigh
yourself every day and notify Dr. [**Last Name (STitle) 171**] if your weight
increases more than 3 pounds in 1 day or 6 pounds in 3 days. You
were started on an antibiotic course for c-difficile infection.
Finally, you were found to aspirate or inhale food and water. It
was decided to allow you the pleasure and comfort of eating and
drinking despite the risk.
Medication changes:
1. Increase aspirin to 325 mg
2. Discontinue Amiodarone and spironolactone
3. Torsemide 30 mg daily
4. change Metoprolol Tartrate
5. Vancomycin 125 mg every six hours until [**8-3**].
6. Rifaximin three times daily for 2 weeks, starting [**8-3**]
7. Stop omeprazole
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name8 (NamePattern2) 4283**] [**Last Name (NamePattern1) 10803**] [**Telephone/Fax (1) 250**] Date/time: please make an appt
to see when you get out of rehabililtation.
.
Cardiology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2123-8-11**]
11:20
.
.
Pain clinic:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1652**]
Date/Time:[**2123-8-3**] 12:50
.
Department: PAIN MANAGEMENT CENTER
When: TUESDAY [**2123-8-3**] at 12:50 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
.
Gastroenterology:
Dr. [**First Name8 (NamePattern2) 6665**] [**Name (STitle) 1356**]
[**Hospital1 18**]-Division of Gastroenterology/GI East
[**Location (un) 830**],DA-601
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 7091**]
Fax: [**Telephone/Fax (1) 12403**]
Please make an appt for 3-4 weeks.
Completed by:[**2123-7-28**]
ICD9 Codes: 5849, 5990, 4280, 2449, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2917
} | Medical Text: Admission Date: [**2131-7-24**] Discharge Date: [**2131-7-27**]
Date of Birth: [**2089-3-19**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Codeine / Ciprofloxacin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
abdominal pain, coffee ground emesis
Major Surgical or Invasive Procedure:
Esophagogastroduodonoscopy ([**First Name3 (LF) **])
History of Present Illness:
42 year old man with a history of alcohol dependence, alcoholic
cirrhosis with grade II varices s/p banding, and chronic
pancreatitis, presenting with one day of coffee-ground emesis
and abdominal pain. Mr. [**Known lastname 53917**] was recently admitted to [**Hospital1 18**]
from [**2131-7-15**] to [**2131-7-21**] for coffee ground emesis and abdominal
pain following an episode of heavy drinking, which was thought
to be due to esophagitis/gastritis in the setting of vomiting
from an exacerbation of chronic pancreatitis. Upon discharge
from [**Hospital1 18**], he drank 1.5 pints of vodka and a few beers 1 day
prior to admission and 1 pint of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] on the day of
admission.
.
In the late morning on the day of admission, Mr. [**Known lastname 53917**] began
to feel sharp, epigastric/right upper adbominal pain that was
[**6-29**] in severity and radiated to the back. Associated with the
pain was nausea, which resulted in 3 episodes of emesis. The
first episode was yellow in color, but the last vomitis had a
coffee ground appearance. He presented to the ED at [**Hospital1 18**] due
to this emesis.
.
His current abdominal pain is more severe than his baseline [**2-27**]
epigastric pain associated with his chronic pancreatitis and was
similar past episodes of acute on chronic pancreatitis. In the
past, his similar pain has been improved by sitting still and
Dilaudid, and his nausea has subsided with Zofran. He last ate a
large breakfast at 10 AM the day of admission. He denies recent
the consumption of fatty or spicy foods or coffee.
.
Last fever was [**2131-7-20**] in the hospital. He reports several weeks
of intermittent night sweats. He has mild, intermittent chronic
right knee pain. He has mild pain in the nasal passageway from
an NG tube from his recent hospitalization. He has experience
recent episodes of loose stool without hematochezia, melena, or
bright red blood. He denies the use of aspirin or Tylenol.
.
In ED, he continued to experience abdominal pain and nausea. He
received Protonix 80 mg IV, IVF, Zofram4 mg , Dilaudid 3mg IV,
and Ciprofloxacin 400mg IV, and octreotide bolus + drip. He was
seen by GI, and a NG lavage revealed brown coffee grounds that
cleared after 500 mL. He was guaiac negative. Vitals afebrile HR
68 BP 133/71 RR 18 O2sat 93% RA.
.
Past Medical History:
-Alcoholic cirrhosis with [**Month/Day/Year **] on [**6-28**] with Grade II varices.
-Variceal bleeds, 6 episodes from [**2128**] to [**11-27**] s/p multiple
bandings. Bleed in [**11-27**] was grade II on [**Date Range **], s/p banding.
-Chronic pleural effisions
-Chronic pancreatitis
-Alcohol dependence: heavy drinking started at age 30-35. Has
been to detox and dual diagnosis clinics in the past. Has had
periods of sobriety. H/o delirium with past withdrawal; no h/o
seizures.
-Bipolar disorder and anxiety disorder NOS, well controlled on
citalopram, quetiapine, and ativan. Has psychiatrist in the
community.
-S/p cholecystectomy on [**5-29**]
-S/p right ACL replacement and meniscectomy in [**2126**]
Social History:
Currently homeless. Divorced. Has daughter in [**Name (NI) 614**] and
son in [**Name (NI) 3320**]. 12 year history of drinking 1-1.75 liters of
vodka daily. Denies tobacco or other illicits.
Family History:
History of alcoholism. Paternal grandfather died of prostate
cancer. Maternal grandmother died of MI; no other family h/o
CVD. Father alive, with h/o kidney cancer. Mother and children
healthy.
Physical Exam:
General: comfortable, NAD.
HEENT: No scleral icterus, MMM, oropharynx clear.
Lungs: CTA bilaterally with no w/r/r.
CV: RRR with no m/r/g.
Abdomen: Soft, non-distended. No mottling of skin. +BS in all 4
quadrants. Warm to touch. Diffusely positive to light palpation
and percussion but increased tenderness in epigastric and right
upper quadrants. No guarding or rigidity. Scar located in right
upper quadrant from prior cholecystectomy. No caput medusa. No
angiomas.
Ext: Warm, well perfused, 2+ DP and PT pulses, no clubbing,
cyanosis or edema. No asterixis.
Neuro: A+O to person, place, time.
Pertinent Results:
[**2131-7-27**] 05:50AM BLOOD WBC-2.5* RBC-4.25* Hgb-10.6* Hct-33.8*
MCV-80* MCH-25.0* MCHC-31.4 RDW-14.9 Plt Ct-126*
[**2131-7-26**] 03:45PM BLOOD Hct-33.6*
[**2131-7-26**] 06:25AM BLOOD WBC-1.7* RBC-4.08* Hgb-10.8* Hct-32.3*
MCV-79* MCH-26.6* MCHC-33.6 RDW-14.9 Plt Ct-111*
[**2131-7-26**] 12:05AM BLOOD Hct-32.4*
[**2131-7-25**] 12:43PM BLOOD Hct-30.7*
[**2131-7-25**] 07:57AM BLOOD Hct-31.0*
[**2131-7-25**] 04:30AM BLOOD WBC-2.0* RBC-3.82* Hgb-10.1* Hct-29.9*
MCV-78* MCH-26.5* MCHC-33.9 RDW-15.8* Plt Ct-105*
[**2131-7-25**] 12:29AM BLOOD Hct-31.1*
[**2131-7-24**] 08:20PM BLOOD Hct-30.8*
[**2131-7-24**] 01:15PM BLOOD WBC-2.9* RBC-4.34* Hgb-11.7* Hct-33.5*
MCV-77* MCH-27.0 MCHC-35.0 RDW-15.8* Plt Ct-113*
[**2131-7-27**] 05:50AM BLOOD Glucose-117* UreaN-3* Creat-0.8 Na-142
K-3.6 Cl-104 HCO3-28 AnGap-14
[**2131-7-24**] 01:15PM BLOOD Glucose-117* UreaN-9 Creat-0.8 Na-142
K-3.5 Cl-105 HCO3-22 AnGap-19
[**2131-7-27**] 05:50AM BLOOD ALT-18 AST-31 Amylase-8
[**2131-7-24**] 01:15PM BLOOD ALT-25 AST-49* LD(LDH)-170 AlkPhos-255*
TotBili-0.8
[**2131-7-27**] 05:50AM BLOOD Lipase-8
[**2131-7-24**] 01:15PM BLOOD Lipase-12
[**2131-7-27**] 05:50AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8
[**2131-7-25**] 04:30AM BLOOD Albumin-3.8 Calcium-8.3* Phos-3.7 Mg-1.7
Iron-30*
[**2131-7-25**] 04:30AM BLOOD calTIBC-334 VitB12-501 Folate-GREATER TH
Ferritn-23* TRF-257
[**2131-7-24**] 01:15PM BLOOD ASA-NEG Ethanol-154* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2131-7-24**]: [**Month/Day/Year **]: stage 1 varices, portal hypertensive gastropathy,
and 2cm non-bleeding nodule consistent with pancreatic rest
.
[**2131-7-25**]: EKG: Sinus rhythm. Mildly prolonged Q-T interval.
Non-specific inferior and anteroseptal T wave changes. Compared
to the previous tracing of [**2131-7-18**] the heart rate is slower. QT
interval prolonged. QTc: 466
.
[**2131-7-26**]: Sinus rhythm. Non-specific anterolateral ST-T wave
changes. Compared to the previous tracing of [**2131-7-26**] the Q-T
interval is not as long on the current tracing. QTc: 410.
Brief Hospital Course:
Assessment/Plan: This is a 42 yo [**Male First Name (un) 4746**] with extensive alcohol
abuse, alcoholic cirrhosis with grade I varices s/p banding, and
chronic alcoholic pancreatitis, MICU transfer, admitted for
coffee-ground emesis following and acute drinking binge.
.
# Upper GI bleed: Due to findings of bright red blood via
nasogastric lavage, patient was admitted directly to the MICU.
Patient's vital signs and Hct were stable. Liver service was
consulted, and pt underwent endoscopy, which showed stage 1-2
varices, portal hypertensive gastropathy, and 2 cm non-bleeding
nodule consistent with pancreatic rest grade. There was no
active bleeding visualized. Esophagitis was noted. Pt was
continued with protonix. Cipro was started for SBP prophylaxis,
then held for hx or prolonged QTc. As patient's symptoms
improved, he was restarted on a regular diet, and was considered
stable for call out to the floor.
.
Upon reaching the floor, vital signs and hematocrits were
measured often and remained steady. An active type and screen
was maintained. Patient was continued with [**Hospital1 **] PPi and
sucralfate. Given lack of variceal bleeding found on [**Hospital1 **],
ciprofloxacin and octreotide were no longer warranted. Patient
did not experience any further episodes of vomiting, nausea, or
melena. Upon discharge, patient was started on nadolol to
decrease portal hypertension and reduce the risk of future
episodes of variceal bleeding. Given lack of ascites, patient
was not initiated on spironolactone.
.
Patient has extensive past medical history of alcoholic
cirrhosis complicated by history of numerous episodes of UGI
bleeding and grade II varices that were banded in the past. The
lack in finding an active source of bleeding via [**Hospital1 **] makes it
difficult to cite a clear source, but bleeding etiology may have
been multifactorial. It was thought by GI that the most likley
cause of bleeding was from esophagitis secondary to alcohol
consumption and vomiting. Patient was discharged on nadolol for
reduction in portal hypertension and reduction in the risk of
variceal bleeding. Patient will follow up with Dr. [**Name (NI) **]
in 2 weeks for follow up.
.
# Alcohol dependence. Given extensive alcohol abuse, recent
binge, and history of prior withdrawal episodes (no prior
seizures), patient was at risk for alcohol withdrawal during
this admission. Upon reaching the MICU, pt was started
initially on CIWA scale but later discontinued. It was believed
by the MICU team that pt was unlikely to develop significant
withdrawal as he was abstinent from alcohol from [**Date range (1) 61239**]/09
during his prior admission. However, patient reported binging
upon returning home and appeared anxious, jittery, and
tachycardic upon reaching the floor. He was restarted on
diazepam 10mg PO q3h:PRN for CIWA > 10 and agitation. Patient's
sympathetic symptoms improved. Patient was continued on
outpatient regimen of folate, thiamine, and MVI. Addictions
social work saw the patient and provided counselling regarding
cessation. Patient also spoke with social work and agreed to
follow up with alcoholics anonymous.
.
#Abdominal pain and nausea: Patient has chronic [**2-27**] baseline
pain secondary to chronic pancreatitis that was exacerbated with
alcoholic binge prior to admission. Lack of fever,
leukocytosis, and abdominal distension was less worrisome for
spontaneous bacterial peritonitis. LFTs and lipase were within
normal limits. Patient was initially placed NPO, with diet
advanced and tolerated well. Patient was given PO dilaudid with
an attempt to wean doses throughout her admission. Zofran was
given for nausea. PPi and sucralfate were continued as above.
Patient was discharged with 20 pills (4 day supply) of 5mg
oxycodone PO q6-8 hours and told to follow up with his scheduled
appointment with his primary care physician [**Name Initial (PRE) 176**] 4 days of
discharge. Patient will follow up with Dr. [**Name (NI) **] in 2
weeks for follow up.
.
# Alcoholic cirrhosis: Complicated by coagulopathy, varices,
and gastric changes on [**Name (NI) **] consistent with portal hypertension
gastropathy. LFT, [**Name (NI) **], and CBC abnormalities were at baseline
during this admission. No indication of hepatic encephalopathy
was observed. Lactulose was given and no signs of
encephalopathy were present.
.
# leukopenia, anemia, thrombocytopenia: Lab disruptions were
most likely secondary to bone suppression secondary to alcoholic
suppression of bone marrow. Stable during this admission.
Liver disease also likely contributing. Patient given ferrous
sulfate upon discharge to help with anemia secondary to
bleeding.
.
# Coagulopathy. Believed to be secondary to liver cirrhosis,
but may also be due to poor absorption due to poor nutritional
status. Patient reported complying with vitamin K supplements.
Recently received vitamin K injection x 1 during hospitalization
at [**Hospital1 18**] in prior week.
.
#Bipolar disorder and anxiety disorder NOS: Conditions were
well controlled on outpatient regimen of citalopram, quetiapine,
ativan, and trazadone.
Medications on Admission:
Medications on admission:
-Ciprofloxacin 500 mt PO daily for 7 days until [**2131-7-27**] was
being given for SBP ppx
-Oxycodone 5 mg PO Q6-8H PRN pain. Takes ~10 mg Q4H but does not
frequently run out of medication.
-Citalopram 40 mg PO daily
-Quetiapine 400 mg SR once daily
-Trazadone 100 mg PO QHS PRN insomnia
-Amylase-lipase-protease 20,000-4,500-25,000 unit capsule, one
capsule three times daily with meals.
-Folic acid 1 mg PO daily
-Thiamine 100 mg PO daily
-Multivitamin once daily
-Pantoprazole 40 mg PO Q12H
-Propanolol 10 mg PO BID hold for pulse <60
-Sucralfate 1 gram PO QID
-Ativan 0.5 mg, [**12-22**] rablets PO Q8H PRN anxiety
-Lactulose 10 gram/15mL, 30 mL PO TID PRN constipation.
.
Medications on transfer:
citalopram 40 mg po daily
folic acid 1 mg IV q24h
dilaudid 2 mg po q4h:prn pain
lactulose 30 ml PO TID titrate to BM, hold after BM
lorazepam 0.5-1 mg PO q8h:prn anxiety, hold for sedation (CIWA
scale d/c'ed in AM of [**7-25**])
MVI
zofran 8 mg IV q8h: prn nausea
quietiapine XR 400 mg PO daily
sucralfate 1 gm PO qid
thiamine 100 mg IV daily, for 5 days
trazodone 100 mg PO HS: prn insomnia
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
2. Quetiapine 200 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Lactulose 10 gram Packet Sig: One (1) PO three times a day
as needed for constipation.
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
8. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO three times a day: Take with meals.
10. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for anxiety.
12. Nadolol 20 mg Tablet Sig: [**12-22**] Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- upper gastrointestinal bleed
- alcohol dependence
- alcoholic cirrhosis
- chronic pancreatitis
.
Secondary:
- stage I esophageal varices
- portal hypertensive gastropathy
- 2cm non-bleeding nodule/pancreatic rest
- bipolar disorder
Discharge Condition:
Afebrile, vital signs stable. Nausea and vomiting have
resolved. No melena. Abdominal pain significantly improved.
Discharge Instructions:
You were admitted for coffee ground vomitting and abdominal
pain. You spent 2 days in the intensive care unit due to your
upper gastrointestinal bleeding. You underwent a scoping
procedure and were found to have no active bleeds. It is
believed that your bleeding was from irritation of your
esophagus. You were also treated for alcohol withdrawal. Upon
going home, please do not consume any alcohol.
.
We have added the following NEW medications:
1) nadolol 10mg PO daily
2) Ferrous sulfate 325mg twice a day
.
Please take all other medication as previously directed.
We have made the following CHANGES to your medications:
-stopped the cipro
-stopped the propranolol
.
Should you develop worsening abdominal pain, fever, chills,
lightheadedness, bloody vomiting, please contact your primary
care physician or visit the emergency room.
Followup Instructions:
Please follow up with your previously scheduled appointment with
your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 75523**]. She will
also be availble any Tuesday of the month for walk-in
appointments.
Date: [**2131-8-21**] at 9:30AM
Phone: [**Telephone/Fax (1) 5135**]
.
Please follow up with a hepatologist, Dr. [**Name (NI) **]:
[**2131-8-6**] at 8:30 AM. Phone Number: Phone: [**Telephone/Fax (1) 2422**]
.
Please attend the alcoholic anonymous meetings, as directed by
paperwork given to you by social work.
ICD9 Codes: 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2918
} | Medical Text: Admission Date: [**2176-2-21**] Discharge Date: [**2176-2-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac cath with stenting
History of Present Illness:
The patient is an 86 y.o. male with pmh significant for DM II,
hyperlipidemia, and hypertension, presenting with two episodes
of chest pain. The first episode was [**2-17**] while he was clearing
snow off of his car. He experienced 1.5 hours of chest tightness
followed by vomiting. On [**2-21**] the patient had another episode of
chest tightness, lasting for 1.5 hours and followed by vomiting.
This episode occurred while the patient was driving to his
volunteer work. A co-worker noticed him vomiting and told him to
go to the hospital.
.
In the ED vitals were 96.4, 86, 183/76, 18 100% RA. EKG showed
sinus rhythm with ST elevations in V1-V3, and troponins were
increased to 1.15. he was given aspirin 325mg, plavix 600mg,
heparin gtt, integrillin, and lopressor.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
.
Cardiac review of systems is notable for presence of chest
tightness, absence of dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
hypertension
diabetes mellitus, type 2
hypercholesterolemia
BPH
glaucoma
hypothyroidism
Social History:
-Tobacco history: Quit smoking: 35 yrs ago
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION: 139/54 76 100% RA
GENERAL: Elderly
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not elevated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
Labs on admission:
.
[**2176-2-21**] 05:30PM BLOOD WBC-8.6 RBC-3.93* Hgb-12.3* Hct-34.3*
MCV-87 MCH-31.2 MCHC-35.8* RDW-13.5 Plt Ct-180
[**2176-2-21**] 05:30PM BLOOD Neuts-72.9* Lymphs-21.5 Monos-4.5 Eos-0.6
Baso-0.5
[**2176-2-21**] 05:30PM BLOOD PT-14.0* PTT-27.2 INR(PT)-1.2*
[**2176-2-21**] 05:30PM BLOOD Glucose-152* UreaN-34* Creat-1.4* Na-138
K-4.1 Cl-103 HCO3-24 AnGap-15
[**2176-2-22**] 03:41AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.0
.
CARDIAC ENZYMES:
[**2176-2-21**] 05:30PM BLOOD CK(CPK)-1109* CK-MB-89* MB Indx-8.0*
cTropnT-1.59*
[**2176-2-22**] 03:41AM BLOOD CK(CPK)-1093* CK-MB-66* MB Indx-6.0
cTropnT-4.33*
[**2176-2-22**] 09:59PM BLOOD CK(CPK)-693* CK-MB-30* MB Indx-4.3
[**2176-2-23**] 04:12AM BLOOD CK(CPK)-678* CK-MB-33* MB Indx-4.9
cTropnT-3.20*
[**2176-2-23**] 03:03PM BLOOD CK(CPK)-577* CK-MB-24* MB Indx-4.2
cTropnT-2.96*
.
URINE:
[**2176-2-22**] 11:02PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.023
[**2176-2-22**] 11:02PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2176-2-22**] 11:02PM URINE RBC-0 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
.
MICROBIOLOGY:
Urine - coag neg gm negative
Bl Cx - NGTD
.
CARDIOLOGY:
Cardiac Cath ([**2-21**])
COMMENTS:
1. Selective coronary angiography of this right dominant
revealed three
vessel disease. The LMCA was free of significant stenoses. The
LAD had
a long, complex 90% proximal stenosis and a 70% lesion in the
distal
vessel. The LCx had a 50% proximal lesion and a 80% stenosis in
the OM1
branch. The RCA had a subtotal occlusion of a small (<1mm) PDA
branch.
2. Limited resting hemodynamics revealed a central aortic
pressure of
114/53mmHg.
3. Left ventriculography was deferred.
4. Successful stenting of the proximal LAD with two overlapping
MiniVision BMS (2.5x23 distally and 2.5x12 mm proximally) with
excellent
flow through the proximal two thirds of the LAD and no flow in
the
distal third supplying the apex.
5. Distal LAD dissection/noreflow without hemodynamic compromise
or
evidence of ischemia on ECG. No chest pain.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful stenting of the proximal LAD with two overlapping
BMS.
3. No reflow to the distal third of the LAD supplying the apex.
.
TTE ([**2-23**])
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with akinesis of
mid-septal and anterior walls, and the distal [**2-3**] of the left
ventricle (mid LAD distribution). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Moderate (2+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD. Moderate mitral regurgitation. Mild
pulmonary hypertension. LVEF 30-35%.
Brief Hospital Course:
86 y.o. man w/ pmh significant for DMII, Hypertension,
Hyperlipidemia, presenting with chest pain and found to have
STEMI.
.
# STEMI: EKG with ST elevations in V1-V3, and positive
troponins. Patient's chest pain occurred the week before
presentation, then re-occured early in the morning of [**2-21**] and
he did not present to the ED until the afternoon. He was
chest-pain free when transferred to the CCU. Given the time
delay there was no urgent reason to bring the patient
immediately for cardiac catheterization. Pt on integrilin gtt,
heparin gtt, aspirin/clopidogrel, metoprolol, statin. Cath on
[**2-22**] w BMS to prox LAD w small dissection, stable. Post-cath
course unremarkable. Hct stable ~30. Discharged on ASA,
clopidogrel, lovenox to coumadin bridge given anterior
hypokinesis/akinesis (should continue for [**4-5**] mos, regular INR
checks needed), metoprolol, pravastatin, blood pressure meds. Pt
instructed to call PCP and cardiology for f/u (difficult to
arrange appointments over the weekend).
.
# Diabetes: oral hypoglycemics were pre-cath and pt started on
insulin sliding scale. Metformin and glipizide were restarted
post-cath.
.
# Hypertension: lisinopril and hydrochlorothiazide were held in
the setting of expected IV contrast load during cath. Restarted
post-cath.
.
# Hypothyroidism: Continued levothyroxine.
.
# Glaucoma: Continue cosopt and travatan eye drops.
Medications on Admission:
GLIPIZIDE - 5 mg Tab,Sust Rel Osmotic Push 24hr - 1 Tab(s) by
mouth once a day
LEVOTHYROXINE [LEVOTHROID] - 50 mcg Tablet - 1 Tablet(s) by
mouth
once a day
LISINOPRIL-HYDROCHLOROTHIAZIDE - 10 mg-12.5 mg Tablet - 1
Tablet(s)(s) by mouth once a day
METFORMIN - 1,000 mg Tablet - 1 Tablet(s)(s) by mouth twice a
day
PRAVASTATIN - 80 mg Tablet - 1 Tablet(s)(s) by mouth once a day
Cosopt eye drops [**Hospital1 **] both eyes
Travatan eye drops left eye QHS
Discharge Disposition:
Home
Discharge Diagnosis:
acute ST-elevation myocardial infarction
.
hypertension
diabetes mellitus, type 2
hypercholesterolemia
Discharge Condition:
chest-pain free, hemodynamically stable
Discharge Instructions:
You were admitted to the hospital with chest pain. You were
found to have a heart attack from obstruction in your coronary
vessels. We treated you with cardiac catheterization and
stenting.
.
We changed your medications as follows:
1. started aspirin 325mg by mouth daily for your heart, do not
stop taking this medication without talking to your cardiologist
2. started clopidogrel 75mg by mouth daily for your heart, do
not stop taking this medication without talking to your
cardiologist
3. started warfarin 5mg by mouth daily for anticoagulation
4. started enoxaparin 70mg subcutaneous injections daily until
your warfarin becomes therapeutic
5. continued pravastatin 80mg by mouth daily
6. continued lisinopril-HCTZ 10-12.5mg by mouth daily
7. continued metformin 1000mg by mouth twice daily
8. continued glipizide SR 5mg by mouth daily
9. started Toprol XL 25mg by mouth daily
10. continued levothyroxine 50mcg by mouth daily
11. started docusate, senna to help you with bowel movements and
reduce exertion
12. continued your eyedrops
.
You should have your INR checked regularly while your are taking
warfarin.
.
You should follow up with your physicians as recommended below.
Please do not exert yourself, talk to your physician before
resuming regular exercise.
.
If you have chest pain, shortness of breath, dizziness or any
other concerning symptoms, please call your physician
[**Name Initial (PRE) 2227**].
Followup Instructions:
Please call your primary care physicin, Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] for
appointment on Monday ([**2-26**]) for an appointment: [**Telephone/Fax (1) 133**].
You should have your INR checked on that day. The script was
provided on your discharge.
.
You should call [**Telephone/Fax (1) 62**] to schedule an appointment with a
cardiologist within a week of your discharge.
Completed by:[**2176-2-24**]
ICD9 Codes: 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2919
} | Medical Text: Admission Date: [**2121-10-29**] Discharge Date: [**2121-11-4**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 yo female, reportedly with witnessed fall
from 4 steps per the family, +LOC. Family reports after fall
patient
stated "it hurts" repetitively, then began speaking nonsensical
sentences, with increased confusion to incoherence. She was
brought to
an area hospital where found to have a small Left SDH, acute IPH
with small
SAH. She was then transported to [**Hospital1 18**] for further care.
Past Medical History:
Neck injury with fusion
TMJ
GERD
Family History:
Noncontributory
Pertinent Results:
[**2121-11-3**] ECHOCARDIOGRAM
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-10mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%) There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The 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 mild mitral valve prolapse. Mild to
moderate ([**11-26**]+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
.
[**2121-11-2**] AP/LAT PELVIS
IMPRESSION:
No fracture.
.
[**2121-10-30**] CT HEAD
IMPRESSION:
1. Stable appearance of left temporal intraparenchymal
hematomas, left-sided subdural hematoma, and diffuse
subarachnoid hemorrhage.
2. Longitudinal fracture through the right temporal bone.
.
[**2121-10-29**] CXR
IMPRESSION: Overriding fracture through the midshaft of the
right clavicle.
.
[**2121-10-29**] 10:20AM POTASSIUM-4.5
[**2121-10-29**] 10:20AM PHENYTOIN-22.4*
[**2121-10-29**] 08:03AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.033
[**2121-10-29**] 08:03AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2121-10-29**] 08:03AM URINE RBC-[**10-14**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0
[**2121-10-29**] 08:03AM URINE MUCOUS-RARE
[**2121-10-29**] 06:45AM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.1
[**2121-10-29**] 06:45AM GLUCOSE-154* UREA N-20 CREAT-0.6 SODIUM-139
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13
[**2121-10-29**] 06:45AM WBC-10.3 RBC-3.87* HGB-11.6* HCT-35.2* MCV-91
MCH-29.9 MCHC-32.9 RDW-13.6
[**2121-10-29**] 06:45AM NEUTS-90.8* BANDS-0 LYMPHS-6.4* MONOS-2.6
EOS-0.1 BASOS-0
Brief Hospital Course:
She was admitted to the Trauma Service. Neurosurgery and
Orthopedics were consulted due to her injuries. Her injuries
were non operative. She was loaded with Dilantin; serial head CT
scans were followed and were stable. There were no observed or
reported seizure activity. The Dilantin will need to continue
for at least another 4 weeks until follow up with Dr. [**Last Name (STitle) **],
Neurosurgery; she will have an repeat head CT scan at that time.
Her Orthopedic injuries were managed non operatively as well.
Once the swelling subsided she was casted because of her
olecranon fracture. She will be non weight bearing on her right
upper extremity and will follow up with Dr. [**Last Name (STitle) **],
Orthopedics, in 2 weeks. She was started on Calcium and Vitamin
d for bone prophylaxis.
Geriatrics was consulted given her age and mechanism of injury.
Several recommendations were made pertaining to her medications.
Physical and Occupational therapy evaluated her and have
recommended rehab stay after acute hospitalization.
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: [**11-26**] Tablet PO twice a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*2*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime: hold
for loose stools.
6. Milk of Magnesia 400 mg/5 mL Suspension Sig: 20-30 ML's PO
twice a day as needed for constipation.
7. Calcium Carbonate 650 (1,625) mg Tablet Sig: One (1) Tablet
PO three times a day.
8. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
Normandy Senior Care Center - [**Location (un) **]
Discharge Diagnosis:
s/p Fall down stairs
Intraparenchymal hematoma
Subdural hematoma
Subarachnoid hematoma
Right clavicular fracture
Right olecranon fracture
Discharge Condition:
Good
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **], Orthopedic Surgery, in 2 weeks.
Please call ([**Telephone/Fax (1) 2007**] to schedule an appointment.
Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Neurosurgery, in 4 weeks.
Please call [**Telephone/Fax (1) **] to schedule an appointment. You will
need a Non-Contrast Head CT prior to this appointment.
Completed by:[**2121-11-4**]
ICD9 Codes: 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2920
} | Medical Text: Admission Date: [**2162-7-11**] Discharge Date: [**2162-7-16**]
Date of Birth: [**2093-4-2**] Sex: F
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 31853**] is a 69 year old female with past medical history
significant for longstanding type II DM, HTN, hypothyroidism,
h/o small cell lung cancer (in remission) and PVD who presented
to ED with worse confusion from baseline, weakness and new
inability to ambulate for "past few days." FSBS's at home 600's
despite home insulin which includes 22 Units Lantus and sliding
scale. She is followed at [**Last Name (un) **] by Dr. [**First Name8 (NamePattern2) 712**] [**Name (STitle) 713**] for her
type II diabetes management. Of significance, patient's
daughter states patient has poor compliance with prescribed SSI
at home. She also explains that her mother gets very sleepy and
more confused when she gets UTIs and she has noticed these
symptoms over the past week. Daughter also states her mother is
incontinent of urine most of time but has been going more
frequently x 1 week.
.
Of note, patient was recently admitted to the vascular surgical
service from [**Date range (1) 32029**] for further assessment of a left heel ulcer
and she underwent left lower extremity arteriogram. She was
found to have Left stenosis at the aortobifem/CFA anastamosis
and left SFA occlusion. No intervention was performed and it was
decided to medically manage patient at this juncture. During
this admission she also had a UTI recognized and was treated
with 5 days of Ciprofloxacin. Urine cultures grew out group B
Beta Streptococcus species but no R/S data performed.
.
.
In the ED, initial vs were: T 98.7F, P 80, BP 112/43, RR 18 and
O2 saturation was 100% RA. CXR showed no infiltrates or
effusions. UA revealed 11-20 wbcs, few bacteria, moderate
leukocytes, negative nitrites, >1000 glucose and ketones. Blood
cultures and urine cultures sent in ED. EKG showed peaked T
waves so she was given 2g calcium gluconate and t-waves were
less prominent on telemetry prior to transport per report. While
in ED, she was given IV Zofran for mild nausea, 1g IV
ceftriaxone for UTI , 10 Units regular insulin followed by
placement on an insulin drip for DKA management. Labs notable
for an elevated K 6.1, HCO3 17, lactate 2.2 and serum glucose of
701. Cr was 1.4 which is up from usual baseline of .9 range. She
had an initial anion gap of 24 which came down to 18 by time of
transfer from ED. Also received total of 3L IVFs while in ED.
.
On arrival to the [**Hospital Unit Name 153**], initial vitals were: T 97.7, HR 90, BP
130/46, RR 17 and O2 sat 95-96% RA. She appeared to be in no
apparent distress but very tired. Also was confused and alert
and oriented to person only. Per patient's daughter she has
progressing dementia and she is near usual baseline with
exception of her extreme fatigue.
.
.
Review of systems:
- Limited due to patient's dementia.
- Denies sore throat, cough, diarrhea, abd pains, dysuria,
headaches and photophobia. Refused to cooperate with rest of
ROS.
.
Past Medical History:
1. Insulin dependent Diabetes type 2 (for past 30 years)
2. Hypertension.
3. Hypothyroidism.
4. Hyperlipidemia.
5. Osteoporosis.
6. Pyelonephritis.
7. Status post hip replacement.
8. PVD s/p Fem-[**Doctor Last Name **] bypass.
9. Bilateral cataract surgery.
10. Hand surgery for carpal tunnel.
11. Lumpectomy.
12. Lung Cancer: Small cell lung cancer, limited stage, s/p
etoposide/carboplatin, XRT completed [**6-/2159**]
13. s/p left femur fracture
PSH: Status post hip replacement, s/p aorto-bifem bypass,
Bilateral cataract surgery, Hand surgery for carpal tunnel,
Lumpectomy.
12. Lung Cancer: Small cell lung cancer, limited stage, s/p
etoposide/carboplatin, XRT completed [**6-/2159**]
Social History:
Social History: Patient lives alone in [**Location (un) 2312**]. She
previously worked as a typist but is now retired. She has 3
children, one son died 2 [**Name2 (NI) 1686**] ago and he had been her primary
caretaker in past. Now her daughter [**Name (NI) 32030**] helps a few times a
week with shoppping and cooking and ADLs. [**Name (NI) **] sisters live
nearby and also help. She does not have home VNA now. She
currently smokes 1ppd x 45 years, but no current EtOH use or
illicits. She walks with walker at baseline and is incontinent
of urine and sometimes stool per daughter.
Family History:
Emphysema in her father. Mother had head and neck cancer.
Physical Exam:
Admission physical:
Physical Exam:
Vitals: T 97.7, HR 90, BP 130/46, RR 17 and O2 sat 95-96% RA.
General: Alert and oriented x1, no acute distress, very tired
appearing with pallid complexion
HEENT: PERRLA EOMI. Anicteric sclerae. Very dry MM, oropharynx
clear but poor dentition noted.
Neck: supple, JVP at 5-6cm , no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: vertical well healed scar at midline, soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place
Ext: warm, 1+ PT pulses and 2+ DP pulses bilaterally, no
clubbing or overt cyanosis but [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 32031**] below the ankles.
Small left heel ulcer with depth of about 5-7mm and diameter of
2cm, no bleeding/scabs or discharge expressed, appears clean.
Neuro: exam limited due to AMS, but CNs [**2-5**] in tact and
sensation to light touch in tact over face and upper
extremities, unable to cooperate with motor testing
.
.
Discharge VS:
97 178/85 (prior to Rx); 109-178/56-85 82 18 100RA
GEN: non-toxic, awake interactive.
RESP: CTA B
CV: RRR. No mrg.
ABD: Benign.
Neuro: A+O x 2; self/location. No focal defecits.
Pertinent Results:
Admission labs:
[**2162-7-10**] 10:50PM GLUCOSE-701* UREA N-39* CREAT-1.4*
SODIUM-118* POTASSIUM-6.1* CHLORIDE-77* TOTAL CO2-17* ANION
GAP-30*
[**2162-7-10**] 11:14PM LACTATE-2.2*
[**2162-7-10**] 11:14PM TYPE-[**Last Name (un) **] PO2-63* PCO2-36 PH-7.30* TOTAL
CO2-18* BASE XS--7 COMMENTS-GREEN TOP
.
[**2162-7-10**] 10:50PM WBC-8.3# RBC-3.86* HGB-11.9* HCT-35.9* MCV-93
MCH-31.0 MCHC-33.2 RDW-14.4
[**2162-7-10**] 10:50PM NEUTS-82.1* LYMPHS-15.1* MONOS-2.3 EOS-0.3
BASOS-0.3
[**2162-7-10**] 10:50PM PLT COUNT-297
[**2162-7-11**] 12:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2162-7-11**] 12:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
.
Most recent labs:
[**2162-7-14**] 07:15AM BLOOD WBC-3.0* RBC-3.20* Hgb-9.8* Hct-29.3*
MCV-92 MCH-30.6 MCHC-33.4 RDW-14.5 Plt Ct-253
[**2162-7-14**] 07:15AM BLOOD Glucose-114* UreaN-11 Creat-0.8 Na-134
K-4.3 Cl-96 HCO3-32 AnGap-10
[**2162-7-14**] 07:15AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.7
.
[**2162-7-12**] 04:13AM BLOOD %HbA1c-10.2* eAG-246*
[**2162-7-12**] 04:13AM BLOOD TSH-4.1
.
Urine CX [**7-10**]:
[**2162-7-11**] URINE CULTURE (Final [**2162-7-13**]):
LACTOBACILLUS SPECIES. >100,000 ORGANISMS/ML..
.
CXR [**2162-7-10**]: No acute process.
.
Pending:
[**7-10**], [**7-11**] Blood cultures: no growth to date; pending
Brief Hospital Course:
69 year old female with past medical history significant for
longstanding type II DM, HTN, hypothyroidism, h/o small cell
lung cancer (in remission) and PVD who presented to ED with
worse confusion from baseline, weakness and new inability to
ambulate for "past few days." Pt was found to have HONC with
hyperglycemia to 700's, and ititially managed in the ICU.
.
.
#Hyperosmolar Non-Ketotic Coma: Patient with long history of
type II diabetes on home Lantus and sliding scale insulin. She
states she complies with home medication, although the
reliability of this has been questioned. She was admitted to the
ICU and treated with IV fluids, insulin drip and consulted by
the [**Last Name (un) **]. Presumed cause of HONK was UTI (although recently
treated with 5 days of cipro) and possible poor compliance with
A1C of 10%. [**Last Name (un) **] continued Lantus 20 units, and prandial
coverage doses were titrated. Please see insulin sliding scale
from discharge below:
.
Breakfast Glargine 20 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 Proceed with hypoglycemia protocol
71-90 0 Units 0 Units 0 Units 0 Units
91-150 4 Units 2 Units 2 Units 0 Units
151-200 6 Units 4 Units 4 Units 0 Units
201-250 8 Units 6 Units 6 Units 2 Units
251-300 10 Units 8 Units 8 Units 3 Units
301-350 12 Units 10 Units 10 Units 4 Units
351-400 14 Units 12 Units 12 Units 5 Units
> 400 mg/dL Notify M.D.
.
#Urinary Tract Infection:
Patients UTI dates back to her last admission 1.5 weeks ago when
she was noted to have group B Beta Streptococcus species >100k
colonies. On admission, she was afebrile with no leukocytosis
but UA with evidence of persistent infection. She is s/p 5 days
of Cipro completed on [**7-5**]. Urine culture grew out
lactobacillus, > 100K.
- continue ampicillin for 10 day course. Complete [**2162-7-22**].
.
#Acute renal failure: Baseline Cr is .9 and now up to 1.2-1.4
range in setting of polyuria and DKA. Acute renal failure was
attributed to dehydration. Returned to baseline with hydration.
.
#Hyponatremia: She was admitted with hyponatremia, with
combination of pseudohyponatremia from hyperglycemia, but with
persistent hyponatremia after correction. Hyponatremia was
initially attributed to dehydration and hypovolemic state.
Hyponatremia resolved with glucose control and IV hydration.
.
# Acute encephalopathy in setting of chronic Alzheimer's
dementia. She was admitted with acute delirium in the setting of
hyperglycemia and UTI. She improved but remains with baseline
dementia.
- resolved to baseline with treatment of UTI and glucose control
.
#Hypertension: She was normotensive on admission, and captopril
was held due to hyperkalemia on admission. Her blood pressure
gradually increased with hydration, and captopril was restarted
on [**7-13**].
- contin Captopril at increased dose 37.5 mg TID, Metoprolol 50
mg po bid
.
#Hypothyroidism: TSH within normal limits at 4.1.
-continue home 100mcg daily levothyroxine therapy
.
#Heel Ulcer / PVD: She had recent admission for left heel ulcer,
with workup that revealed stenosis at the aortobifem/CFA
anastamosis and left SFA occlusion. Medical management was
pursued. After admission on this occasion, she was seen by the
wound service, who recommended wound care. There was no evidence
of infection.
--continue [**Hospital1 **] wound dressings
.
#hyperlipidemia:
-continue daily aspirin 325mg
-continue daily atorvastatin therapy
.
#GERD:
--continue home omeprazole therapy
--Misoprostol 200 mcg PO QID
.
# FEN: diabetic diet
# Prophylaxis: Subcutaneous heparin
# Communication: Patient & daughter (HCP) [**Name (NI) 32030**] [**Name (NI) **] at
#[**Telephone/Fax (1) 32032**]
# Code: DNR/DNI, confirmed with HCP
.
# Disposition: To [**Location (un) 582**] [**Location (un) 583**] today
Medications on Admission:
Home medications:
Aspirin 325 mg Daily
Atorvastatin 20 mg Daily
Becaplermin 0.01 % Gel: Apply to left heel ulcer at bedtime.
Captopril 25 mg PO TID
Fludrocortisone 0.1 mg daily
Levothyroxine 100 mcg daily
Misoprostol 200 mcg PO QID
Omeprazole 40 mg once a day.
Metoprolol Tartrate 50 mg PO BID
Metoclopramide 10 mg PO QID
Insulin Glargine - 22 Units SC daily
Fosamax 70 mg PO once a week.
Oxycodone 5 mg PO once a day in P.M. as needed for pain
Acetaminophen 325 mg, 1-2 Tablets PO q6hrs PRN
Multivitamin supplement
Senna tablet PRN constipation
.
Medications at transfer:
Ampicillin 500 mg po q6 hours
Aspirin 325 mg Daily
Atorvastatin 20 mg Daily
Becaplermin 0.01 % Gel: Apply to left heel ulcer at bedtime.
Captopril 25 mg PO TID
Fludrocortisone 0.1 mg daily
Levothyroxine 100 mcg daily
Misoprostol 200 mcg PO QID
Omeprazole 40 mg once a day.
Metoprolol Tartrate 50 mg PO BID
Metoclopramide 10 mg PO QID
Insulin Glargine - 20 Units SC daily (decreased from 22 units
daily) and sliding scale
Fosamax 70 mg PO once a week.
Acetaminophen 325 mg, 1-2 Tablets PO q6hrs PRN
Multivitamin supplement
Senna tablet PRN constipation
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical DAILY
(Daily) as needed for lle ulcer .
4. Captopril 12.5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
5. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Misoprostol 100 mcg Tablet Sig: Two (2) Tablet PO QIDPCHS (4
times a day (after meals and at bedtime)).
8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
11. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain .
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
15. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 6 days.
17. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous Q Breakfast.
18. Humalog 100 unit/mL Solution Sig: as per sliding scale
provided units Subcutaneous QACHS.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
# Hyperosmolar non-ketotic coma;
with confusion and glucose >700
# Urinary tract infection
# Acute renal failure
# Hyponatremia
# Acute encephalopathy
# Alzheimer's dementia
# Hypertension
# PVD, heel ulcer
# GERD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with confusion and extremely elevated blood
sugar levels. You were initially managed in the ICU. You were
also found to have a urinary tract infection, and were treated
with antibiotics for this. Please complete your course of
antibiotics as prescribed, and take your insulin as prescribed.
You will need to follow up with your endocrinologist as an
outpatient.
Followup Instructions:
Department: GERONTOLOGY
When: MONDAY [**2162-7-19**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 13171**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: THURSDAY [**2162-7-22**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2162-7-29**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5849, 5990, 2761, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2921
} | Medical Text: Admission Date: [**2197-11-13**] Discharge Date: [**2197-11-27**]
Date of Birth: [**2143-11-7**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Shellfish / Fish Product Derivatives / Barium
Sulfate / Iodine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Lumbar pain
Major Surgical or Invasive Procedure:
anterior lumbar fusion L5-S1 [**2197-11-13**]. posterior lumbar fusion
L5-S1 [**2197-11-14**]
History of Present Illness:
Pt has a history of chronic lumbar pain and radiculopathy
Past Medical History:
RA--on chronic prednisone and arava
osteoporosis
spinal stenosis s/p laminectomy and decomp of C6-C7
recent pyelo/ horshoe kidney
ulcerative keratitis from RA
reactive airway disease
RLL nodules (seen [**2197-3-29**])
chronic anemia-Fe deficiency
reactive airway disease
Social History:
Denies EtOH, tobacco, illicits
Family History:
NC
Physical Exam:
A+OX 3 NAD. Afebrile. generalized weakness secondary to chronic
illness.
Pertinent Results:
[**2197-11-13**] 11:00AM GLUCOSE-194* UREA N-22* CREAT-1.1 SODIUM-139
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18
[**2197-11-13**] 11:00AM HCT-29.4*
Brief Hospital Course:
Pt had surgery [**0-**] post op course uneventful.
Medications on Admission:
. Albuterol Sulfate 0.083 % Solution Sig: [**1-15**] Inhalation Q6H
(every 6 hours) as needed for wheezing.
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-15**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) as needed for wheezing.
7. Alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Sig: One (1) PO twice a day: hold
if HR < 60.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasm.
14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
15. Leflunomide 10 mg Tablet Sig: Two (2) Tablet PO qd ().
. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week:
verify dose with Patient
. Leflunomide 10 mg Tablet Sig: Two (2) Tablet PO qd ().
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Albuterol Sulfate 0.083 % Solution Sig: [**1-15**] Inhalation Q6H
(every 6 hours) as needed for wheezing.
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-15**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) as needed for wheezing.
7. Alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Sig: One (1) PO twice a day:
hold if HR < 60.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasm.
14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
15. Leflunomide 10 mg Tablet Sig: Two (2) Tablet PO qd ().
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for breakthrough pain.
17. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
18. Dolasetron Mesylate 25 mg IV Q8H:PRN n/v
19. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week:
verify dose with Patient.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Degenerative disc disease.
Discharge Condition:
good
Discharge Instructions:
keep incisions clean and dry X 2.
Physical Therapy:
no lifting > 15 lbs. no bending/twisting
Treatments Frequency:
keep incision clean and dry
Accuchecks twice a day
Followup Instructions:
10 days with Dr [**Last Name (STitle) 363**] [**Telephone/Fax (1) 3573**]
Completed by:[**2197-11-16**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2922
} | Medical Text: Admission Date: [**2118-4-4**] Discharge Date: [**2118-4-19**]
Date of Birth: [**2038-7-8**] Sex: F
Service: MEDICINE
Allergies:
Interferon Alfa
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
shortness of breath, chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
central line placement
Swan-Ganz line placement
History of Present Illness:
79 year old F, hx renal cell CA s/p R nephrectomy and s/p chemo
for recurrence, adrenal insuffiency, anemia with intermittent
outpt transfusions. Pt was admitted to OSH, c/o four days of SOB
and chest pain, palpitations, increased when lying down. Pt had
CXR c/w pulmonary edema, BNP 83K, treated with diuresis BIPAP
with some improvement.
This morning developed chest pain at 10AM, EKG with T wave
inversions, echo performed with LVEF 25%, 3+ MR and 3+ TR (nl
last year), found to have elevation in troponin to 0.09.
Subsequently pt developed AFib with RVR in the 200s, resistant
to small doses of lopressor. Started on heparin qtt, nitro qtt,
given [**First Name3 (LF) **].
Arrived to [**Hospital1 18**], found to have AFib with RVR at 150 bpm,
started on amiodarone, cardioverted to NSR, had cardiac
catheterization showing LCx with large ramus 80% lesion, tx with
BMS x2. LAD with 60% DI lesion, RCA without stenosis.
Aorta: 101/72/84
RV: 42/9/15
PA: 42/27/34
PCwp: 22
CO: 2.88 (CI 1.88)
Upon transfer to CCU patient denies any chest pain, palpitations
or shortness of breath. She attributes the beginning of her
breathing problems to the weight gain she experienced after
starting on hydrocortisone for adrenal insufficiency leading to
15 lb weight gain.
Past Medical History:
1. Renal cell CA s/p right nephrectomy [**2104**]
2. 2nd primary renal cell CA L kidney: clear cell path, treated
w/ IFN x 12 weeks ([**4-13**] - [**7-13**]), s/p sorafenib ([**8-13**] - [**9-13**])
d/c'd [**2-10**] rash; 6mm met in RML
3. HTN
4. Depression
5. Hyperlipidemia
6. Anemia [**2-10**] IFN: baseline HCT 25 over past 2 months,
transfusion dependent
7. Adrenal insufficiency, dx 1 month ago after presenting with
weight loss.
Social History:
retired teacher; remote smoking history (quit 45 years ago);
drinks 1 glass of wine daily. Has 5 children who live nearby.
She lives at home with husband, independent with ADLs.
Family History:
NC, no hx of cardiac disease, no hx of cancers
Physical Exam:
VS T , BP 123/77, HR 96 (NSR), RR 22, O2 sat 97% RA on NRB
Gen: elderly, frail appearing woman, lying in bed flat,
conversant in full sentences without getting short of breath,
NAD
HEENT: anicteric, OP clear, MMM
Neck: JVP 9-10cm
CV: reg s1/s2, II/VI systolic murmur at LLSB
Pulm: CTA b/l, bibasilar crackles
Abd: +BS, soft, NT, ND
Ext: warm, 2 distal pulses b/l, no pedal edema, R groin with
a-line, no hematoma, non-tender.
Pertinent Results:
Echo ([**Hospital1 **] [**Location (un) 620**]) [**4-4**]: LF fxn severely depressed, hypokinesis
of distal anteroseptum and inferoseptum, apex akinetic. 3+ MR,
3+ TR.
[**2118-4-4**] 07:36PM BLOOD WBC-15.3* RBC-2.79* Hgb-7.4* Hct-23.4*
MCV-84 MCH-26.6* MCHC-31.7 RDW-17.0* Plt Ct-479*
[**2118-4-12**] 06:25AM BLOOD WBC-11.0 RBC-3.43* Hgb-9.3* Hct-29.0*
MCV-85 MCH-27.1 MCHC-32.1 RDW-16.5* Plt Ct-254
[**2118-4-15**] 05:45AM BLOOD WBC-12.5* RBC-3.15* Hgb-8.7* Hct-26.8*
MCV-85 MCH-27.6 MCHC-32.5 RDW-16.3* Plt Ct-261
[**2118-4-7**] 05:20AM BLOOD Neuts-93.9* Bands-0 Lymphs-3.5* Monos-2.4
Eos-0.1 Baso-0.1
[**2118-4-10**] 07:10AM BLOOD PT-14.1* PTT-27.3 INR(PT)-1.2*
[**2118-4-15**] 05:45AM BLOOD PT-30.9* PTT-42.7* INR(PT)-3.3*
[**2118-4-4**] 05:15PM BLOOD Glucose-155* UreaN-19 Creat-0.9 Na-137
K-3.5 Cl-97 HCO3-26 AnGap-18
[**2118-4-9**] 07:10AM BLOOD Glucose-172* UreaN-43* Creat-1.3* Na-144
K-2.9* Cl-103 HCO3-27 AnGap-17
[**2118-4-12**] 06:25AM BLOOD Glucose-78 UreaN-34* Creat-1.0 Na-145
K-2.6* Cl-97 HCO3-37* AnGap-14
[**2118-4-15**] 05:45AM BLOOD Glucose-97 UreaN-36* Creat-1.1 Na-142
K-4.0 Cl-100 HCO3-33* AnGap-13
[**2118-4-5**] 06:50AM BLOOD ALT-17 AST-107* CK(CPK)-30 AlkPhos-253*
TotBili-2.3*
[**2118-4-8**] 03:52AM BLOOD ALT-31 AST-37 AlkPhos-197* TotBili-0.5
[**2118-4-4**] 05:15PM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2118-4-5**] 06:50AM BLOOD CK-MB-NotDone cTropnT-0.17*
[**2118-4-5**] 03:00PM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2118-4-6**] 05:37AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2118-4-4**] 07:36PM BLOOD Calcium-8.2* Phos-5.7* Mg-1.7
[**2118-4-14**] 03:55AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.6
[**2118-4-5**] 06:50AM BLOOD calTIBC-113* Ferritn->[**2112**] TRF-87*
[**2118-4-5**] 06:50AM BLOOD TSH-1.1
[**2118-4-5**] 06:50AM BLOOD PEP-HYPOGAMMAG IgG-1066 IgA-149 IgM-101
IFE-NO MONOCLO
[**2118-4-9**] 10:54PM BLOOD Type-ART pO2-85 pCO2-44 pH-7.47*
calHCO3-33* Base XS-7
[**2118-4-4**] 05:07PM BLOOD Type-ART pO2-91 pCO2-46* pH-7.43
calHCO3-32* Base XS-4
[**2118-4-5**] 08:17AM BLOOD Lactate-17.3*
[**2118-4-5**] 11:15AM BLOOD Lactate-11.9*
[**2118-4-5**] 03:09PM BLOOD Lactate-2.0
[**2118-4-6**] 04:06PM BLOOD Lactate-1.2
.
CXR [**4-4**]:
1. Asymmetric pulmonary edema, right greater than left.
2. Left basilar consolidation in the left retrocardiac region
which may represent some atelectasis or edema.
3. Pulmonary artery catheter is directed into left main
pulmonary artery.
4. Residual contrast persisting in the left renal collecting
system and left renal parenchyma - question time of contrast
administration.
.
C. Cath [**4-4**]:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
2 vessel coronary artery disease. The LMCA had no
angiographically
apparent flow limiting lesions. The LAD had mild luminal
irregularities
and gave rise to a moderate sized D1 which had a 60% stenosis.
There was
a large ramus which had a 80% ulcerated proximal stenosis. The
LCX did
not give off any other branches. The RCA was a dominant vessel
with mild
luminal irregularities.
2. Resting hemodynamics revealed elevated left sided filling
pressures
with PCWP of 22mmHg with depressed cardiac index and low
systemic blood
pressure.
3. Left ventriculography was deferred.
4 The proximal lesion in the ramus intermedius was predilated
with a
2.5 X 15mm Voyager balloon, stented with overlapping 2.5 X 12mm
and 2.5
X 08mm Minivision (Bare metal) stents with lesion reduction from
80% to
0%. the final angiogram showed TIMI III flow with no dissection
and no
embolisation. (see PTCA comments)
5. On arrival to teh cath lab pateint with in atrial
fibrillation with a
rapid ventricularresponse. She was started on IV amiodarone and
constinued to be tachycardic. ANesthesia was called and she was
successfully cardioverted with 300J-->NSR. She developed AF
again atthe
completion of the procedure with rates of 120-140bpm.
.
0FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Elevated left sided filling pressures, reduced cardiac
index.
3. Systemic hypotension.
4. Rapid atrial fibrillation.
5. Successful stenting of the ramus intermedius lesion with bare
metal
stents
.
CXR [**4-5**]: IMPRESSION: AP chest compared to [**4-4**]:
Pulmonary edema is markedly asymmetric, severe in the right
lung, though improved since [**4-4**], and mild on the left.
Mild-to-moderate cardiomegaly with suggestion of left atrial
enlargement is unchanged. Small bilateral pleural effusions
stable. No pneumothorax. An ascending Swan-Ganz catheter tip
projects over the left descending pulmonary artery. No
pneumothorax.
.
Echo [**4-5**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and
cavity size are normal. There is moderate regional left
ventricular systolic dysfunction with severe hypokinesis of the
inferior wall, mid inferolateral wall, distal half of the septum
and apex . No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened. There is a minimally increased
gradient consistent with minimal aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a fat pad.
.
CXR [**4-13**]: IMPRESSION: Resolving asymmetrical combined alveolar
and interstitial process, likely due to resolving asymmetric
edema. Underlying infection in the right lung is not excluded in
the appropriate setting.
.
Echo [**4-18**]: Conclusions:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. Overall left ventricular systolic
function is mildly depressed with inferior hypokinesis. The mid
to distal septum has borderline systolic thickening. No masses
or thrombi are seen in the left ventricle. Right ventricular
systolic function is borderline normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**1-10**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2118-4-5**], LV
systolic
function has improved.
Brief Hospital Course:
79 y.o. F hx renal CA s/p nephrectomy, chemo presented with 1 wk
of CHF sx's, found to have new cardiomyopathy, combination of
ischemic and non-ischemic.
.
# Cardiac -
Cardiomyopathy/systolic CHF - at presentation to outside
hospital, pt was reportedly found to have both mitral and
tricuspid severe regurgitation, , severely depressed LVEF and
anteroseptal and inferoseptal hypokinesis. Her cardiac enzymes
had increased slightly, and her cardiac cath revelaed only a
ramus lesion, which was stented with 2 bare metal stents.
However, this was not thought to be sufficient to explain her
extensive echocardiographic changes. Work-up for other
non-ischemic causes of her cardiomyopathy reveal a normal TSH,
iron labs showed Fe 326, TIBC 113, and although she had required
some transfusions as outpatient since chemotherapy, this was not
thought to be sufficient to cause iron overload or
hemochormatosis type CM. Given that the patient presented with
AFib and tachycardia, tachycardia induced CM was thought to be
the most likely secondary explanation. However, multiple
routine EKGs on outpatient basis did not reveal resting
tachycardia.
The patient was treated with agressive diuresis using
Swan-Ganz line for hemodynamic monitoring. Her symptoms
improved significantly. She was started on metoprolol, which
was titrated up as tolerated by her HR, and also started on
ACE-I, titrated as tolerated by BP. The patient's toprol dose
was decreased [**2-10**] mood depression, and on 50mg of Toprol XL at
time of discharge. Her ACE-I was held in light of increased Cr
to 1.4, although improving at time of discharge. Fluid status
needs to be monitored carefully. Pt appears to be euvolemic at
time of discharge. Echo on day before discharge showed markedly
improved systolic function, suspect that this is related to the
resolved tachycardia.
.
# CAD - ramus lesion stented, started on [**Last Name (LF) **], [**First Name3 (LF) **] need plavix
for 1 month. Started on lipitor 80mg initially in setting of
MI, but outpt labs on [**1-14**] revealed normal lipids with LDL of
43, decreased lipitor to 10mg. She was started on BB, ACE-I as
above, ACE-I currently on hold.
.
# Rhythm - initially found to have AFib in the setting of
decompensated CHF, started on metoprolol which was insufficient
to rate control, and amiodarone was added. She was loaded for
one week with 200mg three times daily dosing, this was decreased
to 200mg daily on day of discharge because of persistent nausea
and poor po intake. She converted to NSR early on and remained
in this rhythm during remainder of hospitalization. She was
initially started on heparin for anticoagulation after
discussion of anticoagulation risks with her oncologist, who did
not find any contraindications to this. She was switched to
coumadin, INR increased rapidly after 2 doses of 5mg, decreased
to 2.5mg. She did experience an episode of significant R sided
anterior nasal bleeding while on heparin, however her PTT at
this time was 41.8 and INR was 1.9. The nose bleeding was
controlled with pressure, Afrin, and silver nitrate localized
cauderization. This was thought to be most likely related to
irritation from oxygen and the nasal cannula, however she may
need to have a goal INR slightly lower of 1.8-2.5. No further
nose bleeds noted over next few days. At time of discharge on
2mg of coumadin, INR 2.4.
.
# UTI - she was complaining of dysuria, U/A was sent and found
to have >200 WBC, + bacteria, started on bactrim on [**4-14**], her Cr
jumped slightly and Bactrim was switched to cipro starting on
[**4-18**] for a 5 day course.
.
# Renal carcinoma - in the past pt has been on experimental
chemotherapy, however was intolerant to side effects. Currently
plans are ongoing to find other chemotherapy regimen, possibly
at [**Hospital 3340**] Clinic. She has known metastases to lungs, and
adrenal gland. Given malignancy, the thought of pulmonary
embolus to exlain her shortness of breath was entertained,
however given her improvement with diuresis thought less likely.
In addition, given her single kidney, and worsened renal
function while inpatient, in addition to her having a solitary
kidney, and her already being anticoagulated, CTA was not
performed. On previous CT images, she is noted to have a
possible IVC thrombus, cardiac echo did not demonstrate
extensive progression of this. She has chronic anemia related
to past chemo, epo has been tried in past and ineffective, needs
occassional outpt transfusions.
.
# Depression - continued celexa, pt had poor nutrition and flat
affect, although this seemed to improve at the time of
discharge. Psychiatry was consulted to recommend something for
mood and possibly for appetite. Recommended continuing Lexapro.
Would consider psychiatry consult at rehab. Consider remeron
7.5 mg depending on whether her mood depression persists.
.
# FEN - cardiac diet, bowel regimen, required a lot of K
repletion during diuresis, would follow closely after discharge.
.
# Ppx - bowel meds, on coumadin
.
# Code - full
Medications on Admission:
Hydrocortisone 20mg QAM, 10mg QPM
Lexapro 10mg
Citracal
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Coronary artery disease
Congestive Heart Failure
Atrial Fibrillation
Acute Renal Failure
Secondary:
Depression
Anemia of chronic disease
Stage IIIb Renal Cell Carcinoma
Hypertension
Adrenal Insufficiency
Discharge Condition:
Fair
Discharge Instructions:
Please continue antibiotics until [**4-22**]. Please continue taking
Plavix (clopidogrel) unless directed otherwise by your doctor.
Take your other medications as prescribed. Follow-up with your
doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. Call your PCP to make [**Name Initial (PRE) **] follow-up
appointment as needed. You should seek medical attention if you
develop chest pain, worsened shortness of breath, fever, or any
other concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2118-6-1**] 12:30
Follow-up with PCP as needed
Completed by:[**2118-4-19**]
ICD9 Codes: 4280, 9971, 4254, 5849, 5990, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2923
} | Medical Text: Admission Date: [**2162-4-23**] Discharge Date: [**2162-4-30**]
Date of Birth: [**2090-8-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2162-4-23**]
Coronary Artery Bypass x 4 (LIMA-LAD, SVG-Diag, SVG-OM2,
SVG-RCA)
History of Present Illness:
71 year old man who underwent a coronary artery CT last week
which revealed multivessel coronary artery disease. He continues
to have some chest and left shoulder discomfort upon waking up
that normally resolves after gentle stretching in the mornings.
He himself thinks this is positional given that he often sleeps
on his left shoulder. He is very active by horseback riding and
walking his dog. When pressed, he reports one episode of dyspnea
on exertion when going briskly up a [**Doctor Last Name **] during deer hunting
season last Fall. He presented for a cardiac catheterization
which he was found to have three vessel coronary artery disease
and is now being referred to cardiac surgery.
Past Medical History:
Coronary artery disease
Hypertension
? Dyslipidemia
Abnormal Holter with ventricular ectopy
Valvular heart disease (1+ MR, 1+ TR)
Mildly dilated ascending aorta
Obesity
Presumptive complex partial seizures
Vitamin B12 deficiency
Uremia x2 [**59**]-15 years ago
Social History:
Last Dental Exam: >1 year ago
Lives with: Wife
Contact: [**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 68738**]
Occupation: Works part-time as a CPA
Cigarettes: Smoked no [x] yes []
Other Tobacco use: Denies
ETOH: Drinks one glass of wine per day and [**12-21**] rum-and-cokes per
week
Illicit drug use: Denies
Family History:
Premature coronary artery disease- Father died at
56 of a CVA, and may have had hypertension. Mother died at 51 of
heart failure secondary to possible MI; also had a history of
congenital heart disease
Physical Exam:
Pulse: 57 Resp: 16 O2 sat: 100/RA
B/P: 168/85
Height: 6' Weight: 218 lbs
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [x] Edema/Varicosities:
None
[X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2 Left:2
DP Right: 1 Left:1
PT [**Name (NI) 167**]: 2 Left:2
Radial Right: 2 Left:2
Carotid Bruit Right: - Left:
Pertinent Results:
Intra-op TEE [**2162-4-23**]
Conclusions
PRE-CPB: 1. The left atrium is mildly dilated. No thrombus is
seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild regional
left ventricular systolic dysfunction with inferolaterqal
hypokinesis..
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. AV pacing temporarily.
Preserved biventricular systolic function, with the LVEF now
45-55%. Some inferolateral hypokinesis. MR remains 1+. AI
remains trace. The aortic contour is normal post decannulation.
.
[**2162-4-29**] 10:34AM BLOOD WBC-5.0
[**2162-4-29**] 05:16AM BLOOD Hct-26.7*
[**2162-4-28**] 04:25AM BLOOD WBC-5.1 RBC-2.56* Hgb-8.4* Hct-26.4*
MCV-103* MCH-32.7* MCHC-31.7 RDW-13.9 Plt Ct-218
[**2162-4-27**] 03:11AM BLOOD WBC-5.3 RBC-2.58* Hgb-8.5* Hct-26.8*
MCV-104* MCH-33.0* MCHC-31.8 RDW-13.8 Plt Ct-191
[**2162-4-26**] 09:30PM BLOOD WBC-5.5 RBC-2.45* Hgb-8.4* Hct-24.8*
MCV-101* MCH-34.3* MCHC-33.9 RDW-13.5 Plt Ct-196
[**2162-4-29**] 05:16AM BLOOD UreaN-13 Creat-0.9 Na-139 K-3.9 Cl-104
[**2162-4-28**] 04:25AM BLOOD Glucose-106* UreaN-16 Creat-0.9 Na-136
K-4.0 Cl-101 HCO3-25 AnGap-14
[**2162-4-27**] 03:11AM BLOOD Glucose-100 UreaN-17 Creat-0.9 Na-138
K-3.8 Cl-101 HCO3-28 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname 68739**] was admitted to the [**Hospital1 18**] on [**2162-4-23**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent cornary artery bypass grafting
to 4 vessels. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next several hours, he awoke neurologically
intact and was extubated. On postoperative day one, he was
transferred to the step down unit for further recovery. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. On POD 3 he developed confusion and exhibited strange
behavior. He was returned to the CVICU. A head CT did not
reveal any acute process. Neurology was consulted. MRI/A was
negative and it was determined that the patient was affected by
multi-factorial delirium. He transferred back to the floor.
Mental status cleared to his baseline. He was oriented and
appropriate at the time of discharge.
By the time of discharge on POD 7 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with appropriate follow up instructions.
Medications on Admission:
LAMOTRIGINE [LAMICTAL] 200 mg [**Hospital1 **]
LAMOTRIGINE [LAMICTAL] 100 mg HS
LISINOPRIL 10 mg daily
LORAZEPAM [ATIVAN] 0.5 mg TID, PRN for aura take one tablet, can
repeat in 10 minutes, not to exceed 3 tabs a day
METOPROLOL TARTRATE 12.5 mg [**Hospital1 **]
NITROGLYCERIN 0.4 mg Tablet sublingually as needed for chest
pain
as needed for may repeat every five minutes up to a total of 3
doses
OXCARBAZEPINE 600 mg [**Hospital1 **]
SIMVASTATIN 20 mg Daily
ASPIRIN 81 mg Daily
CALCIUM CARBONATE-VITAMIN D3 [CALTRATE 600 + D]- Dosage
uncertain
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
12. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 5 days.
Disp:*10 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Coronary artery disease
Hypertension
? Dyslipidemia
Abnormal Holter with ventricular ectopy
Valvular heart disease (1+ MR, 1+ TR)
Mildly dilated ascending aorta
Obesity
Presumptive complex partial seizures
Vitamin B12 deficiency
Uremia x2 [**59**]-15 years ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage
Edema - trace
Discharge Instructions:
1) 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.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) 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) **] [**2162-6-2**] at 1:00p
Cardiologist: Dr. [**Last Name (STitle) **] [**2162-5-11**] at 3:20
[**Name6 (MD) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 2928**] Date/Time:[**2162-9-13**] 10:30
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 13532**],[**Doctor First Name **] G. [**Telephone/Fax (1) 2010**] in [**3-25**]
weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2162-4-30**]
ICD9 Codes: 2930, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2924
} | Medical Text: Admission Date: [**2108-6-18**] Discharge Date: [**2108-6-21**]
Date of Birth: [**2032-11-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
ARF, Hyperkalemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
75 y.o. Spanish-speaking female c/ PMHx CHF (EF 20-25%), CAD,
CRI who presented to the ED after routine labs revealed ARF w/
creat. to 3.8 and K of 6.
.
In early [**Name (NI) **], pt. was restarted on Lisinopril, a medication
which has been held in the past because of hypotension and acute
renal failure. Labs drawn after initiating a second trial of
Lisinopril revealed the aforementioned renal compromise with
associated hyperkalemia. On discovering the hyperkalemia, the
lab called the patient at home and instructed the pt. to come to
the ED when the lab recognized the abnormalities. Pt admits to
some light-headedness before coming-in to hospital.
.
In the ED, patient was hypotensive to SBP 70s, but asymptomatic.
Persistently elevated creatinine and potassium were noted.
Hyperkalemia was treated [**Last Name (un) 22121**] Kayexalate, Insulin, glucose and
calcium. Pt. additionally received small IVF boluses with
improvement in SBP to her baseline of high 90s, low 100s.
Patient was then triaged to the ICU for closer overnight
monitoring while treating for ARF and hyperkalemia.
.
Patient's hypotension improved to systolic 90's in the MICU,
which is thought to be her baseline. She was tranferred to the
service for continued treatment of renal failure and associated
electrolyte changes in the setting of prior history of CHF.
.
On admission to the floor, patient denies poor PO intake or
increased ostomy output, denies nausea/vomiting, dysuria,
hematuria, SOB, CP, lightheadedness. She does note decreased
urine output over the last two weeks.
.
OUTPATIENT MEDICATIONS:
Baby ASA
Lisinopril ("for past two months")
MV
.
ROS negative for h/o stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. She
denies recent fevers, chills or rigors. She denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
.
MEDICAL DECISION MAKING
[**2108-6-19**]: CXR No acute cardiopulmonary process.
ECG [**2108-1-9**]: Sinus rhythm
Ventricular premature complex
Nonspecific ST-T abnormalities
Since previous tracing of [**2108-1-2**], ventricular ectopy present
and ST-T wave changes appear slightly less prominent
Stress: TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 55
INTERPRETATION: 74 yo woman (severe cardiomyopathy with LVEF ~
20%)
was referred for a CAD evaluation. The patient was administered
0.142
mg/kg/min of persantine over 4 minutes. No chest, back, neck or
arm
discomforts were reported by the patient during the procedure.
In the
presence of baseline ST-T wave abnls, no additional ECG changes
were
noted during the procedure. The rhythm was sinus with occasional
vea;
occasional isolated VPDs, rare ventricular couplets. In
addition, rare isolated APDs were noted. The hemodynamic
response to the persantine infusion was appropriate. Three min
post-MIBI, the patient received 125 mg aminophylline IV.
IMPRESSION: No anginal symptoms or ECG changes from baseline.
Nuclear
report sent separately.
2D-ECHOCARDIOGRAM performed on [**2107-7-1**] demonstrated:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated with severe global hypokinesis. [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] . No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size is mildly increased with free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Left ventricular cavity enlargement with severe
global hypokinesis. Moderate mitral regurgitation. Pulmonary
artery systolic hypertension. Right ventricular free wall
hypokinesis.
CLINICAL IMPLICATIONS:
Based on [**2106**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
LABORATORY DATA:
See below.
.
INITIAL ASSESSMENT AND PLAN: 75yo fem c/ PMH of HTN, CRI
presenting with hyperkalemia and hypotension likely secondary to
exacerbation of renal failure due to Lisinopril.
.
#. A on CRF: Recent baseline creatinine around 1.2, currently
at 3-4. DDX includes ACE-I induced ARF esp. given reported prior
history. There is no clear h/o decreased PO intake or decreased
volume, and Feena <1. There is likewise no hx suggestive for
post-renal obstruction. Intrinsic causes include her recently
started ACE-I or simple hypotension. U/A not suggestive of ATN.
-We have D/C'd the ACE-I and expect improving renal function.
-Support BP with gentle NS boluses if SBP < 85 and symptomatic
-QD potassium and creatinine
-QD lytes in setting of metabolic acidosis
-strict I/O's
-Renal u/s --> renal consult
-Avoid nephrotoxins (ie, contrast/NSAIDS)
.
#. Pump: CHF not an active issue, but EF = 20-25% ([**12-2**])
limits [**Female First Name (un) **] of fluid resuscitation for kidneys.
-strict I/O's
-If exacerbation of CHF, gentle diuresis with non-K sparing
diuretic only.
.
#. Hyperkalemia: Likely 2dary to ARF as discussed above. K =
5.6 this AM --> 4.4 this pm, trending down s/p Kayexalate,
Insulin, glucose and Ca yesterday. Expect further resolution as
kidneys recover function s/p Ace-I d/c.
-Replicate hyperkalemic regimen if K > 6 (Kayexalate, Insulin,
Glucose, Ca).
-Continue tele
.
#
CAD: Non-contributory to complaint.
-con't ASA
-Atorvastatin 10 mg PO DAILY
-check lipid profile
.
#Hypotension: Likely 2dary to new ACE-I. There are no signs/sx's
of evolving infection. In setting of impaired renal function,
adequate BP is necessary for adequate renal perfusion.
Currently stable without evidence of evolving HTN s/p Ace-I d/c.
-small (250-500) NS bolus for low BP
.
#Non-gap Acidosis: Pt has bicarb of 16 on transfer. Likely
represents metabolic acidosis secondary to ARF as above. Expect
resolution as compromise resolves. Other possibilities include
diarrhea from Kayexalate, or dilutional effect from boluses of
NS.
#Anemia: Baseline crit = 28-32, currently at 28.5. Pt. appears
to be within baseline range, but will f/u with iron studies.
-f/u iron studies, B-12, Folate
.
#. FEN: Follow and replete electrolytes. Cardiac diet. No IVF at
present.
.
#. Access: PIV
.
#. PPx: PO diet.
.
#. Code: Full
.
#. Dispo: Pending good BP control off Ace-I and resolved
creatinine. Hope for d/c in [**12-28**] days.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 44432**] PGY1
Past Medical History:
1) CHF: EF 20-25%, presumably ischemic
2) CRI: baseline creatinine of 1.1 - 1.7 recently in 1/'[**07**], now
at 3 on transfer
3) CAD (Persantine MIBI 8/'[**06**]): Large reversible defect
involving the LAD, fixed defects in the PDA with hypokinesis of
the anteroseptal, distal anterior, distal septal,distal inferior
and apical walls. Patient deferred cardiac catheterization
4) Colon Cancer - s/p subtotal colectomy and ileostomy on 7/'[**06**]
5) Relative Hypotension - baseline SBPs in 90 - 100s
.
Cardiac Risk Factors: Dyslipidemia, HTN
.
Cardiac History: CHF, CAD and hypotension as above
Percutaneous coronary intervention: not applicable
Pacemaker/ICD: not applicable
.
Social History:
No TOB. EtOH limited to a "sip" of beer very occasionally. There
is no family history MI.
Family History:
+ for Ca, no h/o CHF, HTN, MI or SCD
Physical Exam:
PHYSICAL EXAMINATION:
VS 98.4, 97/65, 90R, 18, 100%2L
Gen: Well-appearing, [**Last Name (un) 1425**], supine in bed. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple, JVP not able to be assessed.
CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Minimal crackles RLL.
No wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits. There is a empty colectomy bag
with clear/dry/intact origin.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 3 PT 2+
Left: Carotid 2+ 2+ DP 2+ PT 2+
Pertinent Results:
[**2108-6-19**]: CXR No acute cardiopulmonary process.
[**2108-6-18**] 10:41PM K+-4.4
[**2108-6-18**] 08:18PM cTropnT-<0.01
[**2108-6-18**] 08:18PM cTropnT-<0.01
[**2108-6-18**] 08:13PM WBC-6.0 RBC-3.61*# HGB-11.1*# HCT-32.1*
MCV-89 MCH-30.9 MCHC-34.7 RDW-13.7
[**2108-6-18**] 08:13PM PLT COUNT-329
[**2108-6-18**] 08:13PM PT-11.8 PTT-21.9* INR(PT)-1.0
[**2108-6-18**] 10:00AM UREA N-91* CREAT-3.8*# SODIUM-129*
POTASSIUM-6.8* CHLORIDE-99 TOTAL CO2-17* ANION GAP-20
[**2108-6-18**] 08:13PM CK(CPK)-86
[**2108-6-18**] 08:13PM CK-MB-NotDone
Brief Hospital Course:
The patient presented to the ED with hypotension to the systolic
70's and acute renal and briefly was admitted to the MICU for
evaluation, observation and management. The patient's active
issues quickly resolved as below and the patient was transferred
to the [**Hospital1 1516**] service for a final 36 hours of monitoring before
discharge.
#Renal Failure: On admission, the patient was found to have
creatinine = 3.8 up from baseline .8. The patient's moderate
metabolic metabolic acidosis was thought secondary to this
failure. It was noted that the patient had recently re-stated
Lisinopril, which had previously been noted to induce
hypotension and renal failure in this patient. The patient's
creatinine quickly corrected and returned to near baseline with
fluids and discontinuation of Lisinopril, such that creatinine
was trending down to 1.8 on discharge.
#Hyperkalemia: On admission, the patient was found to have K =
6. Calcium Gluconate, Dextrose, Insulin, Kayexealae 30gm were
given. EKG showed no peaked T waves. Potassium quickly improved
to WNL without any arrhythmias as monitored on telemetry.
#Hypotension: In the ED, the patient was fond to have BP =
70's/52. It was noted that the patient had recently re-stated
Lisinopril, which had previously been noted to induce
hypotension and renal failure in this patient. There was no
evidence of infection as a driver for septic hypotension. Home
anti-hypertensives were held. Her pressures responded quickly to
fluid boluses and cessation of her anti-hypertensives, including
Lisinopril. Pressures were nted to be 100-120 systolic before
discharge.
#CHF: The patient has known EF = 20-25%. No evidence of heart
failure on exam.
#CAD: Patient has known CAD. Given concern for demand ischemia
from hypotension, the patient's enzymes were cycled and she
ruled out for MI. ASA was continued but BB was held given
hypotention, with plan to re-start if possible after discharge
in conjunction with the patient's PCP. [**Name Initial (NameIs) **] statin was added to the
patient's treatment regimen and prescribed at time of discharge.
Lipid studies are pending and will need to be followed-up as
outpatient.
#Proph: The patient was maintained on Heparin SQ throughout the
hospitalization. Physical therapy worked with the patient at the
end of the hospitalization and cleared the patient for
discharge. The patient was discharged in good condition.
Medications on Admission:
Aspirin 81mg QD
Lisinopril 2.5mg QD
Toprol XL 25mg QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute Renal Failure
Hyperkalemia
Secondary:
CHF
CAD
Heart Failure
Anemia
Discharge Condition:
Stable.
Discharge Instructions:
You were found to have a problem with your kidneys that was
likely caused by Lisinopril. We believe the Lisinopril caused
your body to retain a higher than normal amount of potassium.
Because high potassium can damage the heart, we treated you with
medications to lower the amount of potassium in your body,
including Kayexelate. The amount of potassium in your body
decreased and is now normal. The function of your kidneys is
improving.
During your hospitalization, we stopped the following
medications:
Lisinopril
Toprol XL (please discuss resuming this medication with your PCP
[**Name Initial (PRE) 503**]).
We began the following medications:
Atorvastatin 10mg daily
Please keep all follow-up appointments. They are listed below.
Please return to the ED or call Dr. [**Last Name (STitle) 31**] ([**Telephone/Fax (1) 2130**])
for shortness of breath, chest pain, dizziness, "fainting", or
any other concerning symptom.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 31**], your PCP, [**Name10 (NameIs) 503**] at
11:20 at [**University/College 70860**]. Please bring this paperwork with
you to the appointment. Please ask Dr. [**Last Name (STitle) 31**] to discuss 1.
the management of your blood pressure, and 2. the addition of
Atorvastatin to your medication regimen, and 3. the addition of
a beta blocker as your blood pressure and HR permit.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2108-12-10**]
ICD9 Codes: 5849, 2762, 2767, 4280, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2925
} | Medical Text: Admission Date: [**2106-7-8**] Discharge Date: [**2106-7-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 53693**] is a [**Age over 90 **] F with h/o aflutter, HTN, CVA who
presented to ER initially with dyspnea, LE edema and was found
to have elevated JVD, Atach vs aflutter, CXR c/w CHF. She
started having dyspnea on exetrtion 7 days prior to admission
with a nonprod cough, without CP. When she arrived to the ED,
her BP was 208/110, HR 122, T 98.2, RR 30, Sat 90% on RA. She
received Aspirin 325mg, Acetaminophen 650mg, Furosemide 40mg x
2, Nitroglycerin gtt, Metoprolol 5mg x 3, Lorazepam 2mg. While
in the ER she vomited into her face mask and had an acute
worsening of her respiratory distress at which time repeat CXR
showed bibasilar opacities consistent with aspiration and
possible worsening edema. She then received Vancomycin 1g,
Piperacillin-Tazobactam Na 2.25 gm. Discussion at that time with
her family and PCP resulted in decision to make pt DNR/DNI/CMO
and start a morphine drip for relief of respiratory distress or
discomfort. The plan was to admit her to Medicine for further
supportive comfort care. However, while in the ED her resp
status seemed to improve, and the family requested to treat her
conservatively for her pneumonia/CHF. She is to remain DNR/DNI
per family, but to receive appropriate antibiotics and diuresis.
Of note, while on the morphine gtt her BP dropped to 83/30. She
had a lactate of 2.3. Her morphine gtt was decreased and her BP
rose to 99/39, then back 86/50 (MAP 62) before transport to the
[**Hospital Unit Name 153**]. The ED staff spoke with her family about pressors/central
line, and they said that would be OK if necessary to keep her
alive.
Past Medical History:
PMHx:
- Strokes-first was prior to [**2094**], grandson does not know
details. Next was in [**2094**] p/w slurred speech. Next was in [**2099**]
with severe left sided weakness. All required physical therapy
rehab. Currently on coumadin and baby asa. PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11139**] at
[**Location (un) 2312**]. Etiology of strokes is unclear to the family.
- hard of hearing, + tinnitus
- hypothyroidism
- HTN
- high cholesterol
- cataract surgery bilaterally
-? CAD and CHF- no old records here.
.
Social History:
SHx: lives with daughter and grandson, walks with a cane,
daughter (60 YO) does all cooking and finances. Widowed since
WWII. Former
farmer from [**Country 5881**], moved to US over 20 yrs ago. No
Tob/etoh/drugs.
Family History:
FamHx: DM, HTN, stroke
Physical Exam:
VS: Tc 97.2, Tm 101 in ED, BP 83/58(65), HR 93 in Aflut, RR 23,
Sat 100% on NRB
Gen: frail, elderly caucasian woman, lying in bed, HOB 15
degrees, asleep and in no respiratory or other distress
HEENT: no bruises or lacerations, eyelids closed, NRB mask in
place
Neck: supple, JVP elevated @ 10cm
Lungs: diffusely rhonchorous, with insp and exp wheezes
CV: irreg irreg, difficult to hear HS over her breathing; faint
systolic murmur loudest at LUSB
Abd: soft, mildly distended, no grimace to palpation, decreased
BS, no guarding
Ext: 1+ LE edema to ankles, inapprop warm for low BP
Neuro: sedated from morphine and ativan in ED, unable to assess
mental status
Pertinent Results:
[**2106-7-16**] 10:55AM BLOOD WBC-9.8 RBC-3.65* Hgb-10.8* Hct-32.7*
MCV-90 MCH-29.6 MCHC-33.1 RDW-16.1* Plt Ct-335
[**2106-7-15**] 06:40AM BLOOD WBC-13.8* RBC-4.03* Hgb-12.0 Hct-37.7
MCV-94 MCH-29.8 MCHC-31.8 RDW-16.1* Plt Ct-346
[**2106-7-8**] 04:35AM BLOOD WBC-27.0*# RBC-4.00* Hgb-11.9* Hct-36.2
MCV-91 MCH-29.8 MCHC-32.9 RDW-15.5 Plt Ct-270
[**2106-7-7**] 07:40PM BLOOD WBC-11.9* RBC-4.49 Hgb-13.1 Hct-39.9
MCV-89 MCH-29.2 MCHC-32.9 RDW-16.0* Plt Ct-326
[**2106-7-16**] 10:55AM BLOOD Neuts-78* Bands-0 Lymphs-11* Monos-6
Eos-4 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2106-7-16**] 06:10AM BLOOD PT-20.1* INR(PT)-1.9*
[**2106-7-8**] 04:35AM BLOOD PT-24.6* PTT-34.9 INR(PT)-2.5*
[**2106-7-16**] 06:10AM BLOOD Glucose-144* UreaN-25* Creat-0.7 Na-143
K-3.5 Cl-105 HCO3-28 AnGap-14
[**2106-7-7**] 07:40PM BLOOD Glucose-240* UreaN-23* Creat-0.8 Na-134
K-7.6* Cl-101 HCO3-23 AnGap-18
[**2106-7-15**] 06:40AM BLOOD Glucose-131* UreaN-25* Creat-0.8 Na-147*
K-4.3 Cl-107 HCO3-26 AnGap-18
[**2106-7-15**] 06:40AM BLOOD ALT-33 AST-37 AlkPhos-92 TotBili-1.3
[**2106-7-10**] 02:57AM BLOOD CK-MB-4 cTropnT-0.05*
[**2106-7-7**] 07:40PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-4035*
[**2106-7-16**] 06:10AM BLOOD Calcium-8.7 Mg-1.9
[**2106-7-8**] 04:35AM BLOOD Albumin-3.8 Calcium-8.6 Phos-3.3 Mg-1.7
[**2106-7-16**] 06:10AM BLOOD Osmolal-301
[**2106-7-14**] 10:30AM BLOOD Osmolal-311*
[**2106-7-8**] 04:35AM BLOOD TSH-3.2
[**2106-7-16**] 06:10AM BLOOD Digoxin-1.1
[**2106-7-8**] 04:35AM BLOOD Digoxin-1.0
[**2106-7-8**] 11:10AM BLOOD Type-ART pO2-233* pCO2-41 pH-7.41
calTCO2-27 Base XS-1
[**2106-7-15**] 11:06AM BLOOD Lactate-7.4*
[**2106-7-16**] 07:25AM BLOOD Lactate-2.2*
[**2106-7-7**] 07:49PM BLOOD Lactate-2.3* K-4.9
[**2106-7-14**] 01:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2106-7-14**] 01:55PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-TR
[**2106-7-14**] 01:55PM URINE Hours-RANDOM Creat-93 Na-101
[**2106-7-8**] 12:10 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2106-7-10**]**
GRAM STAIN (Final [**2106-7-8**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2106-7-10**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
YEAST. MODERATE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
YEAST. SPARSE GROWTH. 2ND TYPE.
[**2106-7-14**] 3:50 pm BLOOD CULTURE SET #2.
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2106-7-14**] 3:30 pm BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2106-8-7**] 4:43 am URINE Source: Catheter.
**FINAL REPORT [**2106-7-9**]**
URINE CULTURE (Final [**2106-7-9**]): NO GROWTH.
CXR - IMPRESSION: Marked improvement of previously identified
congestive pattern and parenchymal infiltrates in this elderly
patient. Comparison with the study of [**2106-7-7**] demonstrates
now also improvement of the initially seen fluffy infiltrates on
the right base.
Non-contrast head CT.
COMPARISON: [**2105-11-23**].
FINDINGS: There is no evidence of new infarction or hemorrhage.
There is no mass effect or shift of midline structures. The
ventricles, cisterns, and sulci are enlarged secondary to
involutional change. Marked periventricular white matter
hypodensities are unchanged, and old bilateral basal ganglia
infarcts are again noted. The visualized paranasal sinuses are
aerated, and no fractures are identified.
IMPRESSION: Stable appearance of the brain without intracranial
hemorrhage
Cardiology Report ECG Study Date of [**2106-7-9**] 6:48:26 PM
Atrial fibrillation. Right bundle-branch block with left
anterior fascicular
block. Diffuse ST segment changes could be secondary to
myocardial ischemia or
rapid ventricular rate. Compared to prior tracing of [**2106-7-9**] no
interim
diagnostic change.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
87 0 142 390/434.42 0 -76 -97
CXR - IMPRESSION: Diffuse fluffy opacities more reminiscent of
edema given cardiomegaly and effusion. Please note atypical
pneumonia may present in a similar fashion. Correlate
clinically. Repeat radiography following diuresis may be
indicated to assess for underlying infection.
Brief Hospital Course:
Sepsis from aspiration pneumonia - the hypotension resolved with
IVF initially. The dyspnea was multifactorial - mostly from a
severe aspiration pneumonia. Aspiration risk is high as
confirmed with swallow therapist and with video swallow.
Appropriate changes were made to the diet. Strict aspiration
precautions were maintained and the patient was assisted with
all meals. The patient specifically aspirated with thin liquids.
She completes a 10 day course of antibiotics (levofloxacin) on
[**2106-7-17**].
Repeat CXR revealed improved pneumonia.
Congestive heart failure - diastolic, pulmonary edema - from
aggressive IVF and rapid A fib. Responded to diuresis and HR
control. Warfarin was held during the hospital stay and the INR
at most times was between [**2-13**] (from drug interaction with
levofloxacin). The warfarin should be started 1 day after
stopping levofloxacin and close monitoring of INR should be
done.
Lasix was not continued as the patient was very volume depleted
due to decreased po intake and diuresis.
Delerium - multifactorial - from infection and also from
hypovolemia. Refer below.
Hypernatremia - hypovolemia - Due to above reason, the patient
was severly free water restricted. After IV D5water the sodium
returned to [**Location 213**]. Lactic acidosis was from the hypovolemia as
it resolved after volume repletion.
Atrial fibrillation with rapid rate - as above
h/o CVA - warfarin as above. ASA was stopped as she will also be
on anti-coagulation and give her age and risk of fall, is at
high risk of bleeding.
Hypothyroidism - levothyroxine continued at home dose. TSH was
normal.
PT evaluated her and recommended rehab. Discharged to [**Hospital 100**]
rehab. Family involved and aware.
DNR/DNI
Medications on Admission:
1.Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed
2.Atorvastatin 20 mg PO DAILY
3.Aspirin 81 mg PO DAILY
4.Tolterodine 4 mg DAILY
5.Levothyroxine 50 mcg PO DAILY
6.Glucosamine 1 tab po qday
7.Digoxin 125 mcg PO DAILY
8. Senna 8.6 mg PO BID
9.Docusate Sodium 100 mg PO BID
10.Metoprolol Tartrate 50 mg PO TID
11.Warfarin 3mg po qday- adjust to INR
12.MVI po qday
*** of note, was on Lasix 20 mg PO DAILY, but this was stopped
at her last clinic appt ***
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q2H (every 2 hours) as needed.
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q8H (every 8 hours) as needed.
8. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Start
1 day after levofloxacin is completed.
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days: completes a 10 day course on [**2106-7-17**].
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Sepsis from aspiration pneumonia
Congestive heart failure - diastolic, pulmonary edema
Delerium
Hypernatremia - hypovolemia
Lactic acidosis
Atrial fibrillation with rapid rate
h/o CVA
Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
Please inform your doctor if you have any new symptoms of
concern to you. The doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] rehab will care further
for your medical issues.
Take medicines as instructed.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 11144**] - please follow up with Dr [**Last Name (STitle) 11139**]
when discharged from [**Hospital 100**] Rehab.
The doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] rehab will care further for your medical
issues.
ICD9 Codes: 0389, 5070, 4280, 5849, 2760, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2926
} | Medical Text: Admission Date: [**2122-4-14**] Discharge Date: [**2122-4-17**]
Date of Birth: [**2122-4-14**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] [**Known lastname 12598**] is a 3020 gram, 34 [**3-18**] week male
product of a 32 year-old gravida II, para 0, now I mother.
Infant serologies: O positive, antibody negative, hepatitis
B surface antigen negative, RPR nonreactive, rubella immune
mother. Pregnancy was complicated by preterm premature
rupture of membranes [**2122-3-30**]. She was treated with
intravenous Clindamycin. Mother is also a type 1 insulin
dependent diabetes times 11 years with well controlled
glucoses. She also has a history of pregnancy-induced
hypertension with elevated blood pressures prior to delivery.
Mother went into spontaneous labor on [**2122-4-13**] and was taken
to cesarean section secondary to failure to progress. Sepsis
factors were premature rupture of membrane. There was no
fever and a fetal tachycardia. Baby emerged active and pink.
Apgars were 8 and 9.
PHYSICAL EXAMINATION: On admission weight 3.02 kilos (95th
percentile for gestational age), length 49 cm (75th to 90th
percentile) and OFC 32 cm (50th to 75th percentile). Vital
signs were stable. In general this is a well developed
slightly LGA male. His facies were symmetric. His anterior
fontanelle was soft and open. His pinnae were well formed
without pits or tags. His palate was intact. He had a good
suck. His neck was supple. His heart was in regular rate and
rhythm without murmur. His lungs were clear to auscultation
bilaterally. His abdomen was soft, nondistended without
hepatosplenomegaly. He had a three vessel cord. GU: [**Male First Name (un) 33542**]
1 male with testes descended bilaterally. Anus was patent.
Back was without hair tuft or dimple. Extremities were all
intact and were warm and well perfused. Neurologically he had
a good suck. Symmetric Moro. Tone was appropriate for
gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
Respiratory: Cal remained stable on room air throughout his
stay.
Cardiovascular: The patient has been cardiovascularly
stable.
Fluid, electrolytes and nutrition: Cal had initial D stick
of 37 and he was fed Enfamil 22 fortified with Polycose.
Repeat D stick was done soon after his feeding was 55. He
continued to p.o. ad lib and on day of life day number two
was switched from Enfamil 22 with Polycose to staight Enfamil
20 or breast milk. His D sticks remained stable from 50s to
60s. He is currently waking for feeds approximately every
three to four hours. His most recent D stick was 65. His D
stick on breast milk/E-20 was 49 and that was approximately
four hours after a feeding. His most recent weight was 2.84
kilograms.
GI: Cal is currently on a phototherapy blanket for a peak
bilirubin of 13.1 on day of life number three. He will have
a follow up bilirubin tomorrow.
Hematology: The patient's initial hematocrit was 60. He has
received no blood transfusions during his hospitalization.
Infectious disease: Initial white count was 9.8 with 2 bands,
35 segs. Blood culture was drawn. He was not initiated on
antibiotics. Blood culture was negative at 48 hours.
Sensory:
1. Audiology: Hearing screening is due to be completed
before discharge.
2. Mother has been seen by lactation consultation.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To the Newborn Nursery.
PRIMARY PEDIATRICIAN: Is Dr. [**Last Name (STitle) 17029**].
CARE RECOMMENDATIONS:
1. Feeds: P.o. ad lib breast milk then to be supplemented
with Enfamil 20. Please check a Dextrostix if Cal goes
longer than four hours between feedings.
2. Cal should have car seat position screening before
discharge.
State Newborn Screening was sent on day of life number two.
Results are pending at this time.
Cal has not yet received his hepatitis B vaccination.
IMMUNIZATIONS RECOMMENDATION:
1. RSV prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: 1) Born at less than 32 weeks. 2) Born between 32
and 35 weeks with two of the following: 1) Day care during RSV
season or a smoker in the household, neuromuscular disease,
airway abnormalities or school age siblings or 3) with
chronic lung disease.
2. Influenza immunization is recommended annually in the
fall for all infants over six months of age. Before this age
influenza for first 24 months of child's age (immunization
against influenza is recommended for household contacts and
out of home care-givers).
FOLLOW UP APPOINTMENT:
1. Follow up to be scheduled with Dr. [**Last Name (STitle) 17029**].
DISCHARGE DIAGNOSES:
1. Prematurity at 34 weeks.
2. Hypoglycemia, resolved.
3. Hyperbilirubinemia.
4. Sepsis ruled out
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2122-4-17**] 13:27
T: [**2122-4-17**] 14:05
JOB#: [**Job Number 56197**]
ICD9 Codes: V053, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2927
} | Medical Text: Admission Date: [**2191-1-3**] Discharge Date: [**2191-1-5**]
Date of Birth: [**2137-5-2**] Sex: M
Service: [**Location (un) 2655**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 303**] is a 53-year-old
gentleman who was transferred to [**Hospital1 190**] Medical Intensive Care Unit from an outside
hospital for esophageal bleeding. The history is obtained
from the chart only as the patient is Portugese speaking.
Mr. [**Known lastname 303**] was transferred to [**Hospital **] [**Hospital3 2063**]
after presenting with hematemesis on [**1-3**]. He had a
first episode at 6 am on the morning of presentation, five
episodes of bright red blood per mouth associated with some
nausea. He also relates some melena and two episodes of
syncope at home along with persistent lightheadedness.
Patient in addition, had an episode of rectal bleeding now
for a few months, although he denies any abdominal pain.
Patient has a long history of alcohol abuse, but no other
complications from the alcohol abuse per report. Upon
admission, the patient's hematocrit was 40.3 and his coags
were normal. The patient apparently last drank at 2 am the
morning of admission.
An esophagogastroduodenoscopy was performed at outside
hospital which showed severe acute and chronic esophagitis.
Varices were not definitively identified, but there is a deep
esophageal ulcer tear with the bleeding vessel that was
treated with BiPAP and epi in the lower esophagus. There is
also bleeding vessel just below the GE junction which was
injected with good hemostasis. Three clips were placed.
There was no banding of any vessels due to fibrosis. The
patient was intubated for airway protection and he received 2
units of packed red blood cells, and had a repeat hematocrit
of 39.5. He was transferred to [**Hospital1 188**] MICU for further management.
Initially, he was evaluated by the Thoracic Surgery Service,
as it was felt he was high risk for rebleed due to his
[**Doctor First Name **]-[**Doctor Last Name **] tear. However, Surgery felt that no other
intervention was necessary from a surgical standpoint. At
that point, he was then transferred to the MICU for potential
alcohol withdrawal and further management of his
gastrointestinal bleed. The patient was changed to CPAP with
pressure support the day following admission.
PAST MEDICAL HISTORY:
1. Alcohol abuse 20 years drinking 1 liter of hard alcohol
per day.
2. Status post right herniorrhaphy.
3. Status post left knee surgery from a motorcycle accident.
HOME MEDICATIONS: None.
MEDICATIONS INHOUSE:
1. Protonix.
2. Folic acid.
3. Thiamine.
4. Atrovent.
5. Levofloxacin.
6. Clindamycin.
7. Colace.
8. Senna.
9. Valium prn.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient drinks 1 liter of hard alcohol a
day and has tobacco history.
In the Medical Intensive Care Unit, the patient had the
following physical examination:
VITAL SIGNS: Temperature 100.8, blood pressure 138/78, pulse
94. He was breathing at 30 and sating 98%.
General: The patient was intubated and sedated.
HEENT: Pupils are equal, round, and reactive to light. His
mucous membranes were dry, poor dentition.
Neck: Neck was supple. There was an IJ line in his right
neck.
Lungs: He had absent breath sounds on the right, but clear
on the left.
Cardiovascular: Patient has a regular, rate, and rhythm with
no murmurs, rubs, or gallops.
Abdomen: His abdomen is soft, nontender, nondistended with
normal bowel sounds and no caput medusae or spider angiomas.
Extremities: No edema or palmar erythema.
Neurologic: The patient was opening his eyes to voice and
looking at examiner, but did not follow commands.
LABORATORY DATA: On admission from the outside hospital, the
patient had the following laboratories: His white blood cell
count was 9.5, hematocrit of 40.3, and platelets were 189.
Sodium was 137, potassium of 3.9, chloride 100, bicarb 24,
BUN 20, creatinine 1.0, and sugar 141. His albumin was 4.2,
his AST was 73, ALT was 59, alkaline phosphatase was 79, T
bilirubin 0.8, CK was 143, lipase 21, amylase 19. His PT was
13.0, PTT is 24.8, and INR is 1.1.
His electrocardiogram was normal sinus rhythm at 92 with
normal axis. There were no Q waves. There were no ST-T wave
changes.
A chest x-ray was read as no acute infiltrate or
cardiopulmonary abnormalities. The patient had a chest x-ray
on [**1-4**] which showed right slight atelectasis at the right
space, but no pneumothorax.
The day of the patient's discharge, the patient's
laboratories were as follows: His white blood cell count was
12.7, hematocrit 35.3, platelet count was 145. His potassium
was 3.9, BUN 15, creatinine 0.7, glucose of 25. He had the
following cultures grown during his stay in [**Hospital1 346**]. On [**1-4**], he had sputum which grew
Staphylococcus aureus that was sensitive to levofloxacin and
penicillins, and 3+ Gram-negative rods. He had blood and
urine culture sent on [**1-4**] which have been negative
to date.
SUMMARY OF HOSPITAL COURSE:
1. Gastrointestinal: The patient had this acute large volume
of hematemesis at the outside hospital with the
esophagogastroduodenoscopy done at the outside hospital with
the intervention previously mentioned. Since his arrival at
[**Hospital1 69**], he has had no further
incidences of active bleeding and his hematocrit has remained
stable at 35.3 the day of discharge. He has had no further
symptoms of lightheadedness, chest pain, shortness of breath.
He was placed on Protonix 40 mg [**Hospital1 **], but received no
additional transfusions at [**Hospital1 188**]. He was seen by the Thoracic Surgery team prior to
discharge, who cleared him without any further intervention
necessary for the [**Doctor First Name **]-[**Doctor Last Name **] tear. Of note, he had normal
LFTs and normal coags despite his history of alcohol abuse.
2. Infectious Disease: During the patient's stay in the
MICU, he was weaned from the ventilator with some difficulty
and he was found to have copious secretions that were green
in color, to have spiked a fever, growing Staphylococcus
aureus, and Gram-negative rods in the sputum. He was
initially covered with levofloxacin and Flagyl which after
one day was changed to levofloxacin and clindamycin. He
subsequently was afebrile and he had a good oxygen
saturations without any shortness of breath. He was
continued on the levofloxacin and the clindamycin until the
day of discharge when he was discharged on a 10 day course of
levofloxacin for presumed aspiration pneumonia versus
pneumonitis from the esophagogastroduodenoscopy.
3. EtOH abuse: The patient has a 20+ year history of alcohol
abuse drinking roughly 1 liter of alcohol per day. During
the stay in the Medical Intensive Care Unit, he received 2
doses of Valium for agitation, but thereafter remained stable
with no evidence of alcohol withdrawal. He was continued on
prn Valium, but required no additional doses.
Prior to his discharge, he was explained in Portugese by an
interpreter the danger that his continued drinking opposed to
his health. In particular, he was instructed if he continues
to drink, his risk of rebleed, and potentially additional
bleeding episodes remain significant. The patient indicates
that he understood the risks and would refrain from further
alcohol.
In addition, the patient was given daily doses of folic acid
and thiamine during his hospital stay and sent home on a
multivitamin on discharge.
4. Hematologic: The patient was found to have a low platelet
count on admission and it gradually rose to 145, but remained
depressed. This is possibly due to splenic sequestration and
the patient's cirrhotic liver, given the increased in the
platelets of the course of his hospitalization, no further
workup was undertaken as there is no spontaneous active
bleeding. He should follow this up with his primary care
physician.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed secondary to esophageal
bleeding vessels.
2. Esophageal tear consistent with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear.
3. History of alcohol abuse.
4. Thrombocytopenia.
5. Aspiration pneumonia.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po bid x2 weeks followed by 40 mg po q day.
2. Levofloxacin 500 mg po q day x10 days.
3. Multivitamin one tablet po q day.
FOLLOW-UP PLANS: The patient is to call [**Hospital 191**] Clinic at ([**Telephone/Fax (1) 46694**] for follow-up appointment with a new primary care
physician three days after discharge. He should be seen
within 3-4 days of his discharge to have his hematocrit
checked. This is communicated to the patient through the
Portugese interpreter. The patient understood the importance
of doing so.
The patient at that time is also in addition his primary care
physician that he should have followup with [**Hospital **]
Clinic roughly eight weeks from his discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2191-1-7**] 14:28
T: [**2191-1-11**] 11:42
JOB#: [**Job Number 47476**]
ICD9 Codes: 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2928
} | Medical Text: Admission Date: [**2119-11-16**] Discharge Date: [**2119-12-5**]
Date of Birth: [**2048-8-27**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 71-year-old female
patient with a known history of aortic stenosis reports
recent increase in dyspnea on exertion over the past month.
She was admitted to the [**Hospital1 69**]
for cardiac catheterization prior to undergoing a scheduled
aortic valve replacement.
Patient at that time denied history of syncope or chest pain.
Cardiac catheterization performed on [**2119-11-16**]
revealed a right dominant system with single vessel coronary
artery disease, severe aortic stenosis with a calculated
aortic valve area of 0.86 cm squared and a mean gradient of
33 mm Hg, left ventricular ejection fraction estimated at
58%, and a left ventricular end diastolic pressure of 24.
PAST MEDICAL HISTORY: Patient has a history of
supraventricular tachycardia which was treated with atenolol,
known aortic stenosis, spastic colon. The patient describes
a history of scarlet fever as a child, arthritis of both
knees, history of renal calculus, significant hearing loss,
cataract surgery, status post D&C, status post bilateral knee
replacements, bilateral appendectomies, status post
tonsillectomy.
ALLERGIES: The patient states allergies to Biaxin.
MEDICATIONS ON ADMISSION TO THE HOSPITAL: Atenolol 25 mg po
q day, cholestyramine 4 mg po q day, Fosamax 70 mg once a
week. She also took nitroglycerin sublingual prn, Percocet
prn, Compazine prn, and Serax prn.
SOCIAL HISTORY: The patient is retired, former 40 pack year
smoker, quit 10 years ago. Denies alcohol intake and she is
recently widowed.
FAMILY HISTORY: Is significant for a mother who died of
complications related to a CVA. Father died of complications
related to a CVA.
PHYSICAL EXAMINATION ON ADMISSION TO THE HOSPITAL:
Temperature 97.3, blood pressure 128/52, pulse 62 and
regular, on room air oxygen saturation is 95% and respiratory
rate of 20. Neurologically, the patient is alert and
oriented with no apparent deficits. HEENT were unremarkable.
Pulmonary examination: Lungs were clear to auscultation
bilaterally. Coronary examination was regular, rate, and
rhythm with a systolic murmur evident. Abdomen was soft,
obese, and nontender with positive bowel sounds. Her
extremities were warm and well perfused.
Patient was taken to the operating room on [**2119-11-17**]
where she underwent a minimally invasive aortic valve
replacement with a 21 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial
valve. Please refer to operative report for details of
surgical procedure and operative event.
Postoperatively, the patient was transported from the
operating room to the Cardiac Surgery Recovery Unit on
intravenous amiodarone, intravenous Levophed, and IV
propofol drips. She was initially atrially placed via her
temporary epicardial wires. Patient was initiated on insulin
drip for hyperglycemia at that time.
On the night of her surgical day, [**11-17**] into the
morning of [**11-18**], the patient was noted to have
questionable seizure activity. Patient's anesthesia drugs
were reversed and she was noted to have increased jerky-type
movements. Emergency neurologic consult was obtained. The
patient spiked a fever to 102 at that time, and otherwise
remained hemodynamically stable.
On the morning of [**11-18**], Neurology consult was
obtained. Patient was started on Dilantin for witnessed
seizure activity. She was felt to have had partial complex
seizures at that time. She had a stable cardiac rhythm at
that time and her epicardial wires were discontinued to
facilitate emergent MRI scan to evaluate the etiology of her
seizure activity. The MRI from later that morning was
suspicious for an acute right middle cerebral artery infarct
with a small left hemisphere infarct stressed to embolic
events.
Patient was then initiated on a Heparin drip. She was also
pancultured for fever and increasing white blood cell counts.
These cultures other than a positive urine culture for E.
coli ultimately were negative. Patient was placed on
ceftriaxone empirically pending results of a culture which
was sent at that time. Patient was transfused to maintain a
hematocrit of approximately 30%. She also was placed on
intravenous Levophed to keep her systolic blood pressure
greater than 130 mm Hg to optimize cerebral perfusion at the
recommendation of the Neurology staff.
She remained hemodynamically stable, although febrile at
times with full ventilator support and no seizure activity
noted. The patient continued to be febrile for the next 24
hours or so, and remained on empiric antibiotics pending
results of cultures.
A repeat CT scan on [**11-19**] showed no hemorrhage with no
evidence of shift and some, mild edema in the right frontal
lobe area. On [**11-20**], patient remains on IV amiodarone
drip, although no other vasoactive drips were continued at
that time. She remained on some insulin intermittently to
treat hyperglycemia.
She had some atrial fibrillation also on that day for which
she received an additional bolus of IV amiodarone. An
electroencephalogram was done at that time which was
consistent with mild encephalopathy, however, no focus seen
for seizure activity. There are also no clear periods of
wakefulness noted at that time.
On the following day, [**11-21**], the patient continued
with ventilator weaning. Required minimal ventilator
support, but it was felt inappropriate to extubate her at
that time due to patient's inability to protect her airway.
She was maintained on Dilantin to prevent further seizure
activity and her electrolytes were being repleted. She also
had some intermittent bursts of atrial fibrillation at that
time with rates between the 80s and 120s with ventricular
rates.
On [**11-22**], the patient showed some signs of
wakefulness. She began to nod her head in response to
questions asked, although she was noted to have left arm
weakness at that time. Patient was started on tube feeds
which she was tolerating well and appeared to be waking up
appropriately. Patient at that time later on that day began
to follow one-step commands. Repeat head CT scan also on the
[**11-22**] revealed evolution of multiple small right
frontal and parietal infarcts.
Chest x-ray at that time revealed a left lower lobe collapse
and some left pleural effusion. The following day on the
[**11-23**], patient continued with burst of atrial
fibrillation treated with intravenous Lopressor and continued
on the intravenous amiodarone. Chest x-ray showed a
persistent left lower lobe collapse with some effusion.
On [**11-24**], the patient was much brighter mentally. She
was much more interactive with people's surrounding her. She
was moving both of her legs. She was moving her right arm
freely and moving her left arm, although with less vigor than
her right arm. Her tube feeds were held, and later morning
of [**11-24**], the patient was extubated successfully.
On [**11-25**], physical therapy became involved with her
care. Her intravenous central line has been discontinued and
sent for culture which ultimately turned out to be negative,
and her ceftriaxone was discontinued since the only positive
culture from the previous fever spike was urine, which had
been adequately treated.
On [**11-26**], the patient had intermittent periods of
confusion, however, was overall very interactive with her
caregivers. [**Name (NI) **] chest x-ray showed a continued left pleural
effusion for which a chest tube was placed. She remained at
this time in normal sinus rhythm.
The following day, [**11-27**], she continued with physical
therapy. She was noted to have a large raised area at the
superior aspect of her sternal incision with no erythema and
she had some serous drainage on the superior aspect of her
incision. Patient also underwent a bedside swallowing
evaluation by the Speech and Swallowing therapist to evaluate
safety of airway protection and risk of aspiration. It was
felt that she visually did at least fairly well by her
bedside evaluation and a modified barium swallow is
recommended to be followed up on.
Patient's white blood cell count at this time rose to 22,000
and she was again pancultured. She was begun empirically on
Vancomycin IV and levofloxacin via nasogastric tube at that
time due to increasing white blood cell count. Also
Gastroenterology consult was obtained for possible placement
of a PEG if she were unsuccessful with her barium swallow
which was scheduled for the following day.
On [**11-28**], the patient did undergo a modified barium
swallow, which she passed well, and she was at a low risk for
aspiration. She was then supervised. She also began to have
very large amounts of diarrhea over the next 24-48 hours.
Patient has a history of "spastic colon", and however, stated
that this was much more significant than her baseline. Her
white blood cell count had come down minimally to 20.8
thousand, however, she had a fever of 101.7. She was resumed
on her cholestyramine and the Gastroenterology service was
reconsulted on [**11-29**] due to increasing diarrhea.
Three Clostridium difficile specimens were sent and were all
negative, as well as subsequent stool cultures which also
came back negative.
Neurologically the patient had been waking up significantly
on a daily basis. She was much more bright and interactive.
She had some left arm weakness, but otherwise was moving her
other three extremities fairly well. She was begun on
Coumadin at the recommendation of the Neurology Service for
her stroke as well as for her history of multiple
postoperative episodes of atrial fibrillation.
The following day, [**2119-11-30**], the patient continued to
remain stable hemodynamically. Remained in normal sinus
rhythm. White blood cell counts were slowly coming down to
16.9 thousand and all subsequent cultures came back positive.
She continued to have some sternal drainage with moderate
amounts of erythema around the drainage area and just
superior to the top of her sternal wound incision.
Over the next 48 hours, the patient remained stable. Her
white blood cell count has been slowly decreasing. She
remains alert and oriented. Her diarrhea has subsided. Her
IV Heparin drip for anticoagulation was discontinued because
her INR had become therapeutic with Coumadin dosing, and she
remains stable today on [**2119-12-4**] and is ready to be
discharged to rehabilitation facility to continue with
physical therapy and increasing mobility.
Patient's status today on [**2119-12-4**] is as follows:
temperature 99.4. Patient is in normal sinus rhythm at
82/minute, her blood pressure is 110/54, her oxygen
saturation on a 2 liter per minute nasal cannula is 96% with
a respiratory rate of 23/minute.
Most laboratory values are from today, [**12-4**] which
revealed a white blood cell count of 13.0 thousand,
hematocrit of 32.3, platelet count of 480. PT of 20.6, INR
of 2.8. Sodium of 143, potassium 3.9, chloride of 106, CO2
20, BUN 14, creatinine 0.7, glucose 99.
Physical examination: Neurologically, the patient is awake,
alert, and interactive with some left arm weakness.
Cardiovascularly, patient remains in normal sinus rhythm,
regular S1, S2 with no murmur noted. Her respiratory
examination is stable. Her lungs are clear to auscultation
bilaterally. Her sternum is stable with a small amount of
serous drainage at the top area of her wound. Erythema is
significantly decreasing on the Vancomycin and levofloxacin.
Patient remains on a cardiac diet with aspiration
precautions.
The patient is scheduled to have a PICC line placed today in
the Interventional Radiology Department so that she may
continue to receive her Vancomycin for another five days.
Most recent Vancomycin levels revealed a trough of 6.8 and a
peak of 18.1. Most recent Dilantin level is 8.6 on [**2119-11-29**].
DISCHARGE MEDICATIONS: Amiodarone 400 mg po q day, Dilantin
300 mg po bid, metoprolol 75 mg po bid, aspirin 81 mg po q
day, cholestyramine 4 grams po q day, psyllium one packet po
q day, pantoprazole 40 mg po q day, acetaminophen 650 mg po
q4h prn, miconazole powder 2% topically qid prn, Vancomycin 1
gram IV q12 hours x5 more days. Her last dose should be on
[**2119-12-10**] morning dose. Levofloxacin 500 mg po q day
x5 more days, also to end on [**2119-12-10**]. Patient is
on a sliding scale of regular insulin coverage for a glucose
of 150-200 she should receive 3 units subQ, blood glucose of
200-250 6 units subQ, and a glucose of 250-300 9 units subQ.
The patient is also on daily Coumadin. She received 1 mg on
[**Month (only) **] and 1 mg on [**12-4**]. Her INR should be between
2 and 2.5 as a goal for her stroke as well as atrial
fibrillation. The recommendation of the Neurology Service,
is to continue anticoagulation for at least 6-8 weeks.
The patient is to followup with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] at area
code ([**Telephone/Fax (1) 1504**] upon discharge from rehabilitation
facility. Please contact our service at that number for any
surgical-related questions for Mrs. [**Known lastname **]. The patient is
also to followup with her primary care cardiologist, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in [**Hospital1 1474**], [**State 350**] at telephone number
([**Telephone/Fax (1) 16005**]. She should follow up with him regarding
continued amiodarone dosing and also for anticoagulation
followup.
She is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], attending
neurologist here upon discharge from rehabilitation facility
and her telephone number is ([**Telephone/Fax (1) 15319**].
Discharge diagnosis is aortic stenosis status post aortic
valve replacement, postoperative atrial fibrillation,
cerebrovascular accident with seizure activity, pleural
effusion, urinary tract infection.
DISCHARGE STATUS: Stable.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2119-12-4**] 15:42
T: [**2119-12-4**] 16:12
JOB#: [**Job Number 45069**]
ICD9 Codes: 4241, 5119, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2929
} | Medical Text: Admission Date: [**2200-10-4**] Discharge Date: [**2200-10-17**]
Date of Birth: [**2149-11-20**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Zyprexa
Attending:[**First Name3 (LF) 12657**]
Chief Complaint:
Supraglottic hematoma
Major Surgical or Invasive Procedure:
Tracheostomy
History of Present Illness:
patient with a history of schizoaffective d/o, found down after
falling in bathroom and striking his neck on the bathtub
(secondary to EtOH intoxication). Presented to ER complaining of
hoarseness of voice and difficulty breathing since the incident.
Past Medical History:
HTN, seizure, gout, chronic back pain
Social History:
Positive for smoking, alcohol use.
Family History:
non-contributory
Physical Exam:
Gen: awake, alert, interactive. Hoarse voice quality
HEENT: OP clear, no external neck swelling, hematoma. no
stridor, no retractions. Neck tender but no crepitus over
cricoid or laryngeal cartilages.
FOE: Positive for ecchymosis of L supraglottic larynx. Airway
patent.
CV: RRR
Pulm: CTAB
Pertinent Results:
[**2200-10-4**] 11:00PM GLUCOSE-91 UREA N-17 CREAT-1.2 SODIUM-134
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-21* ANION GAP-18
[**2200-10-4**] 11:00PM WBC-7.6 RBC-4.62 HGB-14.3 HCT-41.8 MCV-91
MCH-31.1 MCHC-34.3 RDW-13.7
[**2200-10-4**] 11:00PM NEUTS-68.7 LYMPHS-26.4 MONOS-4.1 EOS-0.6
BASOS-0.2
[**2200-10-4**] 11:00PM PLT COUNT-352
[**10-7**]: PORTABLE UPRIGHT CHEST: No prior studies for comparison.
Endotracheal tube
tip is at the level of the superior margin of the clavicles, 6.5
cm above the
carina. Cuff balloon is not overinflated. NG tube is in place
with its tip
in the fundus of the stomach. There is a prominent left
retrocardiac opacity
and a equivocal right medial basilar opacity. No pneumothorax or
pleural
effusion. No congestive heart failure.
IMPRESSION:
1) ETT tip at the thoracic inlet and NG tube tip in the gastric
fundus.
2) Medial bibasilar opacities, which may relate to atelectasis,
aspiration,
and/or pneumonia.
Brief Hospital Course:
patient admitted on [**10-4**]. Transferred to ICU for monitoring of
respiratory status. Patient intubated for airway protection. On
[**10-8**] patient underwent tracheostomy under general antesthesia (#7
portex). Patient transferred from surgery to regular floor.
Patient's respiratory status was followed closely. Tracheostomy
was changed on POD 5. On [**10-15**] patient's trach was downsized to
#6 portex. Patient was d/c'd to acute rehabe on [**10-17**].
Medications on Admission:
zyprexa, trazodone, depakote, seroquel, clonazepam
Discharge Medications:
1. Benztropine 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
Disp:*100 Tablet(s)* Refills:*0*
3. Perphenazine 8 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
5. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Laryngeal hematoma
Discharge Condition:
Stable
Discharge Instructions:
please call if you develop fever >101.5, bleeding, swelling,
shortness of breath, chest pain or if you have any other
concerns.
Followup Instructions:
Dr. [**Last Name (STitle) 3878**] [**Telephone/Fax (1) 7767**] in [**3-7**] weeks
Completed by:[**2200-10-17**]
ICD9 Codes: 5185, 4019, 2749, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2930
} | Medical Text: Admission Date: [**2161-7-26**] Discharge Date: [**2161-8-11**]
Date of Birth: [**2092-3-26**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 20506**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Mechanical Ventilation
Central Line
Pheresis Line
History of Present Illness:
Mr. [**Known lastname 112140**] is a 69 year old man with atrial fibrillation,
diabetes, and hypertension who presents with confusion and
respiratory failure. He was admitted yesterday to an OSH with
the new onset of shortness of breath. He was given a diagnosis
of CHF and discharged today. He went home and suddenly had the
onset of acute shortness of breath with diaphoresis. He
represented to the same hospital. He was noted to be pale, cool,
diaphoretic, and hypertensive. He was placed on BIPAP. He was
noted to have ST depressions in V3-6 on EKG. He had a chest xray
which showed fluid overload. He was given aspirin 325mg, ativan
2mg IV, dilt 10mg/hr, and nitro paste prior to transfer. Of
note, he has a recent history of right 3rd nerve palsy. He was
supposed to have an MRI with neuro on Monday.
In the ED he was severely obtunded and minimally responsive to
painful stimuli. He was also hypertensive to the low 200's. He
was immediately intubated. He was given cefepime and
levofloxacin to cover for urinary/pulmonary pathogens. A CT head
was obtained given a reported history of a headache and being on
anticoagulation. It did not show any acute processes. In the ED
neurology was consulted given concern for possible brainstem
stroke vs hypertensive encephalopathy.
They recommended covering with empiric meningitis coverage with
vancomycin, ceftriaxone, ampicillin, and acyclovir. He
reportedly had a headache. They would like an LP, but it is
being deferred given the INR of 2.6. They also wanted an MRI and
MRA head/neck as an aneurysm could cause a partial 3rd nerve
palsy. They have a low threshold for continuous EEG if mental
status does not improve.
His labs were significant for a WBC of 19.8, potassium of 6.8,
creatinine of 1.1. He received insulin and glucose with eventual
lowering of potassium to 4. During the ED stay Mr. [**Known lastname 112140**] became
hypotensive in the setting of propofol use. He was switched to
fentanyl and midazolam, but remained severely hypotensive.
Levophed was started. A FAST exam was performed which was
negative. A bedside echo showed very poor squeeze and possible
small pericardial effusion. Cardiology was consulted to do an
emergent echo. This revealed an EF of 40% without any
significant effusion. A central line was placed in the R IJ. A
CTA was then done to look for aortic dissection. This showed a
bilateral pneumonia.
Pt's potassium elevated, given insulin/D50, calcium gluconate.
Vitals on transfer were 84 108/62 on 0.03 of levo. He received
all of the ordered antibiotics.
On arrival to the MICU,
Review of systems:
Unable to obtain.
Past Medical History:
Afib (on coumadin) recently diagnosed in the past 2 weeks
Hypertension
Hyperlipidemia
Partial 3rd nerve palsy
Diabetes mellitus type II (metformin, lifestyle)
s/p MVA decades ago with resultant injury to his left eye
requiring
surgery
CHF
Social History:
He is retired and lives with his wife. [**Name (NI) **] is independent of
ADLs.
Family History:
Unable to obtain
Physical Exam:
General: Well appearing
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neuro Exam:
Normal mental status.
CNs: Ptosis L > R. Improved eye movments with virtually full
extraocular movements. Diplopia on left lateral gaze. Neck
flexors [**5-21**] and extensors 5-/5
Motor exam notable for deltoid weakness 4+/5 bilaterally with
fatiguability.
Normal sensation
No dysmetria on finger to nose.
Gait is slow and steady without ataxia.
Pertinent Results:
[**2161-7-26**] 04:48PM PT-21.6* INR(PT)-2.1*
[**2161-7-26**] 02:54PM PT-24.4* INR(PT)-2.3*
[**2161-7-26**] 02:52PM TYPE-[**Last Name (un) **] TEMP-38.1
[**2161-7-26**] 02:52PM O2 SAT-76
[**2161-7-26**] 02:51PM WBC-10.2 RBC-4.12* HGB-12.7* HCT-36.8* MCV-89
MCH-30.8 MCHC-34.5 RDW-13.7
[**2161-7-26**] 02:51PM PLT COUNT-118*
[**2161-7-26**] 02:17PM TYPE-ART TEMP-36.8 RATES-20/ TIDAL VOL-500
PEEP-5 O2-50 PO2-86 PCO2-38 PH-7.51* TOTAL CO2-31* BASE XS-6
INTUBATED-INTUBATED
[**2161-7-26**] 05:50AM TYPE-ART TEMP-37.2 RATES-20/ TIDAL VOL-500
PEEP-5 O2-70 PO2-107* PCO2-40 PH-7.49* TOTAL CO2-31* BASE XS-6
-ASSIST/CON INTUBATED-INTUBATED
[**2161-7-26**] 05:50AM LACTATE-1.9
[**2161-7-26**] 05:50AM O2 SAT-98
[**2161-7-26**] 05:04AM GLUCOSE-166* UREA N-25* CREAT-1.1 SODIUM-136
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-32 ANION GAP-13
[**2161-7-26**] 05:04AM CK(CPK)-88
[**2161-7-26**] 05:04AM CK-MB-3 cTropnT-<0.01
[**2161-7-26**] 05:04AM CALCIUM-9.1 PHOSPHATE-1.7* MAGNESIUM-1.9
[**2161-7-26**] 05:04AM WBC-17.2* RBC-4.88 HGB-14.7 HCT-43.6 MCV-89
MCH-30.1 MCHC-33.7 RDW-13.5
[**2161-7-26**] 05:04AM NEUTS-81.2* LYMPHS-14.0* MONOS-4.4 EOS-0.1
BASOS-0.3
[**2161-7-26**] 05:04AM PLT COUNT-175
[**2161-7-26**] 05:04AM PT-31.4* PTT-31.7 INR(PT)-3.0*
[**2161-7-26**] 01:12AM TYPE-ART TEMP-37.2 RATES-22/ TIDAL VOL-500
PEEP-5 O2-100 PO2-191* PCO2-40 PH-7.48* TOTAL CO2-31* BASE XS-6
AADO2-482 REQ O2-82 -ASSIST/CON INTUBATED-INTUBATED
[**2161-7-26**] 01:12AM LACTATE-2.7*
[**2161-7-26**] 12:22AM SODIUM-138 POTASSIUM-4.0 CHLORIDE-97
[**2161-7-25**] 11:21PM PO2-304* PCO2-56* PH-7.34* TOTAL CO2-32* BASE
XS-3 COMMENTS-ABG ADDED
[**2161-7-25**] 11:21PM LACTATE-2.1*
[**2161-7-25**] 11:15PM TYPE-[**Last Name (un) **] PO2-34* PCO2-81* PH-7.24* TOTAL
CO2-36* BASE XS-3
[**2161-7-25**] 10:02PM K+-6.0*
[**2161-7-25**] 09:15PM GLUCOSE-221* LACTATE-1.3 NA+-136 K+-6.4*
CL--88* TCO2-35*
[**2161-7-25**] 09:15PM HGB-18.0 calcHCT-54
[**2161-7-25**] 09:10PM UREA N-23* CREAT-1.1 SODIUM-133
POTASSIUM-6.8* CHLORIDE-92*
[**2161-7-25**] 09:10PM estGFR-Using this
[**2161-7-25**] 09:10PM LIPASE-36
[**2161-7-25**] 09:10PM cTropnT-<0.01
[**2161-7-25**] 09:10PM proBNP-1152*
[**2161-7-25**] 09:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2161-7-25**] 09:10PM URINE HOURS-RANDOM
[**2161-7-25**] 09:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2161-7-25**] 09:10PM WBC-19.8* RBC-5.60 HGB-16.7 HCT-51.6 MCV-92
MCH-29.9 MCHC-32.4 RDW-13.3
[**2161-7-25**] 09:10PM PLT COUNT-177
[**2161-7-25**] 09:10PM PT-26.7* PTT-34.3 INR(PT)-2.6*
[**2161-7-25**] 09:10PM FIBRINOGE-453*
[**2161-7-25**] 09:10PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.038*
[**2161-7-25**] 09:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN->600
GLUCOSE-70 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2161-7-25**] 09:10PM URINE RBC-6* WBC-19* BACTERIA-FEW YEAST-NONE
EPI-<1
[**2161-7-25**] 09:10PM URINE HYALINE-3*
[**2161-7-25**] 09:10PM URINE MUCOUS-FEW
MRI Brain: Normal
MRI Spine: IMPRESSION:
1. Mild degenerative changes in the cervical and lumbar spine
as described above. No evidence of epidural abscess.
2. Bilateral pleural effusions.
3. Multiple T2 hyperintense lesions arising from bilateral
kidneys, likely represent renal cysts, may be non emergently
evaluated by an ultrasound study.
INR: 1.7 on [**2161-8-11**]
Brief Hospital Course:
Mr. [**Known lastname 112140**] is a 69 year old man with diabetes, hypertension,
atrial fibrillation, and new 3rd nerve palsy who presented with
hypotension, respiratory failure, and altered mental status.
Ultimately found to have positive Tensilon test and
fatigueabilty with prolonged upgaze, and positive antibodies,
indicating diagnosis of myasthenia [**Last Name (un) 2902**].
ICU and hospital course as follows:
Neuro - Myasthenia [**Last Name (un) 2902**]: New diagonosis made and etiology of
patient's respiratory failure. Had a positive tensilon test and
fatiguability of muscles. Found to have positive antibody test.
Had placement of pheresis line and 5 sessions of plasmapheresis
with subsequent improvement. Was placed on Mestinon and an up
titration of PO steroids. On discharge the patient is doing well
with medication plan as follows:
PLAN:
1. Mestinon 60 mg q6
2. Prednisone 40 mg daily, increase to 50 mg on [**8-15**], increase
to 60 mg on [**8-20**]. Continue 60 mg daily until told otherwise by
your Neurologist.
-- Please follow blood glucose until stable on steroid regiment.
-- On Bactrim for prophylaxis while on steroids.
Resp - Respiratory Failure and Pneumonia: Patient was
hypotensive/requiring pressors on admission. Treated for a
pneumonia. Covered with vancomycin, cefepime initially. Initial
concern for meningitis, so treated with ampicillin and
acyclovir. LP unremarkable. Initially required intubation for
inability to protect airways. He was treated with antibiotics
and extubated. Within 30 minutes of extubation, he needed
reintubation because of poor musle movement and hypoxemia, lack
of cough. This prompted further workup which led to diagnosis of
myasthenia [**Last Name (un) 2902**]. Respiratory status required frequent
monitoring of NIFs and vital capacity.
NIFs and VC improved on the floor intially however, subsequently
began to dip down and perhaps related inpart to the heat -
patient improved with cooling and was stable or improving over
greater than 72 hours prior to discharge. Last NIFs ranging -54
to -60 and VC 2.5 -2.8 L.
PLAN:
-- Please continue twice daily testing of respiratory function.
CV - Systolic Heart Failure: Apparently a new diagnosis from OSH
on admission. Echo performed here with EF 55%. Restarted on home
lasix (held while on presssors) because of volume overload. Did
well through the rest of his hospitalization.
CV - Atrial Fibrillation: Rates well controlled in ICU, but
required uptitration of metoprolol on the floor. Will continue
to need monitoring. His warfarin was held for LP and subsequent
pheresis. It was restarted prior to discharge with last INR: 1.7
on [**2161-8-11**].
PLAN:
-- Continue Metop and Lasix, titrate as needed
-- Coumadin 5 mg daily, please adjust for goal INR of [**3-20**]
Diabetes Mellitus type II: Maintained on insulin sliding scale.
Generally, tolerating steroids well.
PLAN:
-- Please follow blood glucose until stable on steroid regiment.
The patient is being discharged to rehab in good condition. He
has Neurology Follow-up after rehab.
Medications on Admission:
Atenolol
Lisinopril
Coumadin
Discharge Medications:
1. Insulin SC
Sliding Scale
Fingerstick q6
Insulin SC Sliding Scale using HUM Insulin
2. Metoprolol Tartrate 25 mg PO TID
hold for sbp<100 or hr<60
3. Pyridostigmine Bromide 60 mg PO Q6H
4. Warfarin 5 mg PO DAILY
5. PredniSONE 40 mg PO DAILY
increase from 30 to 40 mg daily starting [**8-9**]
6. Furosemide 40 mg PO DAILY
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
8. Famotidine 20 mg PO BID
9. Heparin 5000 UNIT SC TID
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
12. Docusate Sodium (Liquid) 100 mg PO BID
13. Senna 1 TAB PO BID
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
1. Myasthenia [**Last Name (un) **]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro Exam: AOx3 with normal mental status, Persistent ptosis
left > right,
Discharge Instructions:
Mr. [**Known lastname 112140**], you were admitted to [**Hospital1 18**] with weakness and
respiratory distress. You were found to have Myasthenia [**Last Name (un) **]
an autoimmune disease that affects the junction of your nerves
and muscles and causes weakness. You were in the ICU for a
period of time and then transferred to the floor. You were
treated with plasmapheresis that washes away abnormal
antibodies. You did well with improving strength and breathing.
You are being discharged to rehab to continue your recovery.
You should undergo regular physical therapy.
Medication plan:
1. Mestinon 60 mg q6
2. Prednisone 40 mg daily, increase to 50 mg on [**8-15**], increase
to 60 mg on [**8-20**]. Continue 60 mg daily until told otherwise by
your Neurologist.
-- Please follow blood glucose until stable on steroid regiment.
3. Coumadin 5 mg daily, please adjust for goal INR of [**3-20**]. INR:
1.7 on [**2161-8-11**].
Followup Instructions:
You will have follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1206**], Thursday [**9-17**] at 4:30. He is in the Division of Neuromuscular Neurology,
[**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] 8, f:([**Telephone/Fax (1) 112141**], p: ([**Telephone/Fax (1) 21904**]
ICD9 Codes: 0389, 486, 2767, 2875, 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2931
} | Medical Text: Unit No: [**Numeric Identifier 12788**]
Admission Date: [**2122-1-26**]
Discharge Date: [**2122-1-30**]
Date of Birth: [**2063-6-13**]
Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
gentleman, who was status post a fall from [**2121-12-29**], who
sustained severe subdural hematoma, subarachnoid hemorrhage,
and intracranial hemorrhage, managed conservatively, who was
recovered and transferred to rehab, presented today for a
follow-up head CT by Dr. [**Last Name (STitle) **] from [**Hospital3 **] after the
patient had a seizure. The patient found to have increasing
size of subdural hematoma, 2 cm in depth along the left side
with midline shift. The patient was sent directly to the
Emergency Room and admitted to the neurosurgical service.
EXAM: The patient's heart rate is 72, BP 130/40, respiratory
rate 24. In general, an obese gentleman in no acute
distress. CHEST: Clear to auscultation. CARDIOVASCULAR:
Regular rate and rhythm, no murmur, rub or gallop. ABDOMEN:
Soft, nontender. The patient has a PEG. EXTREMITIES: Left
leg is status post a left ankle fracture. MENTAL STATUS:
Awake, alert, globally aphasic, does not speak or follow
commands, appears with a right neglect. CRANIAL NERVES: Has
a right facial droop, EOMs are full, pupils are 2 down to 1
mm bilaterally. He has positive corneals. Positive gag.
MOTOR STRENGTH: He does have a right footdrop with a brace.
He also has a fracture of his left ankle. He is in a
bivalved cast. He moves the left side more vigorously than
the right. Can hold his left arm up to gravity. Right arm
flops down immediately when lifted up. Bends both legs, hips
and knees to noxious stimulation. His reflexes are 3 plus on
the right side in the upper extremities, trace on the left
side in the upper extremities. His patella is a 3 plus. He
does have clonus on the right side, and his lower extremity
reflexes were not tested secondary to the cast on the left
leg. Coordination and gait were not tested.
STUDIES: Head CT shows a left convexity subdural hematoma
with subfalcine herniation.
HOSPITAL COURSE: The patient was admitted to the ICU and had
bedside drainage of a subdural hematoma. He had a repeat
head CT day 1 post drainage which showed good evacuation of
subdural hematoma. The patient's drain was left in place.
The patient showed no evidence of infection. His vital signs
were stable, and he was afebrile. His mental status was
improving. He was awake, alert and oriented, following
commands.
He was transferred to the Stepdown Unit on [**2122-1-28**]. He
was oriented to self, following commands x 4. His drain put
out 14 cc over the last 8 hours. He was improving. The
drain was DC'd on [**2122-1-28**] in the evening, after head CT
showed good evacuation of the subdural.
The patient was seen by physical therapy and occupational
therapy and found to require a short rehab stay. He was also
evaluated by orthopedics for his left ankle fracture, who
felt the patient should just remain in his bivalved cast. He
is only partial weightbearing on that. The patient's
neurologic status remained stable, although he did have
periods of agitation. He was overall improving.
DISCHARGE MEDICATIONS:
1. Lansoprazole 30 mg po once daily.
2. Doxazosin 4 mg po q at bedtime.
3. Lisinopril 40 mg po once daily.
4. Venlafaxine 37.5 mg po tid.
5. Colace 100 mg po bid.
6. Metoprolol 150 mg po tid.
7. Diltiazem 120 po tid.
8. Hydralazine 10 po q 6 h.
9. Lamotrigine 200 mg po once daily.
10. Dilantin 200 mg po bid.
11. Clonidine 0.3 mg po tid.
12. Subcu heparin 5,000 units subcu [**Hospital1 **].
13. Insulin per sliding scale.
14. Bisacodyl 10 mg po/pr q at bedtime prn.
15. Acetaminophen 650 mg po q 4 h prn.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: He will follow-up with Dr. [**Last Name (STitle) 739**] on [**2-26**] with a repeat head CT, and with Dr. [**Last Name (STitle) 1005**] in 3 weeks
from orthopedics.
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2122-1-30**] 11:00:16
T: [**2122-1-30**] 11:49:38
Job#: [**Job Number 12789**]
ICD9 Codes: 5990, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2932
} | Medical Text: Admission Date: [**2192-2-17**] Discharge Date: [**2192-3-6**]
Date of Birth: [**2122-6-18**] Sex: M
Service: MEDICINE ICU
HISTORY OF PRESENT ILLNESS: The patient is a 69 year-old
gentleman with an extensive tobacco history complaining of
fever to 102, productive cough and progressive shortness of
breath for two to three days. The patient also commented on
associated malaise and diarrhea for two episodes. The
patient denied sick contacts, chest pain, did report
receiving the flu vaccine this year and has no history of
prior hospitalizations for chronic obstructive pulmonary
disease flares, pneumonias or any other pulmonary
complications. The patient denies recent travel, lower
extremity trauma, calf pain or any other risk factors for
pulmonary embolus. Review of systems was otherwise negative.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Fast heart rate.
3. Increased cholesterol.
4. Benign prostatic hypertrophy.
5. Status post appendectomy.
6. Emphysema without steroid or inhaler use.
ALLERGIES: Penicillin, which produces a rash.
MEDICATIONS;
1. Toprol 100.
2. Lipitor 10 q.d.
3. Cardura 2 q.d.
SOCIAL HISTORY: Significant for greater then 100 pack years
tobacco history. Occasional ethanol use.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 101.8. Heart
rate 95. Blood pressure 175/76. Respiratory rate 23.
Satting 88% on room air. 97% on 2 liters. In general, alert
and oriented times three, mild distress, shortness of breath
with speech. HEENT pupils are equal, round and reactive to
light. Bilateral injected sclera. Flat JVP. Lungs with
diffuse rhonchi, expiratory wheeze and delayed expiration.
Cardiovascular regular rate and rhythm. S1 and S2 with
distant heart sounds. Abdomen was soft, obese, nontender,
nondistended with normoactive bowel sounds. Extremities were
without clubbing, cyanosis or edema and were warm, dry and
pink.
PERTINENT DIAGNOSTIC STUDIES ON ADMISSION: Normal CBC with
normal differential with white blood cell count. Normal
electrolytes. Blood cultures that were sent remain negative.
Chest x-ray with emphysematous changes without evidence of
acute cardiopulmonary disease. CT angiogram with diffuse
emphysematous changes without evidence of infiltrate,
effusion or pulmonary embolus. Initial electrocardiogram
normal sinus rhythm without evidence of acute ischemic
changes.
HOSPITAL COURSE: 1. Chronic obstructive pulmonary disease
exacerbation: The patient was initially admitted to the
General Medical Service for a presumed chronic obstructive
pulmonary disease exacerbation in the setting of a upper
respiratory infection with negative DFAs for influenza A and
B. Subsequently the patient was transferred to the Intensive
Care Unit and intubated for hypercapnic respiratory failure
and was continually treated with Levofloxacin, steroids and
nebulized Albuterol and Atrovent for this chronic obstructive
pulmonary disease exacerbation with full ventilatory support.
Several days into the Intensive Care Unit course bile
cultures for influenza came back positive. The patient
completed a course of Levofloxacin and was briefly extubated
for two to three days with recurrent respiratory failure,
reintubated and eventually underwent tracheostomy. On the
day of discharge the patient's chest x-ray remained clear.
The patient was afebrile and tolerating recurrent spontaneous
breathing trials on trach mask with intermittent requirement
of pressure support ventilation. Sputum samples sent from
the day of discharge revealed gram positive cocci without
evidence of infiltrate on chest x-ray, evidence of a fever,
stable white blood cell count and improved respiratory
status.
2. Cardiovascular: The patient developed positive
intubation hypotension and intermittently required pressures
for support of his blood pressure throughout his Intensive
Care Unit course. The patient also developed rapid atrial
fibrillation during his Emergency Department course that was
initially treated with Diltiazem. The patient was placed on
Diltiazem drip and required intermittent boluses of Diltiazem
throughout his Intensive Care Unit course. After extubation
the patient was switched to po Metoprolol of which he was
maintained as an outpatient for his known history of
paroxysmal atrial fibrillation and supraventricular
tachycardia. At the time of discharge the patient had been
without pressers for several days and had his heart rate well
controlled on b.i.d. Metoprolol. The patient's outpatient
cardiologist Dr. [**Last Name (STitle) 1147**] was involved in the care of this
patient on a day to day basis and frequently added input to
the care of his supraventricular tachycardia.
3. Gastrointestinal bleed: After intubation and placement
of a nasogastric tube the patient was noted to have evidence
of an upper gastrointestinal bleed. The Gastroenterology
Service was consulted and performed an endoscopy and
discovered events of trauma from the nasogastric tube that
was thought to be the cause of this self limited upper
gastrointestinal bleed while on anticoagulation for the
paroxysmal atrial fibrillation. The patient was without
evidence of gastrointestinal bleed throughout the remainder
of his hospitalization.
4. Hematuria: During the patient's Intensive Care Unit
course the patient developed gross hematuria in the setting
of continuous indwelling Foley catheters. This hematuria was
associated with a brief drop in the patient's hematocrit,
which required 2 units of packed red blood cells for
transfusion. After continuous bladder irrigation the
hematuria resolved and the patient was without such findings
throughout the remainder of his hospital course.
5. Fluid, electrolytes and nutrition: The patient was
maintained on tube feeds throughout his Intensive Care Unit
stay and received a percutaneous feeding tube placement and
was tolerating tube feeds at goal at the time of discharge.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To rehab.
DISCHARGE DIAGNOSES:
1. Respiratory failure.
2. Chronic obstructive pulmonary disease exacerbation.
3. Influenza.
4. Paroxysmal supraventricular tachycardia.
5. Atrial fibrillation.
6. Hematuria.
7. Emphysema.
DISCHARGE MEDICATIONS:
1. Metoprolol.
2. Colace.
3. Bisacodyl.
4. Nicotine patch.
5. Doxazosin.
6. Albuterol.
7. Atrovent
8. Fluticasone
FOLLOW UP PLANS: The patient is to contact Dr. [**Last Name (STitle) 1147**] for
follow up within one to two weeks of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**]
Dictated By:[**Name8 (MD) 28700**]
MEDQUIST36
D: [**2192-3-6**] 12:24
T: [**2192-3-6**] 12:31
JOB#: [**Job Number 97945**]
ICD9 Codes: 4271, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2933
} | Medical Text: Admission Date: [**2137-7-11**] Discharge Date: [**2137-7-16**]
Service: MEDICAL - MICU
HISTORY OF PRESENT ILLNESS: This is an 89-year-old male with
a history of chronic obstructive pulmonary disease and ITP,
who presented to the Emergency Department after a few hour
history of chest and abdominal discomfort, increasing
shortness of breath, and nausea with an episode of vomiting
x1. He notes chest pressure with radiation to the back into
the left arm, severity [**4-20**] and associated epigastric
discomfort with nausea and vomiting x1 in the Emergency
Department. He reports recent sweats and chills, but did not
take his temperature. He reports intermittent chest
discomfort of short duration over the past few days in
addition to a long history of chronic nausea.
In the Emergency Department, he presented febrile with a
temperature of 101.7, tachypneic, and tachycardic, and was
found to have an elevated white blood cell count with
bandemia. The patient was started on Levaquin and Flagyl,
and given 3 liters of normal saline for rehydration to bring
his systolic blood pressure to the mid 90s. Patient was
given albuterol and Atrovent nebulizer treatment for
persistent shortness of breath in addition to IV Solu-Medrol
125 mg IV x1 for suspected chronic obstructive pulmonary
disease exacerbation.
On review of systems, the patient denied diarrhea,
constipation, leg swelling, cough, melena, bloody stool,
dysuria, paroxysmal nocturnal dyspnea.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease, however, patient
does not use home O2 or MDIs.
2. Mild dementia.
3. Lumbar radiculopathy.
4. Gastroesophageal reflux disease.
5. ITP with chronically low platelet count.
6. Anxiety.
7. History of iron deficiency anemia.
8. History of transient ischemic attacks, question
cerebrovascular accident.
9. History of a deep venous thrombosis in [**2133**].
PAST SURGICAL HISTORY:
1. Status post TURP.
2. Status post tonsillectomy.
ALLERGIES:
1. Penicillin produces a rash.
2. Aspirin produces GI irritation.
MEDICATIONS ON ADMISSION:
1. Mylanta one tablet po prn.
2. Prozac 20 mg po q day.
3. MVI one tablet po q day.
4. Lorazepam 0.5 mg po qid prn anxiety.
5. Prilosec 20 mg po q day.
6. Extra Strength Tylenol 1 gram two tablets po q4h prn pain.
SOCIAL HISTORY: Patient is a widower, former vender sales
person, who lives alone in [**Hospital3 **]. He quit smoking
approximately 10 years ago, but has an approximately 70 pack
year history of smoking. Denies alcohol use. His son, [**Name (NI) 1399**]
[**Name (NI) 7514**] is a lawyer, who lives in the area.
PHYSICAL EXAMINATION: This is a pleasant-elderly male in
moderate respiratory distress. Vital signs: Temperature
100.5, blood pressure 99/50, heart rate 126, respiratory rate
42 decreasing to 34 with nebulizer treatment, and O2
saturation 94% on 2 liters. HEENT: Extraocular muscles are
intact. Pupils are equal, round, and reactive to light and
accommodation. Anicteric sclerae. Dry mucosal membranes.
Neck: No lymphadenopathy, no jugular venous distention,
supple. Lungs: Marked and diffuse rhonchi bilaterally
anterior and posterior lung fields, bibasilar rales to 1/3 up
the posterior lung fields. Heart: Tachycardic, regular
rhythm, no murmurs, rubs, or gallops. Abdomen is soft,
nondistended, mild epigastric and right upper quadrant
tenderness to minimal palpation, positive bowel sounds in all
four quadrants, guaiac negative. Extremities: No cyanosis,
clubbing, or edema, positive 1+ dorsalis pedis pulses
bilaterally. No calf pain. Neurologic: Alert and oriented
x2-3, moving all extremities, 5/5 strength in all
extremities. Cranial nerves II through XII intact.
Finger-to-nose within normal limits. Plantar flexes are
downgoing.
LABORATORY DATA ON ADMISSION: White count 17.6 with 65%
neutrophils, 28% bands, 4% lymphocytes, 2% metamyelocytes, 1%
monocytes, and no eosinophils, and no basophils, hematocrit
38.5, platelet count 116. Electrolytes on admission: Sodium
137, potassium 4.0, chloride 101, bicarb 20, BUN 21,
creatinine 1.5, platelet count 262. Calcium 9.3, phosphorus
0.5, magnesium 1.5. Urinalysis: Specific gravity 1.024,
small amounts of blood, 30 protein, 250 glucose, 50 ketones,
red blood cells 0, white blood cells 0-2, bacteria none,
epithelial cells 0-2.
Arterial blood gas on admission: 7.33, 40, 120, 22, and -4.
AST 18, ALT 11, total bilirubin 0.6, alkaline phosphatase 57,
albumin 4.0, lipase 12, amylase 51.
CHEST X-RAY: Left lower lung zone opacity, mild congestive
heart failure.
ELECTROCARDIOGRAM: Heart rate of 126, normal sinus rhythm,
right bundle branch block, T-wave inversion in V1, left axis
deviation noted, no acute ischemic changes, however, no
comparison electrocardiogram was available.
ASSESSMENT AND PLAN: An 89-year-old male with a history of
chronic obstructive pulmonary disease and ITP, who presented
with fever, elevated white count, and evidence of pneumonia
on chest x-ray with suspected sepsis and chronic obstructive
pulmonary disease exacerbation.
HOSPITAL COURSE:
1. Sepsis: Patient's blood pressure responded well to IV
fluid hydration and at no time did the patient require
pressure control using intravenous pressors. He was
initially started on a course of Levaquin, Flagyl, and
ceftriaxone, but was switched to a 14 day course of Levaquin
for treatment of community acquired pneumonia. His white
blood cell count did drop to 11.8 in the setting of continued
use of steroids. He remained afebrile during his admission
with the only episode of fever occurring in the Emergency
Room with a temperature of 101.7.
2. Chronic obstructive pulmonary disease exacerbation: The
patient was started on a course of Solu-Medrol 60 mg IV q6h
for three days, and then was placed on a prednisone taper for
control of ongoing chronic obstructive pulmonary disease
exacerbation. The patient remained intermittently
rhonchorous, did respond to continued albuterol and Atrovent
nebulizer treatments ranging from q4 to q6h, and was also
continued on a salmeterol inhaler [**Hospital1 **].
3. Myocardial infarction: The patient did rule in for a
myocardial infarction by the third set of enzymes for 24
hours after admission. Peaked CKs reached 421, troponin peak
was at 0.19. Cardiology consult was obtained. The etiology
was attributed to demand ischemia in the setting of the
patient having tachycardia with his pneumonia and chronic
obstructive pulmonary disease exacerbation. The patient was
started on aspirin, Lipitor, and beta blocker regimen to
control his heart rate.
Echocardiogram was done and the results are the following:
left ventricular systolic function is mildly depressed with
an ejection fraction of 40-50% secondary to hypokinesis of
the mid apical segments of the inferior and posterior walls,
right ventricular chamber size and free wall motion are
normal. There is mild 1+ aortic regurgitation. There is no
aortic valve stenosis. There is no mitral regurgitation and
no evidence of pericardial effusion. The patient did
experience an episode of [**9-20**] chest pain during the second
day of his hospital stay. Electrocardiogram changes were
noted including depressions in V2 and V3, pain and
electrocardiogram changes did respond to nitroglycerin
treatments, which are also continued on a prn basis. A
stress test was recommended for assessment of his cardiac
function once his active medical issues were resolved.
4. Gastrointestinal: Patient's epigastric discomfort was
attributed to an anginal equivalent as his liver function
tests were within normal limits. The patient was continued
on Mylanta and Prilosec for control of his chronic heartburn
and nausea issues. Also, the patient was given Zofran prn
for control of ongoing nausea.
5. Renal: The patient presented with an increase in his
creatinine to 1.5 which is slightly above his baseline of
1.0. This acute renal failure was suspected to be attributed
to dehydrated state. His FENA was consistent with a prerenal
state, and his creatinine returned to [**Location 213**] limits with IV
fluid hydration.
6. Hematology: The patient has a history of iron deficiency
anemia and thrombocytopenia from ITP. During his hospital
stay, his platelet count remained above 100,000. His
hematocrit was initially decreased on admission at 38.5 from
a baseline of 43.9. His hematocrit did drop during his
hospital stay down to 30.8. This was thought to be secondary
to IV fluid hydration and iatrogenic effects. He did return
to 38.1 on discharge.
7. Neuropsych: The patient has a history of anxiety that had
been controlled in the past with prn Ativan. During the
hospital stay, the patient did become agitated and
disoriented on a few occasions usually at night. The patient
did respond to Ativan prn, Haldol prn, and was started on a
course of Zyprexa q hs for control of his nighttime symptoms
of agitation and anxiety.
CONDITION ON DISCHARGE: Stable. The patient has maintained
adequate O2 saturations on 3 liters nasal cannula for over 24
hours. Patient is alert and oriented times three, and has no
shortness of breath. Patient did have episodes of transient
abdominal discomfort and chest discomfort shortly before
discharge, but had no electrocardiogram changes or other
worrisome symptoms.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Chronic obstructive pulmonary disease exacerbation.
3. Acute myocardial infarction.
4. Hypotension.
DISCHARGE MEDICATIONS:
1. Acetaminophen 325 mg 1-2 tablets q6h prn pain.
2. Docusate sodium 100 mg po bid.
3. Fluoxetine 20 mg po q day.
4. Prilosec 20 mg po q day.
5. Levofloxacin 250 mg po q day for nine days.
6. Maalox 15-30 mL po qid as needed for constipation.
7. Multivitamin one capsule po q day.
8. Olanzapine 5 mg po q hs.
9. Atorvastatin 10 mg one tablet po q day.
10. Salmeterol 1 discus inhaled q12h.
11. Metoprolol 50 mg half tablet po bid.
12. Nitroglycerin 0.3 mg one tablet sublingual po prn chest
pain q5 minutes x3 for chest pain, hold for systolic blood
pressure less than 100, [**Name8 (MD) 138**] M.D. if pain persists.
13. Combivent inhaler 1-2 puffs inhaled q4-6h prn for
shortness of breath.
14. Prednisone taper 40 mg on [**2064-7-16**] mg on [**2054-7-18**] mg on [**7-19**], and 10 mg on [**7-20**].
15. Albuterol nebulizer treatments q4-6h prn shortness of
breath for seven days.
16. Ipratropium nebulizer q4-6h prn shortness of breath for
seven days.
17. Haldol 0.5-2 mg IV q6h as needed for agitation.
18. Enteric coated aspirin 81 mg po q day.
FOLLOW-UP PLANS: Patient was advised to contact Dr.
[**Last Name (STitle) 7790**] regarding this admission, and make an appointment
to see him within the next week to discuss new medications
and his hospital stay. Patient was advised to have stress
test scheduled to assess his cardiac functional status after
resolution of his ongoing medical problems including
pneumonia and chronic obstructive pulmonary disease flare.
The patient was advised to keep his appointments with Dr.
[**Last Name (STitle) 7790**] on [**2137-8-14**] as well as [**2137-8-20**].
Patient was discharged to [**Hospital **] Nursing and Rehab Facility,
and his primary care physician was informed about his
hospital stay, and his discharge location.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 1615**]
MEDQUIST36
D: [**2137-7-22**] 16:53
T: [**2137-7-25**] 08:08
JOB#: [**Job Number 49573**]
ICD9 Codes: 486, 5849, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2934
} | Medical Text: Admission Date: [**2184-10-25**] Discharge Date: [**2184-10-30**]
Date of Birth: [**2110-4-10**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Codeine / Percocet
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
weakness, numbness in legs
Major Surgical or Invasive Procedure:
cardiac catheterization
Vertebral artery stenting
d/c cardioversion
History of Present Illness:
74 y/o vasculopathic diabetic female with htn, PVD s/p multiple
stent PCI most recently [**2184-10-4**] with stenting of ISR of left
subclavian, POBA and brachy of ISR of SVG-PDA, stenting of LMCA,
Stenting of left CIA and EIA. She has since
developed acute bilateral numbness with weakness beginning in
lower extremities and rapidlly progressing up to face. No LOC,
fall. daughter noted slurred speech. lasted several minutes
before resolving, symptoms improved on sitting. had mild nausea
folowing episodes. no tonic-clinic, post-ictal confusion,
dizziness/vertigo, visual changes, aura, chest pain, SOB,
paliptations. Has had prior episodes in past but only inolved
lower extremities below hips occuring after walking apporx 200
feet.
She presented to [**Hospital3 **] who r/o MI by enzymes and EKG, CT
negative for hemorrhage, carotid u/s. no mra/mri since had [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] PCI <1 month ago. She is referred to [**Hospital1 18**] for angiogram.
Past Medical History:
CAD s/p CABG LIMA-LAD, SVG-RCA, SVG-Cx s/p multiple stent PCI
PVD s/p
DM-2
HTN
dyslipidemia
Pertinent Results:
ETT:
5.5 min [**Doctor Last Name 4001**] protocol terminated for fatigue. No symptoms,
EKG ischemic changes, max HR 46%.
Angiogram:
1. Three vessel coronary artery disease.
2. Patent LIMA-LAD.
3. Patent SVG-PDA.
4. Patent left subclavian artery.
5. Severe bilateral ostial vertebral disease.
6. 90% stenosis of left and right vertebral artery. Successful
stenting of left vertebral artery at origin c/b perforation
requiring covered stent placement.
CT neck:
Stents within the left vertebral, subclavian, and carotid
arteries. There is a small amount of contrast extravasation
between the left common carotid and vertebral arteries near
their origins, however, there is a moderate amount of hemorrhage
into the superior mediastinum that tracks into the
retropharyngeal space. There is hematoma further cephalad in the
left neck anteromedial to the carotid artery.
CT head:
No acute intracranial hemorrhage or territorial infarction.
L-spine:
Scoliosis and degenerative disc disease without fracture or
destructive leson. Extensive vascular calcifications and
bilateral iliac artery stents.
Hip, bilateral
Scoliosis and degenerative disc disease without fracture or
destructive leson. Extensive vascular calcifications and
bilateral iliac artery stents.
Laboratory on Discharge:
Hct 32.9 stable x24 hrs.
plt 199
Cr 0.8, BUN 28
K 4.2
Brief Hospital Course:
74 y/o vasculopath s/p mulitple stent procedures now with
bilateral leg weakness, numbness, with presyncope suspiscious
for vertebrobasilar insufficiency. She was admitted for
evaluation and treatment of her symptoms. Exercise treadmill
failed to elicit any symptoms and telemetry showed no evidence
of arrythmia associated with her symptoms. She had a single
episode following ambulation on the floor without any findings
on neuro exam. She underwent catheterization which demonstrated
bilateral vertebral artery stenosis 90% with very poor flow
through the right artery. Her left vertebral artery was
successfully stented with good flow into the basilar artery
however the procedure was complicated by a left vertebral artery
perforation. Hemorrhage was controlled with overlapping stents.
Emergent ENT and stroke consult
demonstrated no evidence of airway compromise or acute cerebral
infarct. CT neck confirmed a hematoma extending from the
bifurcation of the left vertebral artery and artery extending
into the retropharyngeal space and down the mediastinum. She
received 3 doses of IV steroids to reduce swelling and
transferred to the CCU overnight for observation. She showed no
evidence of further extension of her hematoma with stable
hematocrit and no respiratory distress. At the time of
discharge she does report intermittent dysphagia, but not worse
since her procedure.
Her hospital course was also complicated by the development of
asymptomatic coarse atrial fibrillation. EP consultation was
made and since she carried no prior diagnosis of atrial
fibrillation in the last 48hrs, she was taken immediately for a
successful external d/c cardioversion into sinus rhythm. Her
rhythm has since fluctuated between a sinus rhythm with frequent
PAC and a wandering pacemaker. Her ventricular rate remained
slow at 40-50's on metoprolol. She was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
of Hearts monitor and instructions to follow up with Dr. [**First Name (STitle) **],
and with EP in one month.
Medications on Admission:
lantus 16unit qPM
humalog SS
asa 325
synthroid 112qd, none sunday
lopressor 50 [**Hospital1 **]
zocor 60 mg qPM
lasix 40mg qd
omeprazole 20mg [**Hospital1 **]
norvasc 5mg tid
diovan 80mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*90 Tablet(s)* Refills:*0*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*90 Tablet(s)* Refills:*6*
3. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
Disp:*90 Tablet(s)* Refills:*2*
5. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Valsartan 80 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*180 Capsule(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
vertebral artery insuficiency s/p stenting of left vertebral
artery c/b perforation
PVD
CAD
HTN
DM
atrial fibrillation
syncope
anemia
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc/daily
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2184-12-14**] 1:00
Provider: [**Name10 (NameIs) 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2185-2-25**] 10:00
[**Hospital **] clinic please call ([**Telephone/Fax (1) 8793**] to set up an appointment
after completing the [**Doctor Last Name **] of hearts monitoring
ICD9 Codes: 2851, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2935
} | Medical Text: Admission Date: [**2196-2-11**] Discharge Date: [**2196-2-19**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Pneumonia, respiratory failure
Major Surgical or Invasive Procedure:
Intubation, mechanical ventilation
History of Present Illness:
[**Age over 90 **]yo Spanish speaking only male with COPD on advair at home, 60
pack year smoking history, and CAD presenting from home on [**2-11**]
with 1 day of "chest congestion," cough, fever, chills, sweats.
Symptoms started with dry cough on evening prior to admission
then subsequently progressed to include shaking chills, fever,
malaise, and progressive SOB. Denies sick contacts with similar
symptoms, recent nausea, comiting, diarrhea, chest pain,
palpitations. Per family, he received flu shot and they are
unsure if he is up to date on pneumovax. He was last
hospitalized 3-4 years ago with similar symptoms at [**Hospital 882**]
Hospital but he had never been intubated.
.
In the ED, initial VS: 100.0 80 140/65 18 89% on RA and 99% NRB.
CXR revealed left lingular PNA. Labs were significant for
lactate 2.1, WBC 11.8 with 90% neutrophils, and Cr 1.7 from
baseline 1.4 in [**2188**]. He received Ceftriaxone, Azithromycin,
levofloxacin, Aspirin 325mg and tylenol. He remained tachypneic
with RR 30s and it was difficult to maintain sats>90-93% even on
NRB. He was thus intubated due to hypoxic respiratory failure
and transferred to the MICU.
Past Medical History:
1. Labeled Asthma/COPD but PFTs normal in [**2188**] (Spirometry [**2188**]
shows FEV1 and vital capacity 1.9 and 2.4 (103 and 83% of
predicted respectively). FEV1/FVC ratio is 124% of predicted.
2. CAD s/p MI [**10**] years ago s/p angioplasty
3. s/p pacer inserted 15 years ago for syncope, followed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] at [**Hospital6 1708**].
4. Diverticulitis
5. Remote history of gout
6. Mild chronic renal insufficiency, baseline Cr 1.4 in [**2188**]
7. h/o elevated PSA
8. h/o urinary retention
9. h/o Aspergillus in sputum but normal IgE and no evidence of
bronchiectasis on chest CT [**2188**]
10. Hyperlipidemia
11. GERD
12. HTN
Social History:
Lives with his wife of 60 years, does all of his own ADLs but
wife does cooking at home. He has three grown children, and is a
retired cafeteria worker. 60 pack year smoking history (1-2ppd
x 40 years), quit 20 years ago. He has no history of significant
asbestos exposure.
Family History:
NC
Physical Exam:
ADMISSION PE:
VS: T 96.8 BP: 132/59 HR: 60 RR: 18 O2sat 92-95%3L
GEN: NAD, bretahing comfortably
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: Soft insipratory crackles at the bases bilaterally.
CV: Distant. RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Sedated, arouses to voice
.
Discharge PE:
O: T 97.5 164/79 66 20 90-95% 3L
I: 600 O : 1650
GEN: NAD, bretahing comfortably
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: bibasilar crackles
CV: Distant. RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
GU: Patient with penile edema, ? foreskin retraction
SKIN: no rashes/no jaundice/no splinters
Pertinent Results:
ADMISSION LABS:
.
[**2196-2-11**] 07:20PM BLOOD WBC-11.8* RBC-4.27* Hgb-13.4* Hct-39.9*
MCV-94 MCH-31.3 MCHC-33.5 RDW-13.5 Plt Ct-178
[**2196-2-11**] 07:20PM BLOOD Neuts-90.7* Lymphs-5.0* Monos-3.5 Eos-0.4
Baso-0.4
[**2196-2-12**] 12:24AM BLOOD PT-16.7* PTT-26.0 INR(PT)-1.5*
[**2196-2-11**] 07:20PM BLOOD Glucose-126* UreaN-31* Creat-1.7* Na-139
K-4.4 Cl-103 HCO3-26 AnGap-14
[**2196-2-12**] 12:24AM BLOOD ALT-55* AST-79* LD(LDH)-277* CK(CPK)-375*
AlkPhos-75 TotBili-0.7
[**2196-2-11**] 07:20PM BLOOD cTropnT-0.03*
[**2196-2-11**] 07:20PM BLOOD Calcium-9.2 Phos-1.7* Mg-2.0
[**2196-2-12**] 12:18AM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5
FiO2-100 pO2-75* pCO2-40 pH-7.33* calTCO2-22 Base XS--4
AADO2-614 REQ O2-98 -ASSIST/CON Intubat-INTUBATED
.
ECHO:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with focal basal
inferolateral akinesis and inferior hypokinesis. The remaining
segments contract normally (LVEF = 45-50%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: No intracardiac shunting seen. Mild regional left
ventricular systolic dysfunction, c/w CAD. Mild mitral
regurgitation. Moderate functional tricuspid regurgitation. Mild
pulmonary hypertension.
.
[**2196-2-15**] EKG:
Sinus rhythm with a ventricular premature beat. Modest
inferolateral lead ST-T wave changes are non-specific. Since the
previous tracing of [**2196-2-11**] ventricular ectopy is present.
Otherwise, no significant change
.
Imaging:
.
[**2196-2-16**] CXR:
Mild pulmonary edema is still present. Increase in the extent of
residual consolidation in the left lower lobe could reflect
changes in fluid balance, but should be followed carefully to
exclude recurrent infection. Heart size is normal. There is no
appreciable pneumothorax or pleural effusion.
.
CXR [**2-15**]
Pacemaker leads terminate in right atrium and right ventricle.
Cardiomediastinal silhouette is stable. Interval improvement in
interstitial pulmonary edema is seen which is currently mild.
Small bilateral pleural effusions cannot be excluded but no
appreciable amount of pleural effusion is demonstrated on the
current study. No focal consolidations to suggest infectious
process are seen.
.
CXR [**2-13**]
The relatively symmetric distribution of opacification with a
basal
predominance favors pulmonary edema rather than pneumonia,
unchanged since [**2-12**], worsened since [**2-11**]. Small
right pleural effusion is presumed. Heart is normal size. No
pneumothorax. Transvenous right atrial and right ventricular
pacer leads are unchanged in their standard positions,
continuous from the right pectoral pacemaker.
.
CXR [**2-11**]:
Lingular pneumonia. Recommend followup radiographs to document
resolution.
.
CXR [**2-12**]:
Mild-to-moderate pulmonary edema has worsened, lung volumes are
lower. Bibasilar consolidation is hard to assess but has not
worsened. Small right pleural effusion has developed. ET tube in
standard placement. Nasogastric tube ends in the region of the
pylorus. Transvenous right atrial and right ventricular pacer
leads in standard placements.
Brief Hospital Course:
[**Age over 90 **]yo Spanish speaking only male with 60 pack year smoking
history, CAD, presenting with respiratory distess, intubated for
respiratory failure, sputum culturs positive for stre pneumo,
indicating pneumococcal pneumonia.
.
# Pneumonia/Respiratory failure: In the MICU, patient received 2
L NS for hypotension. He was initially started on tamiflu due
to deterioration and comorbidities; however, this was
discontinued when rapid flu returned negative. Patient was
extubated successfully on [**2-12**]. Earlier on [**2-13**], sputum cultures
returned + for strep pneumo, thus antibitoics were narrowed to
ceftriaxone only. Patient was then treansferred to the floor,
bretahing comfortably on 3L, vitals HR 64, 121/59 92-95% 3L,
c/o mild SOB and cough. He completed an 8 day course of IV
ceftriaxone.
.
#. Pulmonary edema: In the setting of recieving several liters
of NS and with a mildly depressed EF, CXR showed pulmonary
edema. He recieved 2 x 20 mg IV lasix, and put out well with
improvement in oxygenation. Team was concerned for an
intracardiac shunt, so patient got an echo with a bubble study,
which showed no intracardiac shunting, mild regional left
ventricular systolic dysfunction c/w CAD, moderate functional
tricuspid regurgitation. Initially, patient was doing well on
transer to the floor and was weaned to 2L NC, but developed
respiratory distress with O2 sat 88% on 2L NC and tachypnea to
30s. He was placed on NRB. His CXR was consistent with possible
pulmonary edema and he received 20 mg IV lasix. Patient
transferred back to MICU. In the ICU, his breathing improved and
he was started on lasix 40 mg PO daily. He diuresed severaol
liters over the next several days upon transfer back to the
floor and his respiratory status returned to [**Location 14917**]. He was
discharged on 20 mg PO lasix.
.
#. ?COPD ?????? Patient had PFTs which did not show an obstructive
pattern in [**2188**]; however, pulmonolgy felt that he would benefit
from inhaled corticosteroids. He was dsicharged on his home
advair, and with home oxygen with pulmonary follow-up as an
outpatient.
.
#. Aspiration: Patient was evaluated for aspiration and had a
video swallow evaluation. It was determined that he is at
extremely high risk for aspiration. After discussion with the
family, it was decided to assume this risk and have the patient
eat whatever he pleases.
.
#. CAD/HTN: on ASA, beta blocker, CCB, nitro patch and lipitor.
Amlodipine 5 mg once a day was started for better blood pressure
control.
.
#. CKD: Baseline Cr 1.3-1.4, 1.3 on discharge.
.
#. BPH; h/o urinary retention: Continued on finasteride.
.
#. GERD: H2 blocker
.
#. Hyperlipidemia: Continue statin.
Medications on Admission:
Lipitor
Metoprolol tartrate
Diltiazem
Ibuprofen
Proventil
Advair
Nitropatch
Ranitidine
Calcium plus Vitamin D
Senna
Finasteride
Aspirin 81mg
Discharge Medications:
1. Oxygen
3L continuous, pulse dose for portability
Dx: COPD
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Proventil HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
8. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO once a day.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
12. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
Please check Chem7 (Na, K+, Cl, HCO3, Cr, BUN, Glucose) on
Monday [**2-22**] and phone in the results to [**Telephone/Fax (1) 14918**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pneumonia
Congestive Heart Failure
Secondary: Questionable history of COPD/Asthma
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for pneumonia. Because you had
extreme difficulty breathing while in the emergency room, you
had a breathing tube placed to help. You were able to be taken
off of the breathing tube after several days without difficulty.
Your pneumonia was treated with 8 days worth of antibitoics and
had resolved by the time of your discharge. Your cough and
breathing should continue to improve over the next 4 weeks.
.
While in the hospital, you also had excess fluid in your lungs
called pulmonary edema. This is secondary to your heart
disease. In order to help take some of the excess fluid off, we
started you on a pill called lasix. Because of this condition,
you should weigh yourself every day and call your doctor if your
weight increases more than 3 pounds.
.
We also started a new medication called amlodipine to help
better control your blood pressure.
.
Please see your primary care physician within the next week for
follow-up as [**Hospital 4030**] below. Please bring this sheet and the
list of your discharge medications to this appointment and go
over them with your doctor.
.
We have also made an appointment for you to see the lung doctors
as [**Name5 (PTitle) 4030**] below. They will help to manage your lung disease.
.
We made the following changes to your medications:
ADDED Lasix 20 mg by mouth once a day
ADDED Amlodipine 5 mg by mouth once a day
STOPPED Ibuprofen
Followup Instructions:
Name: [**Last Name (LF) 14919**],[**First Name3 (LF) **] E.
Address: [**Apartment Address(1) 14920**], [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 14918**]
**Your PCP has [**Name Initial (PRE) **] walk in clinic for patients. Please go between
the hours of [**8-11**](Monday-Friday). You should see your PCP [**Name Initial (PRE) 176**]
1 week of discharge from the hospital.**
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2196-3-3**] at 12:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2196-3-3**] at 12:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5849, 4280, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2936
} | Medical Text: Unit No: [**Numeric Identifier 65199**]
Admission Date: [**2162-1-19**]
Discharge Date: [**2162-1-21**]
Date of Birth: [**2162-1-19**]
Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname 33754**] is a 2.35 kg product of a 38 week
gestation born to a 40-year-old primiparous mother. Pregnancy
notable for insulin dependent diabetes requiring insulin
treatment during pregnancy. Fetal screens complete and
unremarkable. GBS unknown. No substance risk factors noted.
Delivery via C-section and same for fibroids. Apgars were 7
and 9. Infant was brought to the newborn intensive care unit
after an initial D-stick in the 20s unresponsive to PO feeds.
PHYSICAL EXAMINATION: Birth weight 2.350 kg, length 47 cm,
head circumference 31.5 cm. Pink, active, non-dysmorphic
infant, well saturated and perfused in room air. Head, eyes,
nose, throat within normal limits. Skin without lesions.
Cardiovascular: Normal S1 and S2. No murmurs. Abdomen benign.
Genitalia normal female. Neuro: Nonfocal and age appropriate.
Spine intact. Hips normal.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Infant
has been stable in room air throughout hospital course.
CARDIOVASCULAR: No issues.
FLUIDS, ELECTROLYTES AND NUTRITION: Initial D-stick was 26,
unresponsive to enteral feedings. Infant was started on D10W
with background of 80 cc per kg per day which has been weaned
over the last 48 hours. The infant is currently ad lib
feeding and secure 24 calorie every 3 hours taking in
adequate amounts with dextrose sticks consistently greater
than 60.
HEMATOLOGY: Hematocrit on admission was 58.1. She has not
required any blood transfusions. CBC and blood culture
obtained on admission. CBC was benign and blood cultures
remained negative.
NEUROLOGIC: Infant has been appropriate for gestational age.
SENSORY: Hearing screen will be performed in the nursery prior to
diacharge to home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To newborn nursery.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 38807**] in [**Hospital1 3597**],
[**State 350**].
FEEDS AT DISCHARGE: Continue ad lib feeding EnfaCare 24
calorie.
MEDICATIONS: Not applicable.
CAR SEAT POSITION SCREEN: Not applicable.
THE STATE NEWBORN SCREEN: The State Newborn Screens have
been sent per protocol and have been within normal limits.
IMMUNIZATIONS RECEIVED: The patient is yet to receive any
immunizations.
DISCHARGE DIAGNOSES:
1. Term infant, SGA.
2. Infant of a diabetic mother.
3. Hypoglycemia.
4. Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2162-1-21**] 20:11:49
T: [**2162-1-22**] 00:48:19
Job#: [**Job Number 65200**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2937
} | Medical Text: Admission Date: [**2188-5-24**] Discharge Date: [**2188-6-5**]
Date of Birth: [**2155-12-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
pheresis
renal biopsy
History of Present Illness:
This is a 32 year old male who was recently discharged from
[**Hospital1 18**] and presents again to us with chief complaint of abdominal
pain (sudden onset left-sided abdominal pain). Of note, he had a
recent kidney biopsy on [**2188-5-19**] and his Cr bumped from 4.7 to
5.7. Also, HCT on admission 21 from 25.
Past Medical History:
ESRD on HD (M,W,F) ([**1-18**] glomerulonephritis)
HTN
Hypercholesterolemia
*
PSH:
AVF - R radial-cephalic
AVF - L aneurysm resection
Tunneled L subclavian catheter
Social History:
denies tobacco, ETOH, drugs
Family History:
sister who is 26 also has ESRD on HD (?etiology)
Physical Exam:
VS: Afebrile, HR: 70-80, 99/70
Lungs: CTA bilaterally
CV: RRR
Abd: Non-distended, tender to palpation LLQ
Pertinent Results:
ADMISSION LABS --> [**2188-5-24**]
WBC-6.8 RBC-2.50* Hgb-6.8* Hct-21.2* MCV-85 MCH-27.2 MCHC-32.1
RDW-18.0* Plt Ct-149*
PT-11.9 PTT-31.1 INR(PT)-1.0 Fibrinogen-148*
Glucose-144* UreaN-52* Creat-5.7* Na-138 K-4.1 Cl-107 HCO3-17*
AnGap-18
[**2188-5-24**] 06:09PM BLOOD Calcium-8.3* Phos-5.0* Mg-2.2
Discharge Labs: [**2188-6-5**]
WBC-5.7 RBC-3.10* Hgb-8.9* Hct-26.2* MCV-85 MCH-28.7 MCHC-33.9
RDW-15.4 Plt Ct-186
PT-11.5 PTT-25.6 INR(PT)-1.0 Fibrinogen-443*
Glucose-104 UreaN-60* Creat-4.8* Na-139 K-4.3 Cl-105 HCO3-26
AnGap-12
Calcium-8.8 Phos-5.0* Mg-2.2
.
DISCHARGE LABS --->
[**2188-6-5**] 05:47AM BLOOD WBC-5.7 RBC-3.10* Hgb-8.9* Hct-26.2*
MCV-85 MCH-28.7 MCHC-33.9 RDW-15.4 Plt Ct-186
[**2188-6-5**] 05:47AM BLOOD Plt Ct-186
[**2188-6-5**] 05:47AM BLOOD PT-11.5 PTT-25.6 INR(PT)-1.0
[**2188-6-5**] 05:47AM BLOOD Fibrino-443*
[**2188-6-5**] 05:47AM BLOOD Glucose-104 UreaN-60* Creat-4.8* Na-139
K-4.3 Cl-105 HCO3-26 AnGap-12
[**2188-6-5**] 05:47AM BLOOD Calcium-8.8 Phos-5.0* Mg-2.2
Brief Hospital Course:
This patient was admitted on [**5-24**] after a recent discharge from
the hospital for sudden onset of left sided abdominal pain. In
the emergency room, his ultrasound showed mild hydronephrosis
with new perinephric fluid surrounding the transplant kidney and
hence, underwent a CT scan of his abdomen/pelvis which showed a
large left-sided of retroperitoneal hemorrhage extending down to
the level of the renal transplant possibly related to recent
transplant biopsy. Renal transplant medicine and transplant
surgery were made aware and the pt was admitted to transplant
[**Doctor First Name **] and to the ICU. Serial hematocrits and abdominal exams were
performed. He was not taken to the OR. On [**5-26**], he received 2
units of pRBC and underwent plasmaphersis, followed by 10mg of
IVIG. He received another unit pRBC on [**5-27**]. By [**5-27**], it was
thought there was improvement of his labs. In the am of [**5-28**], he
was given 1 unit pRBC for a Hct of 21.8. His Hct was stable on
[**5-29**] at 24.4; he had plasmapheresis on [**5-29**] (followed by 10mg
IVIG). He was transfered to the floor on [**5-29**]. On [**5-30**], his am
Hct was 21.9, hence, he received 1 unit pRBC. On [**5-30**] class I
and II antibody levels were sent. He had plasmapheresis on [**5-31**],
followed by 10mg IVIG. This was repeated on [**6-2**]. Hct remained
stable. On [**6-4**], he went for pheresis/IVIG. No new issues.
LLQ pain has improved over the course of this hospitalization.
He is eating and ambulating w/o difficulties.
Pheresis to continue as an outpatient with supervision of
transplant nephrology on [**6-3**] and [**6-11**]. Prograf was
increased to 12mg [**Hospital1 **] on [**6-5**] for a trough level of 7.1. He was
instructed to have labs drawn on [**6-6**] to check trough level of
prograf as well as cbc, chem 10, coags.
Medications on Admission:
Bactrim, Valcyte, MMF, Prednisone, FK, Nifedipine, Protonix
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours).
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Minoxidil 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
13. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
14. Epogen 40,000 unit/mL Solution Sig: One (1) ml Injection
once a week.
Disp:*8 * Refills:*2*
15. syringes
for epogen q week
1 box
refill:none
16. Tacrolimus 5 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
17. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
18. Outpatient Lab Work
Friday [**6-6**] and Monday [**6-9**] cbc, chem10, pt/ptt/inr and trough
prograf level.
Discharge Disposition:
Home
Discharge Diagnosis:
humoral rejection of renal transplant
perinephric transplant hemorrhage
Discharge Condition:
good
Discharge Instructions:
Please call transplant office [**Telephone/Fax (1) 673**] if fevers, chills,
nausea/vomiting, bleeding, decreased urine output, weight gain
of 3 pounds in a day, abdominal pain or shortness of breath
Pheresis Friday [**6-6**] then Monday [**6-9**]
Labwork every Monday and Thursday per [**Hospital 1326**] clinic: CBC,
Chem 7, Ca, Phos, AST, T Bili, U/A and Trough Prograf level. Fax
results to [**Telephone/Fax (1) 697**]
Followup Instructions:
PHERESIS,BED FIVE PHERESIS ROOMS Date/Time:[**2188-6-6**] 9:15
PHERESIS,BED SIX PHERESIS ROOMS Date/Time:[**2188-6-9**] 2:00
[**Name6 (MD) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2188-6-10**] 9:50
Completed by:[**2188-6-5**]
ICD9 Codes: 2851, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2938
} | Medical Text: Admission Date: [**2103-4-2**] Discharge Date: [**2103-4-11**]
Date of Birth: [**2029-10-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Zinc/Petrolatum,White
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Occasional chest tightness
Major Surgical or Invasive Procedure:
[**2103-4-3**] Replacment of Ascending Aorta and Hemiarch(34mm Gelweave
Graft) and Single Vessel Coronary Artery Bypass Grafting
utilizing the left internal mammary artery to left anterior
descending artery.
History of Present Illness:
Dr. [**Known lastname **] is a 73 year old male who underwent nasal surgery in
[**2102-9-30**] which was complicated by atrial fibrillation,
bradycardia and hypotension. Cardiac evaluation at that time
revealed single vessel coronary artery disease and ascending
aortic aneurysm measuring 6.4 centimeters. Echocardiogram showed
only mild aortic insufficiency and an LVEF of 65%. Based upon
the above, he was referred for cardiac surgical intervention.
Past Medical History:
Ascending Aortic Aneurysm
Coronary Artery Disease
History of Atrial Fibrillation
Elevated Cholesterol
Obesity
Benign Prostatic Hypertropy
Peripheral Neuropathy
Cholelithiasis
Nasal Surgery
Tonsillectomy
Umbilical Hernia Repair
Prior ORIF Right Radial Fracture
Social History:
He is a physician. [**Name10 (NameIs) 78079**], live with his wife. Quit [**Name2 (NI) 78080**]
in [**2058**]. Quit pipe [**2085**]. Admits to one ETOH drink/day.
Family History:
Denies premature coronary artery disease.
Physical Exam:
ADMISSION EXAM:
Vitals: 150/84, 84, 18, 98% RA
General: WDWN elderly male in no acute distress
HEENT: Oropharynx benign, EOMI, slight bilateral ptosis
Neck: Supple, no JVD, no carotid bruits
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, faint systolic ejection murmur
Abdomen: Soft, nontender with normoactive bowel sounds. Obese.
Ext: Warm, no edema
Pulses: decreased distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2103-4-10**] 05:35AM BLOOD WBC-9.8 RBC-3.49* Hgb-10.8* Hct-32.6*
MCV-93 MCH-30.9 MCHC-33.1 RDW-15.8* Plt Ct-412
[**2103-4-11**] 05:30AM BLOOD PT-18.4* INR(PT)-1.7*
[**2103-4-10**] 05:35AM BLOOD PT-17.6* INR(PT)-1.6*
[**2103-4-9**] 05:45AM BLOOD PT-14.8* INR(PT)-1.3*
[**2103-4-8**] 07:25AM BLOOD PT-13.6* PTT-30.5 INR(PT)-1.2*
[**2103-4-10**] 05:35AM BLOOD Glucose-89 UreaN-16 Creat-0.9 Na-140
K-4.2 Cl-101 HCO3-30 AnGap-13
[**2103-4-3**] Intraop TEE:
Pre Bypass: There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is markedly dilated, (6.9 cm in proximal
ascending, 5.6 cm at the distal ascending just prior to the
aortic arch. The aortic arch is moderately dilated. There are
complex (>4mm) atheroma in the aortic arch. The descending
thoracic aorta is moderately dilated and tortuous. There are
complex (>4mm) atheroma in the descending thoracic aorta. There
are three aortic valve leaflets. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The aortic regurgitation jet
is eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
Post Bypass: Patient is a-paced on phenylepherine infusion.
Preserved biventricular function LVEF >55%. Aortic Insufficiency
is now trace to mild. A tube graft is partially visualized above
the sinotubular junction extending into the ascending aorta.
Flow appears laminar in the proximal graft. Remaining aortic
contours intact. Remaining exam is unchanged. All findings
discussed with surgeons at the time of the exam.
[**2103-4-9**] Chest x-ray: A small right apical pneumothorax is
slightly decreased in size with chest tube remaining in place in
the lower right hemithorax. Cardiomediastinal contours are
stable in the postoperative period. Small left pleural effusion
is again demonstrated. A small amount of subcutaneous emphysema
is present in the right chest wall adjacent to the chest tube
insertion site.
CHEST (PA & LAT) [**2103-4-10**] 9:14 AM
CHEST (PA & LAT)
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
73 year old man with
REASON FOR THIS EXAMINATION:
r/o ptx
HISTORY: 73-year-old man status post coronary artery bypass and
ascending aortic replacement.
COMPARISON: [**2103-4-9**].
CHEST PA AND LATERAL: The post-operative appearance of the
cardiac, mediastinal and hilar contours are unchanged. Pulmonary
vasculature is unremarkable. The lungs are clear. The small
right apical pneumothorax is unchanged. Small bilateral pleural
effusions are stable. Right-sided chest tube is again noted.
IMPRESSION: Unchanged small right pneumothorax.
[**2103-4-10**] 05:35AM BLOOD WBC-9.8 RBC-3.49* Hgb-10.8* Hct-32.6*
MCV-93 MCH-30.9 MCHC-33.1 RDW-15.8* Plt Ct-412
[**2103-4-11**] 05:30AM BLOOD PT-18.4* INR(PT)-1.7*
Brief Hospital Course:
Dr. [**Known lastname **] was admitted on [**4-2**]. Preoperative evaluation
was unremarkable and he was cleared for surgery. On [**4-3**],
Dr. [**Last Name (STitle) 1290**] performed replacement of ascending aorta and
hemiarch along with coronary artery bypass grafting surgery. For
surgical details, please see seperate dictated operative note.
Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. Low dose beta
blockade was resumed and diuretics were initiated. He maintained
stable hemodynamics and transferred to the SDU on postoperative
day two. He experienced atrial fibrillation on postoperative day
three and was started on Amiodarone. He successfully converted
back to normal sinus rhythm. Amiodarone was titrated accordingly
and beta blockade was advanced as tolerated. Given his history
atrial fibrillation, he was started on Warfarin. Dr. [**Known lastname **] also
required replacement of a right sided chest tube for a residual
pneumothorax. He was followed closely by serial chest x-rays and
by discharge, his pneumothorax had significantly improved and
his chest tube was discontinued.
Prior to discharge, Dr. [**Last Name (STitle) 1683**] was contact[**Name (NI) **] who agreed to
monitor his PT/INR as an outpatient. Warfarin should be dosed
for a goal INR between 2.0 - 2.5. First blood draw is scheduled
for Friday [**4-13**].
He was eventually cleared for discharge to home on postoperative
day #8.
Medications on Admission:
Metoprolol 25 [**Hospital1 **], Finasteride 5 qd, Lipitor 10 qd, MVI
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed: Take with food.
Disp:*40 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
2 days: Take 5 mg today [**4-11**] and 5 mg [**4-12**];then take as directed
by Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] for INR goal of [**3-3**].5.
Disp:*30 Tablet(s)* Refills:*0*
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Country Home Care and Hospice
Discharge Diagnosis:
Ascending Aortic Aneurysm
Coronary Artery Disease
Postoperative Atrial Fibrillation(History of AF preop)
Elevated Cholesterol
Obesity
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
6)Monitor PT/INR every Monday, Wed and Friday. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**]
will manage Wafarin as an outpatient. INR should be dosed for
goal INR between 2.0 - 3.0. Please call results to Dr.[**Last Name (STitle) 1683**]
[**Telephone/Fax (1) 78081**].First blood draw Friday [**4-13**].
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**5-5**] weeks, call for appt
Dr. [**Last Name (STitle) 1683**] in [**3-4**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**3-4**] weeks, call for appt
Completed by:[**2103-4-11**]
ICD9 Codes: 2762, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2939
} | Medical Text: Admission Date: [**2183-11-13**] Discharge Date: [**2183-11-17**]
Date of Birth: [**2105-3-10**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
hardware failure
Major Surgical or Invasive Procedure:
Revision of thoracic fusion T1-11
History of Present Illness:
78 female who underwent thoracic instrumented fusion [**9-3**] for
lymphoma presents with hardware eroding through skin.
Past Medical History:
Rheumatoid arthritis
Rosacea
Compression Fractures
CHF, EF 30% (cath showed clean arteries
Social History:
lives alone, never married, no children
Family History:
no hx of breast or ovarian CA
Physical Exam:
a and ox3
perrla
ht rrr, nl s1,s2
lungs cta
abd soft nt
neuro: motor full
[**Last Name (un) 36**] intact LT
back: severe kyphosis thoracic with hardware end through skin [**Company 30332**] 8 left
exam upon discharge: neuro intact
Pertinent Results:
[**2183-11-13**] 02:11PM HGB-11.1* calcHCT-33 O2 SAT-99
[**2183-11-13**] 02:11PM GLUCOSE-87 LACTATE-0.9 NA+-140 K+-3.6 CL--109
Brief Hospital Course:
Pt was admitted electively to hospital and taken to OR where
under general anesthesia she underwent revision/extension of
thoracic instrumented fusion. She tolerated this procedure well.
Due to long time prone she remained intubated and transferred to
ICU post op for close monitoring. her LE motor exam post op
showed no focal deficits. She was extubated uneventfully on
POD#1. She was transferred out of the ICU to the floor. her
diet and activity were advanced. She had JP drain that was
monitored and removed on POD#2. She remained on ancef while
waitng for OR cultures though there was no evidence of gross
infection at time of surgery. Her foley was removed. She was
evaluated by PT and felt suitable for rehab.
Medications on Admission:
fosamax
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Hardware failure
Discharge Condition:
neurologically stable
Completed by:[**2183-11-17**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2940
} | Medical Text: Admission Date: [**2179-9-11**] Discharge Date: [**2179-9-21**]
Date of Birth: [**2179-9-11**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 56811**] is a 1,565-gram product of a 31-
[**4-9**]-weeks gestation born to an 18-year-old primiparous
mother, whose pregnancy was notable for marginal previa and
cervical shortening. She was admitted to [**Hospital1 346**] yesterday after transfer from
[**Hospital 1474**] Hospital with vaginal bleeding. She was treated
with betamethasone and monitored. Today she was noted to
have abnormalities of EFM prompting delivery via cesarean
section.
MATERNAL PRENATAL SCREENS: Blood type A positive, antibody
negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, group B Strep status unknown.
Infant did well after cesarean section. Apgar scores were 7
at 1 minute and 8 at 5 minutes of age. She was given blow-by
oxygen and stimulation, and continuous positive airway
pressure in the delivery room for poor inspirations. She was
pink and comfortable. Brought to the newborn ICU after
visiting with the parents.
PHYSICAL EXAMINATION: Weight 1566 grams (50th percentile).
Length 40.5 cm (25th-50th percentile). Head circumference 27
cm (10th-25th percentile). Vital signs: Temperature 97.2,
heart rate 181, respiratory rate 58, and oxygen saturation 98
percent, blood pressure 53/24 with a mean arterial pressure
of 32, and D-stick 71. On exam, infant is pink, active, and
nondysmorphic. Well saturated and perfused. Skin without
lesions. Head, eyes, ears, nose, and throat: Normal.
Heart: Normal S1, S2 without murmurs. Lungs: Crackly
breath sounds bilaterally with fair air entry bilaterally.
Abdomen is benign. Normal preemie female genitalia.
Neurologic is nonfocal and age appropriate.
A chest x-ray shortly after admission to the Newborn
Intensive Care Unit shows mild ground-glass pattern. Normal
cardiothymic silhouette.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
infant was intubated shortly after admission to the Newborn
Intensive Care Unit. She received two doses of Surfactant,
and was weaned off ventilator and to room air by day of life
three. She has remained on room air throughout the
hospitalization. Caffeine citrate was started on day of life
two. She has not had any issues of apnea of prematurity and
caffeine was discontinued on day of life seven ([**9-18**]). She has had no apneic spells to date.
Cardiovascular: Her blood pressure has been stable
throughout her hospitalization. No fluid boluses or pressors
required. There has been a soft intermittent murmur since
day of life four most likely peripheral pulmonic stenosis.
Fluid, electrolytes, and nutrition: IV fluids of D10W were
started at 80 cc/kg/day shortly after admission to the
Newborn Intensive Care Unit via peripheral IV. Enteral feeds
were started on day of life two. She advanced to full volume
feeds of breast milk at 150 cc/kg/day by day of life seven.
Caloric density has been advanced to 26 calories/ounce with
HMF 4 calories/ounce and MCT 2 calories/ounce. Feeds are
given per gavage over two hours due to history of spits. Her
last electrolytes on day of life three were a sodium of 142,
potassium of 3.4, chloride of 111, and a bicarb of 22. Her
weight at time of transfer is 1,490 grams, length 42 cm, head
circumference 27.5 cm.
GI: Peak bilirubin of 7.2 on day of life two. Phototherapy
was started at that time. Phototherapy was discontinued on
day of life five for a bilirubin of 4.9. A rebound bilirubin
of 5.7 on day of life six.
Hematology: No blood products were given during her
hospitalization. Hematocrit on day of life two was 31.4.
Infectious disease: A CBC and blood culture were drawn upon
admission to the Newborn Intensive Care Unit with a white
count of 12,600, hematocrit of 39.7, platelet count of
312,000 with 8 percent polys and 1 percent band. Blood
culture was negative. She was started on ampicillin and
gentamicin upon admission to the Newborn Intensive Care Unit,
and that was discontinued at 48 hours of age with a negative
blood culture.
Neurology: The infant received a head ultrasound on [**9-21**]. Results
Sensory: No hearing screen or eye exams have yet been done.
An eye exam is recommended at three weeks of age.
Psychosocial: Parents are involved. [**Hospital1 190**] Social Work has been involved with the family.
The contact social worker can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Stable on room air. Tolerating full
volume feeds. Temperature stable in air mode isolet.
DISCHARGE DISPOSITION: To [**Hospital 1474**] Hospital via ambulance.
PRIMARY PEDIATRICIAN: Undecided.
CARE RECOMMENDATIONS:
FEEDS AT TIME OF TRANSFER: Breast milk enriched to 26
calories at 140 cc/kg/day given slowly per gavage over two
hours (spits).
MEDICATIONS: Iron sulfate 0.1 cc daily.
Vitamin E 5 units daily.
STATE NEWBORN SCREEN STATUS: Infant's last newborn screen
was sent on [**9-15**]. No abnormal results have been
reported.
IMMUNIZATIONS RECEIVED: None.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the three criteria: 1. Born at less than 32 weeks, 2.
Born between 32 and 35 weeks with two of three of the
following: daycare during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
DISCHARGE DIAGNOSES: Prematurity at 31-5/7 weeks gestation.
Respiratory distress syndrome.
Hyperbilirubinemia.
Rule out sepsis.
Gastroesophageal reflux.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2179-9-21**] 01:36:32
T: [**2179-9-21**] 04:43:05
Job#: [**Job Number 27460**]
ICD9 Codes: 769 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2941
} | Medical Text: Admission Date: [**2193-1-12**] Discharge Date: [**2193-1-14**]
Date of Birth: [**2148-10-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
This is a 44 y.o. female with history of 1 vessel CAD s/p MI and
placement of DES to LAD in [**2186**], insulin dependent DM, and
Polysubstance abuse who presented with 3-4 days of crescendo
chest pain. The patient complained of 2 weeks of SOB with
exertion and talking that worsened over time. Three days prior
to presentation this was accompanied by chest pain that felt
like substernal chest pressure; she took sl nitro on two
occasions to good effect. On the day prior to admission, she
took 3 sl NTG. Then, at 0400 on [**2193-1-12**], she awoke from sleep
with a 10/10 chest pain/pressure that radiated to both arms and
her back. It was accompanied by an inability to move or talk and
lasted 30 minutes. She stood up, went to the bathroom, and then
went back to sleep. She awoke in the later AM, felt [**4-13**] Chest
pressure, arranged a babys[**Name (NI) 1786**] for her child, and asked her
ex-husband to take her to the [**Name (NI) 487**] [**Name (NI) **] (11:15 AM).
.
At [**Hospital1 **], pt presented with ST Elevation in 2,3, aVF, V5 and
V6. received ASA 324, Heparin Drip, Nitro drip, Plavix (600mg),
and 10u Regular insulin (bg 417). Transfered to [**Hospital1 **] with VSL
104/70, HR 76, RR 18.
.
At [**Hospital1 **], patient straight to cath lab. RCA with 95% distal
stenosis, received IC ntg, balloon angioplasty, Endeavour stent
with 2nd Endeavour to repair proximal edge restenosis. 105 ml
Omnipaque given.
.
Cardiac review of systems is notable for presence of:
DOE (walking, talking), chest pain as above.
absence of:
chest pain (at present), paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
.
On other review of systems:
+ occ. nausea, occ. nightsweats (when sugar low), menorrhagia,
calf pain ("charleyhorse") with ambulation, leaning on shopping
cart, numb toes, tingling fingers. All of the other review of
systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: IDDM, Dyslipidemia, Hx of Hypertension
2. CARDIAC HISTORY:
[**2186**] - Lateral NSTEMI; Single vessel disease
- PTCA to D1, Dx w/ Severe Diastolic Dysfunction
- EF 45;Anterior, mid and distal septal, apical akniesis
[**2186**] - Cath: CYPHER stent to mid-LAD, D1 subtotal occlusion
[**2187**] - negative ETT
[**2188**] - Nuclear Stress: ECG changes at 64% HR; mod perfusion
deficit
[**2188**] - Cath: Moderate Single Vessel disease
- Left Sublclavian stenosis with Bare Metal Stent
[**2190**] - Cath: 40% in-stent stenosis of LAD; no RCA disease
- LCX had mild diffuse disease and was also small
-PERCUTANEOUS CORONARY INTERVENTIONS: 4 previous caths
3. OTHER PAST MEDICAL HISTORY:
A. IDDM: a1c 13.3% in [**6-/2191**]
B. Hyperlipidemia
C. Polysubstance Abuse: Heroin (years sober), Cocaine (year
sober), Tobacco
D. Hepatitis C Ab, Negative Viral Load in [**2186**]
E. Obesity.
F. Breast Abcess [**2189**]
G. History of tuberculosis exposure s/p 9 months of tx ([**2173**]'s)
Social History:
-Tobacco history: smoked since age 12, [**2-6**] ppd --> 4 cigs/day x
6months
-ETOH: none
-Illicit drugs: hx of heroin, cocaine (Intranasal)
Lives in basement apartment of in-laws house with 7 year old
son. Trying to achieve rapprochement with seperated husband.
Subsists on $700/month. Not on MassHealth
Family History:
Major FHx of CAD; father with MI at 38, mother, uncle and
brother with CAD/MI. Father died of Esophageal Ca
Physical Exam:
VS: T= 97.1 BP=104/72 HR=70 RR=18 O2 sat= 99 on 2L
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.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**2-9**] crescendo/decrescendo murmur in
LLSB that is slightly better with valsalva and worse with hand
grip, no r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. No
splinters, [**Last Name (un) **] or oslers.
PULSES:
Right: Carotid 2+ Femoral 2+ Radial 2+ Popliteal 1+ DP 2+
Left: Carotid 2+ Femoral 2+ Radial 1+ Popliteal 1+ DP 2+
Pertinent Results:
ADMISSION LABS:
[**2193-1-12**] 03:49PM BLOOD WBC-10.9 RBC-4.22 Hgb-12.2 Hct-37.1
MCV-88 MCH-28.9 MCHC-32.8 RDW-12.8 Plt Ct-271
[**2193-1-12**] 03:49PM BLOOD Neuts-69.6 Lymphs-26.5 Monos-2.4 Eos-1.0
Baso-0.5
[**2193-1-12**] 03:49PM BLOOD Glucose-275* UreaN-11 Creat-0.7 Na-133
K-3.8 Cl-100 HCO3-26 AnGap-11
[**2193-1-12**] 03:49PM BLOOD CK(CPK)-1430*
[**2193-1-13**] 05:32AM BLOOD CK(CPK)-1147*
[**2193-1-12**] 03:49PM BLOOD CK-MB-170* MB Indx-11.9* cTropnT-4.16*
[**2193-1-13**] 05:32AM BLOOD CK-MB-112* MB Indx-9.8* cTropnT-3.38*
[**2193-1-12**] 03:49PM BLOOD Mg-1.7 Cholest-266*
[**2193-1-12**] 03:49PM BLOOD Triglyc-323* HDL-41 CHOL/HD-6.5
LDLcalc-160*
Urine tox positive for methadone, cocaine and benzodiazepines
--------------
DISCHARGE LABS:
--------------
STUDIES:
Cardiac catheterization [**2193-1-13**]:
1. Selective coronary angiography in this right dominant system
demonstrated one vessel disease. The LMCA had no
angiographically apparent disease. The LAD had a patent stent
and no angiographically apparent disease. The Cx had no
angiographically apparent disease. The RCA had a distal 95%
stenosis with TIMI 2 flow into the more distal branches.
2. Limited resting hemodynamics revealed an elevated left sided
filling pressure of 30 mmHg (LVEDP). The central aortic pressure
was 97/58 mmHg. There was no transaortic gradient on pullback
from the LV to the aorta.
3. Left ventriculography revealed a calculated LVEF of 34%.
There was hypokinesis of the posterobasal, inferior, apical and
anterolateral walls.
Qualitative wall motion:
1. Antero basal - normal
2. Antero lateral - hypokinetic
3. Apical - hypokinetic
4. Inferior - hypokinetic
5. Postero basal - hypokinetic
Final DX
1. One vessel coronary artery disease.
2. Moderate left ventricular diastolic dysfunction.
.
Brief Hospital Course:
Ms. [**Known lastname 27534**] was admitted to the hospital s/p STEMI. Hospital
course by problem:
.
1. ST-ELEVATION MI
She presented with worsening chest pain and was found to have
RCA disease on cath. She received a DES to the RCA during cath.
Tox screen was positive for cocaine which likely contributed to
coronary vasospasm and cause the MI. She was given Integrilin
for 18 hours post-cath. She was started on Atorvastatin and
Lisinopril while in the hospital as well as Plavix. Due to
difficulty paying for medication, the Atorvastatin and
Lisinopril were not continued on discharge. She worked with
physical therapy prior to discharge and was chest pain free.
She was discharged only on aspirin and Plavix to facilitate
medication compliance. She has follow-up with cardiology and
her PCP.
.
2. CONGESTIVE HEART FAILURE
She has both systolic and diastolic dysfunction. Preliminary
Echo showed EF of 40-45%. She had no symptoms of decompensated
heart failure during this admission and did not require
diuretics. She was counseled on limiting her salt intake. She
has cardiology follow-up. She was not discharged on an ACE due
to inability to pay for medications.
.
3. DIABETES
Blood sugars were difficult to control. She was continued on
NPH 28 units [**Hospital1 **] as per her home regimen and was given a humalog
sliding scale. She has an appointment with [**Last Name (un) **] to follow-up
on blood sugar management as an outpatient. She was not given
an ACE due her inability to pay for medications.
.
4. SUBSTANCE ABUSE
She denied cocaine use despite urine tox screen result which was
positive for cocaine. When confronted about this she continued
to denies using cocaine and became tearful. Social work met
with her for substance abuse counseling. An HIV test was sent
and she will follow-up with her PCP for these results.
.
5. HYPERLIPIDEMIA
Cholesterol panel revealed elevated total cholesterol of 266 and
LDL of 160. She was given Atorvastatin while in-house but was
not discharged on this due to her difficulty paying for
medications.
.
6. TOBACCO USE
She was given a Nicotine patch while in house and counseled on
tobacco cessation.
.
7. FEN: Cardiac Heart Healthy, Diabetic diet.
.
FOLLOW-UP
She has an appointment to see [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks and will
follow-up on diabetic control, medication compliance and further
symptoms. She will obtain her results of her HIV test. She can
also receive the final read of her echo at that time. If she is
able to get Mass Health and pay for her medications, we would
recommend adding Pravastatin 40mg (on the [**Company **] $4 drug use)
and Lisinopril 5mg daily. She will follow-up with Dr. [**Last Name (STitle) **]
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1661**] of [**Last Name (un) **].
Medications on Admission:
Lipitor 80 (not taken for > 1 month)
Aspirin (not taken for > 1 year)
Humulin 28 [**Hospital1 **]
Humulog 6 qMeal
Metformin 500 TID
Lisinopril 5 qd (not taken for > 1 yr).
Methadone 75 mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
1. ST-Elevation MI
Secondary Diagnoses:
2. Cocaine Use
3. Systolic Congestive Heart Failure
4. Medication Non-compliance
Discharge Condition:
clear mental status, chest pain free.
Discharge Instructions:
You were admitted to the hospital after having a heart attack.
You had a procedure to place stents into the arteries that
supply your heart. It is extremely important that you take
PLAVIX (CLOPIDIGREL) to prevent these stents from closing. You
need to take this medication for the next year.
The following medications were added:
PLAVIX 75mg by mouth once a day
ASPIRIN 81mg by mouth once a day
Please continue to take your Humalin twice a day and Humalog
with meals. Please continue to take your Flovent and Albuterol
inhalers.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Please call your doctor or come to the emergency
room if you experience chest pain, shortness of breath, arm or
back pain, sweating, nausea or vomiting. Avoid salty foods such
as soups, lunch meats and canned food.
Followup Instructions:
APPOINTMENTS:
PRIMARY CARE:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP - [**2193-1-25**] at 10:00am. She is the Nurse
Practitioner who works with Dr. [**Last Name (STitle) 483**]. [**Telephone/Fax (1) 250**]
CARDIOLOGY:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - [**2193-2-4**] at 3:20pm. [**Hospital Ward Name 23**] Building, [**Location (un) 3971**]. [**Telephone/Fax (1) 62**]
DIABETES AT [**Last Name (un) **]:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1661**] - [**2193-1-18**] 3:30pm. One [**Last Name (un) **] Place. ([**Telephone/Fax (1) 17256**]. Please bring your meter and insurance card to the
appointment.
ICD9 Codes: 412, 2724, 3051, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2942
} | Medical Text: Admission Date: [**2201-1-5**] Discharge Date: [**2201-1-8**]
Date of Birth: [**2129-2-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
71M with complex hstory of pancreatic pseudocst and vent
dependence presenting with acute onset lower GI bleeding. Per
nursing at the rehab facility,he was passing small blood clots
per rectum on [**2201-1-4**]. No other symptoms or precipitating
events noted.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is well known to the surgical service, with a
complex history of pancreatic pseudocyst, ventilator dependence,
and multiple septic episodes. He was most recently dischargded
to [**Hospital 1319**] rehab on [**10-9**] after a prolonged hospital course,
which included management of a cystgastrostomy, G-tube, J-tube
placement, ultimately complicated by pneumonia and chest tube
placement. He re-presented to [**Hospital1 18**] on [**12-4**] with a presumed LLL
pneumonia, increased secretions. Subsequent cultures confirmed
MRSa/GNR. Initially patient needed full ventilator support, but
was weaned to just night support by the time of his discharge on
[**2200-12-24**].
Past Medical History:
HTN
CAD, s/p angioplasty
s/p AVR [**7-6**]
Respiratory failure
tracheostomy
Failure to thrive
s/p R knee surgery
ventilator associated pneumonia
pancreatic pseudocyst
Atrial fibrilation
galstone pancreatitis
picc line placement
cholelithiasis
COPD
CHF
sepsis
Social History:
lives with his wifeformer tobacco use
Physical Exam:
99.3 79 149/65 22 SaO2 100% on 60% TM
Alert & Oriented x3. No Acute Distress.
Currently on ventilator support via tracheostomy.
CN II-XII intact.
Slow amplitude facial tremor noted (old).
Pupils equal bilaterally. Scalarae on non-icteric.
Oral mucosa is dry. Trachesotomy well secured with cuff up.
Neck is supple.
Cardiac is irregular, no murmors or rubs nited.
There are course breath sounds bilaterally.
Abdomen is soft, non-tender. Good bowel sounds.
J-tube secured in place.
Lower extremities are warm, well perfused, 1+ edema noted
bilaterally.
Pertinent Results:
[**2201-1-5**] 11:38PM HCT-27.3*
[**2201-1-5**] 01:30PM GLUCOSE-95 UREA N-24* CREAT-0.5 SODIUM-144
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-34* ANION GAP-7*
[**2201-1-5**] 01:30PM ALT(SGPT)-15 AST(SGOT)-27 ALK PHOS-658*
AMYLASE-12 TOT BILI-0.2
[**2201-1-5**] 01:30PM LIPASE-21
[**2201-1-5**] 01:30PM ALBUMIN-2.5*
[**2201-1-5**] 01:30PM DIGOXIN-1.0
[**2201-1-5**] 01:30PM WBC-9.1 RBC-2.70* HGB-8.2* HCT-26.1* MCV-97
MCH-30.6 MCHC-31.6 RDW-16.2*
[**2201-1-5**] 01:30PM NEUTS-77.0* BANDS-0 LYMPHS-15.2* MONOS-4.2
EOS-3.4 BASOS-0.2
[**2201-1-5**] 01:30PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
STIPPLED-OCCASIONAL
[**2201-1-5**] 01:30PM PLT COUNT-240
[**2201-1-5**] 01:30PM PT-12.2 PTT-25.9 INR(PT)-0.9
Brief Hospital Course:
On hospital day one, patient was evaluated by Dr. [**Last Name (STitle) 957**] and
his surgical team. At that time his hematocrit was noted to be
26.1, down slightly from 28 on [**12-24**]. He was transfused 2 units
of packed red blood celss with an appropriate increase in
hematocrit to 28. While stool was noted to be guiac positive,
subsequent NG levage cleared easily, and there was no evidence
of further bleeding. Over the next 2 days of observation,
patients vital signs remained stable, and there was no change in
hematocrit. After a final evaluation by Dr. [**Last Name (STitle) 957**], it wa
fealt that the patoent was appropriate for discharge back to
rehab.
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
[**12-7**] Caps Inhalation DAILY (Daily).
3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO TID (3 times a day).
9. Chlorhexidine Gluconate 0.12 % Liquid Sig: One (1) ML Mucous
membrane TID (3 times a day) as needed.
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Levothyroxine Sodium 137 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
13. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
17. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) Intravenous Q8H (every 8 hours) for 7 days.
18. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1)
Intravenous PRN (as needed) as needed for K+< 4.0.
19. Magnesium Sulfate 50 % Solution Sig: One (1) Injection PRN
(as needed) as needed for mg +< 2.0.
20. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
transient upper GI bleed
Resolving GI bleed
Hyppertension
Coronary Artery Disease, s/p angioplasty
s/p Aortic Valve Repair [**7-6**]
Respiratory failure
Failure to thrive
s/p R knee surgery
h/o ventilator associated pneumonia
pancreatic pseudocyst
Atrial fibrilation
galstone pancreatitis
cholelithiasis
COPD
CHF
sepsis
Discharge Condition:
stable, tolerating daytime trach mask
Discharge Instructions:
Resume all pre-hospitalization treatments and plans.
Continue daytime vent wean as tolerated.
Followup Instructions:
Resume [**Hospital 34968**] rehab. plan
Completed by:[**2201-1-8**]
ICD9 Codes: 486, 496, 4280, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2943
} | Medical Text: Admission Date: [**2195-7-9**] Discharge Date: [**2195-7-12**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88 y.o. Female w/ h.o. RA on Methotrexate BIBA from home with
fevers, dyspnea.
Per the pt she states she was experiencing cold symptoms for the
past week, she was seen by her nurse practitioner [**First Name (Titles) **] [**Last Name (Titles) 112**] at home
and had a CXR. She was told she had a spot in her lungs, it is
unclear if this referred to an infection vs nodule. She denies
any cough, sore throat, chest pain but did not some fevers and
shortness of breath at home for the past 2 days. Her home health
aide called 911 given her difficulty breathing.
Per ED report EMs noted she was 84% on RA so they applied a NRB
to her. Coming to the ED she was able to wean down to 5L nasal
canula.
In the ED here initial VS were noted to be T104.9, BP 161/96, HR
131, RR 44, Sat 96% on 5L. She triggered in the ED on arrival
and was documented to be alert, orientated x 3. Given her fevers
she was given Tylenol 650mg PR. A CXr revealed a retrocardiac
opacity, she was thus started on Levofloxacin and Vancomycin.
Her initial labwork was notable for leukocytosis of 13.4,
neutrophillic (94.5). Na 131, Phos 2.0. PT/INR noted to be
14.9/1.3. AG of 19 with HCO3 21. Lactate 1.7. Given her level of
tachypnea the ED discussed code status with the pt. The pt
expressed to the ED that she was DNR/DNI. She does not want to
be intubated. They attempted BiPAP, however pt did not tolerate
it. They also gave her Toradol 30mg IV for her fevers as she was
still feverish to 101 and uncomfortable. She was given a total
of 2L IVF with her HR responding, decreasing from 140 to 111.
She usually gets her care at [**Hospital1 112**], her Rheumatologist is also
there, she has been taking Mtx for her RA. She denies any
history of PNA, denies any constipation, diarrhea. She does have
LE edema which she says usually occurs when she uses her
wheelchair.
Past Medical History:
RA
Cataract Surgery ([**2188**])
Mastectomy (?[**2153**])
Social History:
Pt currently lives at home, has home health aide. Per the pt her
sister who would usually make healthcare decisions for her
passed away in [**Month (only) 321**]. She has one cousin in [**Name (NI) **] plans
([**First Name4 (NamePattern1) **] [**Name (NI) 11679**] [**2153**]), she has no children or other
siblings
Family History:
N/C
Physical Exam:
per admitting resident
GEN: Caucasian Female laying down in bed appears flushed, mildly
tacypneic
HEENT: PERRL, EOMI, anicteric
Neck: Difficult to observe JVP
RESP: Crackles noted left mid thorax down on anterior exam
CV: S1, S2, II/VI late peaking systolic murmur noted over the rt
sternum, systolic murmur radiating to apex
ABD: Soft, non tender, non distended, normoactive BS x 4
EXT: b/l hands and fingers show deformities consistent with RA,
LE show mixed edema up to ankle. RUE warm to touch, LUE slightly
cooler, LLE warm to touch, RLE slightly cooler
NEURO: AAOx3. Cn II-XII intact.
Pertinent Results:
labs on admission:
[**2195-7-8**] 10:30PM WBC-13.4*# RBC-4.13* HGB-13.4# HCT-38.3
MCV-93# MCH-32.5*# MCHC-35.1*# RDW-18.5*
[**2195-7-8**] 10:30PM NEUTS-94.5* LYMPHS-3.8* MONOS-1.2* EOS-0.2
BASOS-0.3
[**2195-7-8**] 10:30PM PLT COUNT-187
[**2195-7-8**] 10:30PM PT-14.9* PTT-31.3 INR(PT)-1.3*
[**2195-7-8**] 10:30PM GLUCOSE-159* UREA N-10 CREAT-0.7 SODIUM-131*
POTASSIUM-3.6 CHLORIDE-91* TOTAL CO2-21* ANION GAP-23*
[**2195-7-8**] 10:36PM LACTATE-1.7
[**2195-7-9**] 05:11AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2195-7-9**] 05:11AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
cardiac enzymes:
[**2195-7-9**] 04:04PM CK-MB-20* MB INDX-6.2* cTropnT-0.30*
[**2195-7-9**] 04:04PM CK(CPK)-324*
[**2195-7-9**] 10:56PM CK-MB-21* MB INDX-7.4* cTropnT-0.56*
[**2195-7-9**] 10:56PM CK(CPK)-285*
[**2195-7-10**] 04:54AM CK-MB-17* MB Indx-6.8* cTropnT-0.44*
[**2195-7-10**] 02:28PM CK-MB-9 cTropnT-0.39*
[**2195-7-11**] 05:55AM CK-MB-7 cTropnT-0.31*
Imaging:
Echo: [**2195-7-9**]
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 ascending
aorta is mildly dilated. The aortic arch is mildly dilated. The
aortic valve leaflets are severely thickened/deformed. There is
moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is severe mitral annular
calcification. There is mild functional mitral stenosis (mean
gradient 5 mmHg) due to mitral annular calcification. Trivial
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a very small pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mildly dilated asending aorta and aortic arch. Moderate aortic
stenosis with mild aortic regurgitation. Mild functional mitral
stenosis in the setting of extensive mitral annular
calcification. Moderate pulmonary artery systolic hypertension.
EKG: [**2195-7-8**]
Sinus tachycardia. Intra-atrial conduction delay. Consider
inferior myocardial infarction of indeterminate age, although is
non-diagnostic. Early precordial QRS transition is non-specific.
Consider left ventricular hypertrophy. ST-T wave changes. Cannot
exclude myocardial ischemia. Clinical correlation is suggested.
No previous tracing available for comparison.
CXR: [**2195-7-8**]
The study is limited by portable technique and patient
positioning.
Please note the patient's chin overlies the left apex. There is
marked
elevation of the right hemidiaphragm. There is poor evaluation
of the right hilar structures. There is suggestion of streaky
opacity in the retrocardiac left lower lobe. Conceivably, this
could be atelectasis, although an early developing infiltrate
cannot be entirely excluded. No gross consolidation is noted.
The mediastinum is grossly unremarkable again within limitation
of not fully evaluating the right perihilar region. The cardiac
silhouette size is difficult to assess but is presumed enlarged.
There is blunting of the right costophrenic angle indicating a
small effusion. Left effusion is difficult to entirely exclude.
There is no large pneumothorax. The bones are severely and
diffusely osteopenic. There is deformity of the proximal right
humerus which may be due to prior trauma.
IMPRESSION: Numerous limitations as above. There is a left
retrocardiac
opacity which may represent atelectasis, although an early
developing
pneumonia cannot be entirely excluded. There is a small right
effusion with an elevated right hemidiaphragm. Remaining
findings as above.
CXR: [**2195-7-9**]
In comparison with the study of [**7-8**], respiratory motion greatly
obscures the image. Continued retrocardiac opacification that
could represent volume loss in the left lower lobe, though
superimposed pneumonia can certainly not be excluded in the
appropriate clinical setting. Bilateral pleural effusions with
evidence of increased pulmonary venous pressure
CXR: [**2195-7-11**]
Comparison is made to previous study from [**2195-7-9**]. Cardiac
silhouette is enlarged but stable. There is again seen a
moderate-sized right-sided pleural effusion and a left
retrocardiac opacity. Left-sided pleural effusion is also seen.
Ununited severe fracture deformity of the left proximal humerus
at the surgical neck is again seen and stable.
Brief Hospital Course:
88 y/o female with hx of rheumtoid arthritis on methotrexate who
presented with sepsis from a suspected pulmonary source.
Hospital course was complicated by the development of atrial
fibrillation with rapid ventricular response, a seizure,
hypotension, NSTEMI and worsening respiratory status. On
admission, the pt's wishes for DNR/DNI status and no aggressive
measures be done were expressed. She was treated with broad
spectrum antibiotics (Vanc/Cefepime/Azithro) for presumed LLL
pulmonary infection in the setting of Methotrexate use; she was
also treated with Atovaquone for PCP [**Name Initial (PRE) 1102**]. However, she
continued to spike fevers and was hypotense. She developed AFib
with RVR and was treated with nodal agents for rate control but
eventually necessitated Amiodarone loading and infusion. She
also NSTEMI'd with positive cardiac enzymes and was therefore
treated for ACS with a Heparin gtt, statin, ASA, and beta
blocker. TTE showed aortic stenosis, mild MR/TR, normal EF,
symmetric LVH, no WMA's. She was treated for pulmonary edema
with IV diuresis. She also had an episode of generalized
tonic-clonic seizure and was treated with IV Ativan and
Phenytoin. She had persistent hypotension, and continued to
deteriorate such that on the morning of [**2195-7-11**] she asked to
be made comfortable. Her cousin [**Name (NI) 109232**] [**Name (NI) 11679**] and HCP [**Name (NI) **]
[**Name (NI) 3647**] were made aware, and she was started on a Morphine gtt.
Her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**] was notified by email. She passed away on
[**2195-7-12**].
Medications on Admission:
Methotrexate (per pt)
Old medication list [**Name8 (MD) **] NP (incomplete):
- Methotrexate
- Lasix 20mg alternating with 10mg(?) daily
- Gabapentin 100 mg PO/NG HS
- Phenytoin Sodium Extended 100 mg PO QAM
- PrimiDONE 125 mg PO HS
- Tiotropium Bromide 1 CAP IH DAILY
- Fluticasone Propionate NASAL 1 SPRY NU DAILY
- Lansoprazole Oral Disintegrating Tab 30 mg PO/NG [**Hospital1 **]
- OxycoDONE 5mg [**Hospital1 **] prn pain
- Vicodin prn pain
- FoLIC Acid 1 mg PO/NG DAILY
- Calcium/Vitamin D
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiopulmonary arrest
pneumonia
atrial fibrillation with rapid ventricular response
pulmonary edema
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
Completed by:[**2195-7-13**]
ICD9 Codes: 0389, 486, 2762, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2944
} | Medical Text: Admission Date: [**2109-10-31**] Discharge Date: [**2109-11-13**]
Date of Birth: Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 71-year-old gentleman
who experienced a presyncopal episode and was admitted to the
[**Hospital 1474**] Hospital Emergency Department.
There, the patient had an exercise tolerance test which was
positive and was then transferred to [**Hospital1 190**] for cardiac catheterization. Cardiac
catheterization revealed an ejection fraction of 33%, left
ventricular end-diastolic pressure of 25, and severe 3-vessel
coronary artery disease; including left main with mild
disease, the left anterior descending artery with 70% to 80%
proximal to mid stenosis, the left circumflex with 95%
proximal, 70% at the second obtuse marginal, and the right
coronary artery which was nondominant with a 99% stenosis.
The patient was then referred for coronary artery bypass
grafting.
PAST MEDICAL HISTORY: (The patient's past Medical History
includes)
1. Non-insulin-dependent diabetes mellitus.
2. Hypertension.
3. Hypercholesterolemia.
4. Former heavy smoker.
5. He drinks alcohol; he has had more to drink recently.
6. History of Alzheimer's disease/dementia.
7. Status post appendectomy.
8. Status post motor vehicle accident as a child.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: (His medications on admission
included)
1. Glyburide 5 mg by mouth twice per day.
2. Aricept 10 mg by mouth at hour of sleep.
3. Lipitor 10 mg by mouth once per day.
4. Zestril.
5. Effexor 75 mg by mouth once per day.
6. Lopressor 25 mg by mouth twice per day.
7. Aspirin by mouth every day.
8. Plavix 75 mg by mouth once per day.
SOCIAL HISTORY: The patient is married and lives with his
wife. [**Name (NI) 1139**] and alcohol as above.
REVIEW OF SYSTEMS: The patient's review of systems was
noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient was an alert and oriented
pleasant gentleman. He was in no apparent distress. His
neurologic examination revealed the patient to be grossly
intact. He did have a right carotid bruit, but no left
carotid bruit was noted. The patient's lungs were clear to
auscultation bilaterally. His heart was regular in rate and
rhythm. No murmur was noted. His abdomen was benign. The
abdomen was nontender and nondistended. Extremity
examination revealed his extremities were warm and well
perfused with no varicosities.
PERTINENT LABORATORY VALUES ON PRESENTATION: His laboratory
values revealed his white blood cell count was 7.8, his
hematocrit was 37.8%, and his platelet count was 167,000.
His INR was 1.2. His sodium was 138, potassium was 3.9,
chloride was 105, bicarbonate was 25, blood urea nitrogen was
15, creatinine was 0.8, and blood glucose was 128. His liver
function tests were within normal limits.
PERTINENT RADIOLOGY/IMAGING: His electrocardiogram showed a
normal sinus rhythm with no acute ischemia.
His echocardiogram showed mild mitral regurgitation, trace
tricuspid regurgitation, no aortic regurgitation, and global
hypokinesis.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient underwent a
carotid ultrasound which showed moderate plaque in the right
and left internal carotid artery with narrowing of the right
internal carotid artery to 60% to 69% and the left 40% to
59%. His vertebrals were noted to be normal.
The patient had no events while awaiting surgery. On
[**2109-11-4**] the patient underwent coronary artery bypass
grafting times three with a left internal mammary artery to
the left anterior descending artery, a saphenous vein graft
to the second obtuse marginal, and a saphenous vein graft to
the third obtuse marginal.
The surgery was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] with Dr.
[**Last Name (STitle) 16398**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] assistants. The surgery was
performed under general endotracheal anesthesia. There was a
cardiopulmonary bypass time of 82 minutes and a cross-clamp
time of 72 minutes. The patient tolerated the procedure well
and was transferred to the Coronary Care Unit in a normal
sinus rhythm. The patient was on epinephrine,
nitroglycerin, insulin, and propofol drips. The patient had
two atrial and two ventricular pacing wires and two
mediastinal and one left pleural chest tube.
Initially, on the first operative night, the patient was
noted to have a low cardiac index and a low ejection fraction
on epinephrine. This was eventually weaned off, and he did
have some ventricular ectopy. He was also given 500 cc of
crystalloid for a low cardiac index. Therefore, the patient
was not extubated on his first operative night. The patient
was eventually A-paced to help with his cardiac index.
In the morning on postoperative day one, the patient was
extubated without difficulty. Over postoperative day one,
the patient was weaned off all of his drips. By late in the
day, he was transferred to the surgical floor.
On postoperative day two, he had his chest tubes discontinued
without incident. He was started on Lopressor twice per day
and encouraged to ambulate.
On postoperative day three, his cardiac pacing wires were
discontinued without incident. During that day, he had his
Foley catheter discontinued, but he did fail to void.
Therefore, his Foley catheter was replaced that night. His
Foley catheter was removed the following day, and he was able
to void without difficulty.
On postoperative day four, the patient was complaining of
having multiple loose stools. Flagyl was started
empirically, and Clostridium difficile cultures were sent.
Subsequently, the Clostridium difficile cultures sent were
all negative. The Flagyl was discontinued. His loose stools
did resolve on their own.
Throughout the remainder of his hospital course, he continued
to work with Physical Therapy to increase his strength and
ambulation. By postoperative day eight, it was felt that he
would be ready for discharge to home with a visiting nurse
and physical therapy services on postoperative day nine.
PHYSICAL EXAMINATION ON DISCHARGE: The patient's physical
examination revealed the patient to be alert and oriented
times three. In no apparent distress. The lungs were clear
to auscultation bilaterally. His heart was regular in rate
and rhythm. No murmurs, rubs, or gallops. His wounds were
clean, dry, and intact. His sternum was stable. His abdomen
was soft, nontender, and nondistended. His extremities
revealed no signs of edema.
PERTINENT LABORATORY VALUES ON DISCHARGE: His discharge
laboratories will be dictated in an Addendum.
His discharge chest x-ray showed small bilateral effusions,
but no sign of infiltrate or pneumothorax.
CONDITION AT DISCHARGE: The patient's condition on discharge
was good.
PRIMARY DISCHARGE DIAGNOSIS: Status post coronary artery
bypass grafting times three on [**2109-11-4**].
SECONDARY DISCHARGE DIAGNOSES:
1. Diabetes mellitus.
2. Alzheimer's disease/dementia.
3. Hypertension.
4. Hypercholesterolemia.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Enteric-coated aspirin 325 mg by mouth every day.
2. Glyburide 5 mg by mouth twice per day.
3. Effexor-XR 75 mg by mouth once per day.
4. Lipitor 10 mg by mouth once per day.
5. Aricept 10 mg by mouth at hour of sleep.
6. Lopressor 50 mg by mouth twice per day.
7. Percocet one to two tablets by mouth q.4h. as needed.
8. Lasix 20 mg by mouth twice per day (times seven days).
9. Potassium chloride 20 mEq by mouth twice per day (times
seven days).
10. Multivitamin one tablet by mouth once per day.
11. Iron sulfate 325 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with his primary
care physician (Dr. [**Last Name (STitle) 27098**] in one to two weeks.
2. The patient was instructed to follow up with his
cardiologist (Dr. [**First Name (STitle) **] in two to three weeks.
3. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1537**] in four weeks.
4. The patient was instructed to continue an 1800-calorie
American Diabetes Association diabetic diet with low sodium
and low cholesterol.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Dictator Info 3114**]
MEDQUIST36
D: [**2109-11-12**] 16:57
T: [**2109-11-12**] 17:16
JOB#: [**Job Number 27099**]
ICD9 Codes: 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2945
} | Medical Text: Admission Date: [**2128-11-1**] Discharge Date: [**2128-11-19**]
Date of Birth: [**2084-7-24**] Sex: F
Service: SURGERY
Allergies:
Flagyl / Bactrim / Reglan
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal pain with nausea, vomiting
Major Surgical or Invasive Procedure:
[**2128-11-2**]:
1. Exploratory laparotomy with lysis of adhesions (4
hours).
2. Small bowel resection with primary anastomosis.
3. Small bowel repairs (2).
History of Present Illness:
43 F with ulcerative colitis s/p proctocolectomy and ileostomy
and history of multiple episodes of small bowel obstruction
(last episode a couple of years ago) presents with abdominal
pain since 9AM the day prior to admission. Pain was intermittent
initially upper abdomen and then now mainly lower abdomen, no
radiation of pain, intensity 8 at the worst, relieved with pain
meds in the OR, no other definite relieving or aggravating
factors. Associated nausea vomiting. Vomited at least 10 times
on the day prior to admission, initially clear then bilious. No
blood. Is still passing gas from ileostomy and has noticed any
decrease in [**Street Address(1) 13068**] zosyn in the ED.
Past Medical History:
1. Ulcerative colitis - diagnosed age 11, [**Last Name (un) 13069**] pouch [**2107**],
revision with ileostomy [**2109**]
2. GERD - diagnosed [**2123**], partially controlled on pantoprazole,
gastroscopy [**10-21**] showed mild GE junction inflammation but no
Barrett's
3. Multiple episodes of partial small bowel obstruction due to
adhesions - last in [**2124**], usually relieved by rehydration in the
ED, have not required hospitalization
4. Depression
5. Seasonal allergies
6. Frequent UTIs - on nitrofurantoin prophylactically
7. Lateral epicondylitis
8. Unclear history of thyroid disease
9. RLQ reducible incisional hernia
Social History:
Lives with husband and six month old infant. Works as
psychologist. No tobacco, social alcohol.
Family History:
Father with SLE. Mother with Ulcerative colitis. Grandmother
with Rheumatoid arthritis. Multiple other family members with
ulcerative colitis or [**Name (NI) 4522**] disease, including uncle, great
aunt, and [**Name2 (NI) 12232**].
Physical Exam:
On Admission:
VS: 98.7 92 101/72 20 98
General: moderately uncomfortable appearing
HEENT: Looks dry
Cardiovascular: regular rate and rhythm, normal S1 and S2, no
m/c/r
Lungs: clear to auscultation bilaterally
Abdomen: Minimal distension, soft tenderness lower abdomen more
suprapubic and LLQ. No guarding or rebound. Ileostomy present
with some output in bag with no gas. Bag was just emptied.
Digital exam of ileostomy showed no narrowing suggestive of
stenosis.
Extremities: warm and well perfused, 2+ pulses
Neurological: alert and oriented x3
Pertinent Results:
On Admission:
[**2128-11-1**] 04:15PM LACTATE-1.4
[**2128-11-1**] 03:50PM GLUCOSE-145* UREA N-11 CREAT-0.6 SODIUM-147*
POTASSIUM-3.3 CHLORIDE-112* TOTAL CO2-25 ANION GAP-13
[**2128-11-1**] 03:50PM CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-1.9
[**2128-11-1**] 03:50PM WBC-10.1# RBC-4.63 HGB-13.2 HCT-38.8 MCV-84
MCH-28.6 MCHC-34.1 RDW-14.2
[**2128-11-1**] 03:50PM PLT COUNT-254
[**2128-11-1**] 03:50PM PT-13.2 PTT-23.6 INR(PT)-1.1
[**2128-11-1**] 08:56AM LACTATE-1.6
[**2128-11-1**] 08:45AM GLUCOSE-152* UREA N-10 CREAT-0.7 SODIUM-144
POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-24 ANION GAP-13
[**2128-11-1**] 12:00AM PLT COUNT-319
[**2128-11-1**] 12:00AM NEUTS-90.9* LYMPHS-4.7* MONOS-3.8 EOS-0.2
BASOS-0.3
[**2128-11-1**] 12:00AM WBC-17.5*# RBC-5.59* HGB-16.0 HCT-46.7 MCV-84
MCH-28.6 MCHC-34.1 RDW-14.1
[**2128-11-1**] 12:00AM GLUCOSE-147* UREA N-14 CREAT-0.7 SODIUM-144
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-21* ANION GAP-27*
.
IMAGING:
[**2128-11-1**] ABD/PELVIC CT W/CONTRAST:
1. Findings concerning for a closed loop small bowel
obstruction, likely secondary to adhesions. No free air.
2. Cholelithiasis.
3. Left ovarian cyst.
.
[**2128-11-1**] KUB/upright:
ABDOMEN, SUPINE AND UPRIGHT: An ileostomy is noted within the
right lower quadrant. There is a paucity of bowel gas throughout
the abdomen, with suggestion of fecalized small bowel loops in
the pelvis. No free air or pneumatosis is identified. No
abnormal intra-abdominal calcifications are seen. A prominent
[**Last Name (un) 13070**] lobe is noted, making determination of hepatomegaly
uncertain.
IMPRESSION: Paucity of bowel gas, with suggestion of fecalized
small bowel loops in the pelvis. Correlation with CT is
recommended.
.
[**2128-11-3**] ECG:
Sinus tachycardia. Tracing is normal except for rate. Compared
to the previous tracing of [**2120-5-24**] there is no change.
Intervals Axes:
Rate PR QRS QT/QTc P QRS T
107 120 72 320/402 68 70 60
.
[**2128-11-7**] ABD COMPL INCLUDING LAT:
Markedly dilated loops of apparently both small and large bowel
as well as of the stomach. Paucity of gas within the stomach.
This raises the possibility of an obstruction. CT would be
superior to plain radiographs for evaluating this possibility.
Brief Hospital Course:
Pt was seen and evaluated in the ED and determined to have a
small bowel obstruction. She was admitted to the floor for
conservative management of a small bowel obstruction. An NG tube
was placed and the patient was made NPO and started on mIVF. Her
symptoms initially improved, with resolution of her nausea and
vomiting. On HD 2, the patient had return of her symptoms and
exploratory laparotomy was discussed and agreed to proceed with
the procedure. She was taken to the OR, where she underwent
exploratory laparotomy with lysis of adhesions (4 hours), small
bowel resection with primary anastomosis, and small bowel
repairs (2). Intraoperatively she required neosynephrine to
maintain pressures and was admitted to the SICU intubated. She
was weaned off of neosynephrine in the unit, and was maintained
on propofol and intubated secondary to tenuous respiratory
status. On POD4 (HD6), the patient was extubated without
complication. On POD5, she had increasing ostomy output. The
patient was transferred to the floor for further recovery. The
patient was seen and evaluated by physical therapy, nutrition
and the ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) 13071**] planning during this
admission. Once her ostomy output was stable, her NG tube was
discontinued without complication. She was started on TPN for
prolonged NPO status and increased metabolic needs on POD#7. The
patient was unable to tolerate sips or clears during two
attempts early on post-operatively. Ultimately, she was able to
tolerate sips on POD#10, and her diet was prodressively advanced
to a low residue regular by POD#13 with good intake. TPN was
discontinued on POD#12. The patient required multiple IV fluid
boluses for increased ostomy output. Loperamide was used to
control and stabilize her ostomy output, and the patient
eventually was able to tolerate her fluid intake goal of greater
than 1.5 liters daily, which enablabled discharge as she no
longer required IV fluids. A small area of erythema was noticed
around her surgical wound, and she was started on Ciprofloxacin
for a wound infection. Her wound was opened in two locations and
packed with AMD moist-to-dry dressings twice daily with
improvement.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge on [**2128-11-19**], the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
low residual regular diet and daily fluid requirement of 1.5
liters, ambulating, voiding without assistance, and pain was
well controlled. She received ostomy teaching and supplies. She
was discharged home with VNA services. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
FEXOFENADINE [[**Doctor First Name **]] - (Prescribed by Other Provider) -
Dosage
uncertain
FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - Dosage
uncertain
LEVOTHYROXINE - (Prescribed by Other Provider; 50 mcg) - 75 mcg
Tablet - 1 Tablet(s) by mouth daily
NITROFURANTOIN MACROCRYSTAL [MACRODANTIN] - 50 mg Capsule - one
Capsule(s) by mouth as directed
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth twice a day
RANITIDINE HCL - 150 mg Capsule - 1 Capsule(s) by mouth twice a
day
SERTRALINE - (Prescribed by Other Provider; 125 mg daily) - 25
mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day
TRIMETHOBENZAMIDE - 300 mg Capsule - 1 Capsule(s) by mouth tid
prn vomiting
.
Medications - OTC
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by
Other Provider) - 500 mg (1,250 mg)-200 unit Tablet - 1 (One)
Tablet(s) by mouth once a day
LOPERAMIDE - 2 mg Tablet - 1 Tablet(s) by mouth daily in am prn
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea: Titrate as described.
Disp:*60 Capsule(s)* Refills:*2*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) as needed for shortness of breath
or wheezing.
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
7. Sertraline 50 mg Tablet Sig: 0.25 Tablet PO QHS (once a day
(at bedtime)).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-19**]
hours as needed for fever or pain.
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. Trimethobenzamide 300 mg Capsule Sig: One (1) Capsule PO
three times a day as needed for nausea.
11. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**1-16**] each
nostril Nasal once a day as needed for allergy symptoms.
13. [**Doctor First Name **] Oral
14. Calcium Oral
15. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO As directed by PCP for prophylaxis [**Name9 (PRE) **] symptoms.
16. Ostomy Supplies:
Convatec Surfit Natura Wafer # [**Numeric Identifier 13072**] as directed.
.
Disp: #10/box, 1 box with 11 Refills
17. Ostomy Supplies:
Convatec Surfit Natura Pouch # [**Numeric Identifier 13073**] as directed.
.
Disp: #10/box, 1 box with 11 Refills
Discharge [**Numeric Identifier **]:
Home With Service
Facility:
CareGroup VNA
Discharge Diagnosis:
1. Small intestinal obstruction.
2. Multiply operated abdomen.
3. Status post total proctocolectomy - ulcerative colitis.
Discharge Condition:
Good.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-23**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2128-12-6**]
8:00. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Please call ([**Telephone/Fax (1) 13074**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 13075**] (PCP) in [**2-17**] weeks.
Completed by:[**2128-11-19**]
ICD9 Codes: 311, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2946
} | Medical Text: Admission Date: [**2144-7-3**] Discharge Date: [**2144-7-16**]
Date of Birth: [**2087-5-8**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Head trauma s/p MCA
Major Surgical or Invasive Procedure:
R craniotomy with frontal and partial temporal lobe resection
History of Present Illness:
57M presents with head trauma s/p motorcycle accident during
which his skull cap fell off. Unknown whether accident was
witnessed. Per EMS report, BP 160/90 HR 80, GCS 3, pupils 3mm,
+purposeful movements in UE only. Patient was intubated by rapid
sequence and medflighted to [**Hospital1 18**] where GCS 3, 101.2 rectal,
147/90, 62 100% on vent. On exam in ED, patient localizes with
left UE, withdraws to right UE and bilateral legs. Does not open
eyes spontaneously or to voice. Does not follow commands.
Positive gag and corneals. Head CT showed b/l SDH R>L. Large
amounts of SAH. Hemorrhagic contusions in R frontal and temporal
lobes. Effacement of perimesencephalic cisterns and right uncal
herniation. Nondisplaced fractures through the left occipital
bone and the left temporal bone, extending down to the anterior
middle cranial fossa. Patient was taken emergently to OR for
bolt and craniotomy.
Past Medical History:
Unknown
Social History:
Has a son [**Name (NI) **] [**Name (NI) 60531**] [**Telephone/Fax (1) 67504**].
Family History:
NC
Physical Exam:
101.2 rectal 147/90 62 100% on vent
sedated and intubated
lacerations to scalp, blood oozing from left external meatus and
nostrils
breath sounds bilaterally
soft abdomen
extremities warm, well perfused, nonedematous
Neuro:
Sedated and not waking up with painful stimuli.
Cranial Nerves:
I: Not tested
II: Pupils equally round 2mm bilaterally.
V, VII: +corneal
IX, X: +cough
Motor: Normal bulk bilaterally. Localizes on RUE and withdraws
LUE, LLE and RLE.
Pertinent Results:
Labs:
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
Color Straw Appear Clear SpecGr 1.009 pH 5.0 Urobil Neg
Bili
Neg Leuk Neg Bld Tr Nitr Neg Prot Neg Glu Neg Ket Neg
RBC<1 WBC<1 Bact None Yeast None Epi<1
BUN 9 Cr 0.8
[**Doctor First Name **]: 40
Serum EtOH 36
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
Na:142 K:3.5 Cl:106 TCO2:26 Glu:99 Lactate:2.4
WBC 10.3 HGB 15.0 PLT 166 HCT 43.2
PT: 12.8 PTT: 26.2 INR: 1.1
Fibrinogen: 193
Head CT: Bilateral subdural hematomas, right greater than left.
Large amounts of subarachnoid hemorrhage. Hemorrhagic
contusions in the right frontal and temporal lobes. Effacement
of the perimesencephalic cisterns and right uncal herniation.
Mild amounts of cerebral edema are present. There are
nondisplaced fractures through the left occipital bone and the
left temporal bone, extending down to the anterior middle
cranial fossa. Nasal bone and orbital floor fractures.
CT spine: No fractures or dislocations of the cervical spine.
Temporal bone fracture and subarachnoid and subdural blood
present within the brain. Please see the head CT for discussion
of the report.
CT pelvis w/contrast: There is linear high attenuation material
around the ascending aorta most consistent with prior aortic
arch stent graft repair. There is a focal 8 x 6 mm outpouching
in the mid ascending aorta of uncertain chronicity. There is no
definite evidence of acute contrast extravasation. There also
appear to be clips in the aortic arch, likely related to the
aortic graft repair.
1. Patient appears to be status post graft repair of ascending
aorta/aortic arch. There is an 8 x 6 mm ascending aortic wall
outpouching of uncertain age. Most likely, however, this
represent a chronic finding. There is no definite evidence of
periaortic hematoma. Results discussed with the trauma team and
a _____ will be performed while the patient undergoes
craniotomy.
2. No acute injuries to solid organs hollow organs, vascular
structures, or bony structures.
3. Moderate bilateral dependent atelectasis.
L-spine CT: No acute fractures or acute dislocations
T-spine CT: No fractures or dislocations of the thoracic spine.
No malalignment. No obvious central canal compromise
Brief Hospital Course:
Briefly, this is a 57 year old man status post motorcycle
accident, helmet off with R frontal-temporal contusion and
bilateral SDH taken emergently for R frontal craniotomy on [**7-3**].
Bolt was placed and intracranial pressures were monitored
closely. Patient was continued on mannitol and hyperventilated
with goal PCO2 30-35. Transducer was replaced on [**7-8**] and ICP
normalized. Trach and PEG were placed. Patient spiked a
temperature of 102 and grew enterobacter (cipro sensitive) and H
flu from sputum. Patient was initially started on Zosyn and
switched to Ciprofloxacin and completed a 7 day course for
empiric treatment of pneumonia. Bolt was removed on [**7-10**] and
staples were removed on [**7-13**]. Patient was weaned to trach mask
and CT spine was cleared by ICU team. At time of discharge,
patient was opening eyes to voice, moving all extremities and
wiggling toes to command. Plan for patient to go to rehab. Goal
to wean ativan with slow taper and to follow-up in [**Hospital 4695**]
clinic to clear c-spine when mental status improved. CT spine
negative for fxs. Keep hard c collar on until follow-up with
Neurosurgery.
Medications on Admission:
Combivent INH 2 puffs QID
Naproxen 500mg [**Hospital1 **]
Lisinopril 10mg QD
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
4. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
5. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 2-6 Puffs Inhalation
Q4H (every 4 hours) as needed.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane QID (4 times a day) as needed.
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): Please slowly taper off ativan as tolerated.
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO PRN (as needed) as needed
for K<40.
15. Insulin Regular Human 100 unit/mL Solution Sig: PER SLIDING
SCALE UNITS Injection ASDIR (AS DIRECTED).
16. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
17. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day): hold for SBP<100 or RR<55.
18. Magnesium Sulfate 50 % (4 mEq/mL) Solution Sig: Two (2)
Injection PRN (as needed) as needed for Mg<2.0.
19. Calcium Gluconate 100 mg/mL (10%) Solution Sig: Two (2)
Intravenous PRN (as needed) as needed for iCa<1.12.
20. Phenytoin Sodium 50 mg/mL Solution Sig: One Hundred (100) mg
Intravenous Q8H (every 8 hours): Please check dilantin level
and adjust accordingly with therapeutic goal [**10-9**]. [**Month (only) 116**] change
to PO as tolerated.
21. Haloperidol Lactate 5 mg/mL Solution Sig: 1-5 mg Injection
Q4H (every 4 hours) as needed.
22. Diphenhydramine HCl 50 mg/mL Solution Sig: 12.5-25 mg
Injection Q6H (every 6 hours) as needed for itching.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
R frontal-temporal contusion and bilateral SDH s/p MCA
Discharge Condition:
Neurologically stable
Discharge Instructions:
Please take medications as prescribed. Please keep follow-up
appointments.
.
Please keep hard C-collar on until follow-up with Neurosurgery
(see below).
Followup Instructions:
Please follow-up with in Dr.[**Name (NI) 2845**] office (NEUROSURGERY) with
repeat head CT on [**2144-8-26**] 10:00am. Phone: [**Telephone/Fax (1) 45015**]. The
office will call you with the time and date of your head CT
appointment.
Location: [**Last Name (NamePattern1) **] [**Location (un) **] [**Hospital Unit Name **].
.
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] (PCP) in [**12-23**] weeks of
discharge. Phone: [**Telephone/Fax (1) 67505**]
Completed by:[**2144-7-16**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2947
} | Medical Text: Admission Date: [**2147-4-16**] Discharge Date: [**2147-5-1**]
Date of Birth: [**2077-2-28**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Prochlorperazine / Remicade / Demerol / Morphine /
Dilaudid / Darvocet-N 100
Attending:[**First Name3 (LF) 2006**]
Chief Complaint:
Hip pain/fracture
Major Surgical or Invasive Procedure:
[**2147-4-17**] Open reduction internal fixation of the left hip
History of Present Illness:
70 yo W w/ refractory Crohn's disease s/p total
colectomy/ileostomy, short gut syndrome, rheumatoid arthritis on
prednisone, PEs in [**2144**] (on coumadin), osteoporosis and falls
who was admitted to medical service s/p fall on [**4-16**], found to
have left intertrochanteric hip fracture and s/p intramedullary
nailing with cephalomedullary
system today, post op developed hypotension/resp. distress felt
to be due to mucous plug, requiring reintubation, now
re-extubated and admitted to MICU for persistent tachycardia and
hypoxia.
.
Patient had a mechanical fall on [**4-16**] in setting of increased
sedating medications (gabapentin), initially evaluated at OSH,
where she was found to be in moderate pulmonary edema. On
arrival to [**Hospital1 **], was found to have a Leukocytosis 12K (felt to be
reactive) but was started on Cipro/Flagyl in case GI source and
given 3mg of Vitamin K.
.
Has had progressively worsening dyspnea for months, attributed
ILD and CHF? She is on coumadin for recurrent DVTs.
.
Post-op, post extubation, noted to be tachypneic w/ O2 sats in
80s, HE in 140s and BP in 150s w/o significant improvement on
NRB, thus was reintubated. Bronch -> mucus plug, suctioned, VBG
7.18/57/49. After 2 hrs, noted to have improving MS and O2 sats,
was thus extubated at 1300. Weaned to 3L NC, however, remained
tachycardic in 120-130 sinus with SBP 90/50s (pre-op BPs in
110-130s) and oliguria. She was treated with 1U PRBCs, 5.5 L NS
total, UOP improved to 30cc/hr (prior < 10cc/hr). In addition
to above, pt. received 10mg of esmolol for NSVT on tele w/ SBP
to 80s transiently, Flagyl 250mg, Prednisone 5mg, Coumadin 5mg,
Dilaudid 0.6mg and APAP 1g. Given persistent tachycardia and
hypotension, transferred to MICU.
.
On arrival to the MICU, VS 121 87/42, RR 22 95% 3L NC. C/O of
hip pain and SOB.
Past Medical History:
-CVA with deficits in her right frontal lobe.
-Neuropathy
-Restless legs
-h/o DVT in [**12/2144**], denies any history of PEs
-small, subsegmental PE on [**2144-6-11**] CTA
-Rheumatoid arthritis, dx in [**2134**]
-Crohn's dx in [**2129**], c/b pyoderma gangrenosum developed recently
at ostomy
-Asthma/chronic bronchitis
-Depression/anxiety
-Recent falls
-Osteoporosis with multilevel compression fracture T11-L3
.
Surgical History:
-[**6-7**]: Laparotomy and extensive lysis of adhesions, Excision of
abdominal wall and en bloc resection of abdominal wall and small
intestine, Complex abdominal wall closure, Permanent ileostomy,
Ventral hernia repair with placement of SurgiMend mesh.
-[**2143-7-13**] - VAC change and debridement
-[**2143-7-2**] - Wound opening and debridement of devitalized skin and
subcutaneous tissues; Irrigation of the wound; Debridement of
devitalized fascia and removal of some mesh and suture;
placement of VAC.
-s/p multiple abd surgeries (13-14) [**Street Address(1) 23362**]??????s
procedure and [**Doctor Last Name **] reversal.
-s/p colectomy/ileostomy
Social History:
Shows that she is a widow who has three daughters and a niece
who is very close to her ([**Doctor First Name **], with her today). She likes
doing crafts and likes cooking.
She does not drink, smoked for 20 years, but quit in [**2122**],
denies TB exposure.
Family History:
Brothers and sister with heart disease, inc. sister with CABG.
No family history of IBD. Daughters healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM
General: Awake, slightly sleepy, but awakens to voice.
HEENT: Sclera anicteric, dMM, oropharynx clear
Neck: supple, JVP 12cm, no LAD
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: crackles bilaterally, laterally, unable to assess
posteriorly, due to pain
Abdomen: soft, obese, NT, loose stool in stoma
GU: foley
Ext: warm, well perfused, 2+ pulses, no edema.
Neuro: Awake, sleepy, but responds to voice and follows
commands. DOWf but not backwards, intact naming, [**Location (un) 1131**]. Did
not test other cognitive functions.
VFF to confrontation. EOMI, b/l 4->2mm, face symmetric, tongue
midline, palate symmetric.
UEs antiresistance, unable to assess [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] to hip pain. toes
down
DISCHARGE PHYSICAL EXAM
VS: T 98.5 BP 101/53 (101-110/50-60) P 88 (73-88) R 20 O2 95% RA
General: Awake, alert, interactive.
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: RR, normal S1 + S2, II/VI SEM at RUSB no rubs, gallops
Lungs: bibasilar crackles but otherwise clear
Abdomen: soft, obese, minimally tender to palpation diffusely,
loose stool in stoma
Ext: warm, well perfused, 2+ pulses, no edema.
Pertinent Results:
ADMISSION LABS
[**2147-4-16**] 09:15AM BLOOD WBC-11.7* RBC-3.34* Hgb-9.1* Hct-29.6*
MCV-89 MCH-27.2 MCHC-30.7* RDW-22.7* Plt Ct-263
[**2147-4-16**] 09:15AM BLOOD Neuts-90.0* Lymphs-4.8* Monos-5.0 Eos-0.1
Baso-0.2
[**2147-4-16**] 09:15AM BLOOD PT-31.7* PTT-35.3 INR(PT)-3.1*
[**2147-4-16**] 09:15AM BLOOD Glucose-120* UreaN-24* Creat-0.6 Na-139
K-3.5 Cl-111* HCO3-21* AnGap-11
[**2147-4-16**] 09:15AM BLOOD ALT-22 AST-23 CK(CPK)-74 AlkPhos-100
TotBili-0.4
[**2147-4-17**] 06:00AM BLOOD Calcium-7.0* Phos-1.2*# Mg-1.6
RELEVANT LABS
[**2147-4-17**] 10:10AM BLOOD WBC-20.5*# RBC-3.95* Hgb-10.7* Hct-36.3#
MCV-92 MCH-27.1 MCHC-29.4* RDW-21.8* Plt Ct-245
[**2147-4-19**] 04:07AM BLOOD PT-57.4* PTT-34.2 INR(PT)-5.7*
[**2147-4-20**] 03:58AM BLOOD PT-72.7* PTT-34.2 INR(PT)-7.3*
[**2147-4-18**] 01:12AM BLOOD CK-MB-7 cTropnT-0.35*
[**2147-4-18**] 05:56AM BLOOD CK-MB-7 cTropnT-0.24*
[**2147-4-18**] 04:14PM BLOOD CK-MB-7 cTropnT-0.16*
[**2147-4-25**] 01:37PM BLOOD CK-MB-4 cTropnT-0.02*
[**2147-4-26**] 04:03AM BLOOD CK-MB-3 cTropnT-0.02*
[**2147-4-18**] 01:12AM BLOOD Cortsol-20.5*
[**2147-4-18**] 05:56AM BLOOD Cortsol-11.5
[**2147-4-18**] 06:48AM BLOOD Cortsol-35.4*
DISCHARGE LABS
[**2147-5-1**] 05:33AM BLOOD WBC-12.7* RBC-3.19* Hgb-8.3* Hct-29.2*
MCV-92 MCH-25.9* MCHC-28.3* RDW-20.4* Plt Ct-518*
[**2147-5-1**] 05:33AM BLOOD PT-26.2* PTT-35.2 INR(PT)-2.5*
[**2147-5-1**] 05:33AM BLOOD Glucose-85 UreaN-14 Creat-0.6 Na-137
K-4.0 Cl-106 HCO3-27 AnGap-8
[**2147-5-1**] 05:33AM BLOOD Calcium-7.9* Phos-2.1* Mg-1.8
MICROBIOLOGY
Blood Culture, Routine (Final [**2147-4-22**]): NO GROWTH.
Blood Culture, Routine (Final [**2147-4-22**]): NO GROWTH.
Blood Culture, Routine (Final [**2147-4-24**]): NO GROWTH.
Blood Culture, Routine (Final [**2147-4-24**]): NO GROWTH.
URINE CULTURE (Final [**2147-4-19**]): NO GROWTH.
MRSA SCREEN (Final [**2147-4-20**]): No MRSA isolated.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2147-4-18**]):
Feces negative for C. difficile toxin A & B by EIA.
[**2147-4-19**] SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2147-4-19**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2147-4-19**]):
TEST CANCELLED, PATIENT CREDITED.
Blood Culture, Routine (Final [**2147-4-30**]): NO GROWTH.
Blood Culture, Routine (Final [**2147-5-1**]): NO GROWTH.
URINE CULTURE (Final [**2147-4-25**]): NO GROWTH.
FECAL CULTURE (Final [**2147-4-26**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2147-4-26**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2147-4-25**]):
Feces negative for C. difficile toxin A & B by EIA.
(Reference Range-Negative).
Cryptosporidium/Giardia (DFA) (Final [**2147-4-26**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
OVA + PARASITES (Final [**2147-4-26**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
[**2147-4-26**] BLOOD CULTURE Routine (Pending):
IMAGING
ECG [**4-16**]: Sinus rhythm. Within normal limits. No significant
change compared to previous tracing of [**2147-4-16**] and that of
[**2146-3-30**].
ECG [**4-18**]: The rate is slightly slower with persistent sinus
tachycardia. Otherwise, no significant change compared to
tracing #1.
ECG [**4-20**]: The rhythm appears to be supraventricular which could
still be sinus tachycardia. However, this raises the possibility
of a supraventricular tachycardia (atrial flutter or A-V
re-entrant tachycardia) with low voltage compared to tracing #2.
This could represent a pneumothorax or pericardial effusion,
among other things. Clinical correlation is suggested.
TTE [**4-18**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50%). The
right ventricular free wall thickness is normal. 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. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate to severe [3+]
tricuspid regurgitation is seen (may be underestimated). [In the
setting of at least moderate to severe tricuspid regurgitation,
the estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.]
Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2146-12-2**], severe right ventricular contractile
dysfunction and moderate-to-severe (possibly frankly severe)
tricuspid regurgitation are now present. The pulmonary artery
pressure is probably significantly elevated.
CTA [**4-18**]: IMPRESSION: 1. No acute aortic pathology. If there is
a filling defect in the left lower lobe subsegmental artery, it
is isolated and too small to be clinically significant. No other
filling defect concerning for pulmonary embolism.
2. Mild right heart failure with significant right atrial and
right
ventricular enlargement, exacerbated by interstitial lung
disease and
emphysema.
3. Small perihepatic ascites.
4. Lesion at the carina may be mucus or an endobronchial lesion
covered with mucus. Consider repeat CT for reassessment(preceded
by vigorous coughing) after treatment of heart failure.
CT ABD [**4-20**]: IMPRESSION: 1. No evidence for abscess.
2. Ileostomy in the right lower quadrant.
3. Anterior abdominal wall hernia containing small bowel, no
evidence of
obstruction.
CXR [**4-20**]: FINDINGS: In comparison with study of [**4-18**], there is
little overall change. Substantial cardiomegaly with bilateral
opacifications most likely reflecting pulmonary edema. The
possibility of supervening pneumonia would have to be raised in
the appropriate clinical setting.
Central catheter remains in place. Slight impression on the
lower cervical
trachea on the right could possibly represent a small thyroid
mass.
CXR [**4-25**]: Comparison is made to prior study, [**4-24**].
Moderate-to-severe cardiomegaly is unchanged. There are low lung
volumes. Left Port-A-Cath tip is in the right atrium. There is
no pneumothorax or pleural effusion. Mild-to-moderate pulmonary
edema is stable.
TTE [**4-26**]: The left atrium is mildly dilated. The estimated right
atrial pressure is at least 15 mmHg. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). The right ventricular free wall thickness is normal.
The right ventricular cavity is moderately dilated with mild
global free wall hypokinesis. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is at least mild
tricuspid regurgitation. There is mild-moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Moderately dilated and
mildly hypokinetic right ventricle with at least mild tricuspid
regurgitation and mild-moderate pulmonary hypertension.
Preserved left ventricular systolic function.
CXR [**4-26**]: As compared to the previous radiograph, there is
unchanged evidence of moderate-to-severe pulmonary edema.
However, the interstitial component of the edema is more
prominent on the current image. The presence of a small pleural
effusion cannot be excluded. Unchanged mild cardiomegaly.
Unchanged position of the left pectoral Port-A-Cath.
PORTABLE ABDOMEN [**4-29**]: There are dilated loops of presumably
small bowel in the lower abdomen. Although most likely
reflecting adynamic ileus, the possibility of an obstruction
cannot be unequivocally excluded. If this is a serious clinical
concern, CT would be the next imaging procedure.
Brief Hospital Course:
70 yo W w/ refractory Crohn's disease s/p total
colectomy/ileostomy, short gut syndrome, rheumatoid arthritis on
prednisone, PEs in [**2144**] (on coumadin), osteoporosis and falls,
admitted s/p L hip fracture, now s/p L ORIF w/ post op
hypotension/resp. distress [**3-2**] mucous plug,
re-intubation/extubation, atrial tachycardia, called-out of the
MICU and is now doing well.
ACUTE ISSUES
# Left hip fracture s/p ORIF - Mechanical fall likely [**3-2**]
osteoporosis with chronic steroid use. Stitches removed on
[**2147-5-1**] and pt can weight-bear as tolerated. Pt has been
tolerating PT well. She will be discharged on her home oxycodone
and acetaminophen prn for pain control. She has follow-up with
NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2147-5-30**].
# Hypotension. Etiology remained elusive, however after
extensive evaluation, most likely etiology initially was felt be
a combination of sepsis from pulmonary source (HCAP in setting
of mucous plug), volume overload (right sided failure, confirmed
by TTE) in setting of aggressive volume resuscitation 8L and
possible atrial tachycardia. CTA showed no PE and ground glass
opacities as well as findings consistent with interticial lung
disease and emphysema. CT abdomen w/o IV contrast showed no
evidence of large abcess or additional fistulae. Adrenal
insufficiency was ruled out with [**Last Name (un) 104**] stim test. On multiple
occasions, patient was found to have SVT to 160s, felt to be
consistent with atrial tachycardia with drop in BP by over 10mm
Hg. With SVT to 130s, no appreciable change in BP was noted.
Pt. was weaned off pressors on [**4-20**]. Residual hypotension was
noted in correlation to narcotic pain medication administration,
though pt always mentated well. This was also in the setting of
giving metoprolol for atrial tachycardia, which was then reduced
to 12.5mg [**Hospital1 **] metoprolol in house with some improvement in
hypotension.
# Fever. Unclear in etiology. Pt was treated with
Vancomycin/Zosyn for HCAP and on the day that they were supposed
to be completed ([**4-24**]), she developed sudden fever to 102.8 with
severe wheezing and tachypnea. Symptoms improved with APAP.
Port was de-accessed and pt. was pancultured. She was restarted
on Vancomycin and Meropenem. On [**4-26**] port was re-accessed and
cultures obtained w/o further incident. Given negative cultures
from [**2147-4-24**], antibiotics were discontinued. Pt remained
afebrile through the rest of the hospitalization.
# Tachycardia. Sinus during acute illness phase, however with
runs of atrial tachycardia in setting of volume overload. With
diuresis and completion of antibiotics, patient continued to
have frequent runs of a-tach. She was started on Metoprolol and
loaded with digoxin. Subsequent HRs were in 70-80 range with BPs
in 90s-100s. Digoxin was then discontinued as pt was in sinus
rhythm. Cardiology was consulted who suggested rate control with
Toprol 25mg daily.
# RV dysfunction. ECHO on [**2147-4-18**] showed the right ventricular
cavity dilated with severe global free wall hypokinesis and
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. Moderate to severe [3+]
tricuspid regurgitation was seen. It was recommended that pt be
adequately diuresed and repeat ECHO obtained, which on [**2147-4-26**]
showed the right ventricular cavity moderately dilated with mild
global free wall hypokinesis and still abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. However, it only showed at least mild
tricuspid regurgitation. Discussion was held with Cardiology
about possibility of performing a right heart catheterization,
which was deferred to the outpatient setting. Pt will be seen in
Cardiology as an outpatient for further follow-up.
# Acute on chronic diastolic dysfunction - TTE w/ EF > 55% and
evidence of RV dilatation and volume overload. Pt was
aggressively diuresed in the MICU with repeat ECHO, though
minimal change was seen, except for improvement in tricuspid
regurgitation. Pt is not on any diuretics at home and none were
started upon discharge. Pt will have f/u with Cardiology as an
outpatient.
# Pulmonary Hypertension. Pt w/ PASP of 35mm Hg. Could be due to
ILD or COPD. Pt has outpatient f/u with pulm for repeat PFTs in
[**Month (only) 116**].
# Recurrent DVTs and hx of PE. Coumadin temporarily held on
admission in setting of hypotension. Patient bridged at that
time with lovenox. INR again increased in setting of meropenem
initiation, coumadin temporarily held and restarted on [**4-25**]. She
has been on 3mg daily with therapeutic INRs. Recommend checking
INR level tomorrow and re-dosing as appropriate since pt is on
acetaminophen and zoloft which can affect INR levels.
# Crohns disease. Stable, pt. w/o c/o of abdominal pain/cramping
(typical for her). No changes in stoma output. Held MTX as
above. Steroids were restarted once patient was HD stable. GI
was consulted to assess whether some of her infectious
presentation could be due to an underlying fistula, which was
not felt to be the case. Her Methotrexate was re-started upon
discharge per her outpatient gastroenterologist.
# Rheumatoid arthritis dx. Per discussion with OP
rheumatologist, all of her w/up has been negative (all
serologies), and her arthralgias were felt to be more consistent
with Crohns related arthritis rather then RA. Prednisone 5mg
daily was restarted and continued throughout the
hospitalization.
# Neuropathy. Topamax was stopped in setting of lack of
efficacy, persistent acidosis and family concerns re: AEs
(mental slowing). Can consider re-starting as an outpatient if
indicated.
TRANSITIONAL ISSUES
# Incidental finding f/u: CTA chest [**2147-4-18**] showed a lesion at
the carina may be mucus or an endobronchial lesion covered with
mucus. Consider repeat CT for reassessment(preceded by vigorous
coughing) after treatment of heart failure. She is currently
scheduled for CT CHEST W/O CONTRAST on [**2147-5-23**].
# Recommend discussion with Dr. [**First Name (STitle) 572**] regarding utility for
flagyl (on this previously, stopped during MICU course)
Medications on Admission:
- lidocaine 5 %(700 mg/patch) Adhesive Patch
- gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
- prednisone 5 mg Tablet
- ropinirole 1 mg Tablet tid (confirmed with pt)
- topiramate 25 mg PO BID
- sertraline 25 mg qHS
- omeprazole 20 mg qd
- methotrexate sodium 15 mg qd
- warfarin 5 mg qd
- lorazepam 0.5 mg qHS
- promethazine 25 mg Q6H prn for nausea.
- folic acid 1 mg qd
- oxycodone 5 mg q4-6 hours as needed for pain
- mupirocin 2 % Ointment tid
- Flagyl 250 mg qd (confirmed with pt - though pt reports not
taking)
.
OTC
- magnesium oxide 500 mg qd
- potassium chloride 99 mg 6 tablet
- vitamin A 8000 units qd
- cyanocobalamin (vitamin B-12) 1,000 mcg po qd
- lysine 500 mg PO bid
- carbonyl iron Sig: Twenty Seven (27) mg once a day (pt reports
not taking)
- brimonidine 0.2 % Drops Sig: One (1) drop each eye
Ophthalmic twice a day.
- Vitamin D 2,000 unit Capsule qd
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
2. gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. sertraline 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. lorazepam 1 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed
for insomnia/anxiety.
10. ropinirole 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. ropinirole 1 mg Tablet Sig: One (1) Tablet PO Q NOON ().
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
13. brimonidine 0.2 % Drops Sig: One (1) drop Ophthalmic twice a
day: Please apply to both eyes.
14. vitamin A 8,000 unit Capsule Sig: One (1) Capsule PO once a
day.
15. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
16. lysine 500 mg Capsule Sig: One (1) Capsule PO twice a day.
17. magnesium oxide 500 mg Capsule Sig: One (1) Capsule PO once
a day.
18. potassium 99 mg Tablet Sig: Six (6) Tablet PO once a day.
19. cyanocobalamin (vitamin B-12) 1,000 mcg/15 mL Liquid Sig:
Fifteen (15) mL PO once a day.
20. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
21. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**1-30**] Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
22. 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.
23. methotrexate sodium 15 mg Tablet Sig: One (1) Tablet PO once
a week.
24. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
25. Symbicort 160-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary Diagnosis
Hip fracture
Secondary Diagnosis
Atrial tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 3321**],
It was a pleasure taking care of you during your hospital stay
at [**Hospital1 18**]. You were admitted due to a hip fracture and you had
this surgically repaired. However, you had a brief stay in the
intensive care unit after surgery due to low blood pressures and
fast heart rate. Your low blood pressures were likely related to
your pain medication. Your fast heart rate is being managed by a
new medication that you should take daily, called Toprol. You
will have follow-up with the Cardiology clinic, at which time
they will re-assess your heart.
Please note the following changes to your medications.
Please START taking:
1. Toprol 25mg daily
2. Acetaminophen as needed for pain
3. Zofran as needed for nausea
Please CHANGE:
1. Warfarin - take 3mg daily instead of 5mg
2. Gabapentin - take 400mg three times daily
Please STOP taking:
1. Topiramate
2. Promethazine
Otherwise, please continue taking your medications as
prescribed.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital1 18**]-DIVISION OF GASTROENTEROLOGY/ GI/WEST
Address: [**Doctor First Name **], STE 8E, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 463**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: RADIOLOGY
When: TUESDAY [**2147-5-23**] at 10:15 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2147-5-23**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2147-5-30**] at 10:40 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2147-6-1**] at 11:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**2147-6-20**] 10:30a [**Doctor Last Name **],TCC
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
PULMONARY UNIT-CC7 (SB)
[**2147-6-20**] 10:30a [**Month/Day/Year 1570**],INTERPRET W/LAB NO CHECK-IN
[**Month/Day/Year 1570**] INTEPRETATION BILLING
[**2147-6-20**] 10:10a [**First Name9 (NamePattern2) 1570**] [**Hospital Ward Name **] 7 - RM 1
[**Hospital6 29**], [**Location (un) **]
PULMONARY LAB
Completed by:[**2147-5-1**]
ICD9 Codes: 0389, 486, 9971, 2762, 4280, 311, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2948
} | Medical Text: Admission Date: [**2161-3-16**] Discharge Date: [**2161-3-19**]
Date of Birth: [**2073-12-15**] Sex: M
Service: MEDICINE
Allergies:
Optiray 350 / Clinoril / Keppra / Codeine
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 109590**] is an 87 yom with history of CAD s/p RCA and left
circumflex stent in [**2146**] and [**2151**], TIAs, afib on coumadin, MVR
s/p bioprosthetic MV in [**2151**], pacemaker, prostate cancer s/p
radiation c/b obstructive uropathy and suprapubic [**Last Name (un) **] a
urostomy p/w weakness.
.
Per family report, patient has been uncomfortable with his
catheter recently. Typically has his catheter changed every six
weeks but he had to go longer this time. Having difficulty
holding his urine, was having several accidents during the last
week. Last infection just prior to catheter change. Today he was
working out in the gym in his independent living facility,
returned to his aprtment to his wife reporting feeling weak,
rigoring severely, and was unable to stand. He was also unable
to communicate and was grunting responses only.
No documented fevers. Symptoms started acutely today. He was at
his baseline two days ago.
.
In the ED, patient triggered for appearing critically ill.
Initial vital signs were T99.4 HR84 BP148/68 RR20 O2 sat 99%RA.
He was pale, not verbally responsive, but able to shake his head
yes or no to commands. Repeat rectal temp was 102.6. Examination
was notable for lower abdominal tenderness. He had no focal
neurologic symptoms. Guaic was negative. He underwent evaluation
with head CT and CT abdomen. CBC was notable for leukocytosis.
UA strongly consistent with UTI. He received 850cc NS, and was
started on Vancomycin and Zosyn. Per report his vital signs
remained stable throughout his time in the ED. Vital signs were
HR 60, BP 139/37, RR 20, 100% on 3L NC.
.
On arrival to the MICU, patient verbally responsive but only
able to respond to simple questions.
.
Review of systems:
increase forgetfullness (comes and goes), chills. no recent
chest pains or shortness of [**Last Name (un) **]. mild abdominal discomfort,
increased urinary frequency.
(+) Per HPI
(-) unable to provide
Past Medical History:
1. prostate ca, initially treated c radiation [**2136**] now recurrent
and treated with lupron for many years. recent psa of 2 (up a
little)
2. chronic urinary retention c recent permanent foley s/p
radiation from prostate ca
3. recent UTI
4. CAD status post RCA and left circumflex stenting in [**2146**] and
[**2151**] respectively.
5. Mitral valve regurgitation status post bioprosthetic mitral
valve in [**2151**].
6. Atrial fibrillation status post Maze also in [**2151**], currently
on Coumadin.
7. Status post pacemaker following MVR. This is a [**Company 1543**] AV
sequentially pacing.
8. Hypertension.
9. Numerous TIAs on Coumadin.
10. gerd
11. constipation
12. h/o GIB, requiring discontinuation of asa. last transfusion
[**10-23**]
13. COPD
Social History:
per OMR, confirmed c pt: Married, lives with wife in [**Hospital 4382**], recently moved from FL, has 3 children. Former tobacco
quit 50 years ago, very rare EtOH, no drugs. Used to work as
dress distrubutor and in personnel.
Family History:
per OMR: Father with RCC and DM II.
Physical Exam:
Physical Exam on Admission:
General: Lethargic, responds to voice, oriented to person and
place. No acute distress.
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, harsh holosystolic
murmur. No rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
suprapublic foley catheter in place. suprapubic tenderness,
without rebound or guarding.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, strength 4/5 in all extremities. grossly
normal sensation, gait deferred. pt responding to simple
questions and commands, has difficulty with concentration.
Physical Exam on Discharge:
General: NAD, A+Ox3
HEENT: mucous membranes moist
Neuro: responds appropriately to qurestions and commands
Pertinent Results:
Lab Results on Admission:
[**2161-3-16**] 04:45PM BLOOD WBC-15.3*# RBC-4.37* Hgb-10.3* Hct-33.0*
MCV-76* MCH-23.5* MCHC-31.1 RDW-15.4 Plt Ct-216
[**2161-3-16**] 04:45PM BLOOD Neuts-92.6* Lymphs-2.6* Monos-4.4 Eos-0.1
Baso-0.3
[**2161-3-16**] 04:45PM BLOOD PT-40.9* PTT-50.0* [**Year/Month/Day 263**](PT)-4.0*
[**2161-3-16**] 04:45PM BLOOD Glucose-130* UreaN-22* Creat-1.1 Na-138
K-4.0 Cl-100 HCO3-25 AnGap-17
[**2161-3-16**] 04:45PM BLOOD ALT-16 AST-33 AlkPhos-57 TotBili-1.0
[**2161-3-16**] 04:45PM BLOOD proBNP-1131*
[**2161-3-16**] 04:45PM BLOOD cTropnT-<0.01
[**2161-3-16**] 04:45PM BLOOD Albumin-3.9 Calcium-9.5 Phos-2.7 Mg-2.7*
[**2161-3-16**] 04:53PM BLOOD Type-[**Last Name (un) **] pO2-65* pCO2-40 pH-7.45
calTCO2-29 Base XS-3
[**2161-3-16**] 04:53PM BLOOD Lactate-1.9
Studies:
Cardiovascular Report ECG Study Date of [**2161-3-16**] 4:35:06 PM
Atrial pacing and ventricular pacing. Compared to the previous
tracing
of [**2161-1-29**] no significant change.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2161-3-16**]
4:47 PM
IMPRESSION: No acute intracranial pathology.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-3-16**] 4:47
PM
IMPRESSION: Lower lung volumes on the current exam. Left lower
lobe opacity
seen medially, potentially due to atelectasis; however,
infiltrate is not
completely excluded. Clinical correlation is suggested.
Radiology Report CT ABD & PELVIS W/O CONTRAST Study Date of
[**2161-3-16**] 5:15 PM
IMPRESSION:
1. Cholelithiasis without evidence of acute cholecystitis. No
acute abdominal
pathology.
2. Moderate-to-severe atherosclerotic disease of the abdominal
aorta and
visceral arteries.
Cardiovascular Report ECG Study Date of [**2161-3-17**] 1:25:12 PM
Atrio-ventricular pacing. Compared to the previous tracing of
[**2161-3-16**] the
ventricular rate is slower.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-3-17**] 8:06
PM
FINDINGS: As compared to the previous radiograph, there is an
increased area
of atelectasis at the left lung base, presence of a minimal left
pleural
effusion cannot be excluded.
Borderline size of the cardiac silhouette. No pneumonia, no
pulmonary edema.
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 109591**]Portable TTE
(Complete) Done [**2161-3-18**] at 4:44:26 PM FINAL
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Trace aortic regurgitation
is seen. A bioprosthetic mitral valve prosthesis is present. The
transmitral gradient is normal for this prosthesis. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
[Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2160-1-11**],
the degree of pulmonary hypertension has increased. The right
ventricle appears mildly dilated/hypokinetic. The other findings
are similar.
Microbiology:
[**2161-3-16**] 4:45 pm URINE
**FINAL REPORT [**2161-3-18**]**
URINE CULTURE (Final [**2161-3-18**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
[**Date range (1) 92289**] blood culture: no growth
Lab Results on Discharge:
[**2161-3-19**] 10:45AM BLOOD WBC-5.6 RBC-3.95* Hgb-9.1* Hct-30.1*
MCV-76* MCH-23.0* MCHC-30.3* RDW-15.4 Plt Ct-175
[**2161-3-17**] 03:19AM BLOOD Neuts-94.7* Lymphs-2.4* Monos-2.6 Eos-0.2
Baso-0.1
[**2161-3-19**] 10:45AM BLOOD PT-17.3* PTT-33.7 [**Year/Month/Day 263**](PT)-1.6*
[**2161-3-19**] 10:45AM BLOOD Glucose-126* UreaN-15 Creat-1.0 Na-138
K-3.5 Cl-101 HCO3-29 AnGap-12
[**2161-3-17**] 03:19AM BLOOD ALT-13 AST-27 AlkPhos-46 TotBili-1.1
[**2161-3-19**] 10:45AM BLOOD Calcium-8.1* Phos-1.7* Mg-2.3
Urinue:
[**2161-3-16**] 04:45PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2161-3-16**] 04:45PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
[**2161-3-16**] 04:45PM URINE RBC-15* WBC-153* Bacteri-MOD Yeast-NONE
Epi-0
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is an 87 yo male
with PMH of CAD, afib, MVR, prostate cancer with suprapubic
catheter, and COPD who presents from home with rigors and
weakness. He was being treated for UTI and possible pneumonia as
well and discharged with a home course of antibiotics to
follow-up with PCP.
.
ACUTE CARE:
1. Urinary tract infection: Patient developed altered mental
status suddenly on the afternoon of admission after what is
described to be rigors. He was symptomatic with suprapubic
tenderness, weakness, and inability to communicate. His
neurologic exam, as much as he was able to cooperate at the time
is nonfocal. His catheter was changed, and with antibiotics
ovenight his mental status improved and he was transferred from
the ICU to medical floor. He again transiently spiked a fever on
transfer to the floor but remained mentating well and then
defervesced. He had a positive UA and a UC which grew mixed
flora. He received antibiotic treatment with great improvement
and was discharged home on a course of levofloxacin.
.
2. Hypoxia: Patient developed new oxygen requirement on
transition to floor from the ICU. CXR showed vascular
congestion. His home lasix which was temporarily held was
restarted, patient had excellent urine output and his hypoxia
improved. He was discharged on home lasix and satting well on
room air.
.
3. Acute Diastolic Heart Failure: On transfer to the floor from
MICU, patient's chest exam revealed rapid onset rales and his
oxygen saturation dropped from 98%RA to 94%RA. CXR revealed
increased left pleural effusion and increased pulmonary vascular
congestion. With resuming lasix therapy, patient had a
successful diuresis and his oxygenation improved to no oxygen
requirement. Echo revealed normal EF, showing this was likely an
episode of acute diastolic heart failure.
.
4. Delirium: On presentation, patient was only responsive to
questioning with grunts while his baseline mental status is
A+Ox3 and capable of organizing club activities with groups at
his living facility. This was likely secondary to infectious
process on top of underlying mild chronic cerebral vascular
disease. The altered mental status resolved with IV antibiotics
and patient returned to his baseline mental status with
treatment of UTI.
.
CHRONIC CARE:
1. CAD w/ history of stent: Patient presented off of ASA given
anemia secondary to GIB. He was continued on his home
antihypertensives.
.
2. Mitral Valve Pathology: [**2159**] echo showed moderate MR. [**First Name (Titles) **] [**Last Name (Titles) **]F is not in patient's PMH, he does report a history swollen
ankles and does require home lasix suggesting predilection to
CHF. Repeat echo showed normal EF and mild MR. [**Name13 (STitle) **] was discharged
to PCP [**Last Name (NamePattern4) 702**].
.
3. H/o [**Female First Name (ambig) 27349**]: [**Last Name (ambig) **] coumadin was initially held for
supratherapeutic [**Last Name (ambig) 263**] but was restarted at discharge to be
followed-up by his coumadin clinic.
.
4. Afib s/p MAZE: Patient was rate controlled with AV pacing at
60, and is on warfarin anticoagulation.
.
5. Asthma: Continued home inhalers.
.
6. Prostate ca: Continued Leupron.
.
7. GERD: Continued PPI
.
8. Constipation: Patient received bisacodyl suppository
.
TRANSITIONS IN CARE
1. Communication: Patient, daughter [**Name (NI) **] [**Name (NI) 109590**]
2. Code Status: confirmed FULL on this admission
3. Medication changes:
START** Levofloxacin antibiotics 250 mg once a day for 7 more
days (to end [**2161-3-26**])
START** Senna 1 tablet twice a day as needed for constipation
START** Colace 1 tablet twice a day as needed for constipation
4. FOLLOW-UP:
Name: [**Last Name (LF) **], [**First Name3 (LF) **]
Location: [**Hospital1 **] SENIOR HEALTH
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 60246**]
Appointment: FRIDAY [**3-20**] AT 9:30AM
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2161-3-26**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2161-3-31**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2161-3-31**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
5. OUTSTANDING CLINICAL ISSUES:
-titration of warfarin dosing
-managemnt of suprapubic catheter.
Medications on Admission:
warfarin
alendronate
amlodipine
furosemide
leuprolide
omeprazole
miralax
spiriva
symbicort 89/4.5 strength [**2160-11-7**]
albuterol sulfate prn
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for sob/wheeze.
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
4. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lupron Depot (3 Month) Intramuscular
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO as directed.
11. Vitamin C Oral
12. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One
(1) Tablet PO once a day.
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
15. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day: Last day [**2161-3-26**].
Disp:*7 Tablet(s)* Refills:*0*
16. Symbicort 80-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
Urinary tract infecion
Community acquired pneumonia
Secondary diagnosis:
Hypertension
Atrial fibrilation s/p MAZE procedure
Obstructive uropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 109590**],
It was a pleasure taking part in your care. You were admitted to
the hospital because you had sudden onset weakness and chills
and we found that you had a urinary tract infection. You also
had shortness of breath which may have been from a pneumonia.
You were treated with antibiotics and have had much improvement.
You were discharged home to complete a course of antibiotics and
will follow up with your primary care physician (we have made
appointments for you - please see below).
You also were found to have a large amount of stool on your CT
scan so we recommend that you take the stool softeners to ensure
you have a bowel movement once a day.
You also were found to have an elevated [**Known lastname 263**] from your coumadin
so we held this while you were here. Today we restarted it
because your [**Known lastname 263**] was too low. Please have your doctors [**Name5 (PTitle) 4169**]
your [**Name5 (PTitle) 263**] at your follow up visit tomorrow.
Please make the following changes to your medications:
START** Levofloxacin antibiotics 250 mg once a day for 7 more
days (to end [**2161-3-26**])
START** Senna 1 tablet twice a day as needed for constipation
START** Colace 1 tablet twice a day as needed for constipation
Please keep all follow-up appointments (see below)
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name3 (LF) **]
Location: [**Hospital1 **] SENIOR HEALTH
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 60246**]
Appointment: FRIDAY [**3-20**] AT 9:30AM
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2161-3-26**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2161-3-31**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2161-3-31**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5990, 4271, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2949
} | Medical Text: Admission Date: [**2155-9-26**] Discharge Date: [**2155-10-3**]
Date of Birth: [**2092-12-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
post prandial satiety, bloating and distension for two months
Major Surgical or Invasive Procedure:
endoscopic cystgastrostomy complicated by gastric perforation
History of Present Illness:
The patient is a 62 year old female with a past medical history
significant for a laproscopic cholecystectomy in [**2154-12-28**]
for gallstone pancreatitis and a negative intraoperative
cholangiogram, who presented with early satiety and bloating for
two months, with occasional bilious vomiting. In Februuary
[**2154**], the patient was readmitted for abdominal pain. An MRCP
done at that time was negative except for some soft tissue
swelling in the body of the pancreas. A CT scan done one month
priot to this admission demonstrated a 12 cm pseudocyst, and a
repeat CT scan 2 weeks priot to admission showed no increase in
the size of the pseudocyst. Her liver function tests have
always been normal. She denies any bleeding, weight loss,
fevers, or jaundice.
Past Medical History:
glaucoma, hypercholesterolemia, appendectomy, colon resection
for leiomyoma, tonsillectomy, right breats cyst, right knee
surgery
Social History:
Quit smoking ten years ago, drinks two-three glasses of wine per
day
Family History:
none
Physical Exam:
General: no apparent distress
HEENT: sclerae anicteric, pupils equal round and reactive to
light
Neck: supple
Lungs: clear to ascultation bilaterally
Heart: regular rate and rhythum, no murmurs
Abdomen: soft, bowel sounds +, very distended, minimal
tenderness, no rebound or guarding
Extremities: no clubbing, cyanosis or edema, full range of
motion
Neurologic: no focal deficits, alert and oriented X3
Pertinent Results:
[**2155-9-26**] 10:30AM BLOOD WBC-5.0 RBC-5.09 Hgb-14.5 Hct-42.8 MCV-84
MCH-28.5 MCHC-33.9 RDW-12.9 Plt Ct-292
[**2155-9-26**] 07:43PM BLOOD WBC-13.1*# RBC-4.79 Hgb-14.3 Hct-41.4
MCV-86 MCH-29.8 MCHC-34.6 RDW-12.8 Plt Ct-318
[**2155-9-27**] 03:35AM BLOOD WBC-10.5 RBC-4.68 Hgb-13.8 Hct-39.6
MCV-85 MCH-29.5 MCHC-34.9 RDW-12.9 Plt Ct-255
[**2155-9-28**] 05:55AM BLOOD WBC-7.5 RBC-4.65 Hgb-13.6 Hct-40.2 MCV-86
MCH-29.3 MCHC-33.9 RDW-12.9 Plt Ct-260
[**2155-9-26**] 10:30AM BLOOD PT-12.5 PTT-27.2 INR(PT)-1.0
[**2155-9-26**] 10:30AM BLOOD Plt Ct-292
[**2155-9-26**] 07:43PM BLOOD PT-12.8 PTT-23.2 INR(PT)-1.1
[**2155-9-26**] 07:43PM BLOOD Plt Ct-318
[**2155-9-26**] 07:43PM BLOOD Glucose-180* UreaN-14 Creat-0.9 Na-139
K-3.9 Cl-102 HCO3-27 AnGap-14
[**2155-9-27**] 03:35AM BLOOD Glucose-138* UreaN-10 Creat-0.7 Na-140
K-3.9 Cl-104 HCO3-26 AnGap-14
[**2155-9-28**] 05:55AM BLOOD Glucose-131* UreaN-7 Creat-0.8 Na-140
K-4.3 Cl-105 HCO3-26 AnGap-13
[**2155-9-26**] 10:30AM BLOOD ALT-24 AST-24 AlkPhos-62 Amylase-27
TotBili-0.7 DirBili-0.1 IndBili-0.6
[**2155-9-26**] 07:43PM BLOOD ALT-140* AST-146* AlkPhos-71 Amylase-25
TotBili-0.6
[**2155-9-27**] 03:35AM BLOOD ALT-137* AST-83* AlkPhos-63 Amylase-26
TotBili-0.9
[**2155-9-28**] 05:55AM BLOOD ALT-86* AST-34 AlkPhos-59 TotBili-1.0
[**2155-9-26**] 07:43PM BLOOD Calcium-8.5 Phos-4.3 Mg-1.8
[**2155-9-27**] 03:35AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.6
[**2155-9-28**] 05:55AM BLOOD Calcium-9.0 Phos-2.3* Mg-1.7
[**2155-9-30**] 05:25AM BLOOD WBC-4.2 RBC-4.61 Hgb-13.5 Hct-38.9 MCV-84
MCH-29.3 MCHC-34.7 RDW-12.8 Plt Ct-277
[**2155-9-30**] 05:25AM BLOOD Plt Ct-277
[**2155-10-1**] 05:50AM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-140
K-4.4 Cl-105 HCO3-25 AnGap-14
[**2155-10-2**] 06:00AM BLOOD Glucose-101 UreaN-7 Creat-0.8 Na-141
K-4.1 Cl-105 HCO3-24 AnGap-16
[**2155-10-1**] 05:50AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9
[**2155-10-2**] 06:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.9
Brief Hospital Course:
The patient was admitted on [**2155-9-26**] for an elective endoscopic
cystgastrostomy, which was complicated by gastric perforation.
Three 10Fx5cm double pigtail stents were placed during the
procedure, but the pseudocyst most likely separated from the
gastric wall at some point during stent placement. A CT scan
done at that time showed findings consistent with tension
pneumoperitoneum causing compression of the IVC, presumably due
to a leak of air from the stomach into the retroperitoneum and
in the intraperitoneal space. The plan was made by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] to decompress her with angiocatheter placement, keep her
NPO, begin orogastric tube drainage,and begin Ampicillin,
Levofloxacin, Flagyl, and Fluconazole prophylactically. The
patient was transferred to the intensive care unit in stable
condition for further monitoring. An abdominal X-ray
demonstrated increased free peritoneal. An angiocatheter was
placed and a gush of free air was released. The patient felt
much better. On postprocedure day one, the patient was doing
much better and was transferred to the floor. On postprocedure
day two, the patient again did well, however there was some
scant bloody drainage from her OG tube. On postprocedure day
three, her abdominal examination was benign and she was
afebrile. She passed bowel movements and flatus. Her OG tube
was removed. She was started on sips of clears on postprocedure
day five. Her diet was advanced to clears and then soft pureed
diet on postprocedure day six. The patient continued to look
excellent and was discharged home on postprocedure day seven
after having completed her full antibiootics course.
Medications on Admission:
glaucoma eye drops
Discharge Medications:
1. Betimol Ophthalmic
2. 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:
pancreatic pseudocyst
Discharge Condition:
good
Discharge Instructions:
Please come to the ER with fevers > 101.4. Come to the ER with
increasing abdominal pain or distension, nausea or vomiting or
significant change in bowel habits. Please continue to take
Protonix until atleast your follow-up visitw with Dr. [**Last Name (STitle) **].
Please continue with a soft diet until follow-up visit.
Followup Instructions:
Please call Dr.[**Name (NI) 2829**] office to schedule a follow-up
appointment for one week from this Monday.
Completed by:[**2155-10-3**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2950
} | Medical Text: Admission Date: [**2148-10-29**] Discharge Date: [**2148-11-1**]
Date of Birth: [**2074-3-16**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 74-year-old female
with chronic obstructive pulmonary disease on three liters of
home O2 recently discharged from the [**Hospital3 2576**] [**Hospital3 **] on
[**2148-10-28**] disability and rehab for pulmonary rehab. She was
admitted to [**Hospital6 256**] on
[**2148-10-29**] for shortness of breath. The patient was
originally admitted to [**Hospital1 2025**] for five days of chronic
subjective left-sided swelling. Patient was found to have a
low hematocrit and transfused two units of blood cells.
Upper extremity Dopplers were negative for deep venous
thrombosis. Stools were guaiac positive.
Esophagogastroduodenoscopy and colonoscopy were performed
without evident source of bleeding.
Regarding her COPD, patient's pulmonary function tests were
repeated showing poor baseline and severe obstructive defect.
FEV1 was 19%. Patient was discharged to [**Hospital1 **] for
pulmonary rehab on [**2148-10-28**] and respiratory status
decreased at [**Hospital1 **]. Arterial blood gases showed a PCO2
of 90; however, her baseline is approximately 70. Patient
was given one dose of Solu-Medrol 80 mg intravenous and Lasix
40 mg intravenous and transferred to [**Hospital1 **].
In the Emergency Department the patient was placed on
bilateral positive airway pressure, and arterial blood gases
repeated showing a pH of 7.25, PCO2 of 81, and PO2 of 54,
which was similar to her gas on discharge from MTH. Patient
was transferred to the [**Hospital Unit Name 153**] for COPD exacerbation and BiPAP.
Patient refusing BIPAP in the SICU was treated with
Venti-mask and nasal cannula. O2 saturations were 95 to
100%. Patient was given two days of Prednisone at 60 mg to
complete approximately a two-week taper. No further diuresis
was required. There are no clinical indications for
antibiotics during this course. Patient remained afebrile
without cough or sputum.
PAST MEDICAL HISTORY:
1. COPD requiring three liters of home O2; no history of
intubation.
2. Obstructive sleep apnea.
3. Anemia.
4. Type 2 diabetes not requiring insulin.
5. Chronic headaches.
ALLERGIES: Iodine; patient gets hives.
MEDICATIONS:
1. Albuterol.
2. Ipratropium.
3. Fluticasone.
4. Metformin 850 t.i.d.
5. Thiamine.
6. Folate.
7. Multivitamins.
8. Lipitor.
9. Protonix.
10. Calcium carbonate.
11. Clonazepam.
12. Colace.
13. Senna.
14. Sarna.
15. Glyburide.
SOCIAL HISTORY: 60-pack-year smoking history; quit
approximately 20 years ago. Currently bedridden and lives
with daughter.
PHYSICAL EXAMINATION: Vitals on admission: 98.3, blood
pressure 151/62, heart rate 116, O2 95% on face mask at 10
liters per minute. Exam notable for an obese female.
Uncomfortable in bed. Neck: Soft and supple.
Cardiovascular: Regular rate and rhythm, tachycardiac; S1,
S2 present. Lungs were with distant breath sounds
bilaterally with expiratory wheezing and bibasilar crackles.
Abdomen was soft, nontender, nondistended. Extremities were
with 1+ pitting edema. Pulses were 2+ bilaterally.
Neurologic: Alert and oriented times three.
LABORATORY DATA: Notable for gas of 7.26, 78, 71 which
improved to 7.32, 72, 77. PFTs from [**2148-10-28**]: FEV1/FVC
ratio 19% of predicted. Sodium 137, potassium 5.4, chloride
96, bicarbonate 34 approximately at baseline, BUN 33,
creatinine 0.8, glucose 167, lactate 0.9.
HOSPITAL COURSE:
1. Patient was treated for hypercarbic respiratory failure
with BiPAP, however, patient refusing BiPAP and managed with
Venti-mask and nasal cannula. Patient maintained O2 sats
greater than 93%. Patient was continued on nebulizers p.r.n.
Patient was placed on Prednisone taper. No current
indications for antibiotics. O2 was weaned for sats greater
than 95%. Currently patient is satting 93% liters at 4
liters.
2. Hyperkalemia: Patient found to be hyperkalemic with
maximum value of 6.1. Patient was given two doses of
Kayexalate with appropriate decrease in potassium. Potassium
last checked was 5.6 and decreasing.
3. Type 2 diabetes: Patient was started on Glyburide 2.5
and continued on Metformin 850 t.i.d. Patient has had
difficulty maintaining glycemic control secondary to constant
use of steroids. Given diabetic and cardiac diet.
4. Hypertension: [**Last Name (un) **] withheld secondary to potential renal
effect and concern for hyperkalemia. Patient was started on
Hydrochlorothiazide. Blood pressure elevated but stable.
Patient was also started on Nifedipine for increased blood
pressure control.
5. Anemia: Patient noted to have a hematocrit of
approximately 30 on admission; however, this noted to be her
baseline and currently stable. No significant changes in
hematocrit were noted during hospital course. Patient was
placed on TPI for general prophylaxis.
6. FENGI: PO intake was encouraged over intravenous fluids.
Patient was given. Patient was given 500 cc of intravenous
fluids with improvement in volume status. Patient was also
continued on folate, thiamine, and multivitamins.
7. Contraction alkalosis: Serum bicarbonate was thought to
be elevated; however, baseline was approximately 30 to 35.
Bicarbonate on discharge was approximately 38 and trending
down. PO intake was encouraged, as were .............
8. Prophylaxis with subcutaneous Heparin and PPI.
9. Full code.
DISPOSITION: Patient was screened for [**Hospital1 **] Pulmonary
Rehab as well as by Physical Therapy for general rehab.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehab for physical therapy and
Pulmonary Rehab.
DISCHARGE INSTRUCTIONS: Follow-up appointment with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], patient's primary care physician. [**Name10 (NameIs) **] instructed
to call in one to two weeks.
DISCHARGE MEDICATIONS:
1. Albuterol metered-dose inhaler one to two puffs q. 6
p.r.n. shortness of breath, wheezing.
2. Hydrochlorothiazide 20 mg p.o. q.d.
3. Ipatroprium nebulizer q. 4 p.r.n. shortness of breath and
wheezing.
4. Ipratropium MDI two puffs q.i.d.
5. Fluticasone 110 mcg, two puffs b.i.d.
6. Metformin 850 mg t.i.d.
7. Thiamine 100 mg p.o. q.d.
8. Atorvastatin 20 mg p.o. q.d.
9. Pantoprazole 40 mg p.o. q.d.
10. Calcium carbonate 1.25 grams p.o. q.d.
11. Multivitamins, one capsule, p.o. q.d.
12. Folic acid 1 mg p.o. q.d.
13. Clonazepam 0.5 mg p.o. t.i.d. p.r.n. anxiety.
14. Colace 100 mg p.o. b.i.d. p.r.n. constipation.
15. Senna, two tablets, q. h.s. as needed for constipation.
16. Sarna lotion, topical, q.i.d. p.r.n.
17. Glyburide 2.5 mg p.o. b.i.d.
18. Albuterol 0.83 mg per ml solution nebulizer q. 2 to 4 h.
p.r.n. shortness of breath and wheezing.
19. Nifedipine 30 mg p.o. q.d.
20. Prednisone taper 40 mg times two days, then 30 mg times
four days, then 20 mg times four days, then 10 mg times four
days, then 5 mg times four days, then off.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 20637**]
MEDQUIST36
D: [**2148-11-1**] 13:08
T: [**2148-11-1**] 16:01
JOB#: [**Job Number 94577**]
ICD9 Codes: 2767, 2762, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2951
} | Medical Text: Admission Date: [**2172-2-21**] Discharge Date: [**2172-3-28**]
Date of Birth: [**2097-8-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / lisinopril / Toprol XL
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
incisional chest pain/sternal click
Major Surgical or Invasive Procedure:
[**2172-2-21**] Sternal debridement/pect. flaps/plating
[**2172-2-28**] Sternal washout/Removal of Hardware/VAC Dressing
[**2172-3-6**] Mediastinal exploration, evacuation of hematoma and
control of pulmonary bleeding.
History of Present Illness:
This 74 year old male with severe COPD and extensive cardiac
history in [**2171-10-5**]. Since surgery in [**2171-10-5**], patient
has always complained of a sternal click and incisional
discomfort. This finding was confirmed at his postoperative
visit in [**2171-12-5**]. At that time, his incisional discomfort
was described as mild and did not affect his routine ADL's.
However over the last several weeks following another bout of
pneumonia with significant coughing
episodes, his sternal click and incisional discomfort have
significantly worsened. Currently, he rates his pain 10 out of
10 and is no longer able to function. He denies fevers,
chills,palpitations, orthopnea, PND, syncope and pedal edema.
He has just completed a course of Prednisone and Levofloxacin
for
presumed pneumonia. The ACE inhibitor was also recently stopped
due
to persistent dry cough. He presents for surgical repair.
Past Medical History:
Mitral Regurgitation
s/p redo redo sternotomy and redo Mitral valve replacement
chronic obstructive pulmonary disease
Asthma
Hypertension
Hyperlipidemia
paroxysmal Atrial fibrillation
h/o peptic ulcer
Descending aortic anuerysm 2.8cm (followed by Dr. [**Last Name (STitle) **]
s/p removal of bladder cancer [**2166**] )
s/p coronary artery bypass
s/p redo sternotomy, mitral valve replacement,MAZE
Social History:
-Tobacco history: quit 20 years ago, 65 pack year history
-ETOH: occasional wine with dinner
-Illicit drugs: no reported illicit drug use
Retired UPS trailer driver (20 years), lives at home with wife.
3 children, 1 grandchild. Active lifestyle (rides bikes,
motorcycles, golfs)
Family History:
Family history is significant for a mother who died in her 60s
of cardiac causes, a father who died in his 40s of unknown
(?cancer) causes, a sister who died in her 40s from an MVC (with
known CAD) and a brother who has significant CAD
Physical Exam:
VS: BP 152/77 HR 92 RR 18 SAT 97% room air
gen: patient is somewhat anxious, and has obvious discomfort
when
moving and taking deep breaths
CV: regular rate and rythm, [**1-10**] murmur appreciated
pulm: [**Month/Day (4) 7968**] breath sounds at bases o/w clear
abd: soft, nontender, nondistended with NABS
extremities: minimal pedal edema
inc: significant sternal non-[**Hospital1 **] with flail segments.
extremely
painful with palpation. incision is clean, dry and intact with
no
signs of infection.
Pertinent Results:
IMPRESSION:
1. Bony dehiscence, the length of the postoperative sternum,
with little to
suggest associated infection.
2. Left upper lobe lung lesions could be inflammatory or early
malignancy.
Careful followup, noted.
3. Right upper lobe hematoma, pulmonary hemorrhage and pleural
effusion last
seen on [**11-9**] have resolved.
4. Severe emphysema. Probable tracheomalacia.
[**2172-2-24**] 05:00AM BLOOD WBC-11.9* RBC-3.79* Hgb-10.8* Hct-32.3*
MCV-85 MCH-28.5 MCHC-33.4 RDW-16.9* Plt Ct-209
[**2172-2-24**] 05:00AM BLOOD Glucose-129* UreaN-13 Creat-0.9 Na-138
K-4.1 Cl-103 HCO3-25 AnGap-14
[**2172-2-20**] 01:00PM BLOOD ALT-18 AST-24 LD(LDH)-397* AlkPhos-90
TotBili-0.4
[**2172-2-24**] 05:00AM BLOOD Calcium-8.6 Mg-2.0
[**2172-2-27**] CT SCan
1. Thickened soft tissues with components of both hemorrhagic
and complex
Preliminary Reportfluid and gas extending anteriorly along the
sternum and retrosternally may Preliminary Reportrepresent
normal, post-operative change. Infection in any of these
collections
Preliminary Reportand in the fluid pocket in the left upper is
indeterminate.
Preliminary Report2. Stable left upper lobe lung lesions could
be inflammatory or malignant,
Preliminary Reportand warrant followup CT in no more than six
months..
Preliminary Report3. Resolving post-inflammatory changes related
to prior hematoma in the right
Preliminary Reportupper and right lower lobes.
Preliminary Report4. Stable severe emphysema.
Preliminary Report5. Possible inward displacement of aortic
intimal calcifications with
Preliminary Reporteccentric thickening of aortic wall may
represent intramural hematoma vs
Preliminary Reportdissection, though comparative evaluation with
recent limited as described
Preliminary Reportabove. Please correlate with clinical
symptoms.
CT Scan [**2172-2-20**]
1. Bony dehiscence, the length of the postoperative sternum,
with little to suggest associated infection.
2. Left upper lobe lung lesions could be inflammatory or early
malignancy. Careful followup, noted.
3. Right upper lobe hematoma, pulmonary hemorrhage and pleural
effusion last seen on [**11-9**] have resolved.
4. Severe emphysema. Probable tracheomalacia.
Brief Hospital Course:
The patient is a 74-year-old male who 1-1/2 months ago underwent
a third time re-do mitral valve operation. He did well for
about 30 days following which he
got an upper respiratory infection resulting in severe coughing
and a sterile dehiscence of the sternum. A CT scan was obtained
which showed left upper lobe lung lesions which could be
inflammatory or early malignancy. Thoracic surgery was consulted
who recommended a repeat CT in 3 months.
He had sternal plating performed at which time the adhered lung
to the undersurface of the sternum had a couple of tears with
resulting pneumothorax. The air leak subsequently infected the
sterile sternum and the plates and resulted in a secondary
infection requiring removal of the plates and packing of the
wound for awhile. He after that underwent pectoral flap
advancements by Plastic Surgery filling in the gap between the
sternum and closure over chest tube and drains. He was
susequently extubated on [**3-6**] and had some coughing episodes and
then sudden increased drainage in his chest tube and development
of hematoma under his pectoral flap and massive hemoptysis. He
returned to the Operating Room emergently for mediastinal
exploration, evacuation of the hematoma and control of pulmonary
bleeding.
He subsequently was extubated again and progressed slowly.
Vancomycin was dosed by level and the Infectious Disease service
followed him closely. He had some dysphagia and a Dobhoff tube
was placed for tube feedings. He slowly progressed and the diet
advanced to the present solids and thin liquids as tube feeds
were weaned and dicontinued.
He had a fair amount of confusion after the last operation, but
was clearing. His short term memory remained marginal at times.
He twice had a significant leukocytosis, without an obvious
source and then this resolved Vancomycin will continue for 8
weeks total (through [**4-27**]) and ID followup is arranged. The
sternal wound is clean and healing and the two JP drains remain
in situ, being managed by the Plastic Surgical service.
He was ready for rehab on [**3-28**] and was sent to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] .
All follow up appointments were made.
.
Medications on Admission:
- verapamil 240 mg daily
- lovastatin 40 mg daily
- aspirin 81 mg daily
- losartan 25 mg daily
- albuterol MDI 2puffs prn
- ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler: Two
(2) Puff Inhalation QID (4 times a day).
- tramadol 50 mg as needed for pain
- fluticasone-salmeterol 250-50 mcg/dose Disk: One (1) Disk with
Device Inhalation once a day
- furosemide 20 mg every other day
- iron 325 mg daily
Discharge Medications:
1. vancomycin 500 mg Recon Soln Sig: 750 mg Recon Solns
Intravenous Q 24H (Every 24 Hours): last dose [**2172-4-27**].
2. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) SQ
Injection TID (3 times a day).
5. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
6. Enteric Coated Aspirin 81 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day.
7. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
9. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-10**]
hours as needed for fever or pain.
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day for 2 weeks.
14. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
15. potassium chloride 20 mEq Packet Sig: One (1) Packet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **]
Discharge Diagnosis:
sternal dehiscence
s/p plating and pectoral flaps
s/p debridement, removal of hardware
s/p emergent sternal exploration, repair of pulmonary injury and
sternal closure
Coronary artery disease
Chronic Systolic Congestive Heart Failure
chronic obstructive pulmonary disease
Asthma
Hypertension
Hyperlipidemia
paroxysmal Atrial fibrillation
Peptic Ulcer Disease
Descending aortic aneurysm 2.8cm (followed by Dr. [**Last Name (STitle) **]
s/p removal of bladder cancer [**2166**] - s/p coronary artery bypass
[**2152**]
s/p coronary artery bypass grafts
s/p redo sternotomy, mitral valve replacement/MAZE [**2164**]
s/p redo,redo sternotomy, mitral valve replacement [**2171**]
Discharge Condition:
Alert and oriented x3, nonfocal. Forgetful at times
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema; 2 J-P drains in place
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 cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Cardiac Surgery: Dr.[**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2172-4-22**] at 1:45pm
Cardiologist:Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2172-4-6**] at 10:30am
Please call to schedule appointments with your:
Infectious Disease: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]([**Telephone/Fax (1) 457**]) on [**2172-5-5**] at
9:30am
weekly CBC, lytes,BUN,creatinine, trough vancomycin level while
on Vanco.phne results to [**Hospital **] clinic at [**Hospital1 18**] [**Telephone/Fax (1) 457**]
Primary Care: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8522**] in [**4-9**] weeks ([**Telephone/Fax (1) 8577**])
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
.
Please schedule follow up appointment with Plastic and
Reconstructive Surgery, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 1416**]
Completed by:[**2172-3-28**]
ICD9 Codes: 7907, 5990, 4280, 2859, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2952
} | Medical Text: Admission Date: [**2195-8-2**] Discharge Date: [**2195-8-7**]
Date of Birth: [**2116-12-21**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
dyspnea and altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78 yo F with Afib on coumadin, CHF (EF 55-60 [**2192**]), stroke, CAD
(MI [**2182**]), HTN and asthma p/w mental status changes and dyspnea.
History is limited by pt's mental status. Per nurse [**First Name (Titles) **] [**Name (NI) 78493**] pt is usually A&O x3. This morning she was agitated
and having increased dyspnea. Given Nebs @ 12:00 and Ativan
without relief. Transported to hospital by EMS for further
evaluation. Of note, patient's baseline weight is 168lbs (which
she was close to at discharge on [**2195-6-3**]) and today is 198.8lbs.
Patient is additionally having back pain.
.
In ED VS were 97.5 72 110/72 20 97% RA. CBC significant for WBC
of 11.8, hct 35.2. Chem7 significant for Cr 2.4 (baseline
1.0-1.2, [**5-/2195**]), UA negative, lactate 1.2, INR 3.3. BNP [**2141**]
(increased from 827 on [**5-/2195**]), trop neg X1, LFTs WNL. Blood
cultures drawn. Given Naloxone for AMS because of history of
recently being started on oxycodone- did not help mental status.
CXR showed mild pulmonary edema. Head CT prelim read showed no
acute changes.
.
On transfer, pt's vitals were: 98.4 Tc rectally, HR 67, BP
126/58, RR 22, 99%2L NC. On the floor, the patient is confused
and not appropriately answering questions. Unable to get good
HPI. Patient's only complaint is her lower back pain.
Past Medical History:
CAD s/p MI [**2182**]
Atrial fibrillation on coumadin
h/o stroke [**2177**] left PCA and right superor MCA infarcts
diastolic CHF, EF 55-60% in [**12-31**]
Hypertension
Hypercholesterolemia
Pulmonary hypertension
Asthma
Allergic rhinitis
GERD
Social History:
The patient lives alone in senior housing at Springhouse in JP,
but lives 2 blocks away from her daughter. She moved here from
[**Male First Name (un) 1056**] many years ago.
She has never smoked, does not drink EtOH, or use illicit drugs.
Family History:
There is family history of hypertension and asthma.
Physical Exam:
Admission PE:
VS: 96.5, 106/53, 65, 18, 97%RA
General: easily arousable and wakeful, but incoherent and not
answering question, A&OX2, NAD
HEENT: PERRLA. MMM.
NECK: No LAD, JVP 6-7cm. Neck supple.
Cardiovascular: Irregularly irregular. Normal S1/S2. [**1-25**]
systolic murmur. No gallops/rubs.
Pulmonary: CTAB, no wheezes, rales, rhonchi. Equal breath sounds
bilaterally, good air exchange.
Abd: Soft, NT, minimally distended, +BS. No HSM.
Extremities: WWP, no cyanosis/clubbing, 3+ edema. DPs, PTs 2+.
Skin: No rash, ecchymosis, or lesions.
Neuro/Psych: confused, and not cooperating with interview. Only
repeating interpreter's questions and thanking her.
Discharge PE:
Brief Hospital Course:
78 yo F with Afib on coumadin, CHF (EF 55-60 [**2192**]), CVA, CAD (MI
[**2182**]), HTN and asthma initially admitted to medical floors with
mental status changes and dyspnea. became somnolent on [**8-5**],
found to have respiratory acidosis, presumed CO2 narcosis,
transferred to CCU for bipap on [**8-6**].
.
Patient with known diastolic CHF and history of CAD/MI is
presenting with dyspnea, a 30lb weight gain, satting 97% on RA.
CXR and physical exam shows mild pulmonary edema suggestive of
fluid overload, likely due to CHF exacerbation. Ruled out for
ACS with 2 sets of trops. ECG unchanged from baseline. Patient
does not appear to be infected- no productive cough or signs of
consolidation on exam, CXR did not show evidence of
consolidation. Pt was aggressively diuresed, developed
contraction alkalosis and on [**8-5**] became somnolent. Abg at this
time revealed hypercarbic respiratory failure. Echo was
performed which showed aortic stenosis, mild MR, 3+ TR, and
moderate pulmonary hypertension. She was transferred to the CCU
on [**8-6**] for Bipap and after 3 hrs self d/ced bipap mask,
somnolence resolved. O2 sats were normal on RA. However, pt
became increasingly agitated overnight and by morning of [**8-7**] O2
saturations dipped into 80s and SBP went into 190s. Concern for
flash pulmonary edema, but CXR looked unchanged from baselines.
Blood pressures improved on nitro gtt, and bipap was restarted.
Pt's O2 saturations initially improved on BIPAP but after
several hours she became hypoxic again. Pt was being prepared
for intubation, pt's next of [**Doctor First Name **] was contact[**Name (NI) **] the decision was
made to make pt [**Name (NI) 835**]. She continued to deteriorate and next of
[**Doctor First Name **] made decision to make pt [**Name (NI) 3225**]. She was given ativan and IV
morphine and expired at 16:02 on [**2195-8-7**].
.
Medications on Admission:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for prn breakthrough pain.
4. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
10. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for dizziness.
11. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed for constipation or gas
pains.
16. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
30 min prior to lasix.
17. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. Diphenhist 25 mg Capsule Sig: One (1) Capsule PO at bedtime
as needed.
19. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
20. azelastine 137 mcg Aerosol, Spray Sig: One (1) spray Nasal
once a day.
21. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for wheezing, sob.
22. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours as needed for SOB.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 5849, 2930, 4280, 4241, 4168, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2953
} | Medical Text: Admission Date: [**2114-11-20**] Discharge Date: [**2114-11-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
placement of central line, left sided IJ
History of Present Illness:
87 y.o. female wtih h/o MVR ([**2108**]), CAD, CHF, pAF, and recent
admissions in [**9-9**] and [**10-10**] for colitis and Cdiff
respectively, presents from rehab with asymptomatic hypotension
to 70s. The patient complains of abdominal discomfort and
nausea which has been going on since her last admission in
[**10-10**], along with some fatigue/weakness.
During her last hospitalization ([**Date range (1) 96313**]), the patient
completed a course of cipro for infectious colitis, and was
discharged on oral vancomycn for presumed Cdiff. She also had a
PICC line placed and was receiving TPN at rehab until 5 days
prior to admission, when the line became infected with Staph Epi
which was resistent to oxacillin. Stool came back positive for
Cdiff on [**11-19**] and she was restarted on oral Vanco (had been
d/c'd when diarrhea resolved). The line was pulled and she was
started on Linezolid.
ROS: negative for CP, SOB, fever, chills. + for abd discomfort
and nausea. Also + for poor appetite since last admission.
In the ED, T 95.1, BP 92/41 (dropped to SBP 80), HR 124, RR 16,
94% 2L. U/A was floridly positive wiht > 1000 WBCs. Left IJ was
placed. She was given 4L NS, Ceftaz, Vanc, and Flagyl and sent
to MICU for sepsis.
Past Medical History:
Past Medical History:
1. Recent Cdiff colitis following ABX for presumed infectious
colitis
2. Coronary & Valvular Disease
-S/p post-op NSTEMI in the [**2066**] after CCY, though no CAD seen
on cardiac cath in [**2108**]
- Flail mitral valve, s/p mitral valve repair, [**9-4**].
-Stress [**2-7**]: Rest and stress perfusion images reveal a mild
fixed defect in the inferior wall. Gated images reveal global
hypokinesis, worse in the septum in this patient post MVR. The
calculated left ventricular ejection fraction is 44%. Echo at
this time showed EF 55%, Mild TR, no MR, and well-seated mitral
annulus.
3. Paroxysmal atrial fibrillation s/p pharmacologic conversion
(not currently on anticoagulation). Holter [**10-7**] showed
underlying sinus rhythm with normal intervals, occasional PACs
and frequent PVCs. Rare short bursts of atrial tachycardia and
occasional short runs of NSVT.
4. Systolic CHF: nuclear stress on [**2114-2-6**] showed global
hypokinesis; LVEF 45-50%, although recent echo [**10-10**] showed EF
60%
5. Pulmonary Artery Hypertension, mild based on echo [**2-7**]
6. Hypertension
7. Diverticulosis of the ascending colon, transverse colon,
descending colon and sigmoid colon based on colonoscopy [**2-4**]
Social History:
Never smoked, doesn't drink ETOH, no illicits. Had been living
with her with her son until recent hospitalization. Widowed. .
Family History:
Two sisters died with breast cancer. All children are healthy.
Physical Exam:
VS: T 96.2 BP 125/55, HR 102, RR 13, 98% 2L
Gen: well appearing, no apparent distress
HEENT: dry MMM, flat JVP
Lungs: bibasilar crackles b/l
Heart: RRR nl S1 S2, no M/R/G
Abd: soft, +BS, ND/NT, no rebound or guarding
Ext: no edema 2+ DP pulses
Neuro: AAO x3, no sensory or motor defecit
Pertinent Results:
Micro at rehab:
Cdiff toxin [**11-19**] - positive
[**11-14**] Blood cultures - 4/4 bottles pos for Staph Epidermidis,
[**Last Name (un) 36**] to linezolid, resistent to oxacillin
[**11-15**] PICC line tip - pos for Staph Epidermidis
CXR: [**2114-11-20**]: No acute cardiopulmonary process
.
CT abd [**2114-11-20**]:
1. Pancolitis, slightly less severe than colitis seen on
previous
exam. C. diff colitis is a consideration. No pneumatosis or
free air.
2. Ventral hernia containing non-obstructed small bowel loops
.
COLONOSCOPY [**2114-10-22**]
Diverticulitis of the transverse colon, descending colon and
sigmoid colon
Stool in the transverse colon, descending colon and sigmoid
colon
Erythema and congestion in the sigmoid colon compatible with
diverticulitis (biopsy)
Otherwise normal colonoscopy to mid transverse colon
EGD [**2114-10-22**]
Normal mucosa in the whole esophagus
Normal mucosa in the whole stomach
Normal mucosa in the first part of the duodenum and second part
of the duodenum
Otherwise normal EGD to second part of the duodenum
Surface Echo [**2114-10-19**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is normal (LVEF 60%). There is no ventricular septal
defect. The right ventricular cavity is dilated. Right
ventricular systolic function is normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. A mitral valve annuloplasty ring is
present. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The supporting structures
of the tricuspid valve are thickened/fibrotic. 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 [**2114-2-5**],
the findings are similar
ECG: Afib with RVR at 138. Repeat pending (pt now in sinus)
.
Labs on the day of discharge:
.
[**2114-11-23**] 05:04AM BLOOD WBC-7.7 RBC-2.69* Hgb-8.2* Hct-24.7*
MCV-92 MCH-30.5 MCHC-33.2 RDW-15.9* Plt Ct-372
[**2114-11-23**] 05:04AM BLOOD Glucose-82 UreaN-4* Creat-0.4 Na-143
K-3.5 Cl-114* HCO3-18* AnGap-15
[**2114-11-21**] 05:30AM BLOOD CK(CPK)-19*
[**2114-11-23**] 05:04AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.7
Brief Hospital Course:
87 y.o. female with MVR, remote CAD, and recent admissions for
colitis/Cdiff, presents with hypotension and presumed urosepsis
with shock.
# Septic shock: Upon admission, the patient had elevated WBC,
was tachycardic, and hypotensive requiring pressor. Potential
sources were urosepsis (floridly positive UA, but also known to
have Cdiff (stool was positive at rehab). Also considered was
line sepsis (recent PICC line). She received fluid
resuscitation and was started on neosynephrine which was later
changed to norephinephrine. The pressor was weaned off and the
pt was able to maintain her BP. She was initially covered
broadly with vancomycin, ceftazidine, and flagyl, all started on
[**2114-11-20**]. Vancomycin was stopped on [**2114-11-22**] when cultures had
been negative for 48 hours. Ceftazadine was changed to
ceftriaxone. She should complete a 7 day course of
ceftaz/ceftriaxone and then complete 14 days of flagyl after the
other abx are completed for Cdiff.
.
# Hypokalemia/hypomagnesemia: Likely [**1-5**] diarrhea. Repleted and
remained stable. She will need her potassium checked in 3 days
and at least once a week afterward.
.
# Afib with RVR: The patient has a h/o paroxysmal Atrial
fibrillation. Likely triggered by septic shock. Has converted
to sinus after IVF resuscitation. Her metoprolol was held
because of hypotension, but should be restarted as an outpt.
She should discuss coumadin for pAF with her outpt provider.
.
# Non-anion gap metabolic acidosis: [**Month (only) 116**] be [**1-5**] volume
resuscitation with NS or diarrhea. Remained stable throughout
hospitalization.
.
# GI: The patient has been having nausea and abdominal
discomfort since last admission, along with very poor PO intake
(she only will eat tootsie rolls and ginger ale). CT abd
without new finding, but revealed pan-colitis which was reported
to have improved since last scan. Neg ECG and colonoscopy last
admission. Was seen in GI clinc for these symptoms which were
thought [**1-5**] meds (flagyl/vanco) vs colitis. She was given
antiemetics and treatement for Cdiff. GI evaluated her for
possible PEG tube, but because of her ventral hernia, she can
not have it placed endoscopically and would instead need it done
by radiology of surgery. The patient and her daughter both
agreed to [**Name (NI) 9945**] placement. Interventional radiology was called
and will try to schedule this procedure as an outpt. In case
they do not, the phone number to schedule this is [**Telephone/Fax (1) 327**].
She needs to remain OFF Asprin, NSAIDs for 1 week and also
should have a PT/PTT/INR done prior to the procedure. The
gastroenterologists recommended she follow up in [**Hospital **] clinic (she
has seen Dr. [**Last Name (STitle) 2473**] in the past) and have the following tests
performed: Upper GI series (barium swallow) and Gastric emptying
study. A call was placed to her PCP and [**Name Initial (PRE) **] message left for him
to call back to update him on this matter.
# FEN: regular cardiac diet was ordered. She will likely need
TPN at rehab until her G-tube can be placed.
# PPx: SC heparin, PPI
# Access: Left IJ, PIVs
# DNR/DNI
# Communication - daughter [**Name (NI) **] [**Name (NI) **] (HCP) [**Telephone/Fax (1) 96314**]
# Dispo: discharge to rehab.
Medications on Admission:
Tigan 200mg q6H prn nausea
Bisacodyl 10mg PR prn
Senna 2 tab qhs prn
Aspirin 325 daily
Nexium 40mg daily
Compazine 10mg PO q6H prn
Lactobacillus 1 tab daily
Ferrous sulfate 300mg daily
Metoprolol 12.5mg PO BID
Linezolid 600mg po BID (started [**11-19**])
Vancomycin 250mg PO QID (started [**11-19**])
Insulin SS
Tylenol prn
MOM prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 17 days: This will continue for 14 days past the
completion of Ceftriaxone.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) MG
Injection Q8H (every 8 hours) as needed for nausea.
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) Gram Intravenous Q24H (every 24 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Septic shock
2. Urinary tract infection
3. Cdiff colitis
Discharge Condition:
stable, normotensive, afebrile.
Discharge Instructions:
You were admitted with infections (urinary tract infection and
Cdiff colitis) which caused your blood pressure to be too low,
and you needed IV fluids and pressors to keep your blood
pressure high enough. You improved with antibiotics and are
safe to discharge to rehab.
Your intake of food was poor during your admission, as it was
during the last 2 months. You had been getting food through a
IV line at rehab, but this was stopped once the line became
infected. We recommend that you have a feeding tube (G-tube)
placed in your stomach for tube feeds. You will be contact[**Name (NI) **] by
our radiology department for an appointment time, hopefully next
week.
.
You were seen by our gastroenterologists who recommended that
you have the following tests done as an outpt: Barium swallow
and gastric emptying study).
.
In the meantime, you should not take aspirin, ibuprofen, or
other NSAIDs or blood thinners.
Followup Instructions:
Please call your primary care doctor for a follow up appointmnet
in the next 1-2 weeks.
.
It is also important for you to call your gastroenterologist
(Dr. [**Last Name (STitle) 2473**] for an appointment for further testing
([**Telephone/Fax (1) 463**]).
Completed by:[**2114-11-23**]
ICD9 Codes: 0389, 2762, 5990, 4280, 4168, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2954
} | Medical Text: Admission Date: [**2147-11-13**] Discharge Date: [**2147-11-15**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Cholangitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
[**Age over 90 **] year old woman with history of hypertension, hyperlipidemia,
type 2 DM who presented to [**Hospital3 26615**] with nausea/vomiting,
abdominal pain, fevers/chills on [**2147-11-12**] that had been going
on for 3-4 days. Also had some loss of appetite and discomfort
in the bilateral upper abdominal quadrants with coughing. Prior
to admission, she had a T101 and some shortness of breath. At
the OSH, she had at least one episode of emesis but good bowel
movements, RUQ ultrasound showed a single stone with no dilated
bile ducts, slight gall bladder inflammation. The patient was
admitted for presumed cholecystitis.
.
The patient improved clinically with IVF but became hypotensive
to SBP90 --> 83 and she was transferred to the ICU, briefly on
Neo-synephrine (stopped [**11-13**]) and her antibiotics broadened to
from Zosyn to Levofloxacin. Urinalysis and CXR were negative for
infectious etiology. Her Lipitor was discontinued given her
elevated LFTs. Her LFTs were found to be elevated (ALT 515, AST
542, TBili 2.1, DBili 1.5, AlkPhos 700). Her WBC was found to
bump from 15 to 26 and her blood cultures grew out GNRs. She was
switched to Meropenem in discussions with Infectious Disease.
She also received 1 unit pRBC with lasix post-transfusion for
Hct 24.6. CT abdomen showed 4 mm common bile duct with a
non-dilated biliary tree. General Surgery was consulted and
recommended transfer to [**Hospital1 18**] for ERCP and further management.
.
Upon arrival to [**Hospital1 18**] ICU, the patient was asymptomatic, lying
in bed comfortably. She underwent ERCP with successful biliary
cannulation, stone at the lower third of the common bile duct
(8mm), normal intrahepatics. Successful sphincterotomy was
performed and two stone (4-6mm) in size were removed. ERCP was
normal to third part of the duodenum.
Past Medical History:
Left sided mastectomy
Hypertension
Hyperlipidemia
Type 2 diabetes mellitus
Social History:
Patient has "good quality of life," per family - lives
independently at home. Her daughter, son and other family are
around, actively involved in her care.
Family History:
Noncontributory
Physical Exam:
VS: Temp: 99.9 BP: 116/42 HR: 86 RR: 16 O2sat 96% on RA
GEN: Pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, slightly dry mucus membranes,
[**Last Name (un) **]/oropharynx, no jvd, neck soft/supple
RESP: CTA b/l with good air movement throughout
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt
EXT: no c/c/e
SKIN: no rashes/lesions
NEURO: AAOx3. Cn II-XII intact. Strength and sensation grossly
intact
Pertinent Results:
Admission Results:
.
[**2147-11-13**] 09:12PM BLOOD WBC-14.6* RBC-3.52* Hgb-10.2* Hct-30.3*
MCV-86 MCH-28.9 MCHC-33.5 RDW-16.4* Plt Ct-109*
[**2147-11-13**] 09:12PM BLOOD PT-16.1* PTT-26.7 INR(PT)-1.4*
[**2147-11-13**] 09:12PM BLOOD Glucose-106* UreaN-18 Creat-1.0 Na-140
K-3.6 Cl-110* HCO3-22 AnGap-12
[**2147-11-13**] 09:12PM BLOOD ALT-372* AST-223* LD(LDH)-234
AlkPhos-456* TotBili-6.6*
[**2147-11-13**] 09:12PM BLOOD Calcium-8.0* Phos-1.9* Mg-1.9
.
TTE ([**2147-11-14**]): The left atrium is normal in size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Normal global and regional biventricular systolic function. Mild
mitral regurgitation. Mild pulmonary hypertension.
.
CXR ([**2147-11-14**]): Scoliosis, probably moderate cardiac enlargement
and bilateral basal densities suspicious for pleural effusion.
No conclusive evidence for acute infiltrates or pneumothorax. A
lateral view could be helpful to document better the amount of
pleural effusion.
.
Discharge Results:
.
[**2147-11-15**] 04:03AM BLOOD WBC-7.8 RBC-3.39* Hgb-9.9* Hct-29.5*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.6* Plt Ct-110*
[**2147-11-15**] 04:03AM BLOOD Glucose-54* UreaN-13 Creat-0.9 Na-140
K-4.0 Cl-113* HCO3-18* AnGap-13
[**2147-11-15**] 04:03AM BLOOD ALT-228* AST-80* LD(LDH)-168 AlkPhos-361*
Amylase-52 TotBili-1.1
[**2147-11-15**] 04:03AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.6
Brief Hospital Course:
[**Age over 90 **] year old woman with history of hypertension, hyperlipidemia,
left-sided mastectomy who presented from OSH with cholangitis.
.
#. Cholangitis: Patient was transferred to [**Hospital1 18**] for cholangitis
with need for ERCP. Patient received ERCP prior to transfer to
the ICU during which two gallstones were removed. The patient
was monitored closely following the procedure for bleeding,
perforation and pancreatitis. LFTs were monitored without event.
The patient was made NPO the night following the ERCP but was
advanced to a liquid diet the next morning, which she tolerated
well. The patient had been admitted to [**Hospital1 18**] on Zosyn, Meropenem
and Levofloxacin. Zosyn was stopped the morning after the ERCP
but Meropenem and Levofloxacin were continued until the day of
discharge. ** Per GI recommendations, the patient should start
Augmentin 876 mg by mouth twice a day for a total of 14 days,
beginning on the day of discharge ([**2147-11-15**]). **
.
#. Atrial Fibrillation: The evening following her ERCP, the
patient developed atrial fibrillation without no known history
of arrhythmias. The patient was given a dose of Metoprolol 5 mg
IV and subsequently dropped her SBP from the 110s to 70s.
Cardiac enzymes were negative. Cardiology was consulted and
recommended the patient be placed on Amiodarone. The following
morning, per cardiology recommendations, the Amiodarone was
stopped and the patient was placed on Metoprolol tartrate 12.5
mg PO BID. The patient's Atenolol was held throughout her
hospitalization. ** It is likely that the patient's atrial
fibrillation was self-limited. The patient can likely be
switched back to her Atenolol as an outpatient but this decision
was deferred to the outpatient setting. **
.
#. Hypertension: Patient had been normotensive on arrival (SBP
110s). Patient developed atrial fibrillation with RVR (HR180s)
and received Metoprolol 5 mg IV and dropped her blood pressures
from SBP 110s to 70s ~3 hours after MRCP. The patient was
admitted on Valsartan 160 mg PO daily and Hydrochlorothiazide 25
mg PO daily. These medications were held due to her low blood
pressure. ** These medications were not restarted prior to
discharge but can likely be resumed following discharge. **
.
#. Hyperlipidemia: The patient's Atovastatin was held throughout
her hospitalization given her transaminitis. ** This medication
can likely be restarted oncer her transaminitis resolves. **
.
#. Diabetes: The patient was continued on her insulin Lispro
sliding scale throughout her hospitalization without event.
.
#. thrombocytopenia: Platelets were low (around 110), but stable
throughout admission. [**Month (only) 116**] consider outpatient monitoring and
workup.
Medications on Admission:
Insulin sliding scale
Levofloxacin 250mg daily
Meropenem 500mg q12 daily
Zosyn 2.25grams q6 daily
Acetaminophen 650mg q4hr PRN pain
Atenolol 25mg daily
Bisacodyl 10mg qAM PRN
Docusate 100mg [**Hospital1 **] PRN
Pantoprazole 40mg daily IV
Ondansetron 4mg q8 PRN Nausea
Insulin lispro per sliding scale
HCTZ 25mg daily
Heparin 5000 units q12
Valsartan 160mg daily
Discharge Medications:
1. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
2. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO QAM as needed
for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. ondansetron 4 mg Film Sig: One (1) PO every eight (8) hours
as needed for nausea.
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. insulin lispro 100 unit/mL Solution Sig: ASDIR Subcutaneous
ASDIR: Lispro Insulin Sliding Scale to be administered as
directed. .
8. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day: Start on [**2147-11-21**] and continue twice a day for 14 days. .
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
Cholangitis
Atrial Fibrillation with Rapid Ventricular Response
.
Secondary Diagnoses:
Hypertension
Hyperlipidemia
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:
Ms. [**Known lastname **]:
.
You were admitted to [**Hospital1 18**] for an infection in your gallbladder.
A procedure called an ERCP was performed and the stones
responsible for your infection were removed. You were started on
antibiotics for your infection and will need to continue them
for several days after the procedure.
.
The evening after your procedure you were found to have a fast
heart rate due to a condition called atrial fibrillation. We
think this may have been due to your acute illness. Cardiology
was consulted and you were initially started on a medication
called Amiodarone. You were switched to a medicine called
Metoprolol prior to discharge. It is believed that this was a
temporary condition and that this medication can likely be
stopped eventually. Your outpatient physicians can make this
determination.
.
The following changes were made to your medications:
.
1. Start Levaquin 250 mg by mouth daily. The total course will
need to be 7-10 days pending clinical improvement. This
medication was started by [**Hospital3 26615**] Hospital prior to transfer
to [**Hospital1 18**].
2. Start Meropenem 1000 mg intravenously every twelve hours. The
total course will need to be 7-10 days pending clinical
improvement. This medication was started by [**Hospital3 26615**] Hospital
prior to transfer to [**Hospital1 18**].
3. Start Metoprolol tartrate 12.5 mg by mouth once a day.
4. Stop Atenolol 25 mg by mouth daily. This medication is
similar to Metoprolol. Your physicians at [**Hospital3 26615**] or your
outpatient physician may decide to switch you back to
Metoprolol.
5. Stop Zosyn. You no longer need this antibiotic.
6. Your Valsartan 160 mg by mouth daily was held during this
hospitalization as your blood pressure was low. Your pressures
were back to normal at the time of discharge. Your outside
physicians can restart this medication.
7. Your Hydrochlorothiazide 25 mg daily was held during this
hospitalization as your blood pressure was low. Your pressures
were back to normal at the time of discharge. Your outside
physicians can restart this medication.
.
No other changes were made to your medications during this
hospitalization.
Followup Instructions:
Please keep all follow-up appointments.
ICD9 Codes: 4019, 2724, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2955
} | Medical Text: Admission Date: [**2149-4-6**] Discharge Date: [**2149-4-16**]
Date of Birth: [**2103-8-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
alcohol withdrawal and witnessed seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
45 yom with h/o etoh abuse brought to ER after a witnessed GTC
by family at home. Fell back and hit his head. Patient has h/o
etoh abuse and has had seizures in the past. Last drink was 1
nights ago by report from ED, although patient said on admit it
had been several days..
In the ER, vitals, 98.8 BP 160/108 HR 71 O2 100%RA. FS was 94.
He was given 2 mg PO ativan and 1 mg IV ativan with no further
seizures. He had a CT c-spine and CT head done and neuro was
consulted and they recommended treating EtOh withdrawl.
At time of transfer to the ICU, he denies any complaints.
Denies recent fevers, chills, nausea, vomiting.
Past Medical History:
alcoholism
Social History:
drinks when he works, works as a carpenter. Has been drinking
for ~25 years; states that he drinks about a pint a day of
vodka.
Family History:
noncontributory
Physical Exam:
Afebrile, VSS
Gen -- pleasant, interactive
HEENT -- unremarkable
Heart -- regular
Lungs -- clear
Abd -- benign
Ext -- no edema
Neuro -- grossly intact
Pertinent Results:
[**2149-4-5**] 08:00PM WBC-2.6* RBC-3.99* HGB-12.7* HCT-38.3* MCV-96
MCH-31.8 MCHC-33.2 RDW-14.8
[**2149-4-5**] 08:00PM NEUTS-66.9 LYMPHS-29.0 MONOS-3.4 EOS-0.4
BASOS-0.4
[**2149-4-5**] 08:00PM PLT SMR-VERY LOW PLT COUNT-62*
[**2149-4-5**] 08:00PM PT-11.6 PTT-20.8* INR(PT)-1.0
[**2149-4-5**] 08:00PM GLUCOSE-129* UREA N-11 CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-28 ANION GAP-17
[**2149-4-5**] 08:00PM CALCIUM-9.7 PHOSPHATE-1.9* MAGNESIUM-1.6
[**2149-4-5**] 08:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2149-4-5**] 08:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-8.0 LEUK-NEG
[**2149-4-5**] 08:25PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2149-4-5**] 08:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2149-4-5**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2149-4-6**] 05:30AM BLOOD ALT-137* AST-320* LD(LDH)-371*
AlkPhos-127* TotBili-1.6*
CT Head:
1. Subtle widening of the extra-axial spaces overlying the
convexities bilaterally. This could be secondary to atrophy;
however, chronic subdural hematomas are possible. Consider MR
for further characterization as clinically indicated.
2. No acute intracranial process.
CT CERVICAL SPINE WITHOUT IV CONTRAST: The skull base through T2
is visualized, and there is normal alignment without evidence
for fractures or dislocations. The vertebral body and disc
height is preserved. There is no prevertebral soft tissue
swelling. Mastoid air cells and visualized paranasal sinuses are
clear. Interspinous distance is preserved. Lung apices are
clear.
===================
MRI head
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
FINDINGS: This exam was terminated early due to patient
agitation. There are no T2 sequences available for evaluation.
On the T1-weighted sequences, there are bilateral small
extra-axial fluid collections measuring up to 6 mm in diameter,
which likely represent subdural hematomas or hygromas. The [**Doctor Last Name 352**]-
white matter differentiation is normal and the ventricles are
normal in size. On the diffusion-weighted images, there is
increased signal on the ADC maps within the bilateral
occipital/parietal lobes, corresponding to the areas of
hypodensity seen on CT, which may represent T2 shine-through and
vasogenic edema, again supporting the suspicion of PRES. There
is also an area with ADC bright signal within the right
cerebellar hemisphere, corresponding to an area of prior
infarct. No evidence of acute infarction on the
diffusion-weighted images.
MRV OF THE BRAIN: The MRV is limited due to motion. The
visualized portions of the venous structures demonstrate no
gross abnormalities. The majority of the superior sagittal,
inferior sagittal, and transverse sinuses are visualized, with
no evidence of thrombosis.
Subcutaneous swelling over the occiput is again noted.
IMPRESSION:
1. Very limited study, with no T2-weighted images and
motion-limited MRV. High signal intensity within the occipital
and parietal lobes bilaterally on the ADC map suggests T2
shine-through/vasogenic edema, and would be consistent with a
diagnosis of PRES (posterior reversible encephalopathy
syndrome). No gross venous sinus thrombosis is identified,
though again this is limited by motion.
2. Old infarct within the right cerebellar hemisphere.
3. Bilateral subdural collections over the cerebral convexities.
==================
[**2149-4-16**] 05:50AM BLOOD WBC-5.5# RBC-3.27* Hgb-10.5* Hct-31.2*
MCV-96 MCH-32.2* MCHC-33.7 RDW-13.0 Plt Ct-336
[**2149-4-8**] 08:18AM BLOOD PT-12.3 PTT-21.1* INR(PT)-1.0
[**2149-4-16**] 05:50AM BLOOD Glucose-86 UreaN-11 Creat-0.8 Na-139
K-3.8 Cl-103 HCO3-28 AnGap-12
[**2149-4-6**] 05:30AM BLOOD Ret Aut-0.6*
[**2149-4-14**] 07:45AM BLOOD ALT-40 AST-35 AlkPhos-80 TotBili-0.4
[**2149-4-6**] 05:30AM BLOOD ALT-137* AST-320* LD(LDH)-371*
AlkPhos-127* TotBili-1.6*
[**2149-4-12**] 08:15AM BLOOD Albumin-3.7 Calcium-8.9 Phos-4.1 Mg-1.6
[**2149-4-6**] 05:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2149-4-5**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2149-4-6**] 05:30AM BLOOD HCV Ab-NEGATIVE
=================
URINE CULTURE (Final [**2149-4-14**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Brief Hospital Course:
45 yom with h/o etoh abuse and seizures admitted after a
seizure.
.
# Etoh Abuse: Patient was admitted to the ICU for observation of
Etoh withdrawal and seizure. Impression from Neurology was for
etoh withdrawal seizures and head CT at that time showed no
significant acute intracranial processes - ?small subdural
hematomas in frontal region. Patient was started on standing
diazepam 5mg q8 H w/ CIWA q2H PRN. He was observed in ICU for
24 hours and required no PRN diazepam on the CIWA scale, and was
hemodynamically stable. Patient was called out to the floor.
Overnight on the floor he became agitated and delerious pulling
out IV's and with obvious hypertension suggesting acute
withdrawal. He was readmited to the ICU for further management.
On readmission patient was started on aggressive diazepam with
10mg IV q2 h with PRN on CIWA scale and required about 50-80mg
diazepam in a 12 hour shift. Took almost 36 hours to fully
catch up on benzo requirements. Patient had repeat head CT/MRI
that demonstrated PRES syndrome. BP controlled with diazepam
and briefly with hydralazine. Neurology was consulted
recommended BP control and treating diazepam PRN, and followed
throughout his course. He was slowly weaned from scheduled
Valium through the rest of his course. He was offered inpatient
and outpatient rehabilitation options, but at discharge he was
not interested. He did take contact numbers for local AA
groups.
.
# PRES: see above, radiologic findings consistent with PRES in
the setting of hypertension related to EtOH withdrawal. He did
not require antihypertensives after treatment with Valium and
brief hydralazine in the ICU.
.
# Abnml LFTs: AST and ALT elevated 2:1, consistent with
alcoholic liver disease. Discrimant function score is <<30 (PT
is normal and Tbili 1.6) so not fulminant alcoholic hepatitis
and no indication for steroids. As pt has not had prior work-up,
will send hepatitis serologies and check RUQ as well.
Hepatitis core ab positive, HCV negative. LFTs returned to
[**Location 213**] prior to discharge.
.
# Pancytopenia: Suspect due to alcoholism. Improved prior to
discharge.
.
# Enterococcus UTI: treated with ampicillin for 7 days.
Medications on Admission:
None
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q8H
(every 8 hours) for 1 days.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. delerium tremens
2. posterior reversible encephalopathy syndrome
3. hypertensive urgency
Discharge Condition:
stable, no evidence of persistent alcohol withdrawal
Discharge Instructions:
You were hospitalized with very high blood pressure and alcohol
withdrawal. Do not drink alcohol, as it can kill you. Please
follow up with your primary care doctor, which we have arranged
an appointment for you. Return to the emergency department with
fever, chest pain, mental status changes, seizure, or any other
concerning symptoms.
Followup Instructions:
Please see the neurologists, Dr. [**Last Name (STitle) 78578**], on Wednesday [**7-9**] at 1pm.
Please see your primary care physician at [**Name9 (PRE) **] Health Center
[**2149-5-5**] at 9:30am.
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2956
} | Medical Text: Admission Date: [**2178-2-11**] Discharge Date: [**2178-2-13**]
Date of Birth: [**2151-12-29**] Sex: F
Service: MEDICINE
Allergies:
Vicodin / Latex
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
tylenol overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 26y.o F with a PMH of multiple suicide attempts
presenting with tylenol ingestion. The patient has a history of
three tylenol overdoses treated at [**Hospital **] hospital last year. The
patient reported taking 225 (500mg) tablets and 50 (650mg)
tablets in a suicide attempt less than one hour prior to
arrival. Vitals on arrival to OSH ED BP 127/84, HR 80, RR 18,
100%RA T 97.4. Wt 92.7kg. The patient was mute in ED triage at
OSH, would only write answers. The patient then became
uncooperative and refused to drink charcoal. She stated that she
wanted her meds through the IV for the tylenol overdose, like
she had in the past. She then agreed to have an NGT placed.
Refused to take charcoal. NTG attempt followed by nosebleed
documented. Pt again refused charcoal and the patient was
restrained. NGT placed with return of some pill fragments. She
was given charcoal 50g and mucomyst 150mg/kg bolus followed by
50mg/kg IV over 4 hours. ED physician was unable to exam patient
secondary to non-cooperation. The patient was transferred to
[**Hospital1 18**] for treatment and monitoring of tylenol overdose. On
arrival to [**Hospital1 18**], the patient was cooperative and had been
removed from restraints.
.
On arrival to the ICU, the patient is calm and cooperative. She
complains of nausea and thirst. Alert and oriented to time,
place and circumstance. States she wants to contact a friend but
no family.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
# Depression s/p multiple suicide attempts
# Tylenol overdose x 3
# PTSD
# borderliner personality disorder
# GERD
# Leg and arm surgeries
Social History:
Homeless, but reportedly has lived in a group home most
recently. smokes 1 pack cigarettes daily. Occasional EtOH.
Denies IVDU.
Family History:
biological mother with depression
Physical Exam:
(Exam on transfer to the medical service)
T: 97.7 BP: 126/79 HR: 90 RR: 28 O2 99% RA
Gen: Well appearing, tearful, NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear. Purple
discoloration of nose
NECK: Supple, JVP low.
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, good BS BL, No W/R/C
ABD: Obese. NABS. Soft, NT, ND. No HSM
EXT: WWP, Trace LE edema. Full distal pulses
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN 2-12 grossly intact. Moving all extremities.
PSYCH: Emotionally labile. Tearful at times. Listens and
responds to questions appropriately.
Pertinent Results:
ADMISSION LABS:
CBC:
[**2178-2-11**] 08:54PM BLOOD WBC-8.6 RBC-4.43* Hgb-12.4* Hct-37.3*
MCV-84 MCH-28.1 MCHC-33.3 RDW-15.5 Plt Ct-291
[**2178-2-11**] 08:54PM BLOOD Neuts-79.2* Lymphs-16.3* Monos-3.2
Eos-0.9 Baso-0.3
COAGS:
[**2178-2-11**] 08:54PM BLOOD PT-17.4* PTT-27.1 INR(PT)-1.6*
CHEM 7:
[**2178-2-11**] 08:54PM BLOOD Glucose-141* UreaN-7 Creat-0.8 Na-145
K-4.1 Cl-116* HCO3-16* AnGap-17
LFTs:
[**2178-2-11**] 08:54PM BLOOD ALT-13 AST-14 AlkPhos-99 TotBili-0.3
[**2178-2-11**] 08:54PM BLOOD Albumin-4.1 Calcium-9.0 Phos-2.2* Mg-2.4
SERUM TOX:
[**2178-2-11**] 08:54PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-133.8*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
------
DISCHARGE LABS:
CBC:
[**2178-2-13**] 07:08AM BLOOD WBC-6.6 RBC-3.82* Hgb-10.5* Hct-32.4*
MCV-85 MCH-27.4 MCHC-32.3 RDW-15.6* Plt Ct-245
CHEM 7:
[**2178-2-13**] 07:08AM BLOOD Glucose-80 UreaN-1* Creat-0.5 Na-142
K-3.9 Cl-117* HCO3-18* AnGap-11
[**2178-2-13**] 07:08AM BLOOD Albumin-3.5 Calcium-9.0 Phos-2.3* Mg-2.0
ACETAMINOPHEN LEVEL:
[**2178-2-12**] 07:53AM BLOOD Acetmnp-7.2
Liver Function Tests:
[**2178-2-13**] 07:08AM BLOOD ALT-13 AST-14 LD(LDH)-145 AlkPhos-103
TotBili-0.2
---------
---------
Brief Hospital Course:
This is a 26 year old female with a history of depression and
multiple suicide attempts transferred from and outside hospital
for tylenol overdose.
# Tylenol Overdose: Notably, the patient has a history of three
prior tylenol overdoses resulting in hospitalization, the last
time approximately 1 year ago. On this hospitalization the
patient reported taking 225 500mg tablets and 50 650mg tablets
less than one hour prior to arrival at OSH. At OSH, she
initially refused to drink charcoal. She required restraints for
NGT placement and then received 50 grams of charcoal and
mucomyst 150mg/kg bolus followed by 50mg/kg IV over 4 hours. The
patient was then transferred to [**Hospital1 18**] for treatment and
monitoring of tylenol overdose. In the MICU, patient was
continued on Mucomyst IV. Initial tylenol level 133 [**2-11**] at 0900.
On [**2-12**] tylenol level 7.2. She was continued on Mucomyst and
completed 50mg/kg X 4hrs followed by 100mg/kg for 16 hours at ~4
pm on [**2-12**]. LFTs were followed and remained normal. PT/INR
remained stable as did bicarbonate without an anion gap.
# Depression: Questionable history of bipolar. History of
multiple suicide attempts and psychiatric hospitalizations.
Patient was seen by psychiatry on this hospitalization and
following treatment of her tylenol overdose she was restarted on
her outpatient psychiatric medications. While on the floor she
had a 1:1 sitter and did not have any other incidents of self
harmful behavior. She continues to appear withdrawn.
# Anemia: Hct of 32 this am from admission Hct of 37 though hct
has been stable over the past 24 hrs. No evidence of blood loss.
Suspect this is dilutional give drop in all three cell lines.
Would suggest a repeat CBC in a week or two.
# "Shakiness/Tremor": Pt was restarted on her outpatient dose of
propranolol which she is prescribed for shakiness and tremor as
per the med list from her group home. This was restarted at time
of discharge.
Medications on Admission:
Lithium 600mg QAM
Lithium 900mg QPM
Topamax 125mg QPM
Seroquel 200mg QPM
Effexor 75mg [**Hospital1 **]
Pepcid 30mg QAM
Propranolol 10 mg daily
Discharge Medications:
1. Lithium Carbonate 300 mg Capsule Sig: Two (2) Capsule PO QAM
(once a day (in the morning)).
2. Lithium Carbonate 300 mg Capsule Sig: Three (3) Capsule PO
QPM (once a day (in the evening)).
3. Topiramate 25 mg Tablet Sig: Five (5) Tablet PO HS (at
bedtime).
4. Quetiapine 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO HS (at bedtime).
5. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Pepcid 20 mg Tablet Sig: 1.5 Tablets PO once a day.
7. Propranolol 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 7188**] Hospital
Discharge Diagnosis:
Primary: Tylenol overdose without liver injury, Anemia likely
dilutional
Secondary: Bipolar disorder
Discharge Condition:
stable
Discharge Instructions:
You were transferred to this hospital for further management of
your tylenol overdose. You were treated with medication to
counteract the tylenol in your system. Your liver tests do not
indicate that your liver was damaged by this event. You have a
slight anemia which we believe is due to all the fluids you
received.
We feel that you will benefit from a psychiatric hospitalization
given you attempted suicide. You were seen by psychiatry at our
hospital who agreed with restarting your pyschiatric
medications.
No new medications have been started.
If you experience feelings of wanting to hurt yourself,
abdominal pain, fevers, chest pain or shortness of breath please
contact your primary care physician or come to the emergency
department for evaluation.
Followup Instructions:
You should follow up with your PCP and outpatient psychiatrist
within 1 week of discharge from the psychiatric hospital.
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2957
} | Medical Text: Admission Date: [**2193-5-12**] Discharge Date: [**2193-5-20**]
Date of Birth: [**2132-7-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 60 year old man with a
history of right ankle arthrodesis who presented
postoperative, who developed bleeding, and was found to have
a pseudoaneurysm and was taken for ligation. The patient had
a large four inch by two inch by three inch ulcer of the
right anterior ankle. Plastic surgery was consulted on this
patient for possible wound closure.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Hypertension.
3. Chronic obstructive pulmonary disease.
4. Benign prostatic hypertrophy.
5. Gout.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Atenolol 50 mg p.o. twice a day.
2. Lisinopril 40 mg once daily.
3. Allopurinol 300 mg once daily.
4. Norvasc 10 mg p.o. once daily.
5. Detrol 2 mg once daily.
6. Zocor 40 mg once daily.
7. Niacin Sustained Release 500 mg once daily.
8. Aspirin 81 mg once daily.
9. Multivitamin.
PHYSICAL EXAMINATION: On presentation, the patient was
afebrile with vital signs stable. The pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. His chest was clear to auscultation
bilaterally. His heart was without murmurs, rubs or gallops.
His abdomen was soft, nontender, nondistended with positive
bowel sounds. His wound was clean, dry and intact. He had a
4.0 by 3.0 by 2.0 inch wound on the right anterior lateral
ankle with sensation and motor intact distally. He also had
palpable dorsalis pedis and posterior tibial pulses
bilaterally.
LABORATORY DATA: Chest x-ray was within normal limits and
his electrocardiogram revealed normal sinus rhythm.
HOSPITAL COURSE: The patient was admitted to the Plastic
Surgery service on [**2193-5-13**]. He was taken to the operating
room and underwent a rectus abdominal free flap to the right
ankle with a split thickness skin graft for coverage. The
patient tolerated the procedure without difficulty. He was
kept in the Intensive Care Unit overnight NPO postoperative
as a precaution. He was continued on intravenous antibiotics
of Unasyn while hospitalized. He was treated with Dextran
for a total of a seven day course with a three day taper.
The patient had no postoperative complications. He remained
afebrile with normal vital signs. His dorsalis pedis and
posterior tibial pulses remained stable. His graft took well
without any signs of ischemia. He had full sensation. On
postoperative day one, the patient's dressing was taken down
on the split thickness skin graft and a heat lamp was
applied. The patient's wounds were clean, dry and intact
during hospitalization. He had no signs of infection during
hospitalization. The patient had a PICC line placed for long
term intravenous antibiotics since it was decided to treat
the patient as if he had osteomyelitis due to the nature of
the wound and the exposed bone. He was to be treated with a
six week course of intravenous Unasyn q6hours. The [**Hospital 228**]
hospital course was without any other episodes. He remained
stable throughout his hospitalization.
DISCHARGE DIAGNOSES:
1. Rectus free flap to right ankle with split thickness skin
graft.
2. Failure to heal ulcer on the right foot, 2.0 by 3.0 by
5.0 centimeters.
3. Split thickness skin graft.
4. Hypertension.
5. Hypercholesterolemia.
6. Chronic obstructive pulmonary disease.
7. Gout.
MEDICATIONS ON DISCHARGE:
1. Atenolol 50 mg p.o. twice a day.
2. Lisinopril 40 mg once daily.
3. Allopurinol 300 mg once daily.
4. Norvasc 10 mg p.o. once daily.
5. Detrol 2 mg once daily.
6. Zocor 40 mg once daily.
7. Niacin Sustained Release 500 mg once daily.
8. Aspirin 81 mg once daily.
9. Multivitamin.
10 Unasyn three grams intravenously q6hours for a total of
six weeks.
He was also to be discharged home with wound care
instructions.
CONDITION ON DISCHARGE: Good.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 5385**] in one
week. The patient's ambulatory status at discharge is
nonweight-bearing on the lower extremity with elevation of
the foot at all times.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7738**]
Dictated By:[**Last Name (NamePattern1) 5747**]
MEDQUIST36
D: [**2193-5-19**] 10:00
T: [**2193-5-19**] 11:24
JOB#: [**Job Number 48432**]
ICD9 Codes: 496, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2958
} | Medical Text: Admission Date: [**2119-8-1**] Discharge Date: [**2119-8-4**]
Date of Birth: [**2049-9-19**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2071**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
69F w/ remote heavy smoking and GERD who was well until night of
[**7-31**] when she awoke at midnight with 10/10 pain in her LUQ and
lower left chest, radiating to the LUE and L neck. She reports
diaphoreresis, but no SOB, N, V, or presyncope/syncope. The CP
lasted for >1hr, decr to [**1-17**] at OSH and then resolved after
arrival to [**Hospital1 18**]. Pt took two ASA at home. Of note, she has a
history of similar episodes: usually lasting for <5 minutes and
occuring one hr after meals. These episodes had been increasing
in freq over the past few mos. On anti-GERD Rx; has h/o nml EGD.
ROS: Pos urinary freq/urgency/dysuria for several days.
To OSH: BP147/66 HR59. ECG concerning for IMI. Started on O2,
given Plavix 300mg, Morphine 2mg IV, NTG SL x 3, Heparin
bolus/GTT, Intergrilin GTT, and Lopressor.
Transfered to BIDCM: T97.6 HR70 BP85/43-->104/55 RR12 OS98%4L.
CP 1hr after arrival. PE WNL (except incr I:E).
Past Medical History:
PMHx: (1) GERD (Hiatal Hernia) (2) Constipation/Diarrhea (3)
Fatty Infiltration of Liver.
PCP: [**Name Initial (NameIs) 36026**] ([**Hospital3 **] Medical)
ETT MIBI ([**2119-6-30**]): Small reversible defect of infer basal wall.
Social History:
Lives with her boyfriend at home. Has three kids. Quit smoking
16 y/a (120 p-y). Occasional ETOH. No drugs/IVDU.
Family History:
No MI/CAD. Father - died in 80s; ETOH abuse. Mother - died from
TB at 33. Sister - "heart conidition," LungCA. Brother - died
from asbestosis. Has three healthy children.
Physical Exam:
T97.6 HR70 BP85/43-->104/55 RR12 OS98%4L
Pertinent Results:
[**2119-8-1**] 10:50AM GLUCOSE-90 UREA N-19 CREAT-0.8 SODIUM-145
POTASSIUM-4.0 CHLORIDE-112* TOTAL CO2-23 ANION GAP-14
[**2119-8-1**] 10:50AM CK(CPK)-87
[**2119-8-1**] 10:50AM CK-MB-NotDone cTropnT-0.11*
[**2119-8-1**] 10:50AM CALCIUM-8.4 PHOSPHATE-2.1* MAGNESIUM-2.1
[**2119-8-1**] 10:50AM WBC-6.1 RBC-4.14* HGB-12.7 HCT-36.9 MCV-89
MCH-30.7 MCHC-34.4 RDW-12.7
[**2119-8-1**] 10:50AM PLT COUNT-187
[**2119-8-1**] 10:50AM PT-14.1* INR(PT)-1.3
[**2119-8-1**] 05:05AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2119-8-1**] 05:05AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
[**2119-8-1**] 05:05AM URINE RBC-0-2 WBC-[**5-18**]* BACTERIA-NONE
YEAST-NONE EPI-0-2
[**2119-8-1**] 05:04AM PH-7.36 COMMENTS-GREEN TOP
[**2119-8-1**] 05:04AM GLUCOSE-118* NA+-144 K+-4.8 CL--108 TCO2-26
[**2119-8-1**] 05:04AM HGB-13.5 calcHCT-41
[**2119-8-1**] 05:04AM freeCa-1.13
[**2119-8-1**] 04:40AM UREA N-22* CREAT-0.9
[**2119-8-1**] 04:40AM CK(CPK)-79
[**2119-8-1**] 04:40AM CK-MB-NotDone cTropnT-0.09*
Brief Hospital Course:
Pt was transferred from OSH for NSTEMI and Cardiac Cath.
1) CAD/NSTEMI: Pt was CP free throughout her admission. Her TnT
peaked at 0.11 (CK 87) and trended down. Cath on [**8-1**] revealed
LAD-50% mid; RCA-95% mid, distal filling into collaterals. The
RCA was stented. The cath was complicated by arterial
perforation and hematoma formation: see below. She was continued
on ASA, Plavix, Lipitor, and Metoprolol. An ECHO on [**8-2**] showed
preserved systolic dysfunction but impaired relaxation. An ACE-i
was not stated because of borderline BPs. She was instructed to
f/u with a cardiologist or her PCP to resume this med.
2) Arterial Perf (Ext Iliac/Common Fem)/Blood Loss Anemia: As
noted, cath was complicated by external iliac/common femoral
perforationAfter cath, HCT was down to 29.1 and pt had SBPs to
70s-80s. Pt was transfered to ICU where she was transufed,
started on IVF, and then recovered. Per 2nd angio, no continued
bleeding was noted. In total she rec'd 3 units PRBC. Her HCT
remained above 30 after the 3rd unit was given and her SBPs
ranged from 100-120s thereafter as well. An Abd CT confirmed a
retroperitoneal bleed: "Extraperitoneal stranding extending from
the right kidney into the right deep pelvis consistent with
retroperitoneal hemorrhage."
3) UTI: Her initial UA was positive and she was started on a 3
day course of Levofloxacin 500mg q24hr. She was given
Phenazopyridine for symptomatic relief of dysuria.
4) GERD: Continue Pantoprazole and Maalox prn.
5) Pneumonia: At the conclusion of her course, she had mild decr
of O2 sats from baseline (90-94%RA) and a CXR was read as mild
RML PNA. She was continued on Levo for an addn't 7 days.
6) Code: Full.
7) FEN: Cont'd Cards Healthy diet.
8) Dispo. DCed to home.
Medications on Admission:
Maalox, Nexium, ASA
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*90 Tablet(s)* Refills:*3*
4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
5. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*0*
7. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: non ST elevation myocardial infarction
Secondary: coronary artery disease, retroperitoneal hemorrhage,
urinary tract infection, pneumonia, gastroesopheal reflux
disease
Discharge Condition:
Good
Discharge Instructions:
Please follow-up with your primary care physician or come to the
emergency department if you develop chest pain, shortness of
breath, palpitations, lightheadedness, worsening abdominal pain,
or any other symptoms that you find concerning.
Please take all of your medications as prescribed.
Followup Instructions:
1) Primary care: Please call your primary care physician (Dr.
[**Last Name (STitle) 36026**] [**Telephone/Fax (1) 17663**]) to schedule an appointment to be seen
within 1 week of discharge.
-- you will need a blood count (hematocrit) checked within [**2-9**]
days to ensure stability. At the time of discharge, your
hematocrit is 32.1.
2) Please call your outpatient cardiologist (Dr. [**Last Name (STitle) 58043**] to be
seen within 1-2 weeks following discharge.
-- you would likely benefit from a cardiac rehabilitation
program which your outpatient cardiologist can arrange for you.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]
ICD9 Codes: 5990, 486, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2959
} | Medical Text: Admission Date: [**2129-12-28**] Discharge Date: [**2130-1-12**]
Date of Birth: [**2054-7-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Olanzapine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Increasing dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2130-1-3**] 1. Mitral valve repair with a 28 mm [**Doctor Last Name 405**]
annuloplasty band and [**First Name8 (NamePattern2) **] [**Last Name (un) 84256**] stitch between A1 and P1. 2.
Coronary artery bypass grafting x1 with left internal mammary
artery graft to left anterior descending.
History of Present Illness:
75yo man seen in [**2127**] after CHF exacerbation requiring
intubation. During that stay patient had acute delerium and was
deemed porr surgical candidate at that time. He ultimately was
discharged to rehab where after period of recovery he returned
home where he lives alone. He has been in relatively good health
since that time but recently has been experiencing increasing
dyspnea on exertion. He had repeat echo and underwent cardiac
catheterization today. He is now referred to re evaluate
surgical candidacy.
Past Medical History:
Mitral Regurgitation
Paroxysmal Atrial Fibrillation
Hypertension
Hypercholesterolemia
Congestive heart failure
Chronic Obstructive Pulmonary Disease
?CVA
Obesity
Past Surgical History:
s/p left knee replacement
s/p right knee surgery
Social History:
Race: caucasian
Last Dental Exam:
Lives with: alone, wife deceased
Occupation: former truck driver
Tobacco: quit 40 years ago
ETOH: no
Illicit drugs: no
Family History:
non contributory
Physical Exam:
Pulse: 54 Resp: 16 O2 sat: 96%-RA
B/P Right: 159/86 Left:
Height: 72 inches Weight: 243lbs
General: Obese-NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] MMM-normal oropharynx
Neck: Supple [x] Full ROM [x] no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM
Abdomen: Soft[x] non-distended[x] non-tender[x] +BS [x]
Extremities: Warm [x], well-perfused [x]
Edema- 2+ bilat
Varicosities: None []
Neuro: Grossly intact, non focal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left: 2+
Carotid Bruit radiated murmur
Pertinent Results:
Admission labs:
[**2129-12-28**] 05:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2129-12-28**] 05:45PM PT-12.3 INR(PT)-1.0
[**2129-12-28**] 05:45PM PLT COUNT-136*#
[**2129-12-28**] 05:45PM WBC-8.7 RBC-4.67 HGB-13.5* HCT-39.7* MCV-85
MCH-28.9 MCHC-34.0 RDW-14.9
[**2129-12-28**] 05:45PM %HbA1c-5.7 eAG-117
[**2129-12-28**] 05:45PM ALBUMIN-4.2 CALCIUM-9.0 PHOSPHATE-3.2
MAGNESIUM-2.4
[**2129-12-28**] 05:45PM CK-MB-4 cTropnT-<0.01
[**2129-12-28**] 05:45PM LIPASE-54
[**2129-12-28**] 05:45PM ALT(SGPT)-19 AST(SGOT)-21 ALK PHOS-66
AMYLASE-72 TOT BILI-0.8
[**2129-12-28**] 05:45PM GLUCOSE-78 UREA N-15 CREAT-0.8 SODIUM-143
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-31 ANION GAP-11
Discahrge labs:
[**2130-1-12**] 03:59AM BLOOD WBC-11.7* RBC-3.14* Hgb-8.7* Hct-27.2*
MCV-87 MCH-27.6 MCHC-31.9 RDW-15.2 Plt Ct-442*
[**2130-1-12**] 03:59AM BLOOD Plt Ct-442*
[**2130-1-12**] 03:59AM BLOOD PT-13.8* PTT-49.1* INR(PT)-1.2*
[**2130-1-12**] 03:59AM BLOOD Glucose-94 UreaN-19 Creat-0.9 Na-141
K-4.3 Cl-105
[**2130-1-12**] 03:59AM BLOOD Phos-3.9 Mg-2.1
[**2129-12-29**] Carotid U/S: Minimal plaque with bilateral less than 40%
carotid stenosis.
[**2130-1-3**] Echo: PRE-CPB: The left atrium is mildly dilated. No
thrombus is seen in the left atrial appendage. A tiny patent
foramen ovale is present. A left-to-right shunt across the
interatrial septum is seen at rest. There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The descending thoracic aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta. No
thoracic aortic dissection is seen. The aortic valve leaflets
(3) are mildly thickened. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is
moderate/severe prolapse of the P1 portion of the posterior
mitral leaflet. An eccentric, anteriorly directed jet of Severe
(4+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is also a central MR jet.
POST-CPB: There is a mitral annular ring in place. The anterior
mitral leaflet spans the entire mitral annulus, and the
posterior mitral leaflet is minimally visible, consistent with
mitral valve repair. There is no residual MR. The LV systolic
function appears unchanged from preop, estimated EF 50%. There
is no evidence of aortic dissection. Dr. [**Last Name (STitle) **] was notified in
person of the results at time of study.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2130-1-8**] 11:07 [**Hospital 93**] MEDICAL CONDITION: 75 year old man
with new picc
Final Report
One view. Comparison with the previous study done earlier the
same day. A
PICC line has been inserted on the left and terminates in the
upper superior vena cava. A right jugular sheath has been
withdrawn. There is no other significant change.
Brief Hospital Course:
Mr. [**Known lastname 12667**] presented to [**Hospital1 18**] for admission prior to surgery for
cardiac cath and due to being on Coumadin at home for atrial
fibrillation. He stopped Coumadin prior to admission and was
started on IV Heparin. Following cath he was transferred to the
floor for medical management. In addition he underwent extensive
surgical work-up which included echo, carotid U/S, PFT's and
dental clearance. On [**2130-1-3**] he was brought to the operating
room where he underwent a mitral valve repair and coronary
artery bypass graft x 1. Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one EP was consulted for
management of bradycardia, sinus pauses and atrial fibrillation
(brady-tachy syndrome). He remained in the CVICU for a week for
close rhythm monitoring and management. During this time he was
diuresed towards his pre-op weight. Chest tubes and epicardial
pacing wires were removed per protocol. Although pacing wires
remained intact for longer due to rhythm issues. Heparin,
eventually Coumadin, and Amiodarone were started for atrial
fibrillation. On post-op day seven he was transferred to the
stepdown floor for further care. On post operative day 8 his
rhythm was stable in atrial fibrillation at a rate 90-100's with
no required pacing for multiple days. His Heparin was stopped at
this time and pacing wires were pulled. Heparin was then resumed
6 hours later and stopped once patient became therapeutic on
Coumadin. During post-op period he worked with physical therapy
for strength and mobility. On post operative day 9 he was
ambulating with assistance, his incisions were healing well and
he was tolerating a full oral diet. It was felt that he was
safe for discharge to [**Hospital3 **] in [**Location (un) 1294**]. He will
follow-up with Dr [**Last Name (STitle) **] in 3 weeks.
Medications on Admission:
Coumadin 7 alt 6 daily
ASA 81 mg daily
Lisinopril 2 mg [**Hospital1 **]
KCl 10 mg daily
Metoprolol 5 mg [**Hospital1 **]
Lasix 40A/20P
Amlopidine 10 mg daily
Amiodarone 200 mg daily
Vit D 1000 mg daily
Vit C
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg [**Hospital1 **] x7 days then 200 mg QD.
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/temp.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) tx Inhalation every four (4) hours as
needed for wheezing.
9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
10. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) flush
Intravenous PRN (as needed) as needed for line flush: 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.
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. potassium chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day.
13. warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily
at 4 PM: Indication-Afib
Targert INR 2-2.5
Take 7.5mg on [**1-12**] then as directed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Mitral Regurgitation and Coronary artery disease s/p Mitral
valve repair and coronary artery bypass graft x 1
Past medical history:
Paroxysmal Atrial Fibrillation
Hypertension
Hypercholesterolemia
Congestive heart failure
Chronic Obstructive Pulmonary Disease
?CVA
Obesity
Past Surgical History:
s/p left knee replacement
s/p right knee surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Lower extermity edema- 2+ bilat
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) **] [**Telephone/Fax (1) 170**] [**2130-2-2**] 1:30
Cardiologist: Dr. [**Last Name (STitle) 8579**] on [**2130-1-31**] @10:45AM
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8522**] [**Telephone/Fax (1) 8577**] in [**3-28**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication
Goal INR
First draw
Results to phone fax
Completed by:[**2130-1-12**]
ICD9 Codes: 4240, 9971, 4019, 4280, 496, 4168, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2960
} | Medical Text: Name: [**Known lastname 6413**], [**Known firstname **] [**Last Name (NamePattern1) 779**] Unit No: [**Numeric Identifier 8735**]
Admission Date: [**2178-3-3**] Discharge Date: [**2178-3-30**]
Date of Birth: [**2156-8-17**] Sex: F
Service:
This is a continuation of the previous discharge dictation
summary.
On [**2178-3-18**] with the patient's white count climbing to a
value of 17.5, abdominal and pelvic CT scan was performed
which demonstrated a loculated fluid collection in the left
lung at the site of the previous VATS procedure as well as a
large pelvic and gluteal hematoma. At this point, the
Cardiothoracic Surgery service was consulted, and they felt
that an original radiology drainage of loculated fluid
collection in her lung would be the most diagnostic benefit
for the patient.
Overnight from [**3-18**] to [**3-19**], it was decided to reverse the
patient's Coumadin, units of fresh-frozen plasma were given,
and the patient's Heparin was held. The same night the
patient complained of increasing hip pain and late that night
approximately 3 am to 6 am, the patient began to complain of
some numbness and weakness in her foot. In the morning, she
was evaluated by the team on am rounds. Her right foot was
found to be significantly weak in the AT muscles, the calf
muscles. She was unable to activate her [**Last Name (un) **]. She has some
eversion and inversion function. Sensation was diminished in
a L5-S1 distribution. These findings were discussed with Dr.
[**First Name (STitle) **] of the Orthopedic Service, who came to evaluate the
patient, which for a MRI of the L spine was to be performed.
This scan was performed and was negative except for the
pelvic hematoma which was again seen.
At this point, the patient's aspirin was held. Hematocrit
was drawn at that time which demonstrated a drop from 31 to
approximately 21. The patient was transfused 2 units of
blood without a rise in her hematocrit. At this point, Dr.
[**Last Name (STitle) **], the covering Trauma attending was consulted, who
wished to give the patient DDAVP in order to partially
mitigate the effect of the aspirin and Plavix, which the
patient had been maintained on for her carotid dissection.
This was given, and the patient continued to be transfused
with fresh-frozen plasma and red blood cells. Her INR
dropped to a value of 1.1. Her PTT normalized, and her
hematocrit rose to a value in the high 20s to low 30s.
In light of this bleed and new neurologic finding, Dr. [**First Name (STitle) **]
requested that we consult the Neurology Service. The
Neurology Service was consulted and felt that the patient had
a leg weakness and numbness in the distribution which
suggested a lower motor neuron weakness with sensory loss in
the L5 distribution. There is a question of whether or not
this hematoma in the pelvis was either compressing the
lumbosacral roots or the sciatic nerve.
The results of this neurologic evaluation was discussed with
both Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **]. At that time, a CT scan was
performed which demonstrated two-fold increase in the size of
the gluteal hematoma without change in the size of the pelvic
hematoma from the CT scan which had been done several days
previously in evaluation of the patient's rising white count.
At that time, it was decided to take the patient to the
operating room for evacuation of the pelvic hematoma as well
as angiography to rule out the presence of any pelvic vessels
which were still bleeding.
On [**2178-3-22**], late in the evening, the patient was taken to
the operating room. Large amount of pelvic hematoma was
evacuated. The patient tolerated the procedure well, and was
transferred, intubated straight to the angiography suite
where an angiogram was negative for further bleeding.
Patient was transferred from angiography to the PACU, where
she was subsequently extubated. She returned from the PACU
to the floor in good condition.
Postoperatively, the patient's anticoagulation was held for a
number of days. On [**2178-3-26**], it was decided to restart the
patient on Coumadin. Subsequent several days, the patient's
neurologic examination gradually improved in the right foot
to where she was approximately 4/5 strength in dorsiflexion
and 4/5 strength in plantar flexion with some activation of
the [**Last Name (un) **]. Her sensory examination also changed such that she
had recovered sensation in the L5 distribution, although she
did have some pain most likely related to nerve root
compression.
The following week additionally in working with Physical
Therapy service, the patient complained of some right knee
pain. On [**2178-3-28**], the patient had a right knee x-ray which
demonstrated a small transverse patellar fracture. The
Orthopedic service again saw the patient and decided to treat
this fracture in a knee immobilizer.
On [**2178-3-30**] with the patient's INR at a value of 1.9, was
able to tolerate a regular diet, and her pain well controlled
with oral pain medications, it was decided to discharge the
patient to home.
DISCHARGE DIAGNOSES:
1. Motor vehicle crash.
2. Left thalamic versus midbrain bleed.
3. Anterior aspect of C2 fracture treated conservatively with
immobilization in [**Location (un) 6515**]-J collar.
4. Bilateral first rib fractures.
5. Bilateral pneumothoraces.
6. Right acetabular fracture status post open reduction
internal fixation, status post evacuation of gluteal
hematoma.
7. Left cuboid fracture.
8. Right transverse patellar fracture.
9. Left carotid dissection status post cerebral angiography.
10. Pneumonia.
11. Gluteal versus pelvic compartment syndrome with
compression of the sciatic nerve.
12. Status post video assisted thoracoscopy.
DISCHARGE MEDICATIONS:
1. Coumadin 4 mg po q day.
2. Neurontin 300 mg po q day.
3. Colace 100 mg po bid.
4. Mirtazapine 7.5 mg q hs.
5. Aspirin 81 mg po q day.
6. Dilaudid 2-4 mg po q6h prn pain.
FOLLOWUP: Dr. [**Last Name (STitle) 998**] of the Orthopedic Service, phone
#[**Telephone/Fax (1) 5972**] for evaluation of a cuboid fracture. Followup
should be with Dr. [**First Name (STitle) **] of the Orthopedic Service,
[**Telephone/Fax (1) 8155**] for evaluation of her acetabular fracture and
evaluation of her C2 fracture. Followup should be with Dr.
[**Last Name (STitle) 365**] of the Neurosurgical service, [**Telephone/Fax (1) 8659**] for followup
of her midbrain hemorrhage as well as her carotid dissection.
Length of Coumadinization should be approximately 3-6 months
to be followed up by Dr. [**Last Name (STitle) 365**]. The patient should followup
with her primary care physician for INR management. The
patient will receive laboratory draws approximately biweekly,
first to begin tomorrow and then Thursday with results phoned
to her PCP. [**Name10 (NameIs) **] patient should be maintained with a goal INR
of 1.5 to 2. The patient should follow up with the Trauma
Clinic in two weeks, phone #[**Telephone/Fax (1) 8489**] with Dr. [**Last Name (STitle) **] for
evaluation of her chest wounds.
The patient's activity status is to be nonweightbearing on
her right lower extremity x3 months. She should be
touch-down weightbearing for transfer only on the left for
approximately three months. This will be reassessed by Dr.
[**Last Name (STitle) 998**] of the Orthopedic Service. The patient is to
continue on a knee immobilizer until again cleared by the
Orthopedic Service. She should be a right lower extremity
resting splint at night given her foot weakness and the
patient should be in a left lower extremity splint at all
times. The patient should continue in a hard collar until
followup with Dr. [**First Name (STitle) **] in clearance. The patient will receive
home Physical Therapy and occupational therapy as per the PT
and OT recommendations of the services here.
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern1) 3595**], M.D. [**MD Number(1) 3596**]
Dictated By:[**Name8 (MD) 8654**]
MEDQUIST36
D: [**2178-3-30**] 16:39
T: [**2178-4-1**] 07:08
JOB#: [**Job Number 8736**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2961
} | Medical Text: Admission Date: [**2113-6-23**] Discharge Date: [**2113-6-29**]
Date of Birth: [**2045-8-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
severe hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67 year old gentleman known to our service underwent ascending
aortic replacement and AVR on [**5-2**]. Pt. discharged after 6 days
in the hospital. Pt. seen in clinic today by cardiologist, noted
to have a SBP of 205. Pt. essentially asymptomatic. Transferred
here for further w/u. In ER pt's. SBP is 225. Started on Ntg.
echo ordered.
Past Medical History:
Aortic Stenosis dx 1 year ago per patient
Dilated Aortic Root/asc. arch
s/p AVR/repl. asc. aorta [**4-27**]
Paroxsymal Atrial Fibrillation - First occurred 15 years ago
Hypertension
? Chronic obstructive pulmonary disease
Hyperlipidemia
Past Surgical History
Right knee surgery (Pt unsure but likely arthroscopy)
Appenedectomy
Social History:
Race: Caucasian
Last Dental Exam: dental clearance received [**2113-3-27**]
Lives with: Wife in [**Name2 (NI) 392**], MA
Occupation: Retired
Tobacco: 1.5ppd x 25 years. Quit [**1-24**].
ETOH: 2 glasses of wine daily
Family History:
Mother died of stroke at 49. Father died of AAA at 73.
Physical Exam:
Pulse: 69 SR Resp: 16 O2 sat: 99%
B/P Right: 225/64 Left: 145/86
Height: 75" Weight: 219
General: Well-devloped male in no acute distress
Skin: Dry [X] intact [X]. Multiple nevi and actinic keratosis.
HEENT: NCAT, PERRL, Sclera anicteric OP benign. Teeth in fair
repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2,
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X] Ventral hernia
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X] Some mild chronic venous stasis changes
of
lower extremities.
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 2+ Left:2+
Carotid Bruit None
Pertinent Results:
[**2113-6-29**] 05:35AM BLOOD WBC-6.4 RBC-3.68* Hgb-10.7* Hct-33.4*
MCV-91 MCH-29.1 MCHC-32.0 RDW-16.9* Plt Ct-127*
[**2113-6-29**] 05:35AM BLOOD Plt Ct-127*
[**2113-6-29**] 05:35AM BLOOD Glucose-89 UreaN-18 Creat-1.2 Na-140
K-3.8 Cl-105 HCO3-26 AnGap-13
[**2113-6-25**] 02:37AM BLOOD ALT-27 AST-29 LD(LDH)-394* AlkPhos-67
Amylase-45 TotBili-0.8
[**2113-6-25**] 02:37AM BLOOD Lipase-71*
[**2113-6-29**] 05:35AM BLOOD Mg-2.2
[**2113-6-25**] 07:42AM BLOOD %HbA1c-5.1 eAG-100
Conclusions
Overall left ventricular systolic function is normal (LVEF>55%).
RV with normal free wall contractility. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque to 35 cm from the incisors.
No thoracic aortic dissection is seen. A bioprosthetic aortic
valve prosthesis is present. The prosthetic aortic valve
leaflets appear normal. The aortic valve prosthesis leaflets
appear to move normally. A paravalvular aortic valve leak is
present about the non-coronary cusp and possibly from the left
cusp. No masses or vegetations are seen on the aortic valve.
There is no aortic valve stenosis. Moderate (2+) aortic
regurgitation from the paravalvular leak is seen. The mitral
valve leaflets are structurally normal. Trvial to mild mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Bioprosthetic aortic valve with moderate
paravalvular regurgitation leak. Blood pressure at the time of
imaging was 130/60 mmHg on Nipride. If indicated, a repeat TEE
after continued blood pressure should be considered.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2113-6-25**] 11:36
Brief Hospital Course:
Admitted to CVICU from ER for BP mgmt. on [**6-23**]. TEE done which
showed some evidence of prosthetic AI and no evidence of
endocarditis.He was seen by cardiology for med recommendations
and was titrated on blood pressure medications. Transferred to
the floor on HD# 5. Cleared for discharge to home on HD # 6. Pt
is to schedule appt with Dr. [**Last Name (STitle) 83686**] for further BP monitoring
early next week.
Medications on Admission:
Amiodarone 200 mg qd
Verapamil 240 mg qd
HCTZ 25mg daily
Lisinopril 10 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*1*
2. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*1*
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Disp:*180 Tablet(s)* Refills:*1*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
hypertension
s/p AVR ( tissue)/repl. asc. aorta [**2113-5-2**]
A fib
? COPD
hyperlipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 2 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Please call to schedule appointments with your :
Cardiologist Dr. [**Last Name (STitle) 83686**] on Mon or Tues. next week
**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:[**2113-7-5**]
ICD9 Codes: 496, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2962
} | Medical Text: Admission Date: [**2192-3-8**] Discharge Date: [**2192-3-14**]
Date of Birth: [**2127-10-16**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
RECURRENT RIGHT RETROPERITONEAL SARCOMA/SDA
Major Surgical or Invasive Procedure:
s/p ex-lap, LOA extensive, R. RP exploration, partial sarcoma
resection
History of Present Illness:
The patient is a 66-year-old male with a
multiply recurrent low grade leiomyosarcoma of the right
retroperitoneum. He has undergone preoperative radiation. The
sarcoma involves a large mass in the mesentery and two
additional masses in the distal and posterior portions of the
inferior vena cava and anterior to the left renal vein and
vena cava. He presents at this time for abdominal exploration
and possible resection of this tumor per General Surgery and
Vascular Surgery.
Past Medical History:
Recurrent liposarcoma, OSA, HTN, HLD, DM, BPH, COPD, Memory
deficits status post head trauma from MVA, s/p TURP
Social History:
Mr. [**Known lastname 68044**] is retired. He smokes a pack a day and has done so
for almost all his life. He does not drink alcohol. He
previously used to work in a warehouse.
Family History:
There is a family history of colon cancer in his
mother. His father died in his 60s of a "massive heart attack."
Physical Exam:
At Discharge:
Vitals: 98.5, 81, 154/69, 20, 98% on RA
GEN: NAD, A/Ox3
CV: RRR, no m/r/g
RESP: CTAB, no w/r/r
ABD: large, soft, appropriately TTP, +BS, +FLATUS, +BM
Incision: Large midline abdominal incision OTA with staples,CDI
Extrem: no c/c/e
Pertinent Results:
[**2192-3-8**] 07:10PM BLOOD WBC-9.9 RBC-3.20* Hgb-9.5* Hct-26.9*
MCV-84 MCH-29.7 MCHC-35.3* RDW-15.5 Plt Ct-166
[**2192-3-10**] 02:35AM BLOOD WBC-14.1*# RBC-3.50* Hgb-10.1* Hct-29.5*
MCV-84 MCH-29.0 MCHC-34.3 RDW-16.0* Plt Ct-207
[**2192-3-10**] 02:12PM BLOOD WBC-14.9* RBC-3.52* Hgb-10.4* Hct-29.6*
MCV-84 MCH-29.5 MCHC-35.1* RDW-16.0* Plt Ct-226
[**2192-3-12**] 02:13AM BLOOD WBC-11.3* RBC-3.34* Hgb-9.7* Hct-28.4*
MCV-85 MCH-28.9 MCHC-34.1 RDW-15.8* Plt Ct-275
[**2192-3-13**] 04:32AM BLOOD WBC-8.0 RBC-3.22* Hgb-9.8* Hct-28.0*
MCV-87 MCH-30.4 MCHC-35.0 RDW-15.2 Plt Ct-260
[**2192-3-13**] 04:32AM BLOOD PT-13.1 PTT-27.5 INR(PT)-1.1
[**2192-3-8**] 04:14PM BLOOD PT-15.5* PTT-33.8 INR(PT)-1.4*
[**2192-3-13**] 04:32AM BLOOD Glucose-134* UreaN-41* Creat-1.7* Na-141
K-4.0 Cl-106 HCO3-25 AnGap-14
[**2192-3-12**] 02:13AM BLOOD Glucose-155* UreaN-34* Creat-1.6* Na-143
K-4.2 Cl-111* HCO3-25 AnGap-11
[**2192-3-8**] 07:10PM BLOOD Glucose-182* UreaN-32* Creat-1.9* Na-136
K-5.9* Cl-110* HCO3-20* AnGap-12
[**2192-3-12**] 02:13AM BLOOD ALT-34 AST-21 LD(LDH)-194 AlkPhos-65
TotBili-0.5 DirBili-0.2 IndBili-0.3
[**2192-3-11**] 02:28AM BLOOD ALT-41* AST-29 LD(LDH)-186 AlkPhos-64
TotBili-0.6 DirBili-0.3 IndBili-0.3
[**2192-3-10**] 02:35AM BLOOD ALT-51* AST-40 LD(LDH)-187 AlkPhos-52
TotBili-0.5 DirBili-0.2 IndBili-0.3
[**2192-3-13**] 04:32AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2
[**2192-3-12**] 02:13AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.2 Mg-2.4
[**2192-3-11**] 02:28AM BLOOD Albumin-2.6* Calcium-8.4 Phos-4.6* Mg-2.3
.
Brief Hospital Course:
Mr. [**Known lastname 68045**] operative course was prolonged and extensive. He
was trasferred from the PACU to TICU secondary to extensive
surgical measures, intubation, pressure support and low urine
output.
.
[**2192-3-9**]: [**Location (un) 109**] line switched to triple lumen CVL. Monitored urine
output and CVP, given fluid boluses as needed to maintain urine
output. Chest XRAYS revealed bilateral pleural effusions. Fluid
hydration tapered to minimize pulmonary edema. Vitals and
labwork stable.
.
[**3-10**]: weaned sedation and vent -> extubated and doing well; on
BiPAP overnight; decreased IVF with maintained adequate UOP/BP;
added back several inhalers
[**3-11**]: negative fluid balance, hypertension cooperative with no
pressor support. Home medications resumed as indicated.
Continued to stabilize.
.
Patient was transferred to [**Hospital Ward Name 1950**] 5 POD 5 from TICU. He had a
foley and IVF for hydration. On POD 6 patient's Foley and
central venous line were removed. Patient had no difficulty
voiding. Upon return of bowel function his diet was increased
from sips to regular which he tolerated well. Continued to pass
flatus and had a bowel movement a few days post-op. Tolerating
oral medication for pain. Continues with home medication
regimen.
Patient ambulates indpendently, has a large support system and
did not need a physical therapy during this admission.
Discharge paperwork reviewed with patient and advised to call
Dr.[**Name (NI) 12822**] office to make a follow up appointment for removal
of incisional staples.
Medications on Admission:
Atenolol 25', Citalopram 20', Diltiazem 120', Doxazosin 4',
Lantus 25', Metformin 1000', Benicar 20', Actos 30', Simvastatin
40', ASA 81', Omeprazole 20', Ped MVI 0.4 mg-300 mcg-250 mcg
Tablet
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Erythromycin 5 mg/g Ointment Sig: 0.5 mg/g Ophthalmic QID (4
times a day) as needed for both eyes.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain for 2 weeks: Please do
not exceed more than 4000mg of acetaminophen in 24 hrs. .
Disp:*35 Tablet(s)* Refills:*0*
11. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
13. Lantus 100 unit/mL Solution Sig: Twenty Five (25) Units
Subcutaneous at bedtime.
14. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation for 2 weeks: Take only if pain
medication constipates you.
Disp:*14 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Right retroperitoneal liposarcoma
Hypotension
Low urine output post op
Anemia related to acute blood loss
.
Secondary:
Recurrent liposarcoma, OSA, HTN, HLD, DM, BPH, COPD, memory
deficits status post head trauma from MVA, s/p TURP
Discharge Condition:
Stable.
Tolerating a regular diet.
Pain well controlled with oral pain medications.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow up appointment with
Dr. [**Last Name (STitle) 1924**] in [**2-10**] weeks.
-Steri-strips will be applied and they will fall off on their
own. Please remove any remaining strips 7-10 days after
application.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Followup Instructions:
1. Please call Dr.[**Name (NI) 12822**] office [**Telephone/Fax (1) 7508**] to make a follow
up appointment in [**2-10**] weeks.
2. Please call your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) 68046**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 41556**] to make a
follow up appointment in 1 week or as needed.
Completed by:[**2192-3-14**]
ICD9 Codes: 2851, 4019, 496, 3051, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2963
} | Medical Text: Admission Date: [**2188-3-21**] Discharge Date: [**2188-4-8**]
Date of Birth: [**2111-6-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain, nausea, vomiting, poor oral intake associated
with lethargy and confusion x 2days. Transferred to [**Hospital1 18**] from
[**Hospital 8**] Hospital with respiratory distress.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 year old male with COPD, CAD, HTN, long history of smoking
transferred from [**Hospital 8**] Hospital for respiratory distress in
the setting of recent ERCP complicated by post-ERCP
pancreatitis.
Mr. [**Known lastname **] is an [**Hospital3 **] resident, who recently underwent
an ERCP on [**2188-3-18**], and subsequently developed abdominal pain,
nausea, vomiting, poor PO intake, lethargy, and confusion. He
was admitted on [**3-20**] to [**Hospital 8**] Hospital. The ERCP findings
were noteable for a dilated bile duct, cyst duct stump, and
pancreatic ducts s/p stent placement in CBD. At the time of the
[**Hospital 8**] Hospital admission, he was febrile to 101, with a
leukocytosis of 19K and amylase greater than 2400, lipase
greater than 2600, but normal LFTs.
The patient was admitted and treated presumptively for post-ERCP
pancreatitis with NPO diet, aggresive IVF and antibiotics
(Ertapenem x2
doses) for a question of cholangitis. The patient did undergo a
CT scan that revealed, per report, peripancreatic fat stranding.
On [**2188-3-21**], the patient was seen in GI consultation. Over night
he developed respiratory distress and was placed on BiPAP. Due
to failure to improve, the patient was transferred to [**Hospital1 18**] for
further evaluation and care. On [**2188-3-21**], his arterial blood
gases were 7.48/26/79/19/97%.
Upon admission, the patient complained of difficulty breathing
and feeling short of breath. He was intubated shortly
thereafter for increasing tachypnea and work of breathing.
Past Medical History:
CAD, s/p stent x2 [**2183**] (echo [**1-21**] EF 65%), COPD, s/p
cholecystectomy, s/p appendectomy, chronic lower back pain s/p
lumbar laminectomy x3 complicated by left foot drop (wears
brace), HTN, DVT, PE s/p IVC filter placement, AAA 3.6cm,
orthostatic hypotension.
Social History:
Elderly care facility resident. Ex-smoker 35 pk-yr Hx; quit
25yrs ago.
Family History:
Non-contributory
Physical Exam:
VS: T: 99.9 PO, BP: 110/79, HR: 64, RR: 17, SaO2: 100% RA
GEN: Alert, arousable with mental status at baseline in nAD.
HEENT: Sclerae anicteric. EOMI. O-P intact.
NECK: Supple. No lymphadenopathy.
LUNGS: CTA(B).
CARDIAC: RRR; nl S1/S2.
ABD: Normoactive BSx4. Soft/NT/ND.
EXTREM: No c/c/e.
SKIN: Intact. No rashes/lesions.
NEURO: Alert, arousable, baseline.
Pertinent Results:
[**2188-3-21**] 11:36PM TYPE-ART PO2-164* PCO2-19* PH-7.46* TOTAL
CO2-14* BASE XS--6
[**2188-3-21**] 11:36PM GLUCOSE-73 K+-2.3*
[**2188-3-21**] 07:10PM ALT(SGPT)-21 AST(SGOT)-38 CK(CPK)-258* ALK
PHOS-51 TOT BILI-0.9
[**2188-3-21**] 07:10PM LIPASE-91*
[**2188-3-21**] 07:10PM CALCIUM-6.1* PHOSPHATE-1.7* MAGNESIUM-2.0
[**2188-3-21**] 07:10PM CEA-1.9
[**2188-3-21**] 07:10PM WBC-15.8* RBC-4.25* HGB-12.8* HCT-38.1*
MCV-90 MCH-30.2 MCHC-33.7 RDW-14.3
[**2188-3-21**] 07:10PM NEUTS-91.0* LYMPHS-5.8* MONOS-3.0 EOS-0
BASOS-0.1
[**2188-3-21**] 07:10PM PLT COUNT-180
[**2188-3-21**] 07:10PM PT-15.7* PTT-31.3 INR(PT)-1.4*
.
[**2188-3-27**] Torso CT with Contrast:
1. Worsening of pancreatitis, though the imaging findings often
lag behind
the patient's clinical status. There is moderately extensive
peripancreatic fluid and stranding; however, no evidence of
pancreatic necrosis, vascular complication or discrete fluid
collection.
2. New small-to-moderate left and tiny right pleural effusions
with
associated atelectasis.
3. Small ground-glass focus in the left upper lobe may represent
inflammation or infection.
4. CBD stent in situ, with expected pneumobilia and minimal
intrahepatic bile duct dilation.
5. Moderate axial hiatal hernia.
6. 3 cm infrarenal AAA
.
[**2188-3-21**] Admission PA CXR:
Midline gas collection just above the diaphragm is presumably a
loop of bowel or gastric fundus in a midline hernia. Lungs
clear. Heart size normal. No pleural effusion, pneumothorax or
upper mediastinal abnormality. Stomach is below the diaphragm is
severely distended.
.
[**2188-4-3**] AP/Lat CXR:
Examination is limited due to low lung volumes. Within this
limitation, the hiatal hernia unchanged. Compressive atelectasis
at the left lung base is noted adjacent to the hernia. The lungs
are otherwise clear without focal opacity. The heart size is
likely exaggerated due to low lung
volumes and lordotic position. The mediastinal and hilar
contours are normal. The right- sided central line and
nasogastric tube have been removed. Biliary stent and IVC filter
are again seen.
IMPRESSION: No acute cardiopulmonary abnormality.
.
[**2188-4-8**] CXR Line Placement:
Existing PICC line repositioned, now with tip in the SVC. The
PICC line
is ready to use.
Brief Hospital Course:
The patient was transferred from [**Hospital 8**] Hospital and admitted
to [**Hospital1 18**] with post-ERCP pancreatitis with tachypnea and
difficulty breathing. NPO on IV fluids. Baseline portable AP CXR
taken. Arterial blood gases were 7.48/26/79/19/97%. Intubated
and placed on mechanical ventilation. Fentanyl drip for pain
started with good effect. Midazolam drip started for sedation
while intubated. Flexiseal fecal management system placed, foley
maintained. ICU protocols implemented.
[**2188-3-22**]: Received fluid rescusitation. Electrolytes repleted.
ABGs and AP CXR repeated. Vent settings adjusted. CVL placed.
[**2188-3-23**]: Day #1 TPN initiated. Continued on ventilator.
[**2188-3-24**]: Diuresis started with Lasix drip. Given albulin
infusion. Day #2 TPN. Started on Fentanyl patch for pain
control.
[**2188-3-25**]: Diamox added to facilitate diuresis. Continued on TPN.
Spiked fever; pan cultured. Cultures negative. Fentanyl drip
discontinued; continued on patch.
[**2188-3-26**]: BAL performed. Successfully extubated.
[**2188-3-27**]: Re-intubated for respiratory distress. Torso CT
performed.
[**2188-3-28**]: CVL discontinued; tip sent for culture. New CVL placed.
Continued on vent, TPN, IVF.
[**2188-3-29**]: Extubated successfully. Spiked fever. Plan continued.
[**2188-3-30**]: Developed epigastic (R)UQ abdominal pain asscoiated
with increased LFTs. Lasix drip discontinued. Agressive
respiratory toilet. Physical Therapy following.
[**Date range (3) 82549**]: NGT and A-line discontinued. Transferred to
floor NPO, on IV fluids, with a foley in place. Continued on
Fentanyl patch for pain control with good effect. Continued on
TPN. Started clear liquids on [**4-2**] with good tolerability.No
events.
[**2188-4-3**]: Triggered for low systolic blood pressure; responded
well to 1L fluid bolus. CVL discontinued; tip sent for culture.
On PPN while central line out. Diet advanced to full. IV
Vancomycin started for empiric line sepsis. Mentation improved.
Repeat CXR normal.
[**2188-4-4**]: Mental status further improved. Geriatrics conulted.
Home medications started. PICC placed; TPN restarted.
[**2188-4-5**]: IV Vancomycin discontinued; started on Cipro for
possible UTI.
[**2188-4-6**]: Continued on TPN. Full liquids with excellent intatke;
no nausea, vomiting. LFTs improving.
[**2188-4-7**]: Continues on TPN. Tolerating full liquid diet. Foley
remains in place due to incontinence.
[**2188-4-8**]: (L) PICC site erythematous with cephalic vein clot
identified; PICC discontinued and tip sent for culture, (L)
upper extremity elevated with warm compresses applied. New (R)
PICC placed. Foley discontined. Voided.
Medications on Admission:
Ativan 0.5 PO QHS, cymbalta 30mg daily, FeSO4, prilosec 20mg
daily, zocor 80mg daily, singulair 10mg daily, vitD, ASA 81mg
daily, avapro 150mg daily, florinef 0.05mg daily, toprol 50mg
daily, Calcium Carbonate 500mg Chewable TID
Discharge Medications:
1. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal
Q72H (every 72 hours).
2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours: Place with 100 mcg patch.
3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for wheeze.
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation [**Hospital1 **] (2 times a day).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QMON (every Monday): For 10 weeks total then 800 IU
po daily after that.
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Vicodin HP 10-660 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for severe pain.
14. Fludrocortisone 0.1 mg Tablet Sig: one-half Tablet PO once a
day.
15. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
16. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
17. Avapro 150 mg Tablet Sig: One (1) Tablet PO once a day.
18. Cymbalta 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain: Do not exceed 4000mg
acetaminophen daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Post-ERCP Pancreatitis
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2188-5-2**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2188-5-2**] 11:45; Location [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1124**], PA (ERCP) will call Dr. [**Last Name (STitle) 82550**] with
arrangements for follow-up ERCP with stent removal to be
scheduled with Dr. [**Last Name (STitle) **] in 6 weeks. Ms. [**Last Name (Titles) 6417**] contact
information: [**Name (NI) **]: ([**Telephone/Fax (1) 82551**], Pager: [**Numeric Identifier 82552**].
Completed by:[**2188-4-9**]
ICD9 Codes: 5990, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2964
} | Medical Text: Admission Date: [**2147-10-12**] Discharge Date: [**2147-10-29**]
Date of Birth: [**2079-6-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
On admission: Mr [**Known lastname 79336**] states that he experienced two to three
months of abdominal discomfort, which grew in severity and
became more constant. He had a simultaneous loss of appetite,
although he denies nausea or emesis.
Major Surgical or Invasive Procedure:
[**2147-10-12**] - s/p subtotal gastrectomy w/Bilroth II reconstruction,
transverse colectomy, feeding J tube placement
History of Present Illness:
On [**9-6**], the patient underwent a barium upper GI series.
This study demonstrated a large ulcerated mass associated with
the greater curve of the stomach in the distal portion. On
[**9-8**], upper endoscopy was performed, with the finding of
a large ulcerated antral mass. Upon biopsy, he has been
considered to have an invasive adenocarcinoma of the signet ring
type.
On [**9-13**], a CT scan of the torso was obtained. He was
described as having a 4-mm right pulmonary lobe nodule. There
was a 6-mm hypodense lesion in segment III of the liver. A 7.5
cm mass was seen in association with the greater curve of the
stomach within the antrum. There did appear to be some
stranding or nodularity in the greater omentum extending towards
the transverse colon, although there was no clear-cut
involvement of the transverse colon. There did not appear to be
any significant retroperitoneal adenopathy.
Past Medical History:
HTN
Hypercholesterolemia
Arthritis
Social History:
Mr [**Known lastname 79336**] is a 68-year-old retired factory worker from the food
industry
He has a history of heavy cigarette smoking, one pack per day
for 25
years, stopping in [**2146-10-24**].
Family History:
The family history is significant for a brain tumor in his
mother. [**Name (NI) **] believes that his brother died at age 12 from
leukemia but he was uncertain.
Physical Exam:
Deceased
Pertinent Results:
SPECIMEN SUBMITTED: gastrectomy with tranverse colon.
Procedure date Tissue received Report Date Diagnosed
by
[**2147-10-12**] [**2147-10-13**] [**2147-10-19**] DR. [**Last Name (STitle) **]. FU/mb????????????
Previous biopsies: [**-8/3468**] Slides referred for
consultation.
DIAGNOSIS:
Stomach and transverse colon, subtotal gastrectomy and segmental
colectomy:
1. Gastric adenocarcinoma, intestinal type with focal signet
ring cell features. See synoptic report.
2. Segment of colon with serositis and focal adhesion, no
malignancy identified.
Stomach: Resection Synopsis
MACROSCOPIC
Specimen Type: Partial gastrectomy: distal.
Tumor Site: Body, antrum.
Tumor configuration: Ulcerating.
Tumor Size
Greatest dimension: 8.2 cm. Additional dimensions: 8.1 cm
x 3.5 cm.
MICROSCOPIC
Histologic Type: Adenocarcinoma, intestinal type with focal
signet ring cell features.
Histologic Grade: G3: Poorly differentiated.
Primary Tumor: pT3: Tumor penetrates serosa (visceral
peritoneum) without invasion of adjacent structures.
Regional Lymph Nodes: pN1: Metastasis in 1 to 6 perigastric
lymph nodes.
Lymph Nodes
Number examined: 13.
Number involved: 4.
Distant metastasis: pMX: Cannot be assessed.
Margins
Proximal margin: Uninvolved by invasive carcinoma.
Distal margin: Uninvolved by invasive carcinoma.
Omental (radial) margins
Lesser omental margin: Uninvolved by invasive
carcinoma.
Greater omental margin: Uninvolved by invasive
carcinoma.
Distance from closest margin: 29 mm.
Specified margin: Proximal.
Lymphatic (Small Vessel) Invasion: Present.
Venous (Large vessel) invasion: Present.
Perineural invasion: Absent.
Additional Pathologic Findings: Chronic active gastritis with
intestinal metaplasia. Bacilli forms consistent with H. pylori
are present.
Clinical: 68 year old man with diagnosis of gastric
adenocarcinoma. Upper GI series demonstrating a large ulcerative
mass of the distal stomach, along the greater curvature.
Follow-up biopsy demonstrating invasive signet-ring cell
adenocarcinoma.
Brief Hospital Course:
The patient underwent the above procedure on [**10-12**]. He tolerated
the procedure well and was transferred to the surgical floor,
with a foley catheter in place, NG tube in place, J tube to
gravity, PCA for pain control, his diet remained NPO, IVF for
hydration. He received 3 doses of peri-operative antibiotics.
[**10-14**] - Tube feeds were started at 1/2 strength at 10cc/hour, NGT
discontinued
[**10-16**] - transferred to the ICU for tachycardia, oxygen
desaturations. CTA performed showing no pulmonary embolism.
ECHO performed showing moderate symmetric left ventricular
hypertrophy with global normal systolic function and mildly
dilated right ventricle with mild hypokinesis.
[**10-17**] - respiratory status was stable. Had bilious emesis twice
and began burping. Tube feeds were held and pt was made NPO.
[**10-18**]- TPN started, NPO continued. UGI study showed ileus.
[**10-19**] - Transferred to the surgical floor, continued NPO, TPN,
NGT and foley catheter in place, TF at 20 cc/hr
[**10-20**] - transferred to the TSICU for continued respiratory
distress, transfused one unit RBC
[**10-21**] - Zosyn started for blood cultures positive for GNR,
central line removed
[**10-22**] - central line replaced, vancomycin started
[**10-23**] - CT guided drainage of right and left abdominal fluid
collections, drains left in place to gravity, flagyl added
[**10-24**] - cont TPN, TF at full strength at 60, started fluconazole
for yeast in left abdminal drain, transfused 2 units RBC
[**10-25**] - Dr [**Last Name (STitle) 519**] recommended possible re-exploration for a
presumed abscess. He indicated to the family that there was no
evidence of any actual anastamotic dehischence from any of the
imaging studies. However, after extensive discussions, per the
patient and family requests, the patient was made comfort
measures only. All antibiotics, tube feeds, and extraneous
means of support were removed. The patient was transferred to
the surgical floor
[**10-26**] - Palliative Care consulted. Adjustments made to pain
medication regimen.
[**10-29**] - Pt expires at 12:20 PM. Immediate cause of death is
respiratory arrest
Medications on Admission:
Benicar 20/12.5 mg once daily
ranitidine 150 mg once daily
simvastatin 20 mg once daily
aspirin 325 mg once daily
Darvocet p.r.n. for abdominal discomfort
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Signet-ring cell gastric cancer invading trans colon
Discharge Condition:
Deceased
Discharge Instructions:
n/a
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 0389, 2851, 5180, 5119, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2965
} | Medical Text: Admission Date: [**2171-9-26**] Discharge Date: [**2171-10-4**]
Date of Birth: [**2086-5-11**] Sex: F
Service: MEDICINE
Allergies:
Allopurinol / Levaquin
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 85 year old female with a h/o symptomatic
bradycardia s/p recent pacemaker placement, COPD, A.fib on ASA,
vascular dementia who presented from rehab with a complaint of
worsening cough throughout the day, shortness of breath, chest
pain and increasing confusion per her home health aid. She
denied any n/v, diaphoresis. Upon arrival to the ER, her initial
VS were: 96.9, 100, 100/56, 18, 96%. CXR was done with no
evidence of infiltrate, EKG with A.fib in the 100's, however
given her symptoms she was empirically treated with ceftriaxone
and azithromycin. Later during her course in the ER she became
hypotensive with a temperature of 100, had a CTA that ruled out
a PE, at CT head that did not show an acute process, an
abdominal ultrasound was done that did not show any
intra-abdominal pathology, but did show a pericardial effusion.
As a result cardiology did a bedside echo, which showed a small
pericardial effusion, no evidence of tamponade. Blood and urine
cultures were also sent. She then had a right IJ placed for SBP
low of 65, and then persistent SBP's in the 70's, and was
started on levophed at 0.03, with an improvement in her blood
pressures to a systolic in the 100's. Her antibiotic coverage
was also broadened to vancomycin and zosyn. For fluid
resuscitation she received a total of 2LNS during her stay in
the ER.
.
On the floor, initial VS were: 98.3, 127, 128/55, 21, 95% on
3LNC. She is currently denying any pain, denies any CP, SOB,
n/v/d, dysuria, back pain or palpitations. She does say that she
continues to have a cough, that is sometimes productive. She was
oriented times [**2-16**], and somewhat lethargic, falling asleep
during the examination.
.
Review of systems: Unable to obtain a full ROS due to mental
status
(+) Per HPI
(-) Denies headache, congestion. Denies nausea, vomiting,
dysuria.
Past Medical History:
Symptomatic Bradycardia s/p Pacemaker Placement [**8-24**]
Diabetes
Dyslipidemia
Hypertension
Chronic noncardiac chest pain
Anxiety
Gait disorder
Atrial fibrillation on aspirin
Asthma and COPD
History of CVA
Dementia (multi-vascular)
Diabetes mellitus type 2
Hyperlipidemia
Hypertension
Hypothyroidism
Osteoporosis
Gout
Edema
DJD
Social History:
Denies any alcohol. Quit smoking 23 years ago, used to have one
20-pack-year smoking history, and three packs for 40 years.
Lives in [**Location **] Place [**Hospital3 400**] Facility. She never
finished high school and then went to [**University/College **] Extension School
matriculated from there and then went to learn about psychology
and social work from [**University/College **]. She has currently 24-hour social
caregiver with only time that is during mealtime that she will
be by herself.
Family History:
Two sisters died from lung cancer
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2171-9-25**] 08:15PM BLOOD WBC-11.0# RBC-3.28* Hgb-9.5* Hct-28.9*
MCV-88 MCH-28.9 MCHC-32.8 RDW-14.7 Plt Ct-288#
[**2171-9-25**] 08:15PM BLOOD Neuts-74.7* Lymphs-17.5* Monos-7.3
Eos-0.2 Baso-0.2
[**2171-9-25**] 08:15PM BLOOD Plt Ct-288#
[**2171-9-25**] 08:15PM BLOOD PT-14.6* PTT-28.1 INR(PT)-1.3*
[**2171-9-25**] 08:15PM BLOOD Glucose-162* UreaN-30* Creat-1.0 Na-142
K-4.3 Cl-103 HCO3-30 AnGap-13
[**2171-9-26**] 03:41AM BLOOD ALT-8 AST-13 LD(LDH)-238 CK(CPK)-23*
AlkPhos-78 Amylase-21 TotBili-0.4
[**2171-9-26**] 03:41AM BLOOD Lipase-18
[**2171-9-25**] 08:15PM BLOOD cTropnT-<0.01
[**2171-9-26**] 03:41AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-3945*
[**2171-9-26**] 04:09PM BLOOD CK-MB-1 cTropnT-<0.01
[**2171-9-26**] 03:41AM BLOOD Calcium-7.2* Phos-3.3 Mg-1.5*
[**2171-9-26**] 03:41AM BLOOD Hapto-224*
[**2171-9-26**] 03:41AM BLOOD TSH-0.94
[**2171-9-26**] 03:41AM BLOOD Cortsol-20.4*
[**2171-10-3**] 06:49AM BLOOD calTIBC-290 Ferritn-112 TRF-223
.
Micro:
[**2171-9-25**] Blood culture- No growth.
[**2171-9-25**] Urine culture- <10,000 organisms.
[**2171-9-26**] MRSA screen- no MRSA isolated.
[**2171-9-29**] Blood culture- No growth.
[**2171-9-30**] Blood culture- No growth.
[**2171-9-30**] Urine culture- No growth.
........
Studies:
[**2171-9-25**] CXR: Low lung volumes, but no acute cardiopulmonary
abnormality.
.
[**2171-9-25**] CT Head W/Out Contrast: 1. No acute intracranial
hemorrhage or mass effect. 2. Extensive encephalomalacia in the
right frontal and left parietal lobes,compatible with old
infarcts. Comparison with prior studies would be helpful. Given
the lack of priors and presence of pacemaker, consider followup
CT without and with contrast to exclude mass lesions
.
[**2171-9-25**] CTA Chest: 1. No acute pulmonary embolism or aortic
pathology. Small right-sided pleural effusion. 2. Severe
anterior wedge T6 compression fracture, chronic in appearance.
3. Moderate-sized hiatal hernia.
.
[**2171-9-26**] TTE: Small LV cavity size with mild symmetric LVH and
hyperdynamic LV systolic function. Mild resting LVOT gradient.
Probable diastolic dysfunction. Mild pulmonary artery systolic
hypertension. Calcified mitral and aortic valve. Mild mitral
regurgitation.
.
[**2171-9-29**] EKG: Atrial fibrillation with rapid ventricular response
and ventricular paced beat. Left axis deviation may be due to
left anterior fascicular block and/or possible prior inferior
myocardial infarction. ST-T wave changes are non-specific. Since
the previous tracing of [**2171-9-26**] atrial fibrillation has replaced
sinus tachycardia.
.
[**2171-10-2**] EKG: Atrial fibrillation and paced beats at 71 beats per
minute. Compared to the previous tracing of [**2171-9-29**] the patient
is now in a paced rhythm at 71 beats per minute. The atria
remain in fibrillation.
.
[**2171-10-2**] CXR: There is opacification at both bases consistent
with
moderate pleural effusions and compressive atelectasis. Fullness
of pulmonary vessels is consistent with elevated pulmonary
venous pressure in patient with some enlargement of the cardiac
silhouette. Pacemaker device remains in place.
Brief Hospital Course:
Ms. [**Known lastname **] is an 85 year old female with h/o A.fib on ASA,
tachybrady syndrome s/p PPM placement, COPD, hypothyroid who
presented with hypotension, cough, chest pain and worsening
mental status. Her hospital course by problem is as follows:
# Hypotension: Patient was admitted to the medical intensive
care unit. She was initially started on levophed but weaned off
without difficulty shortly after admission. Her stool was
guaiaic negative and transfusion was deferred as the patient was
asymptomatic from her anemia. TSH and cortisol were within
normal limits. She was ruled out for MI. She did not appear
septic as there was no identifiable infectious source- blood and
urine cultures from [**9-25**] were negative. Blood cultures from [**9-29**]
and [**9-30**] were pending on discharge. While in the MICU, the
patient went into afib with tachycardia and developed transient
hypotension - possibly this was a contributing factor to her
initial presentation. There was no evidence of heart failure on
her initial CXR and no discrete cause for her hypotension on
ECHO. Patient's hypotension was responsive to fluid boluses and
she was transferred to the floor where she did not require any
further pressure support or fluid boluses, maintaining pressures
in the 130s-140s.
# Shortness of Breath: Upon admission, patient was maintained on
O2 and nebulizers, and it as thought her symptoms were most
likely [**3-19**] volume overload. The pt was diuresed aggressively
(to the point of some hypotension). However, she remained SOB
at times. She spiked a fever two days prior to transfer to the
wards, and her CXR, although not grossly different, still showed
some RLL process concerning for [**Month/Day (2) 10540**]. She was treated with vanc
and cefepime as above. At the same time, we thought a COPD
exacerbation was contributing, so she was started on steroids,
the [**Month/Day (2) 10540**] abx, and continued on nebulizers (xopenex, given her
AF, and atrovent). A PICC was placed for antibiotic treatment
and blood draws; this was discontinued on the day of discharge.
On the day of transfer to the wards, we were less convinced of
the [**Name (NI) 10540**] (pt was afebrile, without a WBC elevation, and numerous
cultures negative to date), so vanc and cefepime were changed to
abx for COPD exacerbation (azithromycin, as patient is allergic
to levofloxacin). On the wards, patient was sat-ing in the mid
90s on room air and was continued on this regimen (azithromycin
and prednisone) for 4 days. Diuresis for presumed diastolic
heart failure was restarted with IV lasix as patient sounded
crackly on exam and a repeat CXR showed engorged pulmonary
vasculature. Patient was discharged home with instructions to
continue her nebs as needed and to go back to her home dose of
lasix 40 mg PO to continue her diuresis until she followed up
with her PCP at her scheduled appointment the following week.
She will require a check of her electrolytes including BUN and
creatinine at the time of follow up.
.
# Atrial Fibrillation: Patient went into AF with RVR while in
the MICU. At that time her metoprolol dose was increased to 25
TID. Given her hypotension she was started on digoxin with the
goal of tapering down her metoprolol dose. Her digoxin level was
checked and was therapeutic on a qOD dosing schedule. She should
have this level rechecked as an outpatient. For the rest of her
hospitalization, the patient was monitored on telemetry and
remained largely in AF with ventricular pacing at a rate in the
60s-70s. She was discharged with instructions to continue her
digoxin, taper down and eventually discontinue her metoprolol,
and follow up with her primary care doctor.
.
# Anemia: The patient was anemic during this hospitalization
with a low hct close to 24. She received 1 unit PRBCs for
symptomatic treatment and her hematocrit improved over the
course of her hospitalization. Iron studies were sent and seemed
consistent with an anemia of chronic disease picture. Her hct on
discharge was 27.7 and patient was hemodynamically stable.
.
# Hypothyroidism: TSH was checked on [**9-26**] and was 0.94. Patient
was continued on her home levothyroxine.
# Diabetes: Patient's glipizide was held while she was an
inpatient, but she was continued on her home metformin and put
on an insulin sliding scale with QID finger stick blood sugar
checks.
.
# Depression/Anxiety: Patient was continued on her home regimen
of celexa/ativan. She remained stable on this regimen.
.
# Dementia: Patient was continued her home namenda.
.
# Goals of care: Palliative care was consulted and met with the
patient and her family to discuss goals of care. They decided to
pursue hospice after discharge and try to minimize unnecessary
interventions while an inpatient. Patient and family expressed
that they will likely not want to pursue future
hospitalizations. Social work was consulted for family coping.
.
# Code: DNR/DNI
.
Pending on Discharge:
Blood cultures from [**9-29**] and [**9-30**]
Medications on Admission:
CITALOPRAM - 20 mg at night
FUROSEMIDE - 40 mg daily
GLIPIZIDE - 5 mg daily
LEVOTHYROXINE - 75 mcg daily
LORAZEPAM - 0.5 mg [**Hospital1 **] prn
MEMANTINE [NAMENDA] - 5 mg twice a day
METFORMIN - 500 mg twice a day
METOPROLOL SUCCINATE - 50 mg Sustained Release once a day
NITROGLYCERIN - 0.4 mg sublingually prn
SIMVASTATIN - 80 mg at bedtime
TRAMADOL - 50 mg TID as needed
ACETAMINOPHEN - 500 mg Tablet 2 Tablet(s) by mouth Q 8 hours
ASPIRIN - 325 mg daily
CALCIUM CARBONATE-VITAMIN D3 - 600mg-400 unit - [**Unit Number **] Tablet(s) by
mouth twice a day
GUAIFENESIN [MUCINEX]- 600 mg Tablet Sustained Release - 2
Tablet(s) by mouth daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
2. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO once a day as needed for cough .
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Memantine 5 mg Tablet Sig: One (1) Tablet PO BID ().
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety, agitation .
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit
Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
12. Acetaminophen 500 mg Capsule Sig: [**2-16**] Capsules PO every
eight (8) hours as needed for pain.
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*1*
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO once
a day for 2 days: Please take 1 tablet twice daily on Saturday
and one tablet once on Sunday.
Disp:*3 Tablet(s)* Refills:*0*
17. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q4h PRN () as needed for SOB.
Disp:*30 neb* Refills:*0*
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q4H (every 4 hours) as needed for SOB.
Disp:*30 Neb* Refills:*0*
19. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Tachy-Brady Syndrome status post pacemaker placement
Atrial fibrillation
Diastolic heart failure
Hypertension
Anxiety/depression
Chronic obstructive pulmonary disease/asthma
Dementia (multi-vascular)
Diabetes mellitus type 2
Hyperlipidemia
Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital because you had trouble
breathing. While you were in the hospital your blood pressure
was low and you were admitted to the medical intensive care
unit. You were treated with medications to improve your blood
pressure and the function of your lungs. You were transferred to
the medical wards where you were continued on treatments for
your chronic lung disease and your heart disease.
We have made the following changes to your medications:
- Please start taking digoxin every other day as indicated
- Please change your metoprolol from metoprolol succinate to
metoprolol tartrate and take it as indicated on Saturday and
Sunday and then stop taking any kind of metoprolol until you
follow up with your doctor
- Please take xopenex and ipratropium nebulization treatments as
needed for your shortness of breath
You may continue taking your other medications as you were
previously.
Please follow up with your primary care doctor and cardiologist
at the appointments below.
It was a pleasure taking care of you at the [**Hospital1 18**].
Followup Instructions:
Please follow up at your previously scheduled appointments and
with Dr. [**Last Name (STitle) **] at the appointment we scheduled for you next
week:
Department: CARDIAC SERVICES
When: MONDAY [**2171-10-14**] at 3:20 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2172-3-23**] at 1:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GERONTOLOGY
When: THURSDAY [**2171-10-10**] at 3:30 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 13171**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2171-10-4**]
ICD9 Codes: 4589, 486, 2724, 2749, 4019, 2449, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2966
} | Medical Text: Admission Date: [**2106-9-16**] Discharge Date: [**2106-9-19**]
Date of Birth: [**2035-11-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
s/p T tube placement
Major Surgical or Invasive Procedure:
Flexible and Rigid bronchscopy with debridement of granulation
tissue and T tube placement
History of Present Illness:
Ms. [**Known lastname **] is a 70F with DM2, asthma, with a history of chronic
respiratory failure [**1-19**] PNA/asthma (with chronic trach x3
months, previously vented at night only, now off vent) CVA, CAD,
s/p recent tracheal bleed and trach change [**2106-7-4**] who was
admitted after an elective IP procedure to debride granulation
tissue around her stoma and distal trach site, and place a T
tube.
Of note patient was recently admitted to the MICU from [**Date range (1) 87240**]
for tracheal bleed, and difficulty talking. She had a rigid
bronchoscopy by IP which showed diffuse granulation tissue
around her stoma and her trach, as well as subglottic stenosis.
This was debrided and a larger size (#7 non-fenestrated) trach
tube was inserted.
IP performed an elective rigid and flexible bronch and placed a
T tube today (12mm) without complications. Granulation tissue
from the stoma was debrided. After the procedure, patient was
hypoventilating on pressure support, requiring CMV. She was
reportedly hypercarbic and somnolent. She was slowly
transitioned to PS, CPAP, and trach mask. She was admitted to
the MICU for close respiratory monitoring given concerns for
airway edema.
Patient denies any change in respiratory status since here
recent discharge on [**8-31**]. She denies hemoptysis. She hasn't been
able to speak at all. Denies fevers or chills, chest pain,
shortness of breath, orthopnea or LE edema.
Past Medical History:
IDDM2
Asthma
Chronic resp failure ([**1-19**] asthma and PNA) s/p trach and PEG ? 3
months ago
s/p bronch [**7-8**], [**7-6**], cuffless trach replacement to cuffed
catheter in ED [**7-4**]
CVA (L weakness)
CAD
HTN
DJD
GERD
h/o AFB in sputum felt to be colonizer
Polypoid lesion trachea
Hypothyroidism
Hyperlipidemia
Social History:
Resident at [**Hospital1 **] Commons. Has 3 sons. previously worked as
manager of group home.
- Tobacco: Denies
- Alcohol: rare
- Illicits: None
Family History:
Non-contributory
Physical Exam:
VS: Temp: 98.2 BP: 155/62 HR:57 RR:14 O2sat 100% on 10L trach
mask
GEN: pleasant, comfortable, trach mask in place
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: Mild expiratory wheezes bilaterally with good air movement
throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: Obese. ND, +b/s, soft, nt, no masses or hepatosplenomegaly.
PEG tube in place.
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.
1+DTR's-patellar and biceps
Pertinent Results:
Admission Labs:
[**2106-9-16**] 05:53PM WBC-12.8* RBC-3.87* HGB-10.6*# HCT-32.3*
MCV-83 MCH-27.3 MCHC-32.7 RDW-15.5
[**2106-9-16**] 05:53PM PLT COUNT-379
[**2106-9-16**] 05:53PM PT-12.1 PTT-25.1 INR(PT)-1.0
[**2106-9-16**] 05:53PM CALCIUM-9.4 PHOSPHATE-4.4 MAGNESIUM-2.0
[**2106-9-16**] 05:53PM ALT(SGPT)-16 AST(SGOT)-28 LD(LDH)-260* ALK
PHOS-77 TOT BILI-0.3
[**2106-9-16**] 05:53PM GLUCOSE-185* UREA N-35* CREAT-0.8 SODIUM-133
POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-31 ANION GAP-14
Imaging:
CXR [**2106-9-18**]:
As compared to the previous radiograph, there is no relevant
change. Minimal increase in extent of the retrocardiac
atelectasis. Minimal
increase in extent of the right basal atelectasis. Unchanged
course and
position of the PICC line, a tracheostomy tube in situ.
[**2106-9-18**] 06:11AM BLOOD WBC-23.3*# RBC-3.52* Hgb-9.7* Hct-29.7*
MCV-84 MCH-27.5 MCHC-32.6 RDW-15.5 Plt Ct-431
[**2106-9-19**] 04:55AM BLOOD WBC-16.0* RBC-3.42* Hgb-9.5* Hct-29.0*
MCV-85 MCH-27.6 MCHC-32.6 RDW-15.6* Plt Ct-398
[**2106-9-19**] 04:55AM BLOOD Glucose-69* UreaN-25* Creat-0.7 Na-137
K-3.8 Cl-97 HCO3-34* AnGap-10
Brief Hospital Course:
70 yo F with DM2, asthma, chronic respiratory failure s/p trach
complicated by hemoptysis secondary to granulation tissue around
stoma site and subglottic stenosis s/p debridement and T tube
placement.
1. Acute on Chronic respiratory failure: After her debridement,
she briefly required increased ventilator support with CMV that
was felt to be due to oversedation. She also had a significant
amount of airway edema on bronchoscopy and was admitted to the
MICU for monitoring. She was kept on Mucinex twice daily and
kept on her home nebulizers. After T tube placement she was
able to speak. However the following day, she had difficulty
speaking again. She was taken back to the OR for repeat
debridement of granulation tissue around the T tube, and the T
tube was removed.
2. Leukocytosis was attributed to administration of steroids
while in house.
Her home meds were continued. Other than the mucinex, no other
changes were made to her medications.
Code Status: Full code, confirmed on admission
Medications on Admission:
1. Bisacodyl 10mg po daily PRN constipation
2. Docusate 100mg po liquid [**Hospital1 **]
3. Senna 8.6 mg po bid PRN constipation
4. Acetaminophen 650 mg po q6h PRN pain
5. Escitalopram 20 mg po daily
6. Hydrochlorothiazide 12.5 mg po daily
7. Levothyroxine 100 mcg po daily
8. Lorazepam 0.5 mg po q6h PRN anxiety
9. Oxycodone 5 mg/5 mL po q4h PRN pain
10. Quetiapine 25 mg po bid
11. Ropinirole 2 mg po qPM
12. Simvastatin 20 mg po daily
13. Gabapentin 300 mg po tid
14. Albuterol inh 2 puffs q2h PRN
15. Chlorhexidine Mouthwash 1mL [**Hospital1 **]
16. Omeprazole 40 mg po bid
17. Ranitidine 300 mg po qhs
18. Nystatin 100,000 unit/mL Suspension -5mL po qid PRN thrush
19. Levemir 25 units sc bid
20. Novolog sliding scale
21. Aspirin 325 mg po daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) unit PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB.
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q4H (every
4 hours) as needed for pain.
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
12. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
14. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
16. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Insulin Detemir 100 unit/mL Solution Sig: Twenty Five (25) u
Subcutaneous twice a day.
20. Humalog 100 unit/mL Solution Sig: asdir units Subcutaneous
qachs: Please resume prior sliding scale.
21. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Commons Nursing & Rehabilitation Center - [**Location (un) 6691**]
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic respiratory failure
Secondary diagnosis:
Chronic respiratory failure s/p tracheostomy
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure caring for you. You were admitted after an
elective procedure to place a T tube, and remove some
unnecessary tissue near your trach. The following day you were
still having difficulty speaking. You were taken back to the OR
for removal of granulation tissue, and the T tube was removed.
Followup Instructions:
Please follow up with your PCP in the next 2 weeks.
Completed by:[**2106-9-19**]
ICD9 Codes: 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2967
} | Medical Text: Admission Date: [**2139-1-14**] Discharge Date: [**2139-1-21**]
Date of Birth: [**2063-3-17**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
female with a history of critical aortic stenosis who
presented to an outside hospital with a two week history of
worsening shortness of breath and orthopnea. She had been
sent by her PCP for an echo that showed normal left
ventricular ejection fraction, but severe left ventricular
hypertrophy, EF 55%. Right ventricle was normal in size and
function. There was mild apical hypokinesis with 1+ MR and
severe AS. On [**2139-1-11**], patient became confused and
was very short of breath. At that time she was brought to
[**Hospital3 1443**] Hospital where she was found to be in
complete heart block with a heart rate of 30 to 35. She had
an external pacer placed and was diuresed. She was then
transferred to [**Hospital1 69**] on
[**2139-1-14**], for cardiac catheterization to evaluate
her coronaries and her cardiac function. During the cardiac
catheterization a temporary pacer wire was placed. During
the catheterization patient was also noted to have an aortic
valve area of 0.7 cm squared and was scheduled for
valvuloplasty to increase the valve area.
PAST MEDICAL HISTORY: Aortic stenosis with a valvular area
of 0.6 to 0.7 cm squared. Hypertension. Chronic renal
insufficiency. Diabetes mellitus. Status post
cerebrovascular accident 10 years ago with mild dementia.
Hypercholesterolemia. Hypothyroidism.
MEDICATIONS ON TRANSFERS: Lisinopril 40 mg p.o. q.day,
Lipitor 10 mg p.o. q.d., Levoxyl 125 mcg p.o. q.d., Hyzaar
50/12.5 q.day, Bumex 0.5 b.i.d., Risperdal 1 mg p.o. b.i.d.,
insulin NPH 30 units q.a.m. and 10 units q.p.m., regular
insulin sliding scale, Colace p.r.n. Medications at home
apparently were Coumadin 2.5 mg p.o. q.h.s., Glucophage 1000
mg p.o. b.i.d., Lipitor 10 mg p.o. q.d., Zestril 40 mg p.o.
q.d., insulin NPH 60 units q.a.m. and 25 units q.p.m.,
Levoxyl 137 mcg p.o. q.d., Hyzaar 50/12.5 p.o. q.day,
Risperdal 1 mg p.o. b.i.d.
SOCIAL HISTORY: The patient is widowed. She denies alcohol
or tobacco use. Lives with her daughter in a house with
several flights of stairs.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On presentation patient had the
following vital signs. She was afebrile, blood pressure
160/100, pulse 70, sating 94% on 2 liters. In general, she
was an awake, comfortable, elderly, Portuguese female in no
acute distress. HEENT pupils equal, round and reactive to
light. Oropharynx clear. Mucous membranes slightly dry.
Neck jugular venous pressure 12 cm, delayed carotid
upstrokes. Chest crackles at the right base, decreased
breath sounds at the left base. Cardiovascular normal S1,
S2, [**4-9**] crescendo decrescendo murmur with delayed peak,
systolic ejection murmur in the right upper sternal border
that radiated to bilateral carotids. Abdomen soft,
nontender, normal bowel sounds. Extremities trace edema,
warm with good capillary refill.
LABORATORY DATA: EKG on presentation Wenckebach with
bifascicular block, left axis deviation, right bundle branch
block, Qs in 2, 3, aVF, V5 and V6. She subsequently had
another EKG which showed complete heart block with junctional
escape at 35, no right bundle branch block, Qs in 2, 3 and
aVF, ST-T wave depressions in V5 and V6. Prior to discharge
patient was noted to be atrially sensed and ventricularly
paced rhythm with numerous premature ventricular
contractions. She had the following laboratory values. On
admission CBC was white blood cell count 9.7, hemoglobin
10.8, hematocrit 33.4, platelets 256. PT 16.8, PTT 28.5, INR
1.9. Sodium 140, K 5.1, chloride 106, bicarb 20, BUN 59,
creatinine 2.1, glucose 206. She had lipids which showed the
following. Total cholesterol 106, LDL 47, HDL 38,
triglycerides 103. TSH was 3.49. CK and troponin were
negative. She had an echo on [**1-13**] which showed EF of
55%, severe concentric left ventricular hypertrophy 21 to 22
mm, mild apical hypokinesis, aortic valve area of 0.7 cm
squared, mild MR and severe aortic stenosis. She had cardiac
catheterization which showed the following values. Right
atrial pressure 21, right ventricular pressure 85/25,
pulmonary artery pressure 85/30, pulmonary capillary wedge
pressure 35, cardiac output 2.8, cardiac index 1.5, SVR [**2106**],
peripheral vascular distance of 314. AV gradient was 66.
Aortic valve area was 0.5 cm squared. SVC sat 48, pulmonary
artery sat 44. Coronaries showed proximal RCA 40% lesion,
but left main, left anterior descending and left circumflex
were all clear. On the day prior to discharge patient had
the following laboratory values. CBC was 10.3 white blood
cell count, hematocrit 34.0, platelets 169. She had
chemistry 7 of sodium 143, K 3.5, chloride 102, bicarb 29,
BUN 38, creatinine 1.2, glucose 134. Calcium 8.6, mag 1.7,
phos 2.6. She had a chest x-ray on that date, the 17th,
which showed heart upper limits of normal, persistent
vascular engorgement, perihilar haziness consistent with CHF.
She had slight interval improvement in the left retrocardiac
opacity and small bilateral effusions, left slightly larger
than right.
HOSPITAL COURSE:
1. Cardiovascular.
Aortic stenosis. The patient was found to have critical
aortic stenosis with a valvular area of 0.6 to 0.5 cm
squared. She underwent valvuloplasty on [**2139-1-15**],
at which time she had two times valvuloplasty which increased
the aortic valvular area from 0.55 to 0.80 cm squared and
decreased the gradient across the aortic valve from 89 to 50.
In addition, her blood pressure was controlled with Lopressor
and Bumex and lisinopril to generally the 120s to 140s
systolic. She suffered no chest pain or palpitations
in-house. She was found to be mildly short of breath on
several occasions, was diuresed with resolution of shortness
of breath. In addition, patient was also found to be in
complete heart block on presentation. On [**1-16**] she
underwent pacemaker placement and had a DDD pacer placed
without complications and remained atrially sensed and
ventricularly paced through the remainder of her hospital
stay. However, she was noted to have frequent runs of
nonsustained v-tach and frequent PVCs.
2. Infectious disease. The patient was found to have a
temperature to 103 the day following placement of the pacer.
She was started on vancomycin and levofloxacin for possible
pacer placement induced bacteremia and possible retrocardiac
opacity. She continued to have fever through [**1-18**],
but thereafter remained afebrile. She was to continue on a
total 10 day course of levofloxacin and vancomycin to be
dosed for a level less than 15, checked on a daily basis.
All of her blood cultures and urine cultures from her
hospital stay remained negative.
3. Endocrine. The patient has diabetes mellitus and was
treated conservatively with a dose of NPH of 30 in the
morning and 10 at night and regular insulin sliding scale.
Her sugars were fair, between 160 and 300 generally. She was
treated initially with an insulin drip before being
transferred over to NPH and regular insulin sliding scale and
transferred to the floor.
CONDITION ON DISCHARGE: The patient is in fair condition on
discharge.
DISCHARGE STATUS: To rehab to be specified in a discharge
addendum.
DISCHARGE DIAGNOSES:
1. Critical aortic stenosis status post valvuloplasty.
2. Complete heart block status post DDD pacemaker placement.
3. Fever.
4. Insulin dependent diabetes mellitus.
5. Hypertension.
6. Dementia.
7. Possible pneumonia.
DISCHARGE MEDICATIONS: The patient will likely be discharged
on the following medications.
1. Lopressor 37.5 mg p.o. b.i.d.
2. Levofloxacin 500 mg p.o. q.24 to have the last dose given
on [**1-27**].
3. Vancomycin 1 gm q.24 to be dosed for levels less than 15
on a daily basis. Last dose to be given on [**1-27**].
4. Bumex 0.5 mg p.o. b.i.d.
5. Insulin NPH 60 units q.a.m., 25 units q.p.m.
6. Glucophage 1000 mg p.o. b.i.d.
7. Risperdal 0.5 mg p.o. b.i.d.
8. Lisinopril 40 mg p.o. q.day.
9. Albuterol and Atrovent nebulizers q.six hours p.r.n.
10. Synthroid 125 mcg p.o. q.d.
11. Lipitor 10 mg p.o. q.d.
FOLLOWUP: The patient is to follow up with her primary care
physician and cardiologist to be outlined in a discharge
addendum within several days after discharge from the
rehabilitation facility.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 900**] 12-248
Dictated By:[**Last Name (NamePattern1) 17270**]
MEDQUIST36
D: [**2139-1-20**] 15:12
T: [**2139-1-20**] 15:15
JOB#: [**Job Number **]
ICD9 Codes: 4241, 4280, 5070, 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2968
} | Medical Text: Admission Date: [**2173-9-14**] Discharge Date: [**2173-9-17**]
Date of Birth: [**2103-11-27**] Sex: F
Service: SURGERY
Allergies:
A.C.E Inhibitors / Ativan / Ambien
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
malfunctioning hemodialysis fistula
Major Surgical or Invasive Procedure:
- attempted venoplasty and declotting of existing AV fistula
- placement of new left upper extremity AV graft
- placement of new tunneled perm cath for dialysis
History of Present Illness:
69 y/o F w/Right arm fistula placed 9 years ago was transferred
from referring hospital because of inability to undergo
hemodialysis on [**2173-9-13**]. Pt. also had K of 6.1 but denied any
palpitations, confusion, disoritentation, nausea/vomitting,
chest pain, shortness of breath. Pt. did c/o some lower
abdominal pain that resolved prior to arriving at this
institution.
Past Medical History:
multiple drug allergies, ACEI-cough, ativan, confusion w/ ambien
hx delirium in the hospital
hx Dm2
Hx ESRD on HD MWF
hx CAD, CHF, EF 40%
hx CVA
hx DVT
hx hyperhomocystenemia
hx microcytic anemia
hx refractory HTN requiring Hd
hx cervical spondylosis s/p C4-7 fusion
Social History:
She is widowed, lives with her son and daughter.
She ambulates with a cane.
She denies alcohol or tobacco use.
Family History:
CAD/MI
Physical Exam:
Vitals: T 98.8 P 88 BP 106/88 R 20 O2 100ra
Gen: Well developed, well nourished female in no acute distress
CV: RRR, no m/r/g appreciated
Chest: CTAB, no w/c/r appreciated
Abd: soft, non-tender, non-distended, normal active bowel sounds
Ext: wound clean/dry/intact and appropriately tender, +thrill,
no cyanosos/clubbing/edema
Pertinent Results:
[**2173-9-16**] 08:35AM BLOOD WBC-7.1# RBC-3.58* Hgb-11.7* Hct-35.8*
MCV-100* MCH-32.6* MCHC-32.6 RDW-17.5* Plt Ct-229
[**2173-9-14**] 10:00AM BLOOD Neuts-56.4 Lymphs-32.4 Monos-4.3 Eos-5.9*
Baso-0.9
[**2173-9-14**] 10:00AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+
[**2173-9-16**] 08:35AM BLOOD Plt Ct-229
[**2173-9-16**] 08:35AM BLOOD Glucose-107* UreaN-37* Creat-8.5*# Na-142
K-4.6 Cl-101 HCO3-24 AnGap-22*
[**2173-9-14**] 10:00AM BLOOD ALT-11 AST-15 AlkPhos-67 Amylase-135*
TotBili-0.4
[**2173-9-14**] 10:00AM BLOOD Lipase-121*
[**2173-9-16**] 08:35AM BLOOD Calcium-9.7 Phos-4.9* Mg-2.0
[**2173-9-14**] 05:28PM BLOOD K-5.5*
Brief Hospital Course:
69 y/o F was admitted to [**Hospital1 18**] on [**2173-9-14**] for revision vs.
thrombectomy of right arm AV fistula. During the operation the
fistula was not able to be salvaged and a new graft was placed
in the left upper extremitiy. Please see the operative report
for further details. POD 1 Pt. had a tunneled perm cath placed
by interventional radiology so she could continue with dialysis.
This procedure went without difficulty. Pt. successfully
underwent HD later that day. Evening of [**2173-9-15**] pt. blood
pressure dropped to 80/60 and was given a small bolus of 250cc
ns. This blood pressure drop was believed to be secondary to
having 2.5L of fluid taken off during dialysis earlier in the
day. POD [**3-2**] pt. underwent another treatment of hemodialysis -
per renal b/c it had been quite and extended amount of time
between her prior treatments. Pt. tolerated hemodialysis well.
Pt. was afebrile during her stay, pain was controlled on oral
pain medications, and pt was tolerating a regular diet by POD 2
and pt. ready for discharge.
Medications on Admission:
- ASA qday
- plavix 75 qday
- amlodipine 10 qday
- isosorbide mononitrate 30 qday
- lipitor 40 qday
- metoprolol 100 [**Hospital1 **]
- protonix 40 qday
- renagel 800 tid
- sertraline 50 qday
- diovan 160 [**Hospital1 **]
- pyridoxine 50 qday
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6 hours prn as needed for for pain: Do not drive while taking
this medication.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: -
please take while taking pain medications
- hold for diarrhea.
Disp:*20 Capsule(s)* Refills:*0*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
- s/p attempted thrombectomy of existing AV fistula and
placement of new Left upper extrem AV graft
- chronic renal insufficiency
- diabetes mellitis
- s/p myocardial infarction (six years ago)
- peripheral vascular disease
- hypertension
- h/o deep venous thrombosis
- s/p right fem-pedal bipass ([**2173-8-10**])
- congestive heart failure w/EF 40%
- h/o ceberal vascular accident
Discharge Condition:
good
Discharge Instructions:
- Please resume all home medications
vomitting, pain in arm, erythema or purulent drainage from
wound, numbness or tingling in hand/arm, loss of strength in
hand/arm, signigicant swelling, loss of thrill, difficulty with
dialysis, or any other concern.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] at the [**Hospital 1326**] clinic.
Please call [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 15170**] at [**Telephone/Fax (1) 7207**] for an appointment.
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2969
} | Medical Text: Admission Date: [**2189-6-16**] Discharge Date: [**2189-6-25**]
Date of Birth: [**2111-9-2**] Sex: M
Service: MEDICINE
Allergies:
amiodarone
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
seizure-like activity; hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77 year old man with IPF on 6L home O2, A fib on Coumadin s/p
ablation, systolic CHF s/p PPM w/ [**Hospital 26418**] transferred from [**Hospital3 **]
hospital following a witnessed seizure at home. Referred to
[**Hospital1 18**] for seizure, supratherapeutic INR. Admitted to the ICU for
hypoxia.
.
Pt states this morning he awoke at 4:30am with some
lightheadedness and air hunger. He was walking from bed when he
suddenly felt the sensation of falling, he thinks he tripped
over his O2 cord but cannot remember. He does remember hearing
himself fall on the ground. His daughter heard him fall and ran
to his bedroom and noticed the pt was on the floor. His eyes
were rolled up into his head, he was shaking in his arms and his
legs. He had urinary incontinence, per the daughter they could
not feel a pulse but didnt do CPR. After about 3-4mins he
regained conciousness and was initially disorientated for a few
seconds. He remembers waking up and seeing his daughter, when
his daughter told him they called EMS he asked to be sat up.
.
He was taken to [**Hospital3 16673**], per ED report he had a CT Head which
showed no acute intracranial bld, labs were significant for an
INR 6. He was noted to have a HA and was given 0.5mg IV
Dilaudid. Vit K 2.5 PO x 1. Unfortunately no records were found
from [**Hospital3 16673**]. He was thus transferred to [**Hospital1 18**] for his
seizures and elevated INR.
.
In the ED initial VS were noted to be T97.9, HR 70, BP 120/70,
RR 20, Sat 94% on 6L. Labwork was notable for neutrophillic
leukocytosis 14.4 (80N, L11), Hgb/Hct 14.8/43.1, plt 205. Chem
panel was unremarkable, ALT elevated at 58, AST 20. Trop 0.03,
Coags showed INR 9.3, PT 80.7, PTT 35.8. U/A was also obtained
which showed small amount of leuks, 9 WBCs, few bacteria, 2
epis. He was given Vit K 10mg x 1 for his elevated INR.
Neurology were also consulted to determine whether this was a
seizure, their conclusion is seizure vs convulsions s/p syncope.
They also repeated his CT head scan which showed no evidence of
an acute bld. In the ED he was noted to have some episodes of
hypoxia to the high 70s with minimal activity which appears to
be his baseline on review of his last pulmonary note. Per ED
signout he was saturating mid 90s on 6L (his new baseline O2
requirement). they also noted BPs in the 90s-100s with one
[**Location (un) 1131**] reportedly 80/60 which resolved without any
intervention. It is unclear as to why the pt was given
[**Name (NI) 39915**] 1gm, likely given the hypoxia and CXR which appears
to be close to baseline. He was also given Bactrim for his UTI,
although pt has been on Bactrim for ppx whilst on Prednisone.
.
Prior to transfer to the unit VS were HR 74. 99/78, 23, 94% on
6L.
.
Of note pt is usually followed by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **].
On review of the last pulmonary note it appears Mr. [**Known lastname 10132**] [**Last Name (Titles) 39916**]y status had a remarkable decline from 2L of O2 in
[**Month (only) 958**] to 6L with very little reserve for activity in [**Month (only) 116**]. The
decline was thought to be either due to accelerated IPF vs
amiodarone lung toxicity and a component of CHF. His Prednisone
was increased to 60mg daily with NAC. The pt also underwent a
cardiac catheterization given this question of biventricular
failure and chest pain. Cath showed severe native three vessel
coronary artery disease, LMCA showed mild luminal
irregularities, LAD was totally occluded in the mid vessel, LCx
was occluded proximally, RCA was also totally occluded. He had a
widely patent LIMA->LAD w/ large/long intercostal branch off of
the mid LIMA and may represent steal from the LIMA to the LAD.
The SVG->RI was widely patent as was the SVG->PDA. Resting
hemodynamics revealed normal right ventricular filling
pressures, RVEDP of 8mmHG. Mild left ventricular diastolic
dysfunction, with a mean PCWP of 18mmHg. Moderate pul HTN with a
PASP of 51mmHg.
.
On [**2189-6-2**] he underwent a biventricular pacer placement with
AICD, and ablation. On review of the procedure note following
ablation the pt went into CHB with the pacer picking up at
50bpm. His pacer is [**Name6 (MD) 39917**] [**Name8 (MD) 39918**] CRT-P C2TR01, set to DDD at
a rate of 70 bpm.
.
ROS: He denies any nausea, vomiting, fevers, chills, has chronic
cough for months which is thinning in terms of sputum production
per pt, no hemoptysis, no rhinorrhea, phayngitis, diarrhea,
constipation, weakness/numbness in extremities.
Past Medical History:
-h.o. syncopal episodes (?Micturation syncope)
-IPF vs Amiodarone lung toxicity ([**2189-5-7**]: DLCO 27%)
-Myocardial infarction in [**2161**]
-CABG in [**2171**], cath [**2189-3-9**] showed (LAD to LIMA patent, SVG to
Posterior vent - occluded, SVG to PDA & ramus was patent)
-Ischemic cardiomyopathy- 25% EF (echo [**2189-3-6**]); 44% EF (echo
[**2187-11-22**]) s/p Biventricular pacer w/ AICD ([**Company 1543**], placed
[**5-/2189**])
-Atrial fibrillation s/p Ablation ([**5-/2189**])
-EP study ([**2188-9-2**]): non-sustained VT and minimally prolonged
His-Vent interval
-HTN
-HLD
-AAA at 3.8 cm
-MVA -injuries to foot
-History of slips/Falls (10/[**2188**]). Follow-up CT head ([**12-12**])
showed resolution of mild intrahemispheric and tentorial
subdural hematoma
-Osteoarthritis
-Seasonal allergies, Asthma since childhood
-Hx Herpes zoster [**8-/2188**]
-Acute subdural hematoma [**10/2188**]- Coumadin stopped
-Appendectomy
-Tonsillectomy
Social History:
Retired, got second jub as courier and was able to maintain a
very active life style until [**12-12**]. He lives in [**Location 701**], MA
with his daughter and grandaughter.
Tobacco: quit at 50 yo after 30pyrs.
Etoh: denies
Drug use: denies.
Family History:
No CVA. CAD/MI - mom and dad in 50s. Cerebral aneurysm in
daughter.
Physical Exam:
ADMISSION EXAM:
VITALS: T 97.9, HR 70, BP 120/70, RR 20, Sat 94% on 6L
GEN: Caucasian Male sitting up in bed with face mask in
respiratory distress
HEENT: PERRL, EOMI, difficult to asses JVP given body habitus
CV: Distant S1, S2, irregularly irregular, no gross m/g/r,
difficult to auscultate given pul sounds
RESP: Diffuse inspiratory crackles noted, no consolidations or
egophany noted.
ABD: Non distended, TTP, +b/s, soft
EXT: Some clubbing noted in Rt hand, no edema noted in lower
extremities
SKIN: no rashes
NEURO: AAOx3. Cn II-XII intact.
.
DISCHARGE EXAM:
VS: Tm 97, Tc 97, BP 98-108/58-68, P 64-70, R 20s, 96-99% 6L,
I/O [**Telephone/Fax (1) 39919**]
FSBS: 117-144-250(4H)
GENERAL: Sitting up in bed, comfortable, conversing well
HEENT: NC/AT, MMM, OP clear
NECK: Supple, no JVD
HEART: S1S2 RRR, distant heart tones, no MRG
LUNGS: Diffuse dry inspiratory crackles anteriorly and
posteriorly
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: WWP, no edema, 2+ peripheral pulses
SKIN: No rashes or lesions
LYMPH: No cervical LAD
NEURO: Awake, A&Ox3.
Pertinent Results:
ADMISSION LABS:
[**2189-6-16**] 11:23AM BLOOD WBC-14.4* RBC-4.74 Hgb-14.8 Hct-43.1
MCV-91 MCH-31.3 MCHC-34.4 RDW-17.0* Plt Ct-205
[**2189-6-16**] 11:23AM BLOOD Neuts-80* Bands-0 Lymphs-11* Monos-7
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2189-6-16**] 12:00PM BLOOD PT-80.7* PTT-35.8* INR(PT)-9.3*
[**2189-6-16**] 11:23AM BLOOD Glucose-116* UreaN-17 Creat-1.0 Na-139
K-4.3 Cl-98 HCO3-32
[**2189-6-16**] 11:23AM BLOOD ALT-58* AST-20 AlkPhos-60 TotBili-0.6
[**2189-6-16**] 11:23AM BLOOD Lipase-30
[**2189-6-16**] 07:42PM BLOOD CK(CPK)-49
[**2189-6-16**] 11:23AM BLOOD cTropnT-0.03*
[**2189-6-16**] 07:42PM BLOOD CK-MB-4 cTropnT-0.03*
[**2189-6-17**] 04:30AM BLOOD proBNP-1192*
[**2189-6-16**] 11:23AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.9
[**2189-6-16**] 07:54PM BLOOD Lactate-2.6*
[**2189-6-16**] 02:15PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2189-6-16**] 02:15PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2189-6-16**] 02:15PM URINE RBC-2 WBC-9* Bacteri-FEW Yeast-NONE Epi-2
.
DISCHARGE LABS:
Chem 7:
Na: 141, K:4.0, Cl:96, HCO3:34,
MICRO:
[**2189-6-16**] Urine Cx: no growth
[**2189-6-16**] Urine Legionella Ag: negative
[**2189-6-17**] Blood Cx: no growth to date
[**2189-6-17**] Sputum Cx: contaminated; PCP [**Name Initial (PRE) 5963**]
[**2189-6-17**] Nasopharyngeal aspirate: no viruses
[**2189-6-20**] Viral screen/Cx: negative
[**2189-6-20**] Sputum Cx: oropharyngeal flora
.
IMAGING:
[**2189-6-16**] CT Head w/o con: There is no acute intracranial
hemorrhage, edema, mass effect, or major vascular territorial
infarction. There is no shift of normally midline structures.
[**Doctor Last Name **]/white differentiation is preserved. Cavum septum pellucidum
et vergae is noted. Sulcal and ventricular predominance is
compatible with age-appropriate atrophy. There is no fracture.
Visualized paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION: No acute intracranial process.
.
[**2189-6-16**] PA/LAT CXR: S/p sternotomy indicative of previous
bypass surgery. A permanent pacer is seen in left anterior
axillary position with intracavitary electrodes terminating in
right atrial appendage position and apical portion of right
ventricle correspondingly. A third electrode is located in the
coronary sinus and terminates in a superolateral coronary vein
for left ventricular myocardial stimulation. The position of all
three electrodes is unchanged. The lung tissue again
demonstrates changes indicative of advanced pulmonary
interstitial fibrosis, most marked on the lung bases. Now
superimposed on this pattern is a diffuse parenchymal haze most
likely representing beginning pulmonary edema. Consideration was
given that the interstitial fibrosis may be related to patient's
amiodarone medication in the past.
IMPRESSION: Further deterioration of pulmonary function related
to pulmonary congestion superimposed on interstitial fibrosis
pattern.
.
[**2189-6-17**] TTE: The left atrium is elongated. The estimated right
atrial pressure is 10-15mmHg. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded. There
is moderate global left ventricular hypokinesis (LVEF = 30-35
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is mildly dilated with free wall
hypokinesis.The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with moderate global hypokinesis c/w diffuse process
(toxin, metabolic, cannot exclude multivessel CAD). Increased
PCWP. Right ventricular cavity enlargement with free wall
hypokinesis. Moderate mitral regurgitation. Moderate pulmonary
artery systolic hypertension. Dilated ascending aorta.
.
[**2189-6-20**] LUE U/S:
1. Occlusive thrombus within the left cephalic vein, a
superficial vein.
2. Slow flow in the left internal jugular vein, but is
compressible. No left upper extremity DVT seen. Patent bilateral
subclavian veins, but slower flow in the left subclavian with
less variability as compared to the right, therefore, a more
proximal thrombosis/occlusion can not be excluded.
Brief Hospital Course:
77 year old man with IPF on 6L home O2, Afib on Coumadin s/p
ablation, systolic CHF s/p PPM/AICD who presented after a
syncopal episode with seizure-like activity and found to have
hypoxia.
.
# Seizure-like activity: Pt cannot remember specific event of
falling, though it appears that his syncoal episode may have
been preceded by hypoxia given the lightheadedness, also could
prove to be vagal given his history. Pt has no history of prior
seizures, no electrolyte abnormalities, and CT head negative for
acute process. EEG negative for epileptic activity. Seizure-like
activity was likely myoclonic jerks during the syncopal episode.
No further activity witnessed during this admission.
.
# Hypoxia: The patient has a very poor baseline lung function
with a recent DLCO of 27%. Over a period of [**2-5**] months his O2
requirement increased from 2L to 6L. CXR c/w his known IPF +
pulmonary edema. Urine legionella negative. Sputum culture with
commensal respiratory flora. Viral screen/culture negative.
Although no definite evidence for pneumonia, we empirically
treated with levofloxacin ([**Date range (1) 39920**]). We also diuresed with IV
lasix. We recommend aggressive IV diuresis for oxygen
optimization until creatinine bumps. In discussion with his
outpatient pulmonologist, prednisone was decreased to 40mg daily
and this can continue until pulm outpatient f/u per his
pulmonologist. He will be discharged to a pulmonary LTAC.
.
# A fib with RVR: Pt underwent ablation and has remained well
rate controlled since then. Previous Calcium channel blocker and
digoxin have been discontinued. We continued coumadin at a
decreased dose of 4mg daily with goal INR [**2-5**]. Last INR 2.6.
.
# Systolic CHF s/p AICD/pacer: EF 35% on recent echo. CXR c/w
pulmonary edema so we diuresed with IV lasix as discussed above.
Patient is not currently on a BBlocker due to h/o asthma. It is
unclear why he is not on an [**Name (NI) **] or spironolactone. His
cardiologist/PCP was [**Name (NI) 653**] with this question but we are
still waiting to hear back.
.
# CAD: Continued aspirin. It is unclear why the patient is not
currently on a statin. Recommend outpatient workup.
.
# Hyperlipidemia: It is unclear why the patient is not currently
on a statin. Recommend outpatient workup. Still waiting to hear
back from patient's PCP.
.
# LUE Clot: The patient's left arm was noted to be slightly more
swollen than the right. An ultrasound revealed an occlusive
thrombus within the left cephalic vein, which is a superficial
vein. He is already on coumadin and no additional therapy was
undertaken.
.
# Code Status: Patient very anxious about his prognosis. He was
made DNR/DNI, no MICU transfer. He is not ready for CMO status.
He would like another trial of medical treatment. We brought up
the idea of turning off his ICD to the patient and his
cardiologist Dr. [**Last Name (STitle) **], but the patient is considering this
and this will have to be addressed in the future.
Medications on Admission:
1. ASA 81mg daily
2. Omega 3 fatty acids 1,000mg daily
3. Prednisone 60mg daily
4. Spiriva 18mcg INH daily
5. Bactrim 400-80mg daily PRN Prednisone
6. Furosemide 40mg daily
7. Symbicort 80mcg 2 puffs INH [**Hospital1 **]
8. Nac 600mg TID
9. Omeprazole 20mg [**Hospital1 **]
10. Calcium-Vitamin D 600-400u 1 tab [**Hospital1 **]
11. KCL ER 10meq
12. Colace 100mg [**Hospital1 **] PRN
13. Xopenex 45mcg 2puffs QID PRN
14. Butalbital-Acetaminophen-Caffeine 50-325-40 q6hr PRN
headache
15. Coumadin 6mg QOD
16. MVI daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) inhalation Inhalation once a day.
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
7. acetylcysteine 600 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for pulmonary fibrosis end stage.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Calcium-Vitamin D 600-400 mg-unit Tablet Sig: One (1) Tablet
PO once a day.
10. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
12. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
13. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO every six (6) hours as needed for headache.
14. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
15. multivitamin Capsule Sig: One (1) Capsule PO once a day.
16. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: One (1) neb Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
17. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Interstitial pulmonary fibrosis
Amiodarone induced lung toxicicity
Acute on chronic systolic congestive heart failure
Community acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 10132**],
You were admitted after you passed out, and were noted to have
low oxygenation in your blood and difficulty breathing. This is
likely due to both your lung disease as well as Congestive heart
failure. We have been giving you lasix to remove some of the
fluid in your lungs to make it easier to breathe.
.
We made the following changes to your medications:
- START lasix 40mg IV daily
- CHANGE warfarin to 4mg daily
- START albuterol and ipratropium nebs as needed for shortness
of breath
Followup Instructions:
Please call your Primary care doctor, Dr. [**Last Name (STitle) 7047**] [**Telephone/Fax (1) 8725**]
to schedule an appointment within 1 week after you leave rehab.
Please follow up with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 2
weeks after discharge.
ICD9 Codes: 486, 5990, 4280, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2970
} | Medical Text: Admission Date: [**2165-9-12**] Discharge Date: [**2165-9-16**]
Date of Birth: [**2118-5-19**] Sex: M
Service: MEDICINE
Allergies:
Visipaque
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Cath
History of Present Illness:
48 yo male with history of HTN and dyslipidemia experienced
intermittent chest pain throughout the day of admission and the
day prior; at 11pm it became more severe and did not resolve in
the usual fashion; he called 911 and was brought to the [**Hospital1 18**]
ED. Pt reports that on the morning of [**9-10**] he experienced the
sudden onset of [**7-7**] pain in his posterior neck radiating down
his left arm, it then spread to involve his chest and was a
pressure-like sensation worse with breathing. It began at rest,
lasted a few minutes and then completely resolved. He states
that he had never experienced pain like this. This recurred
several times throughout the day.
.
On the day of admission ([**9-11**]), the pt had similar episodes
starting at rest. After dinner, his pain evolved into [**9-6**]
chest pain with involvement of the left arm. This pain made it
very hard to breathe and was so strong that it "stopped him from
walking." Pt went home, noted that the pain was not resolving
and called 911.
.
Pt received ASA 325mg and nitro in the field (dosage/relief
uncertain). In the ED, his vitals were afebrile, HR=80,
BP=125/80, 100% on RA. His SBPs dropped from 130s to 90s. Pt
received 02, 5mgx3 lopressor, Plavix 600mg, Heparin bolus, and
morphine. Nitro was held for SBP less than 100. His EKG showed
NSR with lateral ST elevations and reciprocal changes. Initial
troponin was 0.08 and CK: 439 MB: 10 MBI: 2.3. Pt was taken to
cath lab were a DES was placed for 100% occlusion of the
proximal LAD.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. he denies recent fevers, chills or rigors. he denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for previous absence of
chest pain on exertion, absence of dyspnea on exertion, and
good/unchanged exercise tolerance. Until 6 months ago, he ran
6km per day.
Past Medical History:
1. CARDIAC RISK FACTORS:: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: NONE
3. OTHER PAST MEDICAL HISTORY: KIDNEY STONES, HERNIATED CERVIACL
DISC
.
Social History:
-Tobacco history:none
-ETOH:occasional
-Illicit drugs:none
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
VS: T=97.9 BP=127/70 HR=84 RR= 18O2 sat= 99% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, braces in place, xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Femoral 2+ DP 2+ PT 2+
Left: Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2165-9-12**] 09:20PM CK(CPK)-4048*
[**2165-9-12**] 09:20PM CK-MB-269* MB INDX-6.6* cTropnT-7.84*
[**2165-9-12**] 08:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2165-9-12**] 02:26PM CK(CPK)-5378*
[**2165-9-12**] 02:26PM CK-MB-GREATER TH cTropnT-9.67*
[**2165-9-12**] 05:53AM GLUCOSE-175* UREA N-14 CREAT-1.1 SODIUM-138
POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
[**2165-9-12**] 05:53AM ALT(SGPT)-84* AST(SGOT)-324* CK(CPK)-4926*
ALK PHOS-62 TOT BILI-0.6
[**2165-9-12**] 05:53AM CK-MB-GREATER TH cTropnT-8.43*
[**2165-9-12**] 05:53AM CALCIUM-8.7 PHOSPHATE-2.1* MAGNESIUM-1.8
[**2165-9-12**] 05:53AM WBC-11.4* RBC-4.95 HGB-15.3 HCT-41.9 MCV-85
MCH-31.0 MCHC-36.6* RDW-13.6
[**2165-9-12**] 05:53AM NEUTS-94.8* LYMPHS-3.9* MONOS-1.2* EOS-0
BASOS-0.1
[**2165-9-12**] 05:53AM PLT COUNT-279
[**2165-9-12**] 12:00AM CK(CPK)-439*
[**2165-9-12**] 12:00AM cTropnT-0.08*
[**2165-9-12**] 12:00AM CK-MB-10 MB INDX-2.3
[**2165-9-12**] 12:00AM TRIGLYCER-190* HDL CHOL-52 CHOL/HDL-3.5
LDL(CALC)-92
.
CARDIAC CATH [**2165-9-12**]:
LMCA: normal
LAD: total proximal occlusion
LCX: normal
RCA: normal
LAD crossed, dilated and tx'ed with Export thrombectomy
revealing severe lesion before and just after D1, D1 with
proximal 70% dz. LAD stented with 2.5 x 18mm Xience with no
residual. Normal flow in LAD and in jailed diag. Mynx closure.
total 130ml omnipaque.
.
HEMODYNAMICS:
Fick CO=3.06, CI= 1.70
Ao 141/94 mean114
RA mean 13, A-wave 15, V-wave 13
RV 38/7 End=14
PCW mean 22, A-wave 30, V-wave 31
PA 38/15 mean 26
.
ECHO [**2165-9-12**]: The left atrium is normal in size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 30-40) secondary to akinesis of the anterior
septum, anterior free wall, and apex. The posterior wall is
hyperdynamic. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. 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 structurally
normal. Mild to moderate ([**11-28**]+) mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion. IMPRESSION: extensive
anteroapical myocardial infarct
.
RENAL ULTRASOUND [**2165-9-14**]:
1) No hydronephrosis or renal mass is identified.
2) Equivocal mass in the bladder, which might represent
prominant median lobe of the prostate. Correlate with prior
imaging if available; in not available, MR pelvis suggested
without/with contrast to exclude neoplasm given history of new
onset hematuria.
Brief Hospital Course:
48 year old male with STEMI proximal LAD occlusion s/p DES with
hemodynamics consistent with moderately elevated filling
pressures and low cardiac index. ECHO demonstrates anterior
apical akinesis, EF 30-40%.
.
# CAD s/p STEMI: Patient presented following 1 day history of
severe chest pain (late presentation). Pt received ASA 325mg and
nitro in the field (dosage/relief uncertain). In the ED, his
SBPs dropped from 130s to 90s. Pt received 02, Plavix 600mg,
Heparin bolus, and morphine. Nitro was held for SBP less than
100. His EKG showed NSR with lateral ST elevations and
reciprocal changes. Initial troponin was 0.08 and CK: 439 MB: 10
MBI: 2.3. Pt was immediately taken to cath lab were a DES was
placed for 100% occlusion of the proximal LAD. Patient was
monitored in the Cardiac ICU intially and then transferred to
the floor. Patient with no complications following cath and
chest pain resolved. Troponin-T peaked at 9.67, CK peaked at
5378 and CK-MB 269. Patient started on Atorvastatin 80mg daily,
ASA 325mg daily, Lisinopril, and Toprol XL. Lisinopril and
Toprol were tirtrated for optimal BP and HR control, discharged
on [**Month/Day/Year 4319**] 10mg lisinopril, toprol XL 100 mg qd. Patient to follow
up with his Cardiologists in [**Country 4194**].
.
# PUMP: ECHO s/p STEMI demonstrated LVEF 30-40% and hypokinetic
apical segments. Patient started on anti-coagulation to prevent
thrombus formation. Bridged on Heparin ggt until Warfarin
therapeutic INR [**12-30**]. Patient discharged on 5 mg Coumadin qhs for
at least 3 months. Dr. [**Last Name (STitle) **] to follow INR until patient
returns to [**Country 4194**]. Patient started on B-blocker and ACE
inhibitor. Patient should have repeat ECHO in [**Country 4194**] per
cardiologist.
.
# Rhythm: Patient demonstrated elongated QTc on [**2165-9-13**].
Unknown etiology and resolved without intervention. Kept K > 4.0
and Mg > 2.
.
# Hematuria: Onset [**2165-9-13**] and still occuring. Very small
occasional clots. [**Month (only) 116**] be related to patient's history of kidney
stones vs. Heparin induced small bleed. Continued
anticoagulation in setting of apical akinesis. Urine culture
negative. Renal ultrasound demonstrated equivocal mass in the
bladder, which might represent prominant median lobe of the
prostate. This needs to be followed up by patient's primary care
doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 4194**]. Recommend MRI pelvis and cystoscopy to exclude
neoplasm given history of new onset hematuria. Urine cytology
was pending at time of discharge.
.
# Leukocytosis - Patient's WBC increased on admission, highest
WBC 20. Decreased on discharge. No clinical sign of infection
(afebrile). Urine culture negative, CXR negative for PNA.
Leukocytosis most likely secondary to acute MI.
.
# HTN: Blood pressure medications titrated for goal SBP < 130.
Discharged on 10mg Lisinopril and Toprol XL 100 mg qd.
.
# Dyslipidemia: Started on high dose Atorvastatin 80 mg qd.
Medications on Admission:
Natrilis SR (Brazilian generic of indapamide)
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left ventricular Systolic dysfunction: EF 35%
Anterior ST Elevation Myocardial Infarction
Hypertension
Leukocytosis
Hematuria
Discharge Condition:
Stable.
Hct: 37.5
BUN 17
Creat: 1.2
INR 1.9.
Discharge Instructions:
You had a heart attack that was from blockages in your coronary
arteries. You had a catheterization and received a drug eluting
stent to your left ascending artery. You will need to take
Plavix every day for one year, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop
taking Plavix unless your doctor tells you to. Plavix prevents
the stent from clotting off and giving you another heart attack.
Your heart is now weaker than it was because of the damage. You
should weigh yourself every day in the morning before breakfast
and call your doctor if you have a weight gain more than 3
pounds in 1 day of 6 pounds in 3 days.
.
You should see your doctor immediately after you return to
[**Country 4194**] and bring your paperwork and CD with test results.
.
Please call Dr. [**Last Name (STitle) **] if you notice any changes in your right
groin area such as increased bruising, tenderness, or swelling.
Please also report any further chest pain, nausea, fevers,
trouble breathing, cough or abdominal pain.
.
New medicines:
Warfarin: to prevent blood clots now that your heart is weaker
than before. You will need to get the warfarin level (INR)
checked frequently. Your INR should be between [**12-30**].
Toprol XL: a beta blocker that helps with the healing of your
heart and lowers your heart rate
Lisinopril: a blood pressure medicine
Aspirin: a blood thinner that helps to prevent another heart
attack
Atorvastatin: a drug that lowers your cholesterol level
Nitroglycerin: to take under your tongue if you have chest pain.
Take each pill 5 minutes apart. Call an ambulance if the pain
doesn't go away after 3 tablets.
.
Please talk to your doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 4194**] about the blodd in your
urine
Followup Instructions:
Please come back to [**Hospital3 **] to get your warfarin level (INR)
checked on Wednesday [**9-18**] at the [**Location (un) 32400**] building, [**Last Name (NamePattern1) 12939**], [**Location (un) 448**] outpatient lab. Parking is in the
garage next door.
Completed by:[**2165-9-16**]
ICD9 Codes: 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2971
} | Medical Text: Admission Date: [**2157-9-26**] Discharge Date: [**2157-10-3**]
Date of Birth: [**2092-5-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Thiopental Sodium
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2157-9-26**] Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to
Diag, SVG to OM1 to OM2, SVG to PDA)
History of Present Illness:
65 y/o male with PMH of CAD s/p MI in [**2147**] and [**2152**]. Recently
c/o DOE and underwent an ETT which showed a perfusion defect.
Underwent Cardiac cath which revealed severe three vessel
disease and referred for surgical intervention.
Past Medical History:
Myocardial Infarction [**2147**]/[**2152**], Hypertension,
Hypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder
cancer
Social History:
Active smoker with approx. 1.5ppd x 40yrs. Denies ETOH use.
Family History:
Father with MI in 80's, Brother with MI at 67.
Physical Exam:
VS: 58 14 160/90
Gen: WDWN male in NAD
Skin: w/d, mult. nevi on torso
HEENT: NCAT, EOMI, PERRL, OP benign with poor dentitian
Neck: Supple, FROM, -carotid bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, trace edema
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2157-9-26**] Echo: PREBYPASS: No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thicknesses and cavity
size are normal. There is mild regional left ventricular
systolic dysfunction with thinning and dyskinesis of the basilar
inferrior and inferolateral walls.. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45%). The
remaining left ventricular segments contract normally. Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. An eccentric, posteriorly directed jet of Mild (1+)
mitral regurgitation is seen. POSTBYPASS: LV systolic function
is marginally improved (LVEF-45-50%) Previous wall motion
abnormalities persist. RV systolic function remains normal.
Study is otehrwise unchanged from prebypass.
[**2157-9-26**] 12:24PM BLOOD WBC-15.5*# RBC-3.46*# Hgb-11.0*#
Hct-30.7*# MCV-89 MCH-31.7 MCHC-35.7* RDW-13.9 Plt Ct-144*
[**2157-9-28**] 06:35AM BLOOD WBC-11.9* RBC-3.36* Hgb-10.1* Hct-29.0*
MCV-86 MCH-30.0 MCHC-34.7 RDW-14.1 Plt Ct-111*
[**2157-9-26**] 12:24PM BLOOD PT-13.6* PTT-25.1 INR(PT)-1.2*
[**2157-9-27**] 03:09AM BLOOD PT-12.3 PTT-27.7 INR(PT)-1.1
[**2157-9-26**] 01:48PM BLOOD UreaN-15 Creat-1.2 Cl-108 HCO3-28
[**2157-9-29**] 11:30AM BLOOD Glucose-211* UreaN-17 Creat-1.0 Na-135
K-4.4 Cl-97 HCO3-33* AnGap-9
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On the day of admission
he was brought directly to the operating room where he underwent
coronary artery bypass grafting to five vessels. Please see
operative report for surgical details. Following surgery he was
transferred to the CSRU for invasive monitoring in stable
condition. Later on operative day one, he was weaned from
sedation, awoke neurologically intact and extubated. He was then
transferred to the step down unit for further recovery. Mr.
[**Known lastname **] was gently diuresed towards his preoperative weight. He
remained stable post-operatively and worked with physical
therapy for assistance with his postoperative strength and
mobility. Beta blockers were increased for heart rate and blood
pressure control. He developed atrial fibrillation which was
treated with an increase in his beta blockade. He progressed
well and was discharged home with VNA services on [**2157-10-3**]. He
will follow-up with Dr. [**Last Name (STitle) 1290**], his cardiologist and his
primary care physician as an outpatient.
Medications on Admission:
Aspirin 325mg qd, Lisinopril 20mg qd, Metformin 500mg [**Hospital1 **],
Toprol XL 100mg qd, Lipitor 80mg qd
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*1*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
7. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*1*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks.
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Lasix 20 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:
tba
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
PMH: Myocardial Infarction [**2147**]/[**2152**], Hypertension,
Hypercholesterolemia, Diabetes, Mellitus, Obesity, h/o Bladder
cancer
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not lift more than 10 lbs. for 2 months.
Do not drive for 4 weeks.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office with sternal drainage, temps.>101.5
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**2-12**] weeks
Dr. [**Last Name (STitle) 3314**] in [**1-11**] weeks
Completed by:[**2157-10-4**]
ICD9 Codes: 5180, 2720, 4019, 4240, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2972
} | Medical Text: Admission Date: [**2149-8-15**] Discharge Date: [**2149-9-2**]
Date of Birth: [**2084-1-3**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
abdominal pain with nausea/vomiting
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy with subtotal colectomy, lysis of
adhesions, and repair of ventral hernia.
2. Revision of colostomy.
History of Present Illness:
Pt is a 60 yo white male w/ Hx significant for colon cancer, s/p
two bowel resections, including a colostomy, who presented to
[**Hospital1 18**] on [**8-14**] with C/O crampy abdominal pain and enlarging
parastomal hernia x 1 day.
Past Medical History:
Colon CA
s/p Bowel resections x 2 with Colostomy
Mechanical Mitral Valve
Parastomal hernia
Small Bowel Obstruction
NIDDM
Social History:
Pt denies tobacco, etoh, and illicit drug use.
Family History:
CAD
Physical Exam:
VS: 99.0, 76, 144/78, 16, 98 RA
Gen: alert, oriented, well-nourished male, no distress
HEENT: PERRLA, CN II-XII intact; no JVD or lymphadenopathy
Chest: CTA x 2
Cardio: RRR without murmur
Abd: Nondistended, Stoma pink, hypo-active BS, soft, diffuse
mild TTP without guarding or rebound. Non reducible parastomal
hernia
Ostomy: pink. Guiaic positive.
Brief Hospital Course:
Pt presented [**8-14**] with C/O crampy abdominal pain and enlargement
of parastomal hernia x 1 day. KUB revealed multiple air fluid
levels, and CT abd/pelvis revealed a mid small bowel obstruction
with transition point at mid abd wall in upper portion of hernia
sac. Pt admitted to surgery service. Pt started and maintained
on IV heparin drip.
[**8-15**], with obstruction not resolving, pt underwent exploratory
with subtotal colectomy, lysis of adhesions, and repair of
ventral hernia with mesh. Pt tolerated procedure well, and was
transferred to SICU. Pt remained intubated on propafol drip
posteroperatively, to prevent respiratory complications
secondary to major abd procedure.
[**8-16**], pt remained in stable condition, intubated on propafol
drip. Pt required aggressive fluid resuscitation for low urine
output.
[**8-17**], pt continued to remain stable and intubated. Hematocrit
remained stable, and pt continued to require large amounts of IV
fluids.
[**8-18**], stoma noted to not be viable, and pt taken to OR for
colostomy revision. Pt tolerated procedure well, and was
transferred to SICU in stable condition.
[**8-19**], Pt was weaned from propafol drip and ventilator, and pt
extubation. Pt tolerated extubation well.
[**8-20**], pt continued to tolerate extubation well, and was
transferred to the floor. Pt continued on 10 mg Coumadin for
mechanical mitral valve to achieve INR of 2.5-3.5.
[**8-21**], pt continued to remain in stable condition, and physical
therapy began working with pt, to get him OOB to chair. Pt
began clear liquids, which he tolerated well. Surgical wounds
and ostomy continued to appear well-healing.
[**8-22**], pt's diet advanced to full liquids, which he tolerated
well. He continued working with PT. Ostomy output was good and
wounds appeared well-healing.
[**8-23**], Pt continued with physical therapy and incentive
spirometry. Diet was advanced to regular, which was tolerated
well. HR noted to be tachy into 110s in a-fib- pt put on
telemetry.
For the next several days, pt continued to remain stable,
tolerating regular diet and working w/ PT. HR remained
elevated, and pt remained without cardiac symptoms.
Metoprolol was increased, and a cardiology consult was obtained.
Cardiology felt that pt's elevated HR may be due to decreased
HCT of 26.9. Pt was transfused 2 uprbcs on [**8-30**], and hematocrit
rose. Pt's HR stabilized over the few days.
On [**8-29**], with pt's HR elevated, pt complained of chest
tightness. EKG obtained and reviewed with cardiology was
negative for any acute ischemic process. CTA obtained to R/O
pulmonary embolism, revealed no pulmonary emboliism. Chest
tightness soon subsided, and once again, pt's HR stabilized to
normal.
Over his hospital course, Mr. [**Known lastname 16254**] required increasing doses of
Coumadin to achieve an INR of 2.5-3.5. At home, he reportedly
requires between 10-15 mg/day of Coumadin to maintain
therapeutic INR. During the last several days of [**Hospital **] hospital
stay, he required doses of 17.5mg/day, and 20 mg/day of coumadin
to achieve INR of 2.5-3.5.
On [**9-2**], Mr. [**Known lastname 16254**] continued to tolerate a regular diet. His
wounds continued to appear well-healing and his stoma output
continued to be good. His INR finally acheived the therapeutic
level of 3.0, and he was discharged to home in good condition.
Medications on Admission:
Metformin 250 mg PO TID
Glyburide 1.25 mg PO TID
Warfarin 10-15 mg PO once daily
Metoprolol 150 mg PO once daily
Lipitor 20 mg PO once daily
Discharge Medications:
Metformin 250 mg PO TID
Glyburide 1.25 mg PO TID
Metoprolol XL 200mg PO once daily
Coumadin 17.5 mg PO once daily
Lipitor 20 mg PO once daily
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Small Bowel Obstruction
s/p Exploratory Laparotomy, Lysis of adhesions, repair of
parastomal hernia
Discharge Condition:
Stable
Discharge Instructions:
Keep wounds clean.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] within one week after discharge
by telephone to set up appointment. Dr.[**Name (NI) 6433**] phone # is:
[**Telephone/Fax (1) 6439**]. Pt needs to follow-up with his primary care
physician for coumadin management, etc. within one to two days
after discharge.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2973
} | Medical Text: Admission Date: [**2201-6-25**] Discharge Date: [**2201-6-30**]
Date of Birth: [**2128-3-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
bil. claudication, + ETT
Major Surgical or Invasive Procedure:
off pump CABG x4 (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to
RCA) [**2201-6-26**]
History of Present Illness:
73 yo male with known bil. claudication, underwent recent
positive stress test. Admitted for elective cardiac cath at
[**Hospital1 **]. This revealed severe LM and 3VD. Transferred here for
CABG.
Past Medical History:
PVD s/p bil SFA stents [**2196**]
HTN
elev. lipids
NIDDM
OA
BPH
Social History:
marketing VP
lives with wife and autistic son
one drink per day
[**12-31**] ppd x 7 years
Family History:
no [**Last Name (un) **]. CAD
Physical Exam:
HR 57 RR 15 BP 162/70
NAD
Lungs CTAB
Heart RRR
Abdomen benign
Extrem warm, no edema
Pertinent Results:
[**2201-6-28**] 06:00AM BLOOD WBC-11.9* RBC-3.78* Hgb-12.2* Hct-35.5*
MCV-94 MCH-32.3* MCHC-34.5 RDW-12.9 Plt Ct-230
[**2201-6-28**] 06:00AM BLOOD Plt Ct-230
[**2201-6-26**] 12:07PM BLOOD PT-14.2* PTT-32.7 INR(PT)-1.2*
[**2201-6-28**] 06:00AM BLOOD Glucose-162* UreaN-8 Creat-0.8 Na-137
K-4.3 Cl-102 HCO3-25 AnGap-14
Radiology Report CHEST (PORTABLE AP) Study Date of [**2201-6-28**] 7:02
PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2201-6-28**] SCHED
CHEST (PORTABLE AP) Clip # [**0-0-**]
Reason: assess for pneumothorax after chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
73 year old man s/p CABG, now s/p chest tube removal
REASON FOR THIS EXAMINATION:
assess for pneumothorax after chest tube removal
Provisional Findings Impression: PMB MON [**2201-6-29**] 11:19 AM
No pneumothorax.
Final Report
PORTABLE CHEST, [**2201-6-28**], WITH COMPARISON STUDY OF EARLIER
THE SAME DATE.
INDICATION: Chest tube removal.
Following removal of chest tubes, no pneumothorax is identified.
Left basilar
atelectasis has nearly resolved, and right basilar atelectasis
is slightly
improved. No other changes since recent study.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 275**] [**Hospital1 18**] [**Numeric Identifier 79573**]
(Complete) Done [**2201-6-26**] at 10:04:50 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2128-3-30**]
Age (years): 73 M Hgt (in):
BP (mm Hg): 160/80 Wgt (lb): 177
HR (bpm): 80 BSA (m2):
Indication: Intraoperative TEE for off-pump CABG
ICD-9 Codes: 786.05, 786.51, 440.0
Test Information
Date/Time: [**2201-6-26**] at 10:04 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: [**Pager number 5741**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 7 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 5 mm Hg
Aortic Valve - LVOT pk vel: 0.[**Age over 90 **] m/sec
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *2.2 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes. Good (>20 cm/s) LAA
ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Focal calcifications in
aortic root. Mildly dilated ascending aorta. Simple atheroma in
ascending aorta. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
Physiologic MR (within normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Pre-revascularization:
1. The left atrium and right atrium are normal in cavity size.
No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal.
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta.
5. The aortic valve leaflets (3) are mildly thickened. There is
no aortic valve stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits).
Dr. [**Last Name (STitle) **] was notified in person of the results in the
OR.
Post-revascularization:
Cardiac exam unchanged from pre-revascularization.
Brief Hospital Course:
Admitted from [**Hospital1 **] [**6-25**] and pre-op workup completed.
Underwent OPCABG x 4 with Dr. [**First Name (STitle) **] on [**6-26**]. Transferred to the
CVICU in stable condition on titrated phenylephrine and propofol
drips. Extubated postop. Transferred to floor on POD #1. Chest
tubes and wired discontinued without incident. He did well
postoperatively and was ready for discharge home on POD #4.
Medications on Admission:
lisinopril 5 mg daily
simvastatin 40 mg daily
atenolol 50 mg daily
plavix 75 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 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:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company **]
Discharge Diagnosis:
CAD s/p OPCABG x4
PVD s/p bil.superf. femoral stents
HTN
elev. lipids
NIDDM
OA
BPH
Discharge Condition:
Stable.
Discharge Instructions:
shower daily, pat incisions dry
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 7640**] in [**12-31**] weeks
see Dr. [**Last Name (STitle) 656**] in [**2-1**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2201-6-30**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2974
} | Medical Text: Admission Date: [**2131-1-14**] Discharge Date: [**2131-1-16**]
Date of Birth: [**2062-6-28**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Aspirin / Compazine / spironolactone
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Hypertension, Fluid overload
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68F with CAD s/p CABG in [**2129**], diastolic CHF (EF >55%), h/o CVA
with left sided weakness, HTN, HLD, T2DM on insulin and CKD who
presents with chest pain and was found to be hypertensive and
volume overloaded in the ED. She reports that since Wednesday
[**1-10**] she has been having substernal chest pressure at rest.
She has been receiving SL nitro for the past few days at her [**Hospital1 1501**]
which has relieved the chest pressure. She has not walked since
leaving the hospital on [**1-2**], so she cannot express whether the
CP is worse with exertion. She also reports feeling worsening
SOB over the past 4-5 days. She has not previously has to wear
oxygen until the past 4-5 days. At home, she has 6 pillow
orthopnea and reports waking up feeling suddenly short of breath
on occasion. She states that she has been requesting to take
torsemide for the past few days because she feels more fluid in
her lungs and in her legs, and she was just restarted on
torsemide 20mg PO on Friday, 2 days PTA. She reports good
adherence to a low sodium diet at rehab.
.
On the day of admission, she was not able to keep down any of
her PO medications because of nausea and vomiting, which was
clear and non-bloody. She also reported that she felt
lightheaded today without vertigo.
.
In the ED, there was initially concern for aortic dissection
given decreased right radial pulse compared to the left. A
non-contrast CT chest was ordered which showed no evidence of
dissection but showed moderate pulmonary edema and cardiomegaly.
Cardiology was consulted and she was started on a nitro gtt for
hypertension and likely CHF exacerbation
.
She was recently admitted from [**2130-12-29**] to [**2131-1-2**] for right leg
pain and hyperkalemia. During this admission, her sironolactone
and torsemide were stopped because of elevated potassium and
creatinine, respectively. She was instructed to continue
holding these medications after discharge and has not taken them
since. At her last admission 2 weeks ago, both discharge and
admission systolic BPs were noted to be in the 150s. In the past
year she has had multiple recorded systolic BPs in the 160-180s
at various outpatient appointments. However, at her [**2130-12-27**]
visit in the heart failure clinic, her BP was noted to be
114/68.
.
On review of systems, s/he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, cough, hemoptysis, black stools or red
stools. S/he denies recent fevers or rigors. S/he denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of
palpitations, syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG ([**2129-7-27**]): LIMA-LAD, SVG-OM1, SVG-OM2 c/b non-healing
sternal incision wound
- MI in [**2128**] and [**2129**]
- Diastolic heart failure (EF >55%)
- PERCUTANEOUS CORONARY INTERVENTIONS: None in [**Hospital1 18**] records
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Cerebrovascular accident with L residual hemiparesis ([**10-29**])
-T2DM on insulin (last A1c=6.4%)
-Chronic kidney disease with microalbuminuria (stage III)
-Hyperlipidemia
-Hypertension
-Asthma - intubated "many years ago." Per patient last
exacerbation requiring hospitalization was 2-3 years ago.
-Morbid obesity
-UGIB [**7-30**] suspected d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
Social History:
She is currently in a [**Hospital1 1501**] after her last discharge because of
leg pain and being unable to ambulate. She is [**Name Initial (MD) **] former RN at
[**Hospital1 2025**]. Divorced, has 3 children. Born in Barbaros, in the US
since the [**2089**].
- Tobacco history: Never
- ETOH: Never
- Illicit drugs: Never
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: Diabetes, unsure of cause of death, no reported CAD
- Father: Died in 30s from trauma after falling off a horse
Physical Exam:
Admission Exam:
VS: T=97.7 BP=162/123 HR=68 RR=8 O2 sat=99%/2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Speaking in
full sentences.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 4 cm above the clacivle at 45 degrees.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**2-26**] decrescendo systolic murmur at the
LLSB with radiation to the apex.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles in the lower
lung fields bilaterally.
ABDOMEN: +BS, soft/ND/mild TTP in RLQ. No HSM.
EXTREMITIES: [**2-23**]+ edema of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **].
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact with slight smile asymmetry and slight
tongue protrusion to the left. 4/5 strength in UEs bilat, RLE
[**4-25**], LLE [**3-25**] proximal and distal
PULSES:
Right: Carotid 2+ PT 2+
Left: Carotid 2+ PT 2+
Discharge Exam:
FS: 121, 163, 259 yesterday
VS: 98.5, 97.7, 141/53 (109-157/41-53), 53 (50s), 18, 100% NC
2L.
I/O: in 900/24hrs, out 2750/24hrs. Overnight: 250mg (foley)
Weight: 116.4kg
General: Obese Arfican-American woman, appears comfortable
HEENT: JVP is 4cm above clavicle
CV: RRR, nl S1/S2, 2/6 systolic murmur heard best at the LLSB
radiating to the apex
Lungs: minimal crackles at the lung bases bilat improved from
yesterday, otherwise CTAB
Abd: +BS, soft/NT/obese
Extr: 1+ edema of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
Neuro: 4/5 weakness in LUE, [**5-25**] RUE, [**3-25**] LLE, [**4-25**] RLE. Slight
tongue deviation to the left and asymmetric smile, unchanged
from admission
Pertinent Results:
Admission Labs:
[**2131-1-14**] 07:50PM BLOOD WBC-8.8 RBC-2.77* Hgb-8.4* Hct-26.8*
MCV-97 MCH-30.2 MCHC-31.3 RDW-13.7 Plt Ct-206
[**2131-1-14**] 07:50PM BLOOD Neuts-77.6* Lymphs-12.3* Monos-3.4
Eos-6.3* Baso-0.4
[**2131-1-14**] 08:15PM BLOOD PT-11.5 PTT-32.5 INR(PT)-1.1
[**2131-1-14**] 07:50PM BLOOD Glucose-90 UreaN-77* Creat-2.6* Na-142
K-5.3* Cl-111* HCO3-18* AnGap-18
[**2131-1-14**] 07:50PM BLOOD ALT-29 AST-23 LD(LDH)-237 AlkPhos-209*
TotBili-0.4
[**2131-1-14**] 07:50PM BLOOD Lipase-26
[**2131-1-14**] 07:50PM BLOOD CK-MB-3 proBNP-[**Numeric Identifier 16243**]*
[**2131-1-14**] 07:50PM BLOOD cTropnT-0.04*
[**2131-1-15**] 06:31AM BLOOD CK-MB-3 cTropnT-0.05*
[**2131-1-14**] 07:50PM BLOOD Calcium-9.8 Phos-3.3# Mg-2.0
[**2131-1-15**] 06:31AM BLOOD TSH-2.0
Discharge Labs:
[**2131-1-16**] 06:25AM BLOOD WBC-7.2 RBC-2.63* Hgb-7.8* Hct-25.3*
MCV-96 MCH-29.6 MCHC-30.9* RDW-13.9 Plt Ct-202
[**2131-1-16**] 06:25AM BLOOD Glucose-100 UreaN-75* Creat-2.7* Na-145
K-4.9 Cl-113* HCO3-24 AnGap-13
[**2131-1-16**] 06:25AM BLOOD Calcium-9.0 Phos-4.7* Mg-1.8
Urine:
[**2131-1-14**] 09:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
[**2131-1-14**] 09:30PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2131-1-14**] 09:30PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
[**2131-1-15**] 04:09AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2131-1-15**] 04:09AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2131-1-15**] 04:09AM URINE RBC-3* WBC-18* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
[**2131-1-15**] 04:09AM URINE CastHy-3* CastCel-1*
[**2131-1-15**] 04:09AM URINE Mucous-RARE
Microbiology:
[**2131-1-15**] 4:09 am URINE Source: Catheter.
**FINAL REPORT [**2131-1-16**]**
URINE CULTURE (Final [**2131-1-16**]): NO GROWTH.
Imaging:
[**2131-1-14**] CXR: The heart is moderately enlarged. The hilar and
cardiomediastinal contours are obscured by bilateral linear and
hazy
opacities which extend from the hilum to the periphery, with
multiple Kerley B lines, compatible with pulmonary interstitial
edema. No focal consolidation is seen. There is no pneumothorax
or large effusion. Multiple intact sternal wires are
redemonstrated. There are no osseous lesions identified.
IMPRESSION: Hazy and linear parenchymal opacities, new since
[**2130-12-30**], with increased central pulmonary congestion
and cardiomegaly, most compatible with cardiogenic pulmonary
edema.
[**2131-1-14**] Chest CT: 1. Moderate cardiomegaly with central
pulmonary vascular congestion and interstitial edema, most
compatible with cardiac decompensation. 2. No thoracic aneurysm
or aortic intramural hematoma. Evaluation for dissection limited
due to non-contrast technique.
[**2131-1-15**] ECHO: The left atrium is normal in size. 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 RV free wall is not well seen. The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is at least moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mildly thickened aortic valve leaflets without aortic
stenosis or aortic regurgitation. Trace mitral regurgitation and
mild tricuspid regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2129-12-2**]
the findings are similar.
Brief Hospital Course:
68F with CAD s/p CABGx3, diastolic CHF (EF>55%), HTN, HLD, CKD,
T2DM on insulin, h/o CVA who presents with chest pain and was
noted to be hypertensive with volume overload.
.
# Acute on Chronic Diastolic CHF (EF >55%) - On admission,
patient appeared volume overloaded on exam (crackles, elevated
JVP, LE edema). Her home diuretics (torsemide and
spironolactone) were held after her previous admission 2 weeks
ago which likely contributed to her current CHF exacerbation.
She was given IV lasix with good urine output (2750cc in
foley/24hrs, with 900cc input) and she improved clinically, with
less overload on exam. Prior to discharge, she was tolerating PO
and her HTN had improved on her PO medications (she was
initially given nitroprusside ggt, which she was weaned off of
the day prior to discharge), now with normotensive blood
pressures (109-157/41-53). Dietary indiscretion does appear to
be a factor, which she was counselled on. Ischemia/ACS ruled
out with negative trop x2. Her dry weight not precisely known,
although prior weights in our records are approx 115kg, she was
123kg at admission to the CCU and was 116kg on discharge. Her
home dose of torsemide was restarted. It was not increased given
her euvolemic appearance (minimal LE edema, clear lungs) on
discharge and slight bump in creatinine to 2.7. Metoprolol was
changed to carvedilol 6.25mg [**Hospital1 **] for improved blood pressure
control. The patient is not on a ACEi/[**Last Name (un) **] due to her advanced
chronic kidney disease.
.
# HTN - BP at admission to the ED was 160/60 and she has a
history of HTN to the 160-180s systolic recently. Initially she
was not tolerating PO, and so was started on a nitroprusside
ggt. Her torsemide/spironolactone were recently discontinued,
both of which may have contributed to her HTN. She was weaned
off the nitro drip the day after admission and restarted on her
home medications (amlodipine, isosobride dinitrate,
hydarlazine); however, metoprolol was changed to carvedilol
6.25mg [**Hospital1 **] for improved blood pressure control.
.
# CAD s/p CABG: Patient presented with chest pain prior to
admission which resolved with nitro spray x3. Trop negative x2
and no concern for ACS at this time. Most likely etiology of
her CP is elevated afterload with SBP in the 200s in the ED.
Patient was continued on plavix, and started on carvedilol. No
further concerning symptoms with treatment of blood pressure.
.
# T2DM on insulin - Last A1c from [**10/2130**] was 6.4%, suggesting
good control at home. Patient was managed with home lantus
13units qam and HISS, which she is on as an outpatient.
.
# CKD - Her creatinine at admission is 2.6, which is within her
recent baseline of 1.8-2.6. Likely etiology is combination of
HTN and diabetes. There was concern about creatinine elevation
during prior admission, which is why her diuretics were held at
discharge. Patient was given lasix for fluid overload and
diuresed several liters. On the day of discharge, her creatinine
was 2.7. Lasix was stopped and home torsemide was restarted at
20mg daily. Torsemide was not increased further given slight
increase in creatinine.
.
#Hyperkalemia - Patient received Kayexalate 30gm for K of 5.7 on
the day after admission. Potassium remained within normal limits
for remainder of admission.
.
#Anemia - Baseline Hct is very variable in our records, but
appears to be in the mid-20s to low 30s. She is currently at 26
during this admission. No evidence of current bleeding. Likely
etiology is her CKD. Iron studies in records show nl serum
iron, nl TRF and high ferritin - suggests AoCD. Hct was
monitored and stable.
.
# H/o CVA - Neurologic exam is currently at baseline according
to previous records. She is not reporting any new neurologic
symptoms.
.
# HLD - Continued atorvastatin 80mg PO daily.
.
CODE: FULL (confirmed)
COMM: [**Name (NI) **], daughter is emergency contact ([**Telephone/Fax (1) 106688**])
.
Transitional Issues:
Patient will continued to be followed by physicians at her
extended care facility. She should have her creatinine and
electrolytes monitored regularly while on toresmide.
Medications on Admission:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Telephone/Fax (1) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
2. amlodipine 5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
4. gabapentin 300 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO EVERY OTHER
DAY (Every Other Day).
5. hydralazine 100 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO three times
a day.
6. isosorbide dinitrate 30 mg Tablet PO TID (3 times a day).
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Thirteen (13) units
Subcutaneous QAM.
9. insulin lispro 100 unit/mL Cartridge [**Last Name (STitle) **]: One (1)
Subcutaneous once a day: humalog sliding scale.
10. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO twice a
day.
11. atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. torsemide 20mg PO daily (stopped at last hospitalization
earlier this month, restarted [**2131-1-12**] according to records from
her facility)
13. oxycodone 5mg 1 tab q8h PRN pain
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day/Year **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
2. amlodipine 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
4. gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO EVERY OTHER
DAY (Every Other Day).
5. hydralazine 50 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q8H (every 8
hours).
6. isosorbide dinitrate 20 mg Tablet [**Month/Day/Year **]: 1.5 Tablets PO Q 8H
(Every 8 Hours).
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. insulin glargine 100 unit/mL Solution [**Last Name (STitle) **]: Thirteen (13)
units Subcutaneous once a day: in AM.
9. insulin lispro 100 unit/mL Solution [**Last Name (STitle) **]: One (1) dose
Subcutaneous four times a day: Per home sliding scale. With
meals and at bedtime.
10. carvedilol 6.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. torsemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
13. oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every eight (8)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital-[**Hospital1 392**]
Discharge Diagnosis:
Primary Diagnosis: Hypertension and Acute on Chronic Diastolic
CHF
Secondary Diagnosis:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG ([**2129-7-27**]): LIMA-LAD, SVG-OM1, SVG-OM2 c/b non-healing
sternal incision wound
- MI in [**2128**] and [**2129**]
- Diastolic heart failure (EF >55%)
- PERCUTANEOUS CORONARY INTERVENTIONS: None in [**Hospital1 18**] records
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Cerebrovascular accident with L residual hemiparesis ([**10-29**])
-T2DM on insulin (last A1c=6.4%)
-Chronic kidney disease with microalbuminuria (stage III)
-Hyperlipidemia
-Hypertension
-Asthma - intubated "many years ago." Per patient last
exacerbation requiring hospitalization was 2-3 years ago.
-Morbid obesity
-UGIB [**7-30**] suspected d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for high blood pressure and
fluid overload. You were given blood pressure medication and
water pills to take the excess fluid out of your lungs. Your
blood pressure was well controlled and your shortness of breath
and chest discomfort resolved with treatment. Please adhere to
your salt restrictive diet, as foods with salt will worsen your
symptoms.
The following changes have been made to your medications:
STOP lisinopril
STOP metoprolol
START carvedilol 6.25mg by mouth twice daily.
Please continue all other medications as prescribed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital1 **] MRI (MOBILE)
When: THURSDAY [**2131-1-18**] at 4:05 PM
With: MRI [**Telephone/Fax (1) 327**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2131-2-8**] at 12:40 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2131-4-30**] at 11:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**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: 4280, 2767, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2975
} | Medical Text: Admission Date: [**2153-3-17**] Discharge Date: [**2153-3-19**]
Date of Birth: [**2105-12-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8684**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is 47 yo f with h/o anemia (unclear etiology), s/p
polypectomy on [**2153-3-5**], who awoke at 3 am with crampy abdominal
pain and BRBPR. Pt felt like she was about to have diarrhea,
then went to the toilet and passed large amount of BRBPR. She
felt lightheaded and passed out 2-3 times (no head trauma). She
denies recent black or tarry stools. No N/V, SOB, CP, or F/C. Pt
went to an OSH ED, found to have hct 26.6, and was transfused 2
U PRBC's. She was then transferred to [**Hospital1 18**].
Past Medical History:
- anemia: unclear etiology, but present since childhood
(baseline approx low 30's, dropped to 19 in setting of prior
C-section)
- h/o C-section
- h/o fibroid removal
Social History:
Currently a student (studying education). Married with 1 child.
No smoking. Occasional EtOH.
Family History:
Mother with DM.
Physical Exam:
Vitals: T 97.6 BP 115/72 HR 61 RR 18 O2sat 98% RA
Gen: pleasant, NAD
HEENT: PERRL. Slight R eye ptosis.
Neck: Supple. No JVD.
Cardio: RRR, nl S1S2, [**2-6**] sys murmur @ apex
Resp: CTAB
Abd: soft, nt (mild sensitivity diffusely), nd, +BS
Ext: no c/c/e
Neuro: A&Ox3
Pertinent Results:
Hct:
28.8->31->31->29.4->30.5
Brief Hospital Course:
47 yo f with h/o anemia, s/p recent [**Last Name (un) **]/EGD now with episodes
of BRBPR and anemia.
.
#) GI Bleed: Most likely lower GI bleed, due to BRBPR and modest
fall in hematocrit. Most likely secondary to recent
polypectomies, as post-polypectomy hemorrhage can occur up to 29
days post procedure and patient had multiple polyps, close to
1cm in size, and 1 that was sessile, all of which can predispose
to bleeding. There were no other abnormalities seen on
colonoscopy to account for her BRBPR. She remained
hemodynamically stable with stable hematocrits during her MICU
course. Recent upper endoscopy demonstrated normal oesophagus,
stomach, and duodenum. 2 Peripheral IVs were placed, patient
was typed and screen, and started on intravenous pantoprazole.
After multiple stable hematocrits, her diet was advanced and she
was transferred to regular medicine floor. She was observed one
more night and her hct remained stable. She did not have any
further bleeding and was tolerating a regular diet at the time
of discharge.
.
#) Anemia: Patient appears to have chronic iron deficiency
anemia, with more acute blood loss anemia from GI bleed. This
was the reason for her initial colonscopy, for colon CA workup.
Patient was restarted on supplemental iron per outpatient
regimen with no further events. Her hct was stable at her
baseline at the time of discharge.
.
#) Syncope: most likely [**2-2**] vasovagal events in setting of acute
blood loss. Pt appears to be bradycardic at baseline. No
further events were noted on telemetry.
.
#) FEN: Patient's diet was advanced once bleeding resolved and
her hct was stable. She tolerated a regular diet without
difficulty.
.
#) Code: Full
.
#) Comm: with pt and husband
Medications on Admission:
Ferrous Sulfate
Multivitamin.
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 disks* Refills:*1*
4. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
Puff Inhalation twice a day.
Disp:*1 INH* Refills:*2*
5. Saline Mist 0.65 % Aerosol, Spray Sig: 1-2 Puffs Nasal twice
a day as needed.
Disp:*1 INH* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Post-polypectomy bleeding-resolved
Discharge Condition:
Afebrile. Tolerating PO. Hematocrit stable.
Discharge Instructions:
Please continue to take your medications as directed.
.
If you experience bleeding from your rectum, high fevers,
abdominal pain, difficulty breathing or other concerning
symptoms, please call your doctor or return to the emergency
room.
.
We have started you on an inhaler called advair which you can
take twice daily for your wheezing.
Followup Instructions:
.
Dr.[**Name (NI) 8687**] office will call to schedule a follow up
appointment with you. If you don't hear from them by the end of
the week, call [**Telephone/Fax (1) 608**] to schedule follow up.
.
Provider: [**Name10 (NameIs) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2788**] INTERNAL MEDICINE
Date/Time:[**2153-4-23**] 9:15
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2976
} | Medical Text: Admission Date: [**2154-6-20**] Discharge Date: [**2154-7-11**]
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
L5/S1 laminectomy
History of Present Illness:
[**Known firstname 18882**] [**Known lastname 79357**] is an 83-year-old woman with a history of CLL
and is status post high grade MRSA bacteremia causing L5/S1
osteomyelitis with extension into epidural space, requiring
admission in [**4-23**]. The patient is now status post 6 weeks of
vancomycin and over 2 weeks of linezolid. She has had ongoing
low back and leg pain which has not improved. She was referred
by Dr. [**Last Name (STitle) 17444**] (ID) for further pain control and a repeat MRI. Her
last MRI was approximately 3 wks ago without significant change.
The patient is unable to give an accurate history because "the
pain so bad, don't ask me any questions." She denies any chest
pain, SOB, or other symptoms. She relates pain "through my legs
and low back," which may have been worse over the past day or
so. She does not give a recent history of falls. She refuses to
answer any further questions.
In the ED, the patient had an L-MRI without significant change
from prior. She was given Dilaudid for pain control.
Past Medical History:
CLL
PVD s/p L [**Doctor Last Name **]/PT [**Name (NI) **] and L jump bypass from PT to plantar artery
CAD 3VD, s/p stent x2 [**10-21**]; p-MIBI [**1-23**] fixed, unchanged
moderate defect.
HTN
Dyslipidemia
Chronic right foot ulcer
Social History:
Widowed, lives alone, and has one daughter. [**Name (NI) **] tobacco/alcohol.
Had been independent with her ADLs prior to osteomyelitis.
Family History:
NC
Physical Exam:
VITALS: T=98.5, BP=121/88, HR=60, RR=16, O2=94% on RA
GEN: Pt moving and moaning, "I need more pain meds"
HEENT: Nonicteric, mucous membranes moist
CV: RRR, II/VI SEM
PULM/Back: CTA bilaterally; no spinal/paraspinal tenderness
ABD: Soft, NT, ND
EXT: No LE edema
NEURO: Uncooperative with exam; CN's intact, moving all 4
extremities with grossly normal strength/sensation; negative
straight leg raise
Pertinent Results:
WBC-66.5* RBC-3.76* Hgb-10.9* Hct-32.8* MCV-87 MCH-28.9
MCHC-33.1 RDW-14.9 Plt Ct-183
Neuts-10* Bands-2 Lymphs-86* Monos-1* Eos-0 Baso-0 Atyps-1*
Metas-0 Myelos-0 Other-0
Plt Smr-NORMAL Plt Ct-183
ESR-10
Glucose-99 UreaN-20 Creat-1.0 Na-138 K-4.2 Cl-103 HCO3-22
AnGap-17
Calcium-9.6 Phos-2.6* Mg-1.7
U/A: Sp [**Last Name (un) **] 1.015, pH 5.0, small leuks, 3 WBCs, otherwise
negative
Lumbar MRI on admission: IMPRESSION: Osteomyelitis and discitis
at L5-S1, with slight interval increase in irregularity and T2
hyperintensity within the L5-S1 disc space in comparison with
[**2154-5-7**]. Probable mild increase in enhancing epidural
soft tissue, posterior to L5 through S3 vertebrae without
evidence of canal stenosis. Persistent enhancing soft tissue
within the right psoas, anterior to the L5-S1 interspace, and
surrounding the L5 nerve roots bilaterally.
Angio [**7-4**]: Successful placement of a 40-cm total length right
basilic single lumen PICC with tip in the SVC
Brief Hospital Course:
1. L5/S1 Osteomyelitis: The patient was admitted for evaluation
and treatment of her severe low back pain. She was started on
opiate analgesia in addition to Neurontin. She was started on
Linezolid and then switched to Vancomycin IV for concern about
continuing osteomyelitis. Repeat lumbar MRI was performed and
compared with her study from six week prior; there was note of
continued osteomyelitis and discitis at L5-S1, with slight
interval increase in irregularity and T2 hyperintensity within
the L5-S1 disc space. There was probable mild increase in
enhancing epidural soft tissue, posterior to L5 through S3
vertebrae and persistent enhancing soft tissue within the right
psoas. ESR was 10. CRP was 0.82. Orthopedics and Infectious
Disease were consulted. It was determined that she would need
surgical debridement. Following cardiac clearance and
catheterization, she went to the OR and underwent a L5/S1
laminectomy on [**2154-7-1**]. Cultures from the site were obtained and
were negative except for trace growth of coag negative staph.
She was on antibiotics at the time of the surgery. The pathology
revealed bony changes consistent with chronic osteomyelitis.
Post surgery, she continued to note back pain. She was
maintained on vancomycin which was dosed by levels. A PICC line
was placed for long term IV antibiotic treatment. She will
likely require at least six weeks of antibiotics following
surgery. Her ID doctor, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17444**], wil contact her for a
follow-up appointment.
2. Acute renal failure: The patient's creatinine was 0.6 on
admission. She had a hypotensive episode prior to surgery which
resulted in a MICU admission. Her Cre rose at that time and it
was felt to be prerenal azotemia. Her creatinine then improved.
The day after her surgery, she was again noted to be
hypotensive. This was thought secondary to post-operative
hypovolemia. She received IV fluids with normalization of her
blood pressure. Her creatinine subsequently rose to a high of
1.6. This was thought to be secondary to ATN from her
hypotensive episode. Her ACE inhibitor was held. Her creatinine
slowly improved. Her ACEI was then restarted.
3. NSTEMI/CAD: Patient had known CAD. She also had a hypotensive
episode prior to surgery. During this time, she required MICU
admission for IV fluids and monitoring. She had a small NSTEMI
at that time. She was treated conservatively. When surgery was
deemed necessary cardiology was consulted for cardiac clearance.
She underwent persantine mibi which demonstarted a moderate
fixed inferior wall defect that was unchanged from prior study.
She also had global hypokinesis. Based on these results, the
patient went to cardiac catheterization. On cath, her RCA was
known to be proximally occluded, and thus was not selectively
engaged. The LAD had patent proximal- to mid-vessel stents, and
mild diffuse disease up to 40% otherwise. The Left circumflex
had a 40% proximal lesion, and was then occluded in the
mid-portion. A large OM1 branch had a 50% lesion proximally.
There was a 15-mmHg gradient across the aortic valve during
simultaneous measurement of central arterial and LV pressures,
consistent with mild aortic stenosis. In all, she had Two VD,
patent LAD stents, and mild AS. No interventions were performed
ID had recommended that no stents be deployed as the plavix
requirement would have delayed her necessary back surgery. POBA
would have been performed, but there were no lesions amenable to
this treatment. The patient was restarted on her aspirin post
surgery.
4. Congestive heart failure: Following her surgery and her acute
renal failure episodes, the patient was noted to have worsening
oxygenation and she developed SOB. Chest x ray revealed
congestive heart failure. She was treated with lasix with
improvement in her breathing and oxygenation.
5. Peripheral vascular disease: the patient complained of severe
pain in her lower extremities. The etiology of which was not
clear. The nerve roots did not appear to be infringed upon on
her MRI. She has known severe PVD and is s/p left fem-[**Doctor Last Name **] bypass
graft. She has had problems since that time. Vascular surgery
was consulted to see if the PVD was contribing to her pain. They
felt that she continues to have severe PVD and requires
additional vascular interventions, but that her PVD was not the
etiology of her leg pain.
6. Back and lower extremity pain: the patient was noted to have
severe low back pain and bilateral lower extremity pain. The
etiology was not clear. It could not clearly be attributed to
the osteomyelitis or the PVD. She was maintained on fentanyl
patch, neurontin, and po opiates. This still only provided
moderate pain control. On [**7-5**] she had acute change in mental
status and was arousable only to sternal rub. She had a head CT
that did not show a bleed. She was given narcan with some
improvement in her mental status. She slowly became more alert
and back to her baseline. The etiology of her depressed mental
status is likely multifactorial and included excessive sedation
from opiates and delirium. The fentanyl patch was decreased and
her po opiates were decreased.
7. CLL: The patient has a chronically elevated WBC count in the
20s. Heme/onc was consulted to ensure no additional treatment
was needed perioperatively. IVIG was considered, but given its
potential toxicities, it was held. Her CLL was not an active
issue during her hospitalization.
8. Hallucinations: In addition to her depressed mental status,
the patient suffered from hallucinations. She described seeing
bugs and other animals. These hallucinations were felt to be
opiate induced and improved with Haldol.
9. Anemia: The patient's hematocrit was noted to be dropping
post operatively. She required 4 units of PRBCs. A CT abdomen
was performed to exclude retroperitoneal bleed. This was
negative. She had trace OB positive stool from below. NG lavage
was negative. GI was consulted and EGD was considered, but was
deferred given her delerium. Hemolysis and DIC labs were
negative. The patient's blood counts then stabilized. The cause
of her drop in her hematocrit was not found. She should have a
colonoscopy as an outpatient if her clinical course goes well.
10. Thrombocytopenia: the patient's platelet counts dropped
during her admission. HIT antibody was sent and was negative.
Her platelet count then slightly improved. It was thought that
the Linezolid may have caused some of her thrombocytopenia.
11. Fevers: The patient had low-grade fevers post operatively.
She had chest x-rays which showed only CHF. Blood cultures were
negative. Urine culture demonstrated yeast, which was thought to
be contamination from tinea cruris. She was treated with topical
antifungal treatment for that as well as four days of po
fluconazole. She was also treated with cipro to complete an
8-day course for possible pneumonia.
12. Skin breakdown: The patient had mild skin breakdown on
sacrum and left elbow. Thought to be pressure-induced decubiti.
She was given an air mattress and wound care was consulted. She
had duoderms placed on her sacrum. She had had prophylaxis
instituted to prevent heel ulcerations as well.
13. Full code
Medications on Admission:
Plavix 75mg PO QD
Isosorbide Mononitrate 60 mg QD
Amlodipine 10mg QD
Besylate 10 mg QD
Quinapril 10 mg QD
ASA 325 mg QD
Protonix 40mg QD
Percocet prn
Lipitor 80mg QD
Metoprolol 75mg [**Hospital1 **]
Linezolid 600mg [**Hospital1 **]
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: 1.3333 Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours) as needed for Leg/back pain.
15. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4-6H (every 4 to
6 hours) as needed: Hold for confusion/oversedation.
16. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
17. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for Yeast in groin.
19. Vancomycin 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous once a day: Please check trough after 2nd
dose and fax to Dr. [**Last Name (STitle) 17444**] at [**Telephone/Fax (1) 1419**]. First dose given [**7-12**]
at noon.
Discharge Disposition:
Extended Care
Facility:
Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**]
Discharge Diagnosis:
L5/S1 osteomyelitis
Acute renal failure due to acute tubular necrosis
NSTEMI
CAD
CLL
Delerium
Sacral decubiti
CHF
PVD
Back and lower extremity pain
Anemia
Thrombocytopenia
Fevers of unclear etiology
Discharge Condition:
The patient is able to pivot with assistance. She is requiring
2L of oxygen at rest. She is alert with occasional confusion.
Discharge Instructions:
Multiple medication changes have been made, please see
accompanying medication sheet for accurate list.
Weigh yourself daily.
Adhere to 2 gram sodium/day diet.
Please return to the ED if you have fevers, chills, inability to
tolerate medications or if you have worsening weakness or
decreased sensation in your legs.
Followup Instructions:
-- You have an appointment with your orthopedic surgeon, Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 1022**], [**Street Address(2) 96781**], [**Location (un) **], [**Location (un) **] [**Numeric Identifier 822**],
Phone: [**Telephone/Fax (1) 7807**]. Day/time: [**7-17**], 3:45 p.m.
-- You will need to follow up with your infectious disease
doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17444**], in four weeks. He will contact you with
appointment information. The [**Hospital **] Clinic's phone number is ([**Telephone/Fax (1) 10**].
-- Please call your PCP for an appointment one week after
leaving the rehab hospital.
Completed by:[**2154-7-11**]
ICD9 Codes: 2875, 5845, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2977
} | Medical Text: Admission Date: [**2109-10-15**] Discharge Date: [**2109-10-17**]
Service:
HISTORY OF PRESENT ILLNESS: This is a 79-year-old woman with
a past medical history of coronary artery disease and labile
hypertension who presents with worsening of her nausea over
the past 24 hours and noted this morning to be unsteady on
her feet and unable to walk straight. She also complains of
a massive headache, she described as if her head was going to
explode. Her called her daughter and her primary care
physician and her primary care physician told her to come to
the Emergency Department. CT in the Emergency Department
showed a questionable small bleed in the left cerebellum.
Patient had a recent history significant for nausea which has
been intractable for several months. She also given history
of her head feeling strange at times but this one seems to be
more intense than most times and patient claims that she is
actually very functional at home and lives by herself.
PAST MEDICAL HISTORY: Includes coronary artery disease,
status post catheterization in [**2095**], coronary artery bypass
graft times three in [**2095**], seizure disorder. Work-up done
here showed only temporal lobe swelling, arthritis.
MEDICATIONS ON ADMISSION: Aspirin, disopromine, Toprol,
Trilafon for nausea, Cozaar and Aldactone.
FAMILY HISTORY: Significant for hypertension and coronary
artery disease.
SOCIAL HISTORY: Patient lives alone. Has a woman who comes
in to help her out with the meals. Ambulates independently.
No alcohol use. Ex-smoker times 15 years.
REVIEW OF SYSTEMS: Has occasional blurriness of vision, no
dull vision, no hearing changes. Cardiovascular: No chest
pain, no shortness of breath, no palpitations, no paroxysmal
nocturnal dyspnea, no significant dyspnea on exertion.
Pulmonary: No shortness of breath, no cough, no fevers, no
chills or night sweats. Gastrointestinal: She was positive
for nausea, no vomiting, no diarrhea, no constipation.
Genitourinary: No urgency, no frequency, no polyuria, no
dysuria, no hematuria, no polydipsia, no heat and cold
tolerance. Heme: No abnormal bleeding.
PHYSICAL EXAM ON ADMISSION: Vital signs of a blood pressure
of 220/120 on admission which was then brought down to 150/90
and patient in general was an alert and oriented woman in no
acute distress. Head, eyes, ears, nose and throat: Neck was
supple, no masses, no carotid bruits. Coronary: Regular
rate and rhythm S1, S2, no murmurs, rubs or gallops.
Pulmonary: Clear to auscultation bilaterally. Abdomen soft,
nontender, nondistended, positive bowel sounds. Extremities:
No cyanosis, clubbing or edema. Neurological: Patient was
alert and oriented times three. Speech is fluent. Memory
for three objects intact at five minutes. Cranial nerves:
Pupils are equal, round, and reactive to light and
accommodation. Extraocular muscles intact with left beating
nystagmus. Visual fields were full. Face was symmetric.
Face sensation intact. Palate elevated symmetrically. Gag
was present. Trapezius strength [**6-8**]. Tongue protrudes in
the midline. Motor is [**6-8**], normal tone, no drift. Sensory
is normal sensation to pinprick in bilateral upper
extremities normal sensation to pinprick in bilateral lower
extremities. Proprioception was intact. Vibratory sense was
intact. Gait was normal with narrow-based gait.
Coordination: Mild finger-to-nose unsteadiness on the left.
Heel-to-shin unsteady on the left, rapid alternating
movements increased on left compared to the right. Reflexes:
Upper extremities 2+ symmetric, left lower extremity 2+ and
symmetric. Toes downgoing bilaterally.
LABORATORIES: Patient had a Chem-7 and CBC which were both
within normal limits. On admission patient's laboratories
were notable for sodium of 129, potassium of 5.0, 93/26 BUN
and creatinine 17/0.9, CK was 70, hematocrit was 42.2.
Patient has chronic hyponatremia 129 being at her baseline.
On day of admission patient's sodium was 132 and was stable.
CT scan of the brain showed questionable cerebellar bleed.
HOSPITAL COURSE: Patient was admitted to the Medical
Intensive Care Unit to have hourly neurological checks.
Patient was stable as was her blood pressure in the Medical
Intensive Care Unit with intravenous nitroprusside. Blood
pressure was well under control. Patient remained
neurologically stable throughout her night stay in the
Medical Intensive Care Unit. Patient had a MRI to follow-up
on the bleed which showed no evidence of any more bleed. The
official read was no hemorrhage, no evidence of any recent
infarct, old right frontal meningioma, basilar bilateral
50-75% carotid stenosis. Patient was neurologically stable
in the Medical Intensive Care Unit. Blood pressure was
stabilized with intravenous nitroprusside. Patient was then
changed back to her po blood pressure medications. Patient
was relatively controlled and blood pressure was stable
130/78. On day of discharge, patient's blood pressure was
134/78. Patient was continued on her medications of aspirin
325 mg, disopromine 20 mg q.d., Toprol XL 100 mg q.d., Cozaar
50 mg q.d., Aldactone 25 mg q.d., Zocor 40 mg q.d. and
Trilafon 4 mg prn nausea. Patient was stable upon discharge
with a blood pressure 138/78, fully awake, alert and
oriented. Patient was evaluated by Physical Therapy for home
safety evaluation but can be discharged home. Patient will
follow-up with Dr. [**Last Name (STitle) **] for further blood pressure control
in the future. Patient was stable upon discharge at the time
she left her blood pressure was in the 130s/70s.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8708**], M.D. [**MD Number(1) 10932**]
Dictated By:[**Last Name (NamePattern1) 6234**]
MEDQUIST36
D: [**2109-10-22**] 11:43
T: [**2109-10-22**] 11:43
JOB#: [**Job Number **]
ICD9 Codes: 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2978
} | Medical Text: Admission Date: [**2136-2-23**] Discharge Date: [**2136-2-29**]
Date of Birth: [**2063-9-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
congestive heart failure in past, referred for cabg/mvr after
cardiac catheterization
Major Surgical or Invasive Procedure:
CABG x4(LIMA-LAD,SVG-OM,SVG-Diag, SVG-PDA0MVR(#31 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
porcine)[**2-23**]
Re-exploration for bleeding [**1-/2057**]
History of Present Illness:
multiple episodes of CHF before cardiac cath in [**September 2135**],
then referred for surgical evaluation. Currently symptom free.
Past Medical History:
CAD
Ischemic Cardiomyopathy
CHF
DM2
CRI(2.2)
Nephrolithiasis
s/p Lithotripsy
s/p cystoscopy
Social History:
Retired insurance [**Doctor Last Name 360**]. Lives w/wife in [**Name (NI) 14840**], MA
Denies tobacco, rare ETOH use
Family History:
Brother w/CAD in 50's
Physical Exam:
Admission
VS: T HR 63 BP 136/74 RR 12
Ht 6'1" Wt 202lbs
Gen NAD
Neuro A&Ox3, MAE, nonfocal
Skin unremarkable
HEENT EOMI, PERRL, OP benign
Neck supple no JVD
Pulm CTA bilat
CV RRR distant heart sounds
Abdm soft, NT/+BS
Ext warm, well perfused, no varicosities or edema
Discharge
Pertinent Results:
[**2136-2-27**] 03:07AM BLOOD WBC-6.7 RBC-2.99* Hgb-9.0* Hct-25.8*
MCV-86 MCH-30.2 MCHC-35.0 RDW-13.7 Plt Ct-68*
[**2136-2-29**] 08:30AM BLOOD PT-24.5* INR(PT)-2.4*
[**2136-2-28**] 01:14PM BLOOD PT-15.2* INR(PT)-1.3*
[**2136-2-29**] 08:30AM BLOOD UreaN-47* Creat-1.7* K-3.5
[**2136-2-28**] 01:14PM BLOOD Glucose-199* UreaN-48* Creat-1.6* Na-137
K-3.4 Cl-102 HCO3-27 AnGap-11
[**2136-2-27**] 03:07AM BLOOD Glucose-151* UreaN-42* Creat-1.6* Na-136
K-4.0 Cl-102 HCO3-26 AnGap-12
[**2136-2-26**] 04:57AM BLOOD Glucose-164* UreaN-35* Creat-1.7* Na-133
K-4.6 Cl-102 HCO3-22 AnGap-14
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2136-2-27**] 10:00 AM
CHEST (PORTABLE AP)
Reason: s/p ct removal ?ptx
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
s/p ct removal ?ptx
HISTORY: Status post CABG with removal of chest tube.
FINDINGS: In comparison with the study of 2/29, there has been
removal of all of the tubes except for residual right IJ stent
and right chest tube. No evidence of pneumothorax or change in
the appearance of the heart and lungs.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 74493**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 74494**]Portable TEE
(Complete) Done [**2136-2-24**] at 3:29:00 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2063-9-2**]
Age (years): 72 M Hgt (in): 73
BP (mm Hg): 100/60 Wgt (lb): 220
HR (bpm): 60 BSA (m2): 2.24 m2
Indication: Congestive heart failure. Coronary artery disease.
H/O cardiac surgery. Pericardial effusion. Mitral valve disease.
ICD-9 Codes: 423.3, 423.9
Test Information
Date/Time: [**2136-2-24**] at 15:29 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **],
MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: Cardiology
Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W99-9:9 Machine: Vivid i-4
Sedation: (See comments below for other sedation.)
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Moderately depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3).
MITRAL VALVE: MVR well seated, with normal leaflet/disc motion
and transvalvular gradients.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: Effusion is loculated.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. Local anesthesia was provided by
benzocaine topical spray. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). 0.2 mg of IV glycopyrrolate was given as an
antisialogogue prior to TEE probe insertion. No TEE related
complications. The patient appears to be in sinus rhythm.
Conclusions
Overall left ventricular systolic function is moderately
depressed. Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. The mitral prosthesis appears well
seated, with normal leaflet motion. There is a large echodense
(>2cm) collection (likely clot) in the pericardium. This
echodense mass is impinging on the right atrium and right
ventricle.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2136-2-24**] 16:08
Brief Hospital Course:
Mr [**Name13 (STitle) 74495**] was a direct admission to the operating room where
he had a CABGx4/MVR on [**2-23**]. Please see OR report for details.
In summary he had CABG x4 with LIMA-LAD, SVG-OM, SVG-Diag,
SVG-PDA and MVR with #31 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic porcine valve. His bypass
time was 181 minutes with a cross-clamp of 107 minutes. He
tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition.
He had marked bleeding from the chest tubes on the day of
surgery and returned to the operating room for reexploration. He
tolerated this well and again returned to the ICU in stable
condition. He was kept sedated after the reexploration and on
POD2/1 was allowed to wake, weaned from the ventilator and
extubated. Over the next 24 hours he was weaned from his iv
drips and his PA catherter removed. He was noted to have
intermittant episodes of Atrial fibrilation and was started on
Amiodarone and Warfarin. On POD [**3-29**] he was transferred to the
step down floor for continued care. Once on the floors his
activity level was advanced with PT and nursing, his chest tubes
and epicardial wires were removed and on POD 6 he was ready for
discharge to rehab.
Medications on Admission:
ASA 81'
Lipitor 80'
Januvia 100'
Toprol XL 25'
Avapro 150'
Urocrit-K 20"
Aldactone 25'
Humalog75/25 20 QAM
Lasix 40'
Discharge Medications:
1. Sitagliptin 100 mg Tablet Sig: 0.5 Tablet PO daily ().
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg QD x7 days then 200mg QD.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
10. Lantus 100 unit/mL Solution Sig: Thirty (30) Subcutaneous
at bedtime.
11. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days: 40 [**Hospital1 **] for 10 days then 40 daily as prior to
surgery.
13. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
14. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
check INR [**3-1**]. Goal INR [**1-29**] for atrial fibrillation.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of the [**Hospital3 **] - [**Location (un) 3493**]
Discharge Diagnosis:
s/p CABGx4/MVR [**2-23**]
re-explored for bleeding [**1-/2057**]
Chronic systolic heart failure
PMH: ICM, DM, CRI(2.2), Nephrolithiasis, CHF
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean nad dry. OK to shower, no bathing or
swimming.
Take all medication as prescribed
Call for any fever, redness or drainage from wounds.
Followup Instructions:
Dr. [**Last Name (STitle) 17369**] in [**1-29**] weeks
Dr. [**Last Name (STitle) 7772**] in 4 weeks
Dr. [**Last Name (STitle) 10543**] 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2136-2-29**]
ICD9 Codes: 2762, 4240, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2979
} | Medical Text: Admission Date: [**2194-12-24**] Discharge Date: [**2195-1-3**]
Date of Birth: [**2133-3-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 530**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
This is a 61 yo M with a past history of afib not on
anticoagulation, stroke, motor seizure and labile hypertension
who was admitted to an OSH with bright red blood per rectum that
occurred while sleeping. The day prior, he had a bloody BM and
became diaphoretic and pale and did not respond to his wife,
making it difficult to tell if he had an expressive aphasia or
vasovagal syncope. He was admitted to the OSH for fluid
resuscitation and received 2 units of pRBC's. The morning after
admission, the nurses were ambulating the patient and noticed
him leaning more towards the left side and that he was unsteady
on his feet. He had been off coumadin for 6 months secondary to
chronic anemia from hemorrhoidal bleeding.
.
He has a history of significant rectal bleeding about 5-6 months
ago at which time he underwent upper and lower endoscopies that
revealed internal hemorrhoids that were considered a potential
source of bleeding. Surgery was consulted (he has a history of
hemorroidectomy 15 years ago) but any surgical intervention was
delayed in light of his other medical issues.
.
His hypertension has historically been labile and difficult to
control and he has been evaluated at both [**Hospital1 **] and [**Hospital1 2025**] for
this. His current regimen included labetalol, doxazosin,
lisinopril/HCTZ, Cartia. He also has a history of afib and had
significant episodes of arrhythmia during his admission,
prompting a cardiology consultation.
.
His stroke history is significant for a history of right lateral
temporal lobe infarct extending to the right parietal lobe, pre
and post central cortex and right middle frontal gyrus. On this
admission, he experienced sudden left sided weakness with falls,
and he was evaluated by neurology.
.
He is transferred to [**Hospital1 18**] for further work up and treatment of
his GI bleeding, as well as for his neurologic and cardiac
co-morbidities.
.
On arrival to the MICU, the patient was found to be in a
polymorphic wide complex tachycardia to the 200s. He was
mentating, had stable blood pressures, putting out 50cc/hr urine
with good peripheral pulses. Pacing pads were placed and an
amiodarone bolus was administered with initiation of an
amiodarone gtt. He also received 2g Mag. His rate slowed with
the amiodarone and his rhythm returned to a narrow complex
irregular tachycardia. At the time of transfer he had finished
his 5th unit of pRBCs.
.
In the MICU the patient received an additional 6 units of blood.
He was also noted to have a wide-complex tachycardia and was
started on dofetilide, amiodarone and esmolol gtt per the EP
team which were then stopped and then transitioned to diltiazem,
labetolol, which he was taking as an outpatient. His HR remains
fast at around 110 bpm. On admission the patient was also noted
to have a significant speech delay. [**12-24**] MRI/A: showed acute
infarct of R ACA without discrete vascular abnormality (no
acute cutoff or discrete stenosis) at R ACA. Severe atheromatous
disease noted in other intracranial arteries as well as the
basilar artery. R ACA infarct was thought to be [**1-17**] emboli v.
pressure drop distal to severe stenosis. Neurology was
consulted and recommended holding anticoagulation given lower GI
bleed and to maintain SBP 140s-160s. Pt has remained
hypertensive to a peak sbp of 185/126 and his diastolic blood
pressures remain high.
.
On questioning, the patient denies any new headache, visual
changes, speech difficulties, new weakness though he does report
chronic UE and some LE weakness ?R > L. He has chronic knee
pain but is ambulatory. He denies orthopnea or PND and can walk
one block w/o SOB. He has difficulty climbing stairs [**1-17**] to
knee pain. The patient denies any recent weight loss or night
sweats, fevers/chills, denies chest pain, palpitations, or a new
cough. Currently he denies dizzyness and has not had BRBPR
since prior to admission. He is feeling close to his baseline.
Past Medical History:
- a-fib, not on anticoagulation [**1-17**] h/o lower GI bleed
- lower GI bleed 4 years ago s/p hemorrhoidectomy; colonoscopy
[**2193-12-25**] showed large grade IV external hemorrhoid, enormous
tortuous internal and external hemorrhoids, medium-sized polyp
s/p removal
- DM II newly started on oral regimen
- Obesity
- Sleep apnea on bipap
Social History:
Lives with his wife [**Name (NI) **], works as a lumber salesman, drinks
3-4beers per night and one [**Doctor Last Name 6654**], denies eye opener or h/o
withdrawal, denies h/o IVDU or other illicits.
Family History:
no h/o GI cancers, mother living with HTN and DM, father died of
lung cancer
Physical Exam:
VS: 98.2/98.6 BP 164/112 (141-185/93-126) HR 110s RR 20 98% RA
I/O: 1440/[**2111**]
GEN'L: very obese male, delayed speech, comfortable, NAD
HEENT: nc/at, OP clear, MMM, conjunctivae slightly pale, sclera
anicertic, EOMI, PERRL
NECK: supple, no [**Last Name (un) **]/poster cervical LN, no
submandib/supraclavic LN
CVS: tachycardic, regular rhythm, nml s1/s2, no m/r/g
PUL: CTAB, no wheezes or crackles
[**Last Name (un) **]: obese, +BS, non-tender, no masses
EXT: R > L hand/arm edema, L > R LE edema 2+pitting to knees,
warm extremities, no cyanosis or clubbing
NEURO: CN II-XII intact, speech delayed, sensation grossly
intact to light touch face and extremities stregth [**3-21**] R and [**2-18**]
L deltoid; [**3-21**] R and 3/5 L bicep/tricep; [**3-21**] R and 3/5 L wrist
flexion/extension; [**3-21**] R and 4/5 L hip flexor, 5/5 L and r ankle
flexion and extension; slightly delayed L finger to nose, nml
finger tap, +Babinski on left; 2+ bracial, wrist reflexes
SKIN: cherry spots and red small papules diffusely over body, no
other rashes
Pertinent Results:
ADMISSION LABS:
OSH:
Hct 23
Cr 1.8
.
143 114 39
=============< 137
4.3 23 1.5
Ca: 7.8 Mg: 2.3 P: 4.0
.
6.9 > 28.5 < 126
N:79.1 L:15.7 M:3.6 E:1.2 Bas:0.5
.
PT: 14.3 PTT: 26.3 INR: 1.2
.
Ca: 7.7 Mg: 29.0 P: 3.7
.
ALT: 12 AP: 33 Tbili: 0.6 Alb: 2.6
AST: 14 LDH: 132 Dbili: TProt:
[**Doctor First Name **]: Lip: 23
.
MRI/MRA brain [**2194-12-24**]:
IMPRESSION: Acute infarct of the right ACA without discrete
vascular
abnormality detected of the right ACA. However, severe
atheromatous disease is noted in other intracranial arteries as
well as the basilar artery.
.
Echo [**2194-12-30**].
IMPRESSION: Limited study. No PFO seen. Grossly-preserved
biventricular function. Dilated thoracic aorta.
.
MRI/MRA head [**2195-1-1**].
IMPRESSION:
1. No evidence of new brain ischemia apart. Stable signal
abnormality corresponding to known subacute right anterior
cerebral artery territory infarct.
2. Extensive atherosclerotic disease involving the intracranial
carotid and vertebral branches as detailed above. Abrupt cut
off of the right A2 segment of the anterior cerebral artery
likely correlates with the territory of infarction.
3. New, marked focal short segment stenosis of left A1 segement
of ACA with patent artery distally.
3. Grossly patent major cervical vessels; MRA of the neck was
significantly limited due to decreased contrast in the arteries
(bolus timing problem) as above.
4. Bilateral maxillary sinus mucosal thickening versus fluid as
well as fluid within the left mastoid air cells.
.
Colonoscopy [**2195-1-2**].
Grade 1 internal hemorrhoids
Slightly abnormal/thickened appearing fold in right colon.
Mucosa appeared abnormal on NBI (biopsy)
Possible rectal varices.
Diverticulosis of the whole colon
.
Carotid u/s OSH:
R >50% external carotid stenosis, L < 50% external carotid
stenosis, no internal carotid stenosis bilat
.
EKG: [**2194-12-24**]
Baseline artifact. The rhythm is irregular with both wide and
narrow
complexes. Probable sinus rhythm with intraventricular
conduction delay and frequent ventricular premature beats or
aberrated supraventricular
complexes. There appears to be organized atrial activity in some
leads but
cannot rule out the possibility that this is atrial fibrillation
or multifocal atrial tachycardia. Clinical correlation and
repeat tracing are suggested. No previous tracing available for
comparison.
.
R UE u/s [**2194-12-26**]:
IMPRESSION: Occlusive thrombus in the right cephalic vein. The
remaining
vessels are clear.
.
Brief Hospital Course:
61M h/o Afib, CVA, and recurrent lower GI bleed [**1-17**] hemorrhoids
admitted [**2194-12-18**] with rectal bleeding and near syncopal episode.
Transferred to [**Hospital1 18**] with persistent BRBPR and L sided weakness.
Patient was found to have right sided ACA stroke identified on
head MRI.
.
GI Bleed. Patient was initially admitted to OSH for GIB.
Patient has history of GI bleeds from hemorrhoidal bleeding, but
there was no evidence of hemorrhoidal bleeding seen on anoscopy
at OSH. Patient had unremarkable EGD at OSH 5 months prior to
admission. Patient was transferred 5 units of PRBCs prior to
arrival to [**Hospital1 18**]. Patient has been transfused more than 6 units
during [**Hospital1 18**] stay. Colonoscopy on [**1-2**] revealed several
possible etiologies of bleed: internal hemorrhoids vs. rectal
varices vs. diverticuli. Most recent episode of melena on [**12-31**]
and patients last transfusion of 1 unit was on [**2195-1-1**]. Patient
will need Hct checked tomorrow, on [**2195-1-4**]. If patient had any
further GI bleeding, he would likely need tagged red blood cell
scan or anoscopy to evaluate the source of bleed.
.
CVA. Patient has a history of CVA and presented with left sided
weakness and slurred speeck in setting of GI bleed. An MRI/MRA
on [**12-24**] revealed an acute infarct of R ACA without discrete
vascular abnormality (no acute cutoff or discrete stenosis) at R
ACA. Severe atheromatous disease noted in other intracranial
arteries as well as the basilar artery. Right ACA infarct was
thought to be due to embolic event versus pressure drop distal
to severe stenosis. Anticoagulation was held due to GI bleed,
but patient was eventually resumed on Aspirin 325. He recovered
much of his function on left side, however in setting of low
blood pressure (SBP < 130), patient had re-expresion of these
symptoms. His blood pressure was therefore maintained between
140s-160s. He will need to follow up with his neurologist in
[**1-18**] weeks and they will ultimately lower is blood pressure goal.
.
Atrial fibrillation. Patient has A. fib with RVR, but went into
A. flutter and wide complex tachycardia during hospital staty.
Patient takes defetilide at home, but this was stopped as
patient was unable to remain in NSR. He was rate controlled on
labetolol and diltiazem, however, his HR remained in 90s. Due
to goal of maintaining a high blood pressure, attempts at
improved rate control were unsuccessful. Patient could not be
anticoagulated on coumadin due to GI bleed. He was given full
dose aspirin.
.
HTN. Antihypertensives were intially held due to GI bled, but
were resumed with blood pressure goal of 140s-160s systolic due
to recent CVA. Patients blood pressure medications were
converted from long acting to short acting for better control of
blood pressure goal. Doxazosin was discontinued. At lower BPs
(SBP <130s), patient had re-expresion of CVA with left sided
weakness and slurred speeh. He was maintained on diltiazem,
labetolol, and captopril. He will ultimately need to have
diltiazem switched to long acting form and labetolol will need
to be switched to [**Hospital1 **] dosing if BP remains stable.
.
Pulmonary edema. Patient developed hypoxia in the setting of
hypertension, thought to be due to flash pulmonary edema. He
was treated in the ICU with a nitroglycerin drip and diuresis
with good response.
.
Hyperlipidemia. Patient was contineud on Simvastatin. LDL was
checked and found to be 25.
.
Type 2 Diabetes. Home metformin and Actos were initially held
and patient was maintained on a Regular insulin sliding scale.
He will need this resumed as an outpatient. His HgA1C was
checked and found to be 5.8.
.
Right upper extremity cephalic DVT. Patient had a PICC
associated DVT. PICC was removed. Patient was not
anticoagulated for thrombus.
.
Communication: wife [**Name (NI) 1743**] [**Name (NI) 5749**] ([**Telephone/Fax (1) 77190**] (c),
[**Telephone/Fax (1) 77191**] (h), son [**Name (NI) **] [**Telephone/Fax (1) 77192**] (c)
Medications on Admission:
Cartia XT 240mg daily
Labetalol 300mg [**Hospital1 **]
Doxazocin 2mg daily
Lisinopril/hctz 20/12.5
KCl 20mEQ [**Hospital1 **]
Simvastatin 20mg daily
Iron daily
Actos 10mg daily
Metformin 1000mg [**Hospital1 **]
Tikosyn 0.25mg [**Hospital1 **]
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
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) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
6. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
8. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
9. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]
Discharge Diagnosis:
GI bleed
CVA
.
Diabetes
Hypertension
Hyperlipidemia
Discharge Condition:
Fair. Hct has remained stable for several day. Blood pressure
is well controlled between 140s and 160s systolic. Left sided
weakness is nearly resolved with 4+/5 strength on left side.
Speech is fluent.
Discharge Instructions:
You were admitted for blood in your stools and for a stroke.
You were treated in the intensive care unit.
.
Please take your medications as directed. A number of
medication changes were made during your hospital stay.
.
Please call you physician or come to the emergency department if
you have chest pain, weakness, numbness/tingling, difficulty
walking, blood in stools, black stools, or any other concerning
symptoms.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 77193**] in [**12-17**] weeks. Ph
[**Telephone/Fax (1) 77194**].
.
Please follow up with your neurologist in [**12-17**] weeks.
ICD9 Codes: 5849, 4019, 2720, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2980
} | Medical Text: Admission Date: [**2105-7-4**] Discharge Date: [**2105-7-12**]
Date of Birth: [**2043-5-24**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62M w/HCV and EtOH cirrhosis, s/p liver [**First Name3 (LF) **] [**2104-11-30**],
now presenting with fever and hypotension with pressor
requirement after HD today. Mr. [**Known lastname **] has had a complex course
since his [**Known lastname **], including wash-out for intra-abdominal
hemorrhage, ESRD requiring dialysis, recurrent HCV, pneumonia
with right empyema, and C. diff colitis. He was most recently
discharged from [**Hospital1 18**] on [**2105-6-23**] for his c.diff infection. He
was
doing well at rehab, and had HD today, which went without
incident. After completion, they noted that he was hypotensive
to the 80's and febrile to 103, and he was brought to our ED for
evaluation. His wife reports his stools are still loose, but
are
decreased in amount and the character is improved since
completing c. diff treatment. History is obtained from the
patient's wife and [**Name (NI) **], as the patient is a very poor historian
and is mostly non-verbal currently
Past Medical History:
recurrent hepatitis C with the suspicion of fibrosing
cholestatic hepatitis
s/p ERCP on [**2105-2-24**] with biliary stent placement
HCV; VL on [**2104-12-15**] was 32.6 million
HCV/ETOH cirrhosis w/ hepatorenal syndrome s/p OLT [**2104-11-30**]
Intra-abdominal hemorrhage
Malnutrition
VRE UTI
Social History:
ETOH history 5-6 years ago > 14 drinks/week secondary to
brothers death at age 50. Last drink [**2104-5-20**], Tobacco [**12-22**] pack
x 20 years (quit in [**5-29**]), remote marijuana, no IVDU.
Family History:
Mom survived MI age 35, Father died age 59 of alcoholic
cirrhosis. One brother died age 50 of ?mesothelioma. Sister had
[**Location (un) 38204**] 12 yrs ago. Other four sibs are alive and well.
One niece survived ruptured brain aneurism in her 30s. No other
family h/o liver disease, heart disease, or cancer.
Physical Exam:
PE on admission:
Vitals: T 99.5, HR 128, BP 89/46, RR 16, O2 100%
Gen: sleepy but arousable, oriented x3; sclerae anicteric
CV: tachycardic, no appreciable murmur
Resp: right-sided crackles and decreased breath sounds at base,
dullness to percussion right base; left lung cta
Abd: soft, non-tender, moderately distended, +fluid wave;
incisions well-healed; - [**Doctor Last Name **] sign
Extr: warm, 1+ pulses
DRE: no gross blood, guaiac negative
PE on discharge:
- no vital signs, no resppirtaion, no pulse, no heart sounds, no
pupillary reflexes
Pertinent Results:
imaging:
[**2105-7-3**] Dupplex abdomen
1. Patent portal and hepatic veins and hepatic arteries with
normal systolic upstroke.
2. Coarsened liver with echogenic area in the left lobe
compatible with a
resolving hematoma or complex fluid collection. Simple hepatic
cyst also
seen.
3. Moderate-to-large amount of ascites.
[**2105-7-4**] CT abdomen/pelvis
1. Bilateral pleural effusions with compressive atelectasis.
2. Dobbhoff tube curled twice, once in the stomach, once in the
esophagus.
3. Moderate to extensive ascites.
4. Diffuse colitis, nonspecific in appearance but certainly
could be related to patient's known C. diff infection.
[**2105-7-10**] CXR
Large bilateral pleural effusions and right basal atelectasis
unchanged
acutely. No pneumothorax. A feeding tube and a nasogastric tube
ends in the upper stomach. Right jugular line tip projects over
the low SVC. Heart is not enlarged. No pneumothorax.
laboratory:
[**2105-7-3**] 07:30PM BLOOD WBC-17.0*# RBC-2.70* Hgb-9.1* Hct-30.8*
MCV-114*# MCH-33.8* MCHC-29.6* RDW-18.3* Plt Ct-80*
[**2105-7-4**] 06:36PM BLOOD WBC-34.6* RBC-2.53* Hgb-8.7* Hct-26.7*
MCV-105* MCH-34.5* MCHC-32.8 RDW-19.2* Plt Ct-88*
[**2105-7-6**] 01:52AM BLOOD WBC-13.5*# RBC-2.90* Hgb-9.6* Hct-28.2*
MCV-97 MCH-33.2* MCHC-34.2 RDW-19.3* Plt Ct-68*
[**2105-7-7**] 01:42AM BLOOD WBC-9.8 RBC-3.54* Hgb-11.4* Hct-33.0*
MCV-93 MCH-32.2* MCHC-34.6 RDW-19.4* Plt Ct-53*
[**2105-7-10**] 09:27AM BLOOD WBC-12.4* RBC-3.21* Hgb-10.5* Hct-31.7*
MCV-99* MCH-32.6* MCHC-33.0 RDW-19.8* Plt Ct-33*
[**2105-7-3**] 07:30PM BLOOD PT-22.9* PTT-48.2* INR(PT)-2.1*
[**2105-7-4**] 01:37PM BLOOD Plt Ct-92*
[**2105-7-6**] 01:52AM BLOOD PT-38.1* PTT->150* INR(PT)-3.9*
[**2105-7-10**] 09:27AM BLOOD PT-51.0* PTT-88.0* INR(PT)-5.4*
[**2105-7-10**] 09:27AM BLOOD Plt Smr-VERY LOW Plt Ct-33*
[**2105-7-3**] 07:30PM BLOOD Glucose-553* UreaN-18 Creat-2.5*# Na-123*
K-3.2* Cl-92* HCO3-18* AnGap-16
[**2105-7-4**] 02:16AM BLOOD Glucose-72 UreaN-22* Creat-2.9* Na-135
K-3.4 Cl-99 HCO3-15* AnGap-24*
[**2105-7-4**] 01:37PM BLOOD Glucose-43* UreaN-25* Creat-3.4* Na-133
K-4.0 Cl-97 HCO3-12* AnGap-28*
[**2105-7-7**] 01:42AM BLOOD Glucose-89 UreaN-42* Creat-4.7* Na-129*
K-3.1* Cl-99 HCO3-16* AnGap-17
[**2105-7-7**] 04:45PM BLOOD Glucose-93 UreaN-19 Creat-2.6*# Na-136
K-3.7 Cl-102 HCO3-26 AnGap-12
[**2105-7-10**] 01:33AM BLOOD Glucose-133* UreaN-23* Creat-2.4* Na-137
K-3.7 Cl-104 HCO3-25 AnGap-12
[**2105-7-10**] 09:27AM BLOOD Glucose-145* UreaN-25* Creat-2.7* Na-138
K-4.7 Cl-104 HCO3-27 AnGap-12
[**2105-7-3**] 07:30PM BLOOD ALT-79* AST-172* AlkPhos-214*
TotBili-5.4*
[**2105-7-4**] 02:16AM BLOOD ALT-104* AST-239* AlkPhos-188* Amylase-73
TotBili-5.5*
[**2105-7-7**] 01:42AM BLOOD ALT-134* AST-197* AlkPhos-162*
TotBili-13.0*
[**2105-7-10**] 01:33AM BLOOD ALT-63* AST-83* AlkPhos-181*
TotBili-21.3*
[**2105-7-10**] 09:27AM BLOOD ALT-60* AST-76* AlkPhos-181*
TotBili-22.0*
[**2105-7-3**] 07:30PM BLOOD Albumin-1.8* Calcium-6.3* Phos-1.3*
Mg-1.6
[**2105-7-8**] 03:03AM BLOOD Albumin-2.4* Calcium-8.1* Phos-2.8 Mg-1.9
[**2105-7-10**] 09:27AM BLOOD Albumin-2.5* Calcium-8.3* Phos-3.9#
Mg-2.3
[**2105-7-3**] 07:41PM BLOOD pH-7.31*
[**2105-7-4**] 02:41AM BLOOD Type-ART pO2-118* pCO2-29* pH-7.35
calTCO2-17* Base XS--7
[**2105-7-10**] 08:58AM BLOOD Type-ART Temp-36.4 pO2-50* pCO2-47*
pH-7.35 calTCO2-27 Base XS-0 Intubat-NOT INTUBA
[**2105-7-10**] 12:50PM BLOOD Type-ART pO2-160* pCO2-38 pH-7.39
calTCO2-24 Base XS--1
microbiology:
[**2105-7-3**] blood culture
KLEBSIELLA PNEUMONIAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
326-4714B
[**2105-7-3**].
[**2105-7-5**] blood culture
LACTOBACILLUS SPECIES.
Isolated from only one set in the previous five days.
Anaerobic Bottle Gram Stain (Final [**2105-7-7**]):
Reported to and read back by [**First Name9 (NamePattern2) 85588**] [**Last Name (un) 6977**] @ 1810 ON
[**7-7**] - CC6C.
GRAM POSITIVE ROD(S).
IN CHAINS.
[**2105-7-8**] Bclx - pend
[**2105-7-9**] Bclx - pend
[**2105-7-10**] Bclx - pend
Brief Hospital Course:
Patient was admitted to the [**Year (4 digits) **] surgery service with the
bacteremia and sepsis. He was admitted to the ICU.
Neuro: Since the time of admission patient was arousable and
responded to commands. He remained at his baseline until the day
he decompensated when his metal status has worsened and upon
intubation, required no sedation. He received minimal pain
medications for abdominal pain/discomfort.
CV: The patient was initially stable from a cardiovascular
standpoint. He required vasopressors upon admission, in the next
48 hours he was weaned of the pressors. He developed vasopressor
requirement and became hemodynamically unstable approximately 48
hour prior to his demise. Following the aspiration event on the
floor level of care on [**7-10**], patient was transferred to ICU,
where he drooped his systolic blood pressure shortly after. He
was on one vasopressor for the 24 hours, later on 2 pressors,
yet his sbp was in 70s. The family made a decision to withdraw
life support including vasopressors on [**7-12**] in the early
mid-afternoon. Patient expired several hours after.
Pulmonary: The patient remained stable from a pulmonary
standpoint initially. On [**7-10**] he vomited and aspirated. His
oxygen saturation dropped and he was transferred to the ICU. His
oxygen saturation was low, his mental status worsened, thus he
was intubated. He remained intubated until he expired.
GI/GU/FEN: Patient was found to have C. difficile colitis. He
was fed via TPN. The electrolytes was initially repleated. The
hyperkalemia was treated with kayaxylate. Patient also [**Month/Year (2) 1834**]
CVVH. The CVVH no longer continued after [**7-10**], when patient was
intubated, due to family wishes. Patient had diagnostis
paracenthesis, which did not show SBP.
ID: He was treated for C. difficile colitis initially with PO
vancomycin and IV flagyl as well as tigacycine. The Klebsiella
bacteremia was treated with meropenem. Prior to the cultures
becoming available, patient also recieved amikacin and cefepime.
He was afebrile for most of the hospital stay.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay.
As patient status declined rapidly on [**7-10**] following the
aspiration event, family made a well thought out decision to
minimize the patient's suffering as his prognosis was not
favorable. Patient was initially made DNR status for about 24
hours. Next, the family made the patient CMO with continued
ventilation on [**7-12**]. Patient expired one to hours after all the
vasopressors were stopped. He was started on morphine gtt. He
expired comfortable, with no agonal breaths observed. The
medical examiner as well as the family refused an autopsy.
Medications on Admission:
tylenol 500'''' prn fever, darbepoetin alpha 40 qweek, folic
acid, HSQ, lispro sliding scale, reglan 5 iv q8, mycophenolate
180", nepro TF 45/hr, nystatin swish/swallow"", zofran prn,
promod syrup 10ml q8, protonix 40", bactrim', tacrolimus
0.5/0.5,
ursodiol 300", renal vitamin
Discharge Medications:
patient was CMO:
- morphine gtt
Discharge Disposition:
Expired
Discharge Diagnosis:
multiorgan system failure
cardiac arrest
Discharge Condition:
death
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
Completed by:[**2105-7-13**]
ICD9 Codes: 5856, 5845, 5070, 2762, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2981
} | Medical Text: Admission Date: [**2123-3-15**] Discharge Date: [**2123-4-8**]
Date of Birth: [**2068-9-7**] Sex: M
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Small bowel obstruction.
Major Surgical or Invasive Procedure:
Partial vertebrectomy of L3 and L4.
2. Fusion L3-L5.
3. Anterior interbody spacers x2.
4. Autograft, allograft and bone morphogenic protein.
1. Reopening of recent laparotomy wound and exploratory
laparotomy.
2. Small-bowel resection with primary anastomosis.
3. Closure of ventral abdominal wall hernia defect with Vicryl
mesh .
Past Medical History:
s/p lumbar laminectomy 18 years ago.
right rotator cuff tear and tendinosis.
bilateral R> L CTS.
Social History:
schooled to 11th grade. was a gas station manager but has been
on disability due to LBP. lives in the basement of his step-
parents' house. smoked 3 ppd tobacco x 30 years but recently
quit 98 days ago, denies EtOH use, no illicits or IVDA
Family History:
His mother died of CAD and stroke at 76.
Physical Exam:
NAD
RRR
CTA
incision clean dry intact
Pertinent Results:
[**2123-3-15**] 08:01PM HCT-35.3*
[**2123-3-15**] 06:45PM TYPE-[**Last Name (un) **] RATES-/12 TIDAL VOL-700 PO2-69*
PCO2-40 PH-7.27* TOTAL CO2-19* BASE XS--7 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2123-3-15**] 06:45PM GLUCOSE-179* LACTATE-1.8 NA+-139 K+-4.5
CL--108
[**2123-3-15**] 06:45PM HGB-12.6* calcHCT-38
[**2123-3-15**] 06:45PM freeCa-1.23
Brief Hospital Course:
54-year-old gentleman was initially on the orthopedic service
for the last few days
recovering from a spinal fusion operation performed by
Dr.[**Last Name (STitle) 363**]. This required an anterior abdominal approach through
a lower midline incision in this extremely portly gentleman. He
is now in postoperative day 3 and has evidence of bowel
obstruction clinically. A CT scan confirmed this and on this
scan, there was a clear-cut transition point in the middle of
this lower abdominal incision with what looks to be a piece of
bowel extruding out to the skin level. There was dilated
proximal bowel with decompressed distal bowel. The patient
refused an NG tube on multiple occasions proir to OR. Patient
was brought to the OR [**2123-3-20**] for small bowel obstruction and
fascial dehiscence. The patient tolerated the procedure well,
but remained intubated and was transferred to the PACU in
guarded condition. He was transferred to ICU after it ws access
that he aspirated during induction and developed ARDS & ARF.
Patient had an extensive ICU course that included management of
ARDs and ATN. Patient was transfered to the floor POD 21/16
instable condition. He receieved a bedside and video swallow
study that deemed him capable of having a regular ground solids
and thin liquids. On POD 25/20 patient was cleared for discharge
for furhter rehabilatation at a extended care facility.
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol [**Year (4 digits) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Year (4 digits) **]: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
3. Chlorhexidine Gluconate 0.12 % Mouthwash [**Year (4 digits) **]: One (1) ML
Mucous membrane QID (4 times a day) as needed.
4. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Year (4 digits) **]: One (1)
Appl Ophthalmic PRN (as needed) as needed for dry eyes .
5. Bisacodyl 10 mg Suppository [**Year (4 digits) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1)
Injection TID (3 times a day).
7. Acetaminophen 325 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
8. Metoprolol Tartrate 25 mg Tablet [**Year (4 digits) **]: 1.5 Tablets PO TID (3
times a day).
9. Ferrous Sulfate 300 mg/5 mL Liquid [**Year (4 digits) **]: One (1) PO DAILY
(Daily).
10. Haloperidol 2 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times
a day) as needed for agitation.
11. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Year (4 digits) **]: One (1)
Subcutaneous sliding scale.
12. Methadone 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO TID (3 times a
day).
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
15. Epoetin Alfa 3,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
16. Fentanyl 25 mcg/hr Patch 72HR [**Last Name (STitle) **]: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Lumbar spondylosis, disk degeneration and kyphosis of the lumbar
spine,Small bowel obstruction, Fascial dehiscence.
Discharge Condition:
stable
Discharge Instructions:
Resume your regular medications. Take all new medications as
directed. Do not drive while taking narcotics.
You may shower. Allow water to run over the wound, and do not
scrub. Pat the wound dry. Do not take a bath or swim until
after follow-up appointment. No heavy lifting (> 10 lbs) for 6
weeks.
Please call your doctor or return to the ER if you experience:
-Fever (> 101.4)
-Inability to eat/drink or persistant vomiting
-Increased pain
-Redness or discharge from your wound
-Other symptoms concerning to you
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] call to scheduele
appointment.
Please followup with Dr. [**Last Name (STitle) 363**] call to schedule an appointment.
Completed by:[**2123-4-8**]
ICD9 Codes: 5185, 5845, 5070, 0389, 4019, 3051, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2982
} | Medical Text: Admission Date: [**2174-2-21**] Discharge Date: [**2174-3-8**]
Date of Birth: [**2095-6-18**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal Distention
Nausea and vomiting for 5 days
Anorexia
Major Surgical or Invasive Procedure:
Repair Incarcerated Right Femoral Hernia with Mesh
History of Present Illness:
78F with Crohn's disease recently started on 6-MP with 5-day
history of nausea, anorexia, fatigue, and abdominal distention
Past Medical History:
Crohn's colitis (last colonoscopy 5 yrs ago)
s/p Nephrectomy
?hx of hemmoroids, anal stricture
s/p Mastectomy
HTN
Osteoporosis
Hyperlipidemia
Social History:
Lives with daughter and son; denies tobacco/alcohol/IVDA
Family History:
Family History: Non-contributory
Physical Exam:
Admission Physical Exam - [**2174-2-21**]
98.0 115 113/65 16 96%
AOx3, nontoxic. MM dry.
Tachy
CTAB
Soft, (+)distention, nontender, no peritoneal signs, guaiac (-),
right groin lump nonreduceable, mild tenderness, no erythema
No CCE
Pertinent Results:
Admission Labs
-------------------
[**2174-2-21**] 11:45AM BLOOD WBC-6.2# RBC-2.94* Hgb-11.0* Hct-30.6*
MCV-104* MCH-37.5* MCHC-36.0* RDW-22.6* Plt Ct-478*#
[**2174-2-21**] 11:45AM BLOOD Neuts-71* Bands-16* Lymphs-4* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2174-2-21**] 11:45AM BLOOD Hypochr-NORMAL Anisocy-2+
Poiklo-OCCASIONAL Macrocy-2+ Microcy-OCCASIONAL Polychr-1+ Tear
Dr[**Last Name (STitle) 833**]
[**2174-2-21**] 11:45AM BLOOD Plt Ct-478*#
[**2174-2-21**] 11:45AM BLOOD Glucose-116* UreaN-37* Creat-1.2* Na-131*
K-4.8 Cl-87* HCO3-25 AnGap-24*
[**2174-2-21**] 11:45AM BLOOD ALT-12 AST-29 CK(CPK)-67 AlkPhos-53
Amylase-95 TotBili-0.8
[**2174-2-22**] 06:25AM BLOOD Albumin-3.1* Calcium-9.8 Phos-3.8#
Mg-2.9*
[**2174-2-22**] 06:25AM BLOOD Triglyc-78
[**2174-3-1**] 05:45AM BLOOD TSH-2.7
[**2174-2-21**] 03:13PM BLOOD Lactate-1.1
Discharge Labs
-------------------
[**3-8**]: Hct 25.4
[**3-7**]: BUN 29; Creat 0.6
OPERATIVE REPORT
Name: [**Known lastname **], [**Known firstname **] C Unit No: [**Numeric Identifier 33862**]
Service: [**Last Name (un) **] Date: [**2174-2-21**]
Date of Birth: [**2095-6-18**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD 2915
ASSISTANTS: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3446**], MD
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
PREOPERATIVE DIAGNOSIS: Incarcerated right femoral hernia.
with small bowel obstruction
POSTOPERATIVE DIAGNOSIS: Incarcerated right femoral hernia
with bowel obstruction.
ANESTHESIA: General endotracheal anesthesia with 20 cc of
0.5% Marcaine.
IV FLUIDS: 400 cc.
ESTIMATED BLOOD LOSS: Minimal.
URINE OUTPUT: 600 cc.
INDICATIONS: [**Known firstname **] is a 78-year-old female, with a history of
Crohn's disease and multiple surgeries, who presented with
nausea
and vomiting for 5 days. She was evaluated by the emergency
medical staff, a CT scan was performed that showed a small bowel
obstruction. A general surgery consult was obtained. On exam,
she
had a lump in her right groin consistent with an incarcerated
hernia, and the CT scan was reviewed and this was clearly the
transition point of the bowel obstruction.
She was diagnosed with incarcerated, possibly strangulated right
femoral hernia. Risks and benefits of the procedure were
discussed with her, and she signed a surgical consent to
proceed with repair and possible bowel resection if necessary.
PREPARATION: The patient was given intravenous antibiotics,
subcutaneous heparin, and taken to the operating room and
placed in a supine position. Venodyne boots were placed and
activated. The patient was then endotracheally intubated in
normal fashion. A nasogastric tube and Foley catheter had
previously been placed.
PROCEDURE IN DETAIL: A transverse incision was made
overlying the palpable lump with a #10 blade scalpel.
Dissection through the subcutaneous tissue performed with
electrocautery. The Scarpa's layer was divided. The lump was
circumscribed with right angle dissection and electrocautery.
The
peritoneal cavity was opened at the hernia sac with
electrocautery dissection. Serous fluid came out the opening..
There was dusky bowel within the hernia sac. The
femoral hernia defect was widened with blunt dissection and then
the bowel was delivered further through the defect and it pinked
up and was clearly viable. The bowel was reduced back in the
abdominal cavity. The hernia sac was then closed with a running
2-0 Vicryl suture. The sac was reduced, and preperitoneal space
was developed with gentle blunt dissection. A preformed mesh
was
then placed into the defect and sutured in all quadrants with
2-0
Prolene sutures. The wound was irrigated with sterile saline
and small bleeders were controled with electrocautery.
The subcutaneous tissues were reapproximated with 2-0 Vicryl
suture. The skin was reapproximated with a running 4-0
Monocryl subcuticular suture. Steri-Strips and a sterile
occlusive dressing were placed over the wound. The patient
was then extubated in the operating room and transferred to
the post anesthesia care unit in stable condition.
SPECIMEN TO PATHOLOGY: None.
FINDINGS: Incarcerated right femoral hernia with small bowel
without strangulation.
COUNTS: Correct x2 prior to closure.
I, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**], was present for the entire procedure
per
HCFA regulations.
PORTABLE DUPLEX DOPPLER ULTRASOUND OF THE RIGHT GROIN AND RIGHT
DEEP HEMIPELVIS
CLINICAL INDICATION: 78-year-old woman with retroperitoneal
bleed and question of pseudoaneurysm on recent CT scan.
Color flow and pulse Doppler imaging of the common femoral
artery and distally show normal wall-to-wall flow and normal
pulse Doppler waveforms. No hematoma or extravasation was seen
in the thigh. Calcification was noted in the wall of the common
femoral artery. Imaging was then carried higher up to the
external iliac artery into the floor of the pelvis. Several
small tortuous branches were seen extending from the iliac
artery into the pelvic floor, but all of these appear to show
normal albeit tortuous branching patterns. There was no
definable pseudoaneurysm identified. The imaging was performed
extensively through the region of the pelvic wall hematoma.
CONCLUSION: Patent vasculature from the external iliac through
common femoral artery and branches. No pseudoaneurysm identified
around the large pelvic wall hematoma.
CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST
There are small bilateral low-density pleural effusions,
slightly larger than before, with associated bibasilar
atelectasis. Otherwise, the visualized lung bases are clear. No
focal hepatic lesions are identified. Small calcified dependent
gallstones are noted within the gallbladder.
There is a small cystic lesion within or along the neck of the
pancreas, which measures 12 x 11 mm in axial dimensions, and is
unchanged since the earliest study available, which is a CT of
the lumbar spine from [**2173-7-22**]. On more recent scans, it is
difficult to visualize because of the presence of adjacent
ascites and edema. There is no biliary or pancreatic ductal
dilatation. Otherwise, the pancreas is unremarkable. There are
diffuse splenic arterial calcifications, as well as
calcifications in the aorta and common iliac arteries and their
major branches.
The adrenal glands and spleen are unremarkable. The patient is
status post left nephrectomy. There is new mild-to-moderate
hydronephrosis of the right kidney. Of note, small-bowel
obstruction has resolved.
The post-operative appearance of the stomach, small and large
bowel is unremarkable. There is persistent slight herniation of
non-obstructed bowel into the upper portion of the right femoral
tunnel. Residual contrast is present within the colon from a
prior recent CT.
There is no free air or lymphadenopathy. There is, however, mild
ascites and edematous change throughout the mesenteric fat, with
edema also demonstrated diffusely within the subcutaneous soft
tissues. This appearance suggests volume overload or an
edematous state.
CT OF THE PELVIS WITH IV CONTRAST: There is a new large acute
hematoma in the right lower pelvis, which measures 8.9 x 5.2 cm
in maximum axial dimensions, and extends superiorly along the
right pelvic side wall.
Extending from the posteromedial aspect of the right common
femoral artery, and coursing medially anterior to the
acetabulum, is a small arterial branch, which may represent the
right epigastric artery or another small arterial branch.
Along the anteromedial edge of the acetabulum and adjacent to
the large hematoma, there is an 8-mm diameter focus of nodular
arterial contrast, which collects and exhibits a round
configuration of 13 mm in diameter on delayed- phase imaging at
three minutes. This appearance is most consistent with a
pseudoaneurysm with associated large recent hemorrhage into the
pelvis. There is also a separate hematoma in the subcutaneous
tissues overlying the right lower anterior pelvis, measuring 5.1
x 2.3 cm in axial dimensions.
There is distal right hydroureter up to 13 mm with apparent
ureteral obstruction by the large pelvic hematoma, which also
displaces the bladder and rectum toward the left.
There are uterine calcifications, probably related fibroids.
There is also unchanged symmetric rectal thickening with a
metallic device in the pelvis that may represent a pessary. A
Foley catheter is present within the bladder.
There is atherosclerotic change but no abdominal aortic
aneurysm. The right common iliac is ectatic and measures up to
19 mm in diameter. The left common iliac shows a maximum
diameter of 17 mm immediately prior to the left iliac
bifurcation.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. Hematoma in the right pelvis associated with nodular contrast
collection most consistent with a pseudoaneurysm. This is
situated immediately anteromedial to the right acetabulum. A
supplying artery to the pseudoaneurysm is noted, which emanates
from the medial right common femoral artery and courses along
anterior to the acetabulum to the pseudoaneurysm possibly
representing the inferior epigastric artery.
2. New right-sided hydronephrosis associated with obstruction by
the pelvic hematoma.
3. Unchanged cystic lesion in the neck of the pancreas, with
stability demonstrated retrospectively since 6-[**2173**]. The
differential diagnosis includes a pseudocyst or low-grade
neoplasm such as an intraductal papillary mucinous neoplasm
(IPMN). Although stable over six months, continued CT followup
could be helpful to ensure stability within one year.
4. Bilateral pleural effusions, mild ascites, and diffuse edema,
which likely relates to volume overload or an edematous state.
5. Resolution of small-bowel obstruction.
6. Similar rectal wall thickening.
The presence of acute hematoma and a pseudoaneurysm were
discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33863**] from Surgery shortly after the
study.
RENAL ULTRASOUND
------------------
The left kidney is surgically absent and bowel loops fill the
left renal fossa. The right kidney measures 12.5 cm and
demonstrates moderate hydronephrosis and distention of its
extrarenal pelvis. The proximal right ureter is dilated to 11
mm. The mid and distal ureter cannot be visualized. There is no
evidence of stones or solid mass. The cortex is preserved. A
small amount of ascites is noted around the liver and in
Morison's pouch. The urinary bladder contains a Foley catheter
and is empty.
IMPRESSION: Moderate right hydronephrosis.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 7931**] was evaluated in the emergency department at [**Hospital1 18**] on
[**2174-2-21**]. An abdominal CT scan showed small bowel obstruction
and rectal thickening. Urine was positive for infection. She was
made NPO and IV fluids were started. She was evaluated and
admitted to the surgery service under the care of Dr. [**First Name (STitle) 2819**]. An
ECHO was performed which showed normal LVEF and mild TR/AI.
Cipro was started for UTI. A nasogastric tube was placed for
bowel decompression, with a one liter return of feculent
material. The CT scan was reread and showed a right femoral
hernia with right groin bulge on exam. She was taken to the
operating room where she underwent a right femoral hernia repair
with mesh. She tolerated the procedure well and was returned to
the floor after recovery in the PACU.
At POD 1 a PICC line was placed and TPN was started.
At POD 2 she remained NPO and with NGT. There was some bloody
drainage from the NGT for which was attributed to mucosal
irritation and Protonix was started with improvement. She
exhibited signs of postoperative delirium. Haldol and a sitter
were provided. No neurological deficits were noted. The urinary
catheter was discontinued in the evening.
At POD 3 she remained with confusion. Geriatrics was consulted
for recommendations. Her abdomen was distended and tender. A
catheter was inserted for 800mls of urine. She was transfused
one unit PRBCs for a Hct of 23 to prevent end organ ischemia.
Narcotics were minimized and low-dose Haldol was continued. She
continued on TPN for nutritional support.
At POD 6 she was afebrile and doing well. Her delirium/confusion
had resolved. She was (+) flatus. The NGT was removed and the
diet was advanced to sips.
At POD 7 she had a short run of asymptomatic vtach.
Electrolytes were stable and cardiac enzymes were negative x 3.
Urine was negative for infection. The foley was discontinued.
She had difficulty voiding later in the day and was I/O
catheterized for 500ml. A urine culture was sent and was
negative. A KUB was performed which showed no evidence of
obstruction. There was a lot of stool in the colon. Cathartics
were given with response.
At POD 8 Her diet was advanced and medications were
transitioned to PO. Crohn's medications were restarted. She was
afebrile and her pain was controlled. She voided spontaneously.
She was given 1 unit PRBCs for a Hct of 24.3
At POD 9 a recheck of her Hct after transfusion showed 18.8.
She was transferred to the ICU. Urinary catheter was replaced
and she was transfused with good response. There was a large
area of ecchymosis at the right flank and abdomen. CT was
completed which showed a hematoma in the right pelvis with right
hydronephrosis. There was suspect for pseudoaneurysm at the
right femoral artery. Vascular surgery was consulted. Vascular
ultrasound showed no aneurysm.
At POD 11 she was doing well. The bleeding had stopped and
serial Hcts were stable. She was tolerating a regular diet.
She was transferred back to the floor. Urology was consulted
regarding urinary retention and hydronephrosis.
At POD 15 she was discharged to rehab in good condition. She
was afebrile, tolerating a regular diet, and had full return of
bowel function. Her wound was healing nicely and without signs
of infection. She was to continue with the urinary catheter x 2
weeks. The VNA could then attempt to remove the catheter if
voiding trials are passed. She is to have weekly Hct and
Creatinine drawn. She is to have a CT scan completed to
evaluate the hydronephrosis in ~4 weeks and then follow up with
Dr. [**First Name (STitle) **]. She is to follow up with Dr. [**First Name (STitle) 2819**] in [**2-1**] weeks.
Medications on Admission:
Prednisone 15'
Sulfasalazine
6-MP 50'
Boniva
Vit C
Calcium
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 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:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for gastritis.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. PredniSONE 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily)
as needed for crohn's.
Disp:*90 Tablet(s)* Refills:*0*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
Disp:*20 Suppository(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Annmark Nursing
Discharge Diagnosis:
Reduction of a strangulated right femoral hernia
Post-op delerium
Post-op urinary retention
Post-op retroperitoneal bleeding
Acute on chronic blood loss anemia requiring transfusion
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain or persistent pain that is not relieved by
pain medications
*Inability to urinate
* Fever (>101.5 F)
*Nausea or Vomiting that last longer than 24 hours
* Inability to pass gas or stool
* Other symptoms concerning to you
Please take all your medications as ordered
No immersion for 2 weeks
No lifting more than 25 lbs or abdominal stretching exercises
for 4 weeks.
Follow up in one week with Dr [**First Name (STitle) 2819**]. The urinary catheter will
stay in place for ~2 weeks. At this time the home nurses may
begin voiding trials and discontinue the catheter if tolerated.
At ~4 weeks you will need a CT scan to be reviewed by Dr. [**First Name (STitle) **].
You will also have weekly blood tests to check your kidney
function.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in [**2-1**] weeks. Call ([**Telephone/Fax (1) 6347**]
to make an appointment.
Please follow up with Dr. [**First Name (STitle) **]. You will need a CT scan prior
to your appointment with Dr. [**First Name (STitle) **]. Call ([**Telephone/Fax (1) 7287**] to make
an appointment with Dr. [**First Name (STitle) **]. Call ([**Telephone/Fax (1) 6713**] to schedule
your CT scan.
Your blood glucose was elevated while in the hospital. Please
follow up with Dr. [**Last Name (STitle) 2696**] in [**2-1**] weeks to make sure this does
not persist past hospitalization.
Completed by:[**2174-3-10**]
ICD9 Codes: 5990, 4271, 2851, 4019, 2720, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2983
} | Medical Text: Admission Date: [**2193-8-27**] Discharge Date: [**2193-9-2**]
Date of Birth: [**2114-9-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Worsening fatigue
Major Surgical or Invasive Procedure:
[**2193-8-27**] Cardiac Catheterization
[**2193-8-28**] Aortic Valve Replacement utilizing a 19mm St. [**Male First Name (un) 923**]
Tissue Valve
History of Present Illness:
This is a 78 year old female with known aortic stenosis who has
been followed closely with serial echocardiograms by
Dr.[**Last Name (STitle) 30538**]. Her most recent echocardiogram showed [**First Name8 (NamePattern2) **] [**Location (un) 109**]
0.6cm2 and a mean gradient of 61 mmHg/peak gradient of 109 mmHg.
The patient now presents for aortic valve replacement.
Past Medical History:
Aortic Stenosis
Hypertension
Hyperlipidemia
Osteoporosis
Macular Degeneration - receive's injections in right eye
H/o Basal cell CA (shoulder and back)
? Old myocardial infarction and RBBB (Patient denies)
s/p Tonsillectomy
s/p Cataracts
s/p D&C's
Social History:
Occupation: Retired sales clerk
Last Dental Exam: [**2193-2-27**], Upper dentures
Lives with: husband
[**Name (NI) **]: Caucasian
Tobacco: Quit 25 yrs ago
ETOH: Approx. 4 glasses wine/wk
Family History:
No premature coronary artery disease
Physical Exam:
Pulse: 66 Resp: 18 BP Left: 159/74
Height: 5'3" Weight: 135lbs
General: WD/WN female 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 [X] Irregular [] Murmur [X]- 3/6 SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None [] bilateral superficial varicosities
Neuro: Grossly intact [X]
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: Transmitted murmur
Pertinent Results:
[**2193-8-27**] WBC-6.0 RBC-3.43* Hgb-10.5* Hct-29.9* MCV-87 MCH-30.5
MCHC-35.0 RDW-13.7 Plt Ct-215
[**2193-8-27**] PT-12.6 PTT-36.4* INR(PT)-1.1
[**2193-8-27**] Glucose-118* UreaN-17 Creat-0.8 Na-138 K-3.1* Cl-103
HCO3-21* AnGap-17
[**2193-8-27**] ALT-11 AST-18 CK(CPK)-56 AlkPhos-40 Amylase-50
TotBili-0.3
[**2193-8-27**] %HbA1c-5.8
[**2193-8-27**] Cardiac Cath:
1. Selective coronary angiograhpy in this right dominant system
demonstrated no flow limiting lesions. The LMCA, LAD, Cx and RCA
had no
angiographically apparent disease. 2. Limited resting
hemodynamics revealed slightly elevated right and left sided
filling pressures with a RVEDP of 10 mmHg and a mean PCWP of 14
mmHg. There was mild pulmonary artery hypertension with a PASP
of 24 mmHg. The central aortic pressure was 143/56 mmHg.
[**2193-8-27**] Echocardiogram:
The left atrium is elongated. 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 aorta is mildly dilated. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Mild to
moderate ([**11-30**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
[**2193-8-27**] Carotid Ultrasound:
There is antegrade right vertebral artery flow. There is
antegrade left vertebral artery flow. Right ICA stenosis <40%.
Left ICA stenosis <40%.
[**2193-9-2**] 05:40AM BLOOD WBC-10.0 RBC-3.41* Hgb-10.4* Hct-30.9*
MCV-91 MCH-30.6 MCHC-33.7 RDW-13.5 Plt Ct-257#
[**2193-8-28**] 03:25PM BLOOD PT-14.6* PTT-64.7* INR(PT)-1.3*
[**2193-9-2**] 05:40AM BLOOD Glucose-96 UreaN-16 Creat-0.8 Na-130*
K-3.9 Cl-93* HCO3-31 AnGap-10
Brief Hospital Course:
Mrs. [**Known lastname 4318**] was admitted and underwent cardiac catheterization
which confirmed severe aortic stenosis and showed normal
coronary arteries. Preoperative evaluation was otherwise
uneventful and she was cleared for surgery. On [**8-28**],
Dr. [**Last Name (STitle) **] performed an aortic valve replacement (#19mm St.[**Male First Name (un) 923**]
tissue valve). For further surgical details, please refer to
Dr[**Last Name (STitle) **] operative note. She was intubated, sedated, and
required pressor support, in critical but stable condition when
transferred to the CVICU for invasive monitoring. Within 24
hours, she awoke neurologically intact and was extubated without
incident. Pressors were weaned off. All lines and drains were
discontinued in a timely fashion.
Beta-blocker/aspirin/statin/diuresis was initiated. She
continued to progress and POD#2 was transferred to the step down
floor for further monitoring. Physical therapy evaluated and
consulted. POD#4 her rhythm went into rapid atrial fibrillation.
She was treated with Amiodarone and beta-blocker and
subsequently converted to normal sinus rhythm. The remainder of
her postoperative course was essentially uneventful. She
continued to do well and was cleared by Dr.[**Last Name (STitle) **] for discharge
to home with VNA on POD#5. All follow up appointments were
advised.
Medications on Admission:
Metoprolol 50mg [**Hospital1 **]
Lipitor 10mg daily
Fosamax 70mg once a week
ASA 81 mg daily
MVI 1 tb daily
Lisinopril/hydrochlorothiazide 20mg/12.5 mg daily
Flaxseed oil 2000mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic Stenosis, s/p AVR
Hypertension
Dyslipidemia
Discharge Condition:
Stable
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-3**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 39360**] in [**1-1**] weeks, call for appt
Dr. [**Last Name (STitle) 171**] or [**Last Name (STitle) 30538**] in [**1-1**] weeks, call for appt
Completed by:[**2193-9-2**]
ICD9 Codes: 4241, 2761, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2984
} | Medical Text: Admission Date: [**2179-10-15**] Discharge Date: [**2179-10-21**]
Date of Birth: [**2098-8-18**] Sex: M
Service: NEUROLOGY
Allergies:
Ativan
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
Possible Seizure
Major Surgical or Invasive Procedure:
Lumbar Puncture - [**2179-10-15**]
History of Present Illness:
HPI: 81 yo male transferred from [**Hospital3 3583**] after he was
intubated for a seizure. Some time this morning, his [**Last Name (un) 8317**]
found him seizing, it is unclear, whether he had fallen, but the
suggestion was that the patient had a GTC. He was taken to
[**Hospital3 6265**] given 5 mg Diazepam, and the OSH was concerned about
airway compromise hence they intubated him with a rapid
induction
protocol (etomidate/succ/lidocaine). He was given 1 mg Ativan,
and then placed on Propofol. When he arrived at the [**Hospital1 18**] ER, he
was given 1 g Dilantin, and had an LP as he was febrile up to
101.4, and had apparently had his first seizure.
His ROS was unavailable. His HCP and caretaker reported finding
him on the floor with jerking of his upper body, however she
didn't have a good time course for this event.
Past Medical History:
HTN
Social History:
The patient lives at a guest home for disabled veterans. There
is no known family for the patient. He came to the group home
with an initial diagnosis of malnutrition and was living with a
friend of a friend, and was initially found to be 90 pounds. He
has been doing well at the home and often goes to the local VFW
and plays cards with his pals. He has no known smoking history
, occ etoh, no known drug use. His HCP is the caretaker of the
guest home -> [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 84498**] [**Telephone/Fax (3) 84499**]
Family History:
Unknown
Physical Exam:
T-101.4 BP-148/76 HR-77 RR-16 O2Sat-98%
Gen: Intubated and on propofol
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Decreased breath sounds on the right
aBd: +BS soft, nontender
ext: minimal pedal edema
Neurologic examination:
Mental status: Intubated and sedated.
Cranial Nerves:
Pupils are 2 mm bilaterally and sluggishly reactive to light.
Corneals are in tact. Normal dolls head. Normal gag.
Motor:
Normal bulk bilaterally. Tone normal. Moves all 4 limbs away
symmetrically from noxious stimuli
Reflexes:
+2 and symmetric throughout.
Toes upgoing bilaterally
f/u exam on [**10-18**]:
He has remained afebrile
throughout without any other forms of tachycardia or other VS
abnormalities. His exam however has remained encephalopathic. He
is only oriented to person and unable to provide any details of
his PMH. He is unable to follow 2 step commands and is
inattentive with [**Doctor Last Name 1841**] and DOW testing. His CN do not show any
nystagmus, his pupils are [**2-14**] briskly reactive. He blinks to
threat bilaterally. His face appears sunken bilaterally due to
lack of dentition but his facial movements are symmetric. He is
antigravity in all extremities and does not have a clear drift
but does not cooperate with formal strength testing. There is
slightly increased tone in the LE bilaterally but no clonus and
only slightly brisk reflexes.
exam on discharge:
Mental Status: On day of discharge he was oriented to person,
place and date, was able to follow one and two step commands,
appeared to have good recall of distant events but still seemed
confused about recent events. CN: Intact Motor: muscle bulk
decreased throughout, strength full and symmetric in UE/LE
Sensation: intact, Gait: narrow based and steady, able to walk
with walker, small steps
Pertinent Results:
Admission Labs:
[**2179-10-15**] 04:25PM BLOOD WBC-6.2 RBC-3.84* Hgb-11.5* Hct-34.5*
MCV-90 MCH-29.9 MCHC-33.4 RDW-14.2 Plt Ct-194
[**2179-10-15**] 04:25PM BLOOD Neuts-72.6* Lymphs-16.6* Monos-8.5
Eos-1.7 Baso-0.7
[**2179-10-15**] 04:25PM BLOOD PT-12.6 PTT-24.1 INR(PT)-1.1
[**2179-10-15**] 04:25PM BLOOD Glucose-135* UreaN-6 Creat-0.7 Na-129*
K-3.8 Cl-92* HCO3-25 AnGap-16
[**2179-10-15**] 04:25PM BLOOD CK(CPK)-68
[**2179-10-15**] 04:25PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2179-10-15**] 04:25PM BLOOD Calcium-8.3* Phos-2.3* Mg-1.7
[**2179-10-15**] 04:50PM BLOOD Type-ART Rates-16/ pO2-517* pCO2-27*
pH-7.55* calTCO2-24 Base XS-3 Intubat-INTUBATED Vent-CONTROLLED
[**2179-10-15**] 04:43PM BLOOD Lactate-2.8* K-3.7
[**2179-10-15**] 10:15PM BLOOD Hgb-12.7* calcHCT-38
LP:
[**2179-10-15**] 06:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-43
GLUCOSE-96
[**2179-10-15**] 06:00PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-20
LYMPHS-70 MONOS-10
Imaging:
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2179-10-15**]
4:06 PM
FINDINGS: There is no intracranial hemorrhage, mass effect or
edema.
Periventricular regions of hypoattenuation are consistent with
chronic small vessel ischemic change. Prominence of the cerebral
sulci and ventricles are consistent with age-related
involutional change. There is diffuse atrophy ofthe cerebellum.
Ethmoid air cells are partially opacified. The paranasal sinuses
and mastoid air cells are otherwise well aerated. The cavernous
internal carotid arteries are densely calcified.
IMPRESSION: No intracranial hemorrhage or edema.
MR ([**2179-10-17**]):
Limited study due to motion. No mass or midline shift. Apparent
slow flow in the left distal transverse and sigmoid sinus, but
recommend correlation with MRV to exclude venous sinus
thrombosis.
Sinus disease.
EEG ([**2179-10-20**]):
This telemetry captured no pushbutton activations. Routine
sampling and automated detection showed plentiful movement
artifact but
no electrographic seizures. The background appeared mildly slow,
suggesting some encephalopathy. There were no prominent focal
features.
Brief Hospital Course:
Mr. [**Known lastname 35694**] is an 81 yo man transferred from [**Hospital3 **]
after being found unresponsive, reported to have a convulsions
and possibly a generalized tonic clonic seizure, then intubated
for airway protection. He was admitted on [**10-15**]. There
is only limited information know about this patient as he is new
to our system and is unable to provide details regarding his
PMH. After talking with his HCP [**Name (NI) **] [**Name (NI) 84498**], the caretaker of
his guest home, she stated that he only had some HTN, but
otherwise was healthy. He had a question of a TIA four months
ago but otherwise his PMH was unknown. He was then transferred
to an OSH and intubated for "airway protection" and then
transferred to [**Hospital1 18**] for further care. Here he underwent an LP
which was unremarkable (O WBC and 0 RBC). His screening labs
were only significant for a sodium of 129. He also underwent an
MRI brain which showed mild atrophy but no focal or acute
lesions. He was empirically treated with Keppra
for seizure prophylaxis as well as thiamine, folate and a MVI.
Per report he only takes Vasotec. He also does not have a
substance abuse/EtOH history.
He was then extubated and transferred to the floor. He has not
had further seizures clinically. He has remained afebrile
throughout without any other forms of tachycardia or other VS
abnormalities. His exam however has remained encephalopathic. He
initially was only oriented to person and unable to provide any
details of his PMH. He was unable to follow 2 step commands and
was inattentive with [**Doctor Last Name 1841**] and DOW testing. His CN do not show any
nystagmus, his pupils are [**2-14**] briskly reactive. He blinks to
threat bilaterally. His face appears sunken bilaterally due to
lack of dentition but his facial movements are symmetric. He is
antigravity in all extremities and does not have a clear drift
but does not cooperate with formal strength testing. There is
slightly increased tone in the LE bilaterally but no clonus and
only slightly brisk reflexes.
Over the course of the hospital stay he had an EEG which showed
only generalized slowing, with no focal epileptiform activity.
His mental status slowly improved to where he was oriented x 3.
He is able to follow one and two step commands.
Given the lack of history, it is difficult to say exactly what
occurred on the day of admission. It appears most likely seizure
as there have been no cardiac abnormalities. It is also unclear
why he remains significantly encephalopathic. We have spoken to
his primary care doctor and he will follow his mental status and
he can be referred to our cognitive neurology unit if his mental
status does not improve, and a diagnosis of dementia would be
considered
Seizures
- we recommend that the patient stay on this current dose of
Keppra. He can be followed by his PMD, and this has been
discussed with Dr. [**Last Name (STitle) 41415**], his primary doctor.
Confusion
- the patient appears to be improving, however he still exhibits
some signs of confusion. Spoke with his PMD about this and he
will be evaluated in the future to determine if the patient is
suffering from a possible dementia. He can be referred to our
cognitive unit in the future for further testing if needed.
Medications on Admission:
Vasotec 10mg qd
Discharge Medications:
1. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO QAM (once a
day (in the morning)).
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**] Nursing Home
Discharge Diagnosis:
possible seziure, mild and resolving encephalopathy
Discharge Condition:
Mental Status: On day of discharge he was oriented to person,
place and date, was able to follow one and two step commands,
appeared to have good recall of distant events but still seemed
confused about recent events. CN: Intact Motor: muscle bulk
decreased throughout, strength full and symmetric in UE/LE
Sensation: intact, Gait: narrow based and steady, able to walk
with walker, small steps
Discharge Instructions:
You were brought to the hospital because of a possible seizure.
While in the hospital you had a stay in the ICU and intubated
and were started on an anti-epileptic medicine Keppra. You were
extubated the next day and were confused for a couple of days.
You mental status slowly improved over the next couple of days
and will now be discharged to a rehab facility to continue your
care. You had a workup for causes of seizure including MRI,
Lumbar puncture and toxic metabolic workup which did not show
any abnormalities. Your EEG test only showed generalized
slowing, but no focal abnormalities.
Please take all medicines as prescribed. Please keep all follow
up appointments. If you have a worsening of your symptoms,
please call your doctor or go to the nearest ER.
Followup Instructions:
Please follow up with your primary care doctor Dr. [**Last Name (STitle) 41415**]
[**Telephone/Fax (1) 61767**], he was contact[**Name (NI) **] and will contact you with an
appointment when you are discharged from your rehab facility.
We spoke to him about your new seizure medication and about your
cognitive status.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2985
} | Medical Text: Admission Date: [**2163-9-1**] Discharge Date: [**2163-9-8**]
Date of Birth: [**2134-10-31**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Motorcycle crash
Major Surgical or Invasive Procedure:
[**2163-9-1**] I& D open tibia and femur fractures. IM RIGHT FEMUR
[**Month/Day/Year **], and RIGHT TIBIA [**Month/Day/Year **]
[**2163-9-5**] INCISION AND DRAINAGE RIGHT LEG, wound closure and
placement of surface vacc sponge
History of Present Illness:
28 helmeted MCC vs truck, initially pinned beneath vehicle with
multiple LE fractures, small SAH, facial lacs, tx from [**Hospital3 12748**] s/p intubation for agitation. Transferred to
TSICU post-op s/p IM nail of femur & tibia, I& D, and vac
placement.
Past Medical History:
anxiety
PSH:none
Family History:
Noncontrtibutory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
O(2)Sat: 100 Normal
Constitutional: intubated
HEENT: chin laceration, abrasions to face
c collar intact
Chest: Clear to auscultation
Cardiovascular: tachycardic, regular
Abdominal: Soft, Nondistended, FAST negative for free fluid
Extr/Back: RLE: gross thigh deformity with large with
ecchymosis , externally rotated and shortened, large
lacerations present with tibial deformity
Pertinent Results:
[**2163-9-1**] 10:35PM WBC-15.0* RBC-3.39* HGB-11.0* HCT-32.4*
MCV-95 MCH-32.5* MCHC-34.1 RDW-12.9
[**2163-9-1**] 10:35PM PLT COUNT-289
[**2163-9-1**] 06:32PM PO2-132* PCO2-45 PH-7.31* TOTAL CO2-24 BASE
XS--3 COMMENTS-GREEN TOP
[**2163-9-1**] 06:32PM GLUCOSE-202* LACTATE-2.8* NA+-139 K+-3.1*
CL--103
[**2163-9-1**] 06:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CT head:
IMPRESSION:
1. Right inferior frontal small subarachnoid hemorrhage. Left
parietal lobe parenchymal contusions, small extra-axial hematoma
cannot be excluded.
2. Longitudinal right temporal bone [**Month/Day/Year **]. Possible mild
widening of the incudomalleolar articulation. If clinically
indicated a dedicated temporal bone CT can be obtained. Left
parietal scalp hematoma.
Ct cervical spine:
IMPRESSION:
No acute cervical spine [**Month/Day/Year **] or malalignment.
CT chest/abd/pelvis:
IMPRESSION:
1. Multifocal scattered lung contusions.
2. No acute traumatic injury identified in the abdomen, and
pelvis.
3. NG tube tip in the upper cervical esophagus. ETT tip 6 cm
above carina, needs to be advanced.
TIB/FIB XRAYS:
IMPRESSION:
Comminuted fractures through the proximal right tibia and
fibula.
cT ORBITS:
IMPRESSION: Longitudinal right temporal bone [**Month/Day/Year **] extending
into the external auditory canal with partial opacification of
the right mastoid air cells and with mild widening of the
incudomalleolar articulation. Few air locules adjacent to the
site of [**Month/Day/Year **].
Brief Hospital Course:
28 helmeted MCC vs truck, initially pinned beneath vehicle with
multiple lower extremity fractures, subarachnoid hemorrhage,
facial lacerations admitted to the Acute Care Surgery Service
for management of his injuries. He was transferred to the
Trauma SICU for close monitoring.
Neuro: Mr. [**Known lastname 7518**] was transferred intubated and sedated from
the OSH and was taken directly from the trauma bay to the OR
with the ortho trauma team. His pain was controlled with
intermittent Dilaudid after extubation, and he was transitioned
to oral pain medication. Seizure prophylaxis with dilantin was
given with initial loading dose and subsequent TID dosing x7
days. A repeat CT head was obtained on HD2, which did not show
any evidence of progression of intracranial bleeding. When it
also revealed displacement of two teeth, OMFS was consulted and
these were repaired at the bedside on [**9-4**]. Outpatient follow up
in [**Hospital 40530**] clinic has been scheduled. ENT consultation was obtained
for a temporal bone [**Hospital **] and Cipro-dex drops were given per
ENT recommendations. He will follow up as an outpatient with an
audiogram. At time of discharge he is awake, alert -
intermittently confused but very cooperative with care. he was
ordered for Trazodone prn at hs to help regulate his sleep-wake
cycle.
Cardiovascular: Initial sinus tachycardia resolved with pain
control and fluid resuscitation. Continuous ICU cardiac
monitoring was performed and was stable during his ICU stay. For
the remainder of his course his heart rate remained stable
ranging in the 80's-90's range. There were no other cardiac
issues.
Respiratory: He was successfully extubated on [**9-2**] and weaned to
room air without difficulty. His saturations have ranged in the
98-100% range and there have been no further issues from a
respiratory standpoint.
GI: Because of the injuries sustained to his teeth he has been
recommended for a soft diet for which he tolerated without
difficulty.
GU: A Foley catheter was placed initially for urine output
monitoring and eventually this was removed. He is voiding on his
own without any difficulties.
Heme: Initial post-operative HCT was 30, and trended down
slowly to 18 on HD2. He was transfused 2u pRBC on [**9-2**] and an
additional 1u on [**9-3**], attributed to a moderate right thigh
hematoma. This was monitored, and did not develop signs of
compartment syndrome. Serial HCTS were monitored, and remained
stable thereafter. His HCT on [**9-6**] was 23.7 which is up from 21
on [**9-5**].
MSK: Touchdown weightbearing of the RLE, full weightbearing of
LLE was maintained s/p ORIF and VAC placement, per Ortho
recommendations. The incisional VAC was removed on day of
discharge. he will require follow up in [**Hospital 5498**] clinic in
about 2 weeks time. He was evaluated by Physical and
Occupational therapy and is being recommended for rehab after
his acute hospital stay.
Medications on Admission:
Denies
Discharge Medications:
1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
Swish and spit
2. Ciprofloxacin 0.3% Ophth Soln 4 DROP RIGHT EAR TID Duration:
5 Days
3. Dexamethasone Ophthalmic Soln 0.1% 2 DROP RIGHT EAR TID
Duration: 5 Days
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC TID
6. Nicotine Patch 14 mg TD DAILY
7. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
8. Phenytoin Infatab 100 mg PO TID Duration: 1 Days
9. Sarna Lotion 1 Appl TP [**Hospital1 **]:PRN itching
10. Senna 1 TAB PO BID
11. Multivitamins 1 TAB PO DAILY
12. TraMADOL (Ultram) 50 mg PO QID
13. traZODONE 50 mg PO HS:PRN insomnia
14. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
15. Acetaminophen 1000 mg PO Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Motorcycle crash
Injuries:
Left frontal subarachnoid hemorrhage
Lip laceration
Right temporal bone [**Location (un) **]
Pulmonary contusions
Right comminuted femur [**Location (un) **]
Right comminuted tibial [**Location (un) **]
Displaced teeth 8 & 25
Maxillary [**Location (un) **] at tooth 8 site
Acute blood loss hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hopsital after a motorcycle crash where
you susatined multiple injuries including a small bleeding brain
injury; lip laceration, fractures of the bone near your inner
ear, femur(thigh bone) and the bones in your lower right leg.
You underwent an operation to fix the broken bones in your leg.
You were also seen by the oral surgeons for broken teeth;
Plastic surgeons for surturing your lip laceration and the ear,
nose and throat doctors for the [**Name5 (PTitle) **] of the bone near your
inner ear. You will require multiple clinic followup with the
various specialists who helped to take care of you while you
were in the hospital.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] at [**Hospital6 **], [**Location (un) 112330**], [**Location (un) 86**], MA [**Location (un) 442**]. Yawkey Bldg., Oral Surgery Clinic
on [**2163-9-16**] at 10:30am.
*
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 112331**],MD
Specialty: Primary Care
Location: FAMILY MEDICINE ASSOCIATES
Address: [**Location (un) 29112**], [**Location (un) 29113**],[**Numeric Identifier 29114**]
Phone: [**Telephone/Fax (1) 29115**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: ORTHOPEDICS
When: TUESDAY [**2163-9-27**] at 8:55 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2163-9-27**] at 9:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: MONDAY [**2163-10-10**] at 2:00 PM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: MONDAY [**2163-10-10**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 43708**], MD [**Telephone/Fax (1) 2731**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: OTOLARYNGOLOGY (ENT)
When: THURSDAY [**2163-10-13**] at 2:00 PM
With: [**Last Name (un) 6410**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], AU.D. [**Telephone/Fax (1) 6411**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: OTOLARYNGOLOGY-AUDIOLOGY
When: THURSDAY [**2163-10-13**] at 3:00 PM
With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2986
} | Medical Text: Admission Date: [**2123-3-22**] Discharge Date: [**2123-3-26**]
Date of Birth: [**2044-11-16**] Sex: M
Service: CCU
CHIEF COMPLAINT: Biventricular implantable
cardioverter-defibrillator/pacemaker placement.
HISTORY OF PRESENT ILLNESS: This is a 78-year-old male with
multiple medical problems including recurrent arrhythmia,
coronary artery disease, and congestive heart failure with
ejection fraction of 30% who was referred by Dr. [**Last Name (STitle) **]
for APF/LV mapping/biventricular ICD. He was scheduled for
the pacemaker ICD placement in effort to enhance synchrony of
his cardiac function and to capture an element of atrial
kick, as well.
He had the procedure done on [**2123-3-23**] which was complicated
by approximately 400 cc blood loss and hypotension which
ultimately responded to fluid boluses and Dopamine drip. He
was noted to have a drop in hematocrit and, in light of
hypotension, he was monitored in the CCU after his procedure.
In the holding area a quick TTE was done showing no effusion.
Initially he had been monitored on the floor, but blood
pressures were 60s/30s despite Dopamine. His hematocrit
trended from mid 30s to 27.4, and he was started on one unit
packed red cells and admitted to the CCU. He denied back
pain, groin pain, chest pain, shortness of breath.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial
infarction.
2. Congestive heart failure with ejection fraction of 30%.
3. Cardiotoxicity and cardiomyopathy status post Adriamycin.
4. Non-Hodgkin's lymphoma of retroperitoneal space status
post chemo complicated by cardiotoxicity.
5. Hypercholesterolemia/hypertension.
6. Antithrombin 3 deficiency complicated by deep venous
thrombosis.
7. Abdominal aortic aneurysm repair 10/[**2119**].
8. Alternating right bundle branch block/left anterior
fascicular block with left bundle branch block and long PR.
9. Cellulitis complicated by group A Streptococcal
bacteremia [**11/2122**] status post Vancomycin times one month.
10. Hypothyroidism.
11. Clostridium difficile complicated by toxic megacolon
status post hemicolectomy.
12. Right groin pseudo aneurysm.
13. Status post transient ischemic attack.
MEDICATIONS ON TRANSFER TO CCU:
1. Lipitor 10 mg a day.
2. Lasix 80 mg a day.
3. Plavix 75 mg a day.
4. Synthroid 25 mcg a day.
5. Diovan 40 mg a day.
6. Aldactone 25 mg a day.
7. Digoxin 0.125 mg a day.
ALLERGIES:
1. Penicillin.
2. Keflex.
3. Clindamycin.
PHYSICAL EXAMINATION ON ADMISSION: In general, somnolent but
arousable. Vitals: Temperature 97.7, blood pressure 114/80
on 5 mcg of Dopamine, pulse 92, 98% on 4 liters nasal
cannula. HEENT: Pupils equally round, reactive to light
bilaterally; oropharynx clear. Heart: Regular rate, tachy,
II/VI systolic murmur at the left sternal border. Pulmonary:
Bibasilar rales up to halfway up. Abdomen: Normoactive
bowel sounds; soft, nontender, nondistended; guaiac negative.
Extremities: Trace bilateral pitting edema.
LABORATORY DATA: Significant for hematocrit 34 dropping to
30 dropping to 27.4 on admission. Creatinine of 1.4, INR of
1.4.
HOSPITAL COURSE:
1. Cardiovascular rhythm: Patient was ventricular paced
with ICD which was interrogated the day after placement and
working well. Electrophysiology adjusted parameters and
turned down single output as was pacing diaphragm. He
completed a five-dose course of Vancomycin as well as a day
of Levofloxacin per Electrophysiology given the extent of the
procedure for prophylaxis.
2. Ischemia: Patient had no signs or symptoms of active
ischemia. He was continued on his home regimen of statin,
Plavix, and Valsartan.
3. Blood pressure: Patient had hypovolemia likely secondary
to blood/volume loss and was transfused two units packed red
cells initially. He was gradually weaned off Dopamine after
a day and his blood pressure stabilized. He had the rest of
his home cardiac meds added, including Lasix for diuresis.
4. Congestive heart failure: Patient was aggressively
diuresed with intravenous Lasix after his blood pressure
normalized given his chest x-ray is concerning for congestive
heart failure. He diuresed well and weaned off oxygen.
Chest x-ray repeated after diuresis showed improvement with
decrease in infiltrates bilaterally.
Patient will continue on Digoxin, Lasix, and Spironolactone
per home meds. These were started also during admission.
5. Left lower extremity deep venous
thrombosis/hypercoagulability: He will be started on Lovenox
and Coumadin to be followed by primary care physician.
6. Hypothyroidism: Continued on Synthroid.
7. Prophylaxis: INR still subtherapeutic but on Lovenox.
8. Rash/pruritus: Patient complained of generalized
pruritus. Nurse noticed raised area of erythema diffusely
across back which decreased with hydrocortisone cream. A
Dermatology consult was called which recommended topical
treatments including Sarna lotion and Lac-Hydrin. He should
also use Spectazole to feet twice daily for tinea pedis. At
home he will continue on Atarax p.r.n.
DISCHARGE CONDITION: Stable.
DISPOSITION: To home.
DISCHARGE DIAGNOSES:
1. Arrhythmias status post pacemaker and implantable
cardioverter-defibrillator placement.
2. Congestive heart failure.
3. Coronary artery disease.
4. Cardiotoxicities from Adriamycin.
5. Abdominal aortic aneurysm.
6. Non-Hodgkin's lymphoma status post chemotherapy with
CHOP.
7. History of hemicolectomy after Clostridium
difficile-induced toxic megacolon.
8. History of transient ischemic attack.
9. History of atrial flutter status post cardioversion [**2119**].
10. Antithrombin 3 deficiency.
11. Left lower extremity deep venous thrombosis.
12. Recurrent thrombophlebitis.
13. Hypothyroidism.
DISCHARGE MEDICATIONS:
1. Atorvastatin 10 mg p.o. q.d.
2. Levothyroxine 25 mcg p.o. q.d.
3. Hydrocortisone 0.5% ointment.
4. Clopidogrel 75 mg p.o. q.d.
5. Enoxaparin 80 mg subcutaneously q. 12 hours.
6. Digoxin 0.125 mg p.o. q.d.
7. Warfarin 7.5 mg p.o. q.d.
8. Valsartan 40 mg p.o. q.d.
9. Spironolactone 25 mg p.o. q.d.
10. Furosemide 40 mg p.o. b.i.d.
11. Sarna lotion p.r.n.
12. Lac-Hydrin lotion b.i.d. p.r.n.
13. Clotrimazole cream b.i.d.
14. Spectazole to feet b.i.d.
15. Acetaminophen 325 to 650 mg p.o. q. 4 to 6 hours p.r.n.
DISCHARGE INSTRUCTIONS:
1. Patient has appointment for Electrophysiology Clinic
follow up to check pacer and INR on [**2123-3-30**] at 10 a.m.
2. He will also follow up with Dr. [**Last Name (STitle) **] on [**2123-4-27**]
at 11:40 a.m.
3. Follow up with Dr. [**Last Name (STitle) 410**] on [**2123-5-6**] at 9:30 a.m.
4. Patient was informed to follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in the next one to two weeks, as
well.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19954**]
Dictated By:[**Last Name (NamePattern1) 1606**]
MEDQUIST36
D: [**2123-3-26**] 13:47
T: [**2123-3-30**] 12:52
JOB#: [**Job Number 19955**]
ICD9 Codes: 4280, 4271, 4240, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2987
} | Medical Text: Admission Date: [**2139-11-5**] Discharge Date: [**2139-11-9**]
Date of Birth: [**2063-8-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
1. Cardiac Catheterization
2. Emergent vascular surgery with ligation of inferior
epigastric artery and evacuation of right groin/pelvic hematoma
History of Present Illness:
The patient is a 76-year-old female transferred from the [**First Name4 (NamePattern1) 3075**]
[**Last Name (NamePattern1) 3549**] Hospital ER on the evening of [**2139-11-4**] with chest pain
radiating to her right posterior shoulder area. Initial EKG had
some non-specific ST changes concerning for NSTEMI and EF per
ECHO (TTE) done at OSH noted to be 15%. Per outside hospital
records the patient had reported that her pain was relieved
after SL nitroglycerin tablets x 3 and Lopressor 5mg IV x 3. She
was also given a loading dose of Plavix 600mg in the ER and 75mg
the following morning and she was started on both Integrillin
and Heparin and was transferred directly to the cardiac
catheterization lab at [**Hospital1 18**] and found to not have any
obstructive coronary disease, LV-gram showing EF closer to 30%
but prominent apical ballooning consistent with Takotsubo's
Cardiomyopathy presentation. She began to have severe
hypotension during her cardiac catheterization and was started
on Dopamine then switched to Neosynephrine. She was noted to
have an expanding right groin. Of note, given reported
difficulty obtaining access initially thought was that she was
having a iatrogenic bleed.
.
In the operating room the patient was continued on
Neosynephrine, and had a right internal jugular central venous
line placed and failed attempt at a radial arterial line.
Intubation was uncomplicated. The patient was also given a total
of 3.5L of NS and 2 Units blood were given. Just prior to going
to the operating room with the vascular surgery team the patient
was also given IVFs and 2 Units of blood in cardiac
catheterization lab. Thus, she received in total, 4 Units of
blood before transfer up to CCU post-operatively. She was able
to be slowly weaned off of Neosynephrine and BP was 115/70 upon
presentation to the CCU. Per vascular team, the inferior
epigastric artery on the right was ligated and a hematoma was
evacuated, removing roughly 500cc of blood. Pressure dressing
was applied. Patient arrived to the CCU intubated and sedated
and a few continued bouts of intermittent low blood pressures.
Past Medical History:
1. CARDIAC RISK FACTORS: negative for Diabetes, no significant
dyslipidemia, but positive for age, hypertension, sedentary
lifestyle
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None / No priors
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Glaucoma
Osteoporosis
Cataracts
Social History:
The patient is married and lives in [**Location 1110**] with her husband. She
has one daughter who lives locally. In terms of recent stressors
the patient reports some anxiety regarding an upcoming Glaucoma
surgery and some additional stress and residual grief as she
learned that her brother died several months ago.
She denies any smoking history /tobacco use. She drinks
approximately 5 glasses of wine per week and denies any other
illicit drug use.
Family History:
No known family history of significant CAD, premature coronary
artery disease or sudden death.
Physical Exam:
On admission:
Vital Signs: 98.2F, BP 115/70 HR 70s, O2 100% on AC ventilation
550x14, PEEP of 5 and FiO2 of 100%. CVP 11
GENERAL: Intubated and sedated. responds to painful stimuli and
moving all 4 extremities.
HEENT: PERRLA bilaterally, sclera anicteric and EOMI, moist
mucosal membranes
CARDIAC: S1/S2 regular, no murmurs, rubs or gallops appreciated,
soft heart sounds noted, 2+ carotid upstrokes
LUNGS: No tracheal deviation, CTA bilaterally anteriorly and
laterally
ABDOMEN: Soft, nontender and nondistended. No HSM. Abdomnal
aorta not enlarged by palpation. No abdominal bruits.
EXTREMITIES: Right groin with thick pressure dressing, no
ecchymoses or tense areas noted
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: diminished 1+ radial pulses bilaterally, DP and PT
pulses are measured by doppler, PT pulses 1+ and palpable but
DPs difficult to palpate
Pertinent Results:
[**2139-11-5**] 07:24PM TYPE-MIX PO2-29* PCO2-40 PH-7.24* TOTAL
CO2-18* BASE XS--10
[**2139-11-5**] 07:24PM LACTATE-1.5
[**2139-11-5**] 07:24PM O2 SAT-52
[**2139-11-5**] 06:35PM GLUCOSE-178* UREA N-27* CREAT-0.7 SODIUM-139
POTASSIUM-4.4 CHLORIDE-118* TOTAL CO2-18* ANION GAP-7*
[**2139-11-5**] 06:35PM estGFR-Using this
[**2139-11-5**] 06:35PM CK(CPK)-189*
[**2139-11-5**] 06:35PM CK-MB-27* MB INDX-14.3* cTropnT-0.60*
[**2139-11-5**] 06:35PM CALCIUM-6.8* PHOSPHATE-3.1 MAGNESIUM-1.2*
[**2139-11-5**] 06:35PM WBC-15.1*# RBC-3.79*# HGB-11.2*# HCT-32.5*#
MCV-86# MCH-29.6 MCHC-34.5 RDW-14.9
[**2139-11-5**] 06:35PM NEUTS-90.7* LYMPHS-5.5* MONOS-3.6 EOS-0.1
BASOS-0.1
[**2139-11-5**] 06:35PM I-HOS-D
[**2139-11-5**] 06:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2139-11-5**] 06:35PM PLT SMR-LOW PLT COUNT-87*#
[**2139-11-5**] 06:35PM PT-15.7* PTT-47.5* INR(PT)-1.4*
[**2139-11-5**] 06:35PM FIBRINOGE-111*
[**2139-11-5**] 05:54PM TYPE-CENTRAL VE PO2-66* PCO2-48* PH-7.14*
TOTAL CO2-17* BASE XS--12
[**2139-11-5**] 05:20PM TYPE-ART PO2-341* PCO2-43 PH-7.14* TOTAL
CO2-15* BASE XS--14
[**2139-11-5**] 05:20PM HGB-11.2* calcHCT-34
[**2139-11-5**] 05:20PM GLUCOSE-309* LACTATE-4.0* NA+-133* K+-5.7*
CL--113*
[**2139-11-5**] 03:28PM TYPE-ART O2-100 PO2-434* PCO2-30* PH-7.38
TOTAL CO2-18* BASE XS--5 AADO2-267 REQ O2-50 INTUBATED-NOT
INTUBA
[**2139-11-5**] 03:28PM GLUCOSE-205* LACTATE-1.5 K+-4.4
[**2139-11-5**] 03:00PM WBC-7.2 RBC-2.17*# HGB-6.9*# HCT-20.3*#
MCV-94 MCH-32.1* MCHC-34.3 RDW-14.3
[**2139-11-5**] 02:49PM TYPE-ART O2 FLOW-2 PO2-94 PCO2-37 PH-7.32*
TOTAL CO2-20* BASE XS--6 COMMENTS-NASAL [**Last Name (un) 154**]
[**2139-11-5**] CARDIAC CATHETERIZATION RESULTS:
LMCA mild plaquing, LAD 20% origin, LCX patent, mid-RCA with
mild 25% diffuse plaquing. LV gram showing some MR, EF 30%,
bases intact, severe hypokinesis of anterolateral, apical and
inferior walls, bedside echo without pericardial effusion, no
LVOT gradient, depressed EF.
.
HEMODYNAMICS:
RA 4, RV 23/0
PCW mean 4
PA 15/4
Aorta 95/75, MAP 80
post angio:
PCW mean 7, PA 28/9
LV 134
Aorta 134/86
Cardiac index 1.32 pre angio, 1.30 post angio
Art sat 98%, SVC saturation 49%, PA sat 40%
.
[**2139-11-5**] ECHO: Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. The overall LV ejection
fraction appears moderately-to-severely depressed secondary to
extensive apical akinesis , and severe hypokinesis of the
anterior septum. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no pericardial effusion.
Overall impression is severe anteroseptal hypokinesis/akinesis,
LVEF = 30%.
.
[**2139-11-7**] REPEAT ECHO: The left atrium is normal in size. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. LV systolic function appears
moderately-to-severely depressed (ejection fraction 30 percent)
secondary to akinesis of the anterior septum and anterior free
wall; there is extensive apical akinesis with focal dyskinesi..
Right ventricular chamber size and free wall motion are normal.
The aortic arch is moderately dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
There is an anterior space which most likely represents a fat
pad. Compared with the findings of the prior study (images
reviewed) of [**2139-11-5**], the findings are similar.
.
[**2139-11-5**] EKG: NSR, rate 60, normal axis and intervals, poor R
wave progression, no acute ST elevations or prominent
depressions.
.
[**2139-11-6**] EKG : Rate 80s, normal sinus rhythm, delayed R wave
transition. Q-T interval prolongation with QT/QTc = 430/472.
Significant resolution of the T wave abnormalities since
admission.
.
[**2139-11-6**] CXR: Right internal jugular catheter ends in the mid
SVC, mild bibasilar atelectasis, volume overload decreased, no
consolidations or effusions
.
[**2139-11-7**] EKG: Rate 90, Normal sinus rhythm, some
intraventricular conduction delay, poor R wave progression,
nonspecific inferolateral T wave flattening and low limb lead
voltages, Q-T interval appears shorter
.
[**2139-11-7**] LIPID PROFILE: Total Chol 83, Triglyc-147, HDL-26
CHOL/HD-3.2 LDLcalc-28
ADDITIONAL POST-ADMISSION LABS:
[**2139-11-6**] 05:22AM BLOOD CK-MB-28* MB Indx-14.4* cTropnT-0.41*
[**2139-11-5**] 06:35PM BLOOD CK-MB-27* MB Indx-14.3* cTropnT-0.60*
[**2139-11-5**] 06:35PM BLOOD CK(CPK)-189*
[**2139-11-6**] 05:22AM BLOOD CK(CPK)-194*
[**2139-11-7**] 03:49AM BLOOD ALT-9 AST-24 AlkPhos-29* TotBili-1.2
[**2139-11-8**] 01:19PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2139-11-9**] 06:25AM BLOOD WBC-8.0 RBC-3.44* Hgb-10.3* Hct-29.6*
MCV-86 MCH-30.0 MCHC-34.9 RDW-15.5 Plt Ct-133*, Glucose-98
UreaN-19 Creat-0.7 Na-143 K-4.1 Cl-114* HCO3-24 AnGap-9, Mg-2.0
Brief Hospital Course:
ASSESSMENT AND PLAN [**2139-11-6**] :
In summary, patient is a 76-year-old female with a past medical
history of hypertension and glaucoma who presented to her local
ED after several hours of chest "discomfort" and mid-sternal
chest pain with some radiation to her right shoulder which was
relieved after nitroglycerin and Lopressor at OSH. Initial EKG
had
some non-specific ST changes concerning for NSTEMI with possible
cardiogenic shock given EF per ECHO report at OSH noted to be
15%. Repeat ECHO and cardiac catheterization of [**Hospital1 18**] showed
findings consistent with Takotsubo's cardiomyopathy and very
scant evidence of coronary artery disease. Unfortunately the
patient's cardiac catheterization was complicated by a large
right groin hematoma and acute onset of hypotension. Inferior
epigastric artery required emergent ligation by the [**Hospital1 18**]
vascular surgery team and the patient also had about 500cc blood
evacuated from hematoma site.
.
CARDIAC PUMP FUNCTION /TAKOTSUBO CARDIOMYOPATHY: The patient's
heart had classic apical ballooning on ECHO and typical
presentation of Takotsubo's cardiomyopathy. Repeat ECHO [**2139-11-5**]
showing LVEF 30% (at OSH EF 15%). Per patient's spouse she had
been under stress lately regarding the death of a sibling and
her upcoming glaucoma surgery. Upon CCU arrival the patient's
blood pressure had been challenged in the setting of a recent
post-catheterization arterial bleed as noted below. However, she
had been resuscitated with over 5L IVFs and given 4 Units Blood
throughout the day leading up to CCU transfer and her BP had
stabilized to SBPs in the 90s range. An A-line was placed for
more accurate hemodynamic monitoring and the patient had been
weaned off of her pressors prior to CCU presentation. By
hospital day 2 the patient had SBPs in the low 100-110 range and
MAPs were consistently > 65 range. She had minimal crackles on
lung exam. She was given 10mg IV Lasix to optimize extubation on
CCU day 2 which she tolerated well. Fentanyl and Versed were
weaned down and RSBIs were in 50 range. She was successfully
extubated with no complications and by hospital day 3 she had
progressed to 95-99%on 2L NC and then she was weaned to room air
with no residual shortness of breath complaints. On [**2139-11-7**]
repeat ECHO was largely unchanged and EF still 30%. The team
ultimately decided not to maintain the patient on
anticoagulation for her apical enlargement/thrombus risk given
the recent setting of her acute hematoma and hemorrhage.
Moreover, the data on anticoagulation and thrombus/stroke
reduction rates in Takotsubo population is lacking and no clear
recommendations exist.
.
Additional cardiomyopathy etiologies were explored which
included a work-up sent off for TSH, lipid profile and iron
studies (hemochromatosis). Iron Saturation level was 63%,
however in setting of acute event iron studies were felt to be
unreliable. Given that Mrs. [**Known lastname 75808**] has no past medical history
of diabetes (HgAIC 5.5)and limited PMH in general
hemochromatosis is unlikely but she was encouraged to discuss
repeat iron studies at a later date with her PCP as an
outpatient. She was also found to have a borderline high TSH
which is also unreliable in acute setting and she will plan to
follow-up with her PCP on this issue.
.
Once the patient's blood pressure and hematocrits had stabilized
she was placed on additional 25mg daily Toprol XL and her home
dose of 5mg Lisinopril was restarted. She will plan for a repeat
ECHO in [**3-24**] weeks and a follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
.
CORONARIES: The patient had very minimal CAD on cardiac
catheterization with 20% LAD and mild 25% RCA plaques. ST
changes were very non-specific on EKGs and did not reveal
classic ACS presentation for STEMI or NSTEMI. The patient was
monitored telemetry in the CCU and she had no additional bout of
chest pain, shortness of breath, palpitations or lightheadedness
during her hospital stay. The patient's minimal bump in cardiac
enzymes (CK 180-190 range, Troponin peak of 0.60) was attributed
to mild ischemia/microvascular stress in setting oh her
Takotsubo cardiomyopathy. Aspirin therapy was initially held in
the setting of her recovery from an acute bleed but she was
advised to begin taking 81mg of Aspirin daily at time of
discharge. Lipid profile was likely inaccurate in acute illness
setting but showed no hyperlipidemia. She will plan to have a
repeat lipid panel as an outpatient.
.
RHYTHM: The patient was monitored on telemetry and daily EKGs
were performed during her CCU stay. She had slight QT
prolongation which resolved and her nonspecific ST changes also
improved during her hospital course. She was in normal sinus
rhythm at time of discharge.
.
RIGHT GROIN HEMATOMA /ARTERIAL BLEED: As a complication of her
cardiac catheterization the patient suffered a groin hematoma
after an accidental arterial bleed. The inferior epigastric
artery was emergently ligated and a hematoma (approximately
500cc)was evacuated by the vascular surgery team. She had an
initial Hct drop from 34 to 20 which stabilized after 4 Units of
blood and over 6 liters of IVF resuscitation. The patient's Hct
levels were checked q6hrs post-surgery and then twice daily as
her Hct stabilized. At time of discharge her Hct was 29.6 and
she had no residual right groin pain and minimal discomfort with
walking. PT cleared the patient to return home and she was
cautioned to avoid lifting heavy objects 9>10lbs) until her
incision site had healed completely in [**4-26**] weeks. She will plan
to follow up in 2 weeks at the vascular clinic to have her
staples removed.
.
THROMBOCYTOPENIA: Post-operatively the patient had some lasting
thombocytopenia with platelets in the 70-80s range at the nadir.
This was most likely consumption related given her large bleed
with abundant clotting. DIC workup was unrevealing and given the
timeline HIT was felt to be a less likely culprit. Mrs. [**Known lastname 75809**] platelets were trended and fortunately began to rise
into the 90s and she was at 133 platelets by time of discharge.
She had no additional bruising, petechiae, hypotension or
further complications.
.
LEUKOCYTOSIS: The patient had a spike to a white blood cell
count of 17.9 with neutrophilia but no left shift. on [**2139-11-6**]
which soon tapered down to within normal range over the next 48
hours. She had no febrile patterns, UA and urine cultures were
negative and her CXR had no consolidations. IV sites and
surgical staples were in tact,clean,non-erythematous and
without any signs of discharge. The brief leukocytosis was
likely related to stress response of bleeding.
.
HYPERTENSION: Initially, the patient's blood pressures were in
the hypotensive range and all blood pressure medications were
held. As she stabilized by hospital day [**3-24**] she was gradually
restarted on low dose Lisinopril and Toprol XL was added given
her low EF and cardiomyopathy.
.
GLAUCOMA : While an inpatient in the CCU the patient was
continued on her usual eye drops that she takes for her
Glaucoma. She will plan to follow-up as an outpatient with her
opthalmologist regarding the need to post-[**Last Name (un) 9495**] her scheduled
surgery a few weeks until she recovers from a recent acute bleed
and until she recuperates from her current cardiomyopathy.
.
PROPHYLAXIS / CODE STATUS : Anticoagulation was held in the
setting of a new acute bleed. Pneumoboots were used for DVT
prophylaxis and physical therapy was called by hospital day two
to help the patient ambulate better. She was given Protonix for
GI prophylaxis in the setting of her intubation and she was
given a bowel
regimen of Senna and Colace to maintain regularity. Mrs. [**Known lastname 75808**]
was maintained as a full code status for the entirety of her
hospital stay.
.
Upon discharge, she was set up for a repeat echo in a few weeks
and follow-up appointments with Dr. [**Last Name (STitle) **] and the vascular
surgery clinic. She was asked to please return to the emergency
room or call her new cardiologist or PCP as soon as possible if
she had any worsening shortness of breath, chest pain,
dizziness,lightheadedness or signs of bleeding, discharge or
erythema at her incision site in her right groin.
Medications on Admission:
Home Medications:
Dorzolamide-Timolol 2-0.5 % eye drops tid
Travatan 0.004 % eye drops qhs
Lisinopril 5mg daily
Occasional OTC Tylenol
.
Medications on Admission:
Heparin drip and Integrilin started [**11-4**] but discontinued in
setting of acute bleed on [**11-5**] (off both at CCU transfer time)
-plavix 600mg [**11-4**], 75mg [**11-5**]
-lopressor 25mg po .
-lipitor 40mg
-nitro paste 1 inch q 4 hours
-cosopt eye gtts
.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day).
5. TRAVATAN Z 0.004 % Drops Sig: One (1) gtt both eyes
Ophthalmic HS (at bedtime).
6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Takotsubo Syndrome / Cardiomyopathy
Right groin bleed requiring surgical repair
Thrombocytopenia
Glaucoma
Discharge Condition:
Stable
Hct=29.6
Creat=0.7
K=4.1
BUN: 19
Discharge Instructions:
You had a cardiac catheterization and that showed a weakness in
your heart that is consistant with Takotsubo syndrome. This
syndrome is similar to a heart attack but your coronary arteries
do not show any major blockages. You have been continued on your
previous medicines except your Lisinopril was decreased to 5 mg
daily. Your new medicine is Toprol XL ( a beta blocker) that
helps your heart pump better. You will need to have an ECHO in 3
weeks that will evaluate the function of your heart. After your
catheterization, you had a large blood collection in your right
groin that required surgical repair. This is now stable but an
appt to take out the staples has been scheduled for you.
.
Your heart fucntion is somewhat weak, we expect this will
improve over the next few months. Please weigh yourself every
day and tell Dr. [**Last Name (STitle) **] if you develop a weight gain more than
3 pounds in 1 day or 6 pounds in 3 days. Please also call Dr.
[**Last Name (STitle) **] if you see that you have sweeling in your legs and feet
or if you have difficulty breathing.
Call Dr. [**Last Name (STitle) 172**] or Dr. [**Last Name (STitle) **] if you notice increased
swelling, pain or redness in your right groin. Also call for
chest pain, nausea, sweating or fevers.
Followup Instructions:
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 2037**] from Cardiology, [**12-2**]
at 1 p.m. in [**Hospital Ward Name 23**] 7th on the [**Hospital Ward Name 516**] at the [**Hospital3 **].
You have to come in on [**11-30**] at 3 p.m. for an
echocardiogram which is an ultrasound of your heart, this is
also on [**Hospital Ward Name 23**] [**Location (un) 436**].
.
Primary Care:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] Phone: [**Telephone/Fax (1) 133**] Date/time: Tuesday [**11-17**] at 3:00 pm.
.
[**Hospital **] Clinic: for staple removal Dr. [**Last Name (STitle) **] Phone: ([**Telephone/Fax (1) 1804**] Date/time: [**11-25**] at 12:00 pm. [**Hospital Unit Name **]
[**Hospital Unit Name **], [**Last Name (NamePattern1) 439**].
Completed by:[**2139-11-10**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2988
} | Medical Text: Admission Date: [**2124-1-6**] Discharge Date: [**2124-1-13**]
Date of Birth: [**2049-10-14**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
confusion and word-finding difficulties
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74-year-old M with hx HTN, papillary renal cell CA s/p
resection (partial nephrectomy and distal pancreatetomy with
splenectomy for removal of possible mass, later presumed to
represent chronic pancreatitis) [**2123-11-1**], extensive tobacco
history, and remote history of migraine, presenting with
headache
and unsteadiness. The patient's daughter states that since his
operation (and shortly after quitting smoking) he has had
persistent left frontal, throbbing headaches. He reports
symptoms have been rather persistent, possibly worse when lying
down and with valsalva, with transient improvement from
ibuprofen
and nasal decongestant (containing phenylephrine), and similar
to
headaches he had in his 20s. His daughter states over the past
month he has had somewhat "hesitant" speech with occasional
word-finding difficulties and has seemed slower with his speech.
He awoke this AM with a severe headache, but similar in quality
to his recent pain and did not want to get out of bed. He took
6
motrin tabs today due to his headache. At 2 PM while trying to
dress himself he kept falling backwards, but was able to brace
himself and did not hit his head or get injured. His wife
states
he was falling to the left while trying to ambulate, and he was
taken to [**Hospital1 18**] for further evaluation.
Upon arrival to the ED his headache persisted and he vomited x1
upon lying down in anticipation of CT head. He denied any
visual
changes, dizziness, dysarthria, dysphagia, focal weakness,
sensory changes, bowel or bladder changes.
No recent fevers, chills, cough, shortness of breath, chest
pain,
palpitations, or diarrhea.
Past Medical History:
stress [**2116**] neg, HTN, chronic LBP, atrophic left kidney, R renal
mass, h/o SCC, 120 pack yr h/o smoking
L TKR, b/l cataract, sternal fx repair, hemorrhoidectomy, VC bx
Social History:
Married with 5 children. Denies EtOH, history of cigarette
smoking for 60 years, quit one week prior the surgery.
Family History:
Brother and sister with brain tumors
Physical Exam:
ON ADMISSION
VS; BP 210/99 P 88 RR 20 99% on NRB
Gen; elderly male, sitting up in bed, NAD
HEENT; NC/AT, mucous membranes moist, oropharynx clear
CV; RRR, no murmurs
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; no edema
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name DOY backward
without
difficulty. 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.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone. Slight pronation of R hand.
Strength is [**6-16**] at R and L delt, biceps, triceps, WrE, FE, FF,
IP, ham, quad, TA, gastrocs.
-Sensory: No deficits to light touch, pinprick, and no
extinction
to DSS. Decreased vibratory sensation in feet b/l.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was extensor on R, mute on L.
-Coordination: No dysmetria b/l. Slow with RAMs b/l, slightly
worse on right.
-Gait: deferred
********************
ON DISCHARGE
T 97.3 BP 155/76 P 67 R 18 SpO2 96%
GEN: NAD, resting comfortably in bed
HEENT: non-icteric, atraumatic
CV: RRR, no murmurs
Pulm: CTABL
Abd: soft, NT, ND
Ext: no edema
NEURO
MS: asleep, but arousable to voice, oriented to [**Hospital1 **], date, and
name, language fluent, no dysarthria, no paraphasias, able to
follow 3 step commands
CN:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Motor:
slight pronation of R arm, full strength, normal tone
-Sensory: No deficits to light touch, pinprick, and no
extinction
to DSS. Decreased vibratory sensation in feet b/l.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was extensor on R, mute on L.
-Coordination: No dysmetria b/l. Slow with RAMs b/l, slightly
worse on right.
-Gait: deferred
Pertinent Results:
[**2124-1-6**] 10:25PM CK-MB-4 cTropnT-0.01
[**2124-1-6**] 03:20PM cTropnT-0.01
[**2124-1-6**] 03:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2124-1-6**] 03:20PM WBC-9.1 RBC-4.69 HGB-14.2 HCT-42.9 MCV-92
MCH-30.3 MCHC-33.1 RDW-13.8
[**2124-1-6**] 03:20PM NEUTS-78.1* LYMPHS-15.7* MONOS-4.5 EOS-0.3
BASOS-1.4
[**2124-1-6**] 03:20PM PLT COUNT-515*
[**2124-1-5**] 04:20PM %HbA1c-8.5* eAG-197*
HgA1c 8.5
Lipids Tg 123, HDL 41, LDL 33
MRI
1. Limited MRI study demonstrates T1 isointense lesion within
the left
parietal lobe which is compatible with hyperacute hematoma.
2. MRI demonstrates no vascular abnormalities in the anterior
and posterior circulations.
CT (head)
Redemonstration of left intraparenchymal hemorrhage, minimally
changed. The etiology is uncertain- amyloid angiopathy/HTN;
underlying
vascular/neoplastic cause- work up as appropriate.
CT (chest/abdomen/pelvis) PRELIMINARY READ
1) No definite evidence of new metastatic disease. 2) Upper pole
right
partial nephrectomy site appears hypoattenuating with small amt
of fluid and
perinephric stranding, without definite discrete mass. This is
the first
postop CT. Continued attention on follow-up is recommended. (3,
69).
Stable probable multiple R renal cysts, some of which too small
to
characterize. Stable atrophic L kidney. 3) S/P splenectomy and
distal
pancreatectomy with hyperdense curvilinear densities at
resection site with
small amount of fluid. 4) Liver hypodensities some subcentimeter
and too
small to fully characterize but unchanged since [**2123-8-12**],
probable cysts.
6) Gallbladder stone/sludge. 7) Stable R adrenal adenoma. 8)
Diffuse
atherosclerotic disease and coronary arterial calcifications. 9)
Foley in
prostatic urethra. Recommend repositioning.
Brief Hospital Course:
Patient was admitted to the neurology service after a code
stroke was called. He was noted to have confusion and word
finding deficits. He was admitted initially to the floor, but
transferred to the ICU as he blood pressure required a
nicardopine drip to control. He spent 2 days in the ICU, and was
transferred back to the floor where additional antihypertensives
were started. We performed a CT chest/abdomen/pelvis and final
read was pending, w/ stable R adrenal adenoma.
Hypertension
- patient initially required a nicardopine drip for systolic
blood pressures ranging up to 220 systolic. He was
well-controlled, with a goal SBP < 180 due to his hemorrhagic
stroke. On transfer out of the unit he required increased doses
of lisinopril, addition of amlodipine 10 mg daily, and addition
of metoprolol 25 mg [**Hospital1 **]. His BP was well-controlled for 2 days
in the range of 140-170 systolic.
Intraparenchymal hemorrhage
- the patient was found to have a left occipital subcortical
hemorrhage on CT scan. MRI w/ contrast could not be completed
due to his inability to stay still in the MRI. An outpatient MRI
was scheduled for [**2124-2-26**]. He was started on Keppra 500 mg PO
BID for concern of seizure given the location of the bleed,
however his EEG only showed diffuse slowing consistent w/
encephalopathy, but no seizure activity.
Thus, since the MRI could not be performed, we were not able to
rule out that the patient had an amyloid angiopathy as a
possible explanation of the small posterior cingulate gyrus
bleed. Other possible explanations include a hypertensive
hemorrhage, a vascular malformation that bled or a hemorrhagic
metastasis. CTA rule out a major vascular malformation, although
a cavernous hemangioma could not be ruled out.
Urinary Tract Infection
- patient had pseudomonas growing in the urine and was initially
started on IV Ceftriaxone, but switched to PO ciprofloxacin for
a 10-day course to be finished on [**2124-1-17**].
Medications on Admission:
-glyburide/metformin 5/500 2 tabs [**Hospital1 **]
-hydralazine 50 mg tid
-avapro 150 mg daily
-lisinopril 30 mg daily
-actos 30 mg daily
-zocor 40 mg daily
-aspirin 81 mg daily
-motrin PRN for headache
-nasal decongestion containing phenylephrine, as per daughter,
patient uses "all the time"
Discharge Medications:
1. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. irbesartan 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
9. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. glyburide-metformin 5-500 mg Tablet Sig: Two (2) Tablet PO
twice a day.
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days: end date [**2124-1-17**].
14. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left Occipital intraparenchymal hemorrhage (hemorrhagic stroke)
Urinary Tract Infection
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after an epsiode of dizziness
and confusion. You had also been complaining of headache. On
exam he was having some difficulty with word-finding, was
unsteady when standing and was noted to be falling to the left.
Your CT showed evisence of a left subcortical occipital
intraparenchymal hemorrhage. You had an MRI, but an MRI with
contrast could not be done, as you were unable to stay still
during the exam. We decided that you should have an MRI within 2
months as an outpatient. Your blood pressure was elevated during
your stay and you required a nicardopine drip for 2 days. When
you were transferred out we started you on new antihypertensive
medications and increased some of your existing medications. We
also noted that you had a urinary tract growing pseudomonas and
you were started on a medication (ciprofloxacin) for treatment.
The location of your stroke predisposes you to seizures and you
were started on an antiepileptic (keppra), although your EEG
showed no evidence of seizure activity. You will follow up with
Dr. [**Last Name (STitle) **] from neurology on [**2123-3-15**]. You should have an MRI
with contrast prior to this visit.
Medications changed:
1. Lisinopril to 40 mg PO daily - increased
2. Metoprolol tartrate 25 mg PO BID - started
3. Amlodipine 10 mg PO daily - started
4. Keppra 500 mg PO BID - started
5. Ciprofloxacin 500 mg PO BID (end date [**2124-1-17**] - 10 day
course)
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2124-3-14**] 2:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2124-1-31**] 10:45
Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2124-2-1**] 11:30
MRI w/ contrast ordered for [**2124-2-26**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2124-1-13**]
ICD9 Codes: 431, 5990, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2989
} | Medical Text: Admission Date: [**2130-11-14**] Discharge Date: [**2130-11-23**]
Date of Birth: [**2084-10-3**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
[**2130-11-15**] Intramedullary nail, left tibia.
Right Chest Tube
History of Present Illness:
46 yo F s/p motor vehicle crash; T-boned with + airbag
deployment +LOC, intubated in the field for decreased oxygen
saturation. Transferred from referring hospital to [**Hospital1 18**] for
continued trauma care.
Past Medical History:
Back surgery for lipoma removal [**4-13**] c/b seroma
s/p MVC [**12-14**]
Seizures
Psychiatric Disorder
Social History:
Reportedly lives with boyfriend and one son (has 3 sons)
Family History:
Non-contributory
Physical Exam:
VS on admission:
T 98.2 HR 84 BP 108/98 O2 sat 98%
Gen: Intubated/vented & paralyzed
HEENT: Puplis fixed 5-6 mm; left conjuctival hemorrhage; dried
blood in nares
Neck: collared
Chest: CTA bilat
Cor: RRR
Back: no stepoffs
Abd: soft, NT FAST exam negative
Rectum: guaiac negative
Pelvis: stable
Extr: deformity LLE; + ecchymosis; 2+ DP/PT pulses bilat
Pertinent Results:
[**2130-11-14**] 09:40PM TYPE-ART PO2-197* PCO2-41 PH-7.37 TOTAL
CO2-25 BASE XS--1
[**2130-11-14**] 09:40PM LACTATE-1.1
[**2130-11-14**] 09:28PM GLUCOSE-117* UREA N-10 CREAT-0.5 SODIUM-142
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-23 ANION GAP-14
[**2130-11-14**] 09:28PM ALT(SGPT)-152* AST(SGOT)-152* ALK PHOS-89 TOT
BILI-0.3
[**2130-11-14**] 09:28PM CALCIUM-9.0 PHOSPHATE-4.2 MAGNESIUM-1.6
[**2130-11-14**] 09:28PM WBC-13.0* RBC-4.71 HGB-13.5 HCT-39.7 MCV-84
MCH-28.7 MCHC-34.0 RDW-14.3
[**2130-11-14**] 09:28PM PLT COUNT-349
[**2130-11-14**] 09:28PM PT-12.8 PTT-22.7 INR(PT)-1.1
[**2130-11-14**] 02:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2130-11-14**] 02:20PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
CT RECONSTRUCTION [**2130-11-14**] 3:32 PM
CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION
Reason: 46 year old woman s/p MVA
[**Hospital 93**] MEDICAL CONDITION:
46 year old woman s/p MVA
REASON FOR THIS EXAMINATION:
46 year old woman s/p MVA
CONTRAINDICATIONS for IV CONTRAST: None.
EMERGENCY LUMBAR SPINE CT
HISTORY: Motor vehicle accident.
TECHNIQUE: Axial post-intravenously enhanced images of the
lumbar spine were obtained. Images were only submitted at this
time using a bone algorithm.
FINDINGS: Within these limitations, there is no definite
evidence of a fracture or abnormal alignment of the component
vertebrae. The absence of soft tissue algorithm precludes
optimum demonstration of the intervertebral discs and
ligamentous structures. There is no definite paraspinal
pathology seen, although more comprehensive analysis of the
abdomen was obtained by the pre- existent torso CT scan.
CONCLUSION: No definite fracture.
CT RECONSTRUCTION [**2130-11-14**] 3:32 PM
CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION
Reason: 46 year old woman s/p MVA
[**Hospital 93**] MEDICAL CONDITION:
46 year old woman s/p MVA
REASON FOR THIS EXAMINATION:
46 year old woman s/p MVA
CONTRAINDICATIONS for IV CONTRAST: None.
EMERGENCY CT SCAN OF THE THORACIC SPINE
HISTORY: Motor vehicle accident.
TECHNIQUE: Axial non-contrast images of the thoracic spine.
These were acquired only with bone window settings with
corresponding coronal and sagittal reconstructions.
FINDINGS: There is no definite spine fracture seen. There is a
depression of the superior endplate of L1 with small anterior
bridging osteophytes. The depression, when viewed axially,
appears consistent with a Schmorl's node.
There is imaging of the right pneumothorax, consolidation within
the superior segment of the right lower lobe and apparent
collapse or consolidation of the left lower lobe.
CONCLUSION: No definite spine fractures. Please note that the
absence of soft tissue algorithms for reconstruction of the
images precludes optimum depiction of the intervertebral discs
and ligamentous structures.
BILAT LOWER EXT VEINS PORT [**2130-11-16**] 8:49 AM
BILAT LOWER EXT VEINS PORT
Reason: please eval for DVT
[**Hospital 93**] MEDICAL CONDITION:
46 year old woman with BL LE edema, immobilization
REASON FOR THIS EXAMINATION:
please eval for DVT
INDICATION: 46-year-old female with bilateral leg edema and
immobilization.
FINDINGS: Grayscale and Doppler son[**Name (NI) 867**] of the bilateral
lower extremity veins was performed. Bilateral common femoral,
superficial femoral, and popliteal veins exhibit normal flow,
waveforms, augmentation, and compressibility. No intraluminal
thrombus is identified.
IMPRESSION: No evidence of deep venous thrombosis in either
extremity.
CHEST (PORTABLE AP) [**2130-11-17**] 12:52 PM
CHEST (PORTABLE AP)
Reason: S/P CT PULL
AP CHEST 12:55 P.M [**11-17**].
HISTORY: Chest tube pulled. Rule out effusion or pneumothorax.
IMPRESSION: AP chest compared to [**11-15**] and 9:
Study performed at 11:25 this morning excluding the apex of the
right chest showed a right pneumothorax and right lower lobe
collapse both increased substantially since [**11-15**]. Current
film shows little if any change. Left lower lobe atelectasis is
present as well and small left pleural effusion are stable. The
heart is normal in size and midline. Poor definition of the left
bronchial tree suggests significant retention of secretions.
CTA CHEST W&W/O C &RECONS [**2130-11-17**] 7:30 PM
CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST
Reason: r/o PE
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
46 year old woman with tachypnea, difficulty maintaining sats
REASON FOR THIS EXAMINATION:
r/o PE
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: History of tachypnea and difficulty maintaining
sats, evaluate for pulmonary embolism.
COMPARISON: Study from [**2130-11-14**].
TECHNIQUE: MDCT acquired contiguous axial images were obtained
from the lung bases to the thoracic inlet. Multiplanar
reconstructions were performed.
CONTRAST: 100 cc of IV Optiray contrast were administered due to
the rapid rate of bolus injection required for this study.
CTA OF THE CHEST: No filling defects or pulmonary emboli
identified within the pulmonary arteries to the level of the
segmental branches. The aorta demonstrates normal caliber and
contour.
CT OF THE CHEST WITH IV CONTRAST: Soft tissue window images
demonstrate no mediastinal fluid or pathologically enlarged
mediastinal lymphadenopathy. Small bilateral pleural effusions
are noted. Lung window images demonstrate prominent bibasilar
atelectasis. Additionally, within the right lower lung zone,
there is a focal opacity which corresponds to the area of
contusion seen previously. There is now increased area of
opacity adjacent to this, which may represent atelectasis.
Additionally, within the left middle lung zone, there are two
areas of faint opacities which may represent areas of
atelectasis or aspiration. The airways are patent to the level
of the segmental bronchi bilaterally.
There is a right pneumothorax, which is small, but appears to
have increased slightly in comparison to prior study.
Additionally, there is a small amount of pneumomediastinum which
is similar in comparison to the prior exam.
Limited images of the superior portion of the abdomen are
unremarkale.
BONE WINDOWS: Again seen are fractures within the sternum, and
within the first, second and third left ribs, and within the
right first rib.
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential
in delineating the anatomy and pathology.
IMPRESSION:
1. No pulmonary embolism.
2. Prominent atelectasis at the lung bases bilaterally, which
was not seen previously.
3. Opacity within the right mid lung zone corresponds to the
area of contusion seen previously and new adjacent atelectasis.
New opacities within the left mid lung zone may represent focal
atelectasis or aspiration.
4. Right pneumothorax is again seen, and appears slightly
increased in comparison to prior study.
5. Multiple rib fractures again seen, and a sternal fracture.
Results were discussed with Dr. [**Last Name (STitle) **] [**Name (STitle) 46162**] at 10:45 p.m. on
[**2130-11-17**].
Brief Hospital Course:
Patient admitted to the trauma service. Orthopedic surgery was
consulted, patient taken to the operating room on [**11-15**] for IM
nail left tibia fracture. She is currently in a hinged [**Doctor Last Name **]
brace and is on subcutaneous Lovenox. Her staples were
discontinued on day of discharge. She is touch down weight
bearing on her LLE and will follow up with Orthopedics in 1
week.
Plastic surgery was consulted because of her nasal bone
fracture; this injury was treated with splinting for 1 week. She
will need to follow up in [**Hospital 3595**] clinic on [**11-28**].
Psychiatry was consulted because of her history with mental
health problems; it was noted that patient was delirious during
their evaluation. It was recommended that Risperidone and
Klonopin to be initiated. She should have Psychiatry consult
while in rehab for ongoing assessment of her issues.
Social work was consulted for assessment of home situation and
patient's initial reports of abusive relationship with boyfriend
which she ultimately denied when social work investigated this
allegation.
Physical therapy consulted and evaluation revealed need for
short term rehab stay. Patient has been accepted at a facility
in [**Location (un) 8973**].
Medications on Admission:
Percocet
Paxil
Valium
Risperidol
Zonisamide
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
2. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous Q
24H (Every 24 Hours): Continue for 3 weeks.
6. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed for pain.
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Southeastern [**Hospital **] Nursing and Rehab
Discharge Diagnosis:
s/p MVC
Nasal Septum Fracture
Right Pneumothorax
Pneumomediastinum
Left Tibia/Fibula Fracture
Discharge Condition:
Stable
Discharge Instructions:
Follow up in [**Hospital **] Clinic in 1 week.
Follow up in [**Hospital 3595**] Clinic on [**11-28**].
Follow up in Trauma Clinic in [**2-10**] weeks.
Take all of your medications as prescribed.
Followup Instructions:
Call [**Telephone/Fax (1) 1228**] for an appointment in [**Hospital **] Clinic in 1
week.
Call [**Telephone/Fax (1) 4652**] for an appointment in [**Hospital 3595**] clinic for next
Tuesday [**11-28**].
Call [**Telephone/Fax (1) 6439**] for an appointment in Trauma Clinic.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2130-11-23**]
ICD9 Codes: 5185, 5990, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2990
} | Medical Text: Admission Date: [**2128-1-11**] Discharge Date: [**2128-1-16**]
Date of Birth: [**2059-8-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
Transfer from [**Hospital3 2568**] for further workup of pancytopenia and
respiratory distress
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
68 yo F with h/o hypertension and DM who presented to [**Hospital3 **]
ED on [**2128-1-10**] with worsing shortness of breath and fevers to
102. She was found to be anemic to 16.7, thrombocytopenic with
plt of 2, and borderline leukopenia of 3.5. At the time the
etiology was unclear. She had a bone marrow biopsy on [**2128-1-10**]
with a premil read of all cell lines present, L shift of WBC,
increased promyelocytes and megabloblastoid RBCs. She was
transfused multiple blood products including 7.5 PRBC, 12 units
of FFP, 6 packs of platelets with improvement of her counts to
HCT 28.9, plt 9. She was guaiac positive. On the morning of
[**2128-1-11**] she became acutely SOB, CXR Her CXR initially showed,
CXR showed patchy bilateral opacities consistent with either CHF
or TRALI. A report of a CXR earlier in her admission notes mild
interstial edema and a CTA on [**2128-1-7**] was essentially normal.
She had an echo that showed trace MR, normal systolic function,
EF >65%.
.
History per OSH notes and per sister revealed that she has had
worsening DOE for past 3-4 days. She has had some heavy
breathing in the past, but is able to exercise at Curves 3 times
per week. She saw her PCP regarding the SOB who ordered a CXR
and a stress test. Supposedly there was something on the stress
test that cause him to order a CTA.
.
On arrival to [**Hospital1 18**] [**Hospital Unit Name 153**] she was satting in the 70's on BiPap
and was urgently intubated. She was not breathing in sync with
the vent and was having trouble oxygenating. She was started on
cisatracurium. She required 100%oxygen. She had melana and some
bright red blood in her ETT. She was transfused platelets and
given lasix 80 mg IV.
Past Medical History:
DMII
Hypertension
Hypercholesterolemia
s/p tonsillectomy
s/p TAH
Social History:
Never married, no children, lives with her sister, former
[**Name2 (NI) 1818**], quit 8 years ago, no ETOH
Family History:
Father: sinus cancer, Mother: colon cancer, [**Name (NI) 11964**].
Physical Exam:
101.1, HR 100-110, BP 200/115-> 111/44, RR 30's on arrival, 20
on vent, 70's on arrival on NRB/Bipap, 92% on vent AC 450x28,
100%, PEEP 8
GENL: sedated
HEENT: OP with dried blood, no petechiae on palate
CV: RRR
Lungs: occasional crackles, good airmovement
Abd: soft, nt, nd, no splenomegaly appreciated, +BS
Ext: no edema, + petechiae in hands bilat, 2+ pedal pulses
Neuro: Prior to sedation - alert, oriented, following commands
Pertinent Results:
[**2128-1-11**] 05:13PM BLOOD WBC-2.9* RBC-3.52* Hgb-11.1* Hct-30.6*
MCV-87 MCH-31.5 MCHC-36.3* RDW-14.6 Plt Ct-15*
[**2128-1-16**] 03:06AM BLOOD WBC-2.7* RBC-2.85* Hgb-9.0* Hct-25.2*
MCV-88 MCH-31.6 MCHC-35.8* RDW-14.7 Plt Ct-5*
[**2128-1-11**] 05:13PM BLOOD Neuts-39* Bands-9* Lymphs-25 Monos-17*
Eos-0 Baso-1 Atyps-6* Metas-1* Myelos-2* NRBC-9*
[**2128-1-16**] 03:06AM BLOOD Neuts-46* Bands-13* Lymphs-21 Monos-5
Eos-1 Baso-1 Atyps-8* Metas-3* Myelos-2* NRBC-5*
[**2128-1-11**] 05:13PM BLOOD PT-16.7* PTT-26.4 INR(PT)-1.5*
[**2128-1-16**] 03:06AM BLOOD PT-17.6* PTT-24.7 INR(PT)-1.6*
[**2128-1-11**] 05:13PM BLOOD Fibrino-206
[**2128-1-12**] 08:03AM BLOOD Fibrino-439* D-Dimer->[**Numeric Identifier 961**]*
[**2128-1-14**] 01:27PM BLOOD Fibrino-192 D-Dimer->[**Numeric Identifier 961**]*
[**2128-1-15**] 01:13PM BLOOD Fibrino-119* D-Dimer-[**Numeric Identifier 961**]*
[**2128-1-15**] 01:13PM BLOOD FDP-80-160*
[**2128-1-16**] 03:06AM BLOOD Fibrino-101*
[**2128-1-13**] 05:25AM BLOOD WBC-1.4* Lymph-53* Abs [**Last Name (un) **]-742 CD3%-54
Abs CD3-400* CD4%-46 Abs CD4-341* CD8%-8 Abs CD8-58*
CD4/CD8-5.8*
[**2128-1-11**] 05:13PM BLOOD Glucose-253* UreaN-32* Creat-0.9 Na-143
K-4.0 Cl-100 HCO3-29 AnGap-18
[**2128-1-16**] 03:06AM BLOOD Glucose-203* UreaN-149* Creat-2.2* Na-139
K-4.9 Cl-106 HCO3-22 AnGap-16
[**2128-1-11**] 05:13PM BLOOD ALT-18 AST-15 LD(LDH)-490* CK(CPK)-58
AlkPhos-41 Amylase-29 TotBili-4.6*
[**2128-1-16**] 03:06AM BLOOD ALT-30 AST-19 AlkPhos-28* TotBili-2.1*
[**2128-1-11**] 10:23PM BLOOD proBNP-4252*
[**2128-1-14**] 07:05PM BLOOD Triglyc-178*
[**2128-1-11**] 10:23PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2128-1-15**] 03:39PM BLOOD ANCA-NEGATIVE B
[**2128-1-15**] 03:39PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2128-1-12**] 02:30AM BLOOD C3-86*
[**2128-1-11**] 05:42PM BLOOD Type-ART Temp-38.4 Rates-15/5 Tidal V-650
PEEP-5 pO2-77* pCO2-57* pH-7.35 calTCO2-33* Base XS-3
-ASSIST/CON Intubat-INTUBATED
[**2128-1-16**] 09:55AM BLOOD Type-ART Temp-38.6 Rates-30/3 Tidal V-400
PEEP-24 FiO2-60 pO2-105 pCO2-54* pH-7.23* calTCO2-24 Base XS--5
-ASSIST/CON Intubat-INTUBATED
[**2128-1-11**] 05:42PM BLOOD Lactate-3.4*
[**2128-1-16**] 03:40AM BLOOD Lactate-2.6*
Brief Hospital Course:
Impression: 68 yo female transferred from an outside hospital
with pancytopenia and patchy bilateral infiltrates found to have
hemophagocytic lymphohistiocytosis.
.
Hospital Course:
# Pancytopenia: On admission the etiology of the patient's
pancytopenia was unlcear. The initial differential diagnosis
included myelodysplastic syndrome vs. myelosupression from viral
syndrome or toxin vs. hemophagocytic syndrome. Microbiology
studies including Erlichia, EBV, CMV, HCV, parvovirus, and LCM
serologies were all unremarkable. The hematology/oncology
service was involved early in the patient's care. Slides from
the bone marrow biopsy performed at the outside hospital were
received [**2128-1-14**]. The [**Hospital1 18**] pathology report indicated
hypercellular marrow with increased hemophagocytic
histiocytes--findings consistent with a diagnosis of
hemophagocytic lymphohistiocytosis. Hematology offered the
option of treatment with etoposide and dexamethasone. However,
given the often poor response to this therapy and the patient's
severe illness, the prognosis was felt to remain poor.
Therapeutic options were discussed with the patient's family,
including her sister, who is also her health care proxy. [**Name (NI) 227**]
the prognosis the family/HCP felt that it would be in the
patient's wishes to be made comfort measures only. Aggressive
therapy, including ventilatory support was removed. All attempts
were made to make the patient comfortable. The patient expired
and was pronounced dead on [**2128-1-16**] at 3:20 PM.
.
# Bilateral infiltrates: The patient was diagnosed as having
acute respiratory distress syndrome likely secondary to
transfusion related lung injury vs. sepsis. The patient was
urgently intubated upon her arrival to the [**Hospital1 18**] [**Hospital Unit Name 153**]. Her
ventilatory and oxygenation status was monitored closely and her
ventilator was adjusted according to ARDS protoccol. As above,
she was made CMO and was extubated.
.
# Fever: The differential diagnosis for the patient's fever
included an infectious process vs fever associated with ARDS.
The infectious possibilities were numerous given the patient's
relative immunosuppression. The patient was placed on broad
spectrum antibiotics, but continued to spike temperatures
throughout the hospitalization. Microbiology studies as above
were all unremarkable. Multiple blood, sputum, and urine
cultures were all negative. Anti-microbial treatment was removed
when the patient's code status changed to CMO.
.
# Renal failure: The patient was felt to likely be prerenal with
hypoperfusion in setting of sepsis. Urine lytes were consistent
with a prerenal picture. The patient was given aggressive fluid
resuscitation with a minimal response in her creatinine. Her
renal function was monitored closely throughout the admission.
.
# GIB: The patient had evidence of guaiac positive stools during
her admission. She was continued on a PPI throughout her
hospital course.
.
# DM: The patient was placed on an insulin drip for tight
glycemic control.
.
# FEN: The patient was continued on tube feeds throughout her
hospitalization with fluid resuscitation as above.
.
# PPX: Heparin was held given her low platelets. Pneumoboots
were placed. She was placed on a PPI as above.
.
# Code: The patient was full code on admission and was changed
to comfort measures only as above.
Medications on Admission:
Meds at home:
Diovan
ASA
Metformin 1000 mg [**Hospital1 **]
Simvastatin - d/c'd 2 wks ago
.
Meds on tx:
Lasix 40 iv, 60 iv
morphine
Zosyn
Vanco
Calcium gluconate
Discharge Disposition:
Expired
Discharge Diagnosis:
hemophagocytic lymphohistiocytosis
acute respiratory distress syndrome
acute renal failure
Discharge Condition:
The patient is deceased.
Discharge Instructions:
The patient is deceased.
Followup Instructions:
The patient is deceased.
ICD9 Codes: 0389, 4280, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2991
} | Medical Text: Admission Date: [**2115-12-28**] Discharge Date: [**2115-12-31**]
Date of Birth: [**2036-1-27**] Sex: M
Service: MEDICINE
Allergies:
Allopurinol / Aspirin / Lopressor
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
HPI: 79M complicated medical history including cirrhosis with
history of multiple episodes of hepatic encephalopathy,
discharged 2 days PTA after being treated for hepatic
encephalopathy thought to be due to poor dietary compliance,
admitted with lethargy. Pt was home, when he reports feeling
weak and dizzy. On last hospitalization, abdominal u/s showed
hypoechoic liver lesion requiring further workup, CT since
unable to have MRI. In [**Name (NI) **], pt had 1 recorded rectal temp of
100.8, but was afebrile otherwise. He reported an episode of R
sided chest pain, which he reported to the ED team as being old.
There was no obvious evidence in his history of recent
hemorrhage, although he had a decrease in Hct in the ED.
Past Medical History:
1. Cryptogenic cirrhosis likely NASH.
2. CHF with an EF of 35% from [**2112**].
3. CAD status post stent x2.
4. AFib status post DDD pacer.
5. Hypertension.
6. history of CVA.
5. Diabetes, HbA1c [**6-23**]: 6.5
6. history of confusion, multiple admissions for hepatic
encephalopathy
7. history of multiple UTIs
8. history of pancytopenia.
9. Eosinophilic syndrome
10. Iron deficiency anemia, known trace pos stools.
11. Upper GI bleed.
12. Diverticulosis, grade II internal hemmorroids (cscope [**2110**])
13. Chronic renal insufficiency 1.2-1.6 at baseline.
14. s/p Left Total knee replacement
15. history of Gout
Social History:
Lives with his wife; daughter and son-in-law assist them. Worked
for the City of [**Location (un) **]. Was in the Army for 21 years. Denies
past or present tobacco usedenies alcohol consumptiondenies IV
drug use.
Family History:
His father with a MI at age 60. Two brothers with [**Name2 (NI) **] and
diabetes.
Physical Exam:
V: T: 97.0 HR 86 BP 96/43 R 17 Sat 99% RA
*
PE: G: NAD, somnolent, but responds to questions
HEENT: Dry MM
Lungs: BS BL, Occ crackles, no W/R
CV: Irregluar RR, S1S2, No MRG
Abd: Soft, Nt, ND, BS+
Ext: 0-1+ edema
Neuro: minimal asterixis, no gross focal deficits
Pertinent Results:
[**2115-12-31**] 06:30AM BLOOD WBC-3.2* RBC-3.36* Hgb-10.5* Hct-29.1*
MCV-87 MCH-31.3 MCHC-36.1* RDW-15.6* Plt Ct-138*
[**2115-12-27**] 11:44PM BLOOD WBC-6.9 RBC-3.77* Hgb-11.7* Hct-31.9*
MCV-85 MCH-31.0 MCHC-36.7* RDW-15.3 Plt Ct-149*
[**2115-12-31**] 06:30AM BLOOD Plt Ct-138*
[**2115-12-31**] 06:30AM BLOOD PT-18.2* PTT-34.6 INR(PT)-2.1
[**2115-12-27**] 11:44PM BLOOD Plt Ct-149*
[**2115-12-27**] 11:44PM BLOOD PT-22.9* PTT-43.9* INR(PT)-3.3
[**2115-12-31**] 06:30AM BLOOD Glucose-205* UreaN-18 Creat-1.0 Na-140
K-4.2 Cl-111* HCO3-22 AnGap-11
[**2115-12-27**] 11:44PM BLOOD Glucose-235* UreaN-67* Creat-2.5*# Na-134
K-4.4 Cl-101 HCO3-20* AnGap-17
[**2115-12-27**] 11:44PM BLOOD ALT-25 AST-31 CK(CPK)-225* AlkPhos-109
Amylase-33 TotBili-1.6*
[**2115-12-30**] 06:15AM BLOOD Albumin-3.1* Calcium-8.3* Phos-2.4*
Mg-1.8
[**2115-12-28**] 09:50AM BLOOD Calcium-7.4* Phos-2.4* Mg-1.9
[**2115-12-29**] 03:53AM BLOOD Ammonia-79*
[**2115-12-28**] 11:05AM BLOOD Cortsol-33.7*
[**2115-12-28**] 10:35AM BLOOD Cortsol-26.4*
[**2115-12-28**] 03:38AM BLOOD Type-MIX pO2-45* pCO2-31* pH-7.43
calHCO3-21 Base XS--2 Intubat-NOT INTUBA Comment-GREEN TOP
Abdominal U/S - No ascites
CXR - negative
Echo - IMPRESSION: Mild symmetric left ventricular hypertrophy
with good basal
systolic function. ?distal septal/anterior hypokinesis. Mild
mitral
regurgitation.
Based on [**2107**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a moderate risk (prophylaxis recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
Discharge labs:
[**2115-12-31**] 06:30AM BLOOD WBC-3.2* RBC-3.36* Hgb-10.5* Hct-29.1*
MCV-87 MCH-31.3 MCHC-36.1* RDW-15.6* Plt Ct-138*
[**2115-12-27**] 11:44PM BLOOD Neuts-80.2* Lymphs-12.3* Monos-6.0
Eos-1.3 Baso-0.2
[**2115-12-31**] 06:30AM BLOOD Plt Ct-138*
[**2115-12-31**] 06:30AM BLOOD PT-18.2* PTT-34.6 INR(PT)-2.1
[**2115-12-28**] 09:50AM BLOOD Fibrino-587*#
[**2115-12-28**] 09:50AM BLOOD Ret Aut-1.8
[**2115-12-31**] 06:30AM BLOOD Glucose-205* UreaN-18 Creat-1.0 Na-140
K-4.2 Cl-111* HCO3-22 AnGap-11
[**2115-12-30**] 06:15AM BLOOD ALT-27 AST-30 AlkPhos-101
[**2115-12-29**] 03:53AM BLOOD CK(CPK)-91
[**2115-12-28**] 11:05AM BLOOD LD(LDH)-169 TotBili-0.9
[**2115-12-29**] 03:53AM BLOOD CK-MB-4 cTropnT-0.02*
[**2115-12-30**] 06:15AM BLOOD Albumin-3.1* Calcium-8.3* Phos-2.4*
Mg-1.8
[**2115-12-28**] 11:05AM BLOOD Hapto-106
[**2115-12-29**] 03:53AM BLOOD Ammonia-79*
Brief Hospital Course:
1. Hypotension: 79M with a history of Cirrhosis, with multiple
episodes of hepatic encephalopathy the most recent of which was
2 days prior to admission, admitted with somnolence and
lethargy, elevated ammonia. He was started on MUST protocol for
sepsis, it was also felt that he was likely hypovolemic. There
was no evidence of ascites on an U/S performed 4 days prior to
admission. He had no infiltrate on CXR. Based upon no apparent
evidence of infection, antibiotics were not given. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim
test was performed which showed normal funciton. Blood
cultures, urine cultures were drawn. Initially he was started
on Levophed drip for hyptension. He was treated aggressively
with Lactulose until he stooled. His BP recovered rapidly as
did his mental status. Once he was normotensive and no longer
confused he was transfered to the floor. On the floor his diet
was advanced slowly and Lactulose was continued. He did well
and had no further episodes of confusion or hypotension. He was
discharged home on Lactulose.
2. Hepatic encephalopathy/MS: He has a history of poor dietary
compliance. He was started on Lactulose Q2H until he had
multiple large BMs in the ICU. An Ultrasound was performed
which showed no ascites to tap. His mental status cleared and
he was transferred out of the ICU. While on the floor an EGD
was performed to evaluate for varices, this showed grade 1 varix
+ nodule.
3. Decr HCT: His admission HCT was low it was followed closely.
*
4. ARF: He was treated with IV fluids for his acute renal
failure. His creatinine resolved to 1.0 prior to discharge.
*
5. Afib: His INR was supratherapeutic on admission, Coumadin was
held and restarted
Medications on Admission:
Meds:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
(MO,TU,TH,FR,SA).
9. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO 2X/WEEK
([**Doctor First Name **],WE).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO twice a
day.
Disp:*1080 ML(s)* Refills:*0*
11. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
4. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please resume INR checks as per your routine. First INR should
be checked no later than [**1-2**].
8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lisinopril 10 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
hypotension
hepatic encephalopathy
Discharge Condition:
good!
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 L
You have been evaluated for low blood pressure, dehydration and
confusion from your liver disease.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2116-2-6**] 3:30
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2116-2-6**] 3:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 9120**] MEDICINE (PRIVATE) Where: ADULT
MEDICINE UNIT [**Hospital3 **] HEALTHCARE - 1000 [**Location (un) **] - [**Location (un) 2352**],
[**Numeric Identifier 9121**] Phone:[**Pager number **] Date/Time:[**2116-2-5**] 4:30
ICD9 Codes: 5715, 4280, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2992
} | Medical Text: Admission Date: [**2108-12-27**] Discharge Date: [**2109-1-4**]
Service: MEDICINE
Allergies:
Plavix
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
GI bleeding due to Esophageal Ulcers
Major Surgical or Invasive Procedure:
Endoscopic Gastroduodenography (EGD)
External Beam Radiation therapy
History of Present Illness:
89 year-old female with a history of bladder cancer metastatic
to liver who presents with melena, hematemesis. The patient was
initially evaluated in the emergency room and found to be
tachycardic and given IV fluids. The patient was transferred to
11 [**Hospital Ward Name 1827**] where the patient triggered for tachycardia to the
130s. An NG lavage was done that showed coffee ground emesis
that cleared with 700 cc lavage. Shortly after the lavage was
finished a clot with bright red blood was suctioned from the NG
tube. At that point GI consultation was called who recommended
ICU transfer, pantoprazole IV drip and serial hematocrit.
In the ED the initial BP was 133/60 with HR 120s RR 16 with 02
sat 99% RA. She was given Pantoprazole 40 mg IV, zofran 4 mg IV,
kayexelate 30 gm, cipro IV and 0.25 ativan.
On arrival to the medical floor the patient was afebrile with BP
118-123/60-78, HR 120-130s 100% RA. On evaluation on the floor
and on ICU transfer the patient had only mild dizziness and
lightheadeness. She denies chest pain, abdominal pain.
She was also noted with increasing acute renal failure on her
stage III CKD.
ROS: In reviewing the recent weeks with the son, the patient has
had worsening mental status over the last few weeks, increased
weakness in the last month. She has intermittent presyncopal
episodes that have also been increasing in frequency. She has
had persistent LQ abdominal pain that is treated with meds
listed. The pain has been intermittently controlled. This is her
first episode of epigastric chest pain, hematemesis and melena
in the last few years. She has had poor PO intake in the recent
weeks.
Past Medical History:
Bladder cancer [**2-17**] with known lung metastases, currently on
radiation therapy for pain control
Hypothyroidism
anemia
celiac sprue
COPD (previous exacerbations requiring steroids)
history of ventricular septal defect
history of hysterectomy/BSO
Nephroureterectomy in [**3-14**].
CVA [**2-17**]-- d/c with aggrenox
? Hx DVT
Social History:
She lives in [**Location 577**] with her son who moved in with her. She
ambulates around her apartment with a walker. She was a
housewife and raised 6 children. She smoked for 70-pack-years
and quit last year when she developed COPD. She
does not drink alcohol.
Family History:
Non-Contributory
Physical Exam:
GEN: Thin cachetic appearing woman in no acute distress.
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, pale, dry MM, OP Clear, swelling of right cheek
NECK: No JVD, no bruits, no cervical lymphadenopathy, trachea
midline
COR: RRR, no MRG, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: 2+ edema of LE, pitting to knees, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
Alert and oriented x [**2-12**] (in hospital [**Location (un) 34564**], [**Month (only) **],
knows DOB)
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Cardiology Report ECG Study Date of [**2108-12-27**] 12:13:56 PM
Baseline artifact. Sinus tachycardia. Leftward axis. Late R wave
progression. Mild J point and ST segment elevation in the early
precordial
leads with Q waves through to lead V3 may be related to axis but
consider
anteroseptal myocardial infarction, age undetermined. Clinical
correlation is suggested. No previous tracing available for
comparison.
CHEST (PORTABLE AP) Study Date of [**2108-12-28**] 7:15 AM
IMPRESSION:
1. Diffuse intrathoracic metastatic disease.
2. Likely mild volume overload.
ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2108-12-28**] 8:14 AM
IMPRESSION:
1. Extensive infiltrative process in the liver consistent with
the history of metastatic bladder cancer.
2. Mild central biliary dilatation.
3. Lack of visualization of the left kidney.
4. Small aortic aneurysm of 23 mm in diameter.
CT could be performed, if clinically indicated, for a more
thorough staging assessment, and if available, comparison to
prior studies could be helpful.
BILAT LOWER EXT VEINS Study Date of [**2108-12-28**] 8:14 AM
IMPRESSION:
1. Residual evidence of old nonocclusive bilateral lower
extremity deep venous thrombosis. It is unlikely that any of the
findings are acute or even recent.
2. [**Hospital Ward Name 4675**] cyst in the right popliteal fossa.
[**2109-1-4**] 06:40AM BLOOD WBC-10.8 RBC-3.07* Hgb-10.6* Hct-31.4*
MCV-102* MCH-34.6* MCHC-33.9 RDW-17.7*
[**2108-12-31**] 01:18PM BLOOD WBC-7.3 RBC-3.28* Hgb-10.9* Hct-33.7*
MCV-103* MCH-33.3* MCHC-32.4 RDW-17.4*
[**2108-12-27**] 12:05PM BLOOD WBC-11.5* RBC-3.24* Hgb-10.9* Hct-33.7*
MCV-104* MCH-33.6* MCHC-32.3 RDW-16.7*
[**2108-12-29**] 05:11AM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2108-12-30**] 04:24PM BLOOD PT-15.0* PTT-37.2* INR(PT)-1.3*
[**2108-12-29**] 05:11AM BLOOD PT-15.3* PTT-145.1* INR(PT)-1.4*
[**2108-12-27**] 12:05PM BLOOD PT-15.1* PTT-29.5 INR(PT)-1.3*
[**2109-1-4**] 06:40AM BLOOD Glucose-88 UreaN-56* Creat-2.7* Na-140
K-4.9 Cl-112* HCO3-19* AnGap-14
[**2109-1-3**] 05:10AM BLOOD Glucose-95 UreaN-48* Creat-2.4* Na-139
K-4.8 Cl-109* HCO3-19* AnGap-16
[**2109-1-2**] 07:10AM BLOOD Glucose-151* UreaN-47* Creat-2.3* Na-143
K-4.9 Cl-115* HCO3-19* AnGap-14
[**2109-1-1**] 05:20AM BLOOD Glucose-99 UreaN-49* Creat-2.4* Na-142
K-4.8 Cl-111* HCO3-19* AnGap-17
[**2108-12-31**] 01:18PM BLOOD Glucose-152* UreaN-42* Creat-2.3* Na-141
K-4.7 Cl-111* HCO3-19* AnGap-16
[**2108-12-30**] 04:32PM BLOOD Glucose-193* UreaN-40* Creat-2.0* Na-142
K-4.0 Cl-111* HCO3-19* AnGap-16
[**2108-12-29**] 04:47PM BLOOD Glucose-135* UreaN-38* Creat-2.1* Na-139
K-4.0 Cl-109* HCO3-21* AnGap-13
[**2108-12-29**] 05:11AM BLOOD Glucose-124* UreaN-38* Creat-2.0* Na-141
K-3.6 Cl-111* HCO3-22 AnGap-12
[**2108-12-28**] 05:11PM BLOOD Glucose-221* UreaN-42* Creat-2.2* Na-139
K-4.3 Cl-107 HCO3-20* AnGap-16
[**2108-12-28**] 06:33AM BLOOD Glucose-108* UreaN-45* Creat-2.2* Na-140
K-4.8 Cl-113* HCO3-14.3* AnGap-18
[**2108-12-27**] 11:05PM BLOOD Glucose-99 UreaN-49* Creat-2.3* Na-142
K-5.6* Cl-115* HCO3-13* AnGap-20
[**2108-12-27**] 12:05PM BLOOD Glucose-140* UreaN-51* Creat-2.6* Na-138
K-5.8* Cl-106 HCO3-16* AnGap-22*
[**2108-12-27**] 11:05PM BLOOD CK(CPK)-310*
[**2108-12-27**] 12:05PM BLOOD ALT-69* AST-110* LD(LDH)-678*
CK(CPK)-376* AlkPhos-492* TotBili-0.9
[**2108-12-28**] 06:33AM BLOOD GGT-536*
[**2108-12-27**] 11:05PM BLOOD CK-MB-19* MB Indx-6.1* cTropnT-0.16*
[**2108-12-27**] 12:05PM BLOOD cTropnT-0.28*
[**2108-12-27**] 12:05PM BLOOD CK-MB-23* MB Indx-6.1*
[**2109-1-4**] 06:40AM BLOOD Calcium-7.5* Phos-3.4 Mg-2.1
[**2109-1-4**] 06:40AM BLOOD Calcium-7.5* Phos-3.4 Mg-2.1
[**2108-12-29**] 04:47PM BLOOD Calcium-7.6* Phos-3.7 Mg-2.3
[**2108-12-27**] 12:05PM BLOOD Albumin-3.1* Calcium-8.6 Phos-4.2 Mg-1.9
[**2108-12-28**] 06:33AM BLOOD TSH-1.0
[**2108-12-29**] 06:48AM BLOOD Type-ART Temp-37.1 Rates-/13 O2 Flow-2.5
pO2-84* pCO2-38 pH-7.38 calTCO2-23 Base XS--1 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2108-12-28**] 04:05AM BLOOD Glucose-73 Na-138 K-5.0 Cl-114*
calHCO3-15*
[**2108-12-28**] 04:05AM BLOOD Hgb-11.8* calcHCT-35
[**2108-12-28**] 04:05AM BLOOD freeCa-1.16
[**2108-12-27**] 01:49PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.015
[**2108-12-27**] 01:49PM URINE Blood-LG Nitrite-POS Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-4* pH-5.0 Leuks-MOD
[**2108-12-27**] 01:49PM URINE RBC-21-50* WBC->50 Bacteri-MANY
Yeast-NONE Epi-0-2 RenalEp-0-2
[**2108-12-29**] 09:51AM URINE Hours-RANDOM UreaN-580 Creat-67 Na-50
K-24 Cl-26
[**2108-12-29**] 09:51AM URINE Osmolal-404
[**2108-12-27**] 1:49 pm URINE Site: CATHETER
**FINAL REPORT [**2109-1-2**]**
URINE CULTURE (Final [**2109-1-2**]):
GRAM POSITIVE RODS. >100,000 ORGANISMS/ML..
DUE TO LOSS OF VIABILITY, UNABLE TO IDENTIFY FURTHER
CHEST (PORTABLE AP) Study Date of [**2108-12-30**] 4:49 AM
FINDINGS: Metastatic lung nodules are again visualized with
nodules and
diffuse lymphangitic infiltration. There is no new infiltrate.
There is
likely small left effusion that is increased.
CHEST (PORTABLE AP) Study Date of [**2108-12-29**] 5:05 AM
IMPRESSION: AP chest compared to [**12-27**] and 19:
Over the past two days, there has been a slight increase in
background
radiodensity of the lungs. This may be due in part to lower lung
volumes, but a small component of mild pulmonary edema is
probably present even though heart size is normal and there has
been no engorgement of mediastinal or hilar pulmonary
vasculature. Severe metastatic involvement of both lungs
consists of scores of nodules up to 2 cm in size and diffuse
lymphangitic infiltration. Small bilateral pleural effusion is
probably present. There is no pneumothorax.
Brief Hospital Course:
1. Gastrointestinal Bleeding due to Esophageal Ulcers:
She underwent endoscopy, which showed a superficial linear
ulceration in the distal 3rd of esophagus. No evidence of
bleeding during the EGD. At the GE junction, there was more
extensive ulceration with a single 1 cm shelf-like lesion. There
was a 5 mm red spot without a vissible vessel and no active
bleeding. in the esophagus. There was a large greyish material
in fundus. The esophageal ulcerations could be secondary to the
prednisone use. Otherwise normal EGD to second part of the
duodenum. She was started on [**Hospital1 **] protonix, and had no further
bleeding. Her hematocrit remained stable throughout. She was
started on a slow prednisone taper, as the reason for steroids
is unclear. Would be wary of hypotension, and would suspect
adrenal insufficiency if it develops and would give stress dose
steroids.
2. History of Deep vein thrombosis, possible pulmonary embolism:
She was persistently tachycardic, and had lower extremity
ultrasounds that showed evidence of an old DVT. In the ICU, she
was started on heparin and transitioned to low dose lovenox.
Due to risk of bleeding, with recent GI bleed and severe
thrombocytopenia, Lovenox was discontinued except for
prophylaxis dose subcutaneous heparin.
3. Non ST elevation myocardial infarction: She had evidence of
elevated troponin and CK, in the setting of her upper GI bleed.
She did complain of chest pain which resolved with pain control.
Further treatment was deferred given her overall clinical
situation.
4. Bladder cancer metastatic to Liver, Lung: She was recently
diagnosed with a new bladder tumor, after having longstanding
bladder cancer. Per discussions with her oncologist, and work
up here, this was found to be metastatic to liver and lung. She
continued XRT while here in the hospital for palliation of her
bladder tumor, and will continue this as long as she is able to
tolerate it. She was followed by palliative care, and was
started on standing oxycodone for pain control, with good
effect. After she completes XRT, she will likely transition to
home hospice.
5. Acute Renal Failure on Chronic Kidney Disease Stage III,
hyperkalemia: She has baseline stage III chronic kidney disease,
with worsening here in the setting of the bleed. Her abdominal
ultrasound showed no kidney on the left, consistent with her
prior nephrectomy, and no hydronephrosis on the right. She was
hydrated, and continued to have a creatinine of over 2 which is
her baseline.
6. COPD: Patient without signs of current exacerbation. Normal
02 sat. Will continue outpatient meds with albuterol prn
7. History of Stroke: Aspirin is currently on hold, and may be
restarted post discharge for CVA prophylaxis.
8. Urinary tract infection: Her initial UA showed many white
cells, but culture showed gram positive rods. She was treated
with ciprofloxacin for 5 days, although the culture was never
speciated due to technical reasons.
# FEN: IVF, check lytes [**Hospital1 **], NPO for now, but need to address
nutritional status after able to eat.
# Disposition: To nursing facility, with likely transition to
home hospice. Patient is DNR/DNI
Medications on Admission:
Aspirin 81 mg daily
Wellbutrin 150 once a day
megestrol 3 tabs once a day
Tums a thousand mg a day
iron
Flex [**Doctor Last Name **]
Prednisone 15mg a day (COPD?)
Diovan 160 mg qdaily
Spiriva 1 puff a day
Jinseng
L-thyroxine 130 mcg a day ?
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation Q4H (every 4 hours) as needed for dyspnea.
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
5. Oxycodone 5 mg Tablet Sig: 0.5 to 1 Tablet PO Q4H (every 4
hours) as needed.
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 30 days.
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days: Then transition to 5mg Daily x 7 days, then off.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for fever or pain.
14. GlycoLax 100 % Powder Sig: One (1) packet PO once a day as
needed for constipation.
15. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day): For Thrush.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Gastrointestinal bleed
Esophageal Ulcers
Metastatic bladder cancer with Mets to Liver
Acute renal failure
Chronic kidney disease Stage III
Urinary tract infection
Thrombocytopenia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with vomiting blood from an esophageal ulcer.
You were admitted to the ICU and stabilized, and then
transferred to the floor. You did not require any blood
transfusions. You were also found to have old blood clots in
your legs, and worsening kidney failure.
Return to the emergency room if you develop shortness of breath,
chest pain, severe abdominal pain, inability to urinate, black
tarry stools, vomitting blood, vomitting coffee ground material.
Make sure to drink plenty of fluids
Followup Instructions:
Follow up with Drs. [**Last Name (STitle) 27542**] and [**Last Name (STitle) 34565**],[**First Name3 (LF) **] C.
[**Telephone/Fax (1) 11144**] as needed.
ICD9 Codes: 5990, 5849, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2993
} | Medical Text: Admission Date: [**2198-6-12**] Discharge Date: [**2198-6-29**]
Date of Birth: [**2121-7-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfur
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Dehydration, left recurrent chylothorax
Major Surgical or Invasive Procedure:
[**2198-5-30**] and [**2198-6-8**]: Ultrasound-guided therapeutic thoracentesis
(outpt)
[**2198-6-13**]: Left video-assisted thoracoscopy exploration and fibrin
glue application. Right video-assisted thoracoscopy thoracic
duct ligation and fibrin glue.
[**2198-6-22**]: Interventional Radiology - lymphangiography with
embolism of upper abdominal lymphatics up to the level of
cisterna chyli with microcoils and gelfoam slurry
[**2198-6-25**] Right pigtail placement for large pleural effusion
removed [**2198-6-28**]
History of Present Illness:
Ms. [**Known lastname 6955**] is a pleasant 76 year old female who underwent
video-assisted thoracoscopic surgery left upper lobe wedge
resection and left lower lobectomy on [**2198-5-18**]. Pathology
revealed a well differentiated adenocarcinoma from the LUL wedge
resection (with 1 cm of free margin). The lower lobectomy
revealed a 6-cm poorly differentiated mixed acinar and solid
adenocarcinoma (with clean margins). Post-operatively, she
developed a slow-rate chylous effusion which was conservatively
monitored until chest tube removal on [**2198-5-23**]. She was
discharged on [**2198-5-24**].
Upon return to clinic it was noted that she had been doing well
on oxygen therapy, but her pre-visit CXR revealed evidence of
left pleural effusion recurrence. IP was consulted and Dr. [**Last Name (STitle) **]
performed an ultrasound-guided thoracentesis on [**2198-5-30**]. This
removed 1500 mL of chylous fluid (pleural triglycerides > 400).
On [**2198-6-5**] she again returned to clinic with recollection of
the chylous effusion and had a second thoracentesis performed.
It was felt, at that time, that duct ligation may be warranted,
but that her bronchial stump needed adequate healing time. IP
performed thoracentesis on [**2198-6-5**] removing 1800 mL of chylous
fluid.
She was seen in clinic on [**2198-6-12**] with dyspnea, cough symptoms
and dehydration and was admitted directly for surgical
intervention with thoracic duct ligation for her persistent
chylous leak. She had surgery on [**6-13**], but still with a chyle
leak. On [**2198-6-22**], she underwent lymphangiography with
embolization of the leaking area as well as far distal and
proximal to the area.
Past Medical History:
PMH: Hypertension, Dyslipidemia, Osteoporosis
PSH: Status post right oophorectomy, appendectomy, cataract
surgery bilaterally. s/p VATS left upper lobe wedge resection
and left lower lobectomy
Social History:
She is a widowed just recently after a 53-year marriage, has two
daughters, does not work but used to be an office manager. 15-20
pack year history of smoking. Quit 30 years ago. Furniture
stripper and decorator used toxic dye.
Family History:
Mother died 95 unknown causes
Father died 79 of colon cancer
sister had myocarditis and died at age 41
Sister 79 stroke
Offspring: two healthy daughters
Physical Exam:
VS: T 97.3, HR 84 reg, BP 106/54, RR 16, O2 sats 97% 2.5 LNC
Physical Exam:
Gen: pleasant in NAD, Alert and oriented x 4
Lungs: decreased breath sounds on the left, clear on right.
Right and Left VATS incisions healing with clean, dry intact
dressing on bilateral old chest tube sites.
Heart: RRR, S1, S2, no MRG
Abd: soft, non tender, non-distended
Ext: warm, no edema
Pertinent Results:
[**2198-6-29**] 08:20AM BLOOD WBC-19.8* RBC-3.36* Hgb-9.8* Hct-30.7*
MCV-91 MCH-29.1 MCHC-31.9 RDW-15.5 Plt Ct-539*
[**2198-6-28**] 04:10PM BLOOD WBC-25.7* RBC-3.68* Hgb-10.8* Hct-33.3*
MCV-91 MCH-29.4 MCHC-32.5 RDW-15.5 Plt Ct-591*
[**2198-6-27**] 07:35AM BLOOD WBC-22.8* RBC-3.22* Hgb-9.5* Hct-29.0*
MCV-90 MCH-29.3 MCHC-32.6 RDW-15.3 Plt Ct-470*
[**2198-6-24**] 08:34PM BLOOD Neuts-86* Bands-0 Lymphs-1* Monos-3
Eos-6* Baso-0 Atyps-0 Metas-0 Myelos-4*
[**2198-6-29**] 08:20AM BLOOD Glucose-90 UreaN-20 Creat-0.4 Na-140
K-4.6 Cl-103 HCO3-33* AnGap-9
[**2198-6-29**] 08:20AM BLOOD Albumin-3.1* Calcium-9.0 Phos-3.3 Mg-2.3
[**2198-6-28**] 04:10PM BLOOD Calcium-9.0 Phos-2.8 Mg-2.3
[**2198-6-15**] 07:50AM BLOOD calTIBC-199* Ferritn-238* TRF-153*
MRSA on nasal swab [**2198-6-25**]
Bedside swallow evaluation [**2198-6-28**]: no evidence of aspiration
CTA [**2198-6-25**]
IMPRESSION:
1. Left lower lobe pulmonary thrombus in the setting of lower
lobectomy.
2. Moderate-to-large right pleural effusion with right basilar
collapse.
3. 6.0 cm x 5.1-cm fluid collection within the left pleural
space compatible
with loculated hydropneumothorax. Continued followup to this
area is
recommended.
4. Diffuse intralobular septal thickening, findings suggestive
of volume
overload.
5. Scattered punctate areas of hyperintensity seen in both
hemithoraces,
likely related to previous embolization procedure.
CXR [**2198-6-28**]
FINDINGS: PA and lateral chest views have been obtained with
patient in
upright position. Comparison is made with the next preceding AP
single view chest examination of [**2198-6-26**]. During the
interval, the right-sided pigtail ending pleural drainage tube
has been removed. No evidence of increased pleural effusion in
this area and no pneumothorax in the right apical area.
Diffuse left lower thorax density obliterating the diaphragmatic
contour
entirely remains rather unchanged. The same holds for evidence
of
contrast-dense linear structures, apparently remnants from a
thoracic duct
examination, remain in unchanged position. There is, however,
now evidence of a small 3 cm wide air-fluid level overlying the
left hilar area, a finding which was not present on the previous
portable examination. It is unclear whether this finding may
relate to changes in patient's position which is now upright. It
most likely represents a localized hydrothorax in this area
considering that the patient has recently undergone a left lower
lobectomy.
[**2198-6-21**] urine
URINE CULTURE (Final [**2198-6-24**]):
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2198-6-25**] Urine culture: no growth
Brief Hospital Course:
Mrs. [**Known lastname 6955**] was admitted to the Thoracic surgery service on
[**2198-6-12**] directly from clinic due to recurrent left sided
chylothorax, despite two thoracentesis and low fat diet. On
[**2198-6-13**] she underwent bilateral VATS with thoracic duct ligation
and fibrin glue. Her chylothorax persisted, therefore on [**2198-6-22**]
she underwent IR guided embolization of thoracic duct and upper
abdominal lymphatics, which was successful. Her left [**Doctor Last Name **] drain
revealed small serous output, therefore the drain was removed on
[**2198-6-25**]. CXR was stable. The patient however was short of breath
with hypoxemia on ABG. The patient underwent CTA of chest that
revealed increased right sided pleural effusion and thromus to
the [**MD Number(3) 25805**] that was previously resected. Dr. [**Last Name (STitle) 25806**] was
not concerned about PE and anticoagulation with this finding;
but a normal variant given her LLL lung resection. The patient
was transfered to the ICU and underwent emergent pig tail
pleural catheter placement which initially drained 1200ml, then
300-400ml every 4 hours, with about 2L over the evening. The
patient had marked improvement in her pulmonary status,
breathing comfortable, oxygenating well on less oxygen, improved
mentation, and less anxiety. She was transferred back to the
floor where she recovered, tolerating a regular diet, ambulated
with PT and rested. Her chest tube was removed without right
pneumothorax on CXR on [**2198-6-28**].
A bedside swallow evaluation was performed which showed normal
swallow without evidence of aspiration. The patient however was
more comfortable with softer foods and crushed pills.
Of note she was afebrile but had leukocytosis to 28,800.
Initially she presented on [**2198-6-21**] with klebsiella UTI treated
with 5 day course of cipro which was found to be cured on repeat
urine culture. She had a PICC with TPN which was removed but all
cultures were negative to date. She did however on routine
culture test positive for MRSA in the nares.
The patient is ambulating with physical therapy, oxygenating
well on 2.5 Liter Nasal cannula, eating a low fat diet, with
stable electrolytes and vital signs. She is deemed safe for
discharge today to her former rehab as discussed with Dr.
[**Last Name (STitle) **] and the patient and her daughter [**Name (NI) 2270**]. She will
need nutritional optimization and continue vitamin supplements
as ordered. We will see her back in one weeks time for followup.
Medications on Admission:
HYDROMORPHONE - (Prescribed by Other Provider) - 2 mg Tablet -
1
(One) Tablet(s) by mouth every four (4) hours as needed for pain
METOPROLOL SUCCINATE [TOPROL XL] - (Prescribed by Other
Provider) - 25 mg Tablet Sustained Release 24 hr - 1 (One)
Tablet(s) by mouth once a day
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
(One) Tablet(s) by mouth at bedtime
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - (Prescribed by
Other Provider) - 18 mcg Capsule, w/Inhalation Device
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Oxycodone 5 mg Tablet Sig: half to one Tablet PO Q6H (every 6
hours) as needed for pain.
6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY
(Daily): x 8 more days.
8. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (SA): saturdays x 8 more weeks.
9. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily). Capsule(s)
10. Miralax 17 gram/dose Powder Sig: One (1) packet PO once a
day.
11. Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Left chylothorax
Right pleural effusion
Resolving leukocytosis
Resolved klebsiella UTI sensitive to ciprofloxacin
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:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills or shakes
-Increased shortness of breath, cough or sputum production
-Chest pain
-Keep chest tube site covered with a bandaid until healed.
-You may shower no tub bathing or swimming until incision healed
Eat high protein foods, with supplemental protein shakes through
the day. Dietician consultation and management during rehab
stay.
Ambulate three times a day with physical therapy
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on [**2198-7-5**] on [**Hospital1 18**] [**Hospital Ward Name **] at 3:30 pm and get a chest xray at 3pm on [**Location (un) **]
radiology before appointment.
Completed by:[**2198-6-29**]
ICD9 Codes: 5990, 496, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2994
} | Medical Text: Admission Date: [**2185-4-13**] Discharge Date: [**2185-4-29**]
Date of Birth: [**2117-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Malaise
Major Surgical or Invasive Procedure:
Upper endoscopy
Colonoscopy
History of Present Illness:
Mr [**Known lastname 11753**] is a 68 year old man with past medical history
significant for COPD, CLL, Hypertension, and recent admission
for pulmonary embolus complicated by respiratory failure,
intubation and a ventillator associated pneumonia, presenting
from home with weakness, tremmor and fatigue and now found to
have GPC bacteremia.
Patient reports progressive weakness for the past two days, but
most concerning to him is bilateral upper extremity tremmor. He
has never had this in the past, it is not associated with any
numbness or tingling and is present all day. Patient had recent
hospital acquired pneumonia, treated until [**2185-4-2**] with
Vanc/Cefepime, however now he feels his breathing is much
improved. At time of discharge from the hospital he had a 2
liter oxygen requirement. He does however report some low grade
fevers at rehab (~99.0) Of note, he was recently started on
Trazodone and Celexa 40mg daily. Denies any cough or sputum
production, has been active and able to ambulate with PT at
rehab. At the time of discharge from rehab he had a 2L oxygen
requirement.
In the ED, initial VS were: 99.8 96 122/68 16 99% (2-3L ? vs
RA). Patient was given Aspirin, morphine chronic neck pain, NS
at 125/hr and admitted for further managmeent.
Vitals on admission were HR 100 111/74 15 99%3L
On the floor, had A. Fib with RVR in 120's. Increased
metoprolol to 125 [**Hospital1 **] from 100. This afternoon patient growing
GPC's in blood (likely strep). got 250cc bolus at that point
with BP in 90's systolic. HR increased to 130's with systolic
BP in mid 80's. Got further 500cc's, and BP improved to mid
90's. HR still 110 so go another 500cc bolus. Following that
patient with increasing respiratory distress with requiring NRB
for oxygenation. Given nebulizers but lasix held given
hypotension earlier. Now asked for ICU transfer for increasing
oxygen requirement. Vanco/zosyn given on the floor.
At time of ICU evaluation patient with RR 24-26 on 5L via face
mask and c/o shortness of breath. On arrival to ICU satting in
mid 90'd on 2L NC with stable BP of 110.
Past Medical History:
# Chronic lymphoid leukemia (CLL).
# Chronic obstructive pulmonary disease (COPD).
-- FVC 79% pred, FEV1 71% pred, FEV1/FVC 90% pred [**2-/2185**]
# [**Hospital1 **]-ventricular systolic failure with LVEF 45% and dilated RV
with signs of overload
# Pulmonary hypertension
# Pulmonary nodules
# Depression.
# Hypertension.
# Hyperlipidemia
# Peptic ulcer disease.
# Right eye cataract (S/p removal at the age of 12. He had an
injury to his eye and has no vision in that eye for years)
# Deviated nasal septum, s/p surgery
# Cervical arthritis.
# History of colon polyps (? adenoma).
# History of herniated disks with chronic back pain
# Benign Prostatic hypertrophy
Social History:
He is married and lives with his wife in [**Name (NI) 3146**]. She has
significant emotional problems, which requires the patient to
care for her almost constantly. He continues to smoke 1 pack a
day, which he has done for at least 50 years and he is not
interested at this time in quitting. He denies ethanol and
illicit drug use.
Family History:
Mother died at age 85, complications of Alzheimer's disease.
Father died at age 74, complications of congestive heart
failure. He reports no history of colon cancer, polyps or
coronary disease in his family. A brother developed [**Name (NI) 5895**]
disease.
Physical Exam:
VS HR 103, BP 104/72, RR 24 O2 98% NRB -> 95% 5L NC/FM
Gen: Mild distress
HEENT: NCAT, right pupil surgical, neck supple, JVP difficult to
ascertain
Lungs: Rales at right base, otherwise clear, no wheezing
Abdomen: firm, NTND, +BS
Ext: [**12-25**]+ peripheral edema of RLE, LLE trace edema
Neuro: AOx3, appropriate
Pertinent Results:
LABS ON ADMISSION:
[**2185-4-12**] 01:56PM PLT SMR-NORMAL PLT COUNT-211
[**2185-4-12**] 01:56PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL SCHISTOCY-1+
BURR-1+
[**2185-4-12**] 01:56PM NEUTS-48* BANDS-0 LYMPHS-43* MONOS-6 EOS-2
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2185-4-12**] 01:56PM WBC-18.2*# RBC-3.68* HGB-11.0* HCT-33.9*
MCV-92 MCH-29.9 MCHC-32.4 RDW-15.4
[**2185-4-12**] 01:56PM b2micro-3.5*
[**2185-4-12**] 01:56PM ALT(SGPT)-23 AST(SGOT)-16 LD(LDH)-238 ALK
PHOS-72 TOT BILI-0.8
[**2185-4-12**] 01:56PM estGFR-Using this
[**2185-4-12**] 01:56PM UREA N-18 CREAT-0.8
[**2185-4-13**] 05:05PM PT-33.0* PTT-35.9* INR(PT)-3.3*
[**2185-4-13**] 05:05PM PLT COUNT-231
[**2185-4-13**] 05:05PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2185-4-13**] 05:05PM NEUTS-22* BANDS-3 LYMPHS-62* MONOS-7 EOS-0
BASOS-0 ATYPS-6* METAS-0 MYELOS-0
[**2185-4-13**] 05:05PM WBC-14.2* RBC-3.91* HGB-11.6* HCT-35.4*
MCV-91 MCH-29.7 MCHC-32.8 RDW-16.1*
[**2185-4-13**] 05:05PM TSH-2.4
[**2185-4-13**] 05:05PM CK-MB-NotDone
[**2185-4-13**] 05:05PM cTropnT-<0.01
[**2185-4-13**] 05:05PM CK(CPK)-15*
[**2185-4-13**] 05:05PM GLUCOSE-101* UREA N-17 CREAT-0.9 SODIUM-129*
POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-27 ANION GAP-13
[**2185-4-13**] 05:16PM LACTATE-1.8
[**2185-4-13**] 10:02PM URINE RBC-0 WBC-[**2-25**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2185-4-13**] 10:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-SM
[**2185-4-13**] 10:02PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2185-4-13**] 10:02PM URINE OSMOLAL-599
[**2185-4-13**] 10:02PM URINE HOURS-RANDOM CREAT-160 SODIUM-18
POTASSIUM-72 CHLORIDE-29 TOTAL CO2-LESS THAN
========
MICROBIOLOGY:
- [**2185-4-13**] Blood culture:
ENTEROCOCCUS FAECALIS
| ENTEROCOCCUS FAECALIS
| |
AMPICILLIN------------ <=2 S <=2 S
DAPTOMYCIN------------ S
PENICILLIN G---------- 0.5 S 4 S
VANCOMYCIN------------ <=0.5 S 1 S
- [**2185-4-13**] Urine culture: Klebsiella pneumoniae (sensitive to
meropenem)
- [**2098-4-13**] Blood culture: Negative
- [**2098-4-13**] MRSA screen: Negative
- [**2185-4-16**] VRE swab: Positive
-[**4-21**] C diff: negative
-[**4-21**] Abd wall fluid collection: negative
-[**4-25**] BCx: pending
-[**4-25**] UCx: YEAST 10,000-100,000 ORGANISMS/ML
========
IMAGES/STUDIES:
[**2185-4-13**] ECG: Atrial fibrillation with a ventricular rate of 90.
RSR' pattern in leads V1-V2 with a QRS duration of 84. ST-T wave
changes in leads II, III, aVF and V3-V5. Compared to the
previous tracing of [**2185-3-20**] no diagnostic interval change.
[**2185-4-13**] CXR: FINDINGS: PA and lateral views of the chest are
obtained. There has been interval removal of the PICC line and
left IJ central venous catheter. Comparison is also made with a
CT chest from [**2185-3-20**]. Extensive centrilobular and paraseptal
emphysema is better assessed on prior CT, though accounts for
the lucency in the upper lungs, primarily in the left
paramediastinal region. The heart is enlarged. The coarsened
interstitial markings are compatible with known underlying
COPD/emphysema. There is likely a stable small right pleural
effusion. There is no definite sign of new consolidation.
Mediastinal contour is stable. The osseous structures are
intact. IMPRESSION: 1. Chronic interstitial lung disease
secondary to emphysema with prominent paraseptal emphysema
accounting for left upper lobe lucency. 2. Cardiomegaly.
[**2185-4-14**] ECG: Atrial fibrillation at a rate of 112. Compared to
tracing #1 no diagnostic interval change.
[**2185-4-14**] ECG: Marked baseline artifact. The rhythm is probably
atrial fibrillation. Poor R wave progression in leads V1-V3.
ST-T wave changes in leads II, III, aVF and leads V2-V4.
Compared to the previous tracing of [**2185-4-14**] these changes are
similar to those seen at that time. Probably no diagnostic
interval change.
[**2185-4-14**] CXR: SINGLE PORTABLE CHEST RADIOGRAPH: There is
unchanged severe cardiomegaly. The mediastinal and hilar
contours are stable. There has been significant interval
improvement of interstitial pulmonary vascular congestion as
demonstrated on radiograph one day prior. Biapical cystic
changes more prominent on the left due to emphysema are better
demonstrated on prior CT. There is no focal consolidation to
suggest acute pneumonia. There is no large effusion or
pneumothorax. IMPRESSION: 1. Marked interval improvement of
interstitial pulmonary vascular congestion since one day prior.
2. No focal consolidation to suggest pneumonia.
[**2185-4-15**] TTE: The left atrium is mildly dilated. The right atrium
is markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is mildly depressed with
septal hypokinesis (LVEF= 45-50 %). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] The right ventricular cavity is mildly
dilated with severe global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened. Small (~0.5 cm) echodense structure(s)
seen on the aortic side of the aortic valve similar to Lambl's
excrescence although somewhat thickened appearance raises
suspicion of possible vegetation. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is moderate/severe
mitral valve prolapse. An eccentric, laterally directed jet of
moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is a very small
pericardial effusion. Compared with the prior study (images
reviewed) of [**2185-3-10**], findings are similar. Small echodense
structure seen on aortic valve in the prior study slightly more
prominent in the current study but could be due to differences
in image quality. Suggest transesophageal echocardiography to
assess, if clinically indicated.
[**2185-4-15**] CXR: Emphysema is severe, mild pulmonary edema improved
since [**4-13**]. Tiny left pleural effusion may be present. Heart
size normal. Leftward mediastinal shift longstanding and does
not indicate left lower lobe collapse.
[**2185-4-16**] CXR: There is mild progression of consolidation seen in
the left lower lobe. Known extensive bilateral emphysema.
Increased diameter of the right pulmonary hilus is noted;
however, when reviewing previous CT from [**2185-3-12**], it is
seen that this is not caused by pathologic mass. Bilateral small
pleural effusions, left slightly greater than right. The heart
is normal sized.
[**4-18**] TEE: No evidence of endocarditis. Stretched PFO with
resting left-right shunt. Moderate, eccentric mitral
regurgitation. Complex but non-mobile descending aortic
atheroma.
[**4-19**] CT Abd/Pelvis:
1. 0.6 x 1.0 cm right lower lobe nodular pulmonary density,
which could
represent scarring adjacent to the emphysematous bullae, but
enlarging
pulmonary nodule, potentially suspicious for malignancy, cannot
be excluded. Short interval followup is recommended with
dedicated chest CT in three months.
2. 2.7 cm oval hypodense lesion in the left lateral abdominal
wall,
intramuscular in location, may represent a small abscess or less
likely a
hypoenhancing mass. This could be further evaluated with
ultrasound.
3. Diverticulosis without evidence of diverticulitis. This
examination is not sensitive for the detection of colonic
masses. No evidence of bowel
obstruction.
4. Emphysema, atelectasis, pleural effusions, and right atrial
enlargement.
5. Air within the urinary bladder. Please correlate with any
history of
recent Foley catheterization.
6. Abdominal aortic aneurysm measuring up to 3.4 cm and right
common iliac artery aneurysm.
[**4-21**] Abd U/S: 3-cm left flank intramuscular fluid collection,
which is amenable to ultrasound-guided aspiration.
[**4-23**] CTA:
1. Infrarenal AAA. No evidence of aortoenteric fistula.
2. Right common iliac artery fusiform aneurysm.
3. Narrowing and angulation of the celiac artery at region of
median arcuate ligament may be due to respiratory phase of
imaging. If median arcuate ligament syndrome is a clinical
concern, MRA would be performed with inspiratory and expiratory
phase imaging.
4. Severe emphysema.
5. Right lower lobe nodule which requires follow-up, as
previously advised.
[**4-26**] CXR: In comparison with study of [**4-25**], there is little
overall change. Extensive opacification is again seen at the
left base silhouetting the hemidiaphragm and some shift of the
mediastinum to that side. This is consistent with substantial
volume loss in the left lower lobe. The costophrenic angle has
been excluded from the image.
Viewed small right pleural effusion with continued engorgement
of pulmonary vessel is consistent with elevated pulmonary venous
pressure.
[**4-26**] Colonoscopy:
Mucosa: Area of erythema in the proximal ascending colon. [**Month (only) 116**]
be [**1-25**] trauma from scope vs. underlying angioectasias. Cold
forceps biopsies were performed for histology at the proximal
ascending colon.
Other No bleeding found. No mass lesions seen.
Impression: Abnormal mucosa in the colon (biopsy)
No bleeding found. No mass lesions seen.
Brief Hospital Course:
68 year old man with past medical history significant for COPD,
congestive heart failure, recent pulmonary embolism, and
pneumonia admitted with respiratory distress, bacteremia.
.
# Bacteremia/Sepsis: Blood cultures drawn on admission grew
Enterococcus faecalis. He was started on broad spectrum
antibiotics including linezolid given concern for potential VRE
as he had recently been on vancomycin for treatment of
pneumonia. Sensitivities later revealed pan-sensitive
enterococcus, and linezolid was changed to ampicillin. He did
have an episode of tachycardia and hypotension on the floor,
which responded to intravenous fluids. The infectious disease
service was consulted. A trans-thoracic echo was performed to
evaluate for possible vegetation, which showed an echodense
structure on the aortic valve. To further evaluate, an
transesophageal echo was obtained, which showed no endocarditis.
Subsequent cultures were negative, although the patient's VRE
rectal swab was positive.
.
# COPD/Respiratory Distress: On [**4-15**], the patient was
transferred to the ICU for tachypnea and a worsening oxygen
requirement in the setting of IV fluid administration for
hypotension. It is likely that, in this patient with heart
failure and advanced COPD on 2L home O2, he has limited
pulmonary reserve so that even mild pulmonary edema result in
significant distress. He was given IV lasix boluses and
nebulizer treatments with significant improvement in his
respiratory status. There was no evidence of pulmonary infection
on imaging and urine legionella was negative. He was transferred
back to the medicine floor on [**4-17**]. He was continued on
outpatient tiotropium and inhaled steroids.
.
# Lower GI Bleed: On [**4-23**], the patient passed bloody bowel
movements. His hematocrit dropped to 22. He was transferred back
to the MICU. He underwent EGD, which was normal. He required
transfusion of four units of packed RBCs. He underwent CT
angiogram of his abdomen, which was negative for aortoenteric
fistula. The patient subsequently underwent colonoscopy which
was unrevealing for acute bleed, but erythematous mucosa was
biopsied to evaluate for arteriovenous malformation. His aspirin
and warfarin had been held, but were restarted on his day of
transfer to rehab, as his hematocrit had been stable with no
further bleeds for about a week.
.
# UTI. Urine culture with sensitive Klebsiella. He completed a
seven day course of ciprofloxacin.
.
# Hyponatremia: Variably attributed to SIADH and hyervolemic
hyponatremia. The patient was placed on conservative fluid
restrictions. Renal was consulted and the patient was also
diuresed with IV and PO furosemide. Sodium levels subsequently
normalized.
.
# Atrial Fibrillation: He was in atrial fibrillation with
variable rate control. He was continued on rate control with
lopressor and diltiazem. He was anticoagulated with warfarin for
thromboembolic prophylaxis with a goal INR of [**1-26**]. Following his
lower GI bleed, his systemic anticoagulation was held. He and
the rehabilitation center were instructed to restart his
warfarin (and aspirin) on the day of transfer.
.
#. Weakness/tremor: Believed to be related to recent addition of
citalopram. The patient also takes trazodone, but did not
display any other signs of serotonin syndrome such as
nausea/vomitting/diarrhea. His tremor persisted to varying
degrees
.
#. Pulmonary hypertension/PE: No formal workup in setting of
subacute pulmonary embolus. Will need outpatient follow up. PE
Likely contributing to right ventricular volume overload and
pulmonary hypertension as above. Patient tolerated systemic
anticoagulation until he experienced his GI bleed (see above).
Warfarin was subsequently held as noted above.
.
#. CLL: The patient's WBC count trended down from its baseline
level (20-30K) when the patient developed bacteremia (see
above). As his bacteremia was treated, his WBC count rose to a
level consistent with his baseline level.
Medications on Admission:
Medications at time of transfer
-Vanco 1 gram q12
-Zosyn 4.5 IV q8
-metoprolol 100 PO TID
-atrovent
-ambien
-tylenol
-senna
-docusate
-MVI
-nystatin
-diltiazem 30 QID
-albuterol q2h PRN
-tiotropium daily
-aspirin 81mg daily
-warfarin 4mg daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ampicillin Sodium 2 gram Recon Soln Sig: Two (2) grams
Injection Q4H (every 4 hours) for 2 days: Last dose will be
evening dose on [**2185-4-30**].
3. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Nebulizer treatment Inhalation every four (4) hours as
needed for wheezing/SOB.
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
6. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day) as needed for thrush.
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. Warfarin 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home
Discharge Diagnosis:
Primary:
Vancomycin-sensitive Enterococcus septicemia
Gastrointestinal bleed of undetermined origin
.
Secondary:
Urinary tract infection Klebsiella
Atrial fibrillation
Musculoskeletal chest pain
hypervolemic hyponatremia
acute on chronic systolic congestive heart failure
Chronic lymphocytic leukemia
Pulmonary hypertension
History of pulmonary embolism
Hypertension
Pulmonary nodules
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 11753**],
You came to the hospital for weakness, tremor and fatigue. You
were found to have bacteria in your blood. You were given
antibiotics intravenously and your symptoms improved. You also
had a urinary tract infection that improved with antibiotics.
.
You had respiratory distress and had to go to the intensive care
unit, where your breathing improved with medications to help
remove fluid from your body. You later developed
gastrointestinal bleeding and you had an upper endoscopy as well
as a colonoscopy. Your bleeding stopped, and your blood count
was subsequently stable. Please complete a 14-day course of
antibiotics to end on [**2185-4-30**].
.
We made the following changes to your medicines:
- Started AMPICILLIN to treat your blood infection. Please
continue to take this through the evening of [**2185-4-30**], to complete
a fourteen day course
- Started FUROSEMIDE 20 mg tabs, one tab by mouth once daily, to
prevent excess fluid from accumulating in your body
- Started LIDOCAINE 5% patches, applied once daily to area of
rib pain
- Started LORAZEPAM 0.5 mg tabs, one tab every eight hours as
needed for anxiety
- Started DOCUSATE 100 mg tabs, one tab TWICE DAILY for
softening your stools
- Started SENNA 8.6 mg tabs, one tab TWICE DAILY AS NEEDED for
constipation
- Increased DILTIAZEM to 30 mg tabs, TWO TABS by mouth every six
hours
- Discontinued CITALOPRAM, as it may have been exacerbating your
tremor
- Discontinued chlorthalidone
- We had held your aspirin and warfarin (Coumadin) after your
bleed, but we have restarted both of these medications today,
since your bleeding has stopped.
.
Please call your doctor or return to the emergency room if you
experience any fevers, worsening shortness of breath or chest
pain, or other new concerning symptoms. Please weigh yourself
every day, and if you gain more than three lbs, call your doctor
to discuss taking higher doses of diuretics.
Followup Instructions:
You are not currently assigned to a Primary Care physician. [**Name10 (NameIs) **]
will be called within the next week with a new PCP [**Name Initial (PRE) 648**].
If you do not hear by next Friday, please call [**Hospital **] at [**Telephone/Fax (1) 1247**] to establish primary care.
Your currently scheduled appointments are as follows:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2185-5-18**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2185-10-6**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: VASCULAR SURGERY
When: MONDAY [**2185-10-24**] at 10:30 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: VASCULAR SURGERY
When: MONDAY [**2185-10-24**] at 11:10 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5990, 5789, 4280, 2724, 4168, 4019, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2995
} | Medical Text: Admission Date: [**2144-3-27**] Discharge Date: [**2144-4-7**]
Date of Birth: [**2108-3-6**] Sex: M
Service:
CHIEF COMPLAINT: Hypotension, fever, presumed sepsis.
HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old
male who was transferred to the [**Hospital6 2018**] from [**Hospital3 4419**] because of lack of beds
at the [**Hospital6 1708**] where the patient's
primary physicians are. He is a 36-year-old male with a
complicated medical history including ileus for four months
on TPN, acute demyelinating polyneuropathy making him
quadriplegic, schizo-affective disorder, respiratory distress
with tracheostomy not being used, institutionalized at
[**Hospital1 1319**] since [**2143-10-14**], who was transferred from
[**Hospital1 1319**] with history of upper extremity tremors,
hypotension, and temperature up to 104.3?????? for one day.
PAST MEDICAL HISTORY: 1. Acute demyelinating
polyneuropathy, Guillain-[**Location (un) **] syndrome, who is quadriplegic,
slowly improving, diagnosed at [**Hospital6 **] in [**2143-10-14**] and treated at [**Hospital6 1708**]. 2.
History of respiratory distress with prolonged wean and
tracheostomy, now currently not being used. 3.
Schizo-affective disorder for 18 years. 4. B12 deficiency
and megaloblastic anemia. 5. Recurrent right lower lobe
pneumonia with aspiration with right pleural effusion which
has improved. 6. History of peptic ulcer disease status
post cauterization in [**2143-2-14**]. 7. Ileus times four
months, initially presented in [**2143-10-14**] with severe
ileus, and has been unable to tolerate feeds since then. The
patient has been on TPN. 8. Status post exploratory
laparotomy with appendectomy in [**2143-10-14**] at [**Hospital6 8866**]. 9. History of right lung atelectasis
secondary to mucous plugging, status post multiple
bronchoscopies. 10. History of [**Female First Name (un) 564**] fungemia. 11.
Heparin antibodies (HID). 12. Multivitamin deficiency. 13.
MRSA in sputum.
MEDICATIONS ON ADMISSION: Lopressor 5 mg IV q.6 hours,
Neurontin 100 mg per G-tube t.i.d., Clozaril 200 mg per
G-tube q.h.s., Reglan 20 mg IV q.6 hours, Aquasol [**Numeric Identifier 16351**] U IV
q.a.m., Dilantin 100 mg IV b.i.d., Clonodine 1.7 g IV q.d.,
Zantac 150 mg per G-tube q.12 hours, TPN at 92 cc/hr,
Percocet [**1-15**] tab per G-tube.
ALLERGIES: PENICILLIN CAUSING RASH, HEPARIN (HIT),
COMPAZINE, HALDOL, ...................
SOCIAL HISTORY: The patient lived at ...................
prior to [**2143-10-14**]. Since then he has been at
[**Hospital1 756**]/[**Hospital1 882**], [**Hospital1 2025**], [**Hospital1 1319**]. He has a 9-year smoking
history.
FAMILY HISTORY: Positive for Parkinson's, meningioma.
PHYSICAL EXAMINATION: Vital signs: Temperature 102??????, heart
rate 142 and regular, blood pressure 73/52, oxygen saturation
98% on 2 L. General: The patient was a cachectic,
ill-appearing male. Chest: Rales at right base.
Cardiovascular: Tachycardiac. Abdomen: Thin, soft,
diffusely tender. G- and J-tube present. Extremities:
Thin, warm, cold, clammy. Neurological: Alert and oriented
times three. Intermittently talkative/covalent. Face
symmetric. Extraocular movements intact. Pupils equal,
round and reactive to light. Could wiggle toes bilaterally.
In the upper extremities, the patient was able to
................... Rectal: Stool watery, black, guaiac
negative.
LABORATORY DATA: White count 17.9, hematocrit 31.9, platelet
count 310; INR 1.5, PTT 36.8; CHEM7 with a sodium of 139,
potassium 2.8, chloride 104, CO2 22, BUN 25, creatinine 0.6,
glucose 99; ALT 33, AST 20, CK 123, amylase 21, total
bilirubin 1.2, lipase 6, albumin 2.6, calcium 8.2, phosphate
6.6, magnesium 1.5; ABG 7.26, 29, 38 on 3 L.
Chest x-ray showed right apical pleural thickening, right
PICC line. Electrocardiogram showed sinus tachycardia. KUB
showed mild focal dilatation of small bowel loop, nonspecific
bowel gas pattern in the left lower quadrant.
HOSPITAL COURSE: The patient was admitted under the Medical
Service.
At this time, he was then transferred to the Intensive Care
Unit because he needed pressors to maintain his blood
pressure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2144-4-7**] 10:45
T: [**2144-4-7**] 10:47
JOB#: [**Job Number 47295**]
ICD9 Codes: 0389, 2768, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2996
} | Medical Text: Admission Date: [**2113-7-16**] Discharge Date: [**2113-8-14**]
Date of Birth: [**2037-3-13**] Sex: M
Service: UROLOGY
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 6440**]
Chief Complaint:
76M with a complicated course of a prostate infection,
prostetic fistula, intraabdominal sepsis, and malnutrition
presented with Fever, confusion, and malaise.
Major Surgical or Invasive Procedure:
Cystectomy, Prostatectomy, Ileal Conduit
History of Present Illness:
Pt is a 76M s/p brachytherapy on [**2112-11-18**]. Chronic
prostatitis/recurrent prostate abscesses since [**3-11**]. Pt has
undergone at least 2 percutaneous drainages of periprostatic
phlegmons since [**3-11**] and has been treated with long-term
antibiotics, most recently with bactrim since [**5-11**]. Pt
underwent
surgical drainage and debulking on [**2113-7-7**] and was left with a
foley as well as a penrose drain in place. Pt reports a fever
since Friday [**7-14**] with a Tmax of 101.8 this morning. Pt has
been at a rehab facility since his discharge after surgical
drainage.
Past Medical History:
Prostate cancer, hairy cell leukemia, mitral valve prolapse,
glaucoma, depression, hypercholesterolemia
PSHx: Splenectomy ([**2103**])
Social History:
rehab since [**2113-7-8**]
Family History:
Non-Contributory
Physical Exam:
Physical Exam
Gen: Well appearing, no acute distress
CV: Regular rate and rhythm, no R/G/M
RESP: CTAB
ABD: Penrose drain to gravity in ostomy bag, Soft, non-tender
GU: Foley to gravity
Pertinent Results:
Cardiology Report ECHO Study Date of [**2113-7-17**]
Conclusions: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%) Tissue
Doppler imaging suggests a normal left ventricular filling
pressure PCWP<12mmHg). 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.
No mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild mitral leaflet thickening but without definite
vegetation or pathologic flow.
MRI ABDOMEN W/O CONTRAS Study Date of [**2113-7-17**] 10:46 AM
IMPRESSION:
1. Limited evaluation of the pelvis secondary to motion
artifact and the
patient's inability to tolerate the examination. Right
ischiorectal fossa
abscess adjacent to the right prostate gland. Reported Penrose
drain is not identified on this exam.
2. Ill-defined fluid collection within the dorsum of the penis,
which may
represent a second abscess versus non-specific edema secondary
to Foley
catheter.
CT GUIDANCE DRAINAGE Study Date of [**2113-7-17**] 4:03 PM
IMPRESSION:
1. Successful CT-guided drainage of pelvic fluid collection
ECG Study Date of [**2113-7-18**] 9:52:40 AM
Sinus tachycardia. Diffuse non-specific ST-T wave changes. No
previous
tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
101 154 80 292/350 54 34 64
CHEST (PRE-OP PA & LAT) Study Date of [**2113-7-19**] 10:51 AM
IMPRESSION: PA and lateral chest reviewed in the absence of
prior chest
radiographs:
Normal heart, lungs, hila, mediastinum and pleural surfaces.
Two lower
thoracic vertebral bodies are mildly compressed anteriorly.
([**7-25**])CT-fluid collection ischiorectal fossa improved 4cm-1.5
cm, improved since last MRI
Penis Shaft edematous, Need MRI to look at soft tissues, contor
irregularity along left dorsum,? resdiual fluid, No Abscess
SBO, distended loops of SB, adhesion along anterior abd wall
([**7-27**]) CXR-PICC in place, not PTX, able to visualize left
diaphragm better compared to CXR on [**7-25**], improvement of
aspiration pneumaonia
[**7-25**] CXR pos for aspiration pneumonia- New left lower lobe
consolidation consistent with aspiration and/or atelectasis.
[**7-31**]-Penile Wound Culture - positive for Coag negative Staph
Aureus and Vancomycin sensitive Enterrococcus
Negative for AFB, Fungus, HSV 1&2,
[**7-31**]-I&D in OR
PREOPERATIVE DIAGNOSIS: Scrotal abscess.
POSTOPERATIVE DIAGNOSIS: Scrotal abscess.
PROCEDURE: Incision and drainage, wash-out of scrotal
abscess.
Date: [**2113-8-9**]
Signed by [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 69152**], RN on [**2113-8-9**]
Affiliation: [**Hospital1 18**]
Mr. [**Known lastname **] was seen for routine urostomy pouch change and to
re
assess his wounds.
His urostomy stoma is pink and protrudes well. The stents are
still in place but sutures have broken and they have migrated
out
~2 CM. Peristomal skin and mucocutaneous junction are intact.
Pouched with ConvaTec Surfit Natura wafer and Assuseal urostomy
pouch with the 1 [**2-5**] inch flange. Also used [**First Name8 (NamePattern2) **] [**Last Name (un) **] seal for a
better seal around the stoma. Pouch connected to gravity
drainage, urine is clear yellow.
The penial wound is cleaner with less yellow fibrinous tissue in
the wound. There is a thick black necrotic rim of tissue just
below the Glan.
Suggestions for care:
Penal wound cleanse with commercial wound cleanser spray and pat
dry. Lightly pack the wound with Kerlix AMD dressing (anti
microbial dressing)that has been very slightly moisten with
saline. Cover with dry gauze and super absorbent dressing change
[**Hospital1 **] and PRN do not allow the dressing to remain saturated. Apply
Critic Aid anti fungal ointment to peri wound skin and groin.
Does not need Accuzyme enzymatic debrider at this time, please
d/c Accuzyme. Would use DuoDerm gel to the necrotic rim on the
penis then cover with the same moisten AMD dressing.
Midline wound: Cleanse with Wound cleanser then cover with
Aquacel Ag to absorb drainage and decrease the bio burden in the
wound. Cover with dry gauze and ABD pad. If wound gets dry
slightly moisten the Aquacel Ag with saline just over the wound
to release the silver ions, change daily and prn.
Please consider writing orders for the above. I will bring more
of the AMD gauze to the floor tomorrow. Will follow.
[**8-5**]:CT Head:No intracranial hemorrhage or mass effect.
[**8-8**] CXR: Decreased left lower lobe opacity/atelectasis with no
new infiltrates
identified
[**7-31**] Pathology:1)Skin, scrotum (A):
Ulceration, dermal necrosis and diffuse acute and chronic
inflammation consistent with abscess. See note.
2. Skin, penile shaft (B):
Ulceration, dermal necrosis and diffuse acute and chronic
inflammation consistent with abscess. See note.
Note: Both specimens show similar findings . The changes may be
secondary to radiation effect, however, the extensive
inflammation is suggestive of an infectious component. There
are PAS and GMS positive structures identified. Gram stain is
negative for bacteria. Definitive identification is not
possible, however, while some of the structures are irregularly
shaped (possible debris), there are some well formed structures
which raise consideration of fungus (possibly degenerated).
Culture is more sensitive means to detect organisms than
histologic special stains. A fungal culture is pending. A
negative preliminary result does not exclude a fungal infection,
as fungi may take weeks to grow.
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] has reviewed this case and concurs with the
diagnosis.
[**7-30**] CT ABD/Pelvis
IMPRESSION:
1.Slight increase in amount of anterior scrotal fluid collection
just
inferior to known open wound defect and adjacent to the right
testicle.
Overall amount of fluid within the scrotal sac has diminished
since prior
examination. Stable extensive penile edema and a small
ischiorectal simple
fluid collection without CT evidence to suggest underlying
abscess.
2.Improvement to small bowel dilatation.
3.Diffuse anasarca.
Brief Hospital Course:
Pt was admitted to Urology service on [**2113-7-16**] with 3 days of
fevers and a history of chronic prostate infections/abscesses
s/p brachytherapy on [**11-10**] which was surgically drained on
[**2113-7-7**] with a penrose drain left in place draining urine to an
ostomy bag as well as a foley catheter. The patient was begun
on ceftriaxone 1g Qday first dosed in the ED at [**Hospital1 18**], but
remained febrile the evening of HD1. On HD#2 ([**7-17**]) the pt's
antibiotic regimen was switched to Ampicillin and Gentamycin.
An MRI done on [**7-17**] showed a right ischiorectal fossa abscess
adjacent to the right prostate gland which was successfully
drained on the same day under CT guidance and a pigtail drain
was left in place. The pts WBC declined from 31.7 on admission
to 23.0 on [**7-19**] and the pt remained afebrile during that
interval. On HD#5 ([**7-20**]) the patient underwent a cystectomy and
prostatectomy and an ilial conduit urinary diversion. He was
then transferred to the ICU for close monitoring in the post-op
period. During ICU course he remained hemodynamically stable
with good UOP. His hct and coags remained stable. Vancomycin,
gentamicin, and flagyl were continued perurology recs. Pain
control was maintained with IV morphine. The patient also
showed evidence of a quiet delerium, most likely [**1-6**] post-op,
ICU,
and/or infection. He was monitored during his ICU course with
gentle re-orientation and transferred to the floor.
.
#Hem/ID: Leukocytosis: likely secondary to GU source. Trending
down since admission 31.7->20.3. No evidence of other
infectious source. All blood cultures negative to date. Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital1 **] Oncologist)was [**Hospital1 4221**] on [**7-27**]: Patient
is s/p splenectomy and therefore will have elevated WBC
chronically. His current WBC must be interpereted in the light
of his baseline, which is 13-15. Therefore, mid-20s is more
like 15,000 for him. There is almost no chance that his
leukemia could be implicit in his poor wound healing. He is
cured of his Hairy Cell Leukemia, but if we are concerned, we
can recheck compliment fractions and flow cytometry. His WCC
reached 31.3 during his second week but came back down to 13-15
and remained stable until discharge.
He was placed on Broad Spectrum IV antibiotics including
Meropenem, Daptomycin, and Zosyn for his worsening wounds while
awaiting culture and sensitivities. On [**7-25**] wound cultures
demonstrated 1)Coag Neg Staph and 2)Vanc sensitive Enterococcus.
The Zosyn was stopped on [**7-25**] due to a lack of gram negative
orgamism isolation. The Meropenem was stopped on [**8-4**]. The
Daptomycin was switched to Vancomycin on [**8-8**] due to rising
creatinine and possible acute tubular necrosis from daptomycin
use.
# CV: No h/o coronary disease. TTE showed no evidence of
vegetations and has preserved EF. Hyperlipidemia: Cont. statin
# Pulmonary-Mr [**Known lastname **] had an episode of Aspiration Pneumonia
on [**7-25**]. It resolved within a week with antibiotic treatment.
#GI: Patient was on TPN for several weeks in order to improve
his nutrition(pre-albumin of 7) and wound healing. He was
followed closeely by nutrition who optimized his nutritional
status with TPN caloric counting, adjusting carb/fat/protein
ratio's daily based on Chem 10 results and adding zinc and
vitamin C to daily regime. On [**7-28**] a Speech and Swallow
consult was requested which demonstrated in order to make sure
he could start PO's. No aspiration was seen and he was able to
start PO's for Pleasure, and keep TPN for primary nutrition.
However, over the next week his PO intake increased he was on a
regular diet. In addition, he was placed on Ensure shakes and
pudding and nutrition followed him for a calorie count to ensure
the best nutritional status possible. His wound healing
abililty improved as his nutritional status improved. A PEG
tube was an idea that nutrition originally suggested. However,
his appetite improved to the point where his caloric PO intake
was sufficient to maintain his nutrition without requiring tube
feeds. TPN was stopped prior to discharge to the rehab
facility. His nutrition reccomendations consist of a one to one
assist while eating, Ensure shakes TID, and Ensure pudding TID
in order to maintain his caloric intake.
#Dermatology/Wound Care-Patient remained in hospital due to
nonhealing of two wounds. The first wound a midline abdominal
wound was due to failure of closure after surgical incision. He
also had a Penile wound. The Penile wound gradually increased
in size from [**Date range (1) 57820**]. It grew 1)Coag Neg Staph and 2)Vanc
sensitive Enterococcus. In addition to the antibiotic regimine
described above, the wound nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] and asked to
follow this patient. Both wounds were packed three times daily
using Accuzyme and curlex AMD rolls, which aided in wound
debridement and promoted growth of healthy tissue. Both wounds
began to improve from [**8-2**] onward most likely due to the
combination of improved nutrition, careful wound care, and
culture appropriate antibiotics. Plastic Surgery was also
[**Month/Year (2) 4221**] regarding the penile wound, for possibility of placing
a wound VAC. At first the surrounding tissue was not dry enough
due to the constant oozing and drainage. However, as the
surrounding tissue became less friable and more pink Plastics
was [**Month/Year (2) 4221**] again for a wound VAC. They did not think he was
a good candidate for a wound VAC given difficulty of placement
and wound improvement without it. See pertinent results section
for wound care suggestions.
.
#GU-His urine output was monitored daily through his ostomy bag.
Patient had a UTI on [**8-1**] which was positive for funguria. He
was treated with a 3 day course of Fluconazole. On [**8-8**] His
Creatinine was 1.3, possibly due to Accute Tubular Necrosis from
the nephrotoxic Daptomycin. Once changed to Vancomycin the Cr
level dropped to normal range.
#Neuro-Mr [**Known lastname 95299**] mental status flucuated throughout his
hospital course from A+OX3 to orientated only to self.
Geriatrics was [**Known lastname 4221**] on [**8-4**] regarding mental status changes
and possible delrium. A full delerium workup including looking
at medication, lab results, and a CT head without contrast.
Their assessment was uremic delerium due to the nephrotoxicity
of Daptomycin. The Daptomycin was stopped and Vancomycin was
started. The Effexor was also tapered off. His mental status
continued to fluctuate until [**8-12**]. He was Alert and orientated
x3 on discharge. However, Mr [**Known lastname **] never had any focal
neurological symptoms throughout his hospital stay.
# Psych:Depression, continued effexor, was tapered off starting
[**8-9**] due to rising Creatinine.
#HEENT:On [**7-28**] Mr [**Known lastname **] had hoarseness for three days,
therefore an ENT consult was also obtained to rule out vocal
cord paralysis. His scope was negative for vocal cord paralysis.
# Code: FULL
# Access: RIJ placed in OR. The central line was removed and a
PICC line was placed on [**7-27**] under interventional radiology
guidance for long term TPN.
.
.
# Communication: Daughter [**Name (NI) 95300**] [**Telephone/Fax (1) 95301**]
Medications on Admission:
Lipitor 40', Florastor 2 cap [**Hospital1 **], Flomax 0.4',
Xalatan 0.005% 1gtt each eye QD, megesterol susp 400'', Effexor
SR 75', Dilaudid 2mg PRN leg pain
Discharge Medications:
***Stop Vacomycin on [**2113-8-28**]****
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Megestrol 40 mg/mL Suspension Sig: One (1) PO BID (2 times a
day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
5. Insulin Regular Human 100 unit/mL Solution Sig: [**12-6**]
Injection ASDIR (AS DIRECTED).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Ipratropium Bromide 0.02 % Solution Sig: [**12-6**] Inhalation Q6H
(every 6 hours) as needed for wheezing.
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO 1X (ONE TIME) for 1 doses.
11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
12. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed for nausea.
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
14. Chlorpromazine 25 mg/mL Solution Sig: One (1) Injection Q4H
(every 4 hours) as needed.
15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): Stop Vanc on [**8-28**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
76M with a complicated course of a prostate infection,
prostetic fistula, intraabdominal sepsis, and malnutrition.
Discharge Condition:
Stable
Discharge Instructions:
Please Call Urology office or local Emergency Room if
1)Temp greater then 101
2)Inability to Urinate
3)Nausea and Vomitting for more than 24 hours
4)Increased Drowsiness
Nutrition rec's:
1)1:1 assist required while eating
2)Ensure Plus shakes TID
3) Ensure Pudding TID
Followup Instructions:
1)call Urology office for follow up appointment in [**6-13**] days
[**Telephone/Fax (1) 164**]
1)call for outpatient Colonoscopy appointment-overdue for
screening colonscopy
ICD9 Codes: 0389, 5849, 4240, 2875, 2761, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2997
} | Medical Text: Admission Date: [**2158-7-12**] Discharge Date: [**2158-7-15**]
Date of Birth: [**2080-2-16**] Sex: F
Service: MED
Allergies:
Tequin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Tracheomalacia
Major Surgical or Invasive Procedure:
Bronchoscopy, with tracheal stenosis dilated with 10mm scope,
right brochus intermedius stent removed, LUL orifice dilated w/
4mm baloon
History of Present Illness:
78 yo woman with h/o idiopathic tracheobronchial malacia with
tracheostomy tube placed over 2 years ago, s/p left main stem
bronchus stent (c/b bronchial tear causing pneumomediastinum)
and s/p right main stem stent (which was removed and replaced
with silicone stent on [**4-16**]). Also had repositioning of [**Last Name (un) 295**]
trach tube repositioned in [**4-16**] by Dr. [**Last Name (STitle) **] as well.
She was admitted to RIH [**6-15**] with fever, fatigue, and diarrhea.
She was previously treated with antibiotics as an outpatient for
tracheobronchitis. Was found to have C. diff and was treated
with flagyl. Was treated for 2 weeks with diflucan for yeast in
sputum and urine. Spiked temp on [**7-8**] and BCs (from line only)
and central line tip grew pansens pseudomonas. Line resited
[**7-9**]- lt subclavian. Zosyn started [**7-8**] and has been afebrile
since. Patient has been stable with occasional episodes of
bronchospasm that responds to nebs, vent support, and ativan.
She was fist bronched early in course where per report they
found dynamic airways, some airway edema, and stent in Lt main
stem and in trachea. Treated with steroids with small
improvement. Bronch repeated [**7-1**] when realized that right main
stem stent had likely migrated into trachea. Therefore, she was
sent to [**Hospital1 18**] for bronchoscopy and possible stent replacement.
Past Medical History:
1. tracheobronchial malachia (idiopathic)- followed by [**Doctor Last Name **] and
[**Doctor Last Name 952**] (CT [**Doctor First Name **]) s/p right (silicone) left main stem stents. s/p
trach (last replaced [**6-21**].
2. CAD s/p MI [**2147**]. Cath [**12-15**]- 50% LAD, no interventions done
2. CHF- EF 45%
3. htn
4. PMR
5. GERD
6. osteoporosis
7. hypercholesterolemia
8. MRSA (nares)
9. h/o VRE
Social History:
Married and lives with husband in [**Name (NI) 16221**], RI. Lifetime
non-smoker. Denies ETOH. No kids.
Family History:
F died 52- encphalitis (from misquito bites).
Physical Exam:
PE:
T 96.1 HR 56-65 BP 95-109/32-41 RR 18-23 O2 sat 100% (on PCV 14
peep 8 RR 18 30 % fio2)
GEN- awake, alert, trach in place in NAD, mouthing answers to
questions
HEENT- PERRL, EOMI, OP moist
NECK- trach in place, supple
CHEST- left subclav line in place. coarse insp wheezes
throughout
HEART- RRR distant sounds
ABD- NABS, soft, NT/ND
EXT- 2+ LE edema b/l, 2+ DP pulses b/l, warm/dry. No calf
tenderness/cords.
CXR: left subclav line, trach in place, left main stem stent in
place, lungs clear
LABS at OSH: on [**7-9**]- HCT 26.4 WBC 8.9. BC [**7-8**] from central
line- pansens pseudomonas, cath tip- psuedomonas. No peripheral
cultures sent. last UA/urine culture clear s/p diflucan
Pertinent Results:
[**2158-7-15**] 04:40AM BLOOD WBC-20.5* RBC-4.41 Hgb-12.3 Hct-37.1
MCV-84 MCH-28.0 MCHC-33.2 RDW-15.4 Plt Ct-389
[**2158-7-14**] 04:00AM BLOOD WBC-15.3*# RBC-4.06*# Hgb-11.3*#
Hct-34.4* MCV-85 MCH-27.9 MCHC-32.8 RDW-15.6* Plt Ct-342
[**2158-7-13**] 10:47PM BLOOD Hct-35.0*#
[**2158-7-13**] 05:29AM BLOOD Neuts-83* Bands-0 Lymphs-9* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-3* NRBC-1*
[**2158-7-14**] 04:00AM BLOOD PT-12.7 PTT-46.8* INR(PT)-1.1
[**2158-7-13**] 05:29AM BLOOD PT-13.4* PTT-75.4* INR(PT)-1.2
[**2158-7-15**] 04:40AM BLOOD Glucose-140* UreaN-17 Creat-0.9 Na-132*
K-3.9 Cl-96 HCO3-23 AnGap-17
[**2158-7-14**] 04:00AM BLOOD Glucose-156* UreaN-13 Creat-0.7 Na-135
K-3.9 Cl-100 HCO3-25 AnGap-14
[**2158-7-15**] 04:40AM BLOOD Calcium-8.7 Phos-4.7* Mg-1.7
[**2158-7-14**] 04:00AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.8
[**2158-7-13**] 08:35AM BLOOD Type-[**Last Name (un) **] pO2-32* pCO2-42 pH-7.41
calHCO3-28 Base XS-1
Brief Hospital Course:
A/P: 78 yo woman with idiopathic tracheobronchial malacia with a
migrated right main stem bronch stent here for bronchoscopy.
1. Tracheobronchial malacia. Bronched on [**7-13**] am. Notable for
a tracheal stenosis superior to stoma which wad dilated with a
10 mm scope. Right stent in trachea removed. Severe
granulation tissue bilaterally. LUL was ballooned, now 4mm.
Continue atrovent, prn albuterol, prednisone (dose decreased).
Changed to decadron in anticipation of [**Last Name (un) **] stim test which was
ordered for [**7-14**]. Of note, steroids had initially been started
in [**2156**] for history of PMR. Has been on them since then given
the pulmonary issues. Will try to wean them as tolerated and
can be further titrated as an outpatient.
2. VENT- Tried PSV but RR decreased to [**3-16**] so back on PCV. Sats
OK and stable. Consider trial of trach masks if tolerates. NIF
was max 20, then 12 ? deconditioned.
3. C. Diff- Recheck stool for c. diff, although toxin may still
persist. Continue flagyl while on Abx. If diarrhea doesn't
improve may need to consider po vanco. Followed. Had increasing
WBC to 20, but no inc stool output, fever, chills, and on
steroids. Spoke w/ resident at RIH - will follow
4. Pseudomonas Line infection- On zosyn day 5. line re-sited
[**7-9**]. Rechecked blood cultres times one were negative to date.
Culture if spikes. Follow fever/WBC.
5. HTN- continued on BB, ACEI
6. CAD- continue BB.
7. hyperchol- cont zocor
8. Anemia- check iron studies and guiac stool. Has been in high
20s at OSH and got at least 1U PRBCs during that admission. T &
S. S/p 1 unit of pRBCs on [**7-13**] with appropriate bump.
9. CHF- EF 45%. Continue lasix 40 qd. Strict I & O. resume
cardiac/low salt diet.
10. Depression- On zoloft
11. FEN: Watch fluid status given the history of CHF.
12. T/L/D- left sublcal place [**7-9**]. PIVs.
13. PPX- PPI, sq heparin. RISS while on prednisone.
14. [**Name (NI) 55310**] husband- [**Name (NI) **] [**Telephone/Fax (1) 55311**]
15. Full code
Medications on Admission:
MEDs on transfer: zoloft 50 qhs, zocor 20 qhs, zosyn 3.375 qid
IV (started [**7-8**]), flagyl 500 tid po (started [**6-15**]), fluconazole
200 IV qd (last dose 6/30 of 2 week course), prednisone 30 qd,
atrovent/albuterol nebs, lopressor 50 [**Hospital1 **], lasix 40 qd,
quinapril 10 qd, qd heparin, protonix, ativan prn, klonopin [**Hospital1 **],
kcl 40 qd, fosamax 70 qwk (last dose ? before [**7-5**]), metamucil,
nystatin powder
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: Five Hundred (500) mg IV PO
TID (3 times a day).
2. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Psyllium 58.6 % Packet Sig: One (1) Packet PO BID (2 times a
day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Quinapril HCl 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
11. Dexamethasone 1.5 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
12. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
13. Piperacillin-Tazobactam 4-0.5 g Recon Soln Sig: 4.5 g IV
Intravenous Q8H (every 8 hours).
14. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) Units Injection Q8H (every 8 hours).
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Tracheomalacia - s/p bronchoscopy
2. C. Dificile infection
3. pseudomonas bacteremia
4. Hypertension
5. polymyalgia rheumatica
6. Coronary artery disease
Discharge Condition:
good
Discharge Instructions:
1. Return to RI Hospiatl via ambulance for further work-up &
care.
2. follow up with your doctor [**First Name (Titles) **] [**Last Name (Titles) 19039**] as scheduled
Followup Instructions:
1. at [**Hospital 44256**], with your PMD & [**Hospital 19039**] as
scheduled
2. concern is for increasing WBC count - no fever,chills, inc.
in stool output, new cough. also continues on steroids
(dexamethasone 1.5 po q8), but WBC now 20.5 (from 15). Would
continue to follow.
3. cosyntropin stim test pending here from this AM ([**7-15**])
4. F/U re: vent requirement - was on MMV here - did not tolerate
spontaneous breathing trials/trach collars, with apneic periods
- ma NIF's = 15-20. unclear etiology of resp failure
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2998
} | Medical Text: Admission Date: [**2134-4-19**] Discharge Date: [**2134-5-11**]
Date of Birth: [**2061-11-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Endoscopy
Sigmoidoscopy
Portacath removal
[**First Name3 (LF) **] catheter placement
[**First Name3 (LF) **]
History of Present Illness:
72M with pmh significant for metastatic rectal cancer was at
radiology clinic receiving scheduled imaging when blood pressure
at triage recorded 60/40. Recheck was 70/40. His port was
accessed and he was bolused with 300cc of IVF and transferred to
the ED. He denied syncope or lightheadedness but reported mild
SOB and fatigue. He reports having several days of diahrrea,
which began last wednesday [**4-14**]. His last dose of irinotecan and
panitumab chemotherapy was Monday [**2134-3-29**] (patient reports was
[**4-12**] but not recorded in OMR), and he reports always getting
diahrrea with his chemotherapy. He reports haveing watery bowel
movements roughly every 45 minutes since wednesday. HIs bowel
movements are not bloody or melanaic. He has been taking
immodium and diphenoxylate-atropine without improvement. Sunday
night, he reports acute worsening of his diahrrea, which
continued through Monday. EMS gave him another 500cc of NS prior
to arrival to the ED.
.
On arrival to the ED his vitals were 98.0 100/50 83 18 100%RA.
Cr was 1.3 from 1.1. Hct was 27.3. Mg was 0.8mg. He was guaiac
negative. CT torso was without PE or dissection, but did have
multiple stable pulmonary nodules, and a small right pleural
effusion. He also had stable metastatic disease. EKG was sinus
in the 70's. He was given 3L of NS and 4 grams of Mg.
.
Review of Systems:
(+) Per HPI
.
He is denying fevers, abdominal pain, chest pain, hematochezia,
melena.
Past Medical History:
Past Oncologic History:
Adenocarcinoma of the rectum
- [**6-/2131**]: The patient presented with a change in bowel habits
and was noted to have an abnormal rectal exam by his primary
care
physician, [**Name10 (NameIs) 39262**] [**Name Initial (NameIs) **] gastrointestinal evaluation.
- [**2131-7-23**] colonoscopy: Exophytic cancer of the rectum [**9-9**]
cm
above the anal margin. Polyp noted at the anorectal junction.
Biopsy: Invasive, moderately differentiated adenocarcinoma
arising in association with adenoma. Polyp: Adenoma with
high-grade dysplasia.
- [**2131-7-25**] rectal ultrasound: T3 posterior midline tumor with
luminal narrowing of the rectum.
- [**2131-8-2**] CT scan of the torso: Irregular, polypoid lesion
seen within the rectum, with multiple subcentimeter presacral
and
pericolic lymph nodes identified. Two pulmonary nodules seen in
the left lower lobe, the largest measuring 2.9 x 2.2 cm.
Multiple
low-attenuation lesions seen within the liver, the
largest of which may represent cyst, smaller lesions are not
fully characterized. Low-attenuation lesions seen within the
left kidney, possibly a cyst, although too small to
characterize.
Per report, a CT PET performed elsewhere demonstrated uptake in
the left base of the lung.
- [**2131-8-14**] to [**2131-9-25**]: Neoadjuvant chemoradiation with
continuous 5-FU at 225 mg/m2/day and radiation therapy five days
weekly.
- [**2131-12-10**]: Proctosigmoidectomy with stapled coloanal
anastomosis and diverting loop ileostomy. Pathology revealed
adenocarcinoma of the rectum, low-grade, with invasion into the
perirectal adipose tissue and metastasis to 7 of 13 regional
lymph nodes (T3N2). The resection margins were uninvolved.
- [**2132-1-28**] PET Scan: Interval progression of disease with an
increase in the size of the previously identified
lung metastasis. There is a new FDG-avid focus in segment 4A of
the liver which most likely represents metastasis.
- [**2132-2-13**]: Ileostomy takedown with simultaneous flexible
bronchoscopy and VATS with left lower lobe resection. Pathology
from the ileostomy stoma demonstrated no evidence of malignancy.
The left lower lobe wedge resection demonstrated an
adenocarcinoma, 4.1 cm, consistent with metastasis of rectal
origin. The pleural and apparent stapled margins were free of
malignancy.
- [**2132-2-14**]: Evaluation by the hepatobiliary surgery consult
team due to the finding on his recent PET scan of a likely liver
metastasis. It was felt that the lesion was amenable to surgical
resection, and it was planned that the patient would undergo two
cycles of chemotherapy prior to proceeding with hepatic
resection.
- [**2132-4-9**]: FOLFOX chemotherapy initiated. The patient completed
two cycles of therapy on [**2132-6-3**].
- [**2132-7-11**]: Hepatic resection of a 1.7cm segment 4a metastatic
lesion by Dr. [**Last Name (STitle) **].
- [**2132-10-22**]: Cycle 1 Day 1 5FU/LV for further adjuvant
chemotherapy. Oxaliplatin eliminated due to neuropathy. The
patient completed therapy in [**1-5**].
- [**2132-11-26**]: Hospital admission for SVC syndrome secondary to a
catheter-associated thrombus causing occlusion of the SVC and
bilateral brachiocephalic veins. The patient underwent TPA
infusion followed by venous angioplasty with balloon dilation
with resolution of symptoms. He was discharged on enoxaparin.
- [**2133-8-3**]: Initiation of ininotecan for recurrent disease.
- [**2134-2-8**]: Due to laboratory and radiographic evidence of
disease
progression, cetuximab was added to ininotecan; due to an
allergic reaction, cetuximab was changed to panitumumab on
[**2134-2-16**].
.
Other Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. ASCVD, status post MI in [**2111**].
4. Status post appendectomy.
5. Diabetes
Social History:
The patient lives alone and is divorced. He has
three sons in their 40s. He is a construction inspector. He
denies alcohol use and drug use. He smoked one pack of
cigarettes daily for 30 years before quitting.
Family History:
The patient's paternal uncle had an abdominal
cancer, details unknown. His father died of an MI. His mother
died of [**Name (NI) 2481**] disease. He has two brothers who are well.
Physical Exam:
Admission:
GEN: awake, alert, NAD
VS: 97.6 110/46 88 19 100% 2L
HEENT: EOMI, MMM
CV: irregularly irregular, no m/g/r
PULM: crackles at RLL
ABD: well healed scars on abdomen, soft, NT, ND
LIMBS: no edema
SKIN: erythema and excoriation over left antecubital fossa.
Discharge:
GEN: NAD, aaox3
HEENT: MMM, oropharynx clear.
CV: RRR, No m/r/g
PULM: CTAB, decreased breath sounds at bases. Tunneled [**Name (NI) 2286**]
catheter noted on right chest, c/d/i
ABD: Soft, distended, NT, +BS.
EXTR: 2+ bilateral lower extremity edema, 2+ bilateral upper
extremity edema, left > right 2+ DP pulses bilaterally.
SKIN: blanching macules noted scattered across forearms and
upper back.
Pertinent Results:
Admission labs:
[**2134-4-19**] 11:35AM BLOOD WBC-2.8* RBC-3.30* Hgb-9.3* Hct-27.3*
MCV-83 MCH-28.3 MCHC-34.2 RDW-20.0* Plt Ct-283
[**2134-4-19**] 11:35AM BLOOD PT-14.0* PTT-35.5* INR(PT)-1.2*
[**2134-4-19**] 11:35AM BLOOD Glucose-199* UreaN-23* Creat-1.3* Na-139
K-4.0 Cl-106 HCO3-22 AnGap-15
[**2134-4-19**] 11:35AM BLOOD Calcium-8.3* Phos-2.4* Mg-0.8*
.
Discharge labs:
Micro:
[**4-20**]:
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2134-4-21**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
FECAL CULTURE (Final [**2134-4-22**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2134-4-22**]): NO CAMPYLOBACTER
FOUND.
.
[**2134-5-4**] 12:58 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2134-5-4**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2134-5-4**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2134-4-27**] 11:47 am CATHETER TIP-IV
**FINAL REPORT [**2134-4-29**]**
GRAM STAIN (Final [**2134-4-27**]):
TEST CANCELLED, PATIENT CREDITED.
INAPPROPRIATE SPECIMEN FOR GRAM STAIN.
WOUND CULTURE (Final [**2134-4-29**]):
STAPH AUREUS COAG +. >15 colonies.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2134-4-24**] 2:47 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2134-4-29**]**
Blood Culture, Routine (Final [**2134-4-29**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # 294-1510A
[**2134-4-23**].
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
STAPH AUREUS COAG +. SECOND MORPHOLOGY.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final [**2134-4-26**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2134-4-26**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**4-19**] ECG:
Sinus rhythm with ventricular premature beat. Right
bundle-branch block. Since
the previous tracing of [**2132-11-27**] inferior lead Q waves are less
prominent.
.
[**4-19**] CT torso:
1. No evidence of pulmonary embolism or dissection. Multiple
small pulmonary
nodules are overall stable in size. Stable small right-sided
pleural
effusion.
2. Stable extent of metastatic disease in the abdomen.
3. Two small ventral wall hernias containing loops of small
bowel, but no
evidence of obstruction with oral contrast seen to the colon.
4. Cholelithiasis.
.
[**2134-4-26**] RUE ultrasound.
INDICATION: 72-year-old man with swollen left arm and left-sided
Port-A-Cath.
COMPARISON: None.
TECHNIQUE: Grayscale and Doppler evaluation of left upper
extremity.
FINDINGS: Grayscale and Doppler evaluation of the left internal
jugular,
subclavian, axillary, basilic, and brachial veins demonstrate
normal flow,
compressibility, and response to augmentation wherever
applicable. No
intraluminal thrombus was identified.
IMPRESSION: No evidence of DVT in the left upper extremity.
[**2134-4-27**] renal ultrasound:
INDICATION: 72 year old man with acute kidney failure and
sepsis.
COMPARISON: CTA chest performed [**2134-4-19**].
RENAL ULTRASOUND: The left kidney measures 10.9 cm. The right
kidney
measures 10.7 cm. There is no hydronephrosis, stone or mass in
either kidney.
The bladder is unremarkable.
IMPRESSION: Unremarkable renal ultrasound without evidence of
hydronephrosis.
Brief Hospital Course:
Mr. [**Known lastname 1683**] is a 72 yo M with h/o metastatic rectal CA and SVC
syndrome, now resolved on lovenox tx, who was admitted to OMED
on [**4-19**] with intractable diarrhea thought [**3-2**] chemo and
transferred to the [**Hospital Unit Name 153**] on [**4-24**] with BRBPR and hematemesis. GI
was consulted and an EGD was performed on [**4-24**] which showed
diffuse erythema/ulceration, in esophagus, stomach, duodenum.
This was thought due to irinotecan induced GI toxicity. They
recommended PPI and carafate slurry. They were concerned that
patient's whole GI tract was diffusely inflamed as was seen on
EGD and that the anastamotic site from his colectomy might be a
bleeding source; a flex sigmoidoscopy was done on as well and
showed as well diffuse ulceration and inflammation. HCTs and q6H
hemodynamics remained stable throughout his hospital course.
The patient was started on steroid enemas and mesalamine
suppositories to decrease inflammation. The steroid enemas were
discontinued, but the mesalamine suppositories were continued
through to discharge. In total, he received 3 units PRBCs and 2
units of FFP. Stool cultures revealed no evidence of infection.
.
On [**4-24**], the patient was found to have that 2/2 bottles of his
blood cultures drawn from his portacath were growing GPCs,
speciation showed MSSA. He was treated for this with IV
vancomycin, leaving the portacath and PICC in place. Daily
surveillance blood cultures were performed and he was noted to
clear his bacteremia on [**4-26**]. Infectious diseases was consulted
and the patient was switched to nafcillin with confirmation of
MSSA. The port-a-cath was removed which was the source of
infection.
The patient however despite aggressive crystalloid and colloid
(albumin, a further 2 units of blood) resuscitation then
developed sepsis related acute tubular necrosis. The patient
became anuric and nephrology was consulted. Hemodialysis was
initiated which the patient tolerated well, and a permanent
tunneled catheter line was placed on [**2134-5-7**]. The patient was
started on phosphate binders, nephrocaps and erythropoeitin
dosed at hemodialysis. The carafate was discontinued due to
risk of aluminum toxicity. The nafcillin was also changed to
Cefazolin dosed 2mg at each [**Date Range 2286**] session for ease of
administration and avoiding extra volume loading. Should the
patient miss [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2286**] session, extra doses of cefazolin should
be administered as needed. The patient was planned for a 28 day
course of cefazolin to be finished on [**2134-5-22**].
.
Other parts of his hospitalization are outlined by problem
below:
.
#Hypotension/Tachycardia: In setting of extensive diahrrea. Ct
torso is without PE or dissection. His BP initally recovered
with 500cc NS bolus. Once he had an episode of BRBPR, he became
tacycardic to the 140s, with BP 90s/60s. He was bolused NS and
given PRBC with improved HR to the 110s, and BP to 120s/80s.
.
#SVC syndrome: occurred in [**2132**]. s/p TPA infusion followed by
venous angioplasty with balloon dilation with resolution of
symptoms. He was initially treated with lovenox (dose
recalculated this admission, should be lower than his admission
dose), but this was held secondary to GI bleed. This was not
restarted at discharge given the patient's renal failure.
.
#Diarrhea - the patient continued to have diarrhea that was
controlled with titration of his anti-diarrheal medications.
Infectious sources were ruled out and the cause was likely
irinotecan-induced GI toxicity and radiation proctitis.
#Generalized anasarca - The patient was noted to have an
extremely low albumin on admission, likely related to poor
nutrition due to his GI pathology. Albumins ranged between 2.7
and 1.9. During volume resuscitation the patient became grossly
edematous, and albumin was administered to little effect. His
left upper extremity was noted to be more edematous than the
rest of his body, and a LUE ultrasound was acquired. This
demonstrated no evidence of clot. The patient slowly became
less edematous when [**Year (4 digits) 2286**] was initiated and ultrafiltration
was started.
Mr. [**Known lastname 1683**]' code status was confirmed as FULL CODE this hospital
admission.
Medications on Admission:
DIPHENOXYLATE-ATROPINE - 2.5 mg-0.025 mg Tablet - [**1-30**] Tablet(s)
by mouth q6hr as needed for diarrhea
ENOXAPARIN [LOVENOX] - 150 mg/mL Syringe - Inject 150 mg once a
day
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth daily
METOPROLOL SUCCINATE [TOPROL XL] - (Prescribed by Other
Provider) - 100 mg Tablet Sustained Release 24 hr - 1 Tablet(s)
by mouth daily
METRONIDAZOLE [METROGEL] - 1 % Gel - apply to rash twice a day
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
q6hr as needed for nausea
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth daily
LOPERAMIDE [IMODIUM A-D] - 2 mg Tablet - 2 Tablet(s) by mouth
q4he as needed for diarrhea
PYRIDOXINE - (OTC) - 50 mg Tablet - 2 Tablet(s) by mouth once a
day
Discharge Medications:
1. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for diarrhea.
2. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO every four
(4) hours as needed for diarrhea.
5. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating, gas.
9. 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.
10. Ondansetron 4 mg IV Q8H:PRN nausea
11. Prochlorperazine 10 mg IV Q6H:PRN nausea
12. CefazoLIN 2 g IV HD PROTOCOL
HD protocol, to be given during hemodialysis
13. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
14. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
16. Heparin (Porcine) 1,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**]
Unit Injection PRN (as needed) as needed for line flush: DWELL
PRN line flush
[**Numeric Identifier **] Catheter (Tunneled 2-Lumen): [**Numeric Identifier **] NURSE ONLY:
Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen.
.
17. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale units
Subcutaneous ASDIR (AS DIRECTED): 2 units for 101-150
4 units for 151-200
6 units for 201-250
8 units for 251-300
10 units for 301-350
12 units for 351-400.
18. Mesalamine 1,000 mg Suppository Sig: One (1) Suppository
Rectal DAILY (Daily).
19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for dyspnea.
21. Epogen 10,000 unit/mL Solution Sig: Hemodialysis Protocol
Injection with each [**Numeric Identifier 2286**] session.
22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Rectal cancer
Diarrhea
Sepsis
Acute Renal Failure
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Discharge Instructions:
You were admitted to the hospital with diarrhea. We believe the
diarrhea was a side effect of the chemotherapy you had received;
it was treated with 3 anti-diarrheal medications. You also have
a low blood pressure on admission, this was likely due to
dehydration in the setting of diarrhea, and it improved with
rehydration with IV fluids. Your diarrhea then became bloody,
and you also had an episode of vomit with blood in it. As a
result, you were transferred to the ICU. You had an upper
endoscopy and a sigmoidoscopy, which showed ulceration in your
esophagus, stomach and colon. This was thought to be due to the
chemotherapy and radiation that you have been receiving for your
colon cancer.
.
While admitted, you also had a severe bacterial infection that
got into your blood. This severely damaged your kidneys,
requiring you to be started on hemodialysis. You had a
permanent [**Location (un) 2286**] catheter placed and you will need to continue
getting [**Location (un) 2286**] 3 times a week.
You were started on several new medications when you were
admitted.
Nephrocaps 1 capsule daily
Phos-lo 667mg three times a day
mesalamine 1000mg suppositories once a day
Cefazolin 2g given with hemodialysis
pantoprazole 40mg daily
Erythropoetin given with hemodialysis
Your metoprolol was changed from 100mg once a day to 25mg three
times a day
Your lisinopril and enoxaparin have been discontinued.
Followup Instructions:
You need to follow up with your outpatient oncologists, Drs.
[**Last Name (STitle) **] and [**Name5 (PTitle) **] [**Name5 (PTitle) **] discuss any further treatment for you
rectal cancer.
Dr. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] in Colorectal Cancer Clinic on
[**5-31**] at 10 AM. You can reach the office by calling [**Telephone/Fax (1) 22249**].
Provider: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2134-5-24**] 10:00
Completed by:[**2134-5-12**]
ICD9 Codes: 5849, 2851, 2762, 4589, 4019, 412, 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2999
} | Medical Text: Admission Date: [**2101-4-7**] Discharge Date: [**2101-8-6**]
Date of Birth: Sex: F
Service:
DISCHARGE DIAGNOSIS:
1. End-stage liver disease secondary to alcoholic liver
disease.
2. Leaking ileocolostomy
3. Peritonitis.
4. Hepatic failure.
5. Malnutrition.
6. Encephalopathy.
7. Coagulopathy.
PROCEDURES: Exploratory laparoscopy, resection of ileocolic
anastomosis and ileoileostomy and mucous fistula,
Living unrelated liver transplantation, liver biopsy.
DETAILS OF HOSPITAL COURSE: [**Known firstname **] [**Known lastname 55547**] is a very
pleasant female who was transferred from [**Hospital 1727**] Medical Center
to our institution secondary to liver failure. She presented
with a lower gastrointestinal bleed and underwent evaluation
at [**Hospital 1727**] Medical Center where she was found to have what
appeared to be hemangiomas involving the right colon. She
underwent resection of the right colon and primary
anastomosis but subsequent to this she developed
decompensation of her liver disease with ascites and
encephalopathy and jaundice. Eventually she was transferred
to our institution. Upon arrival to our institution she was
septic and having liver decompensation. She was taken to the
operating room on [**2101-4-15**] where she underwent exploration.
She was found to have a leaking ileocolic anastomosis. This
was resected and she underwent mucous fistula creation and
ileostomy. Her postoperative course was complicated by a
prolonged marked coagulopathy and continued decompensation of
her liver disease. She was unable to be discharged home due
to coagulopathy with an INR of 4 to 5 on a routine basis
resulting in spontaneous bleeding and requiring a significant
replacement of a blood product factors.
Over the course of her hospital stay she underwent nasal
jejunal feedings and support both with physical therapy and
social work and her fiance came forward as a potential live
donor. He was worked up and on [**2101-6-6**] she underwent a live
donor liver transplantation. The procedure was
uncomplicated. [**Known firstname **] did quite well, stayed in the intensive
care unit for three days. On postop day nine, when
attempting to remove [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**] [**Last Name (NamePattern1) 1662**] from her right upper
quadrant the JP was found to be sutured in place and she was
taken back to the operating room for removal of the JP and a
liver biopsy. This procedure was uneventful and [**Known firstname **]
continued to make progress while in the Intensive care unit.
Unfortunately she developed a marked critical illness
polyneuropathy resulting in marked muscle wasting and
weakness that required her to be reintubated. After multiple
attempts at extubation we were unable to wean her from the
ventilator and she was taken on [**2101-6-29**] for
tracheostomy. Dr. [**Last Name (STitle) 55548**] [**Name (STitle) 55549**] the tracheostomy without
difficulty and she continued during the hospital course with
excellent liver function but did develop a small bile leak
and a biliary stricture. She underwent a percutaneous
transhepatic cholangiography and two stents were placed in
the two bile ducts that were anastomosed from her donor liver
and she was found only to have a small leak from the anterior
segment. The PTC's were passed across the anastomosis into
the jejunal segment and the leak quieted down.
On [**2101-8-6**] she was discharged to [**Hospital **] Rehabilitation
Facility for rehabilitation. She is scheduled to follow-up
with the Transplant Team in one week and undergo twice weekly
labs.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern4) 3433**]
MEDQUIST36
D: [**2101-12-22**] 10:25:59
T: [**2101-12-22**] 11:09:47
Job#: [**Job Number 55550**]
ICD9 Codes: 5185, 5070 |
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