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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3000
} | Medical Text: Admission Date: [**2153-9-25**] Discharge Date: [**2153-9-28**]
Date of Birth: [**2090-1-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p EtOH ablation of interventricular septum for Hypertrophic
obstructive cardiomyopathy
Major Surgical or Invasive Procedure:
Ethanol ablation of Myocardial interventricular septum
History of Present Illness:
Patient is a 63 yo male with PMH significant for hypertrophic
cardiomyopathy, COPD, hypertension and recently diagnosed Afib
admitted after undergoing EtOH ablation of the interventricular
septum. The patient has had DOE with chest pressure since 1
year. Says that he used to get SOB and CP while walking up only
a slight incline. He denies symptoms at rest. He does have
periodic leg edema which he treats with diuretics. He sleeps on
two pillows for comfort. Denies claudication, PND,
lightheadedness. Gives h/o occasional palpitations of about few
seconds since 1 year. In early [**2153-8-19**], pt had CP and
diaphoresis at rest which subsided after some time. Next day he
went to play golf but soon developed SOB and CP and had to be
admitted to [**Hospital3 **]. Troponin was borderline positive/CK's
negative and he was transferred to [**Hospital1 18**] for cardiac
catheterization which revealed a significant subaortic valve
pressure gradient that increased with Valsalva. He was found in
atrial fibrillation during the admission and discharged on
Coumadin which he stopped taking on [**9-18**]. He now came in
for ethanol ablation of the myocardial interventricular septum.
Past Medical History:
1)Hypertrophic cardiomyopathy (diagnosed 3 years ago)
2)Hypertension
3)COPD
4)Low back pain secondary to herniated disc
5)Atrial fibrillation (newly diagnosed)
6)s/p Cataract surgery
7)Remote knee surgeries
8)Thalasemia minor
Social History:
Patient is single and lives alone. He has two chdilren.
Pt smoked 1ppd x 40-50yrs and quit 10 yrs ago.
1-2 beers/day
Family History:
Mother w/MI
Physical Exam:
vitals BP 142/73 HR 40-50 (irregular) RR 14 O2 Sat ??
Gen: Conscious and cooperative, in NAD
HEENT: JVD elevated to about 10cm, PERRL, EOMI, neck supple
Chest: CTA bilaterally
CVS: S1 S2 muffled. ?Systolic murmur at LSB.
Abd: Soft, non-tender, non-distended, BS+
Neuro: A&Ox3, No FND
Ext: Cath wound on Rt groin. No hematoma or bruit. Peripheral
pulses+
Pertinent Results:
Labs
[**2153-9-25**] 07:22PM BLOOD WBC-6.0 RBC-5.12 Hgb-10.8* Hct-31.7*
MCV-62* MCH-21.1* MCHC-34.1 RDW-15.7* Plt Ct-107*
[**2153-9-25**] 07:22PM BLOOD WBC-6.0 RBC-5.12 Hgb-10.8* Hct-31.7*
MCV-62* MCH-
[**2153-9-25**] 07:22PM BLOOD CK(CPK)-338*
21.1* MCHC-34.1 RDW-15.7* Plt Ct-107*
[**2153-9-25**] 07:22PM BLOOD CK-MB-61* MB Indx-18.0* cTropnT-0.54*
[**2153-9-26**] 06:08AM BLOOD CK(CPK)-743*
[**2153-9-26**] 06:08AM BLOOD CK-MB-128* MB Indx-17.2* cTropnT-3.48*
[**2153-9-28**] 06:30AM BLOOD WBC-8.2 RBC-4.81 Hgb-10.1* Hct-29.7*
MCV-62* MCH-21.0* MCHC-34.0 RDW-15.6* Plt Ct-96*
[**2153-9-28**] 06:30AM BLOOD Glucose-86 UreaN-14 Creat-1.0 Na-141
K-3.5 Cl-104 HCO3-30 AnGap-11
.
ECHO ([**2153-9-25**]) - Pre septal ablation
The left atrium is markedly dilated. There is symmetric left
ventricular hypertrophy. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is systolic anterior motion of the mitral
valve leaflets with a severe (peak 60-70mmHg) resting left
ventricular outflow tract obstruction.
Following administration of 0.5ml Definity (diluted 1.5ml to
8.5ml saline), there was prominent enhancement of the basal
septum abutting the mitral valve [**Male First Name (un) **]. The right ventricular free
wall did not appear to enhance
.
ECHO ([**2153-9-25**]) - Post septal ablation
Following administration of alcohol (total 2.7ml), there was
intense enhancement of the basal interventricular septum in the
area abutting the [**Male First Name (un) **] of the mitral valve. [**Male First Name (un) **] persisted, but
the LVOT gradient declined to <30mmHg peak. Overall left
ventricular systolic function remained intact.There was no
pericardial effusion
.
Brief Hospital Course:
Mr. [**Known lastname 5422**] [**Last Name (Titles) 1834**] ethanol ablation of myocardial
interventricular septum on [**2153-5-29**] after which he was
transferred to the CCU for monitering for development of heart
block.
.
1. Hypertrophic obstructive cardiomyopathy
Patient's initial heart rate was in the 40's and irregular
(Atrial fibrillation). A temporary pacing line was put in at the
time of the procedure so that he could be paced if he developed
complete heart block and became symptomatic. On the second day
his HR picked up and by the 3rd day his temporary pacing line
was removed. Pt was also started on Toprol XL 100mg twice daily
and Verapamil SR 240 twice daily. He also experienced an episode
of chest pain [**2-26**] on the 2nd day. Given his recent cardiac cath
with normal coronoray arteries and unchanged EKG the pain was
most likely due to his HOCM and he was given morphine.
He also experienced 3-4 episodes of groin bleeding at the site
of his cath wound. Each time manual pressure was applied for
about 10 min followed by a pressure dressing. Later his heparin
was discontinued. Pt was transferred to the Step down unit for
where he did fine. There were no more episodes of groin bleeding
and the area was soft without any audible bruit.
.
2) Atrial fibrillation
He was started on heparin drip given his high CHADS score for
risk of stroke due to his atrial fibrillation. However due to
repeated groin bleeding at the site of his cath wound heparin
was stopped. He was started on Coumadin 2.5mg daily. His Toprol
and Verapamil given for HOCM also helped in rate control.
.
3) Hypertension
Patient was continued on Diovan 160mg twice daily. His Toprol XL
and Verapamil were also adjusted to control his BP. Lasix which
had been stopped on admission was continued on day 4.
.
4)FEN
Potassium was continued as his K on admission was 3.1. He was
continued on potassium chloride and slowly his potassium
improved. He was given healthy cardial diet with low sodium.
.
5)Disposition
The patient is being discharged home. He needs to follow up with
his primary care physician, [**Name Initial (NameIs) 2085**] (Dr. [**Last Name (STitle) **] and with
the coumadin clinic. If he develops syncope, palpitations or
persistent chest pain he should immediately contact his
cardiologist.
Medications on Admission:
1)Toprol XL 100mg twice a day
2)Diovan 160mg twice a day
3)Verapamil SR 240mg twice a day
4)Furosemide 80mg daily every morning (sometimes takes up to
160mg
depending on weight)
5)Doxazosin 8mg daily every evening
6)Klor-con 10meq ER, 2 tablets twice a day
7)Aspirin 81mg daily every morning
8)Coenzyme Q 10, 150mg daily every morning
9)Vitamin C 1000mg daily every morning
10)Vitamin D 1000 IU daily every morning
11)Folic acid 400mcg daily every morning
12)MVI
13)Glucosamine/Chondroiton one daily every morning
14)Coumadin 2.5mg daily every morning, last dose [**2153-9-18**]
15)Albuterol prn
16)Advair diskus prn
Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a
day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
3. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Doxazosin 8 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
inhale Inhalation twice a day.
9. Outpatient [**Name (NI) **] Work
PT, PTT, INR
please send results to [**Last Name (LF) 5423**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 5424**].
10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ethanol ablation of Myocardial interventricular septum for
Hypertrophic Obstructive Cardiomyopathy
Atrial Fibrillation, new onset
Secondary:
Hypertension
COPD
Discharge Condition:
Stable
Discharge Instructions:
If you experience syncope, shortness of breath, chest pain or
any other symptoms that concern you, please call your PCP or
return to the ER.
.
Please take all medications as prescribed. Please follow up with
all appointments.
Followup Instructions:
please make a follow up appointment with Dr. [**Last Name (STitle) **] in 3 months.
You will also need a repeat echo at that time.
.
Please get your blood drawn and have the results sent to your
PCP [**Name9 (PRE) 5423**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 5424**].
.
You have an appointment with your PCP [**Name9 (PRE) 5423**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 5424**] on [**10-3**] Wed at 1:30. Please get your labs drawn
prior to your appointment.
.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the [**Hospital **] clinic ([**Telephone/Fax (1) 5425**] in one month.
Completed by:[**2153-10-1**]
ICD9 Codes: 4254, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3001
} | Medical Text: Admission Date: [**2178-3-12**] Discharge Date: [**2178-3-20**]
Date of Birth: [**2135-3-22**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
pancreatitis and alcohol withdrawal
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
45 M with history of etoh abuse originally presented to [**Hospital **]
Hospital on [**3-6**] with nausea, vomiting and abdominal pain.
Initial labs showed Lipase of 1678, WBC 13.1 (76%PMNs), Hct
37.8, AP 140, AST 87, ALT 52. Abdominal CT was done and
consistant with pancreatits but no necrosis. Abd ultrasound
showed Gb sludge without stones or ductal dilitation.
His lipase of 1678 on admission trended down to 129 by [**3-9**], but
rose to 282 by [**3-12**]. His Hct drifted down from 37 to 28. Serial
abd CTs ([**3-5**], [**3-7**] and [**3-12**]) showed progression of pancreatitis
involving 50% of the pancreas, specifically the head and
uncinate process with phlegmon formation by the head and severe
inflammation; body and tail are spared. No abscess noted; no
splenic or portal vein thrombosis. On most recent CT [**3-12**], head
of pancreas showed poor/heterogenous enhancement, suspicious for
necrosis. Surgery and ID were consulted. Given CT findings and
Hct drop concerning for necrotizing pancreatitis, cipro and
flagyl were started on [**3-12**].
.
Additionally, his OSH course was complicated by EtOH withdrawal
on [**3-7**] and was transferred to the ICU. He was placed on a CIWA
scale and required large doses of benzos and dilaudid to control
his withdrawal and pain. He was intubated for airway protection
in setting of agitation and obtundation on [**3-9**].
.
Given climbing white count, progression of fluid on CT, possible
phlegmon development at head of the pancreas and anemia, he was
transferred to [**Hospital1 **] for further managment of ?necrotizing
pancreatitis. Presentation labs revealed normal amylase/lipase,
however WBC count elevated to 19K with 1% bands and hct down to
28 (from 38 on admission to OSH).
Past Medical History:
Polysubstance abue (etoh, benzos, opiates)
Bipolar disorder
s/p shoulder surgery [**3-2**] (arthroscopic subacromial
decompression and distal clavicle excision)
s/p appy
Social History:
+etoh abuse, +tobacco use, h/o narcotic abuse
Physical Exam:
VS 100.7 100 (72-100) 149/93 (111-150-60s-90s) O2 sat 96-99%
AC 550x14 (breathing over at 19), 35%, peep 5; I/Os since
midnight 1897/2645.
Gen: Intubated, sedated, somnolent but aroused
HEENT: mmm, op clear, eomi, perrl
CV: Sinus tachy, no mrg appreciated
PULM: CTAB anteriorally
ABD: soft, +moderate epigastric tenderness, no rebound or
guarding, +BS
EXT: no c/c/e, 2+ DP and PT pulses bilaterally
skin: no rash, +tattoo over chest, no Cullen's nor [**Doctor Last Name 27210**] sign
.
DATA:
OSH LABS:
[**3-12**] labs:
141 110 6
-----------<89
3.8 25 0.9 calcium 8.3,
WBC 17.5 (80.7%polys) , Hct: 28.1, Plt 472
.
Lipase trend: 1678->1241->490->294->129->168
WBC trand:
13.1->13->12.1->11.7->15.5->17.8->20.2->17.9->14.6->16.4->16.7
.
Other labs: Iron 9, transferrin 8.6, TIBC 105; retic 2.9, folate
12.4, B12>1000, albumin 2.6, AP 100, Ast 23, ALT 15, TBili 0.4,
TSH 1.93
EtOH [**3-5**]: 49
.
OSH IMAGING:
[**3-5**] Abd U/S: no obvious stones but biliary sludge
Pertinent Results:
[**2178-3-13**] 06:03AM BLOOD WBC-18.8* RBC-2.92* Hgb-9.6* Hct-27.8*
MCV-95 MCH-32.8* MCHC-34.6 RDW-15.0 Plt Ct-543*
[**2178-3-19**] 05:20AM BLOOD WBC-14.3*# RBC-3.09* Hgb-10.1* Hct-29.3*
MCV-95 MCH-32.7* MCHC-34.6 RDW-14.7 Plt Ct-567*
[**2178-3-13**] 12:01AM BLOOD Glucose-84 UreaN-5* Creat-0.8 Na-139
K-3.7 Cl-107 HCO3-24 AnGap-12
[**2178-3-19**] 05:20AM BLOOD Glucose-76 UreaN-6 Creat-1.0 Na-140 K-4.2
Cl-102 HCO3-28 AnGap-14
[**2178-3-16**] 01:03AM BLOOD ALT-13 AST-24 LD(LDH)-242 AlkPhos-95
Amylase-23 TotBili-0.6
[**2178-3-15**] 01:08AM BLOOD Lipase-56
[**2178-3-19**] 05:20AM BLOOD Calcium-9.4 Phos-4.6* Mg-1.7
[**2178-3-13**] 12:01AM BLOOD Triglyc-176*
.
CHEST (PORTABLE AP) [**2178-3-13**] 12:02 AM
HISTORY: 45-year-old man with pancreatitis, intubated, status
post transfer from outside hospital; evaluate for ET tube
placement and pneumonia.
IMPRESSION:
1. Endotracheal tube is in satisfactory location.
2. Small left pleural effusion and smaller left retrocardiac
atelectasis. No pulmonary edema or pneumonia.
.
Cardiology Report ECG Study Date of [**2178-3-15**] 1:30:54 PM
Sinus rhythm. Incomplete right bundle-branch block.
Non-specific ST-T wave
changes. No previous tracing available for comparison.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
106 152 106 348/428 48 12 47
.
CHEST (PORTABLE AP) [**2178-3-16**] 5:16 AM
As compared to the previous radiograph, the patient is now
extubated. The nasogastric tube has also been removed. The PICC
line is in unchanged position. The pre-described right-sided
parenchymal opacity is no longer visible. There is no evidence
of pleural effusion. The size of the cardiac silhouette is
unchanged.
Brief Hospital Course:
This is a 42 year old man with history of EtOH abuse presents to
OSH with abdominal pain, N/V found to have markedly elevated
lipase and evidence of pancreatitis on CT. Now with fever,
rising WBC count and progressive involvement of pancreas and
concern for necrosis at head of pancreas on repeat CTs at OSH.
Does having rising WBC count and fever currently concerning in
this context; remains HD stable however. Although does have
biliary sludge per OSH RUQ U/S, given h/o heavy EtOH, seems more
likely EtOH pancreatitis. TG mildly elevated, no clear
medication causes as only on pain meds post recent arthroscopic
shoulder surgery. No e/o hemorrhagic pancreatitis thus far on
imaging and exam, no e/o splenic thrombosis, calcium normal.
1. Pancreatitis
His lipase of 1678 on admission trended down to 129 by [**3-9**], but
rose to 282 by [**3-12**]. His Hct drifted down from 37 to 28 (some
dilutional effect). Serial abd CTs ([**3-5**], [**3-7**] and [**3-12**]) showed
progression of pancreatitis involving 50% of the pancreas,
specifically the head and uncinate process with phlgemon
formation by the head and severe inflammation; body and tail are
spared. No abscess or focal fluid collection; no splenic or
portal vein thrombosis. Surgery and ID were consulted. Given CT
findings and Hct drop concerning for necrotizing pancreatitis,
cipro and flagyl were started on [**3-12**].
He continued to receive aggressive IVF hydration.
Once extubated, he was no longer complaining of abdominal pain,
his LFT's, Amylase, Lipase trended down.
We were able to advance his diet and he was tolerating a regular
diet at time of discharge.
2. EtOH withdrawal: He developed acute EtOH withdrawal on [**3-7**]
and was transferred to the ICU. He was placed on a CIWA scale
and required large doses of benzos and Dilaudid to control his
withdrawal and pain ([**Month (only) 16**] not available to verify doses upon
admission). He was intubated for airway protection in setting of
agitation and obtundation on [**3-9**].
Once extubated, he required restraints for agitation. This
passed and he was transferred out to the floor and his
withdrawal symptoms subsided.
He was followed by Psych and we followed their recommendations
as far as weaning benzos and tapering the methadone etc. (please
see full note in OMR). He was set up with serviced (AA, NA)
closer to home in [**Location (un) **], ME.
#Hct drop- likely from pancreatitis and dilutional effect from
IVF. Guiaic negative. He was serially examined and HCT
monitored. His HCT remained stable at 29.
Medications on Admission:
oxycontin, percocet
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*0*
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea, vomiting and abdominal pain.
Pancreatitis
EtOH withdrawal
Leukocytosis
Discharge Condition:
Good
Discharge Instructions:
You were admitted with nausea, vomiting and abdominal pain,
pancreatitis and alcohol withdrawl.
You required an ICU admission and intubation. You have been
weaned off of narcotics, methadone, and benzodiazapams.
You will need services at home to help stay off of alcohol,
narcotics and other medications.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please take any new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
Followup Instructions:
You have an appointment at 10:30am on Monday [**2178-3-23**] with the
Cottage Program at [**Hospital **] Hospital. Call [**Telephone/Fax (1) 78256**] with an
questions.
Please follow-up with your PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 78257**]. Call to
schedule an appointment
Please follow-up with your Psychiatrist. Call to schedule.
Please call BEST: 1-[**Telephone/Fax (1) 20233**] for urgent care psych issues
24hrs/day
Completed by:[**2178-3-20**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3002
} | Medical Text: Admission Date: [**2153-7-25**] Discharge Date: [**2153-8-9**]
Date of Birth: [**2088-2-8**] Sex: F
Service: MEDICINE
Allergies:
Naprosyn
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Status Post Cardiac Arrest
Major Surgical or Invasive Procedure:
Intubation
Cooling protocol
Continuous venovenous filtration
History of Present Illness:
Ms. [**Known lastname 83584**] is a 65 year-old woman transfered from an outside
hospital following hypotensive bradycardic arrest. Per her
daughters, the patient had been feeling fatigued and lethargic
for about one month. She was evaluated by her hepatologist who
adjusted her lasix and aldactone dosing and continued her
lactulose regimen with some limited improvement in symptoms. The
evening prior to admission the patient complained of nausea and
leg cramping. On the morning of admission, the patient had a
witnessed fall after exiting the bathroom. She reportedly hit
her head during this episode, but quickly regained
consciousness.
.
She was taken by EMS to [**Hospital3 **] where her HR was in the
30's and she was noted to be in third degree heart block and had
a K 5.7. Shortly after arrival to the OSH, she vomited and
became unresponsive. She was treated as an arrest and received
CPR, although in between compressions she was noted to have a
pulse in 20's. She was subseqently intubated; she was reportedly
a difficult intubation. As part of her work up for a fall she
received a Head and C-spine CT that was reassuring. Initial CXR
was also reassuring, although post-intubation CXR was concerning
for PNA, possibly aspiration pneumonitis. She received one dose
of zosyn at the OSH for possible PNA. She was then transfered to
[**Hospital1 18**].
.
She arrived intubated to [**Hospital1 18**] paralyzed, intubated and
internally paced through right cordis with OG tube in place.
Arrival vitals were BP 99/58 HR 83 RR 20 SpO2 100% on mechanical
ventilator. Repeat labs at [**Hospital1 18**] revealed a K of 4.4. Cooling
protocol was initiated in the ED and the patient was admitted to
the CCU for further management.
.
On arrival to the CCU, she was intubated, sedated and paralysed
accoring to the cooling protocol. She was accompanied by her
daughters [**Name (NI) **] and [**Name (NI) 402**] who were available to provide her
medical history. Following arrival to the CCU, her external
pacemaker was set to 60 bpm and she remained hemodynamically
stable with BP 108/59 and preserved oxygen saturation of 98%.
.
On review of systems, she denies prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, hemoptysis. She denies recent
fevers, chills or rigors. 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.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Hypertension, Sleep Apnea
2. OTHER PAST MEDICAL HISTORY:
Cirrhosis [**1-31**] autoimmune hepatitis on prednisone -
elevated IgG and a positive [**Doctor First Name **] with a titer of 1:1280. Her
alpha-antitrypsin is normal, tTG < 4, AMA negative, LKM
negative, and smooth
muscle antibody negative.
diabetes
obesity
gallstones
anxiety
depression
diverticulosis
status post hysterectomy
Social History:
She is married, has 2 children. She has had no tobacco in 25
years, remote 15-pack year history. She drinks alcohol socially.
Family History:
Colon CA, fatty liver disease
Physical Exam:
ADMISSION EXAM
GENERAL: Intubated and paralysed. Not responsive.
HEENT: NCAT, pupils are equal and responsive 3mm to 2mm BL. ET
tube and OG tube in place.
NECK: Supple, unable to evaluate JVP 2/2 to RIJ cordis.
CARDIAC: Distant heart sounds regular rhythm, No m/r/g.
LUNGS: symmetric breath sounds, coarse anterior breath sounds.
No chest wall deformities, scoliosis or kyphosis.
ABDOMEN: Soft, .
EXTREMITIES: cool extremities with 2+ LE edema.
SKIN: No ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ radial 1+ DP 1+
Left: Carotid 2+ radial 1+ DP 1+
DISCHARGE EXAM
Tm/Tc: 98.8/98 BP: 93-121/50-69 HR: 60-64 RR:18 02 sat: 99%
GENERAL: 65 yo F in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rHonchi post
CV: S1 S2 Normal in quality and intensity RRR 2/6 systolic
murmur at LUSB
ABD: obese, somewhat firm, non-tender, BS normoactive. no
rebound/guarding, has scattered ecchymotic areas [**1-31**] hep shots,
also has left groin area with old large ecchymotic area.
EXT: wwp, no edema. DPs, PTs 2+.
NEURO: A/O conversant
SKIN: no rash
PSYCH: does not seem depressed, mod tearful when talking about
collapse and family.
Pertinent Results:
ADMISSION LABS:
[**2153-7-25**] 09:20PM TYPE-ART PO2-192* PCO2-27* PH-7.46* TOTAL
CO2-20* BASE XS--2
[**2153-7-25**] 09:20PM LACTATE-2.4*
[**2153-7-25**] 09:17PM ALT(SGPT)-47* AST(SGOT)-68* LD(LDH)-225 ALK
PHOS-107* TOT BILI-1.8*
[**2153-7-25**] 09:17PM CK-MB-5 cTropnT-0.02*
[**2153-7-25**] 09:17PM ALBUMIN-3.2* CALCIUM-8.4 PHOSPHATE-5.3*#
MAGNESIUM-2.8*
[**2153-7-25**] 01:00PM LACTATE-4.9* K+-6.6*
[**2153-7-25**] 12:52PM GLUCOSE-154* UREA N-34* CREAT-2.2*
SODIUM-125* POTASSIUM-7.5* CHLORIDE-95* TOTAL CO2-17* ANION
GAP-21*
[**2153-7-25**] 12:52PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
.
DISCHARGE LABS:
PERTINENT STUDIES:
TTE ([**2153-7-28**]): The left atrium is normal in size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. The
mitral valve leaflets are mildly thickened. There is no
pericardial effusion.
CT HEAD ([**2153-7-29**]): No acute intracranial hemorrhage or mass
effect; mild mucosal thickening of the ethmoid and sphenoid
sinuses. While there is no large hypodense area to suggest an
obvious alrge ifnarct, early/subtle ischemic changes can be
better assessed with MRI if there is continued clinical concern
without contra-indication.
MRI HEAD ([**2153-7-29**]): Subtle T1 hyperintensities in the basal
ganglia are nonspecific, but can be seen in metabolic or hypoxic
encephalopathy.
TTE ([**2153-7-31**]): The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). There is no ventricular septal defect.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened.
There is mild aortic valve stenosis (valve area 1.6 cm2). No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is a trivial/physiologic pericardial
effusion.
Labs at discharge:
[**2153-8-9**] 05:36AM BLOOD WBC-3.1* RBC-3.06* Hgb-9.1* Hct-27.5*
MCV-90 MCH-29.8 MCHC-33.3 RDW-18.0* Plt Ct-87*
[**2153-8-9**] 05:36AM BLOOD PT-16.7* INR(PT)-1.5*
[**2153-8-9**] 05:36AM BLOOD Glucose-77 UreaN-22* Creat-0.9 Na-141
K-3.6 Cl-113* HCO3-21* AnGap-11
[**2153-8-7**] 06:01AM BLOOD ALT-47* AST-65* AlkPhos-122* TotBili-1.1
[**2153-8-9**] 05:36AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.8
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: 65F admitted s/p cardiac arrest
with high grade block likely 2/2 CC overdose s/p cooling
protocol.
.
# BRADYCARDIC RESPIRATORY ARREST:
Patient was found to be bradycardic with high grade A/V block
and hypotension at outside hospital after a syncopal episode at
home. Patient had respiratory arrest requiring CPR x 5 minutes
and intubation at OSH (unclear from notes if pulse was present).
Of note, labs drawn at outside hospital included a sodium of 124
and a potassium of 5.7. Blood pressure stabilized following
transjugular external pacing. Patient arrived paced at 70 BPM.
The cooling protocol was initiated for neuroprotection. Patient
had been taking 180mg Verapamil ER and likely had increased
blood levels due to poor hepatic function and worsening renal
function likely precipitating the syncopal episode and the
bradycardic arrest. By HD3 patient had resumed native conduction
and external pacer was pulled. The patient was successfully
extubated on extubated on HD 8 with continued improvement in her
respiratory status. At the time of discharge she had good
oxygen saturations on room air
.
#ATRIAL FIBRILLATION:
Patient developed atrial fibrillation with RVR on HD4. This was
felt to be reactive in the setting of her systemic process.
Patient was rate controlled with po metoprolol 25mg TID. As she
continued to be in this rhythm, she was placed on a heparin
drip. Heart rates remained in the 110s-130s with a few 1 hr
periods sinus conversion to sinus in the 70s. On hospital day 7
she was noted to have afib with RVR with rates in the 150s, she
was started on digoxin 0.125 mg daily following a digoxin load
on 0.25 mg x 4. She had periods of spontaneous conversion to
sinus rhythm over the next few days and her digoxin and
metoprolol were discontinued on HD 10 after she had maintained
sinus rhythm for 2 days. It was believed her atrial
fibrillation was unlikely to recur however given her extended
period of atrial fibrillation. she was started on Coumadin for a
planned 4-6 weeks of anti-coagulation. Her heparin drip was
discontinued on discharge. At the time of discharge she was on
coumadin 5 mg and her INR was 1.5. She will need an INR check on
[**2153-8-11**].
# ACUTE TUBULAR NECROSIS:
Patient was oliguric with periods of anuria on hospital day 2
with creatinine peaking at 2.3 on [**7-27**] prior to CVVH. Likely
multifactorial including hypovolemic and splanchnic
vasodilation, although patient not in decompensated liver
failure and this is likely not hepatorenal syndrome. Granular
casts (although not muddy brown, per report) were seen prior to
the period of anuria, suggesting progressive acute tubular
necrosis. Patient was started on CVVH for hyperkalemia (5.7)
and began to diurese without standing lasix (patient had
received 100 mg prior to CVVH following 2L NS with increase of
UOP to 50mL/hr). On HD 5 CVVH was stopped and the pt began
making excellent urine. Creatinine remained stable throughout
the remainder of the admission and was 0.9 at the time of
discharge.
.
# AMS:
Patient underwent the Artic Sun cooling protocol for
neuroprotection. She was monitored per protocol with EEG and
there were no signs of seizure activity. Neuro was consulted and
felt this was likely anoxic brain injury. Head CT showed no
mass/shift/bleed and MRI showed nonspecific areas of
hyperintensity in the basal ganglia. Neurology felt that a
clear prognosis could not be made until the patient was 6-7 days
post-cooling. Her condition remained guarded as she continued to
be unresponsive and was intermittently posturing. There was also
concern for a component of hepatic encephalopathy and therefore
she was started on rifaximin and lactulose with adequate stool
production. On day 7 post rewarming the patient was noted to be
significantly more responsive. He mental status continued to
improve and as above she was successfully extubated on HD 11.
She passed a swallow evaluation and tolerated advances in her
diet. At the time of discharge she was near baseline mental
status.
.
# Leukocytosis: While intubated the patient was noted to have
increased thick secretions. Per ventilator associated pneumonia
protocol she had urine showed yeast which cleared with
replacement of her foley and a negative urine legionella
antigen. On HD 8 Sputum gram stain showed 4+ gram negative
rods. The patient was started on cefepime with tobramycin for
empiric coverage of gram negative ventilator associated
pneumonia with resolution of her leukocytosis. Vancomycin was
not initially started however it was added after a blood culture
from her arterial line showed gram positive cocci. The line was
removed. However it was ultimately determined to be coagulase
negative staphylococcus felt to represent a contaminant and
vancomycin was discontinued. Her antibiotics were further
narrowed to ampicillin after sputum and mini bronchoalveolar
lavage cultures showed Haemophilus Influenzae. When she was
tolerating PO this was changed to amoxicillin for better
coverage to complete a total antibiotic course of 7 days.
.
# AUTOIMMUNE HEPATITIS:
Prednisone was increased from 5mg to 15mg daily per hepatology
recommendations. This was decreased to 10 mg on HD 7. The use of
propofol for sedation was initiated to avoid build up of
benzodiazepines, however patient's blood pressures were
difficult to control with propofol. Therefore midazolam was
used for further sedation. Patient did not have frank signs of
ascites secondary to cirrhosis. Liver function tests remained
stable throughout hospitalization. Neomycin and spironolactone
were d/c'ed and Rifaxamin was started for control of ammonia
levels.
.
# HTN
Home verapamil was held in setting of hypotension. Her BP was
well controlled on now medicines.
.
# Anemia: normochromic and normocytic. No evidence of bleeding.
Thought [**1-31**] illness and phelbotomy. Please consider colonoscopy
if does not resolve in [**12-31**] months.
.
TRANSITIONAL ISSUES
Patient was discharged to a rehabilitation for further therapy
Coumadin will be continued for 4-6 weeks. Pt will f/u with Dr.
[**Last Name (STitle) **] to determine if coumadin is still warrented. Will need
transition of INR management to outpatient PCP at discharge with
INR check on [**2153-8-11**].
Medications on Admission:
1. Calcarb 600 With Vitamin D 600 mg(1,500mg) -400 unit Tablet
Sig: One (1) Tablet PO twice a day.
2. Lantus 100 unit/mL Solution Sig: Four (4) units Subcutaneous
at bedtime.
3. Humalog 100 unit/mL Cartridge Sig: Three (3) units
Subcutaneous twice a day: before lunch and dinner.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. verapamil 180 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO Q24H (every 24 hours).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. spironolactone 50 mg Tablet Sig: One (1) Tablet PO DAILY
9. lactulose 10 gram/15 mL Solution Sig: Thirty (30) ML PO QID
10. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID
12. neomycin 500 mg Tablet Sig: One (1) Tablet PO twice a day: 1
Tablet(s) by mouth twice a day Take for 3 weeks starting
[**2153-2-23**], then stop for one week and continue on this regimine .
Discharge Disposition:
Extended Care
Facility:
St. [**Hospital 11042**] Hospital Rehab.Unit
Discharge Diagnosis:
Acute Kidney Injury
Cardiac arrest
Paroxysmal Atrial Fibrillation
Cardiogenic shock
Pneumonia
Anemia
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 collapsed and had a cardiac arrest caused by a combination
of your medicines and dehydration. You underwent a cooling
protocol and needed to have dialysis until your kidneys started
to work again. You have made a very good recovery and your
heart, kidneys and lungs appear to be functioning well. You had
an episode of atrial fibrillation, an irregular heart beat and
will need to be on warfarin (coumadin) for a month to prevent a
stroke. You will also need to complete a week course of
amoxicillin for a pneumonia. You are being discharged to a
rehabilitation center to get physical and occupational therapy
to help you fully recover.
.
We made the following changes to your medicines:
1. Stop taking Aspirin, Verapamil, spironolactone, loratidine,
magnesium and neomycin.
2. Increase prednisone to 10 mg daily
3. Start rifaximin to lower your ammonia level
4. Start Amoxicillin to treat a pneumonia, you have 3 days left
of a 1 week course
5. STart warfarin to prevent a stroke from the atrial
fibrillation.
Followup Instructions:
Department: TRANSPLANT
When: [**8-27**] at 8:20am
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2153-9-5**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2153-10-4**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 486, 5845, 2761, 2762, 2859, 4019, 5715, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3003
} | Medical Text: Admission Date: [**2103-12-29**] Discharge Date: [**2104-1-17**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
PICC line placement [**2104-1-11**]
History of Present Illness:
83 yo male who 3 days prior to admission had undergone an
endovascular procedure was on Coumadin, who was found by his
family lying in bed confused and complaining of chills. He was
taken to an area hospital where he vomitted large amounts of
coffee ground emesis; an NG tube was placed. He was transfused
with 2 units PRBC's and given IV fluids and then transferred to
[**Hospital1 18**] for further care.
Past Medical History:
CABG, LE PTA, L CEA, AAA repair, R fem aneurysm repair, cataract
surgery.
Social History:
Married, resides with his wife
Family History:
Noncontributory
Physical Exam:
99.8, 92, 137/55, 22, 96%2L NC
HEENT: PEERRLA, mucosase moist
Cor: RRR, II/VI SEM
Chest: CTAB
Abd: minimally distended, + BS, nontender, no masses, no bruits
Ext: 1+ edema BLE, L groin/arm incisions
Pertinent Results:
[**2103-12-29**] 01:41PM WBC-5.3 RBC-3.85* HGB-12.4* HCT-36.7* MCV-95
MCH-32.1* MCHC-33.7 RDW-18.1*
[**2103-12-29**] 01:41PM PLT COUNT-222
[**2103-12-29**] 08:17AM GLUCOSE-162* UREA N-37* CREAT-1.4* SODIUM-139
POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-21* ANION GAP-18
[**2103-12-29**] 08:17AM ALT(SGPT)-51* AST(SGOT)-55* CK(CPK)-111 ALK
PHOS-224* AMYLASE-224* TOT BILI-1.3
CHEST (PORTABLE AP)
Reason: - please include upper abdomen on CXR- please eval for
NGT p
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with UGIB, hematemesis s/p EGD, gram neg
bacteremia, now s/p placement of new NG tube
REASON FOR THIS EXAMINATION:
- please include upper abdomen on CXR- please eval for NGT
placement
REASON FOR EXAMINATION: Evaluation of the NG tube placement.
Portable AP chest radiograph compared to [**2104-1-8**].
The NG tube passes below the diaphragm, enters the stomach with
its tip terminating below the field of view, most likely at the
level of the _____ or in proximal duodenum. The heart size and
the mediastinal contours are unremarkable. There is increase in
left retrocardiac atelectasis with no significant change in
right and left small pleural effusions. There is increased
opacity in the right upper lobe which might be due to layering
pleural effusion but underlying infectious process cannot be
excluded.
ABDOMEN (SUPINE & ERECT)
Reason: Eval for obstruction, free air
[**Hospital 93**] MEDICAL CONDITION:
83 year old man with likely ischemic bowel, also w/ SB dilation/
?obstruction
REASON FOR THIS EXAMINATION:
Eval for obstruction, free air
HISTORY: 83-year-old man with likely ischemic bowel and small
bowel dilatation. Evaluate for obstruction or free air.
Comparison is made to prior radiograph dated [**2104-1-5**],
and prior CT dated [**2104-1-2**].
TECHNIQUE: Supine and left lateral decubitus abdominal
radiographs.
Residual barium from prior examination is identified within the
ascending colon, rectosigmoid region and within multiple
diverticula in the sigmoid and descending colon. The colon
appears slightly more dilated when compared to prior
examination, measuring approximately 7.6 cm in the region of the
cecum/ascending colon on today's exam with prior measurement of
6.8 cm. The transverse colon is also slightly more dilated
measuring approximately 6.7 cm on today's examination with prior
measurement of approximately 5 cm. Slightly increased dilatation
is also noted within the region of the sigmoid. Small bowel
appears grossly unremarkable and may be decreased slightly in
caliber.
The patient is noted to be status post median sternotomy, and an
NG tube is noted within the distal stomach or proximal duodenum.
Surgical clips are again identified within the pelvis
bilaterally and a right-sided stent is again identified. There
are degenerative changes of the lumbar spine and mild
levoscoliosis. No evidence of pneumatosis or free air.
IMPRESSION:
1. Dilated ascending/transverse colon may be sequela of ileus in
a patient with an ischemic event or represent pseudoobstruction
([**Last Name (un) 3696**] syndrome).
Given the collapse of the sigmois colon and descending colon,
mechanical obstruction is less likely. Contrast from prior exams
has also progressed to the sigmoid colon
2. Diverticulosis
Cardiology Report ECHO Study Date of [**2104-1-1**]
PATIENT/TEST INFORMATION:
Indication: Evaluate for endocarditis.
Height: (in) 75
Weight (lb): 173
BSA (m2): 2.07 m2
BP (mm Hg): 153/62
HR (bpm): 94
Status: Inpatient
Date/Time: [**2104-1-1**] at 13:45
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W000-0:00
Test Location: West MICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Four Chamber Length: 4.7 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.7 cm (nl <= 5.0 cm)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aortic Valve - Peak Velocity: *2.3 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 20 mm Hg
Aortic Valve - Mean Gradient: 10 mm Hg
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 176 msec
TR Gradient (+ RA = PASP): *33 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Minimally
increased
gradient c/w minimal AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**1-1**]+)
MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Mild
PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is normal in size. The left ventricular cavity
size is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets are mildly thickened. There is a minimally increased
gradient
consistent with minimal aortic valve stenosis. Trace aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**1-1**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no
pericardial effusion.
No definite vegetation seen but cannot exclude.
Brief Hospital Course:
He was transferred to the Surgical Service after being consulted
by the Medicine service for hematemesis. He underwent EGD which
showed gastritis; there was an area of active bleeding which was
injected with Epinephrine and cauterized. On abdominal CT
imaging it was revealed that there was diffuse mural thickening
of the descending colon, sigmoid and rectum. KUB showed dilated
small bowel. He was placed on IV antibiotics; initially Levo and
Flagyl; this was later changed to Zosyn. He was given IV fluids
and was made NPO. A Nutrition consult was placed, he was started
on TPN; this was later stopped and his diet was advanced slowly.
He will require ongoing nutritional support once at rehab
facility; calorie counts and monitoring his weight are being
recommended.
He did have a drop in his hematocrit down to 21.8 and was
transfused with 2 units packed red cells; hematocrit was 29.7 on
day of this dictation. He is not having any dark stools and no
hematemesis has been noted.
Physical therapy was consulted and have recommeded short term
rehab stay.
Medications on Admission:
Pantoprazole
Felodipine
Ranitidine
Metoprolol
Donepizil
Lisinopril
Cyclobenzaprine
ASA
Phenytoin
Azathioprine
Oxybutinin Chloride
Discharge Medications:
1. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO at bedtime.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection [**Hospital1 **] (2 times a day).
4. Acetaminophen 650 mg Suppository Sig: [**1-1**] Suppositorys Rectal
Q4-6H (every 4 to 6 hours) as needed for pain.
5. Phenytoin 100 mg/4 mL Suspension Sig: Eight (8) ML's PO Q8H
(every 8 hours).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection four times a day as needed for per sliding scale.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for HR <60; SBP <110.
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily): PICC line flush.
9. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): apply to left groin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Gastrointestinal bleed
Gram negative bacteremia
Ischemic colitis
Discharge Condition:
Stable
Discharge Instructions:
Per Page One
Followup Instructions:
Follow up in 1 week with Dr. [**Last Name (STitle) **] in Surgery Clinic, call
[**Telephone/Fax (1) 600**] for an appointment.
Follow up with Dr. [**Last Name (STitle) **], Vascular Surgery as previously
directed. Call [**Telephone/Fax (1) 1237**] for an appointment.
Completed by:[**2104-1-17**]
ICD9 Codes: 7907, 5849, 2930, 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3004
} | Medical Text: Admission Date: [**2193-11-24**] Discharge Date: [**2193-12-3**]
Date of Birth: [**2143-4-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
N/V, fever
Major Surgical or Invasive Procedure:
right subclavian line
History of Present Illness:
Pt is 50 yo f with no significant PMH, who had the acute onset
of N/V 2 days prior to admission. 2 days PTA, pt had dinner
which included cooked ground beef and "moldy cheddar cheese". 4
hours later, the pt had "indigestion", took Tums, and then had
the onset of N/V with vague abdominal discomfort. She had
several additional episodes of non-bloody emesis over the next
48 hours. Yesterday, the pt also noted a diffuse, erythematous
rash on her chest, back, arms, and legs (she is unsure where the
rash started). She felt feverish and chilled, and reportedly had
a temp of 99. She continued to have episodic N/V, called her PCP
and was told to come to the ED. Denies any diarrhea,
hematemesis, hematochezia, or dysuria. She has had decreased PO
over the past 2 days. No recent travel. No new medications or
herbal supplements. No sick contacts. [**Name (NI) **] ingestion of raw meat
or seafood. Of note, pt's menstrual period started 3 days ago
and she has been using tampons (currently has a tampon in place
for last 12 hours).
.
In the [**Name (NI) **], pt had temp up to 104.2, BP down to 85/47, and HR up
to 119. She was given 7 L IVF, a R SC central line was placed,
and she was started on levophed. Her BP then improved to 112/61,
and CVP was measured at 12. Her O2 sat also dropped to 81% on
RA, and improved to 100% on 100% NRB. She was given zosyn,
flagyl, tylenol, and zofran. She had an abdominal CT scan, which
was negative.
.
Pt currently c/o mild, vague abdominal discomfort and mild SOB
with cough (cough started in ED). Denies CP. Has a very mild
headache, but no neck stiffness or photophobia.
Past Medical History:
h/o neck pain, buttock pain, and low back pain s/p MVC '[**86**]
- s/p C-sectoin
- s/p tonsillectomy
Social History:
Lives at home with female partner and 12 [**Name2 (NI) **] daughter. [**Name (NI) 1403**] as a
social worker. Denies tobacco or drugs. Occasinoal EtOH.
Family History:
Mother with Parkinsons. Father with heart disease.
Physical Exam:
Vitals: T 103.5 BP 103/52 HR 113 RR 20 O2 100% on 100% NRB
Gen: tired appearing, flushed, but able to speak in complete
sentences
HEENT: PERRL. MM dry. No OP lesions.
Neck: Supple, full neck ROM. Non-tender.
Cardio: regular, tachy, no m/r/g
Resp: decreased BS bilaterally [**1-4**] poor insp effort
Abd: soft, mildly distended, mild generalized tenderness, no
rebound or guarding. + BS.
Ext: no c/c/e
Neuro: A&Ox3.
Skin: diffuse erythroderma/flushing of abdomen, back, buttocks,
neck. No petechiae. No rash on palms or soles.
Rectal: guaiac negative brown stool
Pertinent Results:
[**2193-11-24**] 04:23AM WBC-3.9*# RBC-4.31 HGB-13.7 HCT-39.3 MCV-91
MCH-31.8 MCHC-34.9 RDW-13.8
[**2193-11-24**] 04:23AM NEUTS-80* BANDS-18* LYMPHS-2* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2193-11-24**] 04:23AM PLT COUNT-237
[**2193-11-24**] 04:23AM PT-12.5 PTT-23.6 INR(PT)-1.1
[**2193-11-24**] 04:23AM ALT(SGPT)-21 AST(SGOT)-31 LD(LDH)-174 ALK
PHOS-52 AMYLASE-50 TOT BILI-0.6
[**2193-11-24**] 04:23AM GLUCOSE-117* UREA N-16 CREAT-1.2* SODIUM-139
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
[**2193-11-24**] 05:35AM LACTATE-1.9
[**2193-11-24**] 10:09AM WBC-12.8*# RBC-3.33* HGB-10.6*# HCT-30.6*
MCV-92 MCH-31.9 MCHC-34.6 RDW-13.6
[**2193-11-24**] 10:09AM NEUTS-85* BANDS-10* LYMPHS-1* MONOS-2 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2193-11-24**] 10:09AM ALBUMIN-2.6* CALCIUM-6.2* PHOSPHATE-1.0*
MAGNESIUM-1.3*
[**2193-11-24**] 05:54PM WBC-18.2* RBC-3.36* HGB-10.5* HCT-30.8*
MCV-92 MCH-31.2 MCHC-34.0 RDW-13.2
[**2193-11-24**] 05:54PM NEUTS-55 BANDS-39* LYMPHS-1* MONOS-2 EOS-1
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
Brief Hospital Course:
Note - this hospital course reflects the course as reflected in
the chart and here summarized by Dr. [**Last Name (STitle) **] from [**Location (un) 1131**] through
the medical record. I (Dr. [**Last Name (STitle) **] was the attending of record
only from [**12-1**] through [**2192-12-3**].
.
50 yo generally healthy female, p/w N/V, fever, hypotension,
erythroderma and sepsis on admission requiring pressor support
and agressive hydration on presentation with ICU admission.
.
Sepsis: felt to be due to toxic shock associated with tampon
use. Cervical cx. showed MSSA, all other cultures were
negative. Pt. recieved Vancomycin, clindamycin, and zosyn
initially. She improved hemodynamically and abx were tapered to
clindamycin po and she was transferred to the medical [**Hospital1 **], at
which time wbc again rose with eosinophilia, this was changed to
cefalexin for one day. As WBC continued to rise, all abx were
stopped. At this time a morbilliform drug erruption was noted
truncally, and eosinophilia persisted. These began to resolve
by d/c with discontinuation of all abx. At time of d/c, pt. had
been afebrile for over 72 hours, all surveillance cx were
negative, and she was feeling well.
Her ICU course was complicated by mild acute renal failure that
improved with fluids, as well as mild pulmonary edema,
attributed to massive IV fluid resuscutation on presentation,
which resolved over time with auto diuresis.
Medications on Admission:
Tums only.
Discharge Medications:
Benadryl prn for itching.
Discharge Disposition:
Home
Discharge Diagnosis:
Toxic shock syndrome with septic shock requiring vasopressors
and aggressive IV volume repletion resuting in pulmonary edema
.
Beta lactam allergy (likely) with drug eruption (rash)
Discharge Condition:
Stable, mild, resolving, morbilliform drug rash, afebrile for 72
hours, all surveillance cx. negative, independently ambulating,
voiding, and tolerating po nutrition and fluids.
Discharge Instructions:
No new medications were prescribed. You can resume TUMS as you
were prior to coming to the hospital, and you can use over the
counter benadryl for itching as needed, as we discussed.
Return to the [**Hospital1 18**] Emergency Department for:
Fevers
Worsening Rash
Abdominal pain, malaise
Followup Instructions:
With your primary doctor within two weeks. Call for
appointment: [**Last Name (LF) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 3393**]
ICD9 Codes: 0389, 5849, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3005
} | Medical Text: Admission Date: [**2201-5-12**] Discharge Date: [**2201-5-18**]
Date of Birth: [**2148-9-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Right Craniotomy for Tumor
History of Present Illness:
This is a 52 year old female Haitian Creole speaking female
transferred from OSH after head CT showed a 3 cm x 3 cm R
parietooccipital brain mass with rim of calcification and
associated vasogenic edema. The patient has had headaches for
one month involving her whole head. Recently, they have
increased in intensity and prevent her from sleeping. As a
result of these symptoms, she was referred to an OSH ED where CT
scan showed the above findings.
Past Medical History:
Fibroids, s/p TAH
Social History:
Emigrated from [**Country 2045**] 7 years ago. She works and
[**Last Name (un) 1445**] [**Doctor Last Name **] and KFC. She lives with her husband. She had two
adult children.
Family History:
mother deceased from [**Name (NI) 3685**]
Physical Exam:
EXAM ON ADMISSION:
Vitals: T 97.7; BP 144/80; P 70; RR 18; O2 sat 100%
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple
Extremities: no c/c/e.
Neurological Exam:
Mental status: awake, alert, per family relays coherent history
with no paraphasic errors. Follows simple and multi-step
commands.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light. VF appear full though she
continues to saccade towards finger movements in periphery even
when instructed not to do so.
III, IV, VI: EOMI.
V, VII: facial sensation intact, facial symmetric.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**6-10**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift. Full
strength.
Sensation: intact to light touch.
Reflexes: Bic T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally.
Coordination: FNF intact.
On discharge:
Oriented x 3. PERRL, EOMs intact.
She has a persistent left visual field.
Face symmetric, tongue midline.
No drift.
Full strength throughout.
Sensation intact.
Incision: clean, dry, intact. Sutures in place.
Pertinent Results:
ADMISSION LABS:
[**2201-5-12**] 08:40PM WBC-8.6 RBC-5.02 HGB-12.5 HCT-37.2 MCV-74*
MCH-24.8* MCHC-33.5 RDW-13.4
[**2201-5-12**] 08:40PM GLUCOSE-91 UREA N-11 CREAT-0.6 SODIUM-141
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-29 ANION GAP-11
[**2201-5-12**] 08:40PM PT-11.7 PTT-24.0 INR(PT)-1.0
DISCHARGE LABS:
[**2201-5-18**] 05:35AM BLOOD WBC-17.3* RBC-4.52 Hgb-10.9* Hct-32.7*
MCV-72* MCH-24.1* MCHC-33.3 RDW-13.6 Plt Ct-223
[**2201-5-18**] 05:35AM BLOOD PT-11.4 PTT-22.8 INR(PT)-0.9
[**2201-5-18**] 05:35AM BLOOD Glucose-105* UreaN-12 Creat-0.5 Na-138
K-4.1 Cl-101 HCO3-29 AnGap-12
IMAGING:
CT Head from OSH [**5-12**]:
3 cm x 3 cm R pariet-occipital mass with calcified rim and
associated vasogenic edema.
CT CHEST [**5-13**]:
Limited evaluation of the pulmonary parenchyma due to image
acquisition during the expiratory phase of respiration. However,
no
intra-thoracic malignancy is identified
MRI Brain [**5-14**]:
Large extra-axial mass lesion identified at the right occipital
region, causing mass effect, associated with vasogenic edema and
adjacent and contacting the right transverse sinus as described
above, more likely
consistent with a meningioma.
Head CT [**5-15**]:
Expected post-op changes.
Residual edema in the right temporo-occipital region causing
mass effect on the occipital [**Doctor Last Name 534**] of the right lateral ventricle
and approximately 6 mm of right-to-left midline shift.
MRI Brain [**5-16**]:
There is increased DWI signal surrounding the resection cavity.
Infarct cannot be ruled out at this time but this is likely due
to retraction during the surgery though infarct cannot be
excluded. There is gross total resection.
Brief Hospital Course:
The patient was admitted to the NSurg service for Q 4 hour
neurochecks and for further work up of the CT findings. She was
given a load of Dexamethasone, and maintained on 4 Q 6. A chest
CT was obtained, which revealed no pulmonary lesions or other
areas of tumor. MR head showed large extra-axial mass lesion at
the right occipital region, causing mass effect, more likely
consistent with a meningioma.
She proceeded to the OR on [**5-15**] with Dr. [**First Name (STitle) **] for a craniotomy.
Frozen section was consistent with a meningioma with no atypical
features. The procedure went well without complications. The
patient was in the ICU overnight for Q1 hour neuro checks. She
was transferred to the neurosurgical floor the following night
since she was neurologically stable.
Physical therapy and occupational therapy evaluated the patient
over the weekend and recommended rehab. She was re-evaluated on
[**5-18**] and was still quite unsteady and required significant
assistance. She was screened for rehab and and was sent to an
appropriate facility on [**2201-5-18**].
Medications on Admission:
HCTZ 25 mg daily, Celexa 20 mg daily, Omeprazole 20
mg q day, Simvastatin 20 mg daily.
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain .
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
12. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 6 doses.
13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 doses: Start after 3 mg tapered dose.
14. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day) for 6 doses: Start after 2 mg tapered dose.
15. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right parietooccipital mass
Discharge Condition:
Neurologically stable
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed. You will not require blood work
monitoring.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2201-6-15**]
at 9:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2201-5-18**]
ICD9 Codes: 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3006
} | Medical Text: Admission Date: [**2177-7-6**] Discharge Date: [**2177-7-7**]
Date of Birth: [**2121-5-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Food Impaction
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Intubation
Mechanical Ventilation
History of Present Illness:
This is a 56yoM with h/o COPD, HTN, ?esophageal stricture who
initially presented to OSH today dysphagia that began at 12pm
today. States that he was eating boneless chicken and
immediately had the sensation that food was stuck. He then
presented to a local ER 1.5-2 hours later. There, an EGD under
MAC was attempted however only fragments of food were retrieved.
After one hour, the procedure was aborted. Per report, patient
noted to have varices on EGD. Given inability to retrieve
object, patient was transferred to [**Hospital1 18**].
Of note, per report, patient had a similar episode that occurred
2 years ago with steak. At that time, flexible upper endoscopy
was not successful and required the OR.
VS prior to transfer 147/85, 71, 20, 96RA. Labs at OSH were WBC
12.9, Hct 48.2, Plt 267. AST/ALT 20/20, AP 78, Tbili 0.7, INR
1.0. Cr 1.0
In ED, initial VS were 98.2 73 150/88 94% 2L NP. Evaluation was
significant for WBC increased to 18.4. GI and thoracics were
consulted and planed for EGD in ICU. Patient was then intubated
in preparation for EGD with propofol, versed, etomidate, and
fentanyl for sedation. CXR did not show pneumomediastinum. IV
20g x 2. VS prior to transfer were 97.8 77 153/89.
On arrival to the MICU, patient was intubated and sedated.
Past Medical History:
- COPD
- Hypertension
- Chronic low back pain
- Osteoarthritis
- h/o GERD
- h/o esophageal stricture?
- h/o OSA
Social History:
Lives with his wife, [**Name (NI) **]. [**Name2 (NI) **] is a bartender and waiter in
[**Location (un) 4310**]. He drinks 4-5 beers/day but states he used to drink much
more. Smokes 2 PPD x 40 yrs. Denies illicits.
Family History:
Non contributory
Physical Exam:
Admission Physical Exam:
Vitals: 117/63 72 100% on CMV 500x16, fio2 100% PEEP 5
General: intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, ETT
in place
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: intubated, PERRL
Discharge Physical Exam (changes)
99.7 113/63 98 94%RA
Gen: alert and oriented
Neck: No crepitus or tenderness to palpation
Lungs: faint expiratory wheezing
Pertinent Results:
Admission Labs:
[**2177-7-6**] 07:50PM BLOOD WBC-18.4* RBC-5.52 Hgb-17.6 Hct-52.2*
MCV-95 MCH-31.9 MCHC-33.7 RDW-13.2 Plt Ct-362
[**2177-7-6**] 07:50PM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-140
K-4.3 Cl-99 HCO3-28 AnGap-17
[**2177-7-6**] 07:50PM BLOOD Calcium-9.4 Phos-3.6 Mg-2.2
[**2177-7-6**] 07:50PM BLOOD ALT-24 AST-25 AlkPhos-74 TotBili-0.6
Discharge Labs:
[**2177-7-7**] 04:31AM BLOOD WBC-16.8* RBC-4.62 Hgb-15.1 Hct-43.8
MCV-95 MCH-32.6* MCHC-34.5 RDW-13.1 Plt Ct-257
[**2177-7-7**] 04:31AM BLOOD PT-10.6 PTT-25.8 INR(PT)-1.0
[**2177-7-7**] 04:31AM BLOOD Glucose-93 UreaN-15 Creat-0.8 Na-140
K-4.3 Cl-102 HCO3-30 AnGap-12
[**2177-7-7**] 04:31AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
CXR: ([**7-6**])
FINDINGS: PA and lateral views of the chest. No prior. The
lungs are clear. There is no pneumothorax or effusion.
Cardiomediastinal silhouette is within normal limits. There is
no evidence of pneumomediastinum. Osseous and soft tissue
structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process. No evidence of
pneumomediastinum or pneumothorax.
CXR ([**7-6**])
FINDINGS: In comparison with the study of [**7-6**], there is now an
endotracheal tube in place with its tip at the clavicular level,
approximately 5.5 cm above the carina. Otherwise, no interval
change or evidence of pneumonia or vascular congestion.
EGD:
Findings: Esophagus:
Lumen: A Schatzki's ring was found in the lower third of the
esophagus.
Mucosa: Circumferential erythma and erosions in the distal
esophagus (see photo).
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Other
findings: Food bolus had passed prior to the exam. Food bolus
was seen in the stomach. Ring was present in the distal
esophagus with active esophagitis (see photo).
Impression: Schatzki's ring
Esophagitis
Food bolus had passed prior to the exam. Food bolus was seen in
the stomach. Ring was present in the distal esophagus with
active esophagitis (see photo).
Recommendations: Repeat EGD with dilatation within 6 weeks.
Soft solid diet until repeat EGD.
Brief Hospital Course:
HOSPITALIZATION COURSE:
56yoM with history of COPD, HTN, esophageal strictures who
presented from OSH with acute food impaction. Food bolus had
passed into stomach by time of EGD at [**Hospital1 18**].
ACTIVE ISSUES:
# Food Impaction: Acute impaction of food bolus requiring
retrieval. OSH attempt was unsuccessful prompting transfer to
[**Hospital1 18**]. Given prolonged an complicated initial EGD, the patient
was electively intubated for repeat EGD at time of procedure.
EGD showed esophageal injury without perforation from prior OSH
EGD, as well as a Schatzki Ring. Of note, original food bolus
had passed into the stomach. Recommendations were for follow up
EGD in 6 weeks for dilation of Schatzki ring. After procedure,
patient had a low grade temp of 99.6 F. No clinical signs
concerning for esophageal perforation or mediastinitis.
Recommendations were made for a mechanically soft diet to be
taken for the next 6 weeks until patient undergoes esophageal
dilitation.
-GI will arrange for follow up with Dr. [**First Name4 (NamePattern1) 2795**] [**Last Name (NamePattern1) 908**] for
esophageal dilitation
-Patient provided with phone number for [**Hospital **] clinic
-Outpatient followup with PCP arranged for 24 hours of discharge
# ETOH Abuse: Per report, drinks 4-5 beers a day. No issues
regarding withdrawal in house. CIWA unneeded.
INACTIVE ISSUES
# COPD: Continued tiotropium bromide
# Hypertension: Restarted lisinopril upon discharge from the
hospital.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Food Impaction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to [**Hospital1 18**] because you had food stuck in your
esophagus (the structure that connects your throat to your
stomach). The gastroenterologists performed a procedure to
remove the food. When they looked however the food particle had
passed. They however did see narrowing of your esophagus that
needs to be re-evaluated and dilated.
***IT IS CRUCIAL THAT YOU SET UP A FOLLOW UP APPOINTMENT WITH A
GASTROENTEROLOGIST TO EVALUATE THIS NARROWING AND DILATE YOUR
ESOPHAGUS. FAILURE TO DO SO CAN RESULT IN FOOD GETTING STUCK IN
YOUR ESOPHAGUS AND RUPTURING, WHICH COULD LEAD TO DEATH.***
Because of the procedure, you needed breathing tube to help
protect your lungs. You will need to be re-evaluated by your PCP
[**Name Initial (PRE) 503**]. (Please see appointment below.)
Followup Instructions:
Please be sure to keep the follow appointments:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A
Location: [**Location (un) **] FAMILY PRACTICE
Address: [**Location (un) 66508**], [**Location (un) **],[**Numeric Identifier 28669**]
Phone: [**Telephone/Fax (1) 41186**]
Appointment: TOMORROW [**2177-7-8**] at 2:15pm
Please call ([**Telephone/Fax (1) 2233**] to schedule an appointment at [**Hospital1 18**]
with a gastroenterologist within the next 4-6 weeks.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 496, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3007
} | Medical Text: Admission Date: [**2188-9-5**] Discharge Date: [**2188-9-13**]
Date of Birth: [**2130-9-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Positive stress test with severe CAD on cath
Major Surgical or Invasive Procedure:
s/p CABGx3(LIMA->LAD, SVG->OM, PDA) [**2188-9-8**]
History of Present Illness:
57 y/o male with recent stress test who underwent cardiac cath
which found severe three vessel disease.
Past Medical History:
Hypertension, Hypercholesterolemia, Diabetes Mellitus,
Depression, Sleep apnea, s/p tonsillectomy, s/p removal of left
ear benign tumor
Social History:
Smoke 1ppd x 40yrs. Denies ETOH use.
Family History:
Non-contributory
Physical Exam:
VS: 53 100/72 18
Gen: NAD, A&O x 3
Lungs: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS, very obese
Pertinent Results:
[**9-11**] CXR: patient is status post coronary artery bypass graft.
Multiple sternal wires are unchanged in configuration. The
cardiomediastinal silhouette is upper limits of normal but
stable. The pulmonary vasculature is not engorged. The lung
volumes are low with bibasilar atelectasis. Small bilateral
pleural effusions are new since [**2188-9-7**].
[**9-8**] Echo: PRE CPB The left atrium is moderately dilated. The
left atrium is elongated. A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic arch is mildly dilated. There are simple
atheroma in the aortic arch. There are focal calcifications in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). POST CPB Normal biventricular systolic function.
Ascending aorta intact.
[**2188-9-6**] 05:30AM BLOOD WBC-6.2 RBC-4.00* Hgb-12.3* Hct-35.1*
MCV-88 MCH-30.6 MCHC-35.0 RDW-14.8 Plt Ct-250
[**2188-9-11**] 06:00AM BLOOD WBC-5.8 RBC-2.90* Hgb-8.8* Hct-25.4*
MCV-88 MCH-30.4 MCHC-34.7 RDW-14.9 Plt Ct-176
[**2188-9-12**] 06:10AM BLOOD Hct-28.0*
[**2188-9-6**] 05:30AM BLOOD PT-11.9 PTT-26.8 INR(PT)-1.0
[**2188-9-9**] 02:07AM BLOOD PT-12.2 PTT-32.5 INR(PT)-1.0
[**2188-9-6**] 05:30AM BLOOD Glucose-90 UreaN-16 Creat-0.9 Na-140
K-3.7 Cl-103 HCO3-27 AnGap-14
[**2188-9-11**] 06:00AM BLOOD Glucose-95 UreaN-22* Creat-1.1 Na-140
K-3.8 Cl-105 HCO3-27 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 74448**] was transferred from OSH for surgical
revascularization. He underwent usual pre-operative work-up and
remained stable under medical management for several days. On
0/17 he was brought to the operating room where he underwent a
coronary artery bypass graft x 3. Please see operative report
for surgical details. Following surgery he was transferred to
the CSRU for invasive monitoring in stable condition. Later on
op day he was weaned from sedation, awoke neurologically intact
and extubated. Beta blockers and diuretics were started on
post-op day one and he was gently diuresed towards his pre-op
weight. On post-op day two he was transferred to the SDU for
further care. His chest tubes were removed on this day. On
post-op day three his epicardial pacing wires were removed. He
worked with physical therapy during his entire post-op course
for strength and mobility. He appeared to be doing well on
post-op day five and was discharged home with VNA services and
the appropriate follow-up appointments.
Medications on Admission:
Zoloft 150mg qd, Metformin 500mg qhs, Tricor 45mg qd, Diovan
160/25mg qd, Aspirin
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
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).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Sertraline 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*0*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
9. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **], NH
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Hypercholesterolemia, Diabetes Mellitus,
Depression, Sleep apnea
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
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 74449**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks.
Completed by:[**2188-9-13**]
ICD9 Codes: 4019, 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3008
} | Medical Text: Admission Date: [**2149-8-10**] Discharge Date: [**2149-9-13**]
Date of Birth: [**2080-6-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Shellfish Derived / Latex
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Transferred from OSH for transplant evaluation
Major Surgical or Invasive Procedure:
placement of temporary hemodialysis catheter
continuous [**Last Name (un) **]-venous hemodialysis
endotracheal intubation
placement of central venous catheter
placement of arterial line
History of Present Illness:
69F c h/o EtOH-cirrhosis admitted to OSH with vomiting and
weight loss on [**2149-8-7**] now transferred for transplant
evaluation/ Patient had hip surgery [**6-1**] wks prior to
presentation to [**Doctor Last Name **]-[**Last Name (un) 45902**]. Since then her husband noted
that she has been increasingly confused, trying to dial a
telephone number on the VCR remote. He called her
gastroenterologist who increased her lactulose from 3 tbsp to
4tbsp four times daily and placed her on reglan for chronic
vomiting. One day prior to admission to OSH she had diarrhea all
day, was incontinent and had lost 5-8lbs over the week secondary
to nausea and decreased PO intake so her husband brought her
into the [**Name (NI) **].
In the ED at the osh she was noted to be dehydrated and
encephalopathic. She was hydrated and then had a significant
drop in her hematocrit (from 21 to 26) with hydration over the
next few days. She had guaiac positive stools without overt GIB.
She was transfused to a hct of 24.5 on the day of discharge. She
was also treated for a positive UA (although denied sx) with
cephtriaxone. A culture was not perofrmed.
On presentation to [**Hospital1 18**] patient notes she has been feeling
better and is able to hold down meals as long as she eats
slowly. She has had no dysuria or abdominal pain and no urinary
frequency. She denies h/o GIB, melena, BRBPR. She denies sick
contacts or travel recently. She denies SOB, edema, chest pain.
She does feel a little dehydrated but thinks she can keep up
with it with her meals.
Rest of ROS is negative including no chest pain, palpitations,
syncope or presyncope, falls, fevers, chills, night sweats, SOB,
rash.
Past Medical History:
ESLD from ETOH cirrhosis
Gastric Ulcer in [**2145**]
Hepatic encephalopathy
Transfusion dependend anemia
EGD [**3-3**] with gastral antral vascular ectasia (GAVE) syndrome
and portal hypertensive gastropathy
Depression
Chronic headaches
Valvular heart disease: on recent evaluation with TTE normal LV
size and function with some evidence of diastolic dysfunction,
mod MR [**First Name (Titles) 151**] [**Last Name (Titles) **], mild ao stenosis and trace PR
Social History:
Per OMR, married with 5 children. She had 1 miscarriage during a
pregnancy. She is a retired bookkeeper. She has never smoked
cigarettes nor used recreational drugs. Per OMR initial
hepatology note, "She has a history of alcohol excess with 4
glasses of wine per night over a prolonged period. She has not
consumed any alcohol since she was given her diagnosis of
cirrhosis back in [**2145**]."
Family History:
Negative for liver disease. Brother with prostate CA. Father had
emphysema. Mother died of heart disease in her 80s.
Physical Exam:
VS: 65 103/58 12 98%2L nc
Gen: Responsive to verbal stimuli
HEENT: Scleral icterus. PERRL. Neck supple
CV: Nl S1+S2, II/VI systolic murmur at the base
Pulm: Bibasilar rales
Abd: Distended, NT. +bs
Ext: 2+ pitting edema. 1+ dp bilaterally.
Neuro: Responsive to verbal stimuli. Not oriented. +asterixis.
Pertinent Results:
LABS ON ADMISSION:
[**2149-8-11**] 05:25AM BLOOD WBC-4.8 RBC-2.48* Hgb-8.2* Hct-24.7*
MCV-100* MCH-32.9* MCHC-33.0 RDW-18.8* Plt Ct-51*
[**2149-8-11**] 05:25AM BLOOD PT-20.4* PTT-44.2* INR(PT)-1.9*
[**2149-8-11**] 05:25AM BLOOD Glucose-110* UreaN-15 Creat-1.1 Na-141
K-4.6 Cl-115* HCO3-21* AnGap-10
[**2149-8-11**] 05:25AM BLOOD ALT-51* AST-96* LD(LDH)-318* AlkPhos-79
TotBili-5.7*
[**2149-8-11**] 05:25AM BLOOD Albumin-2.6* Calcium-7.6* Phos-2.1*
Mg-1.1* Iron-140
.
LABS ON [**9-12**]:
[**2149-9-12**] 01:55AM BLOOD WBC-10.1 RBC-2.02* Hgb-6.9* Hct-21.1*
MCV-104* MCH-34.4* MCHC-33.0 RDW-24.1* Plt Ct-30*
[**2149-9-12**] 01:55AM BLOOD Plt Ct-30*
[**2149-9-12**] 01:55AM BLOOD PT-27.6* PTT-49.0* INR(PT)-2.7*
[**2149-9-12**] 01:55AM BLOOD Fibrino-109*
[**2149-9-12**] 01:55AM BLOOD Glucose-157* UreaN-28* Creat-1.9* Na-136
K-3.9 Cl-100 HCO3-22 AnGap-18
[**2149-9-12**] 01:55AM BLOOD Calcium-10.8* Phos-3.4 Mg-2.1
.
CTH ([**8-21**]): No evidence of acute intracranial abnormality.
.
Hip ([**8-21**]): There is no evidence for fracture or dislocation.
Pelvic calcifications likely represent phleboliths.
.
Abd U/S ([**8-18**]): 1. Patent hepatic vasculature but with slow flow
in the main portal vein with possible new non-occlusive thrombus
in the main portal vein wall.
2. Diffuse coarsened echogenic liver consistent with stated
history of cirrhosis.
3. Cholelithiasis, without evidence of acute cholecystitis.
4. Mild-to-moderate ascites around the liver capsule.
.
CXR ([**8-11**]): No previous images. The cardiac silhouette is at the
upper limits of normal in size, with the lungs clear and no
evidence of vascular congestion or pleural effusion. Mild
eventration of the central aspect of the right hemidiaphragm,
with no clinical significance.
.
ECG ([**8-19**]): Sinus rhythm with atrial premature beats including a
four beat run of probable atrial tachycardia. Non-specific ST-T
wave changes. Since the previous tracing of [**2149-8-18**] further T
wave changes are suggested but there may be no significant
change.
.
ECG ([**8-24**]): Sinus with 1:1 conduction. NA-NI. LAA. Non-specific
ST-T wave changes anteriorly present on prior ECGs.
.
TTE ([**8-12**]): The left atrium is moderately dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
EGD ([**8-22**]):
- Varices at the lower third of the esophagus.
- Erythema, congestion, abnormal petechial vascularity and
mosaic appearance in the whole stomach compatible with portal
hypertensive gastropathy
- Linear erythematous streaks in the antrum compatible with
gastric antral vascular ectasia
- Schatzki's ring
.
Flex sig ([**2149-8-18**]):
- Large internal hemorrhoids
- Small non bleeding rectal varices.
Brief Hospital Course:
Ms. [**Known lastname **] is a 69 year old female with MELD ~32 EtOH
cirrhosis c/b encephalopathy, ascites, portal hypertensive
gastropathy, and grade II varices transferred to the MICU for
encephalopathy and renal failure after admission to the floor
for GIB and evaluation for transplant. Pt was admitted to the
MICU where pt underwent flexible sigmoidoxcopy on [**8-18**]
demonstrating internal hemorrhoids and non-bleeding rectal
varices. Pt remained stable and was transferred to the floor.
The pt underwent EGD on [**8-22**] that demonstrated 5 cords of grade
II varices, a Schatzki's ring, GAVE and portal hypertensive
gastropathy. Over the following days pt developed progressive
renal failure and encephalopathy. Pt was started on rifaxamin
and lactulose and transferred back to the MICU. Renal failure
was initially thought to be [**1-27**] hepatorenal and pt was treated
with midodrine, albumin and octreotide, however, renal was
consulted and thought that the renal failure was [**1-27**] ATN and so
these medicines were discontinued. Pt deteriorated further
clinically and started on pressors and intubated for airway
protection. She continued to deteriorate on pressors and renal
function did not recover and so CVVH was initiated. Pt had
recurrent atrial fibrillation and was put on hold on the
transplant list because she was felt to be too sick. Ultimately,
a family mtg was held as it was felt that her ultimate prognosis
was very poor. The decision was made to terminally extubate her
and pressors were discontinued.
Contact: [**Name (NI) **] [**Name (NI) **] (husband) [**Telephone/Fax (1) 82615**]
Medications on Admission:
HOME MEDICATIONS:
neomycin 500mg QID
Omperazole 20mg daily
Aldactone 50mg daily
Lasix 20mg [**Hospital1 **]
Lactulose 4 tbspn 4 times daily
reglan 5mg/5mL 2 tspns QID
.
Medications (on transfer):
Albumin 25% (12.5g / 50mL) 50 g IV DAILY
CeftriaXONE 1 gm IV Q24H
Citalopram Hydrobromide 10 mg PO DAILY
Hemorrhoidal Suppository 1 SUPP PR DAILY
Lactulose 30 mL PO Q2H
Metoclopramide 10 mg PO QIDACHS
Miconazole Powder 2% 1 Appl TP TID:PRN rash
Midodrine 7.5 mg PO TID
Levothyroxine Sodium 37.5 mcg IV DAILY
Metoprolol Tartrate 2.5 mg IV Q6H
Pantoprazole 40 mg IV Q12H
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Discharge Condition:
Discharge Instructions:
Followup Instructions:
Completed by:[**2149-9-13**]
ICD9 Codes: 5845, 5990, 2762, 311, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3009
} | Medical Text: Admission Date: [**2173-7-21**] Discharge Date: [**2173-8-2**]
Date of Birth: [**2106-4-6**] Sex: M
Service: SURGERY
Allergies:
Egg
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Rectal bleeding
Major Surgical or Invasive Procedure:
[**2173-7-22**]
Diagnostic laparoscopy and rigid sigmoidoscopy.
[**2173-7-24**]
Colonoscopy
History of Present Illness:
This is a 67 year old male with a medical history of DM, HTN who
presented to an OSH ED with rectal bleeding. The patient reports
that he was in his usual state of health until 10 days ago. He
initially had 3-4 days of constipation which was then followed
by profuse watery diarrhea for 5-6 days which was then followed
by three days of constipation. During that time he had no other
symptoms, no fevers or chills no nausea, vomiting or abdominal
pain. Today, he was feeling well the AM and then he had
tenesmus. He went to the bathroom and felt lightheaded and weak.
He slipped, but did not loose consciousness. He did not have any
bloody stools at the time. His wife called 911 and he was taken
to [**Hospital3 6592**].
.
At the OSH ED he developed frank rectal bleeding, hypotension
(80/34), tachycardia. A CT with contrast was done that showed
colonic and small bowel distention, no free air or fluid, and a
likely rectal impaction. His labs were notable for INR was 5.4,
patient is not anticoagulated. White count 18.4, hematocrit
42.5, platelets 199. Lactate 8.5. Per report, DIC labs positive,
however no values are found in the record. Received 2 L IV
fluid, 2 units FFP, Unasyn, Flagyl. He was also given 1 unit of
PRBCs in route to the [**Hospital1 18**].
.
At [**Hospital1 18**] ED, his initial vitals were 99.9 102 117/84 16 100% 2L
N/c. His labs were notable for PT: 16.1, PTT: 34.7, INR:
1.4,Fibrinogen: 72, D-Dimer: >[**Numeric Identifier 3652**], WBC of 9.9 (N:87 Band:9 L:3
M:1 E:0 Bas:0) and Hct of 36, plts of 205, Creatine of 1.4. GI
was consulted and an anoscopy was attempted, but they were
unable to visualize secondary active bleeding. He was given more
2 U PRBC. Surgery was consulted. ED resident attempted to remove
stool from rectum, but was only able to remove a small amount. A
repeat CT (CTA) done at [**Hospital1 **] showed interval development of
sigmoid and left sided colitis as well as the new development of
ascities. He was then admitted to the MICU for further
management.
.
On arrival to the MICU, pt was ill appearing. He felt warm and
was shivering. He abd was very tender to palpation, he states to
be worse than earlier in the day. He was guarding his abd. He
was given 4mg of IV morphine with minimal change of pain. I
performed a rectal exam which had significant amount of formed
stool and bright red blood around it. Pt had a large BM after
the exam with semi-formed stool with bright red blood coating
it. He had 2 other BM that as per nursing report looked like
"tomato soup". The repeated labs were then notable for
fibrinogen which increased from 72->99, with D-Dimer at [**Numeric Identifier 24587**].
His Hct had trended up from 36->41, and platelets decreased from
205->170s, PT 15/INR 1.3 (down from 5.4 at presentation). He was
given 2L of IV fluids in the OHS, then 3L of IV fluids in the ED
and 2 L in the MICU. He was also given 3 units of blood, 2 FFP.
I then also ordered 1 unit of cryo given concern for DIC. The
surgical team who had already evaluated the pt in the ED was
called back, given that his abd pain was worsening and he still
had blood BMs. His lactate was also trending back up 8.7 in the
OHS-> 1.4 in the ED to 4.4 in the MICU which was concerning for
worsening ischemia.
Past Medical History:
Diabetes
HTN
Toe amputation
Penile implant
retinal surgery
Social History:
He lives with wife, he is now retired and used to work on as a
sales person. He drinks 3-4 beers per day. He denies smoking. No
drugs.
Family History:
Non-contributory. He denies any colon or GI cancer
Physical Exam:
Temp 99.9 HR 102 BP117/84 RR 16 O2 sat 100% 2L NC
General: Alert, oriented, in significant pain, laying in fetal
position
HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: tender diffusely but worse in the lower abdomen, +
bowel sounds, +gaurding, + rebound
Rectal: frank blood mixed with stool, hard stool palpated, no
rectal mass
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: dry skin noted on the skins bilaterally
Pertinent Results:
IMAGING:
OSH CT:
No AAA but prominent vascular calcifications involving the
aorta, diffuse colonic distention, scattered loops of mildly
dilated small bowel, No free intraab gas or fluid, likely rectal
impaction.
[**2173-7-24**] Colonoscopy :
Internal & external hemorrhoids
Otherwise normal colonoscopy to cecum
[**2173-7-21**] CTA Abd/pelvis :
1. Interval development of bowel wall thickening and
hypoenhancement of the left hemicolon raising strong concern for
ischemic colitis. New small volume ascites.
2. Thick, irregularly walled bladder, concerning for infection.
3. Moderate rectal fecal impaction.
4. Possible active GI bleeding along the ascending colon.
[**2173-7-24**] Colonoscopy :
Internal & external hemorrhoids
Otherwise normal colonoscopy to cecum
8//[**8-29**] Head CT :
No acute intracranial process; evidence of mild sequelae of
chronic small
vessel ischemic disease
[**2173-7-21**] 03:00PM WBC-9.9# RBC-4.01* HGB-12.5* HCT-36.7* MCV-92
MCH-31.2 MCHC-34.0 RDW-13.7
[**2173-7-21**] 03:00PM NEUTS-87* BANDS-9* LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2173-7-21**] 03:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2173-7-21**] 03:00PM PLT SMR-NORMAL PLT COUNT-205
[**2173-7-21**] 03:00PM PT-16.1* PTT-34.7 INR(PT)-1.4*
[**2173-7-21**] 03:00PM FIBRINOGE-72*
[**2173-7-21**] 03:00PM ALT(SGPT)-21 AST(SGOT)-32 LD(LDH)-207 ALK
PHOS-133* TOT BILI-0.4
[**2173-7-21**] 03:00PM LIPASE-31
[**2173-7-21**] 03:00PM GLUCOSE-289* UREA N-29* CREAT-1.4* SODIUM-141
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16
[**2173-7-21**] 05:43PM LACTATE-1.8 NA+-139 K+-4.7 CL--106 TCO2-22
[**2173-7-21**] 08:36PM WBC-12.6* RBC-4.54* HGB-14.2 HCT-41.4 MCV-91
MCH-31.2 MCHC-34.2 RDW-14.0
[**2173-7-21**] 08:36PM GLUCOSE-275* UREA N-31* CREAT-1.7* SODIUM-139
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-19* ANION GAP-18
Brief Hospital Course:
Mr. [**Known lastname **] presented to an OSH ED with history
profuse watery diarrhea for 5-6 days followed by 1-2 days of
constipation and then syncope on standing. At the OSH ED he
developed frank rectal bleeding, hypotension (80/34),
tachycardia
and a CT with contrast showed colonic and small bowel
distention,
and stool impaction. He was given morphine, Unasyn and Flagyl,
transfused PRBC and transferred to [**Hospital1 18**] where he was admitted
to
the MICU. He was transfused again and CTA showed interval
development of sigmoid and left sided colitis as well as the new
development of ascites. He had an elevated lactate, leukocytosis
and tachycardia though was normotensive with IVF and blood
products. He was started on Cefepime/Flagyl. GI was consulted
who felt his clinical picture and rapid decompensation were most
concerning for ischemic colitis. Infectious colitis was also
considered and all stool studies were negative.
.
Patient's abdominal exam continued to worsen, his lactate
increased despite IVF and ABX so surgery was consulted and he
had
an exploratory laparotomy on [**7-22**] that showed diffuse bowel
edema/mucosal inflammation but no necrosis, no resection was
performed. He was transferred to the Trauma SICU and Unasyn
started, Flagyl was continued. On [**7-23**] Unasyn/Flagyl was switched
to Zosyn when OSH called to say he had a GNR in his blood
culture
from ED (pre-antibiotics). He has improved clinically, has been
afebrile and normotensive since [**7-22**] but has had alcohol
withdrawal
and delirium which has complicated his course but is improved
with Diazepam. His GI symptoms have been ascribed to mesenteric
ischemia in a patient with known atherosclerotic disease.
Following his exploratory laparotomy he had a colonoscopy a few
days later which was essentially normal except for hemorrhoids.
Initiating a diet was on hold as he developed DT's and his
nutrition was given via feeding tube. Once his withdrawal
symptoms resolved it took a few days for him to clear the
benzodiazepines and eventually he had a speech and swallow
evaluation and was cleared for a regular diabetic diet.
From an ID standpoint, the team was then called by [**Location (un) 100633**]/[**Location (un) 5503**] micro lab that the GNR had Acinetobacter
Baumannii growing from aerobic blood
culture drawn in the ED prior to antibiotic therapy ([**7-21**]) that
was sensitive only to Collistin and Tigacycline (MIC 4),
intermediate to Zosyn, Levofloxacin, Cefepime, and resistant to
Bactrim, Ceftaz, Cipro, Imipenem, Gentamycin, Tobramycin,
Aztreonam. This was growing in [**12-20**] sets of blood cultures, he
had no more cultures drawn there. The Infectious Disease service
was consulted for their recommendations. He had 2 more sets of
blood cultures done all which were no growth along with stool
cultures. They recommended completing a course of Zosyn as he
was non toxic with a normal WBC and no fevers. He progressed
nicely from that point on.
On two different occasions he failed a voiding trial with
retention in the range of 600-700 mls of urine. His catheter
was replaced this morning and the plan is to try a third voiding
trial once he is more ambulatory.
The [**Last Name (un) **] service was also consulted as his blood sugars were
not controlled and were generally in the mid 200 range. He was
placed on Lantus and was gradually increased to 14 units qPM
with a tighter sliding scale. Prior to admission he was on NPH
[**Hospital1 **].. He has been on a diabetic diet but generally needs
coverage QID.
Following transfer to the Surgical floor he was evaluated by the
Physical Therapy service who recommended a short term rehab
prior to returning home to help increase his mobility and
endurance safely. After a long protracted course he was
discharged on [**2173-8-2**].
Medications on Admission:
diovan 160', crestor 10', asa 81', lisinopril 40', amlodipine
10', metoprolol er 50', lantus, humalog
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) as needed for agitation.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours.
12. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
13. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
14. insulin glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous once a day: at 6pm.
15. insulin lispro 100 unit/mL Solution Sig: 0-14 units
Subcutaneous four times a day as needed for per sliding scale.
Discharge Disposition:
Extended Care
Facility:
Cape Heritage, A [**Hospital 671**] HealthCare Center - [**Location (un) **]
Discharge Diagnosis:
1. Ischemic colitis
2. Acute blood loss anemia
3. Acute alcohol withdrawal
4. Bactermia
5. Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with rectal bleeding from poor
blood flow to the bowel which has resolved. You needed multiple
blood transfusions and you also developed alcohol withdrawal
post op which complicated matters. That too has also resolved
but you must never drink alcohol again. You will be offered
counselling and assistance after you are discharged from rehab.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-2**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incision, cover with clean,
dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-21**] weeks.
Call your PCP for [**Name Initial (PRE) **] follow up appointment when you return home
from rehab.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2173-10-12**] 1:30
Completed by:[**2173-8-2**]
ICD9 Codes: 2851, 7907, 5849, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3010
} | Medical Text: Admission Date: [**2106-1-23**] Discharge Date: [**2106-1-27**]
Date of Birth: [**2055-3-1**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5272**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
central venous line placement
History of Present Illness:
Mr. [**Known lastname **] is a 50 y/o male with depression who presents with
dysuria and fever after a prostate biopsy for an elevated PSA.
Patient had an elective prostate biopsy performed by urology on
[**1-21**]. Of note he had been taking prophylactic cipro beginning 1
day prior to the biopsy, as prescribed by urology. Despite this,
beginning overnight on Friday, he noted fevers and chills to 102
at home as well as dysuria. He had also been having some
hematuria and perineal pain.
Vitals upon presentation to the ED: T 98.5 HR 100 BP 91-63 RR
14 100%RA
In the ED, he received ceftriaxone, vancomycin, and
levofloxacin. Despite this he quickly became hypotensive to
81/43 with HR 100 and T 100.0. Code sepsis was called and he
received 5.3L NS and had a RIJ central venous line placed. He
had an intial SvO2 of 73. He did not receive pressors as MAPs
recovered with IVF resuscitation. He had over 2L UOP in ED. An
EKG was performed with showed a RBBB/question Brugada syndrome.
Cardiology was consulted. Urology examined pt and recommended
admission to ICU for possible urosepsis.
Past Medical History:
Depression
BPH/elevated PSA
Hypertriglyceridemia
Hepatic steatosis
Hx pulmonary tuberculosis
Social History:
Works in the [**Location (un) 86**] Public Library. Originally from [**Country 651**], moved
here 20 years ago. Married with two children. Lifetime
nonsmoker, does not drink. Speaks a good amount of English
Family History:
Two children with asthma. Diabetes and CAD run in family, but no
hx of sudden cardiac death or early MI.
Physical Exam:
Gen: diaphoretic and slightly anxious but otherwise NAD
HEENT: NC/AT, MMM, R IJ TLC in place
Hrt: RRR, borderline tachycardia
Lungs: CTAB
Abd: S/NT/ND, + BS
Ext: WWP, no c/c/e
Neuro: non-focal
Pertinent Results:
Admission Labs:
[**2106-1-23**]
WBC-16.8*# RBC-4.58* Hgb-14.0 Hct-40.3 MCV-88 MCH-30.5 MCHC-34.7
RDW-12.5 Plt Ct-242 Neuts-94.5* Bands-0 Lymphs-2.7* Monos-2.3
Eos-0.3 Baso-0.2
.
PT-13.4 PTT-32.7 INR(PT)-1.2*
.
Glucose-204* UreaN-16 Creat-1.0 Na-135 K-3.6 Cl-101 HCO3-23
AnGap-15 Calcium-9.2 Phos-1.5* Mg-1.8
.
ALT-26 AST-29 AlkPhos-45 TotBili-0.9
.
CK(CPK)-91 cTropnT-<0.01
CK(CPK)-155 CK-MB-2 cTropnT-<0.01
.
Cortsol-6.8
.
CRP-19.0*
.
Lactate-2.7*
.
URINE RBC-[**2-3**]* WBC-[**5-11**]* Bacteri-FEW Yeast-NONE Epi-0-2 URINE
Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
********************MICRO**************
[**2106-1-23**] 7:00 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
CEFTAZIDIME----------- I
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- R
GENTAMICIN------------ R
LEVOFLOXACIN---------- R
MEROPENEM------------- S
TRIMETHOPRIM/SULFA---- R
.
[**2106-1-23**] 5:05 pm URINE Source: Catheter.
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
.
[**1-23**] CXR
UPRIGHT CHEST: Cardiomediastinal silhouette is unchanged
allowing for differences in technique. Pulmonary vascularity is
unremarkable. Lungs are clear and there is no evidence of
pleural effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
.
[**1-24**] CXR
Since earlier on [**1-23**], pulmonary vasculature has become
engorged and there is new perihilar opacification in both lower
lungs as well as a new small right pleural effusion. Overall,
findings suggest cardiac decompensation, but I cannot exclude a
contribution from either infection or aspiration, inducing
atelectasis. The heart is normal size and mediastinal
vasculature is not engorged. Tip of the right jugular line
projects over the low SVC. No nasogastric or endotracheal tube
is seen. No pneumothorax.
Brief Hospital Course:
Mr. [**Known lastname **] is a 50 yo M w/PMHx sx for recent prostate biopsy for
elevated PSA who now presents with fevers, hypotension, and
leukocytosis suggestive of urosepsis.
.
#. Urosepsis. Pt underwent CVL placement in ED. He was
aggressively volume resuscitated receiving over 5L NS, with SVO2
after 5L >70%. He was dosed withh broad spectrum antibiotics
including vanc, ceftriaxone, and levofloxacin. Upon arrival to
the ICU he was hemodynamically stable and not requiring
pressors. He quickly spiked a fever up to 104 with myalgias and
rigors. He was changed to double gram negative coverage with
zosyn and gentamycin. In total he received over ( liters of IVF
but still began to drop his MAPs and SvO2 sats. As a result he
was started on levophed, with successful maintenance of MAPs >
65. A cortisol was sent and returned at 6.8. No stress steroids
were begun. Tight glycemic control was maintained with RISS to
keep FSG <150. Shortly thereafter, his blood cultures returned
with GNRs. His fever curve was trending downwards and he was
able to be weaned off pressors on the morning of Sunday [**1-24**]. Pt
afebrile, switched to ertepenum for 2wks abx course.
.
#. Depression. Continued wellbutrin.
.
#. FEN - ate a regular diet. Put on RISS for tight glycemic
control.
.
#. PPx - sQ heparin
.
#. Code. Full.
.
#. Access. CVL and peripheral
.
#. Dispo. ICU care
Medications on Admission:
Wellbutrin 100 mg daily
Ciprofloxacin 500 mg [**Hospital1 **] (started [**1-20**])
Discharge Medications:
1. Bupropion 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Ertapenem 1 gram Recon Soln Sig: One (1) Intravenous qd ()
for 2 weeks.
Disp:*12 grams* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Sepsis
Discharge Condition:
Stable.
Discharge Instructions:
-You may shower.
-Do not lift anything heavier than a phone book.
-Do not drive or drink alcohol while taking narcotic pain
medication.
-Resume all of your home medications.
-If you have fevers > 101.5 F, vomiting, or increased pain, call
your doctor or the nearest emergency room.
-cont abx for 2wks.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 770**], [**Telephone/Fax (1) 10566**] for f/u appt.
ICD9 Codes: 5990, 2851, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3011
} | Medical Text: Admission Date: [**2166-1-28**] Discharge Date: [**2166-1-31**]
Date of Birth: [**2091-1-9**] Sex: M
Service:
CHIEF COMPLAINT: Hypotension with mental status changes.
HISTORY OF PRESENT ILLNESS: This is a 74-year-old male with
a history of renal cell carcinoma, status post bilateral
nephrectomies, on hemodialysis with metastatic disease to the
lung, eye, penis, also with coronary artery disease, status
post myocardial infarction and a three vessel coronary artery
bypass graft, status post AICD pacer for V-fib arrest and
congestive heart failure with an EF of 30%, diabetes,
hypertension, history of upper gastrointestinal bleed who was
in his usual state of health until yesterday at hemodialysis
when his blood pressures were noted to the in the 60's but
resolved reportedly. Last night when getting up from the
toilet after a bowel movement he fell without loss of
consciousness but hit his head on the sink and was dizzy.
The fire department evaluated him and decided he did not need
to come in.
He saw Dr. [**Last Name (STitle) 16858**] the morning of admission, was somnolent
with blood pressures 50/palp with a weak pulse. He got
intravenous fluids and his blood pressure increased to
62/palp. His O2 saturations were 91% on room air, therefore,
he was placed on four liters. Per his wife his mental status
changes since he hit his head last night but has been weak
for several days. Was transferred to the Emergency Room with
blood pressures in the 60's, heart rate 93, began Vancomycin
1 gram times one and Ceftriaxone 1 gram intravenous times
one, got two liters of normal saline and began a Dopamine
drip. Then subsequently Levophed drip which increased his
MAPS to 65 but he was tachycardiac to 110 and only alert and
oriented times 1-1/2. No elevated white blood count but a
left shift without bands. Arterial blood gases was
7.48/41/141 with a lactate of 2.2 on 100% non-rebreather. He
was transferred to the MICU for further care.
REVIEW OF SYSTEMS: Denies chest pain, diarrhea, headache,
rashes, has felt short of breath (sometimes).
PAST MEDICAL HISTORY:
1. Renal cell carcinoma, status post bilateral nephrectomies
- the right one in [**2164**] and the left in [**2153**]. Status post
[**Last Name (LF) 16859**], [**First Name3 (LF) **]-2, Thalidomide with metastases to the lung, status
post a left lower lobe resection in [**2165-5-29**], metastases to
the right orbit status post [**Year (4 digits) 16859**] in [**2165**], metastases to the
penis status post penectomy in [**2158**] with recurrent metastases
to the lung.
2. Hemodialysis in [**Location 9583**].
3. Coronary artery disease. Status post myocardial
infarction in [**2164-11-29**], status post three vessel
coronary artery bypass graft in [**2165-3-29**]. SVG to left
anterior descending, SVG to Patent ductus arteriosus, SVG to
diagonal, status post VF arrest with a AICD placement.
4. Congestive heart failure with an EF on [**2166-1-7**] of 30%
with mild Aortic regurgitation and MR.
5. Hypertension.
6. Insulin dependent diabetes mellitus Type 2.
7. Stage I colon cancer status post left hemi-colectomy in
[**2165-9-29**].
8. Upper gastrointestinal bleed in [**2164**].
9. Hypercholesterolemia.
10. Arteriovenous fistula four weeks ago.
ALLERGIES: Sulfa causes gastrointestinal upset, Intravenous
contrast causes question of rash, also question of allergies
to Venofere and Iodine.
MEDICATIONS:
1. Glyburide 2.5 mg q day.
2. Aspirin 81 mg q day.
3. Coreg .125 mg twice a day.
4. Plavix 7.5 mg p.o. q day.
5. Mag Oxide 400 mg twice a day.
6. Protonix 40 mg q day.
7. Megace 40 mg q day.
8. Colace 200 mg q day.
9. Nephrocaps one cap q day.
10. Lipitor 20 mg q day.
11. Ativan 0.25 mg q h.s. p.r.n.
PHYSICAL EXAMINATION: Temperature 97.3, heart rate 109 to
123, blood pressure 66/36 which increased 80 to 95/39 to 44.
Respiratory rate 24 to 25, sating 89 to 94% which increased
to 100% on non-rebreather. MAPS from 53 to 61. General
alert and oriented times two. Knows place and name, anxious
male. Head, eyes, ears, nose and throat: Pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements intact. Oropharynx is dry. Neck is supple. CV:
Tachycardiac, regular with occasional premature ventricular
contractions, 2/6 systolic ejection murmur. Respirations,
bronchial breath sounds at base with decreased bowel sounds.
Abdomen soft, normal active bowel sounds, nontender,
nondistended. Healed midline incision. Extremities: Right
femoral trauma line. No erythema or hematoma. Positive
cyanosis to fingertips bilateral. Cool extremities.
Palpable pulses in the lower extremities bilaterally. 1+
radial pulse bilaterally. No clubbing or edema in the lower
extremities, however, 1+ edema in the upper extremities
bilaterally only. Rectal: OB negative per the Emergency
Room.
SOCIAL HISTORY: The patient is married and lives in
[**Hospital1 487**]. He was an antique dealer and has a daughter who
lives in [**Name (NI) **].
DATA: White blood count 4.9, hematocrit 26.1, platelets 160
with 97 polys, 0 bands and 1 lymphocytes. INR of 1.4, sodium
141, potassium 3.8, chloride 105, bicarbonate 26, BUN 22,
creatinine 3.2. Glucose 177, calcium 8.9, phos of 2.4, mag
of 1.9, ALT 8, AST 12, TB 0.5, albumin 2.2, alk phos 130,
uric acid of 4.1, LDH 146. CK 8, Troponin 0.3. Arterial
blood gases 7.48, 41, 145, 2.2 lactate.
Electrocardiogram per report paced, atrial sensed and V-paced
to a heart rate of 94.
Chest x-ray: Increased consolidation of the left lower lobe
atelectasis verses pneumonia, atelectasis of left upper lobe
is new, moderate left pleural effusion with extension to the
left apex, increase in evidence of congestive heart failure.
Head CT without contrast, no intracranial or acute process.
Stable since [**2166-1-6**]. Abdominal and pelvic CT without
contrast. Large bilateral pleural effusions, left greater
than right associated with atelectasis of basis, nodular
densities in the lung, the right lower lobe. Renal: Mass.
Vertebral lesions - lytic osseous lesions. No Triple A or
retroperitoneal bleed. Liver, bowel, gallbladder, pancreas
within normal limits and an enlarged spleen.
ASSESSMENT: 74-year-old male with hypotension in the setting
of metastatic renal carcinoma. Status post nephrectomy, is
on hemodialysis, congestive heart failure with an EF of 30%
and coronary artery disease. Differential diagnosis includes
sepsis however, there is no clear source at this time.
Hypovolemia, adrenal insufficiency and question of an
myocardial infarction but the electrocardiogram was without
changes and the first enzymes were flat.
HOSPITAL COURSE: The patient was admitted to the MICU and
was hypotensive requiring pressors and placed on Dopamine and
Levophed which increased blood pressures. Had a Head CT and
Abdominal CT without contrast showing no head bleed, a large
left greater than right pleural effusion, metastases to the
right lower lobe and an 8x5 cm large renal mass. He was
initially maxed out on two pressors but then was titrated
only to one, Levophed with blood pressures in the 80's to
90's. Minimally responsive to fluid and blood and placed on
stress dose of steroids. The hypotension was of unclear
etiology at first. So it was decided to perhaps to have a
bedside echo done to rule out tamponade as he did have upper
extremity edema with lower extremity edema and this echo
showed a right ventricular mass/tumor, 35% EF with wall
motion abnormalities. It was unclear what this mass was in
the right ventricle an thought it was maybe a clot. We were
hesitant to start anti-coagulation without thoroughly ruling
out brain metastases with a contrast study. However, he had
an allergy to CT contrast and was unable to have an magnetic
resonance scan because of his pacer. It was decided that we
would pre-medicate him for this supposed allergy to
intravenous contrast and go ahead with getting a head CT to
rule out a bleed or metastatic disease as well as we were
interested in looking at the test in order to rule out
inferior vena cava syndrome. He did have his upper extremity
edema and when we tried to place a central line into the
right IJ the tip ended up being diverted into the right
subclavian and it was questioned whether he had elevated
pressures or blockage or clot in the SVC.
On the morning of [**2166-1-30**] the patient underwent another more
formal cardiogram which did not show a clot this time.
However, he did undergo the CT which was consistent with a
SVC syndrome with collateral flow. The left mainstem
bronchus was collapsed secondary to extreme compression of
the lymph nodes. He also had multiple lung and now new liver
metastasis. There was also extreme compression of the SVC
with collateral flow.
Multiple discussions were held with the family with the MICU
attending as well as with his Oncologist Dr. [**Last Name (STitle) 1729**]. At
first the plan was for him to be DNR/DNI however, when the
results of the CT showed the rapid progression of metastatic
disease and lymphadenopathy compressing the SVC and the right
mainstem bronchus it was unable to be treated. The
discussion with the family turned towards palliative-comfort
care.
The family was in agreement that he would be unable to
recover from the progression of his cancer and a Morphine
drip was started in order to ease his pain. The family was
at the bedside when he passed on [**2166-1-31**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 210**]
MEDQUIST36
D: [**2166-2-9**] 19:13
T: [**2166-2-11**] 11:45
JOB#: [**Job Number 16860**]
ICD9 Codes: 5180, 5119, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3012
} | Medical Text: Admission Date: [**2129-4-20**] Discharge Date: [**2129-4-23**]
Date of Birth: [**2072-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56 yo W with ESRD on HD (MWF), HTN (last sBPs in 150s), HCV
cirrhosis, Hypothyroidism, Anxiety, chronic back pain on
methadone, presenting with systolic BPs in the 60s prior to and
during [**Hospital 58910**] transferred to [**Hospital Unit Name 153**] for evaluation and management of
hypotension.
.
She reports 1 month of increasing fatigue, weakness, and
occasional falls (knee buckling). Occasional cough with brown
sputum and chronic loose stools, but no fevers, chills, sweats,
dyspnea, nausea, vomiting, black or bloody stools. Regarding her
complaints, she reports that her BP medications have been
adjusted, but this has not helped. She has also experienced
intermittent L-sided sharp chest pains that worsen with arm
movement, and was prescribed nitroglycerin that she ended up
taking daily instead of on a PRN basis.
.
In the ED, initial vs were: T 97.4 P 69 BP 64/53 R 14 97% O2 sat
on RA. Per report, she was mentating appropriately. A triple
lumen femoral CVC was placed. She was bolused 500 cc, given
Vancomycin and Zosyn, and started on Levophed at 0.06. CXR was
unremarkable. CT C/A/P were obtained and prelim only significant
for a right adenexal cyst (present since [**Month (only) 404**]).
.
On the floor, the patient was appropriate and comfortable. She
was placed on a Nicom. CI and SVI improved with leg raise so Pt
was given 250 cc, then on repeat given additional 250 cc.
Levophed was weaned off.
.
Review of sytems: per HPI, otherwise negative
Past Medical History:
-HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy
Social History:
Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years
Family History:
Father: ESRD and hypertension
Mother: lung cancer
Physical Exam:
VS: 97.6, 63, 133/86, 98% on RA
General: alert, oriented, no acute distress
HEENT: muddy sclera, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, +BS, TTP in RUQ with mild voluntary
guarding
GU: no foley
Ext: warm, well perfused, symmetric pulses, no clubbing,
cyanosis or edema, R hallux with nail bed removed, crusted
blood, no erythema or fluctuance, no purulence
Neuro: face symmetric, moves all extremities, sensation intact,
gait not observed
Brief Hospital Course:
56 yo W with Hx of ESRD on HD, HCV cirrhosis, HTN,
Hypothyroidism, and chronic pain on methadone presenting from HD
with hypotension to systolic BPs, initially admitted to ICU,
quickly transferred to medical floor.
.
# Hypotension: Appears to have been developing subacutely, over
the last month. Hypotension is likely secondary to a too
aggressive antihypertensive regimen, current medication misuse,
or possibly over-diuresis at HD (with need for reassessment of
dry weight). Supporting a possible over beta-blockade is a HR
that has consistently remained in the 60s despite BPs in the
60s. Additionally she was started on nitroglycerin and had been
taking it daily rather than on a PRN basis. She is responsible
for her medications, yet unable to correctly remember dosing
regimen. Other etiologies to consider given the chronicity
include endocrine causes such untreated hypothyroidism (pill
bottle not in bag) or adrenal insufficiency. Received a total
of 1.5 L of volume resuscitation. Levophed weaned off. Outpt
Nephrologist reports dry weight as 74kg. She was started
initially on road spectrum antibiotics which were quickly
discontinued when all cultures were negative.
.
TSH, free T4, and AM Cortisol obtained and pt restarted home
levothyroxine dose for significant hypothyroidism. CT abd/pelvis
was unremarkable except for stable adnexal cyst. Blood pressures
remained stable while patient was off her anti-hypertensives.
After chart review she had been started on these during an
admission for chest pain at which time a cath revealed clean
coronary arteries. Therefore it is felt she does not need these
medications and they were stopped. She will continue on
simvastatin for her cholesterol management and ASA to reduce her
risk of stroke. She will follow up with her PCP or in
[**Name9 (PRE) 1944**] clinic for a BP check off of her medications and
will have VNA checking her BPs at home as well. Her PCP can
titrate medications as necessary
.
# Elevated bicarbonate: Likely [**2-16**] recent HD session, as well as
contraction from intravascular depletion. Supporting this is a
Hct above baseline likely reflecting hemoconcentration. Pt is on
advair without documented hx of COPD. CXR not reflective of this
and bicarb not chronically elevated.
.
# Hyperkalemia: Likely [**2-16**] ESRD. No evidence of peaked T waves
on EKG. She was given insulin, kayexelate overnight and repeated
insulin per renal recs prior to dialysis this AM. K was noted to
be wnl on follow up AM labs.
.
# Prolonged PT/PTT: INR mildly elevated likely [**2-16**] underlying
poor synthetic liver function from cirrhosis. Also may have a
nutritional component as well. Prolonged PTT likely [**2-16**] heparin
received at HD. No evidence to support bleeding.
PTT resolved off heparin.
.
# Thrombocytopenia: Chronic issue, likely [**2-16**] cirrhosis.
Platelets were stable and did not require transfusion.
.
# Anemia: [**2-16**] ESRD. BL Hct around 31. On EPO as outpt. Hct was
trended and stable; pt did not require transfusion of blood
components during her ICU stay.
.
# CAD: No evidence to suggest acute ischemia. EKG consistent
with prior. Trop at 0.05, likely [**2-16**] demand in setting of CKI.
CK and CKMB added on and non-concerning for ACS. Pt
asymptomatic. She was continued on asa 81mg, simvastatin 20mg.
BBlocker and ACEi held for observation of hemodynamic stability
given admission complaint.
.
# Hypothyroidism: TSH grossly elevated with very low T4.
Levothyroxine was not in her pill bag, in discussion with her
pharmacy this prescription had not been filled in many months.
Pt was started on Levothyroxine 188mcg daily, will need repeat
TFT's in [**4-20**] weeks. [**Month (only) 116**] be contributing to hypotension, fatigue
and depression. Arranged for her pills to be delivered in a
bubble pack to help with med compliance in the future.
.
# Seizure Disorder: Continued on Keppra 250 mg [**Hospital1 **].
.
# Depression/Anxiety: SHe has severe depression, uncontrolled.
No SI/HI. Restarted home clonazepam (held on admission given
hypotention), social work consulted, fluoxitine increased from
40 to 60 mg daily. She is interested in outpt therapy, to
arranged by her PCP at follow up.
.
# Chronic Pain: On Gabapentin and methadone dose was confirmed
with [**Doctor Last Name 7594**] Op Co to be 44mg daily.
.
# Given prior hx of renal nodule seen on CT scan, pt was ordered
for MRI to be completed during her stay given concern for poor
outpt followup. MRI renal wo contrast was performed; read was
pending at time of d/c and needs to be followed up by outpatient
providers (either Dr. [**First Name (STitle) 805**] or PCP)
.
# Right adnexal Cyst: Patient was told to follow up with pelvic
ultrasound for right adnexal cyst seen on CT scan. PCP [**Name Initial (PRE) **]/or
[**Hospital 1944**] clinic will help her coordinate this study.
.
Contact: sister [**Name2 (NI) **] at [**Telephone/Fax (1) 98152**]
# Transitions of care:
- Right adnexal cyst needs transvaginal ultrasound for further
evaluation. To be coordinated with PCP's help
- Blood cultures pending at time of discharge and need to be
followed up at [**Hospital 1944**] clinic
- Patient had MRI of abdomen to evaluate a renal cyst. Final
read pending at discharge and needs to be followed up through
outpatient providers either at [**Hospital 1944**] clinic or with Dr.
[**First Name (STitle) 805**]
- Patient seemed depressed and her fluoxetine was increased from
40mg to 60mg daily. Denied SI. At her [**Hospital 1944**] clinic
please assess her mood and help arrange outpt therapy.
- Patient's BP meds were held given hypotension. Post-D/c clinic
will check her BP to ensure stable off meds still.
- Patient had a low blood count (and chronically low plts) which
should be repeated at her post-discharge follow up appt
Medications on Admission:
-Metoprolol succinate 25 daily
-Nitrostat PRN
-Simvastatin 20 daily
-ASA 81 daily
-Fluoxetine 40 daily
-Gabapentin 300 daily
-Lisinopril 2.5 daily
-Keppra 250 [**Hospital1 **]
-Folic acid 1 mg daily
-Sensipar 30 mg PRN
-Trazadone 50 qhs
-Omeprazole 20 daily
Discharge Medications:
1. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a
day: With the 100mcg tab.
Disp:*30 Tablet(s)* Refills:*2*
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
Disp:*30 Capsule(s)* Refills:*2*
6. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. methadone 10 mg/mL Concentrate Sig: Forty Four (44) mg PO
DAILY (Daily).
8. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Disp:*90 Capsule(s)* Refills:*2*
9. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Sensipar 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Cargroup Home Care
Discharge Diagnosis:
Hypotension secondary to medications and dialysis
Hypothyroidism
Right adnexal cyst
Renal Cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with low blood pressure. This
was probably a combination of having dialysis and taking blood
pressure medications. We have stopped your blood pressure
medications as you don't need them. We looked for infections
(which can cause your blood pressure to be low) but could not
find any. Please take your medications exactly as prescribed.
You also had a CT scan which showed a cyst on your right ovary.
You need an ultrasound of your ovary to evaluate this. You
should coordinate this study with your primary care provider.
[**Name10 (NameIs) 2172**] CT scan also showed a cyst on your kidney. You had an MRI
to evaluate this. The read on the MRI is pending at this point
and you should follow up with your primary doctor to find out if
there is anything else that needs to be done about this.
.
Medication Changes:
START: Calcium acetate 667 TID with meals (to keep your calium
higher and your phosphorous lower)
START: Levothyroxine 200mcg daily
STOP: Lisinopril
STOP: Metoprolol
STOP: Nitroglycerin
CHANGE: Fluoxetine to 60mg daily
Followup Instructions:
You will be receiving a call with an appointment for next week
to come to the clinic and have your blood pressure checked and
go over your imaging tests. You will receive a call with this
appointment and if you do not you should call the clinic at
[**Telephone/Fax (1) 250**] to make an appointment.
Department: RADIOLOGY
When: MONDAY [**2129-4-25**] at 9:30 AM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: HEMODIALYSIS
When: MONDAY [**2129-4-25**] at 7:30 AM
Completed by:[**2129-4-23**]
ICD9 Codes: 5856, 2449, 3051, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3013
} | Medical Text: Admission Date: [**2186-6-7**] Discharge Date: [**2186-6-12**]
Date of Birth: [**2109-1-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Augmentin / Vicodin / Zocor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**2186-6-7**]
Aortic valve replacement 19-mm St. [**Hospital 923**] Medical Epic
Biocor tissue valve
Coronary artery bypass grafting x2 with reverse saphenous vein
graft to the marginal branch and the posterior descending
artery.
History of Present Illness:
77 year old female who had been fairly active and had been
limited by fatigue over the previous month. Echo from [**Month (only) 404**]
[**2185**] revealed aortic stenosis with a valve area of 0.83cm2. She
underwent cardiac catheterization [**2186-5-1**] which revealed two
vessel coronary artery disease. She was referred for aortic
valve replacement and revascularization.
Date: [**2186-5-1**] Place: [**Hospital1 18**]
LM- no obstruction
LAD- minimal luminal irregularities
Cx- 85% mid
RCA- 80% mid and distal
[**2186-5-11**] Echo: [**Location (un) 109**] 0.7cm2, pk 65, mn 35
Carotid Ultrasound: 50-69% stenosis of [**Country **]/[**Doctor First Name 3098**]
Past Medical History:
Borderline hyperlipidemia
Aortic stenosis
Psoriasis
Coronary artery disease
Osteoporosis
Gastroesophageal reflux disease
Fibromyalgia
Hepatitis treated in [**2143**]
Sleep apnea-does not use CPAP
4.2 cm abdominal aortic aneurysm
Ectopic pregnancy
Past Surgical History
[**2182**] Right total knee replacement
Tonsillectomy
Appendectomy
Social History:
Race: Caucasian
Last Dental Exam: edentulous
Lives with: husband and daughter
Occupation: Retired
Tobacco: 50 pack years (1ppd until several wks ago)
ETOH: Occasional ETOH and denies illicit drug use.
Family History:
grandmother had "heart condition"
Physical Exam:
Pulse: 74 Resp: 16 O2 sat: 99%RA
B/P Right: 130/69 Left: 136/78
Height: 5'1" Weight: 140lb
General: well developed female in no acute distress
Skin: Dry [x] intact [x] numerous psoriatic plaques- prominent
on
right elbow, bilateral knees and lateral legs (right worse than
left)
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 2/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] (psoriasis as above) (*LLE likely better for vein
harvest*)
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
bruit vs. radiation of cardiac murmur
Pertinent Results:
[**2186-6-9**] 04:45AM BLOOD WBC-12.1* RBC-3.27* Hgb-10.1* Hct-29.8*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.5 Plt Ct-109*
[**2186-6-9**] 04:45AM BLOOD Glucose-129* UreaN-19 Creat-1.2* Na-135
K-4.7 Cl-104 HCO3-21* AnGap-15
Echo [**2186-6-7**]:
PRE-BYPASS:
The left atrium is dilated. Mild spontaneous echo contrast is
present in the left atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). No spontaneous echo
contrast is seen in the body of the right atrium or right atrial
appendage. No mass or thrombus is seen in the right atrium or
right atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
Right ventricular chamber size and free wall motion are normal.
There are complex (mobile) atheroma in the aortic arch. There
are complex (mobile) atheroma in the descending aorta. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2).
Mild to moderate ([**12-31**]+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on Ms.[**Known lastname **]
before surgical incision.
POST-BYPASS:
Preserved biventricualr systolic function. LVEF 50%.
Intact thoracic aorta.
The aortic b ioprosthesis is well seated, stable and functioning
well with residual m ean gradient of 15mm of Hg.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2186-6-7**] for an aortic valve replacement 19-mm
St. [**Hospital 923**] Medical Epic Biocor tissue valve and coronary artery
bypass grafting x2 with reverse saphenous vein graft to the
marginal branch and the posterior descending artery. See
operative note for full details. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
A left sided chest tube was placed post operatively for a large
pneumothorax which resolved after placement. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes were placed to
waterseal on POD2 and she subsequently developed significant
left sided subcutaneous emphysema and was placed back on
suction. She remained hemodynamically stable without
respiratory distress. Repeat chest xray on POD 3 showed stable
pneumothorax with decreased subcutaneous air. Chest tubes and
pacing wires were subsequently discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD #5 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was cleared by Dr. [**Last Name (STitle) **] for discharge to home on
POD#5 in good condition with appropriate follow up instructions.
Medications on Admission:
Motrin 600 mg every 4-6 hours as needed
Omeprazole 20 mg daily
Loratidine 10 mg daily
Aspirin 81mg daily
Allergies: augmentin, vicodin
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
6. Hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for itchiness.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic Stenosis/ Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] on [**7-20**] at 1:00 PM [**Telephone/Fax (1) 170**]
Please call to schedule the following appointments:
Primary Care Dr. [**Last Name (STitle) 3321**] in [**12-31**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] in [**12-31**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2186-6-12**]
ICD9 Codes: 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3014
} | Medical Text: Admission Date: [**2111-2-4**] Discharge Date: [**2111-2-9**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 y/o female with PMH of CAD, Afib,
hemorrhagic stroke ([**April 2110**]), HTN, COPD, Hyperlipidemia, CHF,
pleural effusion and a history of falls. She reports generalized
weakness since her stroke. She states she was in her usual state
of health today but does not have any recollection of falling
just remembers waking up on the floor and pressing her Lifeline
button. She was taken to [**Hospital 86350**]Hospital and was found
to have
a small SAH on CT imaging. She was then transferred to [**Hospital1 18**] for
further care.
Past Medical History:
CAD, Afib, L CVA [**4-12**], HTN, COPD, HLP, CHF, pl eff, h/o falls
Family History:
Noncontributory
Physical Exam:
Upon admission:
T: 97.4 BP:196/90 HR:70 R16 O2Sats 96%
Gen: WD/WN, comfortable, in collar.
HEENT: Pupils: [**3-6**] EOMs full
Neck: in collar no neck pain, no stepoff or point tenderness.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
B T IP Q H AT [**Last Name (un) 938**] G
R 4- 5 5 5 5 5- 2 5
L 4+ 5 5 5 5 5 5 5
No pronator drift
Sensation: Decreased in feet
Reflexes: Pa
Right 5
Left 5
Toes downgoing bilaterally
Pertinent Results:
[**2111-2-4**] 08:58PM GLUCOSE-132* UREA N-19 CREAT-0.6 SODIUM-144
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-30 ANION GAP-13
[**2111-2-4**] 08:58PM CK(CPK)-265*
[**2111-2-4**] 08:58PM CK-MB-10 MB INDX-3.8 cTropnT-0.03*
[**2111-2-4**] 08:58PM WBC-7.1 RBC-4.23 HGB-12.9 HCT-38.8 MCV-92
MCH-30.5 MCHC-33.3 RDW-13.1
[**2111-2-4**] 08:58PM PLT COUNT-198
[**2111-2-4**] 08:58PM PT-12.1 PTT-23.9 INR(PT)-1.0
[**2111-2-4**] 02:10PM cTropnT-0.03*
[**2-4**]
CT head: Right sided subarachnoid blood in temporal area
possibly
small contusion no mass effect or shift.
[**2-4**]
CT cervical spine:
1. No evidence of acute fracture.
2. Degenerative changes including listhesis and mild loss of
height as
described above. These findings are age indeterminate given lack
of
comparison.
[**2-4**]
CXR
1. Moderate cardiomegaly.
2. No focal consolidation.
[**2-4**]
Hip xray
PELVIS, ONE VIEW; LEFT HIP, TWO VIEWS: There is diffuse osseous
demineralization. There are no fractures or dislocations.
Moderate
degenerative disease is noted in the lower lumbar spine.
Retained stool is noted in the rectum. The bowel gas pattern is
nonspecific. The soft tissues are unremarkable.
IMPRESSION: No fractures.
[**2-5**] Rpt head CT:
IMPRESSION:
1. No interval change in size or configuration of right temporal
and right
frontal vertex subarachnoid hemorrhage.
2. Punctate hyperdensity within the left cerebellum is too small
to fully
characterize, but may represent a calcification. Ill-defined
hyperdensity
along the tentorium on the left appears unchanged, possibly
chronic thickening or subtle focal subdural hematoma.
3. No new focus of hemorrhage. No mass effect or midline shift.
4. Chronic small vessel ischemic disease.
Brief Hospital Course:
She was admitted to the Trauma service. Neurosurgery was
consulted for her SAH; frequent neurologic checks and serial
head CT scans were done and remained stable. She was loaded and
started on Dilantin and remained on this for 7 days for seizure
prophylaxis; no seizure activity has been noted during her
hospital stay. She will need to follow up with neurosurgery in 1
month for repeat head CT scan.
Her home medications were restarted with the exception of her
aspirin. Her Dig level was normal at 0.9. Her diet was advanced
for which she is tolerating. She was evaluated by Physical
therapy and is being recommended rehab after her acute hospital
stay.
Medications on Admission:
Dig 0.125', ASA 81', lop 25'', lasix 40''
Discharge Medications:
1. Phenytoin 125 mg/5 mL Suspension Sig: One Hundred (100) MG PO
Q8H (every 8 hours) for 1 days.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for HR <60; SBP <110 .
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for contipation.
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
Port Rehab & Skilled Nursing - [**Location (un) 5028**]
Discharge Diagnosis:
s/p Fall
Right temporal subarachnoid hemorrhage
Left temporal laceration
Right elbow laceration
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 hospitalized following a fall where you sustained a
bleeding injury to your brain. The bleeding was monitored
closely by neurologic examination and by head CT scans. Your CT
scans remained stable with no evidence of further bleeding. Your
mental status has also improved during your hospital stay. You
were given a medication called Dilantin to prevent seizures;
there were no seizure activity noted during your hospital stay.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 548**] in 4 weeks with head CT - please
call [**Telephone/Fax (1) 2992**] to arrange this appt.
You will need to follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from rehab.
Completed by:[**2111-2-10**]
ICD9 Codes: 4280, 496, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3015
} | Medical Text: Admission Date: [**2119-10-31**] Discharge Date: [**2119-11-5**]
Date of Birth: [**2072-1-20**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 47 year old male with HIV( last CD4 301 [**8-7**]),
ESRD on PD, dilated cardiomyopathy (EF 30%) who presents with
cough and SOB. Patient notes being in his usual state of health
until ~ 2 am this morning when he awoke with severe cough and
SOB. He notes chronic SOB x 3-4 months but does note feel this
was significantly worse recently. He notes chronic cough due to
cigarette smoking but did not note significant change in his
cough until waking up the morning of admission. Since the
coughing began this am it has been productive of frothy white
sputum. Denies any blood or other colors. He notes fevers and
chills for months but no changes recently. Denies any recent
travel or sick contacts. [**Name (NI) **] denies any significant LE swelling.
He denies orthopnea or PND. He has not taken any of his HAART
regimen or Bactrim ppx for the last month as he ran out of
prescriptions. The only medications he has been taking are
cinacalcet, clonidine, and sevelamer.
.
In ED, 98.6, 177/134, 116->140, 20, 100% RA(?). Exam notable for
bibasilar crackles and wheezes. Labs remarkable for leukocytosis
to 11,600, anemia with Hct of 26, . ABG on RA was 7.45/35/60.
Lactate 1.8->1.2. BUN/Cr 68/16.5. CXR showed diffuse ground
glass opacities. Head CT was unremarkable with the exception of
mastoid opacification. ECG showed sinus tach to 140s. He
received azithromycin 500 mg po, bactrim DS 1 tab po, 60 mg of
po prednisone, 1 gram of IV ceftriaxone, atrovent nebulizer,
benzonatate 100 mg, morphine 4 mg IV, ativan 2 mg IV, and reglan
5 mg IV. CTA showed no evidence of PE but did show diffuse
infiltrates, consolidations, and moderate edema.
.
ROS was positive as above. In addition, he does note a HA
beginning this am. He denies any vision changes, numbness, or
weakness. He does not make any urine at baseline. He has been
doing his PD regularly and his last ultrafiltrate this morning
was ~990 cc. He denies any chest pain, abdominal pain, diarrhea.
He notes constipation and has not had a BM in several days. He
denies any nausea, vomiting.
Past Medical History:
HIV with a CD4 360 in [**2118-7-19**], viral load 45,900 at that time
End-stage renal disease secondary to HIV nephropathy. on PD
Anemia
Secondary hyperphosphatemia.
Sickle cell trait.
Polysubstance abuse - including cocaine
Dilated cardiomyopathy (last EF 30% on [**4-5**])
HTN
Atrial fibrillation following cocaine use.
Social History:
-Cocaine use; last use 4d ago
-h/o EtOH abuse; 1 drink a month now
-smokes 1 PPD x 35 yrs
-works as a waiter
-lives with friends
-receives care and medications through [**Hospital6 **]
Center.
Family History:
Significant for ethanol abuse in the mother as well as diabetes
and multiple myeloma. Negative for renal disease.
Physical Exam:
Vitals - T: 98.3 BP: 133/99 HR: 95 RR: 20 02 sat: 96% RA
GENERAL: NAD/ comfortable
HEENT: EOMI, PERRL, OP - no exudate, no erythema, JVD not
appreciated
CARDIAC:no m/r/g appreciated, nl S1, S2
LUNG: decreased BS at bases bilaterally, CTA-B/L
ABDOMEN: slightly distended, NT, soft, PD catheter in place
EXT: no c/c/e
NEURO: non-focal
SKIN: no rashes noted
Pertinent Results:
Admission:
[**2119-10-31**] 02:30PM BLOOD WBC-11.6*# RBC-2.67* Hgb-9.1* Hct-26.0*
MCV-97 MCH-34.2* MCHC-35.2* RDW-14.6 Plt Ct-437
[**2119-10-31**] 02:30PM BLOOD Neuts-79.6* Lymphs-11.7* Monos-7.1
Eos-1.3 Baso-0.4
[**2119-10-31**] 09:04PM BLOOD PT-13.1 PTT-31.0 INR(PT)-1.1
[**2119-10-31**] 02:30PM BLOOD WBC-11.6* Lymph-12* Abs [**Last Name (un) **]-1392 CD3%-83
Abs CD3-1162 CD4%-18 Abs CD4-253* CD8%-61 Abs CD8-850*
CD4/CD8-0.3*
[**2119-10-31**] 02:30PM BLOOD Glucose-90 UreaN-68* Creat-16.5*# Na-138
K-3.6 Cl-98 HCO3-28 AnGap-16
[**2119-10-31**] 09:04PM BLOOD ALT-13 AST-37 LD(LDH)-447* CK(CPK)-1224*
AlkPhos-94 TotBili-0.3
[**2119-10-31**] 09:04PM BLOOD CK-MB-22* MB Indx-1.8 cTropnT-0.24*
[**2119-11-1**] 03:45AM BLOOD CK-MB-23* MB Indx-1.3 cTropnT-0.23*
[**2119-11-1**] 01:14PM BLOOD CK-MB-33* MB Indx-1.1 cTropnT-0.22*
[**2119-11-2**] 06:40AM BLOOD CK-MB-43* MB Indx-1.0 cTropnT-0.25*
[**2119-10-31**] 09:04PM BLOOD Albumin-3.0* Calcium-9.4 Phos-5.3*
Mg-1.4*
[**2119-11-2**] 06:40AM BLOOD calTIBC-191* Ferritn-300 TRF-147*
[**2119-10-31**] 09:04PM BLOOD HIV Ab-POSITIVE
[**2119-10-31**] 09:04PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2119-10-31**] 04:34PM BLOOD pO2-60* pCO2-35 pH-7.45 calTCO2-25 Base
XS-0
[**2119-10-31**] 02:34PM BLOOD Lactate-1.8
[**2119-10-31**] 04:34PM BLOOD Lactate-1.2
[**2119-10-31**] 04:34PM BLOOD O2 Sat-88Test
[**2119-11-5**] 06:10AM BLOOD WBC-5.5 RBC-2.79* Hgb-9.4* Hct-26.9*
MCV-96 MCH-33.6* MCHC-34.8 RDW-15.9* Plt Ct-464*
[**2119-11-5**] 06:10AM BLOOD Neuts-51.6 Bands-0 Lymphs-32.1
Monos-11.4* Eos-4.4* Baso-0.6
[**2119-11-3**] 06:25AM BLOOD PT-13.0 PTT-31.8 INR(PT)-1.1
[**2119-11-5**] 06:10AM BLOOD Glucose-114* UreaN-75* Creat-16.8* Na-135
K-3.4 Cl-93* HCO3-24 AnGap-21*
[**2119-11-5**] 06:10AM BLOOD CK(CPK)-720*
[**2119-11-4**] 06:05AM BLOOD CK(CPK)-1247*
[**2119-11-3**] 06:25AM BLOOD CK(CPK)-2352*
[**2119-11-1**] 01:14PM BLOOD CK(CPK)-3127*
[**2119-11-1**] 03:45AM BLOOD CK(CPK)-1824*
[**2119-11-5**] 06:10AM BLOOD Calcium-8.0* Phos-5.8* Mg-1.9
[**2119-11-2**] 06:40AM BLOOD calTIBC-191* Ferritn-300 TRF-147*
Result Reference
Range/Units
COCAINE/METABOLITES NONE DETECTED SEE BELOW
NG/ML
REP. LIMIT 20
ANALYSIS BY ENZYME-LINKED IMMUNOSORBENT ASSAY ([**Doctor First Name **]).
Test Result Reference
Range/Units
COCAINE AND METABOLITES TNP REP. LIMIT 20
NG/ML
CONFIRMATION (COCAINE)
FOLLOWING ORAL OR NASAL INTAKE OF 2 MG/KG: UP TO 200 NG/ML.
Test Result Reference
Range/Units
COCAETHYLENE TNP REP. LIMIT 20
NG/ML
(COCAINE/ETHANOL BY-PRODUCT)
BENZOYLECGONINE (COCAINE TNP REP. LIMIT 50
DEGRADATION PRODUCT)
**FINAL REPORT [**2119-11-4**]**
Rapid Respiratory Viral Antigen Test (Final [**2119-11-2**]):
Respiratory viral antigens not detected.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
This kit is not FDA approved for the direct detection of
respiratory
viruses in specimens; interpret negative result with
caution..
Refer to respiratory viral culture for further
information.
VIRAL CULTURE (Final [**2119-11-4**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
[**2119-11-2**] 4:01 pm SPUTUM Site: INDUCED Source: Induced.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2119-11-3**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
GRAM STAIN (Final [**2119-11-1**]):
<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 [**2119-11-1**]):
TEST CANCELLED, PATIENT CREDITED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2119-11-2**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
ACID FAST SMEAR (Final [**2119-11-2**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2119-11-1**] 2:40 pm Influenza A/B by DFA
Source: Nasopharyngeal aspirate.
**FINAL REPORT [**2119-11-1**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2119-11-1**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2119-11-1**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
Blood Culture, Routine (Final [**2119-11-6**]): NO GROWTH.
Imaging:
CXR [**11-3**]
IMPRESSION: Improvement of the right upper lobe opacification.
Given short
time interval of clearance suggests aspiration. Otherwise,
diffuse
ground-glass opacities bilaterally are similar in appearance.
CXR [**11-2**]
IMPRESSION: Focal progression of disease in the right upper lobe
and
bilateral pleural effusions (more clearly seen on chest CT)
favor a general
bacterial infection over PCP.
ECHO [**11-1**]
The left atrium is dilated. There is severe symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is severe global left ventricular hypokinesis
(LVEF = 30-35 %). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately 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 to
moderate ([**11-30**]+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2118-4-8**],
the aorta does not appear as dilated on the current study. The
other findings are similar.
CTA [**10-31**]
IMPRESSION:
1. Extensive bilateral airspace opacification, with severe
consolidation in
right upper lobe, less extensive consolidation in the left upper
lobe, and
diffuse ground- glass opacity in the lower lobes bilaterally.
These findings
suggest an advanced infectious process such as PCP or CMV
pneumonia, less
likely bacterial pneumonia.
2. No evidence of pulmonary embolism.
3. Moderately extensive mediastinal and hilar lymphadenopathy,
likely
reactive to the pulmonary process.
4. Mild pulmonary edema and small pleural effusions.
CXR [**10-31**]
IMPRESSION: Diffuse air space opacification, which may represent
pulmonary edema or diffuse pneumonia (including PCP).
CT Head [**10-31**]
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect. MRI is more
sensitive
for detection of intracranial malignancy.
2. Near complete opacification of the right mastoid air cells.
Please
correlate clinically for evidence of otitis media or
mastoiditis.
Brief Hospital Course:
47 year old male with HIV(CD4 301), ESRD on PD, dilated
cardiomyopathy(EF 30%) here with diffuse pulmonary ground glass
opacities, consolidations, and pulmonary edema.
# SOB/hypoxia:
The day of admission the patient awoke with cough and SOB that
had acutely worsened. He noted 3-4 months of SOB prior. He
reportedly had a lot of salt over the [**Holiday 1451**] holiday and
missed some of his lisinopril doses. Of note, he has not had
his HAART or Bactrim ppx for the last month as he ran out of
prescriptions. He states he has been doing his PD regularly. In
the ED he was notable for bibasilar crackles and wheezes with
labs significant for leukocytosis of 11,600, anemia with Hct of
26. ABG on RA was 7.45/35/60. Lactate 1.8->1.2. BUN/Cr 68/16.5.
CXR showed diffuse ground glass opacities. Head CT was
unremarkable with the exception of mastoid opacification. ECG
showed sinus tach to 140s. He received azithromycin 500 mg po,
bactrim DS 1 tab po, 60 mg of po prednisone, 1 gram of IV
ceftriaxone, atrovent nebulizer, benzonatate 100 mg, morphine 4
mg IV, ativan 2 mg IV, and reglan 5 mg IV. CTA showed no
evidence of PE but did show diffuse infiltrates, consolidations,
and moderate edema. He was transferred to the MICU due to his
respiratory status.
.
In the MICU, the patient was initially treated with Bactrim and
steroids. ID was consulted and an induced sputum was sent for
PCP and DFA for [**Holiday **] was also sent, that eventually returned
negative. Given the fact that the likelihood of PCP was low
given that CD4 > 250. Bactrim and steroids were stopped, and he
conitued on IV ceftriaxone and azithromycin for CAP. Nephrology
also followed the patient for his PD and fluid was taken off.
CHF regimen also changed to carvedilol and stopped CCB. His
respiratory status improved. The patient continued to improve
and completed a 10 day course of antibiotics for CAP with
azithro and cefpodoxime. He also had repeat PCP and legionella
that was negative. Additionally, viral screen showed was
negative.
# Tachycardia: The patient was previously noted to have sinus
tachycardia on ECG. Given acute presentation, MI was on the list
of potential etiologies however ECG and enzymes were not
consistent with this picture. There is question whether he has
been compliant with his diltiazem, as he was both tachycardic
and hypertensive on presentation. Given his cardiomyopathy his
CCB was changed to carvedilol. A serum cocaine tox show was
negative.
#Elevated CK: The patient's CK continued to trend upward during
his admission. The cause was thought to potentially be due to
infectious insult vs. sickle cell trait (elevated LDH at
baseline as well). The patient's CK trended upwards to 4170 on
[**11-2**]. The CK then trended down and was 720 on discharge.
.
# HTN: Persistently hypertensive during admission, and was
continued on his clonidine. The patient's ciltiazem was
discontinued and he was started on coreg.
.
# Dilated cardiomyopathy: The patient's CE were negative. An
ECHO was performed this admission had showed an EF of 30-35%.
The patient was started on coreg. The patient should have
follow-up with cardiology.
# HIV: ID consulted for this morning. Patient has been
non-compliant with medications in the past, His CD4 count was
251 on admission. His HAART was held given that he had not been
taking the medications in the last month. He has no h/o OI and
was not started on ppx. He was restarted on his HAART regimen
on [**11-5**] and also started on Bactrim ppx.
# ESRD: The patient was followed by renal and continued on
peritoneal dialysis.
# Hyperparathyroidism: Thought to be secondary to renal disease,
on cinecalcet. Patient noted not being compliant with this
medication at times as well (due to insurance issues).
.
# Anemia, The patient's baseline hct high 20s - low 30s, highly
variable. He has a h/o sickle cell trait. There was no evidence
of bleed, or hemolysis (although LDH is elevated, but this is
chronic). His Hct was trended throughout the admission.
.
# FEN: advance diet as tolerated
.
# PPx: heparin sc. PPI.
# ACCESS: PIV, 18G x 2.
# CODE: FULL, confirmed with patient
# COMM: [**Name (NI) **] [**Name (NI) 6183**] (aunt) [**Telephone/Fax (1) 6184**]. [**Name (NI) 6185**] [**Name (NI) 1726**] (friend)
[**Telephone/Fax (1) 6186**]
Medications on Admission:
RITONAVIR 100 mg once a day (not taken for 1 month)
ZIDOVUDINE 300 mg once a day (not taken for 1 month)
FOSAMPRENAVIR 1400 mg once a day (not taken for 1 month)
LAMIVUDINE 50 mg daily (not taken for 1 month)
TENOFOVIR DISOPROXIL FUMARATE 300 mg Tablet q week (not taken
for 1 month)
DILTIAZEM SR 240 mg daily (not taken for 1 month)
TRIMETHOPRIM-SULFAMETHOXAZOLE 400 mg-80 mg once a day (not taken
for 1 month)
OMEPRAZOLE 20 MG DAILY prn
LACTULOSE 30 mL prn
CINACALCET 60 mg [**Hospital1 **]
CLONIDINE 0.1 mg [**Hospital1 **]
SEVELAMER 3 pills with each meal
Discharge Medications:
1. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
10. Fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
Disp:*60 Tablet(s)* Refills:*2*
11. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QFRI (every Friday).
Disp:*4 Tablet(s)* Refills:*2*
12. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Disp:*90 Capsule(s)* Refills:*2*
13. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
14. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
15. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
16. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
17. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Community Aquired Pneumonia
Seconday:
HIV
End-stage renal disease
Dilated cardiomyopathy (last EF 30% on [**4-5**])
hyperparathyroidism
Anemia
Secondary hyperphosphatemia
HTN
Atrial fibrillation
Sickle cell trait
s/p R inguinal hernia repair [**5-7**]
Discharge Condition:
stable, ambulating, satting well on room air
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
your lung. You were treated with antibiotics and improved. You
were continued on antibiotics for a total of 10 days. Your
respiratory status improved and you felt much better. You were
ruled out for PCP, [**Name10 (NameIs) **], and other infectious diseases.
You were also restarted on your HAART and Bactrim for PCP
[**Name Initial (PRE) 6187**].
Please follow the medications prescribed below.
New Medications:
1) Bactrim SS 1 tab daily
2) Flonase
3) Restart your HAART therapy as previous:
RITONAVIR 100 mg once a day
ZIDOVUDINE 300 mg once a day
FOSAMPRENAVIR 1400 mg once a day
LAMIVUDINE 50 mg daily
TENOFOVIR DISOPROXIL FUMARATE 300 mg Tablet q week
4) Nicotine patch
5) Azithromycin 10 days total
6) Cefpodoxine 10 days total
7) Carvedilol 6.25mg [**Hospital1 **]
8) Calcitriol 0.5mcg
Your Diltiazem was discontinuned.
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**11-30**] weeks
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 798**]
Please follow up with the [**Hospital **] [**Hospital **] Clinic
Telephone: [**Telephone/Fax (1) 5972**]
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2119-11-20**]
9:00
Completed by:[**2119-11-8**]
ICD9 Codes: 486, 5856, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3016
} | Medical Text: Admission Date: [**2137-5-8**] Discharge Date: [**2137-5-14**]
Date of Birth: [**2100-7-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Fatigue, dyspnea, epigastric pain
Major Surgical or Invasive Procedure:
Central line placement and removal
History of Present Illness:
Mr [**Known lastname 14637**] is a 36-year-old male with HIV (CD4: 627, VL: 2,880
copies/ml in [**4-/2137**]) not on HAART who presented on [**5-8**] with
worsening SOB and fatigue. An in-house TTE revealed EF 10-15%,
prompting transfer to the CCU in setting of increasing
respiratory distress.
.
Initially, he presented with 2 days worsening SOB and fatigue.
These symptoms started [**5-6**] when walking up stairs. Previously,
Mr. [**Known lastname 14637**] could usually do [**4-2**] flights of stairs, but on
admission experienced SOB after [**1-31**] flights. Shortness of breath
was worse with lying down, better with belching, but also with
associated chest pressure. He had no cough, fevers or wheezing.
Mr. [**Known lastname 14637**] became very thirsty yesterday, drank lots of water,
tea, milk on [**5-6**] but still remained thirsty. On [**5-7**], Mr
[**Known lastname 14637**] awoke with sharp, squeezing epigastric pain that
improved with standing up. He took Pepcid at 2am but did not
feel better, and noted right upper quadrant abdominal discomfort
as well, which was worse with movement, unchanged with eating.
At that time, he did not experience any dysphagia, cough,
hemoptysis, diarrhea, constipation, nausea, vomiting, rashes or
lesions. His last meal was [**5-6**] night, last fluid PO [**5-7**]
10:30am.
.
Patient has a history of IV crystal meth use, last used 1.5
months ago but stopped after developing flulike sx with
myalgias, SOB, fever to 103F that resolved after 4 days. He
denies any illicit drugs since that time and claims not to use
any cocaine ever. He is unaware of having been infected by any
opportunistic infections. He has not been to his PCP or been on
HAART for 3 years.
.
Epigastric pain prompted presentation to the ED. Initial VS:
99.8 125 124/84 24 100% RA. Admission CXR with pronounced
cardiomegaly without pulmonary edema or infiltrate. Bedside
cardiac ultrasound with ?global hypokinesis and no pericardial
effusion or tamponade. EKG was notable for LAE, nl axis,
ischemic changes. Prior to transfer received 3LNS for low UOP,
1g acetaminophen, 1 mg ativan, 30 mg toradol (NO miperidine).
.
Notable labs: BNP 9525, biomarkers negative x2, worsening
transaminitis currently with ALT: 1427 AST:1525, mildlly
elevated AP: 140 nl T.Bili 0.7, INR 1.5. Abnormal LFTs prompted
imaging studies and surgical consult. RUQ u/s demonstrated
thick-walled, edematous gallbladder, no stones, +son[**Name (NI) 493**]
[**Name2 (NI) 515**], splenomegaly to 14cm. Follow-up HIDA scan wnl.
.
Overnight the patient was without event. However [**5-8**] morning,
patient had a temperature of 103.8F with associated rigors and
tachypnea with RR 30s-40s, 98% RA. ID was consulted. Patient
ordered for vancomycin and gentamycin (pcn allergy) however did
not received. RIJ placed for access. PPD placed on right forearm
on [**5-9**]. Extensive ID lab work-up sent off with recs for CT
torso.
.
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 exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for paroxysmal nocturnal
dyspnea, orthopnea, dyspnea on exertion; patient is currently
without chest pain, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
An unknown heart murmur was appreciated by his NP several years
ago.
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
# HIV: Last CD4: 627, VL: 2,880 copies/ml in [**2137-5-9**]
-- Diagnosed ~ [**2121**]
-- Mode of transmission: MSM
-- started on HAART at time of diagnosis in [**2121**]; stopped tx in
[**2131**] when insurance ran out
-- unsure of CD4 nadir.
-- No h/o OI
Social History:
MSM with 1 male partner.
[**Name (NI) 1403**] as dog walker.
Healthy and able to bound up 4-5 flights of stairs previously.
Lives alone in 2-storey house.
Tobacco: Denies ever using tobacco.
EtOH: No h/o of abuse, drinks socially 1-2x/month.
Illicit Drugs: IV crystal meth user, denies usage in 1.5 months.
No cocaine or heroin.
Family History:
- Mother and many relatives of mother: Diabetes
- Father: CVA
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
Physical Examination on Admission:
VS - Temp 99.8F, BP 108/90, HR 100, R 32, O2-sat 100% RA
GENERAL - ill-appearing man, uncomfortable-appearing, tachypneic
but not dyspneic, able to speak full sentences and hold his
breath, appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MM slightly dry,
OP clear
NECK - supple, no thyromegaly, JVD to jaw
LUNGS - CTA bilat, no r/rh/wh, good air movement, tachypneic in
30s, no accessory muscle use
HEART - PMI slightly laterally displaced, weak and diffuse
feeling, RRR, 4/6 systolic murmur at LLSB
ABDOMEN - NABS, soft, RUQ tender to palpation and percussion,
+[**Doctor Last Name 515**], possible splenomegaly but +voluntary guarding with
exam, no rebound or peritoneal signs, CVAT on R flank
EXTREMITIES - cool, no cyanosis or edema, cap refill 3 sec, 2+
peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, track marks on BUEs
LYMPH - nontender cervical, inguinal LAD; no
supra/infraclavicular LNs
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-2**] throughout, sensation grossly intact throughout, gait not
tested
.
Physical Examination on Transfer to CCU:
VS: T=99.0 BP=112/79 HR=115 RR=40 O2 sat=95%
GENERAL: NAD. Oriented x3. Ill appearing, mildly diaphoretic,
tachypneic, ashen color.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No jaundice.
Conjunctiva pink. OP clear without exudates, lesions, thrush. .
NECK: Supple, JVD to the ear.
CARDIAC: non-displaced PMI: located in 5th intercostal space,
midclavicular line. tachycardiac, normal S1, S2, soft SEM heard
best at the apex, +S3.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Visibily Tachypneic, minimal accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, mild tenderness to palpitation in RUQ, no rebound
no guarding, no HSM detected though RUQ limited somewhat
secondary to pain. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers. Tattos on bilateral hips,
small lesion on left 4 toe.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Lymph: post-cervical chain LAD, bilateral inguinal LAD, right
axillary LAD
NEURO: II-XII intact, motor and sensation intact, strength
intact
.
EXAM ON DISCHARGE:
GENERAL: NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No jaundice.
Conjunctiva pink. OP clear without exudates, lesions, thrush. .
NECK: Supple
CARDIAC: non-displaced PMI: located in 5th intercostal space,
midclavicular line. RRR, normal S1, S2, soft SEM heard best at
the apex.
LUNGS: No chest wall deformities, scoliosis or kyphos, CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, nontender, no rebound no guarding, no appreciable
HSM. +BS. Abd aorta not enlarged by palpation. No abdominial
bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers. Tattos on bilateral hips
Lymph: post-cervical chain LAD, bilateral inguinal LAD, right
axillary LAD
NEURO: II-XII intact, motor and sensation intact, strength
intact
Pertinent Results:
On Admission:
.
[**2137-5-8**] 06:50AM GLUCOSE-100 UREA N-35* CREAT-1.3* SODIUM-130*
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-23 ANION GAP-14
[**2137-5-8**] 06:50AM ALT(SGPT)-119* AST(SGOT)-132* ALK PHOS-164*
TOT BILI-0.4
[**2137-5-8**] 06:50AM LIPASE-30
[**2137-5-8**] 06:50AM cTropnT-<0.01
[**2137-5-8**] 06:50AM proBNP-9525*
[**2137-5-8**] 06:50AM TOT PROT-7.5 ALBUMIN-4.1 GLOBULIN-3.4
[**2137-5-8**] 06:50AM HCV Ab-NEGATIVE
[**2137-5-8**] 06:50AM WBC-6.3 RBC-4.44* HGB-12.7* HCT-37.1* MCV-84
MCH-28.7 MCHC-34.3 RDW-14.5
[**2137-5-8**] 06:50AM NEUTS-45.0* LYMPHS-48.6* MONOS-4.8 EOS-0.6
BASOS-1.0
[**2137-5-8**] 06:50AM WBC-6.3 LYMPH-49* ABS LYMPH-3087 CD3-87 ABS
CD3-2672* CD4-20 ABS CD4-627 CD8-63 ABS CD8-[**2069**]* CD4/CD8-0.3*
[**2137-5-8**] 07:15PM GLUCOSE-111* UREA N-33* CREAT-1.2 SODIUM-137
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-18* ANION GAP-18
[**2137-5-8**] 07:15PM ALT(SGPT)-571* AST(SGOT)-601* CK(CPK)-86 ALK
PHOS-142* TOT BILI-0.7
[**2137-5-8**] 07:15PM CK-MB-3 cTropnT-<0.01
[**2137-5-8**] 07:15PM ALBUMIN-3.9 CALCIUM-8.3* PHOSPHATE-3.2
MAGNESIUM-1.9
[**2137-5-8**] 07:15PM WBC-5.5 RBC-4.25* HGB-12.5* HCT-35.5* MCV-84
MCH-29.5 MCHC-35.3* RDW-14.8
.
[**5-9**] ESR 4
[**5-9**] TSH 3
[**5-9**] CRP 20
.
MICRO:
[**5-8**] Blood Culture x2: No Growth.
.
[**5-9**] Blood Culture: ANAEROBIC GRAM POSITIVE COCCUS(I). Isolated
from only one set in the previous five days. (formerly
Peptostreptococcus species). NO FURTHER WORKUP WILL BE
PERFORMED. Anaerobic Bottle Gram Stain (Final [**2137-5-12**]): GRAM
POSITIVE COCCI IN CLUSTERS.
.
[**2137-5-9**] BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS
ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
[**5-9**] Blood culture: pending
.
[**5-10**] Blood cx: pending
.
[**5-13**] Blood cx: pending
.
[**2137-5-9**] URINE CULTURE (Final [**2137-5-10**]): GRAM POSITIVE BACTERIA.
10,000-100,000 ORGANISMS/ML. Alpha hemolytic colonies
consistent with alpha streptococcus or Lactobacillus sp.
.
HBV Viral Load (Final [**2137-5-11**]): HBV DNA not detected.
.
[**5-8**] TOXOPLASMA IgG ANTIBODY: NEGATIVE FOR TOXOPLASMA IgG
ANTIBODY BY EIA.
.
[**5-8**] HIV-1 Viral Load 2880 copies/ml.
.
[**5-8**] HCV VIRAL LOAD: 14,100 IU/mL.
.
[**5-9**] CMV Viral Load: CMV DNA not detected.
.
[**5-8**] HSV 1 IGG TYPE SPECIFIC AB Pos
.
[**5-8**] HSV 2 IGG TYPE SPECIFIC AB Neg
.
[**5-9**] CRYPTOCOCCAL ANTIGEN: CRYPTOCOCCAL ANTIGEN NOT DETECTED.
.
[**5-9**] [**Location (un) 5099**] VIRUS B ANTIBODIES Results Pending
.
[**2137-5-9**] PARVOVIRUS B19 ANTIBODIES (IGG & IGM) : pending
.
[**2137-5-9**] HISTOPLASMA ANTIGEN: pending
.
[**2137-5-9**] [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2137-5-13**]):
POSITIVE BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2137-5-13**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2137-5-13**]):
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop 6-8 weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
LYME SEROLOGY (Final [**2137-5-13**]):
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
Reference Range: No antibody detected.
.
[**5-13**] HCV Genotype pending
.
Imaging:
- ECHO:
IMPRESSION: Severely dilated and hypokinetic right and left
ventricles. The distal anterior, anterolateral, inferolateral
and apical LV segments show prominent trabeculation with
relatively thin myocardium. This appearance could be a normal
variant or due to ventricular non-compaction. There is moderate
tricuspid and mitral regurgitation, likely due to annular
dilatation. No vegetation is seen on this study. If clinically
indicated, a TEE could help exclude endocarditis. Moderate
pulmonary artery systolic hypertension.
.
- CXR:
A right internal jugular central venous line terminates in the
lower aspect of the superior vena cava. Cardiac silhouette is
enlarged, though unchanged, possibly reflecting cardiomegaly or
a pericardial effusion. Mediastinal and hilar contours are
normal. There is no focal consolidation, right pleural effusion,
or pneumothorax. The left cardiophrenic angle is beyond the
field of view.
.
IMPRESSION: Right IJ central line ending in the SVC.
.
- RUQ Ultrasound:
1. Severe gallbladder wall edema and tenderness without stones
or frank gallbladder distention. Differential diagnosis includes
diffuse edema from acute hepatitis, HIV cholangiopathy, cardiac
failure, or systemic hypoproteinemia vs acalculous cholecystitis
in the appropriate clinical setting. Recommend clinical
correlation and consider HIDA scan for further evaluation.
2. Mild splenomegaly.
3. Minimal perihepatic and perisplenic free fluid.
.
- HIDA Scan:
IMPRESSION: Normal gallbladder study.
.
- KUB:
IMPRESSION:
1. Mildly distended small bowel with air in distal colon, likely
reactive ileus, though early partial small-bowel obstruction
cannot be excluded.
2. No radiopaque stones.
.
Other Investigations
- ECG: NSR, nl axis, nl interval, LAE, borderline QT
prolongation, no ST changes, no abnl TWI
.
LABS ON DISCHARGE ([**5-14**]):
136 102 19
------------< 115
4.5 27 1.0
Ca: 9.0 Mg: 1.9 P: 4.3
ALT: 675 AP: 129 Tbili: 0.4
AST: 327
CBC: MCV 85
5.3 > 13.6< 281
40.1
Brief Hospital Course:
Mr [**Known lastname 14637**] is a 36 yo male with history of HIV last CD4: 627,
VL: 2,880 copies/ml who presented with epigastric dyscomfort and
recent onset DOE and was found to have previously unknown
dilated cardiomyopathy with EF ~10% in setting of febrile
illness.
.
# Dilated cardiomyopathy: Patient had no known history of heart
disease and presented with 3 days of progressive dyspnea on
exertion, PND and orthopnea. His TTE showed an EF of [**10-12**]%,
which was likely overestimated in the setting of 2+MR.
Differential dx for dCMP was broad - ischemic, infectious,
toxic, inherited/genetic, left ventricular non-compaction,
endocrine, nutritional deficiency. In this patient, it was felt
the most likely etiology was infecious vs. toxic (though HIV is
correlated with premature CAD, patient was without evidence on
EKG of prior ischemic insult & on this admission biomarkers were
negative; also CD4 count and relatively low VL argued against
this primary etiology). It was felt there was likely a chronic
component to the patient's dCMP given the extent of dysfunction
and most likely was toxin mediated [**1-30**] his extensive history of
crystal meth use. His presentation this admission may have been
related to an acute exacerbation in the setting of a viral
infection. He was transferred to the CCU from the floor due to
worsened respiratory distress. SvO2 was initially 73 and then on
repeat in the 60s, suggestive of cardiogenic shock. He showed
evidence of volume overload with elevated JVP and CVP~20 and was
initially diuresed with lasix gtt, then bolus doses, and then
auto-diuresed with improvement in his oxygenation. He did not
require invasive or non-invasive ventilation. He was started on
metoprolol succinate and lisinopril as his pressures tolerated.
He was discharged to follow up with cardiology.
.
# Fever: Patient with subjective fevers prior to admission and
spiked to 103.8 on morning of transfer to the CCU with
associated rigors and diaphoresis. His CBC was notable for WBC
wnl and no left shift; he had no localized complaints. He was
seen by infectious disease prior to transfer and started on
vancomycin and gentamicin given his PCN allergy. He underwent
TTE as above w/o visible vegetations. Blood cultures were
negative with the exception of one culture from [**5-9**] which grew
GPCs in clusters felt to be Peptostrep; this was felt to be a
contaminant as all other cultures were negative. He underwent an
extensive infectious work up including crypto, toxo, CMV, EBV,
hepatitis serologies, [**Location (un) **], RPR, Lyme, HSV1&2 and
parvovirus. This workup was significant for a positive HCV viral
load of about 14,000 in the setting of a negative IgG antibody.
PPD was negative. Given the negative work up, antibiotics were
discontinued. His fever was attributed to a viral syndrome and
resolved without further intervention. He was discharged with ID
follow up scheduled.
.
# RHYTHM: Remained in sinus, at times tachycardic. Was started
on metoprolol for rate control and in the setting of his
cardiomyopathy.
.
# HIV: CD4: 627, VL: 2,880 copies/ml on [**2137-5-9**]. Not
currently on HAART. No history of OI. No acute management was
initiated during this inpatient stay. PPD was planted and was
negative. Infectious disease was consulted as above and patient
will follow up in the outpatient setting.
.
# Transaminitis: Per patient with no h/o liver disease though
Hep C + on admission testing. He was seen by hepatology who felt
that his elevation in LFTs was attributed to ischemic
hepatopathy in setting of congestion and liver
hypoperfusion/shocked liver. His LFts downtrended with diuresis.
His hepatitis C was not felt to be an acute infection (see
below). He did not show signs of synthetic dysfunction during
this hospitalization. He was discharged to follow up with
hepatology.
.
# Hepatitis C. HCV VL positive at 14,100, but Ab negative. Was
seen by hepatology who did not feel that this was an acute
infection, stating that it not uncommon for patients to have a
negative Ab in the setting of co-infection. HCV genotype was
sent and was pending on discharge. He was discharged to follow
up with hepatology as an outpatient.
.
# Lymphadenopathy. Patient with diffuse palpable non-tender
lymph nodes. Per patient chronic and stable. Likely benign
diffuse lymphadenopathy of HIV disease- no further imaging was
pursued but patient will benefit from close clinical follow up
and potential CT torso to assess for pathologic enlargement.
# Substance Abuse: Patient was counselled on substance abuse,
especially the impact of methamphetamine on his heart by the CCU
team and by social work. He reported being scared by his illness
and denied need for referrals to substance abuse programs or
counseling, citing extensive social support that would help him
stay sober.
.
# CODE: FULL
PENDING ON DISCHARGE:
[**2137-5-9**] [**Location (un) 5099**] VIRUS B ANTIBODIES Results Pending
.
[**2137-5-9**] PARVOVIRUS B19 ANTIBODIES (IGG & IGM): Pending
.
[**2137-5-9**] HISTOPLASMA ANTIGEN: pending
.
[**5-9**] Blood culture: pending
.
[**5-10**] Blood cx x2: pending
.
[**5-13**] Blood cx: pending
.
[**5-13**] HCV GENOTYPE: pending
Medications on Admission:
No medications on admission to the hospital.
.
Medications on admission to the CCU:
Maalox/Diphenhydramine/Lidocaine 15-30 mL PO QID:PRN reflux
Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
Aspirin 325 mg PO/NG DAILY
Tuberculin Protein 0.1 mL ID
Docusate Sodium 100 mg PO BID
Vancomycin 1000 mg IV Q 12H
Heparin 5000 UNIT SC TID
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
2. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Dilated Cardiomyopathy
HIV
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 14637**],
You were admitted to the hospital with shortness of breath. An
ultrasound of your heart was performed which showed dilation of
your heart which we believe may be due to your use of
methamphetamines. It is important that you stop using drugs as
this can have a serious impact on your heart and potentially
cause death. You had a fever while you were in the hospital and
were seen by the infectious disease doctors as [**Name5 (PTitle) **] as the liver
doctors [**Name5 (PTitle) **] some [**Name5 (PTitle) 14638**] in your liver tests. You were
found to have hepatitis C in your blood. Please follow up with
the infectious disease and liver doctors as below. Please weigh
yourself every morning, call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] if your
weight goes up more than 3 lbs.
We have made the following changes to your medications:
- START taking metoprolol for your cardiomyopathy
- START taking lisinopril for your cardiomyopathy
Please follow up at the appointments below (with infectious
disease, liver, cardiology, and your primary care doctor).
It was a pleasure taking care of you at the [**Hospital1 18**]. We wish you a
speedy recovery.
Followup Instructions:
Please follow up at the following appointments. It is very
important that you keep all of these appointments.
Department: [**Hospital3 249**]
When: MONDAY [**2137-5-20**] at 11:20 AM
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
Dr. [**First Name (STitle) 3535**] will be your new provider in [**Name9 (PRE) 191**]. Please call your
insurance company and change your provider to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3535**]
with them.
Department: INFECTIOUS DISEASE
When: MONDAY [**2137-6-10**] at 11:00 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Name6 (MD) **] [**Last Name (NamePattern4) 6851**], MD
Specialty: Cardiology
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
within the next 16-30 days. You will be called at home with the
appointment. If you have not heard within 2 business days or
have questions, please call the number above.
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14639**], MD
Specialty: Liver Center
Location: [**Hospital1 18**]-DEPT OF GASTROENTEROLOGY
Address: [**Doctor First Name **], 8E, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2422**]
We are working on an appointment with Dr. [**Last Name (STitle) **] within the next
16-30 days. You will be called at home with the appointment. If
you have not heard within 2 business days or have questions,
please call the number above.
Completed by:[**2137-5-14**]
ICD9 Codes: 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3017
} | Medical Text: Admission Date: [**2181-8-8**] Discharge Date: [**2181-8-13**]
Date of Birth: [**2124-5-16**] Sex: M
Service: MEDICINE
Allergies:
Midazolam / Lisinopril / Naprosyn / Indocin
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Aortic root to right atrial fistula
Major Surgical or Invasive Procedure:
Pulmonary vein isolation: Dr. [**Last Name (STitle) **] on [**2181-8-8**]
History of Present Illness:
This 57 year old man has a long standing history of atrial
arrhythmias s/p flutter ablation, PVI in [**2178-6-16**] and again in
[**2179-9-16**], and multiple cardioversions. He has been most
recently managed on Amiodarone. He was last here at [**Hospital1 18**] on
[**2181-7-17**] when he complained of dyspnea on exertion and fatigue for
several weeks. He underwent successful cardioversion and had his
Coumadin switched to Pradaxa due to difficulty maintaining
adequate INR levels. Plans were made for repeat attempt at
ablation in [**Month (only) **]. He developed recurrent atrial tachycardia
shortly following his cardio version on [**7-26**]. He underwent
successful DCCV of atrial tachycardia on [**8-2**] with prompt return
to sinus rhythm.
.
Today, pt had planned repeat PVI attempt with CH, but 2nd
transeptal went to aortic root above NCC. Case stopped. TEE
color flow Doppler revealed small fistula between the right
atrium and aortic root with L to R flow. 1U platelets ordered
but not yet given. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**], MD [**First Name (Titles) **] [**Last Name (Titles) **] Surgery consulted
and will patient shortly. Patient was left intubated and sent to
CCU for repeat TEE ~1500 to re-evaluate fistula in hopes that it
will have closed. Last Pradaxa [**2181-8-7**] AM dose.
.
ROS: Unable to obtain.
.
Please note that patient is intubated at time of admission and
therefore details of history are obtained from his electronic
medical record.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
1. Recurrent symptomatic atrial fibrillation
2. Multiple recent DC cardioversions most recent was [**2181-8-2**]
3. PVIs, last before admission was [**2179-9-21**]
4. Recurrent symptomatic left atrial tachycardia following PVI
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
3. OTHER PAST MEDICAL HISTORY:
- Hypertension
- Arthritis involving knees
- Anxiety
- Hepatitis C with elevate LFT's: As of [**2181-4-15**] -> Hepatitis C
genotype is 1. Hep C VL 2,200,000 international units/mL.
HepaScore is 1.00 with a 65% probability that the patient has
cirrhosis. Most recent abdominal ultrasound was obtained on [**4-20**], [**2180**] and did not demonstrate any hepatic lesions. The spleen
was 15.5 cm and a recanalized paraumbilical vein. There was no
ascites noted.
Social History:
Occupation: Retired nurse from the VA system.
Tobacco: Denies
ETOH: he averages 6 drinks a day; he reports going a couple days
at a time without any alcohol and denies any prior DT's. Reports
drinking "too much" in general and has considered detox before.
Home services: Denies
Family History:
FH: No family history of arrhythmias. No family history of liver
or GI disease.
Physical Exam:
Exam on Admission:
VS: T=95.8 BP= 127/59 HR=64 RR=14 O2 sat= 100% on 100% FIO2
Vent Settings: CMV with TV 600, PEEP 5, RR 12, FiO2 100%
GENERAL: Intubated and sedated.
HEENT: NCAT. Sclera anicteric. Pinpoint pupils, symmetric.
NECK: Supple, unable to assess JVP.
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: Clear anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Discharge exam:
GENERAL: alert and orriented.
HEENT: NCAT. Sclera anicteric. Pupils reactive and symmetric.
NECK: Supple, unable to assess JVP.
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: Clear anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs [**2181-8-8**]:
WBC-3.6* RBC-3.98* Hgb-13.5* Hct-38.2* MCV-96 MCH-34.0*
MCHC-35.4* RDW-16.6* Plt Ct-58*
PT-15.6* INR(PT)-1.4*
Glucose-118* UreaN-16 Creat-1.1 Na-136 K-3.5 Cl-95* HCO3-34*
AnGap-11
.
Post-Procedure Initial TEE [**2181-8-8**]:
A mobile 0.3 x 0.3 cm structure consistent with probable
thrombus (or other small mass) is seen in the the left atrium
attached to left atrial wall to the left and posterior to the
aortic root . A trans-septal catheter is seen and following
withdrawal there is residual left-to-right shunt across the
interatrial septum. Left ventricular global systolic function is
normal. There are simple atheroma in the aortic arch and
descending thoracic aorta. No thoracic aortic dissection is
seen. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. Trace aortic regurgitation is seen.
There is an echodense region along the posterior border of the
aorta, adjacent to the non-coronary cusp consistent with a
hemotoma that measures 1.8 cm at the widest. There is a 2mm wide
jet of color Doppler flow through the hematoma from the aortic
root into the right atrium. The mitral valve leaflets are mildly
thickened. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Aortic root to right atrial communication with
associated hematoma. Small left atrial mass as described above.
.
Repeat TEE [**2181-8-9**]:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. A small, approximately 1 x 3 mm
mobile structure consistent with possible thrombus is seen
attached to the wall of the left atrium (clip [**Clip Number (Radiology) **]), although
independent motion is not appreciated. Right atrial appendage
ejection velocity is good (>20 cm/s). No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Right ventricular chamber size and
free wall motion are normal. There are simple atheroma in the
aortic arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. No thoracic aortic dissection is seen. The
aortic valve leaflets (3) are mildly thickened with good leaflet
excursion. Trace aortic regurgitation is seen. There is an
echodense region along the posterior border of the aorta,
adjacent to the non-coronary cusp consistent with a hematoma
that measures 2.3 cm at the widest. There is a 3-5mm wide jet of
color Doppler flow from the aortic root into the right atrium.
[clip [**Clip Number (Radiology) **]] The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Aortic root to right atrial communication with
associated hematoma. Very small left atrial mass suggestive of
thrombus as described above.
Compared with the prior study (images reviewed) of [**2181-8-8**] the
color Doppler jet appears slightly wider and is now continous
throughout the cardiac cycle. The left atrial mass is smaller in
size. The previously appreciated interatrial shunt is no longer
appreciated.
Repeat TTE [**8-13**]:
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. Right atrial appendage ejection velocity is good (>20
cm/s). A left-to-right color flow signal is seen across the
interatrial septum at rest across the mid-interatrial septum
consistent with a small secundum atrial septal defect. Overall
left ventricular systolic function is normal (LVEF>55%). There
are simple atheroma in the aortic arch and the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened with good leaflet excursion. Mild (1+) aortic
regurgitation is seen. There is an echodense region along the
posterior border of the aorta, adjacent to the non-coronary cusp
consistent with a hematoma that measures 1.3x1.5 cm. There is ~3
mm wide continuous jet of color Doppler flow from the aortic
root into the right atrium [clip [**Clip Number (Radiology) **]]. The mitral valve leaflets
are mildly thickened. Mild to moderate ([**12-17**]+) mitral
regurgitation is seen.
IMPRESSION: Stable aortic root to right atrial communication
with associated hematoma. Small secundum-type ASD with left to
right flow at rest. Mild to moderate mitral regurgitation. Mild
aortic regurgitation.
Compared with the prior study (images reviewed) of [**2181-8-9**] the
left atrial mass is no longer seen and may have represented the
tip of the "warfarin ridge.". The aortic root to right atrial
communication and associated hematoma appear similar. The degree
of mitral and aortic regurgitation are both increased.
Brief Hospital Course:
Primary Reason for Hospitalization:
57yoM with h/o L atrial tachycardia/a-fibb, EtOH, HCV, now s/p
attempted PVI c/b transseptal puncture to aortic root with
aortic root to RA fistula.
Active Issues:
# Fistula: On admission to CCU he received 1u FFP and 3u
platelets (platelet count >100). CT surgery was notified and
began pre-op eval in the event that he would need open surgical
repair of the fistula. His blood pressure was tightly
controlled with SBP<100 to reduce pressure gradient between
aortic root and right atrium. Repeat TEE on HD#2 showed slight
enlargement of the fistula. He had a TTE to determine if the
fistula could be monitored with serial TTEs, however it could
not be visualized on TTE. He was extubated on HD#2 and
restarted on his home medications. On HD5, a repeat TEE was
performed which showed Stable aortic root to right atrial
communication with associated hematoma. Small secundum-type ASD
with left to right flow at rest. Mild to moderate mitral
regurgitation. Mild aortic regurgitation.
.
# RHYTHM: Procedure was terminated [**1-17**] fistula, so patient
continued to be in atrial fibrillation. His pradaxa was held due
to concern he may need open surgical repair of the fistula (last
dose pradaxa [**8-7**] AM). He was restarted on his amiodarone on HD
1. Pradaxa was held on discharge and will need to be restarted
in 2 weeks. His rate was controlled in the 80s.
.
# H/o ETOH: He was started on a CIWA scale after extubation and
weaning of sedation due to concern for withdrawal given heavy
reported EtOH history. This was discontinued a day prior to
discharge and the patient did well.
.
Stable issues:
# HTN: Stable. His home BP meds (lasix, losartan, HCTZ) were
initially held while on propofol but restarted on HD#2
post-extubation. His HCTZ was increased to 25 mg and he was
started on amlodipine 10 mg for better blood pressure control.
.
# GERD: Stable. He was continued on his home omeprazole.
.
# Anxiety: Stable. He was continued on his home anxiety meds
(alprazolam, sertraline).
.
# Arthritis: Continue home pain medications (vicodin, celebrex)
as needed for arthritis pain.
Transitional Issues:
-Patient maintained full code status throughout hospitalization.
-Patient will need to be restarted on anti-coagulation in 2
weeks.
- Follow up with Dr. [**Last Name (STitle) **] in 1 week
Medications on Admission:
ALPRAZOLAM - 0.5 mg Tablet - 1 by mouth up to 2 times a day as
needed
AMIODARONE - 200 mg Tablet - 1 by mouth three times daily
CELECOXIB [CELEBREX] - 50 mg - 1 Capsule(s) by mouth daily PRN
DABIGATRAN ETEXILATE [PRADAXA] - 150 mg Capsule - 1 PO BID
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day PRN
HYDROCODONE-ACETAMINOPHEN - 7.5mg-750 mg Tablet - 1- Tablet(s)
by mouth twice daily PRN as needed for knee pain
LOSARTAN-HYDROCHLOROTHIAZIDE - 100 mg-12.5 mg Tablet - 1 PO Qd
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 PO Qd
SERTRALINE - 50 mg Tablet - 1Tablet(s) by mouth once a day
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
4. Celebrex 50 mg Capsule Sig: One (1) Capsule PO once a day as
needed for pain.
5. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
6. hydrocodone-acetaminophen 7.5-750 mg Tablet Sig: One (1)
Tablet PO twice a day as needed for pain.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day as
needed for leg swelling.
9. Pradaxa 150 mg Capsule Sig: One (1) Capsule PO twice a day.
10. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
11. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Aortic Root- left atrial fistula
High blood pressure
Gastroesophageal reflux disease
Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **] it has been a pleasure participating in your care.
You were admitted because there is a hole connecting your aorta
with one of the [**Doctor Last Name 1754**] of your heart. This connection does
not seem to be enlarging so we do not think you need surgery to
fix it at this time. You will need to follow-up with Dr.
[**Last Name (STitle) **] who will continue to follow this issue. During your
hospitalization we held your blood thinner, pradaxa. You can
restart it now at your home dose.
.
We made the following changes to your medications
1. Increase your HCTZ to 25 mg daily
2. Added amlodipine 10 mg daily for blood pressure control
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Appointment: THURSDAY [**8-23**] AT 2:10PM
.
Department: CARDIAC SERVICES
When: MONDAY [**2181-9-10**] at 10:20 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3018
} | Medical Text: Admission Date: [**2130-9-1**] Discharge Date: [**2130-9-6**]
Date of Birth: [**2094-8-24**] Sex: F
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 14689**]
Chief Complaint:
petechiae, dyspnea
Major Surgical or Invasive Procedure:
Central Venous Line Placement , plasmapheresis
History of Present Illness:
36 year old female with hx anemia (baseline HCT 32 in [**2127**]),
hypothyroidism, and alopecia who presented to clinic today with
recent oral mucosal bleeding, mild dyspnea on exertion, and new
petecchial rash. For the last 1-2 weeks, patient has been
experiencing nausea, and some pressure in her fingertips, for
which she was recently seen in the [**Hospital1 18**] ED and discharged.
Patient soon after noticed a petechial rash over her lower
extremities and on her chest. 3-4 days prior to admission, the
patient was noted to have increasing yellowing of face and eyes
that has since resolved. She also noted some bleeding from her
gums over the last 1-2 days. She has had continued nausea and
vomiting, with some diffuse abdominal pain. Patient also notes
some shortness of breath on exertion over the last few days.
Lab work following clinic revealed new thrombocytopenia (12K)
and worsening anemia (24.8). Heme-onc fellow on-call who
suggested patient be sent to ED for expedited work-up (and to
r/o early TTP). Of note, the patient had diffuse rash with
alopecia and malar distribution one year ago. [**Doctor First Name **] checked by
physician at that time elevated.
.
On admission to ED, VS: 97.8 106 114/83 16 100%. Patient
complained of dyspnea on exertion. She was put on oxygen b/c
subjective SOB. She was seen by heme/onc and renal who
recommended urgent pheresis.
.
On the floor, patient denies abdominal pain, nausea, dyspnea.
She is very fatigued. She continues to have petechiae.
.
ROS: No fevers, chills, change in weight. Patient endorses a
headache. No confusion. No cough. No diarrhea/constipation.
No rectal bleeding. No focal weakness or numbness. She
endorses shortness of breath, esepcially on exertion. No focal
numb/tingling.
Past Medical History:
-Hypothyroidism
-Acne
-Alopecia areata
Social History:
Dentist. No substance abuse. Lived in [**Location **] different places.
And workups in many different places.
Family History:
On her mother's side, there is hypothyroidism and alopecia. On
her father's side, there is ovarian and prostate cancer. There
is no alopecia in her father's side. There is no family history
of early colon cancer or early
coronary artery disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
36.4 112/69 78 18 92% RA
Gen: Alert, oriented, laying comfortably in bed in NAD
HEENT: sclera non-icteric, MMM, few palatal petichiae,
petichial lesion on left lower lip and right corner of lips; no
lymphadenopathy
Card: Nl S1, S2, no murmurs, rubs or gallops
Lungs: Clear to auscultation bilaterally
Abdomen: soft, mildly tender to palpation, non-distended
Skin: Scattered non-blanching pinpoint macular lesions on chest
and anterior aspect of shins. Shin lesions intermixed with
raised, non-blanching lesions.
Neuro: CN II- XII intact; Strength 5/5 bilaterally, sensation
intact.
DISCHARGE PHYSICAL EXAM:
97.2 119/80 73 18 100% RA
Gen: Alert, oriented, laying comfortably in bed in NAD
HEENT: NC/AT, sclera non-icteric, MMM, oropharynx clear
NECK: Soft, supple, no lymphadenopathy
Card: Nl S1, S2, no murmurs, rubs or gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, ND/NT, NABS, no organomegaly
Skin: Currently clear, no evidence of hives or petechiae
Neuro: CN II- XII intact; Strength 5/5 bilaterally, sensation
intact.
Pertinent Results:
ADMISSION LABS:
.
Blood Counts
[**2130-8-31**] 04:29PM BLOOD WBC-5.4 RBC-3.32* Hgb-8.3* Hct-24.8*
MCV-75* MCH-25.0* MCHC-33.5 RDW-17.8* Plt Ct-12*#
[**2130-9-1**] 05:05PM BLOOD WBC-5.9 RBC-3.19* Hgb-8.2* Hct-23.2*
MCV-73* MCH-25.7* MCHC-35.3* RDW-17.8* Plt Ct-22*
[**2130-9-2**] 05:57PM BLOOD WBC-6.7 RBC-3.05* Hgb-7.9* Hct-22.5*
MCV-74* MCH-26.0* MCHC-35.1* RDW-18.2* Plt Ct-50*#
Chemistry
[**2130-8-31**] 04:29PM BLOOD UreaN-22* Creat-0.7 Na-140 K-3.8 Cl-106
HCO3-24 AnGap-14
[**2130-9-2**] 05:57PM BLOOD Glucose-161* UreaN-14 Creat-0.8 Na-140
K-3.9 Cl-106 HCO3-23 AnGap-15
Hemolysis / Anemia
[**2130-8-31**] 04:29PM BLOOD LD(LDH)-1204* TotBili-2.6*
[**2130-9-1**] 05:25AM BLOOD LD(LDH)-492* TotBili-1.4
[**2130-9-1**] 05:05PM BLOOD LD(LDH)-455* TotBili-1.9*
[**2130-8-31**] 04:29PM BLOOD calTIBC-346 Hapto-<5* Ferritn-742*
TRF-266
[**2130-9-1**] 02:50AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40 dsDNA-NEGATIVE
[**2130-9-1**] 02:50AM BLOOD C3-169 C4-29
[**2130-9-1**] 02:50AM BLOOD ESR-60*
.
PERTINENT LABS:
.
[**2130-8-31**] 04:29PM BLOOD WBC-5.4 RBC-3.32* Hgb-8.3* Hct-24.8*
MCV-75* MCH-25.0* MCHC-33.5 RDW-17.8* Plt Ct-12*#
[**2130-9-6**] 06:30AM BLOOD WBC-10.7 RBC-2.99* Hgb-8.0* Hct-23.4*
MCV-78* MCH-26.7* MCHC-34.1 RDW-18.5* Plt Ct-289
[**2130-9-1**] 09:58AM BLOOD Fibrino-302
[**2130-9-1**] 02:50AM BLOOD ESR-60*
[**2130-9-4**] 06:35AM BLOOD Ret Aut-3.5*
[**2130-8-31**] 04:29PM BLOOD ALT-24 AST-51* LD(LDH)-1204* AlkPhos-42
TotBili-2.6*
[**2130-9-3**] 06:37AM BLOOD calTIBC-315 VitB12-326 Hapto-63
Ferritn-299* TRF-242
[**2130-8-31**] 04:29PM BLOOD TSH-3.1
[**2130-9-1**] 02:50AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40 dsDNA-NEGATIVE
[**2130-9-1**] 02:50AM BLOOD C3-169 C4-29
[**2130-9-1**] 05:05PM BLOOD HIV Ab-NEGATIVE
[**2130-9-1**] 09:44AM BLOOD Lactate-1.4
.
DISCHARGE LABS:
.
[**2130-9-6**] 06:30AM BLOOD WBC-10.7 RBC-2.99* Hgb-8.0* Hct-23.4*
MCV-78* MCH-26.7* MCHC-34.1 RDW-18.5* Plt Ct-289
[**2130-9-6**] 06:30AM BLOOD Glucose-83 UreaN-15 Creat-0.6 Na-137
K-3.8 Cl-103 HCO3-27 AnGap-11
[**2130-9-6**] 06:30AM BLOOD LD(LDH)-204 TotBili-0.3
[**2130-9-6**] 06:30AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.7
.
MICRO:
.
MRSA SCREEN (Final [**2130-9-3**]): No MRSA isolated.
BCx ([**2130-9-3**]): NGTD x 4 days
UCx ([**2130-9-5**]): NGTD x 2 days
.
IMAGING: None
Brief Hospital Course:
HOSPITAL COURSE
36yo F PMHx anemia (baseline HCT 32 in [**2127**]), hypothyroidism,
and alopecia who presented to clinic with recent oral mucosal
bleeding, mild dyspnea on exertion, and new petecchial rash.
.
ACTIVE DIAGNOSES:
.
#Thrombotic Thrombocytopenia Purpura: Patient presented with
patechiae, found to have microcytic anemia, thrombocytopenia,
markedly elevated LDH, low haptoglobin. Smear consistent with
microangiopathic hemolytic anemia. No evidence of HUS given
lack of fever, renal failure, AMS but she did have significant
headaches. She was admitted to the ICU and diagnosed as having
TTP of unclear etiology and transfered to [**Name (NI) 2035**] following
stabilization. [**Doctor First Name **] equivocal, ADAMTS13 studies sent and
pending. Patient was evaluated by hematology service and
recommended for PO steroids and plasmapheresis. Pheresis was
complicated by mild urticaria, controlled with prn benadryl but
otherwise well tolerated and her calcium was repleted prn. She
had a terrific response to the treatment with her platelet count
on admission of 12 rising to 289 on the day of discharge. She
did not suffer from any catostrophic vascular complications such
as strokes, infarcts, or renal compromise. She was ultimately
discharged home with follow-up set up with the pheresis team
(her pheresis line was left in place) with transfer of care
ultimately to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to ultimately occur.
.
# Steroid-Induced Hyperglycemia: Pt developed moderately
elevated finger sticks likely [**2-22**] initiation of steroids (no
history of DM). She was managed with HISS. Tapering of her oral
steroids was deferred to the outpatient setting with the
pheresis team.
.
# Latex Allergy: Note, patient has latex allergy which has made
ordering medications (heparin, calcium, dextrose, insulin)
complex and has required discussion with pharmacy
.
Chronic Diagnoses:
.
#Hypothyroidism: Stable. She was continued on her home
levothyroxine.
.
#Alopecia: Stable and no apparent areas of alopecia on exam. Her
combination minoxidil, steroid, and retinoid topical solution
was held given concern of minoxidil as possible exacerbating
factor in her TTP. She was instructed to follow-up with her
dermatologist as an outpatient for continued management.
.
Transitional Issues:
She was set up with frequent outpatient follow-up with the
pheresis team for line maintainence, lab draws, and clinic
visits. She was also set up with an appointment with Dr. [**Last Name (STitle) **]
with the intent that he would be assuming her long-term
care/maintenance for TTP.
Medications on Admission:
minoxidil 5 % Topical Soln
Synthroid 100 mcg Tab
Retin-A 0.01 % Topical Gel
Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*1 bottle* Refills:*0*
3. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for urticaria.
Disp:*1 bottle* Refills:*0*
4. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*1 bottle* Refills:*0*
6. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Thrombotic thrombocytopenia purpura
Secondary:
-Hypothyroidism
-Alopecia areata
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you. You were admitted to [**Hospital1 1535**] for evaluation and treatment of
TTP (thrombotic thrombocytopenia purpura). You were treated with
high-dose steroids as well as plasmapheresis. Your condition
improved dramatically and your platelet counts returned to
[**Location 213**].
The following changes have been made to your medications:
-START Prednisone 60mg by mouth once daily (Dr. [**First Name (STitle) 805**] and Dr.
[**Last Name (STitle) **] will be in charge of slowly tapering down the dose of this
medication)
-START Tylenol 500mg 1-2 tablets by mouth every 6 hours as
needed for pain (do not take more than 4 grams daily)
-START Benadryl 25mg by mouth every 6 hours as needed for itch
-START Sarna Lotion apply to affected areas 4 times daily as
needed for itch
-START Vitamin B12 250mcg by mouth once daily (this can be a
lower dose if that's what's available at the pharmacy)
-STOP your topical minoxidil, steroid, retinoid solution (We
recommend speaking with your dermatologist and Dr. [**Last Name (STitle) **] before
resuming use)
We wish you a speedy recovery and hope you feel better. Please
follow-up with the appointments listed below.
Followup Instructions:
You will follow-up in the pheresis unit on Friday for flushing
of your pheresis line and lab draw. You will then follow-up with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] in clinic on Monday who follow you short-term.
You will then see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in his clinic on the day and
time below for long-term follow-up of your condition.
.
Department: INFUSION/PHERESIS UNIT
When: FRIDAY [**2130-9-8**] at 8:15 AM [**Telephone/Fax (1) 14067**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: [**Hospital3 249**]
When: MONDAY [**2130-9-18**] at 11:00 AM
With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] in the [**Company 191**] POST [**Hospital 894**] CLINIC
Phone: [**Telephone/Fax (1) 250**]
Notes: This appointment is with a hospital-based doctor as part
of your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2130-10-5**] at 2:00 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
[**Name6 (MD) **] [**Name8 (MD) 10341**] MD [**MD Number(2) 14690**]
Completed by:[**2130-9-28**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3019
} | Medical Text: Admission Date: [**2193-11-2**] Discharge Date: [**2193-11-5**]
Date of Birth: [**2122-3-13**] Sex: F
Service: MEDICINE
Allergies:
Dairy
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
colonoscopy
IVC filter placement
History of Present Illness:
71 year old woman with history of multiple diverticular bleeds,
type 2 diabetes mellitus, hypertension, hyperlipidemia, GERD and
recent DVT s/p right TKA who presents with bloody stools. The
patient had been started on Coumadin with Lovenox bridge
[**2193-10-23**] after developing a RLE DVT. The patient had stopped
Lovenox injections this past Monday when her INR 2.1 but when it
dropped to 1.8 on Thursday, she was restarted on Lovenox. The
patient woke up at 1pm today and felt the urge to have a bowel
movement. When she wiped, there were streaks of blood mixed with
stool on the toilet paper. She proceeded to have two more bowel
movements with blood mixed in her stools. The patient denies any
crampy abdominal pain, light headedness, chest pain, shortness
of breath with these episodes. She has not had any more bloody
stools since arrival to the [**Hospital1 18**]. She does have a history of
hemorrhoids as well.
.
In the ED, initial vs were: T 98.6 P 110 BP 149/61 R 18 O2 sat
100% on RA. Patient was given IVF. Her labs were drawn which
showed stable normocytic anemia from prior (Hct 27.8) and
therapeutic INR at 2.1. Her creatinine was slightly elevated at
1.2 (baseline 0.9). She received 2 liters of IVF with
improvement in her heart rate, two large bore PIVs were placed
and GI made aware.
.
On the floor, the patient was resting comfortably in bed.
Past Medical History:
* Right TKA [**2193-9-2**] with subsequent DVT (12/07-8/[**2192**])
* Diverticulosis
* Type 2 diabetes mellitus
* Benign essential hypertension
* Hyperlipidemia
* Degenerative joint disease (hip/knee)
* GERD
* History of LGIB X4 ([**7-/2183**], [**5-/2185**], [**4-/2186**], [**2186**], [**10/2192**]):
previously considered diverticular although [**10/2192**] bleed of
unclear source, ?splenic flexure bleed (on tagged RBC scan). No
interventions performed.
Social History:
Lives with husband, independent ADLs with [**Name (NI) 269**] currently to help
with Lovenox injections/Coumadin INR checks. Has three children.
Denies tobacco, alcohol or illicit drugs.
Family History:
Diverticulosis in all three children, son (50s) and daughter
(40s) have had colectomies for LGIBs. Father may have had an MI.
No family history of colitis, Crohn's, ulcerative colitis. No
bleeding disorders or family history of malignancies.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, [**Last Name (un) **]/oropharynx clear
Neck: Soft, supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
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
Rectal: Guaiac positive and streaks of frank blood/small clots
in rectal vault, small hemorrhoids
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
RLE edema, greater than left. No TTP, surgical incision site
c/d/i, healing well.
Pertinent Results:
[**2193-11-2**] 12:17PM HCT-21.4*
[**2193-11-2**] 11:00AM GLUCOSE-173* UREA N-31* CREAT-1.1 SODIUM-143
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-22 ANION GAP-16
[**2193-11-2**] 11:00AM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-1.2*
[**2193-11-2**] 11:00AM WBC-UNABLE TO RBC-UNABLE TO HGB-UNABLE TO
HCT-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO
[**2193-11-2**] 11:00AM PLT COUNT-UNABLE TO
[**2193-11-2**] 11:00AM PT-24.2* PTT-29.1 INR(PT)-2.3*
[**2193-11-2**] 03:00AM GLUCOSE-212* UREA N-30* CREAT-1.2* SODIUM-141
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
[**2193-11-2**] 03:00AM estGFR-Using this
[**2193-11-2**] 03:00AM WBC-9.2 RBC-3.06* HGB-9.1* HCT-27.8* MCV-91
MCH-29.5 MCHC-32.6 RDW-13.5
[**2193-11-2**] 03:00AM NEUTS-68.9 LYMPHS-20.4 MONOS-4.5 EOS-5.1*
BASOS-1.1
[**2193-11-2**] 03:00AM PLT COUNT-424#
[**2193-11-2**] 03:00AM PT-22.1* PTT-33.9 INR(PT)-2.1*
Brief Hospital Course:
71 year old woman with history of multiple diverticular bleeds,
type 2 diabetes mellitus, hypertension, hyperlipidemia, GERD and
recent DVT s/p right TKA who presents with bloody stools.
.
# Bloody stools: She has a personal history of multiple GI
bleeds, thought to be diverticular in origin. Her most recent GI
bleed in [**10/2192**] did not have clear etiology, however. The
patient was being anticoagulated for her RLE DVT and
anticoagulation was held on admission. She also has small
hemorrhoids but they were not frankly bleeding from these on
rectal exam on admission. On [**2193-11-2**], she had 300 cc of
melena/frank blood and her Hct dropped from 27.8 to 21. CTA was
negative. She was transfered to the ICU and transfused 5 units
PRBC and 3 units FFP. An IVC filter was placed. She was
transfered back to the floor when stable and her hematocrits
were monitored. Her hematocrits were stable, ranging from 35 to
41. She underwent a colonoscopy which did not reveal any active
bleeding. Colonoscopy did show diverticula which were not
bleeding. Her hematocrit was checked post-colonoscopy and was
stable. She will be discharged with f/u appointments with her
PCP and plan to f/u with GI in [**12-19**] weeks. She will have a
repeat Hct in 1 week, to be followed up upon by her PCP. [**Name10 (NameIs) **]
will hold anticoagulation at discharge. Given her history of GI
bleeding, she is likely not a good candidate for anticoagulation
in the future. In addition, her DVT was provoked (in the
setting of surgery). The IVC filter is temporary and can be
removed eventually. At this time, we would recommend holding
anticoagulation, keeping the IVC filter in place for now and
repeating a lower extremity US in 3 months. We will leave
management decisions regarding anticoagulation, the IVC filter,
and any repeat imaging to the PCP and outpatient GI team
however.
.
# Right TKA [**2193-9-2**] with subsequent DVT (12/07-8/[**2192**]): INR
was therapeutic on admission and RLE exam stable.
Anticoagulation held given GI bleed. Her INR was reversed with
FFP and an IVF filter was placed. Oxycodone for pain control
was continued. She will have f/u with orthopedic team as
previously scheduled.
.
# Hypertension/hyperlipidemia: Stable - her home medications
were held in the setting of GI bleeding. Her blood pressures
were stable with SBPs around 150s. Her home medications will be
restarted at discharge.
.
# Type 2 diabetes mellitus: Stable - held metformin and
glipizide in-house, will restart at discharge. Blood glucose
managed with SSI in house.
.
# GERD: Stable, no signs of upper GI bleed - Continued home
omeprazole
.
Medications on Admission:
* Atenolol 25mg daily
* Atorvastatin 20mg daily
* Fluocinonide cream 0.05% twice daily PRN
* Glyburide 5mg daily
* HCTZ 12.5mg daily
* Hydrocortisone acetate 25mg suppository twice daily PRN
hemorrhoids
* Lisinopril 10mg daily
* Metformin 1000mg twice daily
* Nifedipine 60mg ER daily
* Omeprazole 20mg daily
* Oxycodone 5-10mg daily q4-6 hours PRN pain
* Coumadin 2mg daily per INR
* Lovenox 70mg injections twice daily
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. fluocinonide 0.05 % Cream Sig: One (1) application Topical
twice a day.
4. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
6. hydrocortisone acetate 25 mg Suppository Sig: One (1) Rectal
twice a day as needed for hemrrhoids.
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
9. nifedipine 60 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
12. Outpatient Lab Work
Please check Hematocrit in 1 week.
Please send results to:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 250**]
Fax: [**Telephone/Fax (1) 3382**]
Email: [**University/College 97051**]
Please also send results to:
Name: Brain, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP
Location: [**Hospital3 249**]
Address: [**Location (un) **], [**Hospital Ward Name **] 6, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 97052**]
Fax: [**Telephone/Fax (1) 30662**]
Email: [**University/College 97053**]
Discharge Disposition:
Home With Service
Facility:
All Care [**University/College 269**] of Greater [**Location (un) **]
Discharge Diagnosis:
lower gastrointestinal bleeding, unclear etiology
* Right TKA [**2193-9-2**] with subsequent DVT (12/07-8/[**2192**])
* Diverticulosis
* Type 2 diabetes mellitus
* Benign essential hypertension
* Hyperlipidemia
* Degenerative joint disease (hip/knee)
* GERD
* History of LGIB X4 ([**7-/2183**], [**5-/2185**], [**4-/2186**], [**2186**], [**10/2192**]):
previously considered diverticular although [**10/2192**] bleed of
unclear source, ?splenic flexure bleed (on tagged RBC scan). No
interventions performed.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
bleeding from your rectum. You were transfused blood and
monitored in the intensive care unit. You had a filter placed
in the major vein in your body to prevent clots in your legs
from traveling to your lungs. Your blood levels were monitored
and were stable. You underwent a colonoscopy which did not show
active bleeding.
The following changes were made to your medications:
STOP Warfarin
STOP Lovenox
Please continue you other home medications
Followup Instructions:
The following appointments have been made for you:
Department: GASTROENTEROLOGY
When: MONDAY [**2193-11-25**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2193-11-19**] at 11:40 AM
With: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2193-11-26**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], PA [**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: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2193-12-11**] at 9:30 AM
With: EYE IMAGING [**Telephone/Fax (1) 253**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3020
} | Medical Text: Admission Date: [**2118-12-5**] Discharge Date: [**2118-12-11**]
Service: Neuromedicine
HISTORY OF PRESENT ILLNESS: In summary, the patient is an
82-year-old right handed woman, who presents as a transfer
from [**Hospital3 **] with CT findings of a left frontal
hemorrhage. She was initially brought to that hospital for a
one day history of generalized weakness and change in mental
status. Her family reported at that time she did not want to
get out of bed.
On the prior evening before she presented to [**Hospital1 **], she was
outside shoveling snow, when she had a headache and fatigue.
She went to bed and the next morning she awoke and appeared
much more confused. She was able to walk down the stairs and
then, however, as the day progressed, she was becoming more
and more aphasic, not answering questions as much and saying,
"no, no, no. I don't know." She is brought to the ED.
There is no history of any trauma or no known visual
complaints. No recent illnesses.
PAST MEDICAL HISTORY:
1. Peripheral edema, which she is on hydrochlorothiazide for.
2. Eye surgery on the left and a cataract on the left.
MEDICATIONS ON PRESENTATION:
1. Hydrochlorothiazide.
2. Potassium supplements.
ALLERGIES:
1. Morphine.
2. Codeine.
3. Naprosyn.
4. Sulfa.
SOCIAL HISTORY: She was a former smoker. She is otherwise
generally well. She lives with her daughter and drives
herself.
PHYSICAL EXAMINATION: She had a blood pressure of 134/63,
pulse of 74, respirations of 18. She is well-nourished in no
acute distress. Lungs are clear to auscultation. Her heart
is regular, rate, and rhythm with no murmurs. Abdomen was
soft and benign. Extremities were warm and well perfused.
Mental status: She was awake and alert. She was cooperative
with examination, but had very impersistent. She was
oriented to person, but not to place, month, day, or
president. She could not say the months of the year
backwards or forwards. She had minimal spontaneous output
and nonfluent language. Her longest was three words, where
she said, " I don't know." She had no dysarthria. She did
make occasional paraphasic errors. She
had difficulty repeating with paraphasic errors, but could
say, "You know how." Naming with multiple errors on high or
low frequency testing. She was able to get [**4-3**] objects on
the stroke scale. She had no focal hemiparesis. Power was
[**5-2**] bilaterally. Sensation was intact grossly to all
modalities. Her reflexes were symmetric. Her toes were
upgoing on the right on Babinski testing.
Her laboratories were sent and her CBC and Chem-8 were
normal. She had a head CT which showed a 4 x 6 x 3 x 5 left
frontal hemorrhage. Repeat head CT scans at one day and MRI
at two days post presentation to the Emergency Room revealed
no increase or change in the size of the bleed. Her MRI also
showed no aneurysm or A-V malformation.
In summary, this is an 82-year-old woman who presents with a
large left frontal hemorrhagic stroke with deficits
suggestive of a transcortical motor aphasia. She was found
to have a UTI during her hospitalization and she was treated
with levofloxacin. Her laboratories on discharge included a
Chem-8 which had a sodium of 133, potassium 3.4, chloride 95,
bicarbonate 29, BUN 18, creatinine 0.6, and a glucose of 88,
magnesium was 1.8, phosphate 3.9, and calcium of 9.2.
This is an 82-year-old lady with left frontal hemorrhagic
stroke (most likely secondary to amyloid angiopathy), who was
discharged in good condition to [**Hospital3 **] on [**2118-12-11**].
DISCHARGE MEDICATIONS:
1. Hydrochlorothiazide 25 mg p.o. q.d.
2. Pantoprazole 40 mg q.d.
FOLLOW-UP INSTRUCTIONS: She is instructed to followup with
the Stroke Service at [**Hospital1 69**] in
[**2-1**] weeks following her discharge from [**Hospital3 **].
Scheduling for the stroke appointment at number [**Telephone/Fax (1) 1694**]
with Dr. [**Last Name (STitle) **].
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**]
Dictated By:[**Name8 (MD) 39948**]
MEDQUIST36
D: [**2118-12-11**] 11:28
T: [**2118-12-11**] 11:27
JOB#: [**Job Number 53755**]
ICD9 Codes: 431, 5990, 2761, 2768, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3021
} | Medical Text: Admission Date: [**2157-8-30**] Discharge Date: [**2157-9-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Fever and hypotension
Major Surgical or Invasive Procedure:
Nephrostomy placement by Interventional Radiology
History of Present Illness:
89 year old Russian speaking female with pmhx of CAD,
anxiety/depression, dementia living a [**Hospital 100**] Rehab Nursing home
was being treated with levaquin [**8-29**] for a positive UA. She
then spiked a fever to 102 last 3 days, was being given tylenol
ATC. Blood cultures returned positive for GNR [**8-29**].
.
In ED her vital signs initially were 104.4 rectal, HR 126,
140/70 94%3L. She was given toradol, a cooling blanket and
ceftriaxone, with 1L NS. She was then started on 0.45% NS given
continued concern for hypovolemia.
.
On arrival to the ICU, patient was awake, follows visually, but
was not following commands.
Past Medical History:
CAD
HTN
Dementia
T2DM
PVD
Benign tremors
Severe OA s/p steroid injection
Depression/Anxiety
s/p frequent falls with multiple fractures
Social History:
Lives at [**Hospital 100**] Rehab. Nonsmoker, no alcohol. Son is involved.
Family History:
Noncontributory.
Physical Exam:
VS Temp 101.1 HR 98, 108/50 25 98%2L
GEN: Mild distress, thin appearing, mild shaking
HEENT PERRL, OP dry, but clear, No LAD, JVD is flat, nonicteric
sclera, supple
CV: tachy, reg rhythm, no mrg
CHEST: Ant: CTA no w/r/r
ABD: +BS soft, scaphoid, NT/ND
Ext: cool, no c/c/e, 1+ DP pulses
Neuro: Awake
Pertinent Results:
[**2157-8-30**] 02:30AM
URINE BLOOD-LGE NITRITE-NEG PROTEIN-100 GLUCOSE-250 KETONE-15
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD
RBC-[**1-17**]* WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-0-2
COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.026
.
[**2157-8-30**] 02:30AM
WBC-19.2* RBC-4.73 HGB-13.1 HCT-38.4 MCV-81* MCH-27.7 MCHC-34.1
RDW-13.8
[**2157-8-30**] 02:30AM NEUTS-82* BANDS-12* LYMPHS-3* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
.
[**2157-8-30**] 02:39AM LACTATE-3.5*
.
[**2157-8-30**] 02:18PM PO2-136* PCO2-39 PH-7.45 TOTAL CO2-28 BASE
XS-3
.
Renal U/S [**2157-8-30**]
Moderate right-sided hydronephrosis with obstructing stones
including a 1 cm calculus at the renal hilum. No left-sided
hydronephrosis.
.
PERC NEPHROSTOMY [**2157-8-31**]
1. Antegrade percutaneous nephrostomy demonstrates moderate
hydronephrosis in the right kidney with a round filling defect
at the level of the UPJ. This might correspond to an impacted
stone at least 1.5 cm in size.
2. Successful placement of an 8 French percutaneous nephrostomy
with pigtail coiled in the renal pelvis and attached to a bag
for external drainage.
Brief Hospital Course:
89 W pmhx CAD, dementia presents with urosepsis from [**Hospital 100**]
Rehab. Found to have GNR in urine (no speciation at HR) and GPC
in blood cultures at [**Hospital1 18**]. GPC growing in clusters and pairs -
awaiting final speciation upon discharge.
.
# Sepsis- With history and laboratory evidence of urinary tract
infection, given fever, tachypnea, tachycardia, and
leukocytosis, and elevated lactate qualifies for severe sepsis
diagnosis. With renal u/s [**2157-8-30**] finding hydronephrosis and
obstructing stone on right and a normal left kidney. Now with
GPC in clusters and pairs on blood culture. On ceftriaxone and
daptomycin (per ID recs, originally given linezolid x 1).
Percutaneous nephrostomy tube place [**2157-8-31**] with return of
purulent fluid, now freely draining. Have consulted Urology who
would not proceed with stone removal while having acute
pyelonephritis - thus it must be an outpatient procedure. On
the day of discharge she had been hemodynamically stable and
afebrile for >48 hours. She will continue an additional 14 days
of antibiotics for complicated pyelonephritis and then return
for Urology follow-up on [**9-19**] with Dr. [**Last Name (STitle) **]. He can then
assess the time for further intervention and ultimate
discontinuation of the nephrostomy tube.
.
# Hypernatremia- Patient originally adimitted with
hypernatremia, Na = 155. Hypovolemic on exam, and with
documented fevers, likely associated with increased catabolic
state. Given [**12-18**] of free water deficit (2L) on first day of
admission. During her intpatient stay her daily free water and
total volume deficits were assessed and she waw repleted
appropriately. The day of discharge her Na was high normal at
144. She should continue to have oral intake encouraged at her
facility.
.
# Hypercalcemia - Given albumin calcium corrects >11 with renal
calculi concerning for chronic process. Likely related to
dehydration but could also be occult malignancy. PTH was
checked and was appropriate. Vitamin D-25 was pending on
discharge and should be followed-up by her primary physician.
.
# DM- Metformin and glipizide were held during admission as
imaging may have been necessary at any point. She was continued
on an insulin sliding scale and was well controlled since admit.
Review of [**Hospital 100**] Rehab UA showed ketones, consistent with
initial presentation of positive anion gap metabolic acidosis,
likely mild DKA. Treated with agressive fluid resuscitation and
glucose control. By the second day of admission her gap had
closed and she continued to have good glycemic control
throughout stay. Will discharge on prior medications of
glipizide and metformin.
.
# Hyperlipidemia- Not an active issue during this admission.
She was continued on her outpatient statin.
.
# CAD- Upon admit denied CP, SOB or other signs concerning for
ACS. She was continued on her 81mg daily aspirin while
inpatient.
.
# Depression- Difficult to assess severity given acute illness,
but she is was clearly withdrawan throughout inpatient stay.
Continued on Sertraline and discharged on outpatient dose.
.
# Contact info :
[**Hospital 100**] rehab 1-West (her [**Hospital1 **]) [**Telephone/Fax (1) 32419**]
Microbiology to follow-up urine culture [**Telephone/Fax (1) 32420**]
[**Name (NI) 7859**] (son) [**Telephone/Fax (1) 32421**] work, [**Telephone/Fax (1) 32422**] cell, [**Telephone/Fax (1) 32423**]
home
.
# Code DNR/DNI
Medications on Admission:
Levofloxacin started [**8-29**] 750mg every other day
Tylenol PRN
Aspirin 81mg
Isosorbide Mononitrate 30mg Daily
Metformin
Glipizide 10mg Twice a day
Sertraline 100mg Daily
Zocor 20 mg Daily
Sorbitol 15 Daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every four
(4) hours as needed for fever or pain.
2. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. Glucophage 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Sorbitol 70 % Solution Sig: Fifteen (15) mL Miscellaneous
once a day.
11. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) g Intravenous Q24H (every 24 hours) for 14 days.
12. Daptomycin 500 mg Recon Soln Sig: Three Hundred (300) mg
Intravenous Q24H (every 24 hours) for 14 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Pyelonephritis, GPC sepsis
Secondary: CAD, T2DM, PVD, Benign tremor, severe OA, depression
& anxiety
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You have been seen for infection in your kidneys that extended
into your blood. You have been treated for you infection with
antiobiotics and IV fluids. Additionally you had a tube placed
into your kidney to help drain the infection until the
obstructing stone can be remove.
.
Take all your medications as previously prescribed.
Additionally you should continue taking Ceftriaxone and
Daptomycin as prescribed.
.
Please keep all follow-up appointments, specifically with Dr.
[**Last Name (STitle) **], Urology, on [**2157-9-19**] at 4pm. His office number is
[**Telephone/Fax (1) 921**].
.
Please contact your primary care physician or return to the
Emergency Department if you should develop fever, chills,
worsening pain at the kidney tube site, redness or warmth in the
skin around the kidney tube or if the kidney tube stops draining
- as these could be signs of worsening infection. Or, for any
other concerns you may have.
Followup Instructions:
UROLOGY FOLLOW-UP:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD
Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2157-9-19**] 4:00
ICD9 Codes: 0389, 5849, 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3022
} | Medical Text: Admission Date: [**2195-1-9**] Discharge Date: [**2195-1-13**]
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 14129**] was admitted on
[**2195-1-9**] to the Medical Intensive Care Unit.
He is an 81-year-old white male with chronic obstructive
pulmonary disease who was admitted to the Medical Intensive
Care Unit with a pneumothorax, status post a bronchoscopy
with multiple biopsies on [**1-9**].
The patient had been in his usual state of health until one
month prior to admission. He had been admitted to [**Hospital **]
Hospital with a chronic obstructive pulmonary disease
exacerbation. A chest computed tomography at that time
revealed new significant right upper lobe mass which was
worrisome for bronchoalveolar carcinoma. The patient had
multiple small nodules in the past which have been biopsied
showing macronodular pulmonary amyloid. Computed tomography
also showed a left-sided pneumothorax that was not treated at
that time.
At bronchoscopy on [**1-9**], multiple biopsies were taken.
He had acute shortness of breath five minutes prior to the
end of the procedure and required nebulizers. He received
albuterol times three and Atrovent times one with
improvement, and a subsequent x-ray revealed a large
right-sided pneumothorax. The pneumothorax was noted and
attempted conservative management with nebulizers and
high-flow oxygen. At that point, he failed conservative
treatment, and a right-sided chest tube was placed for
respiratory distress. The lung was reinflated, and he was
again made comfortable. His shortness of breath was
resolved.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Macronodular pulmonary amyloidosis diagnosed in [**2194-1-4**].
3. New pulmonary nodule in the right upper lobe.
4. Peripheral vascular disease; status post bilateral
vascular surgery.
5. Abdominal aortic aneurysm measured at 4.4 cm X 2.4 cm.
6. Hypercholesterolemia.
7. History of atrial fibrillation.
8. History of an anterior neck mass.
9. Lupus anticoagulation.
MEDICATIONS ON ADMISSION:
1. Albuterol 2 puffs four times per day.
2. Atrovent 2 puffs four times per day.
3. Lipitor 40 mg p.o. q.d.
4. Aspirin.
5. Digoxin 0.25 mcg p.o. q.d.
6. Quinidine 324 mg p.o. times two b.i.d.
7. Serevent two times per day.
8. Lasix 10 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: One son and two daughters. [**Name (NI) **] works at a
dry cleaning shop. He quit tobacco in [**2148**] after 50 pack
years. Occasional alcohol. No intravenous drug abuse.
FAMILY HISTORY: No history of pulmonary disease.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 97.4, blood pressure was 128/60,
heart rate was 72, respiratory rate was 20, oxygen saturation
was 90% on face mask and 95% on room air. In no acute
distress. Spoke in complete sentences. Lungs revealed
bilateral breath sounds were equal. Poor inspiratory effort.
Moved air in all fields. Cardiovascular examination revealed
a regular rate and rhythm. No murmurs, rubs, or gallops.
The abdomen was soft, nontender, and nondistended. Active
bowel sounds. Extremities revealed no clubbing, cyanosis, or
edema.
RADIOLOGY/IMAGING: A chest x-ray on [**1-13**] at 7 a.m.
showed no pneumothorax.
HOSPITAL COURSE:
1. PULMONARY SYSTEM: Status post bronchoscopy complicated
by a pneumothorax. The pneumothorax was initially attempted
conservatively, but conservative treatment failed and a
right-sided chest tube was subsequently required to relieve
respiratory distress. The chest tube resolved the
pneumothorax, and the patient's respiratory distress was much
improved. He was continued on his outpatient chronic
obstructive pulmonary disease medications including
albuterol, Atrovent, and Serevent.
On [**1-12**], the chest tube was switched from suction to
water seal. Again, no pneumothorax developed. At 4 p.m. on
[**1-12**], the patient stood up and the chest tube was
accidentally discontinued. An occlusive Vaseline gauze
dressing was applied with minimal air leak.
A subsequent chest x-ray revealed no reaccumulation of the
pneumothorax but some subcutaneous air. The patient was
maintained on oxygen over the course of the next night
without any respiratory distress or other symptoms. A chest
x-ray on the morning of discharge revealed no reaccumulation
of the pneumothorax. The patient had been stable for greater
than 24 hours status post the discontinuation of the chest
tube.
The preliminary pathology results on the bronchoscopy
specimens revealed a resolving pneumonia and amyloid. No
evidence of bronchoalveolar carcinoma.
2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE: The patient was
maintained on his Atrovent, albuterol, and Serevent without
any problems.
3. CARDIOVASCULAR SYSTEM: The patient was cardiovascularly
stable throughout his hospital stay with the exception of
some hypertension at the time of bronchoscopy. At the time
of discharge, the patient had been hemodynamically stable for
greater than 48 hours. He was restarted on his home
medications of digoxin and quinidine on [**2195-1-12**]. He
also was maintained on Lasix.
4. FLUIDS/ELECTROLYTES/NUTRITION: The patient was
maintained on a regular diet. Electrolytes and laboratories
were stable.
5. PROPHYLAXIS: The patient had been getting out of bed and
moving consistently. He was taking an oral diet. He was
only requiring Pneumo boots while in bed.
6. HYPERCHOLESTEROLEMIA: The patient was continued on
Lipitor.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: The patient was discharged to home.
MEDICATIONS ON DISCHARGE:
1. Percocet one tablet p.o. q.4-6h. for pain as needed.
2. Albuterol 2 puffs four times per day.
3. Atrovent 2 puffs four times per day.
5. Lipitor 40 mg p.o. q.d.
6. Aspirin.
7. Digoxin 0.25 mcg p.o. q.d.
7. Quinidine 324 mg p.o. times two b.i.d.
8. Serevent two times per day.
9. Lasix 10 mg p.o. q.d.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 217**] as
indicated by Dr. [**Last Name (STitle) 217**] to the patient.
2. Return to the Emergency Department if any shortness of
breath, fevers, chills, chest pain, or any other questions or
concerns.
DISCHARGE DIAGNOSES: Right-sided pneumothorax.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], M.D. [**MD Number(1) 36858**]
Dictated By:[**Last Name (NamePattern1) 9126**]
MEDQUIST36
D: [**2195-1-13**] 18:22
T: [**2195-1-17**] 00:16
JOB#: [**Job Number 109429**]
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3023
} | Medical Text: Admission Date: [**2151-5-10**] Discharge Date: [**2151-6-4**]
Service: SURGERY
Allergies:
Cipro / Nitrofurantoin / Acyclovir / Bactrim
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Surgical wound erythema and drainage
Major Surgical or Invasive Procedure:
Wound debridement bedside
OR wound debridement
PICC line placement
VAC placejment
History of Present Illness:
The patient is an 83-year-old female with a history of diabetes
who underwent a left fem below-the-knee [**Doctor Last Name **] bypass in [**Month (only) 956**]
[**2151**] for a nonhealing foot ulcer and presented to [**Hospital1 18**] on [**5-10**], [**2151**] with wound erythema and drainage. This had been treated
with a vac dressing and was found to need further operative
debridement.
Past Medical History:
DM x 20 + years, on oral hypoglycemics
HTN
s/p b/l hip replacement with chronic hip pain
constipation
chronic UTI's on prophylactic Keflex
hypercholesterolemia
s/p CVA- (right-sided)
osteoporosis
lumbo-sacral arthritis
disc disease with spinal stenosis at L3-4 level
DJD b/l hips
Social History:
Lives at home, has home aide 4 hours per day/ VNA. Ambulates
with walker, uses motorized chair for longer distances. No
tobacco, ETOH, or alcohol. Daughter involved with care.
Family History:
NC
Physical Exam:
elderly female
a/ox3
nad
rrr
cta
abd - benign
palp L [**Doctor Last Name **], dopp L DP/PT
Open wound / clean and dry
Pertinent Results:
[**2151-5-27**] 05:04AM BLOOD
WBC-6.1 RBC-2.94* Hgb-8.6* Hct-26.8* MCV-91 MCH-29.2 MCHC-32.1
RDW-16.1* Plt Ct-231
[**2151-6-4**] 05:30AM BLOOD
PT-16.8* INR(PT)-1.5*
[**2151-5-27**] 05:04AM BLOOD
Glucose-108* UreaN-16 Creat-1.2* Na-141 K-3.6 Cl-101 HCO3-35*
AnGap-9
[**2151-5-12**] 04:58AM BLOOD
ALT-9 AST-13 LD(LDH)-176 AlkPhos-60 Amylase-40 TotBili-0.2
[**2151-5-27**] 05:04AM BLOOD
Albumin-3.0* Calcium-8.9 Phos-4.0 Mg-2.0 Iron-23*
[**2151-5-25**] 09:01AM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2
[**2151-5-10**] 8:55 pm SWAB L. LE.
GRAM STAIN (Final [**2151-5-11**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2151-5-13**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ <=1 S
[**2151-5-12**] 10:15 AM
CHEST PORT. LINE PLACEMENT
Reason: Left arm PICC
HISTORY: 83-year-old female with fever, lethargy and new left
PICC line. Evaluate thorax.
FINDINGS: Portable radiograph, comparison [**2151-5-10**],
demonstrates interval placement of a left PICC line which
terminates approximately 2.5 cm below the cavoatrial junction.
The right pleural effusion has decreased since prior study.
There has also been interval clearing at the right base. There
is increased opacity at left base, likely atelectatic. The heart
and mediastinum are normal in appearance.
IMPRESSION:
1. Interval placement, left PICC line terminating in the upper
right atrium.
2. Likely atelectasis at left base.
Brief Hospital Course:
pt admitted
cx's taken
coumadin stopped / heparin started
broad spectrum AB started
OR for wound debridment - no complications or sequela
coumadin started / heparin bridge - for DVT
PICC line placed / xray confirms placement
VAC changed q 3 days.
AB tailored to sensitiviteis
Wound looks good for DC
Stable to rehab
Medications on Admission:
Fentanyl 75 mcg/hr Patch 72HR, Atorvastatin 40', Aspirin 325',
Gabapentin 300", Panntoprazole 40', Furosemide 40 mg',
Metoprolol 25", Docusate 100", Rosiglitazone 8', Mirtazapine 15
QHS, Glipizide 5', Lisinopril 20', Coumadin 1 or 2'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
goal INR [**2-13**].
5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
12. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
16. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. Bisacodyl 10 mg Suppository Sig: [**1-12**] Suppositorys Rectal HS
(at bedtime) as needed.
19. PICC LINE CARE
Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
20. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
Q48H (every 48 hours): PLEASE DRAW TROUGHS EVERY 3 RD DOSE /
DOSE VANCOMYCIN FOR TROUGH BETWEEN 15-29.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
non healing foot ulcer
dvt - COUMADIN GOAL [**2-13**]
wound dehiscance with wound infection
cellulitis
htn
uti
pvd
Discharge Condition:
stable
Discharge Instructions:
Open Wound: VAC DRESSING Patient's Discharge Instructions
Introduction:
This will provide helpful information in caring for your wound.
If you have any questions or concerns please talk with your
doctor or nurse. You have an open wound, as opposed to a closed
(sutured or stapled) wound. The skin over the wound is left open
so the deep tissues may heal before the skin is allowed to heal.
Premature closure or healing of the skin can result in
infection. Your wound was left open to allow new tissue growth
within the wound itself. The wound is covered with a VAC
dressing. This will be changed around every three days.
The VAC:
_ helps keep the wound tissue clean
_ absorbs drainage
_ prevents premature healing of skin
- promotes healing
When to Call the Doctor:
Watch for the following signs and symptoms and notify your
doctor if these occur:
Temperature over 101.5 F or chills
Foul-smelling drainage or fluid from the wound
Increased redness or swelling of the wound or skin around it
Site: THIGH LE
Type: Surgical
Dressing: VAC, Continuous, Black Foam, Target Presure 125 mm Hg
Change dressing: Other
Comment: Q 3RD DAY DRESSING CHANGE
PICC care.
Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Moniter vanco trough / goal is 15-20. please check trough every
third dose and adjust accordingly
INR moniter, goal is [**2-13**], Pt with hx of DVT. Pt PCP may DC at
his discresion.
Pt with foley. DC at rehab when pt is mobile enough to go to
bathroom
Increasing tenderness or pain in or around the wound
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2151-7-26**] 11:00
Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 2625**]. You have an
appointment scheduled on the [**7-1**] at 1430 hrs
Completed by:[**2151-6-4**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3024
} | Medical Text: Admission Date: [**2101-8-7**] Discharge Date: [**2101-9-16**]
Date of Birth: [**2051-7-25**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Low Back Pain
Major Surgical or Invasive Procedure:
L4/L5 vertebra and disc biopsy.
History of Present Illness:
This is a 50 y/o male with a history of IV drug abuse,
cirrhosis, ETOH abuse, DM and HTN who is transfered from [**Hospital6 **] after being diagnosed with L4-L5 osteomyelitis
and epidural inflamation.
.
Patient presents with a history of 12 weeks of lower back pain,
after lifting a steel door. Initially, he felt that it was not
bothering him much, but the pain became progressively worse, and
over the prior 4 days his pain was [**11-15**]. He states that it was
difficult for him to move his left leg. Walking of sitting up
was very difficult. He also refers pain and needles sensation
down his left leg. Denied bowel incontinence, althouh refers
constipation. No urinary incontinence. No fevers, chills, nausea
or vomiting. He has been tolerating po's well.
.
He refers history of IV drug use, and last time was [**2101-7-25**]
using clean needles. On that date, he did miss [**First Name (Titles) **] [**Last Name (Titles) 5703**] and
re-injected without cleaning the needle. He developed a large
cellulitis/furunculosis per the patient which he lanced and
subsequently it healed on its own. He was initially taking
percocet for the pain but given that it was not working, he was
started on methadone that seems to improve his pain control. He
was also drinking vodka over the last 3 days to help with the
pain.
.
He went to see his PCP Dr [**First Name (STitle) 10378**] who decided to sent a Lumbar
MRI. Lumbar MRI [**2101-8-6**] showed discovertebral osteomyelitis at
L4-L5 level with significant epidural inflammation. Also marked
spinal stenosis.
He was admitted to [**Hospital3 **] today. VS: T 99, BP 125/73 Hr 75
RR 16. Labs WBc 9.4, HCt 39.7 Plat 174. Na 130, k 4.6, Cl 94,
HCO3 19.7 glucose 98. bun 13, Creati 0.6 and Calcium 8.8.
.
Given the question of possible vertebraectomy and his other
comorbdities, patient was transfered for Neurosurgical
evaluation.
.
In the [**Hospital1 **] ED: T 99.5 HR 75 BP 124/80 RR 16 Sats 99% RA.
Evaluated by neurosurgery who would not intervene at this point
but recomended obtaining biopsy from IR to identify the type of
infection prior to starting antibiotics. They also recomended
blood cx, CRP and ESR. At 19:30, he spiked to 101 and patient
was given antibiotics in the Ed Unasyn, Vancomycin and Flagyl.
He was also given dilaudid and methadone for pain.
.
On review of systems, the pt. denied recent fever or chills. No
night sweats or recent weight loss or gain. Denied headache,
sinus tenderness, rhinorrhea or congestion. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
Hepatitis C
Cirrhosis - apparently dx about a year ago.
IV drug used (last used 1 month PTA)
Alcohol abuse - He used to drink about half gallon vodka a day.
Diabetes
Hypertension
Social History:
Patient lives at home with his long-term girlfriend. currently
not working. He used to drink about half a gallon of vodka a
day, until diagnosed with cirrhosis and incarcerated for buying
heroin. He has a 1.5 ppd X 30 years smoking, quit while in
jail, but re-started recently. Now smoking [**4-9**] cigarettes/day.
12 year history of significant IV heroin use, off while
incarcerated. Used IV heroin last on [**7-25**] (birthday). No
history of withdrawal from etoh/dts, or heroin withdrawal.
Family History:
Mother history of abdominal cancer.
Physical Exam:
T 100.7, P78, R 20, BP 140/80, O2 sat 98% RA
Gen: uncomfortable white male, track marks on both arms, minimal
motion, complaining of pain
HEENT: no icterus, PERRL, OP clear
Neck: supple, nontender, no lymphadenopathy
Car: RRR no murmur
Resp: CTAB
Abd: soft, nontender, normal bowel sounds, liver edge 3 cm below
costal margin, ventral hernia, umbilical hernia
Ext: track marks on bilateral arms, no lower extremity edema
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R 5 5 5 5 5 4+(pain)5 5 5 5
L 5 5 5 5 5 4+(pain) 5 5 5 5
Sensation: Decreased to from left thigh to top of left foot but
is able to discrimate from pinprick and light touch.
Propioception intact bilaterally
Reflexes: B T Br Pa Ac
Right 1+ 1+ 0 0
Left 1+ 1+ 0 0
Toes downgoing bilaterally
Pertinent Results:
[**2101-8-7**] 08:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2101-8-7**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-12* PH-6.5
LEUK-NEG
[**2101-8-7**] 07:30PM WBC-7.9 RBC-4.10* HGB-12.7* HCT-35.9* MCV-88
MCH-31.0 MCHC-35.3* RDW-14.0
[**2101-8-7**] 07:30PM SED RATE-117*
[**2101-8-7**] 05:05PM CRP-58.5*
[**2101-8-7**] 04:58PM LACTATE-2.3*
[**2101-8-24**] 05:41AM BLOOD WBC-2.9* RBC-2.79* Hgb-8.9* Hct-25.1*
MCV-90 MCH-31.8 MCHC-35.3* RDW-16.5* Plt Ct-20*
[**2101-8-15**] 06:05AM BLOOD ALT-25 AST-51* AlkPhos-327* Amylase-54
TotBili-5.1* DirBili-3.7* IndBili-1.4
[**2101-8-8**] 06:00AM BLOOD %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE
[**2101-8-19**] 05:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2101-8-11**] 05:05PM BLOOD CRP-59.4*
.
Microbiology:
Blood cultures: [**8-7**], [**8-8**], [**8-9**] with no growth
Blood cultures: [**8-12**]: no growth
[**8-11**] Disc culture/swab:[**Female First Name (un) **] ALBICANS. SPARSE GROWTH. [**Female First Name (un) **]
ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE GROWTH. 2ND
TYPE.
[**8-12**] Bone biopsy L4: no growth
[**8-17**] Ucx and Bcx no growth
.
MRI with gad: Comparison is made to outside MR [**First Name (Titles) 767**] [**Hospital1 34585**] dated [**2101-8-6**].
.
There has been no significant change since the prior study.
.
There is destruction of the L4/5 disc as well as the inferior
endplate of L4 and the superior endplate of L5. There is diffuse
enhancement of the vertebral bodies of L4 and L5 as well as
diffuse enhancement of the surrounding paraspinal soft tissues
extending into the psoas muscles bilaterally. There is also
extension of soft tissue enhancement into the epidural space at
the L4/5 level. This is causing moderate compression of the
thecal sac. These findings are consistent with discitis,
osteomyelitis, with paraspinal and epidural phlegmon, the latter
causing moderate thecal sac compression. No discrete fluid
collections identifying an abscess cavity are seen. The involved
vertebrae and disc are T2 hyperintense, consistent with
inflammatory edema.
.
The conus medullaris normally ends at the level of L1 and no
signal abnormalities of the visualized spinal cord are seen.
.
IMPRESSION: No significant change since [**2101-8-6**], with L4 and L5
with osteomyelitis and discitis, with paraspinal and epidural
phlegmon, the latter causing moderate compression of the thecal
sac. Above findings were discussed with directly with Dr.
[**Last Name (STitle) 10351**], the requesting physician, [**Name10 (NameIs) **] an emergent neurosurgical
consult was recommended and obtained.
.
TTE ([**8-8**]):
IMPRESSION: Normal study. No valvular pathology or pathologic
flow identified
.
TEE ([**8-19**]):
IMPRESSION: No valvular pathology or abscess identified.
.
Chest X-ray:
IMPRESSION:
1. No acute cardiopulmonary abnormality.
2. Questionable nodular opacity at left lung apex, finding that
could indicate a superimposition of vascular and osseous
structures, although dedicated PA and lateral chest radiograph
is recommended for further assessment.
.
Scrotal U/S:
IMPRESSION: Hypoechoic, nonvascular right testicular lesion
concerning for possible neoplasm. A focal orchitis is felt to
be less likely given the lack of vascular flow.
.
MRI w/ and w/o contrast ([**9-1**]):
No significant change since [**2101-8-8**] with spondylytic discitis
involving the L4 and L5 vertebral bodies with paraspinal and
epidural phlegmon formation causing moderate compression of the
thecal sac.
Brief Hospital Course:
50 y/o M with h/o IV drug abuse, cirrhosis, ETOH, hep C, and DM
who presents with L4/L5 osteomyelitis. S/p CT-guided bx of L4/L5
disc on [**8-11**]-Yeast grown from disc cx found to be [**Female First Name (un) **]
albicans. Complicated by thrombocytopenia, ARF, and hypotension.
.
1. L4-L5 osteomyelitis w/ phlegmonous extension: An initial
evaluation by neurosurgery was performed. However, neurosurgery
did not feel that the pt was a candidate for surgery. A medical
approach was taken with various antibiotics over the course of
the [**Hospital 228**] hospital stay. An initial blood cx at [**Hospital3 **]
grew [**2-9**] coag-neg staph. No further blood or urine cultures were
positive. So it was thought to be a contaminant although this
could not be ruled out. For this reason, the pt was stared on
Vancomycin which was discontinued later during the hospital
course b/o suspected bone marrow suppression thought to cause
significant thrombocytopenia, leukopenia and anemia. A disc cx
from [**8-11**] grew sparse [**Female First Name (un) **] albicans and beta-glucan lab test
was positive making [**Female First Name (un) **] albicans osteomyelitis most likely
despite a bone cx from [**8-12**] showing no growth. The pt was started
on Amphotericin after the positive cx results. At that time he
was still treated with both Vancomycin and Amphotericin.
However, the pt developed ATN which was attributed to
Amphotericin. So both Vancomycin and Amphotericin have been
D/C'd over the course of his stay b/o ATN and
thrombocytopenia/leukopenia, and treatment with Caspofungin has
been started on [**8-17**] (initially with 35 mg IV q24h, later
increased to 50 mg IV q24h) and continued throughout the
remainder of his stay. The patient was moved to the ICU when
developing recurrent hypotension and worsening renal failure,
but recovered soon thereafter. The patient improved
significantly towards the end of his hospital stay and his
symptoms were well controlled at discharge. He was afebrile and
able to ambulate. A lumbar brace has been placed. CRP was
trending down from 58.6 [**2101-8-7**] to 11.8 [**2101-9-13**]. Further recovery
is expected at an extended care facility. Followup appointments
have been scheduled with ID and neurosurgery. An outpatient MRI
of the L-spine has been scheduled as well. The patient should
also get weekly CBC, LFTs and BUN/Crea while on Caspofungin.
Results should be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**].
.
2. Acute Renal Failure. Baseline creatinine was 0.7-0.9 (0.9 on
[**8-15**]). Crea was 2.4 on [**8-16**].8 on [**8-17**].0 on [**8-19**]. He was
anuric from [**Date range (1) 67404**] with uremic symptoms (nausea/vomiting).
His Crea was 5.7 on [**8-22**] after starting CVV hemodialysis on
[**8-20**]. After having been in the ICU b/o ARF and recurrent
hypotension, the patient recovered quickly on the floor and his
kidneys proceded to the polyuric phase. Crea 1.6 on [**8-28**]. Crea
came down to 1.3 towards the end of his stay. After the polyuric
phase, the kidney function returned to [**Location 213**] output. The
patient was asymptomatic at discharge.
.
3. Thrombocytopenia. Plts 152 on admission, Plts 69 on [**8-13**]
on [**8-20**]. Anti-platelet4 (HIT) antibody was positive and the
patient was initially thought to have HIT. All heparin products
were D/C'ed. However, on [**8-26**] Serotonin Release Ab came back
negative. Since HIT Ab not very specific and SRA test negative,
the diagnosis of HIT was questioned at this point. Treatment
with Vancomycin correlated with the worsening thrombocytopenia
and was thought to be a likely cause. After having D/C'ed
Vancomycin, the CBC improved consistently. The pt did not bleed
significantly except for mild R conjunctival bleeding observed
[**8-22**]. Platelet transfusions were given on [**8-24**] in order to raise
plts temporarily for line removals. Platelets came up from 20 to
31 o/n. Platelets came up considerably towards the end of his
stay (Platelets 77 on [**8-31**]). The patient was discharged without
any signs of active bleeding and hemodynamically stable.
.
4. Anemia: Hct 35.9 on [**8-7**].5 on [**8-24**], Pt received 2U PRBC on
[**8-25**] raising Hct up to 26.3 and stable thereafter. Following
course of renal dysfunction, perhaps due to low erythropoeitin
levels. Iron studies consistent w/ ACD. Also occult bleeding was
considered since pt was also thrombocytopenic, cirrhotic, and
uremic. Stools were guaiaced. Improvement was noted when
Vancomycin was D/C'ed. Vancomycin was likely cause of
suppression of all three lines in the bone marrow although
multiple factors were certainly involved. Patient's Hct came up
again towards the end of his stay. Hct was 29.6 [**2101-9-13**]. Pt was
asymptomatic at discharge.
.
5. Leukopenia: WBC dropped down to 2.9 on [**8-24**], but after that
continuously rising. WBC 4.0 on [**8-28**] and stable thereafter
(previous baseline [**6-13**]). Possible causes were immunosuppression
b/o fungal osteo or medications, especially Vancomycin which
causes bone marrow suppression. Vanco had been D/C'ed. WBC
stable. Patient did not develop any opportunistic infections and
his osteomyelitis stayed stable despite the transient
leukopenia. Pt was asymptomatic at discharge.
.
6. Pain: Low back pain with radiation to both legs (R>L) was
managed throughout the [**Hospital 228**] hospital stay with a variety of
pain medications including a Fentanyl patch, Methadone at
increasing doses, Morphine, Dilaudid IV and PO, Oxycontin and
Oxycodone. The patient became hypotensive on some of these
medications. The fentanyl patch was D/C'ed b/o that although
multiple factors were likely responsible for his hypotensive
episodes. Methadone was tapered during his hospitalization by 20
mg/day with MSContin increased by 30 mg/day throughout the
taper. His pain regimen on discharge is as follows: MSContin 430
mg [**Hospital1 **], Neurontin 900 mg tid, Tylenol 500 mg qid, Dilaudid 30 mg
q4-6h prn, Tramadol 50 mg q4-6h prn.
.
7. Thigh pain: New left lateral thigh pain on [**8-25**] and right
lateral thigh pain on [**8-28**]. No bruise or bulge at either thigh.
DVT on L leg ruled out with LENIS. Pain seems to be muscular and
most likely due to recent use of LE muscles after extended
periods of immobility. The pain was managed with the same
medications as stated above. The new quality of pain subsided
soon after having been mobile for longer periods and was thought
to be different from his radiating back pain [**3-10**] osteomyelitis.
.
8. Acute scrotal pain: Pt developed acute left scrotal pain
radiating up his groin and flank on [**8-17**]. Pt received 500 cc IV
NS bolus, 4 mg Dilaudid, scrotal and renal u/s were unremarkable
except for an incidentally found R testicular lesion. Urology
was consulted. DD included testicular torsion, orchitis, acute
kidney stone, inguinal hernia. Doppler U/S of kidneys negative
for [**Month/Year (2) 5703**] thrombosis on [**8-17**]. The pain subsided soon after having
been treated with Dilaudid. The exact cause of this episode
remains unclear. A followup appointment has been scheduled with
urology in order to work up the R testicular cystic lesion as
outpt.
.
9. DM: Pt was formerly on Glyburide. Last HbA1c normal. Pt was
rather hypoglycemic at beginning of his hospital stay and was
treated as needed. For the majority of his stay, FS were stable.
Pt was started on metformin 500 mg qam one week prior to
discharge. Pt was asymptomatic throughout his stay.
.
10. Cirrhosis/Hep C: no history of GI bleeding, encephalopathy
or any other complications in the past. Pt developed transiently
cholestatic labs during stay, likely due to infectious process
and mulitple medications. Pt was briefly icteric, but returned
quickly to normal state. Labs remained at baseline elevation for
the remainder of his stay. Pt received Hepatitis A vaccination.
The outpatient medication Spironolactone has been discontinued
during the hospital stay because the patient developed acute
renal failure. It was not restarted upon discharge. It is
recommended to discuss the restarting of spironolactone with his
liver team during follow up as an outpatient.
.
11. Hyponatremia: Initially progressed to sodium of 124, but
later wnl. Pt was euvolemic throughout his hospital stay. No rx
was necessary and sodium was stable at discharge.
.
12. Pos UCx: The patient had GNR growing from a UCx on [**8-30**]
after having spiked a fever once the day before. The UA was
repeatedly negative and the patient remained afebrile
thereafter. A CXR was also negative and a repeat MRI of the
L-spine did not show any significant change to previous MRIs.
The patient completed a seven-day course of ciprofloxacin and
remained asymptomatic.
.
13. HTN: Pt was normotensive with an episode of hypotension as
described above. BP medications were held and BP was monitored
throughout his stay. It is recommended that his medications are
started as an outpatient after monitoring his BP for hypotension
and reevaluating his hypertension.
.
14. H/o alcohol abuse: Pt was monitored on CIWA, with prn
Ativan.
.
15. FEN: cardiac/diabetic diet.
.
16. Prophylaxis: Initially SC heparin, pneumoboots when off
heparin. Ambulatory towards the end of his stay. Bowel regimen,
PPI.
.
17. Access: PICC placed on [**8-15**] and kept on discharge for
outpatient treatment. IJ and HD catheter were removed [**8-24**] after
2x platelet transfusions plus 1x FFP b/o low ptls and
chronically high INR [**3-10**] cirrhosis.
.
18. Code Status: Full
Medications on Admission:
methadone 20 mg po qd,
atenolol 50 mg po qd,
Zestril 20 mg Po qd,
Aldactone 25 mg po qd,
glyburide stopped over the last month because BS below 100 in
the am
Discharge Medications:
1. Caspofungin 50 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Four (4)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per sliding scale.
5. Outpatient Lab Work
Please obtain weekly CBC, BUN/Crea and LFTs and fax results to
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**].
6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
8. Hydromorphone 4 mg Tablet Sig: 7.5 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain.
9. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed: Titrate to 3 bm/day.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
12. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
13. Morphine 200 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO every twelve (12) hours.
14. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO every twelve (12) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
L4-L5 osteomyelitis
L4-L5 discitis
Epidural and Paraspinal phlegmon
IVDA
Alcoholism
Hepatitis C
Cirrhosis
Hypertension
Diabetes mellitus
Discharge Condition:
Afebrile. Hemodynamically stable. Tolerating PO.
Discharge Instructions:
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, severe back pain,
increasing pain radiating down your legs, urinary or bowel
incontinence, or any other concerning symptoms.
Please take all your medications as directed.
Please keep you follow up appointments as below.
.
Please keep lumbar half of TSLO brace on while out of bed until
follow-up in [**Hospital 4695**] clinic.
Followup Instructions:
Please follow up with your Primary Doctor ([**Last Name (LF) 67405**],[**Known firstname 177**] J.
[**Telephone/Fax (1) 53045**]) with the next 1-2 weeks after your extended care
facility stay.
.
Please follow up with a urologist regarding the lesion found in
your right testicle within the next 1-2 weeks after your
extended care facility stay. Please call [**Telephone/Fax (1) 61400**] in order
to schedule an appointment at the [**Hospital 159**] clinic.
.
Please have an appointment scheduled at the Infectious [**Hospital 2228**]
clinic in [**7-13**] wks from now ([**Telephone/Fax (1) 457**]). Please have weekly
lab values (CBC, BUN/Crea, LFTs) drawn while on intravenous
treatment with Caspofungin as an outpatient. Results should be
faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**].
.
Please have an MRI of your L-spine with and without contrast
scheduled shortly prior to your outpatient clinic appointment
with Infectious Diseases. Please call [**Telephone/Fax (1) 67406**] for
scheduling. Depending on the result, the Infectious Disease
specialist might switch you to an oral medication for treatment
of your fungal osteomyelitis.
.
Please follow up with L-spine MRI w/&w/o contrast in
[**Hospital 4695**] Clinic (Dr. [**Last Name (STitle) 739**] in 10 weeks or 2 weeks
after completion of antibiotic course. Phone: [**Telephone/Fax (1) 1669**]
ICD9 Codes: 7907, 5990, 5845, 2761, 2762, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3025
} | Medical Text: Admission Date: [**2186-12-4**] Discharge Date: [**2186-12-6**]
Date of Birth: [**2151-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Gastroparesis, Hematemesis
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
Mr. [**Known lastname 14782**] is a 35 year-old man with DMI (c/b retinopathy,
DKA, gastroparesis), ESRD on HD (MWF), HTN presenting with
vomiting. He presents with his usual onset of gastric burning
pain earlier today. Also with nausea and vomiting. He also
described that he also had small a amount of bright red blood in
his vomitus. Denies any bright red blood per rectum or melena.
No fevers or chills. Patient denies any lightheadedness,
palpitations, chest pain, or shortness of breath. Of note, this
presentation is quite similar to prior periods of gastroparesis.
.
In the ED, initial vs were 97.3 105 211/125 18 98% RA. Patient
was tachycardic, with no focal findings including benign
abdomen. Labs were notable for K 5.3, Cr 8.9, BUN 56, glucose
288 and an anion gap of 16. Pt was given 4L NS, 4 units i.v.
insulin was started on an insulin drip, Zofran and morphine.
Guiaic was negative and NG lavage identified blood clots and
coffegrounds that cleard with 100 cc fluid. GI was consulted in
the ED and advised IV PPI, NPO and possible EGD in AM to
evaluate possible [**Doctor First Name 329**] [**Doctor Last Name **] tear from retching. The patient
was then admitted to the MICU for further care. On transfer, VS
were 86 158/80 18 98%RA.
.
Upon arrival to the floor, the patient appears uncomfortable in
bed.
Complains of nausea and retching.
Past Medical History:
- Type I diabetes: since age 19, complicated by gastroparesis,
retinopathy (laser treatment), DKA, chronic kidney disease
- ESRD, on HD MWF, started [**9-3**]
- [**Doctor Last Name 9376**] syndrome
- Hypertension
- Asthma
- HLD
- chronic multifactorial anemia, on Epo, h/o pRBC transfusion x2
in [**2186-7-24**] related to renal failure
Social History:
Lives with his girlfriend and two children ages 14 and [**Location (un) 85328**]. Denies tobacco use, alcohol use, or illicit drug use.
Family History:
Father with CAD/MI, HLD, type II DM. Mother with thyroid cancer.
Physical Exam:
T 97.0, P: 97, BP: 188/111, RR: 15, 98% on RA
GENERAL - well-appearing in NAD, uncomfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucous
membranes, unable to examine OP as pt nauseous
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - tregular rhythm, tachycardic, no MRG
ABDOMEN - NABS, soft, diffuse TTP, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, dialysis catheter in place, fistula
in left UE
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-27**] throughout, sensation grossly intact throughout
Pertinent Results:
Admission:
[**2186-12-4**] 05:56PM BLOOD WBC-7.7 RBC-3.59* Hgb-10.8* Hct-32.8*
MCV-91 MCH-30.2 MCHC-33.0 RDW-15.1 Plt Ct-208
[**2186-12-4**] 05:56PM BLOOD Neuts-84.8* Lymphs-12.3* Monos-1.4*
Eos-0.9 Baso-0.6
[**2186-12-4**] 05:56PM BLOOD PT-9.7 PTT-36.5 INR(PT)-0.9
[**2186-12-4**] 05:56PM BLOOD Glucose-288* UreaN-56* Creat-8.9*# Na-137
K-5.3* Cl-101 HCO3-20* AnGap-21*
[**2186-12-4**] 09:13PM BLOOD Glucose-157* UreaN-54* Creat-8.1* Na-141
K-4.5 Cl-112* HCO3-20* AnGap-14
[**2186-12-4**] 09:13PM BLOOD ALT-15 AST-17 TotBili-0.7
[**2186-12-4**] 05:56PM BLOOD Calcium-9.1 Phos-5.4* Mg-2.0
.
Discharge labs:
[**2186-12-6**] 06:05AM BLOOD WBC-5.1 RBC-2.89* Hgb-8.7* Hct-27.0*
MCV-93 MCH-30.0 MCHC-32.1 RDW-14.7 Plt Ct-163
[**2186-12-6**] 06:05AM BLOOD Glucose-102* UreaN-30* Creat-6.1*# Na-140
K-3.9 Cl-103 HCO3-29 AnGap-12
[**2186-12-6**] 06:05AM BLOOD Calcium-8.1* Phos-5.0* Mg-1.8
.
EGD results [**12-5**]:
Findings:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Recommendations: No source of bleeding was found. There was no
blood in stomach or duodenum.
He may have had a small MW tear that was already healed.
Would continue home dose of omeprazole.
Brief Hospital Course:
Patient is a 35 year old man with type I diabetes mellitus,
gastroparesis, end stage renal disease on hemodialysis and
hypertension admitted with nausea, vomiting and hematemesis who
was initially admitted to the MICU for close monitoring of
hematmesis.
ACTIVE ISSUES:
#. Hematemesis: His small volume hematemesis was likely caused
by retching in the setting of gastroparesis. His NG lavage
cleared with 100mL. The hematocrit drop observed between his
presentation hct of 32.8 and admission hct of 25.9 was likely
hemodilution secondary to 4L NS given in the ED. He was started
on a pantoprazole drip, antiemetics. Endoscopy showed no
evidence of bleeding, so small mucosal tear suspected as
etiology. Hematocrit remained stable, and he had no further
episodes of hematemesis. He was discharged on omeprazole.
#. Nausea/vomiting/gastroparesis: Patient has had multiple
admissions for nausea and vomiting secondary to gastroparesis
most recently discharge on [**11-23**]. It is likely that this
presentation is due to a flare of his gastroparesis. He had no
signs or symptoms of an infectious etiology. Compazine and
zofran were given for antiemetic therapy. Erythromycin and
reglan were continued for motility. He was discharged with an rx
for compazine.
#Type I diabetes mellitus: The patient presented in a
hyperglycemic state with a trend towards DKA given glucose of
288, HCO3 of 20 and AG of 16. He was started on an insulin gtt
in the ED. This was stopped in the MICU and he was restarted on
his home insulin regimen. His sugars from then on were
reasonably controlled. No changes were made to his insulin
regimen on discharge.
#Hypertension: Patient was hypertensive the ED to 210s/120s
likely secondary to distress from nausea and vomiting that
improved rapidly with antiemetic and analgesic therapy. He was
conitnued on his home lisinopril.
#End stage renal disease on hemodialysis: Patient underwent HD
on [**12-5**]. He was continued on Sevelamer, NephroCaps and Epo at
HD.
TRANSITION OF CARE ISSUES:
- Patient remained FULL CODE
Medications on Admission:
1. Sevelamer carbonate 800 mg PO TID
2. Lisinopril 20 mg DAILY
3. Metoclopramide 10 mg QID
4. B complex-vitamin C-folic acid 1 mg DAILY
5. Erythromycin 250 mg TID
6. Acetaminophen 650 mg Q6H
7. Omeprazole 20 mg DAILY
8. Lantus 5 units twice a day
9. Humalog 0-4 units sliding scale:
<150: 0 units
151-220: 1 unit
[**Unit Number **]- 290: 2 units
291- 360: 3 units
> 361: 4 units.
10. Epoetin alfa 3,000 unit/mL Solution Sig: [**2174**] units
11. Acetaminophen 1000 mg Q8H
12. Sodium chloride 0.65 % Aerosol Q4H
Discharge Medications:
1. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times
a day.
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q8H (every 8 hours).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. insulin glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous twice a day.
9. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous
four times a day: <150: 0 units
151-220: 1 unit
[**Unit Number **]- 290: 2 units
291- 360: 3 units
> 361: 4 units.
10. epoetin alfa 2,000 unit/mL Solution Injection
11. prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed for nausea.
Disp:*20 Suppository(s)* Refills:*0*
12. Ocean Nasal Mist 0.65 % Aerosol, Spray Sig: One (1) spray
Nasal every four (4) hours as needed for nasal congestion.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic gastroparesis
Diabetes mellitus type I
Stage V Chronic Kidney Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 14782**],
You were admitted to the hospital because of nausea, vomiting,
and a small amount of blood in your vomit. You sugars were also
high, but you did not have signs of diabetic ketoacidosis. We
believe your nausea and vomiting was a flare of your
gastroparesis, and you symptoms improved with pain and nausea
medicines. An EGD (procedure when a doctor looks down into your
stomach with a tiny camera) did not show any abnormalities or
bleeding. The blood in your vomit was likely due to a small
tear in the lining of your esophagus from all the vomiting.
Changes to your medications:
START prochlorperazine (compazine) 25 mg twice daily per rectum
as needed for nausea
It was a pleasure to take care of you while you were in the
hospital!
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 641**]
Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**]
Phone: [**Telephone/Fax (1) 644**]
Appointment: Friday [**2186-12-15**] 2:40pm
ICD9 Codes: 5856, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3026
} | Medical Text: Admission Date: [**2160-7-1**] Discharge Date: [**2160-7-8**]
Date of Birth: [**2080-9-15**] Sex: M
Service: MEDICINE
Allergies:
Zithromax / Heparin Agents
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
shaking chills
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
79 year old male with history of possible mastocytosis with
recurrent episodes of anaphylactoid reactions with an infectious
prodome presents with shaking chills x 2 days, 1 day of diarrhea
self resolving, 1 day pharyngitis, and temp to 100.5 at home. He
started taking prednisone per Dr. [**First Name8 (NamePattern2) 2602**] [**Name (STitle) 2603**] (allergist)
instructions yesterday. At PCP office on day of admission, rapid
strep was negative. After returning home, he became acutely
dyspneic (particularly on exertion) along with shaking chills
and was instructed by his PCP to go to ED. In ED T 100.3, RR in
30s, O2 initially 89% on RA, improving to 97% w/ 2L. Initial BP
127/58 then dropped to 96/41. A sepsis line was placed and he
was given vanc/levo/clinda/ceftriaxone. He was also given
decadron 10 mg IV X 2. He was then admitted to the medical ICU
for further management.
ROS:
positive: fever, chills, diarrhea, lower extremity edema "from
norvasc"
negative: denied headache, sinus tenderness, rhinorrhea, cough,
shortness of breath, chest pain or tightness, palpitations,
nausea, vomiting, constipation or abdominal pain. No dysuria.
Denied arthralgias or myalgias. No recent travel. Recent bridge
partner ill with an upper respiratory tract infection.
Past Medical History:
1. Anaphylactoid reactions for which hospitalized on several
occasions in late '[**43**]'s and required ICU/pressors
2. HTN
3. hyperlipidemia
4. type 2 dm (last a1c 6 [**9-25**])
5. gout
6. fixed inferior defect on stress mibi '[**56**]
Social History:
lives w/ wife in [**Name (NI) 701**], remote pipe smoking 20 years ago.
Winter home in [**State 108**].
Family History:
Noncontributory
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.3P: 99 R:24-30 BP:107/47 SaO2: 94% on 2L CVP 14
General: Awake, alert
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MM dry, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated R IJ in place
Pulmonary: Lungs with bibasilar crackles.
Cardiac: Distant, RRR, no M/R/G noted
Abdomen: soft, obese, NT/ND, hypoactive bowel sounds, no masses
or organomegaly noted.
Extremities: 1+ lower ext edema,2+ radial, DP and PT pulses b/l.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
Pertinent Results:
Laboratory studies on admission:
GLUCOSE-118 UREA N-26 CREAT-1.3 SODIUM-142 POTASSIUM-3.4
CHLORIDE-108 TOTAL CO2-20
CK(CPK)-42 CK-MB-NotDone cTropnT-<0.01
WBC-5.2 RBC-3.71 HGB-11.1 HCT-32.3 MCV-87 MCH-29.9 MCHC-34.3
RDW-15.3
PLT COUNT-148
[**2160-7-1**] 05:05PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.027
GLUCOSE-180* UREA N-27* CREAT-1.1 SODIUM-140 POTASSIUM-3.5
CHLORIDE-105
[**2160-7-1**] CXR: The right internal jugular vein catheter tip is in
the SVC. No pneumothorax. Unchanged cardiomediastinal contour. A
small left basilar atelectasis.
[**2160-7-1**] Neck CT: Air within musculature of the right temporal
and mandibular region; air within small veins in the right
anterior neck region extending down into the superior- anterior
mediastinum.
[**2160-7-1**] CTA chest: No evidence of pulmonary embolism. Bibasilar
atelectasis. Increase of bony densities in the laminae of
several upper thoracic component vertebrae, which in the absence
of a primary malignancy, most likely represent degenerative
changes. Non-pathologically enlarged mediastinal lymph nodes.
[**2160-7-6**] CT Abd/pelvis w/ contrast: No intra-abdominal malignancy
or lymphadenopathy identified. Cholelithiasis without evidence
of cholecystitis
Brief Hospital Course:
79 year old male with recurrent anaphylactoid reactions presents
with sore throat, fever, and hypotension.
1) Fever/hypotension: The patient was admitted to the medical
ICU, where he was volume resuscitated and empirically covered
with ceftriaxone/clindamycin (for possible retropharyngeal
abscess on Neck CT). He was evaluated by the ENT service, who
examined the patient and felt that retropharyngeal abscess was
unlikely. The patient rapidly improved with
antibiotics/steroids, similar to prior episodes he has had since
[**2151**]. He was transferred to the general medical floor on
[**2160-7-5**]. The etiology of his presenting symptoms remain unclear
(infectious vs immunologic). The infectious disease service was
consulted. They felt that, while possible, bacterial infection
was unlikely, and that the patient likely had a reaction to a
viral illness. They recommended a 10 day course of antibiotics
(initially ceftriaxone/clindamycin, transition to levofloxacin
prior to discharge). At time of discharge, strongyloides
serologieis and HCV PCR were pending. Urine cultures and blood
cultures had no growth to date. Dr. [**Last Name (STitle) 2603**] of allergy, who
follows Mr. [**Known lastname 20008**] as an outpatient, was also consulted. At time
of discharge, serum tryptase and serum IgE, obtained to
determine whether this episode was consistent with an allergic
reaction, were pending.
2) Pancytopenia/Possible immunodeficiency: Initially, the
patient was noted to have a low CD4 (repeat check showed high
CD4 count) as well as depressed igG subsets. HIV Antibody and
viral load were negative, and the infectious disease service
felt that, even if the patient were immunosuppressed, his
clinical picture was not consistent with an opportunistic
infection. In terms of malignancy work-up, hematology/oncology
was consulted for possible bone marrow biopsy (given mild
pancytopenia), which will be performed when the patient follows
up with them as an outpatient. His last colonoscopy was in [**2154**]
and was negative except for diverticulosis. PSA, SPEP/UPEP were
negative during this hospitalization. In order to look for
lymphadenopathy that could suggest malignancy or lymphoma, he
underwent an Abd CT [**7-6**], which showed no evidence of
LAD/malignancy. [**7-1**] chest CTA had showed only small
non-pathologically enlarged mediastinal lymph nodes. The patient
will have a repeat IgG level/subsets and CD4 checked as an
outpatient 2 weeks following discharge. If CD4 count falls
again, PCP prophylaxis may be considered. If IgG is persistently
low, the patient may benefit from Ig infusions.
3) Hyperlipidemia: The patient's lipitor, which had been held in
the setting of acute illness, was restarted prior to discharge
4) Edema/mild CHF: EF 50-55%, [**12-24**]+ MR, impaired LV relaxation.
Following transfer to the floor, the patient was noted to have
marked lower extremity edema, which improved with furosemide
diuresis. This likely represents fluid overload in the setting
of volume resuscitation while in the ICU. There were no EKG
changes suggesting myocardial ischemia. His norvasc was
discontinued, as this could contribute to his edema. He was
started on low dose furosemide, and will have his electrolytes
checked within 1 week followed discharge to ensure stability.
Addition of an ACE inhibitor for afterload reduction, may be
considered as an outpatient.
5) DM-II: The patient was initially placed on a regular insulin
sliding scale, after which he was restarted on
glipizide/rosiglitazone with adequate blood sugar control
6) Code: Full
Medications on Admission:
Norvasc 5 mg PO daily
Rosiglitazone 8 mg PO daily
Glipizide 5 mg PO daily
Atorvastatin 40 mg PO daily
Prednisone/Pepcid prn
Discharge Medications:
1. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-24**]
puffs Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
Disp:*1 MDI* Refills:*2*
5. spacer
use as directed
dispense: 1
refills: 0
6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: hypotension
Secondary: anemia, hyperlipidemia, hypertension, lower extremity
edema, type II diabetes
Discharge Condition:
The patient is hemodynamically stable and ambulating with a
walker without difficulty.
Discharge Instructions:
Please take all medications as prescribed. Your amlodipine has
been discontined (may be restarted at the discretion of your
primary care physician). You will continue levofloxacin to
complete a 10 day course. You have been started on furosemide
given your lower extremity swelling. You should not take
ranitidine/prednisone, unless directed to do so by your
allergist or primary care physician.
Please call your primary care physician or come to the emergency
room if you develop shortness of breath, wheezing, fevers,
chills, lightheadedness, or other symptoms that concern you.
Followup Instructions:
1) Primary Care: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 133**]) within 1-2 weeks following discharge.
- Provider: [**Name10 (NameIs) 20009**],[**Name11 (NameIs) 5557**] [**Name Initial (NameIs) **]. ([**First Name9 (NamePattern2) **] [**Location (un) **]) [**Location (un) **] INTERNAL
MEDICINE (NHB) Date/Time:[**2160-7-14**] 11:45
- you should have your sodium, potassium, and creatinine checked
when you follow-up with your primary care physician.
2) Oncology: Dr. [**First Name (STitle) **]; HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2160-7-11**] 9:30 a.m.
3) Allergy: Please call Dr. [**First Name8 (NamePattern2) 2602**] [**Name (STitle) 2603**] ([**Telephone/Fax (1) 1723**]) on [**7-9**]
to discuss results of laboratory tests
- repeat IgG and T cell subsets in 2 weeks
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2160-7-16**]
ICD9 Codes: 0389, 4280, 4240, 2749, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3027
} | Medical Text: Admission Date: [**2147-1-24**] [**Year/Month/Day **] Date: [**2147-1-30**]
Service: SURGERY
Allergies:
Penicillins / Optiray 350
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
Paravertebral cathether placement
History of Present Illness:
89 yo male s/p trip and fall at home in bathroom falling onto
toilet striking his left chest. He was transported to [**Hospital1 18**] for
further care.
Past Medical History:
Parkinson's disease
DM2 c/b neuropathy on neurontin
diplopia x one year, horizontal, no clear etiology per patient,
followed by ophtho
HTN
Migraines
s/p MI [**57**] yrs ago
s/p cataract [**Doctor First Name **] bilat
s/p laminectomy in [**2089**]
Social History:
Recent move to [**Location (un) 86**] from NY 10 days ago. lives with wife in
senior citizen home, + tob 30yrs x 1ppd, quit 30 yrs ago, no
etoh, no drugs, has 2 sons
Family History:
Father with strokes, no seizures, no parkinsons, sons are
healthy
Pertinent Results:
[**2147-1-24**] 02:30PM GLUCOSE-125* UREA N-57* CREAT-2.1* SODIUM-141
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-21* ANION GAP-19
[**2147-1-24**] 02:30PM CALCIUM-9.3 PHOSPHATE-4.4# MAGNESIUM-2.0
[**2147-1-24**] 02:30PM WBC-11.3* RBC-4.69 HGB-12.1* HCT-37.9*
MCV-81* MCH-25.8* MCHC-31.9 RDW-17.0*
[**2147-1-24**] 02:30PM NEUTS-73.1* LYMPHS-21.5 MONOS-3.8 EOS-1.2
BASOS-0.4
[**2147-1-24**] 02:30PM PLT COUNT-236
[**2147-1-24**] CT Head
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Air-fluid level within the left maxillary sinus without
definitive
fracture detected. Findings likely reflect sinusitis.
[**2147-1-24**] CT C-spine
IMPRESSION:
1. No evidence of acute fracture or traumatic malalignment.
2. Multilevel cervical stenosis secondary to degenerative
change. If there
is clinical concern for myelopathy, MRI of the cervical spine is
recommended
for further evaluation to evaluate for cord edema/injury.
3. Tiny left apical pneumothorax with subcutaneous emphysema.
4. Soft tissue opacity within the right lung apex is
non-specific, possibly
reflecting scar and is little changed since [**2145-12-28**].
[**2147-1-24**] CT Chest/Abdomen/Pelvis
IMPRESSION:
1. Numerous left-sided acute rib fractures causing small left
hemopneumothorax and atelectasis. Significant subcutaneous
emphysema noted.
2. Significantly enlarged prostate gland.
3. Moderate-to-severe coronary artery calcifications and
moderate
calcification of the aortic valve of unknown hemodynamic
significance.
4. Possible mild reaction to IV contrast material as detailed in
technique
portion of the report.
[**2147-1-28**] Chest xray
FINDINGS:
Multiple left rib fractures are again noted, and there is
evidence of left
pleural fluid and atelectasis. Retrocardiac density is not
significantly
different. There is no PTX.
Brief Hospital Course:
He was admitted to the Trauma service and transferred to the
Trauma ICU for close monitoring of his respiratory status
because of his injuries. The Pain Service was consulted for
epidural analgesia; it was decided to place a paravertebral
catheter which remained in place for several days. He was also
started on PCA Dilaudid initially and was then changed oral
narcotics but became disoriented with the narcotics. A short
trial of Ultram was started and then discontinued as his
disorientation did not improve initially. Once off of all
narcotics and the Ultram his mental status improved
significantly. Geriatrics was also consulted and made several
recommendations regarding his pain medications. His current pain
regimen includes Tylenol 1 gram around the clock and Lidocaine
5% patch.
He still requires supplemental nasal oxygen as he does
desaturate on room air to low 90's high 80's. Most recent chest
xray does show some pleural fluid and atelectasis, bu no
pneumothorax. He is able to illicit a fairly strong productive
cough with encouragement.
On hospital day 5 he self discontinued his Foley catheter with
the balloon inflated and was noted to have hematuria following
this. A 3 way catheter was attempted without success and so a
one way Foley was replaced. He is ordered for q shift catheter
flushes with sterile water. The hematuria has decreased
significantly; the catheter can be removed in the next day or so
as long as the hematuria has resolved.
Physical and Occupational therapy were consulted and have
recommended acute level rehab after his hospital stay.
Medications on Admission:
Allopurinol 100, Amitriptyline 25, Atenolol 100,
Carbidopa-Levodopa 25-100"", Enalapril Maleate 10, GlipiZIDE 5",
Gabapentin 300
[**Month/Day/Year **] Medications:
1. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2)
Tablet PO Q6H (every 6 hours).
[**Month/Day/Year **] Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
[**Hospital6 **] Diagnosis:
s/p Fall
Left hemothorax
Left rib fractures [**4-30**]
Traumatic hematuria
[**Month/Year (2) **] Condition:
Hemodynamically stable, tolerating a regular diet, pain fairly
well controlled.
Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery. Call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab; you or your family will need to call for an appointment.
Completed by:[**2147-1-31**]
ICD9 Codes: 5849, 5180, 3572, 4019, 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3028
} | Medical Text: Admission Date: [**2172-3-18**] Discharge Date: [**2172-3-24**]
Date of Birth: [**2102-1-7**] Sex: F
Service:
CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: The patient is a 70 year-old
female with a history of multiple medical problems and severe
emphysema/COPD as well as peripheral vascular disease who had
morning. It was severe, sharp stabbing pain that is in the
center of the back below in the infrascapular area. The
patient denies any nausea, vomiting, abdominal pain or chest
pain. The pain is unchanged in character since it started.
PAST MEDICAL HISTORY: Hypertension, peripheral vascular
disease, status post multiple foot ulcers and multiple
post appendectomy, status post C section times three, former
alcoholic, anxiety, ? Diagnosis of diabetes.
MEDICATIONS ON ADMISSION: Paxil. The patient does report
taking a blood pressure medication, but she cannot recall
what medication that was.
ALLERGIES: Prednisone causes pneumonia.
FAMILY HISTORY: Noncontributory. States that her mother is
in her 90s and alive in [**State 1727**]. Her health care proxy is
daughter [**Name (NI) 2808**] who lives in [**Location 479**] [**Location (un) 1514**].
SOCIAL HISTORY: The patient currently smokes one pack per
day. She has been smoking for a very long time and was a
much heavier smoker in the past. She does have a history of
alcoholism, but she states she quit after her hip surgery and
is unable to recall the date of the surgery. She lives by
herself.
REVIEW OF SYSTEMS: Reports fifteen pound weight loss from 90
to 75 pounds during the last month. She drinks large amounts
and urinates large amounts including wetting bed at night.
She walks with a walker and sometimes in a wheel chair. She
reports no chest pain or shortness of breath, but her
mobility is very limited by COPD.
PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 168/87.
Pulse 72. Respiratory rate 14. O2 sat 91% on 4 liters nasal
cannula. In general, the patient was an elderly ill
appearing female. HEENT was very dry. Chest clear to
auscultation anteriorly, but breath sounds were distant.
Heart had distant heart sounds. Regular rate and rhythm. No
murmur. Abdomen was soft, nontender, nondistended with good
bowel sounds. Extremities showed thin, brown discoloration
of lower half of calf. No palpable dorsalis pedis pulses.
Feet without ulcers. Pulses were dopplerable.
LABORATORY STUDIES ON ADMISSION: White blood cell count 11.5
with a differential of 92% neutrophils, 4% lymphocytes, 2
monocytes. Hematocrit was 34.1, platelet count 476, PT 12.7,
PTT 27, INR 1.1. Chem 7 sodium 134, potassium 3.9, chloride
102, bicarb 26, BUN 10, creatinine 0.4, glucose 284.
IMAGING: 1. Chest CT showed ascending aorta aneurysmally
dilated and measuring 5 cm. The descending aorta had a
normal caliber and intrathoracic diameter measuring 2.5 to 3
cm. However, there was a low attenuation rim around the
descending aorta starting from the aortic arch to about 2 cm
above the origin of the renal arteries. It was
circumferential and was low attenuation most likely
corresponding to old hemorrhage. There was a focal area of
extravasation from the posterior aorta at about 5 cm distal
from the left subclavian artery origin. No frank intimal
flap was identified.
ASSESSMENT/PLAN: In summary, the patient is a 70 year-old
female with a history of severe emphysema/COPD, peripheral
vascular disease, tobacco use who presents with sharp back pain
and was found on CT to have evidence of aortic dissection with
possible oblique aneurysm extending into soft tissue. Myocardial
infarction was r/o.
During this hospitalization the patient's clinical problems
included:
1. Aortic dissection: After extensive discussion with the
family, in consideration of the patients over all health
especially the limitations of her lung disease, the decision was
made to proceed with medical management of the aortic dissection
since the patient was a very poor surgical candidate due to her
age and compromised pulmonary status, malnutrition. The patient
was initially started on Esmolol and nitroprusside drips with
resolved systolic blood pressure around 100. She tolerated the
blood pressure control well and was converted from the drips to
Metoprolol 100 mg po t.i.d., Hydralazine 10 mg po q.i.d., and
Hydrochlorothiazide 12.5 mg po q.d. Following her transfer
to the regular medicine floor the patient's hydralazine was
titrated to 25 mg q.i.d. and Hydrochlorothiazide 25 mg q.a.m.
for better blood pressure control. Her goal blood pressure
is below 120s. After initial drop of her hematocrit from 34
to 27 with hydration the patient's hematocrit remained stable
in the low 30s.
2. Chronic obstructive pulmonary disease: The patient was
maintained on Albuterol inhaler and Atrovent inhaler was
added. She required supplemental oxygen. On repeat chest
x-ray she was found to have pneumonia. In the setting of low
grade fevers as well as sputum production, the patient was
started on Levaquin. The sputum grew penicillin-sensitive
strep pneumo and the patient's antibiotics were switched to
Amoxicillin.
3. During this hospitalization her sugars remained in normal
range.
4. Code: DNR/DNI confirmed with the health care proxy.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Hypertension.
3. Aortic dissection managed medically.
4. Emphysema
5. Peripheral vascular disease status post multiple foot
ulcers and multiple hospitalization.
6. Status post left hip replacement, status post
appendectomy, status post C section times three.
7. Former alcoholic.
8. Anxiety.
DISCHARGE MEDICATIONS: Hydrochlorothiazide 25 mg po q.a.m.,
Hydralazine 25 mg po q.i.d., Metoprolol 100 mg po t.i.d.,
Tylenol 650 mg po q 4 to 6 hours prn, Albuterol one to two
puffs q 4 to 6 prn, Atrovent two puffs q.i.d., amoxicillin
500 mg po q 6 hours for an additional six days, Protonix 40
mg po q.d., Trazodone 50 mg po q.h.s., Colace 100 mg po
b.i.d., Dulcolax 10 mg po prn, Paxil.
DR.[**Last Name (STitle) 1413**],[**First Name3 (LF) 1412**] 12-663
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2172-3-24**] 10:43
T: [**2172-3-24**] 14:01
JOB#: [**Job Number **]
ICD9 Codes: 486, 496, 3051, 4439, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3029
} | Medical Text: Admission Date: [**2184-8-21**] Discharge Date: [**2184-8-24**]
Date of Birth: [**2115-8-20**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Chief complaint: GI bleed
Major Surgical or Invasive Procedure:
Blood transfusion
Colonoscopy
History of Present Illness:
Mr. [**Known lastname 33000**] is a 69 year old male with CAD, HTN, HL, Type 2 DM,
PAF on coumadin, hypothyroidism, PUD, who presented to OSH ED
with BRBPR x 3 last night. He reports that the toild bowl was
filled with blood. He denied lightheadedness, chest pain,
fevers, chills, chest pain, or any other concerning symptoms. He
has never had BRBPR, but has had melena two years ago secondary
to PUD. He had a colonoscopy two years ago which showed
diverticulosis. He denies hematasis, melena.
.
Upon arrival to the [**Hospital1 **] ED, his vitals were 138/83, 62,
16, 98.1. He was given 1 (?or 2) units of PRBCs at OSH and 2.5
mg of vitamin K PO. He underwent EGD and [**Last Name (un) **] at OSH. EGD was
negative for bleeding, but colonsocopy showed significant amount
of bleeding but there were unable to localize source of bleed
due to significant amounts of blood. They were unable to pass
the scope beyond the sigmoid colon due to the extent of
bleeding. After the EGD/[**Last Name (un) **], he was hypotensive to the 70s.
There were no ICU beds and no IR physicians available to
embolize, so he was trasnferred to [**Hospital1 18**]. He was started on a
protonix drip and octreotide drip at [**Hospital1 **]. He got 2 units
of FFP though his INR was 1.6. His Hct at [**Hospital1 **] on arrivals
was 30.9.
.
In the ED, vitals on arrival were T 96.5, BP 108/70, 16, 100% on
RA. He was evaluated by GI and surgery who recommended tagged
RBC scan. He was not hypotensive in the ED. He was transfused 1
unit of PRBCs in the ED. He continued to have large amounts of
bright red blood while in the ED. He was taken directly to
tagged RBC scan which was positive for sigmoid/rectal bleeding.
.
Upon arrival to the floor, patient denies lightheadedness, chest
pain, shortness of breath, fevers, chills. He reports abdominal
cramping prior to bloody bowel movements.
Past Medical History:
CAD s/p RCA stent in [**2175**]
Hypertension
Hyperlipidemia
NIDDM
Paroxysmal atrial fibrillation/flutter s/p pulmonary vein
isolation
CVA
Hypothyroidism
PUD
.
Social History:
Patient denies alcohol, tobacco or drug use.
Family History:
Mother with diabetes.
Physical Exam:
VS: BP 85/50, HR 77, RR 16, 100% on RA, afebrile
Gen: NAD, lying in bed, comfortable
HEENT: EOMI, o/p clear
CV: RRR, no m/r/g
Pulm: CTA bilaterally
Abd: soft, NT, ND, bowel sounds present
Ext: cool extremities, no peripheral edema
Neuro: AxOx3, answering questions appropriately
Pertinent Results:
[**2184-8-21**] 08:22PM HCT-23.6*
[**2184-8-21**] 08:22PM PT-17.8* PTT-33.1 INR(PT)-1.6*
[**2184-8-21**] 06:20PM WBC-5.2 RBC-2.88* HGB-8.0* HCT-24.7* MCV-86
MCH-27.8 MCHC-32.3 RDW-15.8*
[**2184-8-21**] 06:20PM PLT COUNT-168
[**2184-8-21**] 06:20PM PT-18.0* PTT-31.6 INR(PT)-1.6*
[**2184-8-21**] 03:34PM URINE HOURS-RANDOM
[**2184-8-21**] 03:34PM URINE GR HOLD-HOLD
[**2184-8-21**] 03:34PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2184-8-21**] 03:34PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2184-8-21**] 01:23PM COMMENTS-GREEN TOP
[**2184-8-21**] 01:23PM GLUCOSE-198*
[**2184-8-21**] 01:23PM HGB-10.5* calcHCT-32
[**2184-8-21**] 01:10PM GLUCOSE-199* UREA N-22* CREAT-1.1 SODIUM-135
POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-19* ANION GAP-15
[**2184-8-21**] 01:10PM estGFR-Using this
[**2184-8-21**] 01:10PM ALT(SGPT)-23 AST(SGOT)-25 CK(CPK)-170 ALK
PHOS-50 TOT BILI-1.3
[**2184-8-21**] 01:10PM LIPASE-132*
[**2184-8-21**] 01:10PM CK-MB-3 cTropnT-<0.01
[**2184-8-21**] 01:10PM CALCIUM-8.4
[**2184-8-21**] 01:10PM WBC-5.3 RBC-3.30* HGB-9.3* HCT-28.3* MCV-86
MCH-28.3 MCHC-33.0 RDW-16.7*
[**2184-8-21**] 01:10PM NEUTS-58.2 LYMPHS-32.8 MONOS-5.8 EOS-2.5
BASOS-0.7
[**2184-8-21**] 01:10PM PLT COUNT-200
[**2184-8-21**] 01:10PM PT-17.0* PTT-30.1 INR(PT)-1.5*
.
Colonoscopy: no active bleeding, but evidence of colitis and
diverticulosis.
Brief Hospital Course:
Mr. [**Known lastname 33000**] is a 69 yo male with CAD, HL, PAF on coumadin, s/p
CVA, hypothyroid, who is admitted for lower GI bleed localized
to sigmoid/rectum.
# GI bleed/colitis: His GI bleed was localized to the sigmoid
colon or rectal colon on tagged RBC. Over the course of his
admission, he required a total of 11 units of PRBC and 2 units
of FFP. His hematocrit nadired at 24 but was 31 at the time of
discharge and remained stable. He underwent colonoscopy that
demonstrated diverticulosis and mild colitis of the sigmoid
colon of unknown etiology, but no active source of bleeding was
identified. He was started on cipro/flagyl empirically to
manage his colitis. He also underwent an angiography study that
was also unable to localize the bleeding source.
# Atrial fibrillation with rapid ventricular resopnse: He is
anticoagulated at baseline and had an INR of 1.6 on the day of
presentation. He was reversed at an outside hospital with FFP
and vitamin K, and anticoagulation was subsequently held. He
was scheduled to see his cardioglist on [**2184-9-3**] to
further discuss options for thromboembolic prophylaxis, as he
has a CHADS score of at least 4 with diabetes, HTN, and a prior
stroke. He was discharged off coumadin. He also had episdoes
of a. fib with RVR and required a dilt drip intermittently but
was placed back on metoprolol once his heart rate stabilized, as
he takes this at home.
# Type 2 DM: stable, started on ISS.
Medications on Admission:
Medications: (will need to confirm med list with pharmacy or
wife)
Coumadin
Aspirin 81 daily
Tricor 145 mg 1 tab daily
Toprol XL 250 mg 1 tab daily
Glipizide 10 mg 1 tab [**Hospital1 **]
Doxazosin 2 mg 1 tab daily
Levoxyl 25 mcg 1 tab daily
Omeprazole 20 mg 1 tab daily
Fluoxetine 20 mg 1 tab daily
Insulin ?NPH
Discharge Medications:
1. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Insulin Lispro 100 unit/mL Solution Sig: AS DIRECTED
Subcutaneous ASDIR (AS DIRECTED).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute lower gastrointestinal bleed
Atrial fibrillation with rapid ventricular response
Diabetes mellitus
Sigmoid colitis
Discharge Condition:
Good
Discharge Instructions:
You were admitted for bleeding in your gut. We treated you with
blood transfusions and also performed a colonoscopy, which
showed that you have some inflammation in a small part of your
colon. This may be related to the bleeding.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments. Changes to your
medications:
STOP warfarin and aspirin for now. You will need to discuss
risks and benefits of continuing to take a blood thinner with
your cardiologist.
DECREASE metoprolol to 150 mg daily
Followup Instructions:
Name: [**Last Name (LF) 1295**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: HEART CENTER OF [**Hospital1 **]
Address: [**Location (un) **],2ND FL, [**Location (un) **],[**Numeric Identifier 7398**]
Phone: [**Telephone/Fax (1) 6256**]
Fax: [**Telephone/Fax (1) 33001**]
[**2184-9-3**] 3:30 P.M.
Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] to schedule a follow-up appointment with
GI at [**Hospital1 18**].
([**Telephone/Fax (1) 2233**]
Completed by:[**2184-8-24**]
ICD9 Codes: 4019, 4589, 2875, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3030
} | Medical Text: Admission Date: [**2119-2-8**] Discharge Date: [**2119-2-21**]
Date of Birth: [**2079-5-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
cardiac arrest; transferred for cooling protocol
Major Surgical or Invasive Procedure:
ICD (defibrillator) placement [**2119-2-17**]
History of Present Illness:
This is a 39 yo male who was working on a construction site and
was witnessed to fall from a standing position and lose
consciousness. He was also reported to have ?seizure activity.
Bystanders found him to be unresponsive/pulseless and initiated
CPR for 10 minutes. EMS arrived and found him to be in VF arrest
which was converted to sinus with 1 shock. He was intubated on
the field and transferred to [**Hospital6 **]. On arrival he
was unresponsive; and shortly went into PEA arrest and was
?shocked? x 1 with resolution to sinus tach with LBBB.
.
He was taken to the cath lab which showed 100% RCA and 100% LCx;
LAD 20% lesion which appeared "chronic"; EF 15%. When they tried
to cross 1 lesion his HR increased to 180's ?VT; he was shocked
with 200J x [**Street Address(2) 70830**] at 120's; he was also
hypertensive to the 200's which was treated with ?nitro drip. At
[**Hospital6 **] he received 600cc IVF; 325cc IV contrast;
10mg ativan.
.
Post-cath he was noted again to have seizure-like activity
(unsure of character) and was given 10mg ativan and taken to CT
scan which was preliminarily read as negative (although on
review here may be c/w sub-arachnoid hemorrhage)
.
On [**Hospital **] transfer to [**Hospital1 18**] he was noted to have decerebrate
posturing and L-turning of head.
Past Medical History:
HTN
heavy alcohol abuse-[**1-20**] vodka every day until 5 days PTA.
Social History:
very heave alcohol abuse. In [**Month (only) **] started to drink about [**1-20**]
vodka/day until 5 days prior to admission; 2ppd smoker; +MJ,
?cocaine; construction worker
Family History:
no early CAD in family
Physical Exam:
T 98 HR 107 BP 127/76 RR 30 SaO2 100%
Vent settings: AC 12X 600, 100% fiO2, 15 peep
Gen: Intubated, sedated
HEENT: blood in mouth; poor dentition
CV: tachy, no m/r/ ?S3+4?, no murmurs
Pulm: CTA B
Abd: s/nd/nt; no BS
Ext: warm, trace to 1+ DP pulses; no edema
neuro: PERRL 3-2.5mm; w/draws all extremities to pain; + corneal
reflex; eyes wander (conjugate gaze); unable to assess
dolls-head
Pertinent Results:
[**2119-2-8**] CT head: IMPRESSION: Slightly limited study due to
patient motion. Allowing for this, no evidence of intra- or
extra-axial hemorrhage.
.
The findings were discussed with Dr. [**First Name (STitle) **] [**Name (STitle) 1255**] [**Doctor Last Name **] at 9:40 p.m.
on [**2119-2-8**]. The outside hospital CT scan was obtained on hard
copy, and will be brought to the file room in the morning.
Review of that examination at the time of attending review does
show increased density of the tentorium, which presumably
relates to the large volume of IV contrast used for what
apparently was a cardiac catheterization at that facility, which
also resulted in visualization of the vascular tributaries of
the circle of [**Location (un) 431**] on this [**Hospital3 **] CT scan. This tentorial
enhancement is no longer seen, likely due to the renal excretion
of the contrast [**Doctor Last Name 360**].
.
[**2119-2-8**] CXR: 1. Successful intubation.
2. Diffuse bilateral hazy ground-glass opacities. This is
nonspecific, and may represent diverse etiologies depending on
the patient's clinical situation, e.g. aspiration, hemorrhage,
or PCP if the patient is immunocompromised. Followup is
recommended.
.
[**2119-2-10**] CXR: Since the prior chest x-ray, the endotracheal tube
and nasogastric tube have been removed. There has been no
significant change since the prior film of six hours previous.
The cardiomegaly, effusions, and some edema are still present.
.
IMPRESSION: Cardiac failure persists.
.
[**2119-2-10**] EKG: Sinus rhythm. Left axis deviation. Left
bundle-branch block. Compared to the previous tracing sinus
rhythm is now present.
Brief Hospital Course:
#) VF arrest/rhythm: Most likely a primary arrthymic event
(based on story of falling, pulseless with CPR for 10min, and
Vfib when EMS arrived) and secondary to ischemic scar from old
infacts. Does not appear to be ACS (low level CE, stenosis on
cath appeared old). ECGs during hospitalization showed sinus
rhythm/sinus tach with LBBB (no old ECGs for comparison). He
was loaded with amiodarone and maintained on metoprolol for rate
control. He was monitored on telemetry and had no further Vfib
events; rhythm strips obtained from EMS and the outside hospital
did not capture any v-fib events. He had an ICD implanted on
[**2119-2-17**] and tolerated the procedure well. He will follow up in
device clinic on [**2119-3-1**].
.
#) CAD/Ischaemia: He was taken for cardiac catheterization and
was found to have RCA and LCx occlusion which was thought to be
likely chronic. CE's were trended and peaked at low level
(likely related to post-code and not consistent with ACS). He
was continued on aspirin, and was titrated up on metoprolol. A
statin was not started right away given his elevated LFTs, but
once these normalized, he was started on a reduced-dose statin
(20mg atorvastatin)
.
#) Pump: Cath report showed an EF 15%; Multifactorial; ?acute
post code shock, ischemic cardiomyopathy, ?alcoholic
cardiomyopathy. Hopefully he will recover some function. A
repeat echo showed an EF of 20-25% with no major valvular
abnormalities. He will need another echo in approximately one
month to assess for recovery of his systolic function.
.
# fevers: He spiked fevers up to 102. He was initially started
on levo/metronidazole and vanco before a known source was found
to cover for likely aspiration pneumonia and line infections.
He was then found to have strep pneumo in his sputum and
continued to spike fevers until he was stabilized on an
antibiotic regimen of ceftriaxone/azithromycin. There was also
concern that these fevers might be related to alcohol withdrawl
and/or drug fever (from phenytoin, which was stopped on [**2-13**]).
He completed a five day course of azithromycin and his
ceftriaxone will be converted to cefpodoxime to complete a
10-day course.
.
#) Altered mental status/EtOH withdrawl: This has a
multifactorial origin: VF arrest, EtOH, sedation now. Per his
sister (whom he lives with) that he drank about [**1-20**] vodka per
night for 4 months and then stopped abruptly ~4 days prior to
admission. Neurology was consulted especially given question of
seizure activity at the OSH. An EEG was negative for seizures
and an LP showed normal cell count, protein, and glucose with no
evidence of infection. A psychiatry consultation was obtained
and they believed that his prolonged delirium may have been
benzodiazepine intoxication. He was maintained on standing
Haldol and only short-acting benzo's (lorazepam) were used for
his CIWA scale and his mental status gradually improved. He
worked with PT/OT to regain strength, balance, and functioning
prior to discharge.
.
#) Transaminitis: Patient has mildly elevated alt > ast. GGT
mildly elevated as well. Most likely secondary to mild shock
liver in setting of code. Underlying liver disease from h/o
recent heavy EtOH use, high triglycerides (150) could put him at
risk for more damage. His acetaminophen use was limited to
2g/day and he was eventually started on a reduced dose of
atorvastatin for his hyperlipidemia.
.
#) Elevated Cr: Initially had some ARF which was most-likely
ATN/hypoperfusion from cardiac arrest. He was hydrated and
received mucomyst for cath. His Cr trended down and recovered.
.
#) FEN/GI: He was given protonix for GI ppx given alcohol use.
He was also ordered for a speech and swallow eval after
extubation given his still "cloudy" mental status to assess risk
for aspiration. He eventually passed a speech and swallow
study, though was recommeded to have close supervision with
meals given his distractability. Heart healthy low sodium diet.
Medications on Admission:
none known
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
9. 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:
Primary diagnosis: cardiac arrest due to ventricular
fibrillation
Secondary diagnoses: alcohol abuse, ischemic and alcoholic
cardiomyopathy, coronary artery disease
Discharge Condition:
stable, alert and oriented x3, ambulatory.
Discharge Instructions:
You were admitted to the hospital with a cardiac arrest. You
had a defibrillator implanted to help keep your heart beating
properly and prevent against such an arrhythmia.
You were found to have severe disease of your coronary arteries
(the arteries that supply your heart with oxygen). For this,
you should take one aspirin daily for the rest of your life.
You were also started on medication for your cholesterol and
blood pressure. You are also finishing a course of antibiotics
(cefpodoxime) for a possible pneumonia.
In order to optimize the health of your heart, you should
completely avoid both cigarettes and alcohol. In order to help
you decrease your craving for cigarretes, you have been
prescribed the nicotine patch. Do NOT smoke and have the patch
on at the same time. You will be contact[**Name (NI) **] by [**Name (NI) 2411**] [**Name (NI) 51086**] to
talk with you about support systems to help avoid alcohol.
If you experience loss of consciousness, chest pain, high
fevers, or other concerning symptoms, you should seek medical
attention.
Followup Instructions:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2119-3-1**] 11:30 ([**Location (un) **] of [**Hospital Ward Name 23**] Building, [**Location (un) **])
.
You have a follow up appointment with Dr. [**Last Name (STitle) 23651**], ([**Telephone/Fax (1) 70831**], on Feburary 12th. Have your primary doctor schedule a
repeat echo in 4 weeks to assess your heart function.
ICD9 Codes: 4280, 5845, 4275, 412, 3051, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3031
} | Medical Text: Admission Date: [**2154-6-14**] Discharge Date: [**2154-7-5**]
Service: MED-BLUMGA
CHIEF COMPLAINT: Acute renal failure.
HISTORY OF PRESENT ILLNESS: The patient is an 88 -year-old
male admitted from [**Hospital3 2558**] with complaints of loose
bowel movements, tea colored urine, and increasing lethargy
and dehydration. On addition to the Emergency [**Doctor First Name **], the
patient was lethargic with [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing, dry
mucous membranes, bradycardic on admission with a heart rate
of 30 to 40, potassium of 6.2. The patient was treated with
one amp of D50, 5 units insulin, one amp of calcium
gluconate, given Lasix for congestive heart failure verified
by chest x-ray with poor response. He was transferred to the
Cardiac Care Unit / Medical Intensive Care Unit for closer
observation.
PAST MEDICAL HISTORY:
1. Atrial fibrillation, treated with Digoxin and on
admission the level was 2.3.
2. Gastric polyps.
3. History of gastrointestinal bleed.
4. Methicillin resistant Staphylococcus aureus in the urine.
5. Anemia.
6. Hypertension.
7. A massive left sided cerebrovascular accident on [**2154-4-30**], leaving the patient with left sided neglect and left
hemiparesis.
PHYSICAL EXAMINATION: On admission, the patient's neurologic
examination was significant for being able to open eyes
spontaneously and reacting to painful stimuli. He speaks
only Russian. He moves his right side only. Soft restraints
on right wrist to prevent the patient from pulling lines.
The respiratory examination showed coarse breath sounds with
rales in both bases. The patient also had occasional wheezes
noted bilaterally. He remains on room air and O2 saturation
was 97%. He continues with frequent periods of apnea,
lasting 15 to 25 seconds, [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing pattern,
and a question of a left lower lobe pneumonia on examination.
The heart rate was stable in the mid 70s, occasional
bradycardic episodes with rates down to the 30s, occasional
premature ventricular contractions rhythm, consistent also
with atrial fibrillation.
On genitourinary examination, there is a Foley draining
cloudy, amber urine in fair amounts. The Foley was leaking
at the insertion site. Warm saline was added to the balloon
with no effect. Gastrointestinal examination: there was a
G-tube that was clamped and it was flushed well. There was
positive bowel sounds and he was passing small amounts of
soft, dark stool. The skin integrity showed an ulceration on
the left lateral malleolus, the size of a nickel and with
wet-to-dry dressings applied. Numerous small broken areas
were noted on the coccyx and Aloe Vesta Perineal cream was
applied to that. The patient was consistent repositioned on
bed to prevent further breakdown. The patient's vital signs
on admission were a temperature of 99 F, a pulse of 65 to 90,
respiratory rate 26, oxygen saturation of 95% on room air,
and a blood pressure of 161/58.
HOSPITAL COURSE: The patient remained in the Medical
Intensive Care Unit for management of acute renal failure
with creatinine going from 0.5 to 3.6 with minimal urine
output. It should also be noted that on physical
examination, the patient had bilateral hydroceles in the
scrotum. The patient was managed in the Intensive Care Unit
on admission with intravenous fluid hydration and
ciprofloxacin treatment from [**6-14**] through [**2154-6-23**],
for a urinary tract infection. He was transferred to the
Medical floor on [**2154-6-16**].
His hospital course was significant for an increase in
creatinine to a maximum of 7.3. The differential diagnoses
were thought to be acute tubular necrosis or acute
interstitial nephritis, possibly with minimal [**Last Name (un) **]
disease. The patient had significant proteinuria of 1.8 gm
in 24 hours. The potassium managed initially well with
Kayexalate. Prednisone was begun at 60 mg q day on [**6-22**],
to empirically treat possible acute interstitial nephritis.
The ciprofloxacin was discontinued secondary to the possible
contribution of the acute interstitial nephritis.
The decision was made to initiate hemodialysis due to the
worsening problems with the volume overload and electrolyte
abnormalities in the patient. On [**2154-6-25**], the patient
underwent Quinton catheter placement. A right femoral was
attempted without good flow. A left femoral was successful
and had catheter placement. The patient underwent
hemodialysis with a removal of 1.0 kg. On return to the
Medical floor the patient was noted to have a decrease of his
systolic blood pressure to 75, which improved with 500 cc
normal saline and gave a systolic blood pressure of 100.
Later in the evening, the patient had another episode of
systolic blood pressure dropping below 70. The hematocrit
showed 20.2, down from 26.2 earlier in the day. A CT scan of
the abdomen obtained to assess for hematoma showed a right
thigh hematoma, apparently from the venous source. There was
no retroperitoneal bleed seen. The patient was emergently
transfused with one unit packed red blood cells and given
additional 250 cc of normal saline bolus. There was a
systolic blood pressure reaching 100. The patient was still
anuric / oliguric.
Arrangements were made for the transfer of the patient to the
Medical Intensive Care Unit for closer monitoring of the
bleed and respiratory status. The patient's son was notified
of plans for transfer. Full code was verified by the
[**Hospital 228**] medical team.
After being transferred to the Medical floor, the patient
remained stable, except for a continued drop in hematocrit,
such that the patient received a total of six units of packed
red blood cells over the course of [**6-25**] through [**6-29**].
However, over time, the patient's hematocrit stabilized. In
addition, the patient responded well to hemodialysis, such
that his mental status improved and a decrease in his global
body edema was noted on physical examination. The patient's
condition continued to improve with hemodialysis as stated
before, and the ulcer noted on admission on the left lateral
malleolus continued to heal with appropriate granulation and
no other bed sores were noted on the patient, thanks to
appropriate nursing care.
The patient was also noted to have yeast in his urine on [**6-22**] and on [**6-28**], for which he was treated with Diflucan and
he had no other infections.
In summary of his diagnostic procedures done during the
course of his hospital stay, the patient's initial
electrocardiogram showed atrial fibrillation with an average
ventricular rate of 65. Since the previous tracing of [**2154-5-8**], the ventricular response rate has slowed slightly. No
other significant changes had occurred. The intervals were
normal, he had a normal axis. In addition, the patient
underwent several radiological examinations, the significant
one being the CT scan on [**6-25**], which showed a large right
groin hematoma, tracking along the right medial muscle,
compartment to approximately the upper third of the femur.
There was no evidence of retroperitoneal hemorrhage.
Second, there were small bilateral pleural effusions. The
ultrasound of the patient's scrotum on [**6-25**] showed
bilateral hydroceles. Chest x-ray done on [**6-26**] showed
right sided hemodialysis catheter tip in the distal SVC as a
Quinton catheter was placed in the anterior thorax and there
was no pneumothorax after the procedure. There was also
decreased pulmonary edema and congestive heart failure
compared with the admission x-ray and there was persistent
left lower lobe collapse / consolidation. And there was an
unchanged level of bilateral pleural effusions.
A Doppler study of the right thigh to discover the extent of
venous flow within the right leg, although grossly limited
study as described in its longer report, there was no
definite evidence of a deep vein thrombosis. Right common
femoral artery, superficial femoral popliteal veins were of a
small caliber throughout, which they have been related to
venous compression from adjacent soft tissue swelling or the
hypovolemic state. The microbiological studies for the
patient in summary: the stool studies never showed any
Clostridium difficile and the urine culture was positive for
yeast. Blood cultures have been consistently negative with
the exception of a presumed contaminant of Staphylococcus
epidermitis.
The patient received overall, six units of packed red blood
cells during his stay in the hospital. Again, the patient's
mental status improved, the bleeding was clinically
determined to be over, and the patient's volume and
electrolyte status improved with hemodialysis, to the point
where he was ready for discharge.
DISCHARGE MEDICATIONS: Include Albuterol / Atrovent
nebulizer treatment, enteric coated aspirin 325 mg q day,
Zantac 150 mg q day, Diflucan 200 mg q 48 hours, Prilosec 20
mg q day, RenaGel 400 mg q day, Niferex 150 mg [**Hospital1 **], Lopressor
50 mg [**Hospital1 **], Tylenol 650 mg q four to six hours prn, PhosLo
three tablets qid, Nystatin powder [**Hospital1 **] to the appropriate
areas. Tube feeds are Nepro and ProMod at 45 cc/hr for
eighteen hours during the day.
CODE STATUS: Full code.
ALLERGIES: No known drug allergies.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To a nursing facility.
DISCHARGE DIAGNOSIS:
Acute renal failure.
UNDERLYING DIAGNOSES:
1. Hemiparesis from an middle cerebral artery stroke.
2. Atrial fibrillation.
3. Hypertension.
4. Gastrointestinal bleeds.
5. Urinary tract infections.
6. Dementia.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 3033**]
MEDQUIST36
D: [**2154-7-3**] 18:17
T: [**2154-7-4**] 07:15
JOB#: [**Job Number 93889**]
ICD9 Codes: 5849, 5990, 2765, 4280, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3032
} | Medical Text: Admission Date: [**2159-2-18**] Discharge Date: [**2159-2-24**]
Service: ACOVE
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female with Alzheimer's dementia and chronic aspiration,
status post jejunostomy tube, with diverticulosis, urinary
incontinence, and history of a gastrointestinal bleed who
presented to the Emergency Department with several hours of
shortness of breath not resolving.
In the Emergency Department, the patient was tachycardic,
initially normotensive with an oxygen saturation of 96% on
room air. Her troponin T was found to be 0.67 and went to
0.8. The patient was started on aspirin, heparin, and
Lopressor. A chest x-ray revealed a question of pneumonia
and congestive heart failure. The patient was given Lasix 20
mg intravenously times one with levofloxacin and Flagyl and
subsequently developed hypotension to 86/59.
An emergent bedside echocardiogram revealed severe right
ventricular hypokinesis and akinesis, moderate aortic
regurgitation, moderate mitral regurgitation, and severe
tricuspid regurgitation with a tricuspid regurgitation jet of
40 mmHg to 45 mmHg. Of note, the patient has a history of a
right lower extremity edema times one day. Echocardiogram
findings were concerning for hemodynamically significant
pulmonary embolism. Given the acute renal failure the
patient was found to be in, a computed tomography angiogram
was deferred due to concern of dye load. The patient was
started on 2 liters of intravenous fluids and dopamine. The
heparin drip was continued. The patient was transferred to
the Surgical Intensive Care Unit for management of pulmonary
embolism/myocardial infarction.
The patient had brown stool with bright red streaks in the
Emergency Department. External hemorrhoids were found on
examination. The patient could grunt but not answer any
questions. She opened her eyes to voice when she was shaken
gently.
PAST MEDICAL HISTORY:
1. Alzheimer's dementia.
2. Diverticulosis.
3. Aspiration; status post jejunostomy tube in [**2157-1-21**].
4. Gastrointestinal bleed in [**2158-6-20**] with negative
esophagogastroduodenoscopy and diverticulosis on colonoscopy.
5. Previous duodenal ulcer on [**2158-10-21**]
esophagogastroduodenoscopy but healed on [**2158-6-20**]
esophagogastroduodenoscopy.
6. Diabetes mellitus (diet controlled).
7. Urinary incontinence.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lopressor 12.5 mg by mouth twice per day.
2. Lisinopril 2.5 mg by mouth once per day.
3. Aricept 10 mg by mouth once per day.
4. Protonix 40 mg by mouth twice per day.
5. Multivitamin.
6. Vitamin E 400 International Units by mouth every day.
SOCIAL HISTORY: The patient lives with her son and her
daughter-in-law. She has two daughters and one son. She is
cared for by two nurses. She was born in [**Location (un) 6847**] and has
lived in the United States for 30 years.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient's temperature was 100.4
degrees Fahrenheit, her heart rate was 105, her blood
pressure was 104/60, her respiratory rate was 21, and her
oxygen saturation was 98% on 1.5 liters of nasal cannula. In
general, she was an elderly Chinese female in no apparent
distress. She opened her eyes to voice, and she was
nonverbal. Head, eyes, ears, nose, and throat examination
revealed pupils were 1.5 mm and went to 1 mm. The mucous
membranes were slightly dry. Jugular venous pressure was
approximately 8 cm. Chest had bilateral crackles half to
two-thirds of the way up. Heart had a holosystolic murmur
all over the precordium; most pronounced at the left sternal
border and the apex. She had a regular rhythm. The abdomen
was softly distended and nontender. The liver edge was 3.5
fingerbreadths below the costal margin. A PEG-tube was in
place with surrounding tenderness or erythema. Extremities
had 1+ pedal edema on the right side. There was no edema on
the left. No clubbing or cyanosis. There was a hematoma
over the right dorsal hand. On neurologic examination, she
was asleep but arousable to voice.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 10.2, her hematocrit was 35.1, and her
platelets were 277. Her INR was 1.6. Her partial
thromboplastin time was 60.9. Sodium was 139, potassium was
5.8, chloride was 104, bicarbonate was 25, blood urea
nitrogen was 96, creatinine was 1.6 (baseline was known at
0.8), and her blood glucose was 193. Urinalysis was
negative. Liver function tests were within normal limits. As
stated, troponin went from 0.67 to 0.83; however, creatine
kinase and MB values remained flat. Her lactate was 1.8.
Arterial blood gas was 7.41/38/103.
PERTINENT RADIOLOGY/IMAGING: A KUB revealed no free air and
no obstruction.
A right lower extremity Doppler study revealed no deep venous
thrombosis.
A chest x-ray revealed bilateral lobe infiltrates with
bilateral pleural effusions (right greater than left),
moderate alveolar enlargement, dilated aorta, cephalization;
consistent with acute left ventricular failure.
An electrocardiogram revealed a normal sinus rhythm at 92
beats per minute, borderline primary atrioventricular nodal
block, old Q waves seen in III, old T wave inversions in III.
There was poor R wave progression (brand new). New T wave
flattening in the precordial leads.
IMPRESSION: Our impression was that this is an 83-year-old
Cantonese-speaking woman with baseline dementia, diet
controlled diabetes mellitus, and a history of aspiration
(status post a gastrojejunostomy tube), and a history of
gastrointestinal bleed now presenting with hypotension, a
blown right ventricle, likely pulmonary embolism, congestive
heart failure exacerbation, aspiration pneumonia, and acute
renal failure.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. HYPOTENSION ISSUES: Due to blown right ventricle
cardiogenic shock, there was a question of septic shock;
however, the patient's lactate was normal and there was clear
evidence of new right ventricular dysfunction on chest x-ray.
The patient was given aggressive intravenous fluids given
that she was highly preload dependent. The patient was
started on dopamine. She was put on heparin for her
pulmonary embolism and question of myocardial infarction. It
was determined not to give t-[**MD Number(3) 6360**] the fact that she had a
gastrointestinal bleed history.
2. ELEVATED TROPONIN ISSUES: Elevated troponin levels
presumed to be secondary to blown right ventricle; less
likely a myocardial infarction secondary to flat creatine
kinase levels. Cardiac enzymes were followed. The heparin
drip was continued with aspirin, and beta blocker was held
for hypotension as well as ACE inhibitor.
3. ACUTE RENAL FAILURE ISSUES: There was a question of
prerenal secondary to hypotension and poor forward flow.
There was no evidence for acute tubular necrosis found on
urine electrolytes. The patient was maintained on
intravenous fluids and dopamine to keep her blood pressure
adequate.
4. HYPERKALEMIA ISSUES: Hyperkalemia was presumed to be
secondary to acute renal failure versus her ACE inhibitor.
Unclear what her baseline potassium was. She had no
electrocardiogram changes, and Kayexalate was given once with
good affect. Her potassium decreased appropriately.
5. CONGESTIVE HEART FAILURE ISSUES: Congestive heart
failure was presumed to be secondary to mitral regurgitation.
Stable oxygen saturations throughout. She was not diuresed
any further given the fact that she had a blown right
ventricle and was preload dependent for her cardiac output.
6. HEPATOMEGALY ISSUES: There was a question of congestion
from right-sided failure. The patient had normal liver
function tests and normal synthetic function. Given that all
these were normal, it was determined not to work this up
further at this time. There was no evidence of pancreatitis
on examination either.
7. QUESTION OF INFILTRATE/PNEUMONIA ISSUES: This was
thought to be aspiration pneumonia. The patient did not have
poor dentition. She had no teeth. She was covered with
levofloxacin.
8. TYPE 2 DIABETES MELLITUS ISSUES: The patient was given
regular insulin sliding-scale for tight glucose control. Her
glucose was monitored regularly and keep at less than 200.
9. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: Calcium,
magnesium, and phosphate were monitored carefully in the
setting of renal failure. Tube feeds were held initially.
10. ACCESS ISSUES: Access was determined to be peripheral
intravenous because the patient's family wanted to avoid
invasive procedures and wanted to avoid central lines. The
patient continued with a Foley catheter and a PEG-tube.
11. COMMUNICATION ISSUES: Communication was regular with
the son, and daughter-in-law, and sisters.
12. CODE STATUS ISSUES: The patient's code was confirmed
with the interpreter, the son, and daughter-in-law. The
patient was made do not resuscitate/do not intubate. Her son
is the health care proxy. [**Name (NI) **] did not want any central lines
placed. If she were to need dialysis, they wanted her to
receive it if was required for survival. Given the
seriousness of her situation, they wanted to continue full
support until one of her children arrived from [**Location (un) 6847**] on
[**2-15**].
Intravenous fluid boluses causes the patient's blood pressure
to increase appropriately. Lopressor continued to be held.
Tube feeds were started to maintain her nutrition. The
patient was initially hypernatremic. She was given free
water boluses to resolve this. The patient's bicarbonate
dropped occasionally and her chloride increased due to the
high intravenous fluid repletion with sodium chloride in the
setting of renal insufficiency. The patient had persistent
hypotension that was always responsive to intravenous fluid
boluses. The patient's urine output was found to be low.
She was continued on dopamine to improve this. The patient
was started on digoxin to increase her contractility given
that she had a blown right ventricle and severe right heart
failure. Dopamine was discontinued given that the patient's
urine output increased appropriately and was maintained.
The patient was transferred to the floor on [**2159-2-16**]. The patient was found to have a leaking
gastrojejunostomy tube site that became nonfunctional. This
was replaced by Interventional Radiology. At this time, it
was determined that it was the jejunostomy tube. Heparin was
continued. The patient's platelets were found to be low.
Thrombocytopenia became a [**Last Name **] problem. Heparin-induced
thrombocytopenia antibody was found to be negative. Until
heparin-induced thrombocytopenia antibody was negative, the
patient was placed on argatroban and then was returned to
heparin once it was found to be negative. It was determined
that her thrombocytopenia was likely due to marrow
suppression or splenic sequestration or clot consumption
given her large pulmonary embolism.
The patient's initial hypoxia was presumed secondary to her
pulmonary embolism. She had copious secretions. She was
given aggressive chest physical therapy and suctioning. She
was treated with levofloxacin and Flagyl for aspiration
pneumonia and had aggressive pulmonary toilet. She was given
nebulizers as needed for wheezing that she had. The
patient's hypoxia resolved completely and had oxygen
saturation on room air of 97% within a few days after this.
The patient's acute renal failure continued to worsen;
especially after persistent hypotension. The patient was
given adequate feedings with Nepro, and renal protection, and
free water boluses. Given that the patient was approximately
10 liters positive in her fluid balance, even though she had
normal oxygen saturations, it was determined that it was best
to try giving her some Lasix. The patient was given 20 mg of
intravenous Lasix within a period of six hours. The patient
became hypotensive to the 80s. Notably, at this time, the
patient was mentating well and interacting with her son at
this blood pressure; however, she was given boluses of 100 cc
of normal saline twice to bring her blood pressure up to 100
systolic over the next 12 hours. The patient was then found
to be hypernatremic again, and free water fluid boluses were
increased.
After gastrojejunostomy tube was replaced, the patient was
started back on Coumadin to give her a therapeutic INR at 3
mg per night. At this time of summary, the patient had
congestive heart failure with severe right ventricular
dilation, 4+ tricuspid regurgitation, and an ejection
fraction of 45%. She was clinically stable. She was put
back on digoxin at a very low dose of 0.0625. Her vital
signs were found to be at baseline. Her blood pressure was
stable in the low 100s. She was maximally after load
reduced. She was volume overloaded but very preload
dependent.
Regarding her pulmonary embolism, her hypoxia had completely
resolved. She was anticoagulated with heparin and then
Coumadin. She was given a scopolamine patch for her
secretions, and her respiratory rate was very stable and
comfortable at 20.
For aspiration pneumonia, she received a full 7-day course of
levofloxacin and Flagyl and her INR was monitored carefully
after receiving levofloxacin and Coumadin.
Her acute renal failure continued to worsen. Urine
electrolytes were checked again, this was found to be fully
prerenal. It was presumed to be secondary to a poor cardiac
output and poor forward flow given that the patient's cardiac
output was so poor. Her baseline creatinine at best was 30
mL/min. It was presumed to be quite worse than this;
however, the patient made urine well. When urine output
decreased again, after hypotensive episodes, an additional 5
mg of intravenous Lasix was given to the patient with good
affect.
The patient's diabetes was well controlled on an insulin
sliding-scale which was changed to Humalog insulin given her
renal insufficiency. She had peripheral intravenous access
because the patient had wishes for no central lines
whatsoever.
For fluids/electrolytes/nutrition, the patient received tube
feeds and free water boluses via her percutaneous endoscopic
gastrostomy tube. Her tube feeds were half strength of Nepro
at 40 cc per hour with free water boluses of 200 to 300 q.4h.
For prophylaxis, the patient was maintained on a proton pump
inhibitor, anticoagulation, and a bowel regimen and had good
bowel function.
She was do not resuscitate/do not intubate with no central
lines as per the family's wishes.
She was sent to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Location 8391**]. She
continued her treatment donepezil 10 mg at hour of sleep for
her Alzheimer's disease.
CONDITION AT DISCHARGE: The patient was discharged in stable
condition.
DISCHARGE DISPOSITION: Discharged to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
DISCHARGE DIAGNOSES:
1. Alzheimer's dementia.
2. Type 2 diabetes.
3. Chronic aspiration.
4. Hypotension.
5. Hyperkalemia.
6. Acute renal failure.
7. Hypernatremia.
8. Aspiration pneumonia.
9. Urinary incontinence.
10. Pulmonary embolism.
11. Systolic congestive heart failure.
MEDICATIONS ON DISCHARGE:
1. Coumadin 3 mg at hour of sleep.
2. Lansoprazole 30 mg per nasogastric tube once per day.
3. Morphine 1 mg intravenously as needed (for dyspnea).
4. Scopolamine patch every three days.
5. Digoxin 0.0625.
6. Colace 100 mg by mouth twice per day.
7. Senna one to two tablets by mouth as needed.
8. Bisacodyl one to two tablets by mouth as needed.
9. Multivitamin.
10. Nephrocaps by mouth every day.
11. Donepezil 10 mg by mouth at hour of sleep.
12. Aspirin 325 mg per gastrojejunostomy tube once per day.
13. Tylenol as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. Rehabilitation was instructed to check the patient's INR
on [**2159-2-26**] and thereafter; monitor carefully after
levofloxacin was discontinued.
2. Rehabilitation was instructed to monitor her sodium level
for hypernatremia and to monitor her urine output.
DISCHARGE DISPOSITION: All plans were discussed with the
family extensively and the patient was discharged to [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2159-2-23**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 6374**]
MEDQUIST36
D: [**2159-2-23**] 08:17
T: [**2159-2-23**] 08:29
JOB#: [**Job Number 29198**]
ICD9 Codes: 5849, 2767, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3033
} | Medical Text: Admission Date: [**2107-5-1**] Discharge Date: [**2107-5-13**]
Date of Birth: [**2046-1-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
slurred speech and left facial droop
Major Surgical or Invasive Procedure:
right craniotomy
tracheostomy
peg placement
History of Present Illness:
Mrs. [**Known lastname 78838**] is a 61 y/o female with remote history of seizures,
HTN and detatched retina who was in good health until evening of
[**2107-4-30**] when she began to demonstrate slurred speech and left
facial droop. No falls or trauma surrounding this event, and she
did not have a headache or loss of consciousness during this
time. She then developed left sided weakness and was taken to
[**Hospital1 18**] ER by family. Head CT without contrast revealed
approximately 5x4x4 cm right frontal/insular hemorrhage with
some effacement of the right lateral ventricle.
Past Medical History:
hyperlipidemia
Hypertension
detached retina - right eye
PSHx:
hysterectomy
eye surgery for detached retina x 3
Social History:
Works in a sub-[**Location (un) 6002**] shop. Remote tob 20 yrs ago, social
etoh.
Family History:
No strokes or bleeds. Son is congenitally deaf. DM and HTN
in family.
Physical Exam:
Admission:
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech dysarthric with normal comprehension and
repetition; naming intact. [**Location (un) **] and writing
intact. Registers [**2-14**], recalls [**2-14**] in 5 minutes. No right left
confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular
movements intact bilaterally, no nystagmus. Sensation intact
V1-V3. Facial movement symmetric. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift right side
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
withdraws left leg to stimulation, but does not follow commands
with LLE
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Pertinent Results:
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2107-4-30**] 10:37 PM
CT HEAD W/O CONTRAST
Reason: SPONTANEOUS RT FRONTAL BLEED
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman with spontaneous right frontopariteal
hemorrhage.
REASON FOR THIS EXAMINATION:
increased bleed?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Spontaneous right frontoparietal hemorrhage,
evaluate for increased bleed.
COMPARISON: No prior studies available for comparison.
TECHNIQUE: Non-contrast head CT scan.
FINDINGS: There is a large area of hyperdensity consistent with
acute intraparenchymal hemorrhage involving the right frontal
lobe, measuring approximately 6.4 x 5.3 cm in axial dimensions.
Low density area is seen surrounding the hemorrhage, consistent
with edema. There is mass effect on the right lateral ventricle
with leftward shift of approximately 5 mm. Suprasellar cistern
and temporal horns appear preserved. Mucosal thickening in the
right maxillary sinus is incompletely evaluated.
IMPRESSION: Large intraparenchymal hemorrhage seen involving the
right frontal lobe, with surrounding edema. Underlying lesion
cannot be excluded, and further evaluation with MRI could be
helpful. Leftward shift of approximately 5 mm.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: SUN [**2107-5-1**] 9:03 AM
Brief Hospital Course:
61 F admitted to the Trauma ICU found to have a RIGHT MCA
ANEURYSM her BP was kept strictly less than 140, Q1 Neurochecks
implemented and she was brought the the angio suite and had a
formal angiogram and the the aneursym was not able to be coiled.
She brought to the OR and underwent a right sided cranitomy with
coiling of aneurysm. Post operatively she was plegic on the left
side same as pre-op. Post operatively she would follow commands
on the right. On POD#1 she was extubated but had difficulty
managing her secretions she was electively re-intubated on POD#2
. She was also found to have expanding edema in her hemorrhage
site and a right temporal infarct. She was started on hypertonic
saline with good effect her exam improved the saline continued
for 3 days. On [**5-9**] she developed fevers pan cultures showed a
left lower lobe pneumonia and sputum grew H. Influeza and a
urinary tract infection with ecoli in her urine, her foley was
changed.She was started on Vanco and Ceftaz and later changed to
Levaquin due to a rash which was thought to be related to
Dilantin which was also discontinued and changed to Keppra. She
is currently being treated with Levaquin until [**5-20**]. She had
PEG and trach on [**5-10**] she was weaned from the vent on [**5-11**]. A follow up chest xray on [**5-13**] showed a resolving
pneumonia but some air in the diaphram a flueroscopy study
showed no air leak and she was cleared by the general surgeon
for discharge. Her WBC count has been between 14-17 last few
days. She has no fever and resolving pneumonia on CXR. The WBC
should be followed closely. Her wound was clean and dry healing
well. There is some csf under the flap which is resolving her
head should be kept greater than 30 degrees. Neurologically on
discharge she has a right gaze preference, follows commands on
the right side and plegic on the left. She will knod or mouth
appropriate answers to questions.
Medications on Admission:
lipitor
unknown BP med
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q6H (every 6 hours) as needed.
10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 78839**]
Discharge Diagnosis:
intraparenchymal hemorrhage
respiratory failure
right temporal stroke
LLL pneumonia
Urinary tract infection
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions
?????? 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 as
ordered.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow up in 4 weeks with a head CT non contrast, call Dr [**First Name (STitle) **]
office for an appointment [**Telephone/Fax (1) 1669**].
Have your trach stitches removed in 2 weeks.
Completed by:[**2107-5-13**]
ICD9 Codes: 5185, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3034
} | Medical Text: Admission Date: [**2181-1-10**] Discharge Date: [**2181-1-14**]
Date of Birth: [**2140-2-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Latex
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Known MVP, asymptomatic
Major Surgical or Invasive Procedure:
[**1-10**] MVR (#29 [**Company **] mosaic porcine valve)
History of Present Illness:
40 yo M with known MVP followed by echo. New murmur was detected
on PE, subsequent echo showed severe MR with a flail leaflet.
Past Medical History:
MVP, MR
Schatzkis ring with periodic esophageal dilatation
GERD
s/p knee surgery
s/p hernia repair
Social History:
lives with fiance
works as electrical engineer
quit smoking 2 months ago; [**12-19**] ppd
Family History:
nc
Physical Exam:
NAD
Hr 84 RR 20 124/80 right 130/80 left
6'2" 190#
Admission exam unremarkable except for holosystolic murmur.
Pertinent Results:
[**2181-1-12**] 06:30AM BLOOD WBC-13.4* RBC-4.01* Hgb-12.1* Hct-34.7*
MCV-87 MCH-30.2 MCHC-35.0 RDW-13.0 Plt Ct-181
[**2181-1-12**] 06:30AM BLOOD Plt Ct-181
[**2181-1-12**] 06:30AM BLOOD Glucose-104 UreaN-17 Creat-1.0 Na-139
K-4.3 Cl-102 HCO3-30 AnGap-11
[**2181-1-14**] 04:00AM BLOOD WBC-8.7 RBC-3.71* Hgb-11.5* Hct-31.1*
MCV-84 MCH-30.9 MCHC-36.9* RDW-13.1 Plt Ct-271
[**2181-1-14**] 04:00AM BLOOD PT-11.7 PTT-27.6 INR(PT)-1.0
[**2181-1-14**] 04:00AM BLOOD Plt Ct-271
[**2181-1-14**] 04:00AM BLOOD Glucose-108* UreaN-12 Creat-0.9 Na-135
K-4.2 Cl-100 HCO3-28 AnGap-11
[**2181-1-14**] 04:00AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.3
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 58426**] (Complete)
Done [**2181-1-10**] at 12:06:19 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
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: [**2140-2-24**]
Age (years): 40 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Mitral valve disease. Intra-op TEE for MVR
ICD-9 Codes: V43.3, 424.1, 424.0
Test Information
Date/Time: [**2181-1-10**] at 12:06 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW06-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm
Left Ventricle - Ejection Fraction: 50% to 60% >= 55%
Aorta - Sinus Level: 3.5 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Arch: 2.6 cm <= 3.0 cm
Findings
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%). [Intrinsic LV
systolic function likely depressed given the severity of
valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Focal calcifications in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Myxomatous
mitral valve leaflets. Moderate/severe MVP. No MS. [**Name13 (STitle) 650**] (4+)
MR. Eccentric MR jet.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient was under
general anesthesia throughout the procedure. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
Conclusions
Note: Due to this patients history of distal esophageal
stricture, only upper and mid esophageal views preformed. Probe
passed easily and atraumatcially.
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2.. Overall left ventricular systolic function appears normal
from mid esophageal windows. (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.]
3. Right ventricular chamber size and free wall motion are
normal.
4. There are three aortic valve leaflets. There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. The mitral
valve leaflets are myxomatous. There is moderate/severe mitral
valve prolapse. Severe (4+) mitral regurgitation is seen. The
mitral regurgitation jet is eccentric.
POST-BYPASS: Pt is in sinus rhythm and on an infusion of
phenylephrine
1. A bioprosthesis is well seated in the mitral position. No MR
is seen. Leaflets open well. An average mean gradient of 10 mm
of Hg is seen. CO is 8-9 L/min by thermodilution. No obvious
structural problems are seen with the valve. There is no
residual mitral regurgitation. 3-Dimensional reconstruction was
preformed and revealed no obstruction of the LVOT and a widely
opening prosthetic valve.
2. Aorta is intact
3. Biventricular function is grossly preserved.
4. Other findings are unchanged.
5. All findings discussed with surgeons at the time of the exam.
6. Probe removed easily at end of the exam without evidence of
trauma or bleeding.
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
?????? [**2176**] CareGroup IS. All rights reserved.
Brief Hospital Course:
He was taken to the operating room on [**2181-1-10**] where he
underwent an MVR with a tissue valve. He was transferred to the
SICU in critical but stable condition. He was extubated later
that same day. He was weaned from his vasoactive drips and
transferred to the floor on POD #1. Chest tubes and pacing wires
removed without incident. He made good progress and was cleared
for discharge to home with services on POD #4.
Medications on Admission:
prilosec
advil
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily ().
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. 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*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
MVR on [**2181-1-10**]
MVP, MR
Schatzkis ring with periodic esophageal dilatation
GERD
s/p knee surgery
s/p hernia repair
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more then 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving until follow up with surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**Last Name (STitle) 5448**] 2 weeks
Dr. [**Last Name (STitle) 20222**] in [**1-20**] weeks
Completed by:[**2181-1-15**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3035
} | Medical Text: Admission Date: [**2159-5-17**] Discharge Date: [**2159-6-2**]
Date of Birth: [**2091-4-29**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
transfer for ICH
Major Surgical or Invasive Procedure:
PERC G/G-J TUBE PLMT
CT HEAD W/O CONTRAST
Cardiology ECG
MR HEAD W/O CONTRAST
MRA BRAIN W/O CONTRAST
History of Present Illness:
68yo RH M h/o AVM that bled in [**2154**], HTN and EtOH abuse with h/o
DT's who was in his USOH until Saturday night. History is per
the patient's wife and son, as he is unable at present to speak,
as well as his OSH chart and EMS note. He showered Saturday
night and then complained of sudden onset neck pain and flashing
lights. He vomited once then was fine, with his vision clearing.
He had had no recent trauma. No headache.
He was then well until Tuesday when he was sleepy throughout the
day. That night, he again had N/V, this time continued, and he
vomited his meds at 9pm. Wednesday he stayed in bed and could
walk though with difficulty to the restroom (he did so only
once). Thursday, he could no longer get OOB and his conversation
was reduced to yes/no answers to questions. He was easily
arousable to voice but this evening, he had so much difficulty
getting OOB that his wife became concerned (she had previously
thought him to have a GI illness) and called EMS.
On their arrival, he was found to be hypertensive to 190/100 and
with "mild confusion". He was taken to [**Hospital3 1280**], where ICH was
found and he was transferred here for neurosurgical evaluation.
He has received two doses of labetalol IV to lower his bp, which
has ranged as high as sbp 190's. He was also loaded with
dilantin 1.5g IV at 7pm.
On neurosurgical evaluation, he was arousable by voice and could
state his name and follow intermittent commands. By the end of
their evaluation, however, he was sleepy and began closing his
eyes.
The pt was unable to offer a review of systems. Per his wife, he
had had no recent illnesses.
Past Medical History:
L medial temporal AVM extending into the lateral ventricle. It
bled in [**2154**], requiring EVD and ICU stay, leaving him with
subtle
language deficits and mild right hemiparesis (pt refused gamma
knife and surgery was deferred due to the location)
Seizure disorder, subsequent to his hemorrhage
HTN (of note, had not been able to take his meds for 2 days)
Social History:
Lives at home with his wife. Retired bank VP. Quit smoking 20yrs
ago. Drinks 8 beers a day per his wife, has h/o DTs. No other
drug use.
Family History:
Father with early MI, o/w negative.
Physical Exam:
VS 100.6 85 112-182/65-82
Gen lying in bed in NAD
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted
NEURO
MS
Opens his eyes to noxious stimuli only and requires repeated
stimuli to stay awake. No verbal output. Does not follow
commands. To nasal tickle and sternal rub, his left arm
localizes to the stimulus.
CN
PERRL 2 to 1.5mm. EOMI to oculocephalic maneuver; eyes
dysconjugate and roving. Corneal reflex and nasal tickle
present
bilaterally. No overt facial asymmetry.
MOTOR
Normal bulk, tone throughout. Withdraws to noxious stimuli in
all four extremities, both arms purposefully but the left more
vigorously. No asterixis noted. No myoclonus noted. Legs
withdraw to noxious stimuli and are occasionally moved
spontaneously.
SENSORY
Grimaces to noxious stimuli in all four extremities.
REFLEXES
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally.
Pertinent Results:
WBC-12.4* RBC-4.89 Hgb-15.8 Hct-44.3 MCV-91 MCH-32.3* MCHC-35.7*
RDW-13.9 Plt Ct-286 Neuts-87.3* Bands-0 Lymphs-7.8* Monos-4.8
Eos-0.1 Baso-0
Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL
Microcy-NORMAL Polychr-NORMAL
PT-12.1 PTT-28.0 INR(PT)-1.0
Glucose-131* UreaN-16 Creat-0.8 Na-128* K-3.4 Cl-91* HCO3-24
AnGap-16 ALT-19 AST-18 AlkPhos-62 TotBili-1.1
[**2159-5-17**] 06:50PM BLOOD CK(CPK)-87 CK-MB-NotDone cTropnT-<0.01
[**2159-5-18**] 02:40AM BLOOD CK(CPK)-74
[**2159-5-18**] 10:10AM BLOOD CK(CPK)-115 CK-MB-3
[**2159-5-18**] 04:05PM BLOOD CK(CPK)-111
[**2159-5-17**] 06:50PM BLOOD
[**2159-5-18**] 10:10AM BLOOD
[**2159-5-18**] 04:05PM BLOOD CK-MB-3
[**2159-5-18**] 02:40AM BLOOD Albumin-3.5 Calcium-8.1* Phos-3.1 Mg-2.2
[**2159-5-18**] 02:40AM BLOOD Osmolal-270*
[**2159-5-20**] 07:33AM BLOOD Vanco-6.2*
[**2159-5-18**] 02:40AM BLOOD Phenyto-13.4
[**2159-5-17**] 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
WBC 12.4, hct 44.3, plt 286
SMA Na 128, K 3.4, Cl 91, CO2 24, glu 131
Coags normal
CE's negative
UA likely dirty
Imaging
NCHCT [**5-17**]: Bilateral intraventricular hemorrhage is identified
layering in bilateral occipital horns. Two high-density foci
superior to known region of AV malformation may be consistent
with acute bleeding in this region. The likely suspect of
bleeding is the AV malformation. Recommend MRI and MRA for
further evaluation.
MRI [**2156-5-21**]: Left-sided arteriovenous malformation in the left
temporal lobe is again identified with an enlarged posterior
cerebral artery. A draining vein into the vein of [**Male First Name (un) 2096**] is
noted
Brief Hospital Course:
Patient is a 68 yo RHM h/o known L temporal AVM with subsequent
sz disorder, h/o HTN, EtOH abuse who presents with three days of
N/V and progressive decrease in level of responsiveness. Neuro
exam is significant at present for decreased level of arousal
(that is worse than prior NSurg eval) with retained brainstem
reflexes; focal findings include less vigorous withdrawal to
noxious stimuli in the right arm/leg. Head CT shows IV
hemorrhage with extension into both occipital horns. His exam is
notable for right hemiparesis in the absence of signs of
herniation; this suggests cause of decreased level of
consciousness is bilateral pressure on the thalamus from the
third ventricular bleed (and he does have small pupils with
dysconjugate gaze).
.
Exam: Difficult to arouse, aphasic, inattentive. Miotic pupils
with wall-eyed dysconjugate gaze. Right hemiparesis.
.
1. Neurology: Left temporal ateriovenous malformation bled with
intraventricular spread bioccipitally with hydrocephalus. EVD
was placed and repeat head CT was showed stable bleed.
Attempted clamp on [**5-20**] with development of increased ICPs to 30s
and improvement with unclamping. A Repeat head CT for altered
mental status [**5-20**] am was unchanged. Ventriculoperitoneal
shunt placed on Tuesday [**5-29**] with stable post-procedure head CT.
Ativan per CIWA scale given alcohol use history. Initially
started on Dilantin for seizure prophylaxis however it was
discontinued on [**5-21**] given fever, facial erythema and negative
infectious workup. Switched to Keppra which was well tolerated.
MRI/A was performed. MRA demonstrates the left-sided
intraventricular arteriovenous malformation with an enlarged
left posterior cerebral artery and venous drainage to the vein
of [**Male First Name (un) 2096**]. The AVM nidus is somewhat obscured by the hemorrhage.
Patient will follow-up in Brain [**Hospital 341**] Clinic as an outpatient
for possible Cyberknife therapy.
.
2. ID: Spiked in ED and UA, CXR negative. Blood cultures x 2,
UCx negative to date. Lumbar puncture performed with CSF 200
WBC, [**Numeric Identifier **] RBC, but no indication of meningitis, negative gram
stain thought to be likely inflammation. Patient was on empiric
vancomycin while on EVD. Was febrile [**5-19**] without obvious
infection or growth on cultures. Patient then remained afebrile
until time of discharge.
.
3. CV: Kept MAP<130, CPP 60-70, SBP <165. Ruled out myocardial
infarction x 3. Held aspirin and continued lipitor. Monitored
on telemetry without events.
.
4. PULM - no issues, extubated [**5-18**]
.
5. ENDO - tight glycemic control with sliding scale
.
6. GI: Continued PPI. PEG tube placed [**6-1**] by IR without
complications. PEG functioning well.
.
7. Derm: Seen by derm for exfoliative facial skin rash felt to
be consistent with seborrheic dermatits. Improved with derm
creams and facial cleansers.
.
8. FEN/RENAL: Followed Cr, Na as had SIADH while in unit. Was
on free water restriction and continued salt tabs. [**5-25**]
Liberalizing free water restriction given normal Na and elevated
BUN/Cr. Now on salt tab wean.
.
9. PPX: No heparin SQ, +pneumoboots, PPI, bowel regimen
.
10. DISPO:
- Full code
- PT/OT consulted
- PCP [**Name Initial (PRE) 10755**] [**Telephone/Fax (1) 46461**]
Medications on Admission:
Flomax 0.4mg daily
Metoprolol 25mg q12
Lipitor 5mg daily'
Keppra 1500mg [**Hospital1 **]
No asa, coumadin
Discharge Medications:
1. Insulin Lispro (Human) 100 unit/mL Solution Sig: PER SLIDING
SCALE UNITS Subcutaneous ASDIR (AS DIRECTED).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for T>100.4.
3. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) MG
PO BID (2 times a day).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG
PO BID (2 times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Levetiracetam 100 mg/mL Solution Sig: 1500 (1500) MG PO BID
(2 times a day).
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
14. Desonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day): To affected areas on face and neck.
15. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): To affected areas on face and neck.
16. Ketoconazole 2 % Shampoo Sig: One (1) Appl Topical QMOWEFR
(Monday -Wednesday-Friday): as directed to face and scalp.
17. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO twice a
day: for 1 week then discontinue. Until [**6-8**].
18. Wash face
Please wash face twice daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary diagnosis:
Left temporal ateriovenous malformation bleed
Status post external ventricular drain
Status post ventriculoperitoneal shunt
Status post gastrojejunal tube
Secondary diagnosis:
Hypertension
Discharge Condition:
Good. Awake and alert. Oriented to self only. Posterior
aphasia, comprehends and follows commands inconsistently. Right
sided weakness.
Discharge Instructions:
You have had a stroke. You will need to follow-up with the
stroke neurologist.
Take medications as prescribed. Keep follow-up appointments
below.
Followup Instructions:
Stroke neurologist: [**First Name8 (NamePattern2) 4267**] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 2574**]
Date/Time: [**2159-6-27**] 3:30pm
PCP: [**Name10 (NameIs) 46462**] [**Name11 (NameIs) **], MD Phone: [**Telephone/Fax (1) 46461**] Date/Time:
Have your staples out at rehab on [**4-11**] if any question of
infection please have removed at Dr [**Last Name (STitle) 46463**] office call if any
concerns [**Telephone/Fax (1) 1669**]. Dr[**Name (NI) 46464**] office will call for
Cyberknife planning
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2159-6-2**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3036
} | Medical Text: Admission Date: [**2120-12-11**] Discharge Date: [**2120-12-14**]
Date of Birth: [**2050-5-12**] Sex: M
Service: MEDICINE
Allergies:
Wellbutrin / Oxycontin
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name14 (STitle) 67472**] is a 70 year-old gentleman w/ Stage IV NSCLC
metastatic to brain/spine/kidneys, s/p cycle 3 of [**Doctor Last Name **]/taxol
(last [**2120-12-10**]), also with h/o emphysema on 2L home O2, PE on
lovenox, now presenting after he developed a fever overnight. He
felt nauseous as per usual after chemotherapy but felt more weak
and feverish last night, checked temp and was was 101.7, for
which he took two tylenol and defervesced. He also had a an
episode of N/V which improved with Zofran x 1. He had no
increase in his baseline shortness of breath or cough. No
abdominal pain, ongoing N/V, or diarrhea. This AM however, he
had an episode of urinary incontinence and had fever again. He
then presented to the ER.
.
In the ED: V/S 97.1 92 107/90 96%. PE with left basilar crackles
(stable), blanching erythema ? contact dermatitis in groin. Labs
revealed lactate 3.0, WBC 10.9 with 95% PMNs. Spiked in the ER.
CXR showed no obvious infiltrate. EKG showed low voltage
nonspecific TWF in V4-V6, TWI V3. nl axis, nl intervals. U/A
WNL. BPs dropped to the 80s He received vancomycin, cefepime,
tylenol, zofran, 10mg IV dexamethasone, and 4 L IVF. A CVL was
placed. His pressures normalized and he did not requires
pressors. He was then admitted to the [**Hospital Unit Name 153**]. Most recent VS:
100/54 88 21 98%4L.
.
Currently, . ROS is positive for admission to [**Hospital1 18**] [**2039-11-16**] for
shortness of breath which was attributed to pneumonia, treated
with a 7 day course of levofloxacin. Prior to this he had fever,
congestion, and cough x 1 week, given a 5-day course of
azithromycin for presumed URI/bronchitis. He has chronic DOE
with only walking a few steps, and overall fatigue and malaise.
He denies any chest pain, calf pain or leg swelling. He reports
+productive cough yellow sputum, +nasal congestion. +nausea this
morning. He denies any sick contacts, hemoptysis, hoarseness,
headaches, sore throat, vomiting, abdominal pain, diarrhea,
BRBPR, dysuria or back pain. On further questioning patient also
reports difficulty with ambulation the past few days and
lightheadedness. He denies any vertigo or focal weakness or
numbness of the extremities. He denies any back pain, urinary or
stool incontinence. Patient states he feels unsteady while he
walks and that he has been feeling very weak as well.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
Stage IV Non-Small Cell Lung Cancer, s/p Cycle 2 [**Doctor Last Name **]/Taxol
s/p whole brain irradiation
.
PAST MEDICAL HISTORY:
====================
Diabetes Mellitus Type 2
Hx of Pulmonary Embolus on Lovenox
Emphysema
Asbestosis
Right rectus sheath hematoma, [**2-26**] spontaneous coughing in [**Month (only) **]
[**2117**]
Left adrenal adenoma
Small sliding hiatal hernia
Bilateral pleural plaques
Social History:
Mr. [**Known lastname 67473**] is married and lives with his wife.
His daughter [**Name (NI) **] is a [**Hospital1 18**] ER nurse and lives next door. He
used
to work in a navy yard for a year in [**2074**], where he was exposed
to asbestos. He retired 15 years ago from a middle management
position in a defense company. Tobacco: He smoked [**1-26**] PPD x 50
yrs and has tried to quit several times. The last time he quit
was on [**2120-8-22**]. He drinks two beers a day and denies
having
any history of alcohol abuse. He denies illicit drug use
Family History:
His mother died from [**Name (NI) 5895**] disease and his
father had mesothelioma and died at age 58 from a heart attack.
His father worked in a shipyard which was believed to be a
contributing factor to his cancer. His paternal grandfather
also
died from lung cancer and used to work in the coal yards. He
has
one brother who is healthy and one sister, age 63 who has
cervical cancer. He has two daughters who are healthy.
Physical Exam:
GENERAL: pleasant elderly gentleman sitting up in bed in NAD
SKIN: WWP, + erythematous blanching pruritic papular rash in
inguinal area and underneath elastic underwear band c/w
candidiasis vs. folliculitis
HEENT: EOMI, PERRLA, anicteric sclera, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: +crackles at bilateral bases L>R, decreased breath sound
at bilateral bases, +mild expiratory rhonchi L base
ABDOMEN: soft, ND +BS, NT, no rebound/guarding
EXT: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP, PT, popliteal, radial, carotid pulses bilaterally
NEURO: A&Ox3 CN II-XII grossly intact and symmetric B/L; +some
resting tremor of B/L UE most pronounced in hand/fingers; no
asterixis; 2+ patellar and biceps reflexes B/L; 5/5 strength UE
flex/ext, 4+/5 LLE hip and knee extensors, [**5-28**] LLE hip/knee
flexors, [**5-28**] dorsiflexion and plantarflexion B/L; 5/5 strength
RUE & RLE finger to nose intact, downgoing toes B/L, gait not
assessed.
Pertinent Results:
.
Micro:
GRAM STAIN (Final [**2120-12-12**]):
[**11-17**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): YEAST(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2120-12-15**]):
SPARSE GROWTH Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
YEAST. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
.
[**2120-12-11**] 11:50PM CORTISOL-23.8*
[**2120-12-11**] 10:51PM GLUCOSE-197* UREA N-13 CREAT-1.0 SODIUM-137
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-18* ANION GAP-12
[**2120-12-11**] 10:51PM CALCIUM-6.6* PHOSPHATE-2.6* MAGNESIUM-1.7
[**2120-12-11**] 10:51PM CORTISOL-8.4
[**2120-12-11**] 10:51PM WBC-7.1 RBC-2.72* HGB-8.6* HCT-26.6* MCV-98
MCH-31.6 MCHC-32.3 RDW-18.6*
[**2120-12-11**] 10:51PM NEUTS-95.3* LYMPHS-2.5* MONOS-1.8* EOS-0.3
BASOS-0.1
[**2120-12-11**] 10:51PM PLT COUNT-240
[**2120-12-11**] 10:51PM PT-17.1* PTT-70.1* INR(PT)-1.5*
[**2120-12-11**] 06:29PM TEMP-37.1 PO2-75* PCO2-36 PH-7.33* TOTAL
CO2-20* BASE XS--6 INTUBATED-NOT INTUBA
[**2120-12-11**] 06:29PM LACTATE-1.4
[**2120-12-11**] 05:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.032
[**2120-12-11**] 05:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2120-12-11**] 05:55PM URINE RBC-0-2 WBC-[**3-28**] BACTERIA-RARE YEAST-NONE
EPI-0
[**2120-12-11**] 05:55PM URINE GRANULAR-0-2 HYALINE-[**3-28**]*
[**2120-12-11**] 11:42AM COMMENTS-GREEN TOP
[**2120-12-11**] 11:42AM LACTATE-3.0*
[**2120-12-11**] 11:30AM GLUCOSE-151* UREA N-14 CREAT-1.4* SODIUM-138
POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-18* ANION GAP-20
[**2120-12-14**] 06:40AM BLOOD WBC-3.9* RBC-3.10* Hgb-9.6* Hct-29.3*
MCV-95 MCH-31.0 MCHC-32.8 RDW-18.4* Plt Ct-217
[**2120-12-14**] 06:40AM BLOOD Neuts-84.6* Lymphs-11.7* Monos-1.9*
Eos-1.8 Baso-0.1
[**2120-12-14**] 06:40AM BLOOD Plt Ct-217
[**2120-12-14**] 06:40AM BLOOD Glucose-107* UreaN-6 Creat-0.9 Na-140
K-3.9 Cl-109* HCO3-22 AnGap-13.
.
[**2120-12-13**].MR HEAD W & W/O CONTRAST
.
IMPRESSION:
.
1. Minimal increase in the right cerebellar lesion; minimal-mild
decrease in the size of the right frontal parasagittal lesion.
No obvious new lesions within the limitations of motion
artifacts.
2. Extensive paranasal sinus disease as well as mucosal
thickening/fluid in the mastoid air cells on both sides. New
since the prior study.
.
IMPRESSION: [**2120-12-11**]
UPRIGHT AP VIEW OF THE CHEST:
Again, there is a large mass overlying the left hilum,
consistent with
findings from prior chest radiographs and CT exam from [**11-26**], [**2120**],
consistent with the patient's history of lung cancer. The heart
size is
normal and stable. Multiple smaller pulmonary nodules throughout
the lungs
are unchanged in appearance. Stable mild opacification along the
left base,
most likely representing atelectasis. There are no new focal
consolidations
seen. There is no pneumothorax. There is mild blunting of the
right
costophrenic angle, which may represent a small pleural
effusion. There is an
old right rib deformity, seen on prior CT exam.
Brief Hospital Course:
70 year old male with hx of non small cell lung cancer, s/p
cycle 3 [**Doctor Last Name **]/taxol on [**2120-11-12**] presenting with fevers, cough,
SOB found to have likely PNA based on symptoms and infiltrate.
.
# Fever - He was febrile on presentation to the ED raising
concern for infection given WBC count, fever, and elevated
lactate. He presented with cough however his CXR was equivocal
for a PNA. No clinical concern for sepsis as one episode of
hypotension in ED likely [**2-26**] volume depletion given poor PO
intake. He was given broad spectrum antibiotics with
vanc/levo/cefepime. Pt not neutropenic. He was DFA negative,
legionella negative, [**Last Name (un) 104**] stim test was within normal limits.
He was discharged on cefpodoxime and azithromycin for a total
antibiotic course of 14 days.
.
# # NSCLC: He has known brain metastases and was s/p cycle 3
[**Doctor Last Name **]/taxol and was not neutropenic on presentation. MRI head
showed minimal increase in the right cerebellar lesion;
minimal-mild decrease in the size of the right frontal
parasagittal lesion. No obvious new lesions within the
limitations of motion artifacts. Future plan from oncologic
perspective to be made as outpatient.
He continued to take keppra, prophylactic bactrim and
dexamthasone which was increased during his hospitalization from
1mg to 4mg daily.
.
# DM2
-Metformin was held during his hospitalization, and he resumed
taking this medication on discharge.
.
# [**Last Name (un) **]: On presentation his creatinine was Cr 1.4 from 1.1;
likely secondary to volume depletion. He received IVF boluses
with rapid correction of his creatinine which was within normal
limits at the time of discharge.
#. h/o PE: he continued to receive lovenox
Medications on Admission:
1. Acetaminophen 650 mg PO q6h PRN pain
2. Enoxaparin 60 mg/0.6 mL SC q12h
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Levetiracetam 1000mg PO BID
5. Omeprazole 20 mg PO daily
6. Bactrim 160-800 mg 1 tab 3x wk (M,W,F)
7. home Oxygen Sig: Two (2) continuous: 2L nasal cannula
continuous, pulse dose for portability.
8. Dexamethasone 1 mg PO daily.
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
10. sertraline 50mg once daily
Discharge Medications:
1. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*2*
2. Megace Oral 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1)
10ml dose PO once a day.
Disp:*30 doses* Refills:*2*
3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): do not exceed 3000mg/day.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Nystatin 500,000 unit Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
7. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
10. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
14. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
15. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea: Do not drink alcohol or perform
activities that require a fast reaction time. [**Month (only) 116**] cause
sedation.
Disp:*90 Tablet(s)* Refills:*0*
16. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary
Pneumonia
Secondary
Non small cell lung cancer
Discharge Condition:
stable, good
Discharge Instructions:
You were admitted to the hospital because you were having
fevers.
You were found to have a pneumonia and this was treated with
antibiotics.
.
We ADDED Zofran 8mg dissolvable tablet every 8 hours as needed
for nausea
We ADDED cefpodoxime 200mg every 12 hours for 10 days
We ADDED azithromycin 250mg daily for 10 days
We ADDED ativan 0.5 mg every 8 hours as needed for nausea
We ADDED megace 400mg daily
We ADDED dexamethasone 4mg daily
.
Please return to the hospital or call your doctor if you
experience any shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, headache, fever,
chills, night sweats, muscle aches, joint aches, light
headedness, fainting, blood in your stool, blood in your urine,
or any other problems that are concerning to you.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2120-12-16**]
11:55
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2120-12-16**]
2:00
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2120-12-24**] 9:00
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
ICD9 Codes: 486, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3037
} | Medical Text: Admission Date: [**2180-1-4**] Discharge Date: [**2180-1-6**]
Date of Birth: [**2123-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
CC:[**CC Contact Info 42331**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 56 year-old male with a history of ETOH cirrhosis with
esophageal varices s/p TIPS as well as active EtOH use who
presents with hematemesis x2 yesterday per VNA report. He was
brought in by his cousin for concern for GIB, and currently
denies that he had any hematemesis but instead endorses
hematochezia. He Denies abdominal pain, diarrhea, melena or
hematochezia. Denies CP/palps/SOB/lightheadedness. Per report
has been eating/drinking OK w/o aspiration/N/V.
.
In the ED, they did not gastric lavage due to varices and risk
of bleed. He was hemodynamically stable w/ HR 74 BP 117/74 O2sat
98%RA.
GI was consulted and pt was started on an octreotide gtt;
received cipro IV and IV PPI.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity edema, cough, urinary frequency,
urgency, dysuria, lightheadedness, gait unsteadiness, focal
weakness, vision changes, headache, rash or skin changes.
.
Past Medical History:
- Alcoholic cirrhosis - hx of esophageal variceal bleed and
hepatic encephalopathy. He has had 2 TIPS procedures with stent
placement in [**2166**] and again in [**2176**]. Underwent TIPS revision in
[**8-17**] and [**9-17**].
- EGD [**2179-9-14**]: Grade [**2-11**] esophageal varices, Esophagitis, Portal
hypertensive gastropathy
- Chronic pancreatitis complicated by a parapancreatic cyst
that was infected with enteroccocus and coagulase negative
staph. On vancomycin from [**Date range (2) 42329**], then linezolid
[**Date range (1) 42330**].
- Type 2 DM on insulin
- Anemia of chronic disease
- Thrombocytopenia
- Depression
- Umbilical Hernia
- History of delerium tremens
.
Social History:
Pt lives alone with sisters in area and friends in the building.
Unemployed. Last used ETOH "in [**2177**]" - per other reports, still
actively drinking and removed from [**Year (4 digits) **] list. No h/o IVDU
or other drug use. Says he smokes "5 packs a day".
Family History:
father - cirrhosis
Physical Exam:
On Presentation to ICU:
Vitals: T: 98.4 BP: HR: 83 RR: 19 O2Sat: 100% RA
GEN: jaundiced, disheveled, no acute distress
HEENT: EOMI, PERRL, sclera icteric, no epistaxis or rhinorrhea,
dryMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: distended, no peripheral dullness to percussion, Soft, NT,
+BS, + HSM, no masses
Rectal: guiac (-)
EXT: No C/C/E, no palpable cords
NEURO: + asterixis, alert, oriented to place, unable to
reidentify people, not oriented to time. CN II ?????? XII grossly
intact. Moves all 4 extremities. Strength 5/5 in upper and lower
extremities. Patellar DTR +1. Plantar reflex downgoing.
+dysdiadokokinesia.
SKIN: +jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
[**2180-1-4**] 07:00PM WBC-6.8 RBC-3.58*# HGB-13.2*# HCT-35.1*
MCV-98# MCH-36.9* MCHC-37.6* RDW-14.4
[**2180-1-4**] 07:00PM NEUTS-72.7* LYMPHS-12.0* MONOS-6.9 EOS-7.1*
BASOS-1.2
[**2180-1-4**] 07:00PM PLT COUNT-49*
.
[**2180-1-4**] 07:00PM PT-16.7* PTT-32.9 INR(PT)-1.5*
.
[**2180-1-4**] 07:00PM GLUCOSE-293* UREA N-20 CREAT-1.0 SODIUM-128*
POTASSIUM-2.4* CHLORIDE-90* TOTAL CO2-24 ANION GAP-16
[**2180-1-4**] 07:00PM ALT(SGPT)-43* AST(SGOT)-94* ALK PHOS-379* TOT
BILI-12.7*
[**2180-1-4**] 07:00PM LIPASE-138*
.
[**2180-1-4**] 06:50PM AMMONIA-252*
.
[**2180-1-4**] 11:03PM BLOOD Hct-34.2* Plt Ct-51*
[**2180-1-5**] 04:12AM BLOOD Hct-30.3* Plt Ct-47*
[**2180-1-5**] 11:39AM BLOOD Hct-30.7*
.
CXR: IMPRESSION: Interval improvement in right basilar opacity
with persistent small right pleural effusion. Findings are
suggestive of resolving pneumonia. No new areas of abnormality
otherwise identified.
.
Liver U/S with Doppler:
1. Unchanged occluded anterior TIPS and unchanged patent
posterior TIPS with normal flow in the proximal, mid and distal
portions of the stent.
2. Cholelithiasis with no evidence of cholecystitis.
3. Cirrhotic liver.
Brief Hospital Course:
56 yo male with EtOH cirrhosis and esophageal varices s/p 2 TIPS
with multiple revisions, as well as active EtOH use who presents
with hematemesis x2, without further episodes and a stable Hct.
# Hematemesis: Patient had two episodes of hematemesis by report
has a history of grade I-III varices. He initially received an
octreotide drip, IV PPI, and IV cipro, however this was stopped
on the day after admission as his Hct was stable and he did not
appear to have an active GI bleed. He had no further episodes
of hematemesis while hospitalized and has been guaiac negative
here. As his story changes depending who speaks with him, it is
unclear if he actually had hematemesis, however he is not
currently bleeding and his Hct has been stable. He was
continued on a PPI daily and nadolol 20 mg daily for variceal
ppx. His diet was advanced and he was tolerating a regular diet
without problem the night prior to discharge.
# EtOH cirrhosis: The patient has alcoholic cirrhosis and is not
on the [**Month/Day/Year **] list due to recent alcohol use (the patient
denies using alcohol in the past 3 years, however he recently
received a letter in [**Month (only) **] from the [**Month (only) **] board stating he
was being inactivated from the list due to recent alcohol use).
He was continued on rifaximin and lactulose (titrating for [**4-13**]
bowel movements) for ppx of encephalopathy. He was continued on
nadolol and a PPI as above. At discharge he was restarted on
his aldactone.
# Type 2 DM: The patient's lantus was initally held as he was
NPO, however it was added back as he began to eat. His finger
sticks were checked qid and he was covered with sliding scale
insulin. He was discharged on his home dose of 38 units of
lantus qpm.
# EtOH abuse: The patient denies recent alcohol use, but has a
history of DT's. Teh patient was monitored closely for
withdrawal and placed on a CIWA scale. He required no diazepam
during this admission. He was continued on folic acid,
thiamine, and a MVI. He was counceled to avoid alcohol use due
to his liver disease.
# History of depression: The patient was continued on his home
dose of amitriptyline.
# Thrombocytopenia: The patient has chronic thrombocytopenia,
likely secondary to liver disease. His platlets remained stable
during this admission.
Medications on Admission:
Per [**11-27**] d/c Summary. Unclear of pt compliance.
1. Multivitamin one QD
2. Nadolol 20 mg Daily
3. Rifaximin 200 mg Tablet three tabs [**Hospital1 **]
4. Lactulose Thirty (30) ML PO QID
5. Omeprazole 40 mg [**Hospital1 **]
6. Spironolactone 150mg Daily
7. Amitriptyline 10 mg QHS
8. Thiamine HCl 100 mg Daily
9. Folic Acid 1 mg Daily
10. Insulin Glargine 100 unit/mL Solution Sig: 38U Subcutaneous
at bedtime.
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO twice a day.
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO four
times a day: Titrate to [**4-13**] bowel movements per day.
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
6. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin Glargine 100 unit/mL Solution Sig: Thirty Eight (38)
units Subcutaneous at bedtime.
10. Aldactone 100 mg Tablet Sig: 1.5 Tablets PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary-
Hematemeis
Secondary-
Alcoholic cirrhosis
Diabetes
Depression
Discharge Condition:
Stable, no signs of bleeding and tolerating a regular diet.
Discharge Instructions:
You were admitted to the hospital due to two episodes of
hematemesis (vomiting of blood). You were monitored in the ICU
overnight and you had no signs of active bleeding and your blood
counts were stable. Your diet was slowly advanced and you had
no difficulty tolerating a regular diet. Your blood counts
remained stable throughout your hospitalization.
No changes were made to your medications. Continue to take your
outpatient medications as prescribed.
Call your primary doctor or go to the emergency room if you
experience fevers, chills, dizzines, shortness of breath,
vomiting of blood, blood in your stool, or black stool.
Followup Instructions:
Please keep your previously scheduled appointments:
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2180-1-7**] 9:15
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2180-2-9**] 8:40
Completed by:[**2180-1-6**]
ICD9 Codes: 2761, 2768, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3038
} | Medical Text: Admission Date: [**2134-1-18**] Discharge Date:
Date of Birth: [**2102-4-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Biaxin
Attending:[**Known firstname 922**]
Chief Complaint:
Mild Dyspnea on exertion
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Bentall procedure with a 29-mm [**Company 1543**] Freestyle
bioprosthesis with coronary button reimplantation,
serial #[**Serial Number 98091**].
2. Coronary bypass grafting x 1: Left internal mammary
artery to left anterior descending coronary artery.
3. Reconstruction of pericardium with core matrix.
History of Present Illness:
65 year old male with history of a heart murmur who underwent an
echocardiogram [**2167-4-20**] and was found to have bicupsid aortic
valve, moderate aortic valve insufficiency with mild stenosis
and
moderate mitral regurgitation. He returned to clinic in late
Novemeber and underwent a repeat echocardiogram. This revealed a
bicuspid aortic valve with mild aortic stenosis and moderate
insufficiency, mild mitral valve regurgitation and a dilated
aortic root and ascending aorta. When pressed, he admits to mild
dyspnea on exertion. Given that his ascending aorta has nearly
reached 5cm and he has now moderate bicuspid aortic valve
insufficiency, surgery in early [**Month (only) 404**].
Past Medical History:
Past Medical History
Bicuspid Aortic Valve
Hypertension
Nephrolithiasis
Sigmoid diverticulosis
Basal cell carcinoma right shin
Hearing loss
Migraines
Dupuytrens's contracture - right 5th digit
Obesity
Left bundle branch block
GERD
Past Surgical History
Left and right inguinal herniorrhaphy
Right knee menisectomy
Tonsillectomy
Lithotripsy
colon polypectomy
Skin cancer rem. right leg
Social History:
Race:Caucasian
Last Dental Exam: Clearance in office chart [**2167-12-31**]
Lives with: wife
Occupation: sales, part-time
Tobacco: 1 cigar/day
ETOH: social 2 drinks/wk
Family History:
no premature coronary artery disease/CVA
Physical Exam:
Pulse: 64 Resp: 16 O2 sat RA: 97%
B/P Right: 144/78 Left: 136/70
Height: 70" Weight: 226 lb
General:NAD, WDWN
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur-3/6 SEM radiates to
carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
obese, no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema- none
Varicosities: mild superficial spider veins BLE L>R
Neuro: Grossly intact;nonfocal exam;MAE [**5-19**] strengths
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: Trace Left:Trace
Radial Right: 2+ Left:2+
Carotid Bruit : murmur radiates bilaterally
Pertinent Results:
Admssio labs:
[**2168-1-26**] 08:30AM BLOOD WBC-6.1 RBC-5.52 Hgb-16.6 Hct-48.1 MCV-87
MCH-30.1 MCHC-34.6 RDW-14.5 Plt Ct-162
[**2168-1-26**] 08:30AM BLOOD PT-12.8 PTT-27.4 INR(PT)-1.1
[**2168-1-26**] 08:30AM BLOOD Plt Ct-162
[**2168-1-26**] 08:30AM BLOOD UreaN-24* Creat-1.1 Na-142 K-4.2 Cl-102
HCO3-32 AnGap-12
[**2168-1-26**] 08:30AM BLOOD Glucose-86
[**2168-1-26**] 08:30AM BLOOD ALT-31 AST-29 LD(LDH)-184 AlkPhos-89
TotBili-0.9
[**2168-1-26**] 08:30AM BLOOD TotProt-7.4 Albumin-5.0 Globuln-2.4
[**2168-2-1**] 07:00AM BLOOD WBC-8.2 RBC-4.18* Hgb-12.4* Hct-36.4*
MCV-87 MCH-29.6 MCHC-34.0 RDW-14.5 Plt Ct-220
Discharge Labs:
[**2168-2-1**] 07:00AM BLOOD Plt Ct-220
[**2168-2-1**] 07:00AM BLOOD UreaN-28* Creat-1.0 Na-142 K-4.3 Cl-101
[**2168-1-31**] 06:40AM BLOOD Glucose-100 UreaN-35* Creat-1.0 Na-140
K-4.4 Cl-100 HCO3-32 AnGap-12
[**2168-1-31**] 06:40AM BLOOD ALT-16 AST-29 LD(LDH)-267* AlkPhos-65
Amylase-40 TotBili-0.8
[**2168-2-1**] 07:00AM BLOOD Mg-2.2
Radiology Report CHEST (PA & LAT) Study Date of [**2168-1-31**] 9:32 AM
[**Hospital 93**] MEDICAL CONDITION:65 year old man with s/p
bental/cabg pod 4
Final Report
Two views. Comparison with the previous study done, [**2168-1-29**].
There is
interval improvement in bibasilar atelectasis. The patient is
status post
median sternotomy and CABG as before. The heart and mediastinal
structures
are unchanged. The bony thorax is grossly intact. A right
internal jugular
sheath has been removed.
IMPRESSION: Interval improvement in bibasilar atelectasis.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.9 cm
Left Ventricle - Fractional Shortening: 0.36 >= 0.29
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.7 cm <= 3.0 cm
Aorta - Sinus Level: *4.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *4.1 cm <= 3.0 cm
Aorta - Ascending: *4.6 cm <= 3.4 cm
Aorta - Arch: 2.8 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Mitral Valve - MVA (P [**1-17**] T): 4.0 cm2
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 1.40
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. 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. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV
cavity. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildy dilated aortic root. Moderately dilated ascending
aorta Normal aortic arch diameter. Simple atheroma in aortic
arch. Mildly dilated descending aorta. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Bicuspid aortic
valve. Moderately thickened aortic valve leaflets. Minimal AS.
Mild to moderate ([**1-17**]+) AR. Eccentric AR jet directed toward the
anterior mitral leaflet.
MITRAL VALVE: No MS. Mild (1+) MR.
TRICUSPID VALVE: No TS. Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Pre bypass
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is moderately dilated. There are simple atheroma
in the aortic arch. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta.
There are three aortic valve leaflets. The aortic valve is
bicuspid. The aortic valve leaflets are moderately thickened.
There is minimal aortic valve stenosis. Unable to accurately
align doppler in deep gastric views. Mild to moderate ([**1-17**]+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet.
Mild (1+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2168-1-27**]
at 1015am.
Post bypass
Patient is A paced and receiving an infusion of phenylephrine
and epinephrine. Biventricular systolic function is unchanged.
Bioprosthetic valve seen in the aortic position. The leaflets
move well and it appears well seated. Trivial central aortic
insufficiency. Peak gradient acorss the valve is 15 mm Hg and
the mean gradient is 10 mm Hg. Graft material seen in the
ascending aorta and proximal arch. Mild mitral regurgitation
persists.
Brief Hospital Course:
Mr [**Known lastname **] was admitted to [**Hospital1 18**] for surggical repair of his
ascending aorta aneurysm in combination with aortic valve
repair.
On [**1-30**] he was brought to the operating room for repair, please
see operative repoprt for details, in summary he had:
1. Bentall procedure with a 29-mm [**Company 1543**] Freestyle
bioprosthesis with coronary button reimplantation, serial
#[**Serial Number 98091**]. 2. Coronary bypass grafting x 1: Left internal
mammary artery to left anterior descending coronary artery.
3. Reconstruction of pericardium with core matrix.
His BYPASS TIME was 181 minutes with a crossclamp of 151
minutes, and a circulatory arrest time of 23 minutes.
He tolerated the operation well and was transferred
post-operatively to the cardiac surgery ICU in stable condition.
He remained sedated and intubated on the day of suregy. The next
morning sedation was stopped, he woke neurologically intact, was
weaned from the ventillator and extubated. Post extubation
remained in the CVICU to monitor his pulmonary status. He was
transferred to the stepdown floor on POD3 for continued care and
recovery. All tubes lines and drains were removed per cardiac
surgery protocol. He was seen by physical therapy and made quick
recovery in terms of activity and endurance. he was cleared for
discharge to home with visiting nurses on POD5. He is to follow
up in wound clinic in 1 week and with Dr [**Last Name (STitle) 914**] in 3 weeks
Medications on Admission:
Medications at home:
Advil 400mg prn
Ranitidine 150mg prn
Aspirin 81mg daily
Lisinopril 10mg daily
Discharge Medications:
acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
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*
lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 20mg [**Hospital1 **] x 1 week, then 20mg QD x 10 days.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
s/p Bentall procedure with a 29-mm [**Company 1543**] Freestyle
bioprosthesis with coronary button reimplantation, serial
#[**Serial Number 98091**].
2. Coronary bypass grafting x 1: Left internal mammary artery to
left anterior descending coronary artery.
3. Reconstruction of pericardium with core matrix.
Past Medical History
Bicuspid Aortic Valve
Hypertension
Nephrolithiasis
Sigmoid diverticulosis
Basal cell carcinoma right shin
Hearing loss
Migraines
Dupuytrens's contracture - right 5th digit
Obesity
Left bundle branch block
GERD
Past Surgical History
Left and right inguinal herniorrhaphy
Right knee menisectomy
Tonsillectomy
Lithotripsy
colon polypectomy
Skin cancer rem. right leg
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Extremities: 1+ Edema
Discharge Instructions:
) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
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:
[**Hospital 409**] clinic in 1 week- [**2-8**] @ 10:30AM [**Wardname 5010**] [**Telephone/Fax (1) 98092**]
Surgeon: [**Doctor Last Name 914**] [**2168-2-16**] at 1:30PM
Cardiologist: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 14890**] in [**3-18**] weeks. Please call to
schedule an appointment. ([**Telephone/Fax (1) 85645**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] V. [**Telephone/Fax (1) 14888**] in [**4-19**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2168-2-1**]
ICD9 Codes: 4241, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3039
} | Medical Text: Admission Date: [**2198-5-4**] Discharge Date: [**2198-5-11**]
Date of Birth: [**2125-9-25**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
right sided weakness, speech difficulties
Major Surgical or Invasive Procedure:
s/p tpa
History of Present Illness:
[**Known firstname **] [**Known lastname 39440**] is a 72 year old right handed man who presents
for evaluation in the setting of diagnosed left MCA stroke.
The patient's wife states that he appeared well this AM. They
had had breakfast and he was watching TV. Around 11am, the
patient's wife came out of the shower and asked him to look at a
scar on her back from a recent surgery. He said it looked fine
and returned to his seat. About a minute or two later, his wife
turned back to him and she noticed that he was responding to
her. She walked over to him and say that he was drooling out of
his left face and his voice was just slurred. She told him she
was calling 911 and he didn't respond. After calling 911, she
noticed that his right hand had fallen in between the couch and
table. She picked his arm up but it was limp. EMS arrived and
he was quickly taken to [**Hospital3 **].
On arrival to [**Hospital1 **], the patient's NIHSS was 22. CT of the head
was notable for a dense left MCA. Troponins were negative. He
was evaluated by tele-neurology at [**Hospital1 2025**] and was deemed a
candidate for tPA, however his blood pressure was 202/92 and
infusion was delayed as 30mg of labetalol were given to bring
his blood pressure down to goal. The tPA bolus was given at
13:33. Due to
bed avialability issues at [**Hospital1 2025**], the patient was transferred to
[**Hospital1 18**] for additional care. tPA infusion completed on arrival to
this hospital.
The patient is currently unable to complete a thorough review of
systems. According to his daughter, he called his PCP yesterday
complaining of tightness in his throat, concerning for angina.
Otherwise, he had no recent illnesses. At present the patient
denies headache, vision loss, chest pain. He feels his
breathing is a bit difficult. He has no abdominal pain.
Past Medical History:
- CAD- s/p quadruple bypass 15 years ago. Had a catheterization
6 months ago at [**Hospital1 3278**] which demonstrated "70% occlusion" per his
family.
- Diastolic CHF- ECHO [**5-/2197**] with EF 65%
- Hypertension
- Hyperlipidemia
Social History:
Married, retired. No smoking, alcohol or drugs.
Family History:
Not available
Physical Exam:
Initial Exam:
BP 167/90 HR 76 RR 18 O2% 97% 2L
General: Awake
Head and Neck: no cranial abnormalities, no scleral icterus
noted, mmm with copious oral secretions. No carotid bruits
appreciated. Small hematoma on the right lower lip.
Pulmonary: Clear anteriorly
Cardiac: irregular rhythm with frequent PVCs on tele. Distand
heart sounds, no murmurs appreciated.
Abdomen: normoactive bowel sounds, non-tender
Extremities: well perfused
Skin: no rashes or lesions noted.
Neurologic:
Awake, follows midline and appendicular commands but there is
some left right confusion which can be overcome with
re-prompting. Pt is able to state his name. Language is
non-fluent, speech is dysarthric. Naming with phenomic errors
and neologisms (chair= fair, glove= gov). Repetition is intact
for single syllable words (though significantly dysarthric), but
there are dropped articles and/or syllables for longer
phrases/words. He is right handed, but he was able to write the
words "I think" this his left hand.
CN:
PERRL 4 to 2mm. Visual fields. EOMI without nystagmus. Right
face without sensation to touch, pin. Right facial droop.
Hearing
intact bilaterally. Palate elevates symmetrically.
5/5 strength in trapezii and sternocleidomastoid bilaterally.
Tongue protrudes in midline.
-Motor: Normal bulk, decreased tone on the right. No pronator
drift. Strength 5/5 with the exception of the musles of the
right
hand which where flaccid.
-Sensory: Absent sensation to pinprick and touch on the right
hemibody.
-Deep tendon reflexes: 1+ thoughout, right toe upgoing.
-Coordination: FNF intact on left, right side was slow but
accurate.
Exam at discharge: Much improved speech - near fluent but
halting and severely dysarthric. R hand weakness but
antigravity with wrist extension and finger flexion. Also,
numbness of RLE.
Pertinent Results:
13.4 88
10.0>---<245
40.3
N:86.0 L:11.9 M:1.7 E:0.2 Bas:0.2
PT: 13.7 PTT: 21.3 INR: 1.2
135 100 17 AGap=18
-------------<115
4.0 21 0.8
CK: 96 MB: 4 Trop-T: <0.01
Ca: 8.4 Mg: 2.0 P: 3.6
Diagnostic Studies:
EKG: Sinus rhythm with A-V conduction delay. Left atrial
abnormality. Modest intraventricular conduction delay.
Borderline prolonged/upper limits of normal QTc interval.
CXR: Mild cardiomegaly and pulmonary vascular congestion. Left
base opacity which may represent atelectasis although
consolidation
cannot be excluded
CT PERFUSION: There is a matched region of increased MTT and
decreased rCBV in the left frontal lobe that corresponds to the
area of infarction on non-contrast CT. No additional areas of
abnormal perfusion are identified.
HEAD CTA: This portion of the study is limited due to suboptimal
bolus
timing. There is no evidence of intracranial flow-limiting
stenosis,
occlusion, or aneurysm within limits of this study.
NECK CTA: This portion of the study is limited due to suboptimal
bolus
timing. The carotid and vertebral arteries are grossly
unremarkable.
MRI: Expected evolution of the large late acute-early subacute
infarct in the left frontal lobe, territory of the superior
division of the left MCA.
Fairly extensive region of "blooming" susceptibility artifact
involving
much of the infarcted territory, representing hemorrhagic
transformation, new since the CTA performed the preceding day.
There is no evidence of hemorrhage elsewhere. Small focus of
slow diffusion at the right frontovertex, which may be either
embolic or, possibly, ACA/MCA watershed infarction. Scattered
FLAIR-hypointensities in bihemispheric subcortical and
periventricular white matter, likely the sequelae of chronic
small vessel ischemic disease.
TTE: No PFO or ASD seen. Normal global biventricular systolic
function. Mild pulmonary hypertension
Brief Hospital Course:
Mr. [**Known lastname 39440**] initially presented to OSH with right arm weakness
and speech difficulties (he was noted to be not responding
verbally at home). He was given IV tpa at OSH for L MCA stroke
and transferred to [**Hospital1 18**] for further care. His exam was noted to
improve since onset of syptoms, though post-tpa he continued to
have a nonfluent aphasia, weakness of the right lower face and
hand and right sided sensory loss. By report, he had a transient
episodes of AFib in the ambulance bringing him from [**Hospital1 1474**] to
[**Hospital1 18**], but there has been no documentation of this. Upon arrival
to [**Hospital1 18**], CTA/CTP performed and given the improvement and lack
of further clot burden on CTA, no additional intervention was
pursued. He underwent MR imaging, which showed expected
evolution of the large late acute-early subacute infarct in the
left frontal lobe, territory of the superior division of the
left MCA. There was also hemorrhagic transformation noted of his
stroke. In addition, there was a small focus of slow diffusion
at the right frontovertex, which raises the probability of an
embolic event as there are b/l infarcts.
He was initially admitted to the ICU for monitoring s/p tpa. He
was then transferrted to the floor after 24 hours. While
admitted, he underwent testing to determine the etiology of his
stroke. He was monitored on tele for cardiac arrhythmias which
was normal during this admission. He had TTE, which showed no
PFO or ASD and normal global biventricular systolic function;
there was mild pulmonary hypertension. His HbA1C was 5.6. His
cholesterol is 142, with HDL 46 and LDL 76; triglycerides are
98.
Given the hemorrhagic transformation of the stroke, Coumadin was
not started at this time. Instead, he was kept on ASA 325mg once
daily and will get repeat CT head in 2 weeks, with consideration
of starting Coumadin at that time if no further hemorrhage. In
the meanwhile, he was restarted on his home Aspirin.
Of note, he reported blood in his urine. A urine sample was
collected in his next void after blood noted and UA sent; there
was no blood in the UA.
Medications on Admission:
Isosorbide mononitrate 90mg daily
Atenolol 50mg [**Hospital1 **]
Fish oil 1000mg daily
Coenzyme q 200mg daily
Aspirin 81mg daily
Centrum silver (MV with minerals) daily
Zocor 40
Nitro 0.4mg PRN
Discharge Medications:
1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Senna Plus 8.6-50 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Left MCA stroke
Discharge Condition:
Mental Status: Clear but with nonfluent aphasia with
moderate/severe dysarthria
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. R hand weakness.
Discharge Instructions:
You were admitted to the hospital with a stroke; the stroke
affected your speech and also resulted in weakness of your right
lower face and right wrist/hand. Initially, for the stroke, you
were given a medication called tPA, which helps dissolve clots
in the time right after the stroke happens. There was
improvements noted after this medication was given. On your MRI,
there was blood noted in the area of the stroke, so blood
thining medication was not started at this time. You will need
to get a repeat CT scan of your head in 2 weeks to assess if
there is any further blood and then decision will be made at
that time to start you on a blood thinner. In the meanwhile, you
were restarted on your home Aspirin.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2198-7-24**] 2:30
CT head 2 weeks - please call [**Telephone/Fax (1) 327**] (#1) to schedule a
repeat head CT then call Dr. [**First Name (STitle) **] [**Name (STitle) **] for instructions
on when to start Coumadin.
Also, please follow-up with your PCP upon discharge from the
rehabilitation center.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2198-5-11**]
ICD9 Codes: 4019, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3040
} | Medical Text: Admission Date: [**2148-1-11**] Discharge Date: [**2148-1-17**]
Date of Birth: [**2071-11-7**] Sex: M
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old
male with a history of pancreatic cancer status post duodenal
and biliary stent placement who presents with multiple
episodes of coffee ground emesis, dark stools, and bright red
blood per rectum. The patient had five episodes of vomiting
with coffee grounds two days prior to admission. One day
prior to admission the patient had dark stools one of which
was covered by bright red blood. He denies any abdominal
pain, nausea, vomiting, fevers, chills, cough, chest pain, or
shortness of breath. He did have some lightheadedness, which
resolved on its own. The patient came to the Emergency
Department for evaluation. He had single blood pressure
measurement of 80/50, which improved after a fluid bolus.
His hematocrit decreased from 37 to 17 in the course of four
hours for which he was treated with five units of packed red
blood cells. An nasogastric lavage was performed and was
clear of blood. The patient was evaluated by
gastroenterology and was admitted to the MICU.
PAST MEDICAL HISTORY:
1. Pancreatic cancer, status post common bile duct stent,
status post duodenal stent.
2. Cerebrovascular accident.
3. Peripheral vascular disease status post bypass surgery.
4. Hypercholesterolemia.
5. Hernia.
6. Hypertension.
7. Abdominal aortic aneurysm, infrarenal.
8. Status post cholecystectomy.
9. Status post appendectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: 1. Pentoxifylline 400 mg po t.i.d. 2.
Aspirin 325 mg po q day. 3. Prilosec 20 mg po q day. 4.
Norvasc 5 mg po q day. 5. Atenolol 50 mg po q day. 6.
Hydrochlorothiazide 12.5 mg po q day. 7. Lipitor 10 mg po q
day.
SOCIAL HISTORY: The patient has a remote history of alcohol
and tobacco usage. He lives at home with his daughter.
PHYSICAL EXAMINATION: The patient was afebrile with a
temperature of 96.3, heart rate 63, blood pressure 113/64,
respiratory rate 11, and oxygen saturation 99% on 2 liters by
nasal cannula. In general, the patient was an elderly
cachectic male in no acute distress. Head and neck
examination were significant for mild scleral icterus, flat
neck veins and no carotid bruits. Lungs were clear to
auscultation bilaterally. Cardiac examination revealed a
regular rate and rhythm with a 2 out of 6 systolic murmur.
Abdomen was soft, nontender, nondistended with positive bowel
sounds and no rebound tenderness. Extremities had no
clubbing or edema. Rectal examination was heme positive in
the Emergency Department.
LABORATORY STUDIES: CBC was significant for a white blood
cell count of 4.5 and a hematocrit of 16.0. Panel 7 is
significant for a BUN of 55 and creatinine of 1.6. Liver
function tests were elevated with an AST of 507, and alkaline
phosphatase of 387. LDH was 507. Amylase was elevated at
164, and total bilirubin was 0.9. Lipase was elevate at 281.
Coagulation studies were within normal limits.
Electrocardiogram showed normal sinus rhythm at 75 beats per
minute, Q waves in leads 3 and AVF, and flat T waves
throughout.
HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient
was transfused with 5 units of packed red blood cells and his
hematocrit increased to 40.0. He had no further episodes of
hematemesis, and his hematocrit remained stable throughout
the rest of his hospitalization. He was continued on proton
pump inhibitor, and esophageal gastroduodenoscopy was
performed on [**2148-1-12**]. Results showed obstruction of the
pylorus due to the duodenal stent with an associated
nonbleeding ulcer. Also present was Barrett's esophagus and
gastritis. Repositioning of the duodenal stent was performed
by esophagogastroduodenoscopy with fluoroscopy on [**2148-1-16**].
No complications of this procedure were encountered and the
patient tolerated full oral diet afterwards. No further
follow up is recommended at this time.
2. Hypertension: The patient was maintained on low dose
beta blocker during his hospitalization and his calcium
channel blocker and diuretic were held. His blood pressures
remained 110 to 140, and he should be followed and his
hypertensive regimen adjusted by his primary care physician.
3. Peripheral vascular disease: The patient was restarted
on his Pentoxifylline and Atorvastatin during his
hospitalization.
DISCHARGE CONDITION: The patient was discharged in stable
condition to home.
DISCHARGE DIAGNOSES:
1. Pyloric obstruction due to duodenal stent.
2. Upper gastrointestinal bleed.
3. Barrett's esophagus.
4. Gastritis.
5. All prior diagnoses.
DISCHARGE MEDICATIONS: 1. Pentoxifylline 400 mg po b.i.d.
2. Prilosec 20 mg po q day. 3. Lipitor 10 mg po q day. 4.
Atenolol 50 mg po q day.
DISCHARGE PLAN: 1. The patient should follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one week. At
this time the patient can be evaluated for resumption of his
aspirin, Norvasc or Hydrochlorothiazide. 2. If the patient
has further episodes of hematemesis or bleeding, he should
contact gastroenterology. The esophagogastroduodenoscopy was
performed by Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (NamePattern1) 6916**]
MEDQUIST36
D: [**2148-1-17**] 11:09
T: [**2148-1-17**] 12:29
JOB#: [**Job Number 32818**]
ICD9 Codes: 5789, 2851, 4439, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3041
} | Medical Text: Admission Date: [**2102-7-10**] Discharge Date: [**2102-7-17**]
Date of Birth: [**2040-7-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Obtundation
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Pt is a 62 yo female with DM2, bipolar, schizophrenia, hx
hypoglycemic induced seizures, [**First Name3 (LF) **], who p/w delta MS this AM.
Per reports, pt was last seen at 10:30 night PTA in USOH. This
am, ot did not show up for breakfast. She was found
non-responsive, covered in feces. FS was 187 in field. In the ED
VS were T:100.0; HR: 70s; BP: 170s/100s; RR:14; O2 sat: 95 on
NRB. Suspicion was high for meningitis and LP was done. Pt
received ceftriaxone, vancomycin, bactrim, and acyclovir in the
ED.
Past Medical History:
1. DM2
2. Bipolar
3. Schizophrenia
4. NAFLD
5. HTN
6. Asthma
7. H/O hypoglycemic induced seizures
Social History:
Pt is high school graduate. She worked at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] doing
clerical work for 29 years. She lives in a nursing home but is
quite productive and active. She is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10958**] at [**Hospital1 21238**].
Physical Exam:
VS: T: 101.8; BP: 154/42; P: 87; RR: 18; O2: 100% NRB
Gen: Non-responsive to sternal rub. Opens eyes occasionally but
not to stimulus
HEENT: L: 3--2 mm sliggish. R: not reactive to light. Eyes
deviate to right upward.
Neck: No JVD
CV: RRR S1S2. Difficult to auscultate. II/VI systolic murmur
best at LUSB.
LUNGS: CTA b/l anteriorly
ABD: Soft, NT, NT. +BS
EXT: DP 2+. No edema.
Neuro: Biceps, brachio, patellar 3+ b/l. Pt has periods of
clonus L>R on LE and myoclonus in upper extremities. ALso with
periods of flexeril posturing with elbows and wrists flexed and
toes curled. Babinski: downgoing on right. Equivocal on left.
Pertinent Results:
[**2102-7-10**] 09:39AM WBC-19.8*# RBC-4.14* HGB-12.9 HCT-35.6*
MCV-86 MCH-31.3 MCHC-36.3* RDW-12.7
NEUTS-89.5* BANDS-0 LYMPHS-7.0* MONOS-3.2 EOS-0.2 BASOS-0.1
PLT COUNT-232#
GLUCOSE-217* UREA N-33* CREAT-1.4* SODIUM-125* POTASSIUM-3.6
CHLORIDE-81* TOTAL CO2-27 ANION GAP-21*
ALBUMIN-4.7 CALCIUM-9.6 PHOSPHATE-2.7 MAGNESIUM-1.0*
ALT(SGPT)-45* AST(SGOT)-63* CK(CPK)-465* ALK PHOS-165*
AMYLASE-70 TOT BILI-0.5
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
[**Name (NI) 21239**]
PT-12.0 PTT-24.4 INR(PT)-1.0
CK-MB-11* MB INDX-2.4
LACTATE-1.3
.
[**2102-7-10**] 11:10AM CEREBROSPINAL FLUID (CSF) WBC-11 RBC-1203*
POLYS-90 LYMPHS-9 MONOS-1
[**2102-7-10**] 11:10AM CEREBROSPINAL FLUID (CSF) WBC-19 RBC-40*
POLYS-88 LYMPHS-6 MONOS-6
[**2102-7-10**] 11:10AM CEREBROSPINAL FLUID (CSF) PROTEIN-32
GLUCOSE-113 LD(LDH)-29
[**2102-7-10**] 11:55AM O2-21 PO2-90 PCO2-34* PH-7.46* TOTAL CO2-25
BASE XS-0
[**2102-7-10**] 03:15PM TSH-2.8
[**2102-7-10**] 03:15PM OSMOLAL-270*
[**2102-7-10**] 03:15PM VIT B12-1689* FOLATE-GREATER TH
[**2102-7-10**] 08:55PM CK(CPK)-924*
[**2102-7-10**] 09:10PM URINE OSMOLAL-383
[**2102-7-10**] 09:10PM URINE HOURS-RANDOM CREAT-56 SODIUM-20
.
Micro
Blood Cultures x 2 ([**7-10**]) : pending
Urine Culture ([**7-10**]) : NGTD (preliminary report)
RPR ([**7-10**]) : nonreactive
CSF Gm stain ([**7-10**]) : no organisms/no PMNs
CSF Fluid Culture ([**7-10**]) : NGTD (prelim report)
CSF Viral Culture ([**7-10**]) : NGTD (prelim report)
CSF Fungal Culture ([**7-10**]) : NGTD (prelim report)
.
Imaging
CT head ([**7-10**]) : 1) no evidence of intracranial hemorrhage
2)stable appearance of extensive chronic sinus inflammatory
disease
CXR ([**7-10**]) : 1) increased lung volumes 2) heart size within
normal limits 3) no CHF, pleural effusion, or consolidation
MRI with/without contrast ([**7-11**]) : 1) diffuse meningeal
enhancement consistent with meningitis 2) possibly some findings
in the occipital lobe suggesting encephalitis 3) no evidence of
focal mass or hemorrhage
EEG ([**7-11**]) : severe encephalopathy; no official [**Location (un) 1131**] yet
.
Brief Hospital Course:
62 yo female with DM2, bipolar, schizopphrenia, found down on
floor at nursing home and transferred to [**Hospital1 **]. Here, found to be
obtunded, LP and exam consistent with meningoencephalitis.
.
1. Mental status changes- Pt with obtundation and evidence of
decordicate posturing and hypereflexia on initial exam. It was
also remarkable for clonus/myoclonus of lower/upper extremities
with upgoing Babinskis. She also had a right visual field gaze
preference and also questionable left sided neglect. DDx
initially included a seizure vs. a post-ictal state vs.
meningoencephalitis. LP done in the ED showed 19 WBC in tube 4
with normal protein and slightly elevated glucose. It was not
consistent with a bacterial picture except for the neutrophilic
predominance. Rather, a viral etiology was thought to be more
likely (early viral can have a neutrophilic predominance) or
listeria. Pt was empirically covered with Vancomycin,
ceftriaxone, bactrim (PCN allergy and wanted to cover for
listeria), and acyclovir and on precautions. EEG showed severe
encephalopathy and MRI showed meningeal enhancement meningeal
enhancement consistent with meningitis. Possibly some findings
in the occipital lobe suggesting encephalitis. No evidence of
focal mass or hemorrhage. As cultures for both bacteria and for
HSV came back negative the antibiotics were discontinued. WNV,
EEE virus cultures are still pending but a postive result would
not change treatment at this point, especially as the patient
has improved significantly. She has been competely afebrile,
alert + oriented X 3, and her WBCs have normalized.
.
2. Leukocytosis/Pleocytosis- Likely secondary to CNS infection
as above. Blood and urine cultures were negative. Pt continued
to have a leukocytosis with neutrophilic predominance although
becoming more lymphocytic, consistent with an aseptic
meningitis. The leukocytosis resolved completely prior to
discharge.
.
3. Acid/Base- Initially with a mixed respiratory alkalosis/anion
gap acidosis with underlying alkalosis. This normalized while
the patient was still in the ICU (see below). Her acid base
status was normal thorughout the rest of her hospitalization,
and at discharge.
.
a). Respiratory alkalosis- This was attributable to
encephalitic/neurological process occuring, and resolved with
clearing of her mental status.
.
b). Anion gap acidosis- Initially with AGA likely ketoacidosis
from starvation vs. less likely DKA given pt type II. Gap
decreased to 13 with fluids and resolved.
.
c). Metabolic alkalosis-Likely secondary to volume depletion in
setting of HCTZ as well. We held her diuretics and gave her
fluids and this resolved. Given her hyponatremia and tendency to
hyperkalemia, we restarted her lsiinopril and started her on
lasix 10mg po QOD to keep her K down while not causing
hyponatremia. She is discharged without HCTZ.
.
4. Increased CK/Chronic Renal Failure- This was secondary to
being found down/trauma. CK peaked ~1000 and trended down. Pt
was given IVF which helped bring down her CK but worsened her
hyponatremia (see below). Patient's BUN/Cr actually lower than
her usual baseline. Ck has been normalizing throughout her stay,
and is down to 254 on discharge.
.
5. Hyponatremia & hyper kalemia: Pt has appeared to be euvolemic
since time of initial presentation. In the differential we
considered thyroid vs. polydipsia vs. SIADH. Serum and urine
osmolalities were 270 and 383 respectively, pointing more
towards an SIADH like picture. We did a trial of NS hydration to
see if pt was intravascularly dry, but sodium decreased from 125
to 121. Pt was then fluid restricted and medications
concentrated for likely SIADH [**12-28**] encephalopathic process. This
resolved as the patient's mental status resolved. Her sodium
stabilized at a normal value of 133, 134 for 4 days prior to
discharge. Given her low sodium, she is not on HCTZ at this
time. However her K began to rise. Therefore she has been
started on lasix 10mg po QOD to keep her K down without dropping
Na. She should have labs drawn [**2102-7-20**] and the electrolyte
results discussed with her PCP for any management decision. She
will also follow up with her PCP [**2102-7-22**].
.
6. Increased LFTs: These were stable during this
hospitalization. She has a known history of [**Last Name (LF) **], [**First Name3 (LF) **] it is
likely [**12-28**] that.
.
7. F/E/N: Initially, pt was NPO given her lack of mental status
and obtundation. On day #3, pt's mental status was sufficient
where she could take PO safely. Diet was advanced to normal
diabetic/cardiac diet. She continued on this throughout the rest
of her stay, and tolerated it well with no problems. She should
continue a diabetic/cardic diet.
.
8. [**Name (NI) 12329**] Pt was normotensive initially and thus her HCTZ and ace
inhibitor were held. Her BP started to slowly rise and her HCTZ
was held [**12-28**] hyponatremia and ACE reinitiated. She is discharged
on lisinopril, and she was started on lasix 10mg po QOD. She
will follow up with her PCP on [**Name9 (PRE) 2974**] [**2102-7-22**] as well.
.
9. Psych- With extensive psychiatric history including bipolar
d/o and schizophrenia. Held her geodon and SSRI as she has
rather clouded mentation, although improved from time of
admission. When her mental status improved, she was restarted on
her previous doses of Geodon & SSRI.
.
10. s/p trauma: Found down in [**Doctor Last Name **] House. Head CT negative.
C-spine cleared.
.
11. DM: Initially on RISS while obtunded and NPO. Added back her
PO regimen of actos and rapaglinide as her mental status cleared
and she began eating again. She is discharged on her po
medications only, no insulin. She should continue to follow with
[**Hospital **] clinic.
.
12. Access: she was maintained with PIVs. She is discharged with
no IV access.
.
13. Prophylaxis: She was on Heparin SC and a PPI for DVT and
ulcer prophylaxis.
.
14. Communication: HCP [**Name (NI) 1399**] [**Name (NI) 7860**] (office [**Telephone/Fax (1) 21240**]); home
[**Telephone/Fax (1) 21241**]). [**Doctor Last Name **] House [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 21242**] [**Telephone/Fax (1) 21243**]
.
15. Code: Full
Medications on Admission:
Lexapro
Nadolol
Prinivil
Evista
ASA
HCTZ
Folic Acid
Actos
Vitamin E
Geodan
Discharge Medications:
1. Repaglinide 2 mg Tablet Sig: Two (2) Tablet PO TIDAC (3 times
a day (before meals)).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID WITH MEALS ().
3. Ziprasidone HCl 20 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)).
4. Pioglitazone 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
8. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day.
9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO QOD ().
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] HOUSE
Discharge Diagnosis:
primary:
aseptic meningitis
secondary:
1. DM2
2. Bipolar d/o
3. Schizophrenia
4. NAFLD
5. HTN
6. Asthma
Discharge Condition:
medically stable, afebrile, neck stiffness improved, tolerating
food, ambulating, alert, oriented x 3
Discharge Instructions:
Please notify physician or refer patient to the emergency
department if decreased mental status, temperature > 101,
nausea, vomiting, headache, worsening stiff neck.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 8682**] on [**Last Name (LF) 2974**], [**2102-7-21**]
at 3:00 PM. Location: [**Street Address(2) 3375**], [**Location (un) **] Phone:
[**Telephone/Fax (1) 133**].
Please follow-up with Dr. [**First Name (STitle) 10083**] on [**2302-7-28**] at 11:30 AM.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Where: [**Hospital6 29**]
DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2102-8-1**] 9:15
Provider: [**Name10 (NameIs) 9977**] Where: [**Hospital Ward Name **] CLINICAL CENTER
RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2102-8-19**] 8:30
Completed by:[**2102-7-17**]
ICD9 Codes: 2762, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3042
} | Medical Text: Admission Date: [**2154-6-23**] Discharge Date: [**2154-6-28**]
Date of Birth: [**2089-8-3**] Sex: F
Service: MED
Allergies:
Penicillins / Bactrim / Percocet
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
complete sinus arrest, hyperkalemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64F w/ PMH significant for DM2, CAD, HTN, CRI, CHF was in her
usual state of health until 4 days prior to arrival when she
developed a urinary tract infection and began to take
ciprofloxacin [**Hospital1 **], prescribed by her PCP (of which she took 4
pills thus far). On the morning of admission, she developed an
acute episode of nausea, vomiting, diaphoresis, shortness of
breath, light headedness, near syncope, pallor, and garbled
speech for a few minutes. No witnessed LOC/CP/palpitations/sz
activity. EMS found patient with heart rate in the 20s in
complete sinus arrest (junctional escape beat), SBP 60/palpable
with no response to IV atropine, so she was transcutanteously
paced. There were peaked Ts on EKG in field with K=7.3 in our
ED. She was given CaCl/Bicarb/D50/insulin/kayexalate with good
response of K falling to 5.4 and sinus node recovered without
the help of an intravenous pacer. SBP remained 70s-90s, so
dopamine was started. Other initial labs were notable for Hct
19 (bl 30), Na 134, Cr 3.3 (bl 2.5), glucose 324, lactate 3.2,
troponin 0.12, and negative toxicology screen.
Past Medical History:
severe pulmonary hypertension (PAP 60), DM2, CAD s/p NSTEMI '[**52**],
diastolic CHF, HTN, migraines, anxiety/depression, CRI (bl 2.5),
hypercholesterolemia, GERD, ASTHMA, gastroparesis, anemia of
chronic dz, hypothyroidism, pernicious anemia
Social History:
Denies EtOH, tobacco, drugs. Lives with daughter, here from PR
for 26 years, no longer cooks because at times is dizzy.
Family History:
noncontributory
Physical Exam:
Vitals: 97.8, 167/43, 70, 18, 95% on RA
Gen: alert and cooperative, oriented x 3, flat affect, poor
insight since she did not understand that she has chronic renal
insufficiency despite the fact that she continues to urinate
HEENT: MMM, poor dentition, EOMI, PERRLA, CN II-XII individually
tested and intact, conjunctiva pale, - JVD
CV: RRR, -MRG
Pulm: crackles bilaterally at bases
Abd: +BS, soft, NTTP, -masses
Ext: WWP, - CCE, 2+dp, radial pulses bilaterally, strength 5/5
bilaterally
Pertinent Results:
[**2154-6-23**] 11:50PM LD(LDH)-427* CK(CPK)-177* TOT BILI-1.2
[**2154-6-23**] 11:50PM CK-MB-9 cTropnT-0.16*
[**2154-6-23**] 07:08PM GLUCOSE-77 UREA N-74* CREAT-3.3* SODIUM-141
POTASSIUM-5.4* CHLORIDE-112* TOTAL CO2-19* ANION GAP-15
[**2154-6-23**] 07:08PM CALCIUM-9.6 PHOSPHATE-4.1 MAGNESIUM-2.7*
[**2154-6-23**] 05:26PM LACTATE-2.2*
[**2154-6-23**] 03:23PM K+-7.3*
[**2154-6-23**] 03:22PM WBC-4.6 RBC-1.99*# HGB-6.0*# HCT-19.0*#
MCV-96 MCH-30.1 MCHC-31.4 RDW-14.7
Brief Hospital Course:
Cardiovascular: Mrs. [**Known lastname 22003**] had positive troponins but these
were attributed to her asystolic arrest and insufficient
clearance in the face of her chronic renal insufficiency. She
was placed on telemetry, which only showed a few PVCs. Her
potassium was monitored and controlled to within normal limits.
Her ACE inhibitors were held as these can cause hyperkalemia.
The patient was hypotensive in MICU, but stable and even
hypertensive on the floor. Her metoprolol and norvasc were
restarted but the hydrochlorothiazide was discontinued in light
of her acute on chronic renal insufficiency. Her hypertension
was controlled with metoprolol, norvasc, and PRN hydralazine on
the floor. Her metoprolol was not changed to toprol XL in light
of the expense of the latter medication and to reduce confusion
from a changed medical regimen.
Pulmonary: Ms. [**Known lastname 22004**] pulmonary exam was remarkable for
crackles and O2 sats 100% on RA throughout her course. CXR was
consistent with interstitial disease and she was found to have
pulmonary hypertension as well. The patient is currently
asymptomatic. However, we were unable to diagnose any acute or
chronic process as the patient refused CT scan and states that
she would also refuse biopsy.
Heme: Ms. [**Known lastname 22003**] has chronic anemia, worked up in [**Month (only) 547**]. Her
anemia is likely a combination of her poor renal function,
pernicious anemia, and small chronic GI blood losses. An iron
panel, a B12 and a folate were sent and revealed a high ferritin
and a low TIBC consistent with anemia of chronic disease. She
was transfused 2 units PRBCs in the MICU and had a stable HCT on
the floor. Of note, the patient has a history of pernicious
anemia and was restarted on daily oral B12 as well as one IM
injection. Apparently, the patient has missed several nephrology
appointments and was supposed to have been started on Epogen.
The patient stated that she was not interested in ongoing weekly
epogen injections. She did have guiaic positive stools while in
the MICU and so was encouraged to have an outpatient
colonoscopy. Per her outpatient doctor, she has declined these
interventions in the past. Her aspirin was decreased to 81 mg
per day and she was discharged with protonix [**Hospital1 **].
Endocrine: Ms. [**Known lastname 22003**] has well controlled DM with a hemoglobin
a1c of 5.6 on [**6-20**] per Dr. [**Last Name (STitle) **]. She was placed on SSI in the
MICU but it was discontinued before discharge. On the floor, her
glipizide was restarted with good blood sugar control by the end
of her course. She also has a history of hypothyroidism and on
[**6-20**], her TSH was normal at 3.6 per her PCP. [**Name10 (NameIs) **] [**Name11 (NameIs) 22005**]
was continued.
Renal: Ms. [**Known lastname 22003**] had acute on chronic renal failure. The
aspirin, lasix, and lisinopril were discontinued. She returned
to her baseline creatinine of 2.5. Nephrology has been consulted
in past but the patient has missed several outpatient
appointments. Medications were dosed for CrCl of 20. She was
encouraged to call for an appointment with a nephrologist and
given the telephone number at the clinic.
GU: Mrs. [**Known lastname 22003**] was being treated for a UTI shortly before
admission. The organism was klebsiella, sensitive to all
antibiotics except ampicillin. She had 7 total days of a
flouroquinolone, renally dosed (cipro for 4 days before admit,
levofloxacin in the hospital).
Medications on Admission:
MEDICATIONS ON ADMISSION:
1. Aspirin 325 q.d.
2. Iron 325 q.d.
3. Wellbutrin 75 q.d.
4. Protonix 40 q.d.
5. Imdur 90 mg q.d.
6. Lipitor 20 mg q.d.
7. Metoprolol 25 mg po b.i.d.
8. Levothyroxine 75 mg q.d.
9. Hydrochlorothiazide 50 mg po q.d.
10. Glipizide 10 mg po q.d.
11. Norvasc 10 mg po q.d.
12. Lisinopril 40 mg po q.d.
13. Lasix 20 mg po q.d.
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO QD (once a day).
7. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
care group
Discharge Diagnosis:
asystolic cardiac arrest
hyperkalemia
Congestive heart failure with an ejection fraction of 65%
and diastolic dysfunction.
History of non ST segment elevation myocardial
infarction.
Hypertension.
Migraines.
Anxiety.
Chronic renal insufficiency with a baseline creatinine of
approximately 2.5.
Hypercholesterolemia.
Asthma.
Gastroesophageal reflux disease.
History of gastroparesis.
Type 2 diabetes mellitus.
Depression.
Anemia.
Discharge Condition:
good
Discharge Instructions:
Please continue all of your home medications except for the
Lisinopril. Do not restart the Lisinopril. Please take protonix
twice per day. You should be taking a BABY aspirin per day
(81mg). You will also be taking two additional vitamins every
day: folate and B12. You should also get a monthly injection of
B12. We recommend that you have a few outpatient procedures. You
are due for a colonoscopy, a mammography, and an endoscopy. Dr
[**Last Name (STitle) **] can help make these appointments for you. You should also
see a nephrologist regarding your kidney failure. Please call to
make an appointment with Dr. [**Last Name (STitle) 1860**] or Mutte at Phone:
[**Telephone/Fax (1) 60**].
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] in 1 week. You may be able to get monthly
injections of B12 at his office.
ICD9 Codes: 2767, 5849, 4280, 5990, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3043
} | Medical Text: Admission Date: [**2119-9-15**] Discharge Date: [**2119-9-19**]
Date of Birth: [**2057-7-19**] Sex: M
Service:
This is a 62-year-old male who presented with known coronary
artery disease with stable angina who had a positive stress
test, cardiac catheterization showed multi-vessel disease.
The patient's past medical history is significant for high
cholesterol, hypertension and benign prostatic hypertrophy.
He had no known drug allergies.
MEDICATIONS:
1. Aspirin.
2. Lipitor 30 mg q day.
3. Flomax 4 mg q h.s.
4. Vitamins.
PHYSICAL EXAMINATION: Afebrile. Vital signs stable. His
neck was supple. Lungs were clear. Heart was regular rate
with no murmurs. The abdomen was benign. His extremities
were warm and well perfused.
He was taken to the operating room on [**2119-9-15**] where a coronary
artery bypass graft times four was performed. He was
transferred to the CSRU postoperatively where he did well.
He was fully weaned from his ventilator and was extubated.
The patient had a Physical therapy consult for ambulation and
he was also started on Plavix. The patient did well
postoperatively and continued to improve. He was diuresed
with Lasix and was transferred to the floor. His chest tubes
were removed. Postoperatively his Foley was removed and
physical therapy continued to work with him. He did well.
He continued to ambulate and improve and on postop day four
physical therapy cleared him for home.
His dressings were removed. Incisions were clean. The
patient is discharged in stable condition to home with no
home physical therapy required.
DISCHARGE MEDICATIONS:
1. Percocet one to two tabs p.o. q 4 hours.
2. Plavix 75 mg p.o. three times a day.
3. Ecasa 325 mg p.o. q day.
4. KCL 20 mEq p.o. b.i.d.
5. Colace 100 mg p.o.b.i.d.
6. Lopressor 12.5 mg p.o. b.i.d.
7. Lasix 20 mg p.o. b.i.d.
8. Protonix 40 mg p.o. q day.
Instructed to follow-up with primary physician in one to two
weeks and his Cardiologist in two to four weeks. The patient
is discharged home in stable condition.
[**Last Name (STitle) **] DR.[**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] 02-351
Dictated By:[**Last Name (NamePattern4) 44302**]
MEDQUIST36
D: [**2119-9-19**] 11:20
T: [**2119-9-19**] 13:36
JOB#: [**Job Number 44303**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3044
} | Medical Text: Admission Date: [**2145-6-11**] Discharge Date: [**2145-6-29**]
Date of Birth: [**2072-5-17**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
R colon cancer
Major Surgical or Invasive Procedure:
Colonoscopy [**2145-6-15**]
Right Colectomy [**2145-6-18**]
History of Present Illness:
73 year old male with PMHx of EtOH abuse, hyperlipoproteinemia,
CVA with residual RLE weakness, suspected embolic strokes from
PFO who is being transferred to the ICU for altered mental
status. The patient was admitted to the Neurology service on
[**2145-6-11**] for concern of repeat stroke. The plan was to start
aspirin 325mg daily, however this was delayed because he was
noted to be anemic. GI was consulted and a colonoscopy was done
which showed a hepatic flexure mass, which on biopsy showed high
grade dysplasia concerning for colon cancer. Colorectal surgery
was consulted and took the patient to the OR for a right
colectomy. The patient tolerated the procedure well, with EBL
of 100cc. Had epidural catheter placed for anesthesia, received
2 units of PRBC during procedure to ensure adequate perfusion.
He received ciprofloxacin/flagyl intraop. The patient was
extubated and taken to the PACU. In the PACU, he was noted to
be tachycardic, hypertensive, and tremulous. EKG, CEs checked
and normal. Because of concern of EtOH withdrawal, he was given
a total of ativan 1.5mg IV x1. After he received the ativan, he
had acute worsening of his mental status becoming lethargic and
a Code Stroke was called. He had a stat CT and CTA of his head
and neck which showed no evidence of acute stroke per the Stroke
fellow. The patient was then admitted to the ICU for further
monitoring.
Past Medical History:
- Prior CVAs thought to be embolic from PFO (Multifocal stroke
involving left Occipital, left Thalamic/IC [**1-/2145**])
- Hyperlipoproteinemia
- EtOH abuse
Social History:
Mr [**Known lastname 14738**] lives with his mother. [**Name (NI) **] was previously in the
military and retired from being a bus driver.
A friend reports he has abused ETOH for the last 5 years and
drinks [**11-29**] liter vodka daily. He denies ever smoking.
Family History:
His mother has had 3 MIs. His father died from complications of
alcoholism. He has a sister who died from renal failure
secondary to a kidney stone. He reports no history of strokes of
blood disorders in his family.
Physical Exam:
VS: T:97.4; HR: 77; BP: 155/103; RR: 16; Sat: 99% RA
Gen: WD/WN M in NAD
CV: RRR, no m,r,g
Chest: CTA
Abd: Soft, nontender, nondistended, dermabonded midline surgical
wound
Ext: no c/c/e
Pertinent Results:
[**2145-6-22**] 06:00AM BLOOD WBC-4.2 RBC-4.03* Hgb-9.0* Hct-30.6*
MCV-76* MCH-22.4* MCHC-29.5* RDW-21.9* Plt Ct-470*
[**2145-6-22**] 06:00AM BLOOD Glucose-122* UreaN-7 Creat-0.9 Na-139
K-3.6 Cl-106 HCO3-26 AnGap-11
[**2145-6-22**] 06:00AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0
CTA Head/Neck [**6-18**]:
1. Little overall interval change from the complete CTA,
performed only a
week ago; specifically, the known predominantly left frontal
deep "watershed"
infarcts are not well-seen, with no evidence of acute vascular
territorial
infarction (though no dedicated CT-perfusion study was requested
or
performed).
2. No acute intracranial hemorrhage.
3. Unchanged appearance of high-grade stenosis of the proximal
P2 segment of
the left PCA, with preserved distal flow.
4. Diffuse atherosclerotic disease of the intracranial vessels,
most markedly
involving the superior division of the left MCA, as well as the
hypoplastic A1
segment of the right ACA, with no new flow-limiting stenosis.
5. Unremarkable cervical vessels, with no flow-limiting
stenosis.
6. Patchy airspace opacities involving the posteromedial lung
apices,
apparently new, which should be closely correlated clinically
and with chest
radiography.
7. 3-mm sialolith in the proximal left submandibular duct.
ABDOMEN (SUPINE & ERECT) Study Date of [**2145-6-25**] 10:52 AM
IMPRESSION: Continued dilation of small bowel loops and
air-fluid levels.
Dilation is worsened since film from [**2145-6-24**] at 8:35 a.m.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2145-6-25**] 3:40 PM
IMPRESSION:
1. Dilated small bowel to level of the anastomosis. No evidence
of leakage
or infection at anastomotic site. Dilated colon distal to
anastomosis with a second focal area of narrowing in the
transverse colon. Distal to the second narrowing, there again is
dilated large bowel through to the rectum. Findings
are consistent with ileus or partial small bowel obstruction.
2. Multiple unchanged hepatic cysts.
3. Free fluid in the pelvis and minimal perihepatic fluid.
CHEST PORT. LINE PLACEMENT Study Date of [**2145-6-25**] 10:05 PM
IMPRESSION:
1. Interval placement of a right PICC catheter with the tip in
the proximal right atrium. Re-positioning would be advised.
Overall cardiac and mediastinal contours are stable given
differences in positioning. Lung
volumes are low but no focal airspace consolidation, pleural
effusions, or
pneumothoraces are seen. Epidural catheter is no longer seen. A
left
perihilar opacity is less apparent on the current examination
possibly related to differences in positioning or interval
improvement. Continued close followup imaging would be advised.
CHEST (PORTABLE AP) Study Date of [**2145-6-26**] 10:04 AM
IMPRESSION: Normally positioned left-sided PICC. No
pneumothorax.
ABDOMEN (SUPINE & ERECT) Study Date of [**2145-6-27**] 12:12 PM
IMPRESSION:
1. Lung bases appear clear. There is gas scattered throughout
small and
large bowel with some air-fluid levels on the upright study.
Overall, the
bowel loops appear slightly more distended although given the
degree of gas in both the small and large bowel, this would
still favor a postoperative ileus. However, given worsening
distention, early small bowel obstruction can not be entirely
ruled out. Clinical correlation is advised. No free air.
Multiple calcifications in the pelvis are consistent with
phleboliths. Radiopaque material in the left lateral mid abdomen
likely represents retained contrast in diverticula. Chain
sutures are seen in the mid abdomen likely at the anastomosis
site.
ABDOMEN (SUPINE & ERECT) Study Date of [**2145-6-29**] 9:33 AM
Continued ileus per surgical team.
Brief Hospital Course:
Mr. [**Known lastname 14738**] was initially admitted to neurology on [**6-11**] for
weakness and found to have an acute L cortical ischemic stroke.
Please see the neurology admission note for more detail. He was
not a candidate for tPA. He was found to be anemic with
Hemoccult positive stool. On [**6-15**] EGD and colonoscopy were
performed. EGD was normal but on colonoscopy a 2-3 cm
ulcerated, malignant appearing lesion in the hepatic flexure was
seen. The lesion was partly obstructing and the scope could not
be passed beyond this point. The patient was taken to the
operating room on [**2145-6-18**] for a R colectomy. Please see the
operative report for more detail. His postoperative course was
complicated by an acute mental status change in the PACU for
which he was transferred to the ICU. A stroke consult was
obtained, CT and CTA imaging was obtained, neurology felt this
to be likely of toxic/metabolic origin from anesthesia. His
epidural was removed and his mental status returned to baseline.
He was observed in the ICU and transferred to the floor on
POD2. His course was further complicated by bilious emesis on
POD2, an NGT was placed. It was removed on POD4, when he was
passing flatus and having bowel movements. By the day of
discharge he was tolerating a normal diet. After restarting a
regular diet, the patient's abdomen again became distended and
he vomited. On [**2145-6-24**] a repeat KUB showed air fluid levels and
the patient was backed down to sips. On [**2145-6-25**] a PICC line was
placed. Also on [**2145-6-25**] as well as [**2145-6-26**] the patient was noted
to have several runs of nonsustained Vtach, a cardiology consult
was called and the patient's electrolytes were repleated and his
Lopressor doses were titrated. In addition he was noted to have
hypertension post operatively for which he was started on
Lopressor and Lisinopril 5 mg daily. The Lopressor was titrated
up by discharge to 37.5 mg PO BID. The patients blood pressure
was stable. The patient continued to have bowel movements and
pass flatus despite being medically stable and have evidence of
ileus on KUB. The patient was started on TPN and followed
closely by nutrition On [**2145-6-29**] an additional KUB was obtained
which showed continued ileus. The patient remained without an NG
tube, stable. The patient was assessed by the surgical team and
it was thought that perhaps, the patient had an overgrowth of
bacteria causing this ileus. Treatment of bacterial overgrowth
was started with Rifamixin 200mg TID for 10 days. The patient is
to be discharged to rehabilitation hospital on sips of clear
liquids and ensure 30cc/hr until follow-up with Dr. [**Last Name (STitle) **] in 2
weeks when he will have a repeat KUB to access the ileus. TPN
will continue throughout this time period.
Medications on Admission:
Patient endorses taking no meds.
Per prvious d/c [**1-/2145**]:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Reglan 10 mg Tablet Sig: One (1) Tablet PO Three Times Daily
Before Meals and At Bedtime.
9. rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) for 10 days. Tablet(s)
10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
11. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a
day: hold for SBP<100 or HR<60.
12. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED): Please see sliding scale,
use while patient recieving TPN.
13. Regular Insulin Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-70mg/dL Proceed with hypoglycemia protocol
71-159mg/dL 0 Units
160-199mg/dL 2 Units
200-239mg/dL 4 Units
240-279mg/dL 6 Units
280-319mg/dL 8 Units
320-359mg/dL 10 Units
360-399mg/dL 12 Units
> 400mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Acute Ischemic Stroke
Right Sided Colon Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a Right Sided Colectomy
for surgical management of your near-obstructing right sided
colon cancer. You have recovered from this procedure well and
you are now ready to return home. Samples from your colon were
taken and this tissue has been sent to the pathology department
for analysis. Your pathology results were communicated to you by
Dr. [**Last Name (STitle) **], if you have any questions regarding these results,
please call the office. You have tolerated a regular diet,
passing gas and having bowel movements and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
Please monitor your bowel function closely. You have had a
slowing of your intestine called an ileus for the past weeks or
so. You have had multiple Xrays of your abdomen which showed
this slowing as well as a CT scan which showed no [**Last Name 16423**] problem
from the surgery. It is believed that this slowing is related to
am overgrowth of bacteria in your bowels and this will be
treated with an antibiotic called Rifamixin which you will take
for the next 10 days. You will continue to take reglan by mouth
during this time. You will continue to recieve TPN through the
PICC line in your arm until your follow-up appointment. You
cannot take more by mouth than sips of clears and sips of
ensure, which is 30cc of fluid an hour until you are cleared by
Dr. [**Last Name (STitle) **]. You will have an abdominal xray prior to your
follow-up appointment with Dr. [**Last Name (STitle) **]. If you have any of the
following symptoms please call the office for advice or go to
the emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonged loose stool, or
constipation.
You have a long vertical incision on your abdomen that is closed
with sutures underneath the skin and dermabond glue. This
incision can be left open to air or covered with a dry sterile
gauze dressing if the staples become irritated from clothing.
Please monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
exercise.
You will be prescribed a small amount of pain medication. Please
take this medication exactly as prescribed. You may take Tylenol
as recommended for pain. Please do not take more than 4000mg of
Tylenol daily. Do not drink alcohol while taking narcotic pain
medication or Tylenol. Please do not drive a car while taking
narcotic pain medication.
You will continue your physical therapy as recommended to you at
the rehabiliation facility.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**12-31**] weeks, call for an appointment,
[**Telephone/Fax (1) 160**]
Department: NEUROLOGY
When: TUESDAY [**2145-8-3**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2145-6-29**]
ICD9 Codes: 4271, 5990, 4019, 2724, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3045
} | Medical Text: Admission Date: [**2108-6-25**] Discharge Date: [**2108-6-29**]
Date of Birth: [**2036-12-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Esophogastricduodenoscopy - [**2108-6-26**]
Colonoscopy - [**2108-6-27**]
History of Present Illness:
Mr. [**Known lastname 54467**] is a 71yo M with history of CML on Gleevac,
diverticulitis s/p partial colectomy and IBS who presents with
melena. Patient saw his PCP where he was found to have
systolics in the 90s with guaiac positive black stool. He has
taken NSAIDs for chronic joint pain and felt weak for the past
1-2 weeks. Patient has been constipated for the past 5 days
and took MOM yesterday. Today, he had a few episodes of melena.
He denies N/V, heartburn, dysphagia, abdominal pain or bloating.
He has had mild dizziness and lightheadedness with dyspnea on
exertion the past few weeks as well.
.
In the ED, initial vs were: T 98.7 P 65 BP 115/47 R 18 O2 sat
100%. His hematocrit was 17, and he had guaiac positive black
stool. NG lavage was negative and produced clear fluid.
Patient was seen by GI with plan for transfusion and EGD in AM
unless unstable. He was started on PPI drip and started
receiving blood.
.
In the MICU, he reports feeling better than he did this morning.
No current dizziness or lightheadedness. The NG tube is
irritating him but otherwise he feels ok. Patient has had black
stools in the past intermittently (on iron) but none that have
looked like this.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, headache. Denies cough, shortness of
breath at rest, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, abdominal
pain. Denies dysuria, frequency, or urgency. Denies arthralgias
or myalgias. Denies rashes or skin changes.
Past Medical History:
- CML on Gleevac
- Diverticulosis c/b perforated diverticulum, s/p partial
colectomy with temporary colostomy and reversal
- Colonic Polyps
- Hearing Loss Sensorineural
- Psoriasis
- Anxiety
- s/p Vasectomy
- s/p Rotator Cuff Repair
- s/p Appendectomy
Social History:
He is married and has two sons.
- [**Name2 (NI) 1139**]: smoked 2 PPD for 20 years, quit [**2069**]
- Alcohol: drinks a cocktail and beer daily
- Illicits: none
Family History:
Father Deceased at 90 COPD
Mother Deceased at 89 DEMENTIA and Hypertension
Paternal Grandmother Diabetes
Physical Exam:
ADMISSION
Vitals: T: 96.3 BP: 144/73 P: 71 R: 18 O2: 100%
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,
rhonchi
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
DISCHARGE
VS: 96.3 116/57 68 18 97%RA
GEN: Comfortable, NAD
HEENT: Sclera anicteric, MMM, OP clear
Neck: Supple, no JVP, no LAD
Lungs: CTA b/l, no wheezes, rales, rhonchi
CV: RRR, no mrg, nlS1S2
ABD: soft, NT/ND, naBS, no rebound/guarding
Ext: WWP, 2+DP/PT/radial, no clubbing, cyanosis or edema
Pertinent Results:
Blood Count
[**2108-6-25**] 03:50PM BLOOD WBC-3.0* RBC-1.65*# Hgb-6.2*# Hct-17.7*#
MCV-107*# MCH-37.7*# MCHC-35.2* RDW-14.9 Plt Ct-202
[**2108-6-26**] 04:22PM BLOOD WBC-3.6* RBC-2.65* Hgb-9.1* Hct-26.7*
MCV-101* MCH-34.5* MCHC-34.3 RDW-19.2* Plt Ct-192
[**2108-6-27**] 10:40AM BLOOD WBC-2.6* RBC-3.08*# Hgb-10.4* Hct-30.3*
MCV-98 MCH-33.9* MCHC-34.4 RDW-18.6* Plt Ct-189
[**2108-6-29**] 06:51AM BLOOD WBC-4.2 RBC-2.48* Hgb-8.7* Hct-24.6*
MCV-99* MCH-35.1* MCHC-35.5* RDW-17.9* Plt Ct-225
[**2108-6-29**] 01:15PM BLOOD WBC-4.7 RBC-2.60* Hgb-9.2* Hct-26.1*
MCV-100* MCH-35.5* MCHC-35.4* RDW-17.4* Plt Ct-254
.
Chemistry
[**2108-6-25**] 03:50PM BLOOD Glucose-92 UreaN-32* Creat-1.5* Na-140
K-4.3 Cl-106 HCO3-29 AnGap-9
[**2108-6-29**] 01:15PM BLOOD Glucose-116* UreaN-27* Creat-1.3* Na-138
K-4.1 Cl-106 HCO3-27 AnGap-9
.
REPORTS
Endoscopy [**2108-6-26**]
Antral gastritis (biopsy), bulbar duodenitis, otherwise normal
EGD to third part of the duodenum
.
Colonoscopy [**2108-6-27**]
Diverticulosis of the whole colon. Grade 1 internal hemorrhoids.
Old blood in the whole colon. Recently bleeding lesion could not
be identified. The cecum was deformed, however, overlying mucosa
was normal. Semi-solid and liquid stool was noted scattered in
the whole colon. This was copiously irrigated and the patient
was re-positioned to improve mucosal visualization. Despite
these measures, small size pathology may have been missed.
Otherwise normal colonoscopy to cecum and terminal ileum
Brief Hospital Course:
HOSPITAL COURSE
This is a 71-year old M admitted to the MICU with melena and a
Hct of 17, who received 4 units pRBCs w/o focal source of
bleeding identified on EGD and [**Last Name (un) **], with Hct stabilizing at 25,
undergoing capsule endoscopy, discharged with plan for
outpatient follow-up for results.
.
ACTIVE
#. GI Bleed, Uncertain Source: Patient was admitted with melena
and Hct 17, requiring MICU stay and 4 units pRBCs. He underwent
EGD and [**Last Name (un) **] w/o identification of a source of the bleeding.
Capsule endoscopy was performed. Hct stabilized at 25 and, as
patient's Hct was stable and he was tolerating a regular diet
without further melena, the patient was discharged with plan for
outpatient telephone follow-up for discussion of results of
capsule endoscopy. Patient was discharged on protonix, with
home propanolol and iron held.
.
INACTIVE
# CML: Gleevac held in setting of acute illness. Outpatient
thereapy deferred to outpatient oncologist.
.
# Anxiety/Insomnia: Continued on trazodone and mirtazapine
.
TRANSITIONAL
1. Code - Patient remained full code for the duration of this
hospitalization
2. Pending - At discharge results of capsule endoscopy were
pending. GI c/s service Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) 3708**] agreed to
follow-up via telephone w patient to discuss results.
3. Transition of Care - Patient was scheduled for outpatient PCP
and GI followup.
Medications on Admission:
FERROUS SULFATE ORAL 1 by mouth once daily
Mirtazapine (REMERON) 15 mg Oral Tablet take 1 tablet AT BEDTIME
Propranolol 40 mg Oral Tablet TAKE 1 TABLET FOUR TIMES A DAY
Trazodone (DESYREL) 100 mg Oral Tablet 3 po qhs
GLEEVEC TABLET 400MG PO (IMATINIB MESYLATE) 1 by mouth once
daily
MULTIVITAMIN CAPSULE PO (MULTIVITAMINS) 1 by mouth once daily
VITAMIN B COMPLEX CAPSULE PO
Discharge Medications:
1. ferrous sulfate Oral
2. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO once a day.
3. trazodone Oral
4. Gleevec 400 mg Tablet Sig: One (1) Tablet PO once a day.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet PO twice a day. Disp:*60 Tablet, Delayed Release
(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Gastrointestinal Bleed of Uncertain Origin
acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with bloody stools and a fall
in your hematocrit (a measurement of your red blood cell level).
You received blood transfusions and underwent scoping via
endoscopy and colonoscopy. Neither process was able to identify
a clear origin of your bleeding. You underwent capsule
endopscopy--a test where you swallow a small camera which takes
pictures of your gastrointestinal tract looking for signs of
bleeding. The results of this test are still pending. Your
blood levels remained stable and you are ready for discharge.
During your hospitalization the following changes were made to
your medications:
-STOPPED propranolol (please follow up with your primary care
doctor to discuss restarting)
-STOPPED iron (can interfere with testing of your stool for
blood)
-STARTED protonix (a medication to help prevent bleeding from
your stomach)
Please see below for your scheduled follow-up visit
Followup Instructions:
Name: [**Last Name (LF) 54468**],[**First Name3 (LF) 54469**] B.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Friday [**2108-7-6**] 10:30am
We are working on a follow up appointment in Gastroenterology at
[**Location (un) 2274**]-[**Location (un) **] within 1 month. The office will contact you at home
with an appointment. If you have not heard within 2 business
days or have any questions please call [**Telephone/Fax (1) 2296**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 2851, 5849, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3046
} | Medical Text: Admission Date: [**2166-9-25**] Discharge Date: [**2166-10-5**]
Date of Birth: [**2166-9-25**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] [**Name2 (NI) **] is the 2665 gram product of a 35
week gestation pregnancy. He was born to a 34-year-old G2, P1,
now P2 woman with insulin-dependent gestational diabetes
mellitus. Prenatal screens: A+, antibody negative, hepatitis
surface antigen negative, RPR nonreactive, rubella-immune, GBS
gestational diabetes, rupture of membranes 2-1/2 hours prior
to delivery, yielding clear amniotic fluid, proceeded to
spontaneous vaginal delivery under epidural anesthesia.
NEONATAL COURSE: Infant emerged with strong cry, bulb
suctioned, dried, noted to be plethoric but in no distress on
room air. Apgars 8 and 8 at 1 and 5 minutes respectively.
dropped to 38 by 2 hours of life. The infant was transferred
to the Newborn Intensive Care Unit for further management of
hypoglycemia.
PHYSICAL EXAM ON ADMISSION: Birth weight was 2665, 75th
percentile. Head circumference was 31.5, 25th percentile.
Length was 46 cm, 50th percentile. Anterior fontanel was
soft and flat, nondysmorphic, palate intact. Neck and mouth
normal. No nasal flaring. Chest without retractions. Good
breath sounds bilaterally, no crackles. Intermittent mild
grunting respirations with agitation. Cardiovascular:
Well-perfused, regular rate and rhythm. Femoral pulses
normal. S1 and S2 normal, no murmur. Abdomen soft,
nondistended, no organomegaly, no masses, bowel sounds
active. Three-vessel umbilical cord and anus patent. GU:
Normal male genitalia, testes descended bilaterally. CNS:
Active, alert, tone AGA, moving all extremities
symmetrically. Suck, root, gag, grasp, Moro all normal.
HISTORY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY:He remained stable on room air throughout his
hospital course with no issues.
CARDIOVASCULAR: Has been stable without any issues.
FLUID AND ELECTROLYTES: Birth weight was 2665, infant was
managed with enteral feedings of premature Enfamil
20 calories, requiring some gavage feedings within the first
week of life. He is currently taking ad lib amounts of
Enfamil 20 calories with stable dextrose sticks.
GI: Peak bilirubin was on day of life #2 of 13.1/0.3. He was
treated with phototherapy for a total of 3 days and rebound
bilirubin was within normal limits, and the issue has since
resolved.
GU: The infant was circumcised on [**2166-10-2**]. His
circumcision is healing well.
HEMATOLOGY: Hematocrit on admission was 62. He has not
required any blood transfusions during this hospital course.
INFECTIOUS DISEASE: The infant has had no sepsis risk
factors or infectious issues during this hospitalization.
AUDIOLOGY: Auditory brain stem response was performed and
the infant passed both ears.
PSYCHOSOCIAL: A social worker has been involved with the
family and the contact social worker is [**Name (NI) **] [**Name (NI) **] and
she can be reached at [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 23340**] from [**Hospital 246**] Pediatrics,
telephone number is [**Telephone/Fax (1) 37501**].
CARE RECOMMENDATIONS: Continue ad lib feeding Enfamil
20 calorie.
MEDICATIONS: N/A.
Hearing screens and car seat saturation testing were passed.
State newborn screens have been sent per protocol and have been
within normal limits. Infant received hepatitis B vaccine on
[**2166-10-1**].
DISCHARGE DIAGNOSES:
1) Premature infant, born at 35-3/7 weeks.
2) Transient hypoglycemia secondary to maternal insulin
dependent diabetes mellitus.
4) Mild hyperbilirubinemia, resolved.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2166-10-5**] 14:04
T: [**2166-10-5**] 14:06
JOB#: [**Job Number 45144**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3047
} | Medical Text: Admission Date: [**2140-12-14**] Discharge Date: [**2140-12-22**]
Date of Birth: [**2080-2-3**] Sex: M
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Brain tumor
Major Surgical or Invasive Procedure:
Craniotomy for tumor resection
History of Present Illness:
The patient is a 60-year-old male who is well-
known to our service from a previous admission and
stereotactic brain biopsy. The patient had after trauma and
incidentally diagnosed brain tumor. The tumor was largely
asymptomatic initially and underwent a stereotactic biopsy.
This revealed subependymoma. The patient recently became
symptomatic with progressive headaches and it was felt that
ventricular entrapment contributed to this particular
situation. The patient was therefore extensively counseled.
The patient wished to undergo surgical decompression to
decrease his risk in the future and allow for better
treatment options in the future.
Past Medical History:
DM type II
CAD
hyperchol.
arthritis
kidney stones
right inguinal lipoma removal
left shoulder repair
laser kidney stone procedure
Social History:
denies tobacco
minimal EtOH use
works as engineer at [**Company 2676**]
Family History:
NC
Physical Exam:
He is awake, alert, and oriented times 3. His language is fluent
with good comprehension. His recent recall is intact. Cranial
Nerve Examination: His pupils are equal and reactive to light, 4
mm to 2 mm bilaterally. Extraocular movements are full; there is
no nystagmus or saccadic intrusions. Visual fields are full to
confrontation. Funduscopic examination reveals sharp disks
margins bilaterally. His face is symmetric. Facial sensation is
intact bilaterally. His hearing is intact bilaterally. His
tongue is midline. Palate goes up in the midline.
Sternocleidomastoids and upper trapezius are strong. Motor
Examination: He does not have a drift. His muscle strengths are
[**5-7**] at all muscle groups. His muscle tone is normal. His
reflexes are 0-1 bilaterally. His ankle jerks are absent. His
toes are downgoing. Sensory examination is intact to touch and
proprioception. Coordination examination does not reveal
dysmetria. His gait is normal. He does not have a Romberg.
Pertinent Results:
[**2140-12-19**] 04:44AM BLOOD WBC-15.0* RBC-4.88 Hgb-15.7 Hct-45.2
MCV-93 MCH-32.3* MCHC-34.8 RDW-13.7 Plt Ct-360
[**2140-12-19**] 04:44AM BLOOD Plt Ct-360
[**2140-12-19**] 04:44AM BLOOD Glucose-144* UreaN-26* Creat-0.7 Na-137
K-4.3 Cl-104 HCO3-23 AnGap-14
[**2140-12-18**] 02:22PM BLOOD CK(CPK)-20*
[**2140-12-18**] 02:22PM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2140-12-19**] 04:44AM BLOOD Albumin-3.4 Calcium-8.7 Phos-4.0 Mg-2.0
[**2140-12-16**] 03:52AM BLOOD TSH-0.26*
[**2140-12-19**] 04:44AM BLOOD Phenyto-7.9*
[**2140-12-16**] 04:08AM BLOOD Lactate-2.3*
[**2140-12-16**] 04:04AM BLOOD O2 Sat-93
[**2140-12-16**] 04:08AM BLOOD freeCa-1.10*
EKG [**12-19**] Atrial fibrillation with rapid ventricular response.
Since the previous tracing earlier on [**2140-12-16**] no change.
Echo: [**12-16**] : Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Moderate symmetric LVH. Small LV cavity.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Overall normal LVEF (>55%). No resting
LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Focal calcifications in aortic arch.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor parasternal views. Suboptimal
image quality - poor apical views.
Conclusions
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
small. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 70%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. 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. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined
MRI of brain: Residual mass within the left lateral ventricle
demonstrates patchy enhancement that has decreased in size
compared to the preoperative study, now measuring approximately
2.7 x 1.8 x 1.8 cm, previously 2.9 x 2.2 x 2.8 cm. There is a
new tract that extends through the left frontal lobe to the left
lateral ventricle with surrounding signal abnormality and
enhancement. There is post op pneumocephalus. Extraaxial
fluid/blood products are also present, and presumably
postoperative. No new masses are identified. There is mild
ethmoid mucosal thickening.
Brief Hospital Course:
Mr [**Known lastname **] was admitted electively for a endoscopic craniotomy for
tumor resection. Post operatively he was noted to have some
expressive aphasia. A CT showed no hemorrhage, he spent
overnight in the PACU was started on Decadron. His BP was kept
less than 140 overnight. On POD#1 he was transferred to the
surgical floor and later that evening he went into atrial
fibrillation with rapid ventricular response thought to be
related to hypervolemia. He was transferred to the surgical ICU
and started on a Cardiazem drip. on [**12-16**] CTA chest showed
consolidation in the lower lobes bilaterally as well as less
prominent in the upper lobes. The distribution is suggestive of
aspiration pneumonia. no PE, no DVT was seen on lower extremity
dopplers. An Echo showed an EF 70%, LV and RV nrml, valves nrml.
He ruled in for an MI by troponin. He was started on beta
blockers (already on Metoprolol)and a statin. His Cardiazem po
was titrated while the drip was weaned. He remained
neurologically stable with the exception of expressive aphasia.
[**12-15**] MRI Head: Residual tumor in the left lateral ventricle.
On [**12-20**] he was transferred to the neuro step-down unit. The
patient remained neurologically stable, was eating, and
ambulating. He had difficulty voiding and required a new foley
catheter. Bladder training was started and it was successfully
removed on [**12-22**]. His staples were also removed on discharge,
the site was clean and dry.
Medications on Admission:
Atenolol 100 mg po daily, metformin 1,000 mg po
twice daily, Byetta 10 microgram per 0.4 cc twice daily,
diltiazem 240 mg po daily, atorvastatin 20 mg po daily, and
Embrel 50 mg po q week
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
use while on pain medication.
Disp:*60 Capsule(s)* Refills:*0*
2. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Byetta 5 mcg/0.02 mL Pen Injector Sig: One (1) ML
Subcutaneous [**Hospital1 **] (2 times a day) as needed for give when pt is
on po diet.
5. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): use
while on Decadron.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
Disp:*120 Capsule(s)* Refills:*2*
9. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] visiting nurse assoc
Discharge Diagnosis:
Brain tumor
NSTEMI
CHF / acute diastolic dysfunction
diabetes
post operative urinary retention
hypercholesterolemia
atrial fibrillation with RVR
Discharge Condition:
Neurologically stable.
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] / cardiology for an appointment to be
seen for follow up of your Atrial fibrillation and myocardia
infarction, Congestive heart failure at [**Telephone/Fax (1) 2386**]. you should
be seen within 2 weeks of discharge.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU ALSO HAVE FOLLOWING APPOINTMENTS:
Provider [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2141-1-16**]
9:30
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-1-16**]
7:55
Out patient occupational therapy
Completed by:[**2140-12-22**]
ICD9 Codes: 4280, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3048
} | Medical Text: Admission Date: [**2192-2-22**] Discharge Date: [**2192-3-13**]
Date of Birth: [**2125-8-2**] Sex: F
Service: MEDICINE
Allergies:
Linezolid
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**2192-2-22**] intubation
[**2192-2-28**] extubation
[**2192-2-29**] Rigid Bronchoscopy with Trachael Silicone Y stent
[**2192-3-7**] Flexible Bronchoscopy
History of Present Illness:
Pt is a 66 y.o female with h.o COPD, PE, OSA, GIB, HTN, DM, CHF,
anemia who presents from [**Hospital **] Hospital with SOB.
Per report, pt had known PE, COPD, PNA and was at Rehab for that
condition.
However, she worsened (increasing difficulty maintaining sats
and c/o abdominal pain). Per report, pt uses bipap at night and
was noted to have decreased breath sounds on the L.side. She
reported dyspnea with speaking. Therefore, she was transferred
to [**Hospital1 18**] for eval.
Pt was most recently hospitalized at [**Hospital3 417**] and
discharged on levoquin for CAP. At rehab, abx were broadened to
vanco and cefepime and course was completed yesterday per pt's
daughter.
.
In the emergency department, initial vitals were:
Time Pain Temp HR BP RR Pox
10:47 0 97.5 100 120/78 24 98 (nonreb)
last vitals HR 102, BP 118/71, on PS RR 14, PEEP 5, PSV 8, FIO2
50%, sat 90%.
access-PIV and PICC
Given respiratory distress, hypoxia to 74% on RA, 91% on 6L, pt
was trialed on bipap (with no response) and was intubated. Per
[**Name (NI) **], pt on "several liters of o2" at baseline, on bipap at night
and intermittently during the day. ED concerned re: mental
status and without improvement pt was intubated with 7.5 tube.
Given CT findings,
of LLL collapse with occlusion of L.main stem bronchus, and
possible LUL PNA, IP was made aware of pt. Pt also reported
vague upper abdominal pain and was given vanco and zosyn. She
was "shaking", but not localizing nor febrile.
.
.
.
See MICU admit note for complete details, breifly, 66F with h/o
severe COPD (4L O2 @ home, baseline sats high 80s), OSA (bipap
20/5), with chronic cough, and dyspnea since [**1-3**]. She was
treated at OSH with levaquin, and trasferred to rehab, where she
was ultimately started on vancomycin/cefepime by report, but
continued to worsen with regard to her respiratory status,
prompting referral to [**Hospital1 18**], where she was noted to be acutely
hypoxic (74%RA), and intubated in the ED for "airway
proteection" CT CHEST revealed LLL atalectasis with occlusion
of the left mainstem bronchus.
.
Of note, she was evalauted by IP in the recent past for
?tracheomalacia.
.
In ICU, she was treated with vanc/zosyn. Bronch performed,
which revealed severe tracehobronchomalacia main distal
tracehea, copious thick secretions left mainstain and segmental
bronchi. Culture, however, has only shown RSV, although was
done on antibiotics.
.
Admit labs otherwise notable for leukocytosis (14), HCT 30->28,
cre 2.3 (baseline ), HCO3 34, vanco level 15, 7.39/58/81 (last
intubated gas on [**2-23**]). Her lasix dose was decreased from 120
qam; 80 qpm to 120mg qam given rising creatinine. She was
otherwise continued on a steroid taper (30mg qdaily -> 20 mg po
qdaily starting [**2-24**], at baseline is maintained on 10mg po
qdaily per daughter).
.
She is being called out to the medical service after having been
transitioned to heparin gtt (on coumadin for afib, h/o PE), in
anticipation of pulmonary stent later this week.
.
At present, she has no specific complaints, and states her
breathing is much improved compared to her baseline (confirmed
per her daughters).
Past Medical History:
trachobronchomalacia-was scheduled for stent in 1 week.
obstructive sleep apnea on BIPAP
chronic obstructive pulmonary disease (on 4L supplemental
oxygen)
pulmonary embolism in [**2190-2-26**]
GI bleed in [**2191-9-27**]
morbid obesity
hypertension
insulin dependent diabetes mellitus
congestive heart failure
gastroesophageal reflux disease
chronic renal insufficiency
multifactorial anemia? on Procrit
Social History:
Currently at [**Hospital1 **] for rehab
Originally from [**Location (un) 37452**], She currently lives with her 2
daughters and husband and grandson. They have a cat. She is a
retired homeless shelter manager. She does not drink alcoholic
beverages and is a former smoker. She smoked approximately [**1-28**]
packs per day for 30 years. She quit smoking approximately 10
years ago.
Family History:
Her family history is notable for a daughter with asthma and
father who died of emphysema related working in the coal mines
Physical Exam:
HR 105, BP 135/71, RR 19 sat 95% on FI02 50%, PSV 8 PEEP 5,
PHYSICAL EXAM
GENERAL: NAD, intubated, sedated, head nods to questions.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP-difficult to assess given habitus.
LUNGS: b/l ae, decreased BS on the L.middle and lower lobes, no
w/c/r
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES:1+ edema, no calf tenderness, erythema, symmetric,
2+ dorsalis pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO:intubated, sedated, head nods to commandes, able to move
all 4 extremities.
Pertinent Results:
MICROBIOLOGY:
[**2192-2-22**] 11:00 am BLOOD CULTURE
**FINAL REPORT [**2192-2-28**]**
Blood Culture, Routine (Final [**2192-2-28**]): NO GROWTH.
.
.
Time Taken Not Noted Log-In Date/Time: [**2192-2-22**] 8:11 pm
URINE Site: NOT SPECIFIED
CHEM S# [**Serial Number 52788**]D-UCU ADDED [**2192-2-22**] UCU ADDED [**2192-2-22**].
**FINAL REPORT [**2192-2-23**]**
URINE CULTURE (Final [**2192-2-23**]):
YEAST. <10,000 organisms/ml.
.
.
[**2192-2-22**] 5:58 pm BRONCHIAL WASHINGS
**FINAL REPORT [**2192-3-9**]**
GRAM STAIN (Final [**2192-2-23**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2192-2-25**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final [**2192-3-1**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Final [**2192-3-9**]):
YEAST.
.
.
[**2192-2-22**] 5:58 pm Rapid Respiratory Viral Screen & Culture
**FINAL REPORT [**2192-2-25**]**
Respiratory Viral Culture (Final [**2192-2-25**]):
PARAINFLUENZA VIRUS TYPE 3.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
Respiratory Viral Antigen Screen (Final [**2192-2-23**]):
Positive for Respiratory viral antigens.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to Respiratory Virus Identification for further
information.
Respiratory Virus Identification (Final [**2192-2-23**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (4I) ON [**2192-2-23**] @ 11:44AM.
POSITIVE FOR PARAINFLUENZA VIRUS.
Viral antigen identified by immunofluorescence.
Unable to serotype parainfluenza due to insufficient
cellular
content of sample.
Refer to respiratory viral culture for further
information.
.
.
[**2192-2-23**] 12:05 am URINE Source: Catheter.
**FINAL REPORT [**2192-2-24**]**
URINE CULTURE (Final [**2192-2-24**]):
YEAST. >100,000 ORGANISMS/ML..
.
.
[**2192-2-27**] 3:19 pm URINE Source: Catheter.
**FINAL REPORT [**2192-2-28**]**
URINE CULTURE (Final [**2192-2-28**]):
YEAST. ~7000/ML.
.
.
[**2192-3-3**] 3:23 am STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2192-3-4**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2192-3-4**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
.
[**2192-3-5**] 12:09 pm URINE Source: Catheter.
**FINAL REPORT [**2192-3-6**]**
URINE CULTURE (Final [**2192-3-6**]):
YEAST. ~9000/ML.
.
.
[**2192-3-10**] 11:40 am URINE Source: Catheter.
**FINAL REPORT [**2192-3-11**]**
URINE CULTURE (Final [**2192-3-11**]):
YEAST. >100,000 ORGANISMS/ML..
.
STUDIES:
[**2192-2-22**] CT C/A/P:
1. Left lower lobe collapse with occlusion of the left main stem
bronchus of unclear etiology. While findings could be secondary
to mucous secretions a left main stem bronchial lesion remains
of concern and cannot be excluded. Recommend pulmonary
consultation and follow-up to resolution. Bronchoscopy may be
helpful for further evaluation and should be considered.
2. Small area of focal consolidation in the left upper lobe may
represent a small pneumonia. Partial left upper lobe collapse.
3. Severe emphysematous changes.
4. Hyperdense right mid-polar and upper pole renal lesions
incompletely
characterized on this non-contrast CT. Recommend further
evaluation with a
renal ultrasound on a non-urgent basis.
5. 6 mm hypodensity in the left thyroid lobe. If clinically
indicated this
may be evaluated with ultrasound.
.
.
[**Known lastname 52789**],[**Known firstname **] [**Age over 90 52790**] F 66 [**2125-8-2**]
Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study Date of
[**2192-2-28**] 1:09 PM
SPIROMETRY 1:09 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 0.97 2.49 39
FEV1 0.55 1.79 30
MMF 0.29 2.41 12
FEV1/FVC 57 72 78
LUNG VOLUMES 1:09 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 3.00 4.10 73
FRC 1.88 2.36 80
RV 1.91 1.61 118
VC 1.09 2.49 44
IC 1.11 1.74 64
ERV -0.02 0.75 -3
RV/TLC 64 39 162
He Mix Time 3.50
DLCO 1:09 PM
Actual Pred %Pred
DSB 2.48 18.18 14
VA(sb) 1.64 4.10 40
HB 8.10
DSB(HB) 3.15 18.18 17
DL/VA 1.92 4.43 43
NOTES:
No online pulmonary notes available.
.
.
[**2192-3-1**] TTE:
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Hyperdynamic LVEF >75%. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
Trivial MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Normal tricuspid valve supporting structures. No TS. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - body habitus.
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). 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 Final Report
CHEST RADIOGRAPH
[**2192-3-3**] CXR:
INDICATION: COPD, abdominal pain, evaluation for air under the
diaphragm.
COMPARISON: [**2192-3-2**], 10:12 p.m.
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Unchanged bilateral lung alterations as previously
described. No
evidence for free intra-abdominal air.
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion.
.
.
[**2192-3-3**] AXR:
INDICATION: COPD, abdominal pain, diarrhea.
FINDINGS: Air-filled distended focal part of the transverse
colon.
Otherwise, no distention or air-fluid levels. No pathological
calcifications,
no free intra-abdominal air.
.
.
[**2192-3-3**] CT PELVIS:
HISTORY: 66-year-old female with severe abdominal pain and
diarrhea, evaluate
for colitis.
COMPARISON: CT chest, [**2191-2-22**].
TECHNIQUE: MDCT helical acquisition was performed from the
diaphragm to the
pubic symphysis following the uneventful administration of oral
contrast. IV
contrast was not administered due to renal insufficiency.
Multiplanar
reformations were provided. DLP: 810.
CT ABDOMEN WITHOUT IV CONTRAST: The left lower lobe again
demonstrates
collapse, as in recent chest CT. There is also segmental
atelectasis of the right lower lobe without total collapse.
Pulmonary artery trunk appears dilated, to 4.2 cm, likely from
pulmonary artery hypertension.
Assessment of solid visceral structures is limited without IV
contrast.
Allowing for this, the liver, spleen, pancreas, and right
adrenal gland are unremarkable. The left adrenal gland
demonstrates a subcentimeter likely adenoma (2:31). The kidneys
demonstrate numerous hypodensities bilaterally, some of which
are isodense to kidney on this non-contrast study and cannot be
classified as simple cysts. Ultrasound or IV contrast-enhanced
CT or MR was previously recommended.
The large bowel and small bowel appear unremarkable, with no
evidence of bowel obstruction or colitis. There is no mesenteric
or retroperitoneal
lymphadenopathy. There is no abdominal free air or fluid. There
is a
fat-containing umbilical and periumbilical hernia.
CT PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid colon,
bladder appear
unremarkable. Bladder is distended, measuring 13 cm
superior-to-inferior.
There is no inguinal or pelvic lymphadenopathy. There is no
pelvic free
fluid. There are extensive calcifications of the abdominal aorta
and its
branches.
Osseous structures demonstrate moderate degenerative change.
This is also an S-shaped scoliosis of the lumbar spine. There is
vacuum disc phenomenon at L3-L4 and L4-L5 (301B:41). Slight
compression deformities are seen at T8 and T11 vertebral bodies.
IMPRESSION:
1. No evidence of colitis or bowel obstruction.
2. Left lower lobe collapse and right lower lobe segmental
atelectasis.
3. Subcentimeter left adrenal lesion is likely an adenoma.
4. Numerous renal hypodensities bilaterally, for which further
characterization was previously recommended, as these are do not
meet criteria for simple cysts based on this study.
5. Fat-containing umbilical hernia.
.
.
REASON FOR EXAMINATION: Persistent shortness of breath in a
patient with COPD and congestive heart failure.
Portable AP chest radiograph was compared to [**2192-3-2**].
The left PICC line tip can be seen to the level of the junction
of the left brachiocephalic vein and SVC. The cardiomediastinal
silhouette is stable including the left mediastinal shift, most
likely related to left lower lobe atelectasis and pleural
effusion that appears to be unchanged since the prior study. The
right basal opacity and small amount of right pleural effusion
are unchanged as well. There is no tracheostomy seen on the
current radiograph. There is no pleural effusion.
.
.
Cardiology Report ECG Study Date of [**2192-3-6**] 2:23:14 PM
Sinus tachycardia. Frequent atrial premature beats and
ventricular premature beats. Non-specific ST-T wave changes.
Compared to the previous tracing of [**2192-3-6**] there is no
significant diagnostic change.
.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
110 130 82 336/423 72 -10 124
.
.
LABS:
[**2192-2-22**] 11:00AM BLOOD WBC-14.6*# RBC-3.61* Hgb-9.3* Hct-30.8*
MCV-86# MCH-25.7*# MCHC-30.1* RDW-21.0* Plt Ct-295
[**2192-2-23**] 03:52AM BLOOD WBC-11.7* RBC-3.21* Hgb-8.8* Hct-27.9*
MCV-87 MCH-27.4 MCHC-31.5 RDW-20.3* Plt Ct-250
[**2192-2-24**] 05:48AM BLOOD WBC-11.2* RBC-3.31* Hgb-9.0* Hct-28.5*
MCV-86 MCH-27.1 MCHC-31.5 RDW-20.2* Plt Ct-257
[**2192-2-25**] 05:30AM BLOOD WBC-14.2* RBC-3.37* Hgb-9.1* Hct-28.8*
MCV-85 MCH-26.9* MCHC-31.5 RDW-20.7* Plt Ct-288
[**2192-2-26**] 06:25AM BLOOD WBC-10.9 RBC-3.18* Hgb-8.7* Hct-27.1*
MCV-85 MCH-27.3 MCHC-32.0 RDW-20.8* Plt Ct-278
[**2192-2-27**] 06:25AM BLOOD WBC-16.3* RBC-3.12* Hgb-8.8* Hct-27.0*
MCV-87 MCH-28.2 MCHC-32.5 RDW-20.6* Plt Ct-312
[**2192-2-28**] 09:00AM BLOOD WBC-13.8* RBC-2.98* Hgb-8.1* Hct-25.7*
MCV-86 MCH-27.2 MCHC-31.5 RDW-21.3* Plt Ct-299
[**2192-2-29**] 08:22AM BLOOD WBC-12.9* RBC-2.76* Hgb-7.6* Hct-24.6*
MCV-89 MCH-27.4 MCHC-30.8* RDW-21.3* Plt Ct-326
[**2192-2-29**] 08:03PM BLOOD WBC-15.5* RBC-2.86* Hgb-7.6* Hct-25.1*
MCV-88 MCH-26.5* MCHC-30.2* RDW-21.3* Plt Ct-332
[**2192-3-1**] 04:15AM BLOOD WBC-14.0* RBC-2.81* Hgb-7.5* Hct-24.2*
MCV-86 MCH-26.6* MCHC-30.8* RDW-21.6* Plt Ct-347
[**2192-3-2**] 04:01AM BLOOD WBC-18.9* RBC-2.82* Hgb-7.6* Hct-24.7*
MCV-88 MCH-27.1 MCHC-30.9* RDW-21.2* Plt Ct-440
[**2192-3-2**] 04:05PM BLOOD WBC-14.8* RBC-2.71* Hgb-7.5* Hct-22.7*
MCV-84 MCH-27.5 MCHC-32.9 RDW-21.1* Plt Ct-375
[**2192-3-3**] 06:30AM BLOOD WBC-15.8* RBC-2.81* Hgb-7.7* Hct-24.7*
MCV-88 MCH-27.4 MCHC-31.2 RDW-20.8* Plt Ct-410
[**2192-3-5**] 07:10AM BLOOD WBC-13.0* RBC-2.82* Hgb-7.8* Hct-24.2*
MCV-86 MCH-27.8 MCHC-32.4 RDW-20.1* Plt Ct-434
[**2192-3-6**] 02:37PM BLOOD WBC-12.1*# RBC-3.03* Hgb-8.1* Hct-26.1*
MCV-86 MCH-26.8* MCHC-31.1 RDW-20.0* Plt Ct-476*
[**2192-3-8**] 05:26AM BLOOD WBC-12.4* RBC-3.05* Hgb-8.1* Hct-26.0*
MCV-85 MCH-26.5* MCHC-31.0 RDW-19.8* Plt Ct-491*
[**2192-3-11**] 05:15AM BLOOD WBC-12.6* RBC-2.71* Hgb-7.0* Hct-23.1*
MCV-85 MCH-25.8* MCHC-30.4* RDW-19.7* Plt Ct-488*
[**2192-3-11**] 05:00PM BLOOD WBC-10.7 RBC-2.60* Hgb-6.7* Hct-22.2*
MCV-86 MCH-26.0* MCHC-30.4* RDW-19.6* Plt Ct-499*
[**2192-3-13**] 07:04AM BLOOD WBC-8.6 RBC-2.98* Hgb-7.7* Hct-25.2*
MCV-85 MCH-26.0* MCHC-30.7* RDW-19.4* Plt Ct-477*
[**2192-2-22**] 11:00AM BLOOD Neuts-89* Bands-0 Lymphs-10* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-5*
[**2192-2-27**] 06:25AM BLOOD Neuts-66 Bands-1 Lymphs-18 Monos-11 Eos-1
Baso-0 Atyps-1* Metas-0 Myelos-2* NRBC-1*
[**2192-3-10**] 06:06AM BLOOD Neuts-93* Bands-0 Lymphs-5* Monos-0 Eos-1
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2192-2-22**] 11:00AM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-2+
Macrocy-1+ Microcy-1+ Polychr-2+ Schisto-OCCASIONAL
Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 15924**]
[**2192-2-26**] 06:25AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-2+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Tear
Dr[**Last Name (STitle) 833**]
[**2192-3-2**] 04:05PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-1+
[**2192-3-6**] 02:37PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL
Target-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 18670**]
Ellipto-OCCASIONAL
[**2192-3-10**] 06:06AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-2+ Ovalocy-1+
Target-OCCASIONAL Schisto-1+ Burr-1+ Tear Dr[**Last Name (STitle) **]1+ Fragmen-1+
[**2192-2-22**] 11:00AM BLOOD PT-20.4* PTT-21.1* INR(PT)-1.9*
[**2192-2-25**] 05:30AM BLOOD PT-35.4* PTT-150* INR(PT)-3.6*
[**2192-2-27**] 06:25AM BLOOD PT-15.1* PTT-45.4* INR(PT)-1.3*
[**2192-2-29**] 08:22AM BLOOD PT-14.6* PTT-64.8* INR(PT)-1.3*
[**2192-3-1**] 04:15AM BLOOD PT-14.7* PTT-150* INR(PT)-1.3*
[**2192-3-2**] 04:01AM BLOOD PT-15.0* PTT-85.2* INR(PT)-1.3*
[**2192-3-9**] 06:33AM BLOOD PT-35.0* PTT-28.4 INR(PT)-3.6*
[**2192-3-12**] 05:12AM BLOOD PT-36.4* PTT-30.0 INR(PT)-3.7*
[**2192-3-13**] 07:04AM BLOOD PT-39.9* PTT-31.6 INR(PT)-4.2*
[**2192-2-22**] 11:00AM BLOOD Glucose-117* UreaN-55* Creat-2.3*# Na-136
K-4.6 Cl-92* HCO3-31 AnGap-18
[**2192-2-23**] 03:52AM BLOOD Glucose-135* UreaN-49* Creat-2.2* Na-132*
K-4.8 Cl-92* HCO3-34* AnGap-11
[**2192-2-24**] 05:48AM BLOOD Glucose-71 UreaN-55* Creat-2.3* Na-134
K-4.7 Cl-91* HCO3-34* AnGap-14
[**2192-2-25**] 05:30AM BLOOD Glucose-52* UreaN-57* Creat-2.6* Na-132*
K-3.9 Cl-88* HCO3-33* AnGap-15
[**2192-2-25**] 03:28PM BLOOD Glucose-217* UreaN-54* Creat-2.5* Na-130*
K-4.8 Cl-87* HCO3-34* AnGap-14
[**2192-2-26**] 06:25AM BLOOD Glucose-111* UreaN-61* Creat-2.6* Na-136
K-4.2 Cl-92* HCO3-30 AnGap-18
[**2192-2-27**] 06:25AM BLOOD Glucose-43* UreaN-51* Creat-2.4* Na-137
K-3.7 Cl-93* HCO3-30 AnGap-18
[**2192-2-28**] 09:00AM BLOOD Glucose-60* UreaN-44* Creat-2.4* Na-133
K-4.0 Cl-95* HCO3-28 AnGap-14
[**2192-2-29**] 08:22AM BLOOD Glucose-74 UreaN-35* Creat-2.4* Na-137
K-3.7 Cl-100 HCO3-28 AnGap-13
[**2192-2-29**] 08:03PM BLOOD Glucose-139* UreaN-33* Creat-2.3* Na-132*
K-4.5 Cl-97 HCO3-21* AnGap-19
[**2192-3-1**] 04:15AM BLOOD Glucose-108* UreaN-32* Creat-2.3* Na-139
K-3.9 Cl-102 HCO3-25 AnGap-16
[**2192-3-2**] 04:01AM BLOOD Glucose-52* UreaN-26* Creat-2.0* Na-138
K-3.4 Cl-102 HCO3-25 AnGap-14
[**2192-3-3**] 06:30AM BLOOD Glucose-51* UreaN-22* Creat-1.9* Na-137
K-3.3 Cl-98 HCO3-23 AnGap-19
[**2192-3-5**] 07:10AM BLOOD Glucose-80 UreaN-26* Creat-2.5* Na-134
K-3.4 Cl-94* HCO3-26 AnGap-17
[**2192-3-6**] 07:30AM BLOOD Glucose-76 UreaN-27* Creat-2.5* Na-134
K-3.2* Cl-95* HCO3-26 AnGap-16
[**2192-3-7**] 06:30AM BLOOD Glucose-54* UreaN-28* Creat-2.6* Na-135
K-3.8 Cl-94* HCO3-26 AnGap-19
[**2192-3-8**] 05:26AM BLOOD Glucose-129* UreaN-30* Creat-3.0* Na-129*
K-3.7 Cl-91* HCO3-25 AnGap-17
[**2192-3-10**] 06:06AM BLOOD Glucose-122* UreaN-38* Creat-3.6* Na-127*
K-4.2 Cl-92* HCO3-21* AnGap-18
[**2192-3-12**] 05:12AM BLOOD Glucose-32* UreaN-26* Creat-2.0* Na-135
K-3.4 Cl-104 HCO3-20* AnGap-14
[**2192-3-13**] 07:04AM BLOOD Glucose-52* UreaN-19 Creat-1.6* Na-133
K-3.7 Cl-104 HCO3-20* AnGap-13
[**2192-2-22**] 11:00AM BLOOD ALT-21 AST-16 CK(CPK)-11* TotBili-0.2
[**2192-3-2**] 04:01AM BLOOD ALT-26 AST-11 AlkPhos-37 Amylase-110*
TotBili-0.1
[**2192-3-4**] 06:55AM BLOOD ALT-22 AST-13 AlkPhos-52 TotBili-0.3
[**2192-3-11**] 05:15AM BLOOD LD(LDH)-483*
[**2192-3-2**] 04:01AM BLOOD Lipase-8
[**2192-3-3**] 06:30AM BLOOD Lipase-42
[**2192-3-10**] 06:06AM BLOOD Lipase-32
[**2192-2-22**] 11:00AM BLOOD CK-MB-NotDone
[**2192-2-23**] 03:52AM BLOOD Calcium-11.2* Phos-4.9* Mg-2.4
[**2192-2-26**] 06:25AM BLOOD Calcium-9.9 Phos-2.6* Mg-2.0
[**2192-2-29**] 08:03PM BLOOD Mg-1.9
[**2192-3-13**] 07:04AM BLOOD Calcium-8.6 Phos-1.6* Mg-1.9
[**2192-3-11**] 05:15AM BLOOD calTIBC-276 VitB12-GREATER TH Hapto-337*
Ferritn-162* TRF-212
[**2192-2-24**] 01:31PM BLOOD PTH-62
[**2192-2-24**] 05:48AM BLOOD Vanco-15.5
[**2192-2-23**] 05:19AM BLOOD Vanco-22.4*
[**2192-2-22**] 11:00AM BLOOD Theophy-10.0
[**2192-2-22**] 11:23AM BLOOD Type-ART pO2-56* pCO2-49* pH-7.44
calTCO2-34* Base XS-7 Intubat-NOT INTUBA
[**2192-2-22**] 12:11PM BLOOD Type-ART Temp-36.4 Rates-16/0 Tidal V-500
FiO2-50 pO2-66* pCO2-56* pH-7.39 calTCO2-35* Base XS-6
-ASSIST/CON Intubat-INTUBATED
[**2192-2-23**] 10:22AM BLOOD Type-ART Temp-37.0 Rates-/9 Tidal V-727
PEEP-0 FiO2-50 pO2-81* pCO2-58* pH-7.39 calTCO2-36* Base XS-7
Intubat-INTUBATED Vent-SPONTANEOU
[**2192-2-27**] 07:26AM BLOOD Type-[**Last Name (un) **] pO2-209* pCO2-48* pH-7.44
calTCO2-34* Base XS-7
[**2192-3-2**] 09:56PM BLOOD Type-ART pO2-48* pCO2-34* pH-7.49*
calTCO2-27 Base XS-2
[**2192-3-3**] 06:07AM BLOOD Type-ART pO2-50* pCO2-33* pH-7.50*
calTCO2-27 Base XS-2
[**2192-3-10**] 06:07AM BLOOD Type-[**Last Name (un) **] pO2-58* pCO2-36 pH-7.38
calTCO2-22 Base XS--2 Intubat-NOT INTUBA Comment-GREEN TOP
[**2192-2-22**] 11:21AM BLOOD Lactate-2.3*
[**2192-3-2**] 09:56PM BLOOD Lactate-1.8
[**2192-3-3**] 06:07AM BLOOD Lactate-1.1
[**2192-3-10**] 06:07AM BLOOD Lactate-1.0
[**2192-2-22**] 02:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2192-2-23**] 12:05AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2192-2-27**] 03:19PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2192-3-5**] 12:09PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2192-3-9**] 11:36PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.014
[**2192-3-10**] 11:40AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2192-2-22**] 02:45PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
[**2192-2-23**] 12:05AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2192-2-27**] 03:19PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
[**2192-3-5**] 12:09PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2192-3-9**] 11:36PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2192-3-10**] 11:40AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2192-2-22**] 02:45PM URINE RBC-[**12-15**]* WBC-21-50* Bacteri-OCC
Yeast-FEW Epi-0-2
[**2192-2-23**] 12:05AM URINE RBC-18* WBC-114* Bacteri-FEW Yeast-FEW
Epi-<1
[**2192-2-27**] 03:19PM URINE RBC-11* WBC-195* Bacteri-FEW Yeast-RARE
Epi-0
[**2192-3-5**] 12:09PM URINE RBC-0 WBC-30* Bacteri-NONE Yeast-NONE
Epi-0
[**2192-3-9**] 11:36PM URINE RBC-50* WBC-691* Bacteri-FEW Yeast-MOD
Epi-4
[**2192-3-10**] 11:40AM URINE RBC-42* WBC-392* Bacteri-NONE Yeast-MANY
Epi-0
[**2192-2-22**] 02:45PM URINE CastHy-<1
[**2192-3-5**] 12:09PM URINE CastHy-3*
[**2192-3-10**] 11:40AM URINE CastHy-30*
[**2192-2-23**] 12:05AM URINE Hours-RANDOM UreaN-412 Creat-63 Na-51
K-45 Cl-41
Brief Hospital Course:
66 year old woman with past medical history significant for COPD
on home 02, OSA, TBM, hypertension, hyperlipidemia, h.o PE, PNA
who presents with hypoxia.
.
# ACUTE RESPIRATORY FAILURE (hypoxic and hypercarbic) / health
care associated bacterial pneumonia / severe COPD - patient with
COPD, on 4L home o2, bipap. h.o PE. Pt admitted in the setting
of recent community aquired pneumonia treated with levoquin.
Additionally, she completed a course of antibiotics for health
care associated pneumonia (HCAP) with vancomycin/cefepime at
[**Hospital1 **]. On admission, CXR and CT showed LLL collapse with
occlusion of the L.mainstem bronchus. Patient's hypercarbia and
02 sat were slightly worse from her baseline, and she was
intubated in the ED for airway protection. Upon arrival to the
ICU, she was treated with vancomycin and zosyn for resistant
HCAP.
.
Bronchoscopy was performed upon admission, which showed thick
purulent material which was suctioned, severe
tracheobronchomalacia. Bronchial washing cultures showed now
growth, however were felt limited by ongoing antibiotic therapy.
Respiratory viral antigen was significant for positive
parainfluenza, however this was not felt to require therapy per
pulmonary team. Likely post-viral HAP with a resistant organism
leading to complete mucous plugging of left mainstem. She was
extubated on [**2-25**]. She was stable on room air, with 02 sats at
baseline 88-92%. Of note, when she was placed on NC, 02 sat
increased to 100% but she became somnolent with presumed
hypercarbia.
.
Upon arrival to the medical service, she was weaned down to 1-2L
O2 as needed, with goal O2 sats 88-90%. She continued receiving
aggresive pulmonary toilet. As below, she was taken for
tracheal stent placement on [**2192-2-29**]. She was noted to have
transient hypoxia after the procedure, and was monitored
overnight in the ICU. She completed an 8d course of
vancomycin/zosyn on [**2192-2-29**]. She returned to the medical service
on [**2192-3-1**], where she was noted to have episodes of bloody
sputum. Her HCT and oxygenation remained stable. She was seen
by the interventional pulmonary service and felt to be stable.
.
.
Given ongoing dyspnea, pt was taken for repeat bronchoscopy on
[**2192-3-7**] which showed no evidence of pneumonia, minor clot at the
site of tracheal stent, but no other obstruction. Her
persistent LLL collapse was felt [**2-28**] distal disease, which was
not amenable to intervention endoscopically. She was seen by
the thoracic surgery service, who felt she was not a surgical
candidate at this time, but did offer to follow her as an
outpatient. after discussion with the interventinal pulmonary
service and her primary care physician, [**Name10 (NameIs) **] was to
consult the palliative care service to manage her subjective
symptoms of dyspnea with narcotics, before using
benzodiazapenes. it was felt that there were no further medical
options for managing her dyspnea at this time. she was
diuresed aggressively as below, until her creatinine rose, and
she was felt dry. her nebulizer regimen was increasd to q3hrs
and with mucomyst therapy (to maintain stent patency). she was
given aggressive chest physiotherapy.
.
she was started on morphine liquid per palliative care service
for symptoms of subjective dyspnea, which worked well but was
initially associated with itching. she was therefore switched
to oral dilaudid on [**3-9**], however this did not improve her
symptoms, she she resumed oral morphine with good effect.
morphine was also beneficial for intermittent symptoms of
abdominal pain as noted below. per the palliative care service,
given her prognosis, morphine should be titrated up as needed to
treat subjective symptoms of dyspnea.
.
at the time time of discharge, vital signs were 97.5 [**Numeric Identifier 52791**] 110
20 90%1L (with typical range of 1-3L, she was on 4L home O2
prior to admission) with finger stick 116. she was otherwise
continued on her regimen of theophyline, with increase in
nebulizer therapy to Q3HRS per pulmonary recommendation. the
patient and her family understood that she has limited options
with regard to further management of her severe lung disease.
she will continue aggressive nebulizer therapy, chest
physiotherapy, and diuresis as below. should her symptoms
worsen, she expressed the desire to consider repeat
hospitalization for treatment of pneumonia, including intubation
for respiratory failure. however, as below, she confirmed
desire to be DNR.
.
.
# tracheobronchomalacia - Patient has severe disease and was
scheduled for IP stent the week after admission. As above she
underwent succesful tracheal stent placement on [**2192-2-29**]. Mildly
blood sputum was noted after the procedure which was felt to
local trauma, and therapeutic heparin / coumadin. Given stable
HCT, she was followed symptomatically. given ongoing sensation
of dyspnea, and persistent LLL collapse after initial
bronchoscopy, IP service was consulted again, and repeat
bronchoscopy on [**2192-3-7**] showed patent stent, without evidence of
recurrence of pneumonia.
.
she was discharged to rehab, with instructions to continue
albuterol/xopenex nebulizer therapy Q3HRS, especially with
mucuomyst and mucinex therapy to promote stent patency. she
should also continue aggressive chest physiotherapy. as above,
she was evaluated by the thoracic surgery service but not felt
to be a candidate for distal airway intervention at this time,
but may follow-up with the thoracics surgery clinic as needed as
an outpatient.
.
.
# COPD: FEV 1 of .46. Patient was continued on home inhalers and
theophylline. She had been on steroid taper at [**Hospital1 **], and
was at 30 mg prednisone daily on admission. This was tapered to
a dose of 10mg on discharge which has been her usual dose of
10mg po qdaily. she was otherwise continued on her home regimen
of theophyline, fexofenadine, monteleukast, albuterol, xopenex,
spiriva, and atrovent inhalers. these were increased initially
to Q3HRS as above per the pulmonary service, but decreased to
Q6HRs if pulmonary status was stable.
.
.
# history of pulmonary embolism: Patient is on coumadin at home
in the setting of remote PE in [**2190**], with subsequent L UE DVT
(though felt to be catheter related, pt and family elected to
continue lifelong anticoagulation). Pt was transitioned from
coumadin to heparin for stent placement, then resumed coumadin,
with INR= 4.2 on discharge, thus her daily regimen (decreased to
2mg qdaily), was held, and should be resumed at rehab once her
INR is less than 3.0.
.
.
# diastolic congestive heart failure - pt's dose of lasix held
as below. she was continued on rate control with diltiazem.
she was continued on spirinolactone.
.
# chronic renal insufficiency - baseline creatinine ~2, up to
2.6 in ICU, thus lasix was held, with improvement to 1.9 on [**3-3**],
at which time she was restarted on lasix 80mg po qdaily, then
titrated up to home reigmen 120mg po qam; 80mg po qpm. given
ongoing dyspnea, and volume overload on clinical exam, diuresis
was increased to 120mg po qam with prn iv lasix 80mg iv given
once daily starting [**3-6**], with resultant negative fluid balance
of -500cc to 1L on [**2-25**], and [**3-8**]. On [**3-8**], her creatinine
rose from 2.5->3.0, and her lasix was stopped. On [**3-9**],
CRE=3.4. She received ~2L of IVF on [**3-10**] and [**3-11**] with
improvement in her creatinine to 2.0 on [**3-12**] and 1.6 on [**3-13**],
day of discharge. She should have strict daily weights, and
should resume her usual regimen of lasix within 2-3 days, if her
creatinine remains stable.
.
.
# sinus tachycardia - likely multifactorial, but has been
chronic, baseline HR 100-120, with contribution from COPD,
hypoxia, anxiety. on max dose of diltiazem, and prefered to
avoid beta blockade given COPD, however, has diastolic CHF which
could benefit from optimizing rate control. not clearly MAT
based on ECG [**2192-3-6**]. HR remained 100-120, thus she was continued
on her usual regimen as above.
.
.
# anemia, chronic disease - HCT stable at discharge. HCT = 30 on
admit -> 25 nadir, had single trace guaic positive brown stool
[**3-1**], but otherwise, likely [**2-28**] poor nutrition, chronic disease,
and iron, (on repletion), along with phlebotomy. had few blood
tinged sputums after stent placement, with stable HCT. HCT down
to 22 on [**3-11**], thus she recieved 1U PRBC with HCT 22->25, stable
on [**3-13**]. Her HCT drop was felt also likely due to dilution in
the setting of recieving 2L IVF on [**3-10**] and 2L IVF on [**3-1**]. Her
stools remained guaic negative. she was continued on her home
regimen of iron repletion.
.
.
# leukocytosis - WBC noted to be rising [**2-27**], unclear if [**2-28**]
pneumonia or steroids, peak of 16 on [**2192-3-3**] but pulmonary status
continued to improve as above, with tapering of steroid dose as
above. Pt denied diarrhea, dysuria, and no other new drugs
other than antibiotics. Repeat CXR stable without evidence of
pnuemonia. CT ABD/PELVIS obtained given intermittent abdominal
pain below, without acute process. UA repeated which showed
<10K yeast only. her leukocytosis resolved without further
intervention, and was down to 8 on day of discharge.
.
.
# bacterial urinary tract infection / fungal urinary tract
infection- +UA on [**2-27**], in setting of foley, and on abx for HAP
as above. UCx with 7K yeast colonies (imroved compared with
prior UCx with >100K), so initially held off treating for yeast
infection. Given leukocytosis, repeat UA sent which showed
yeast again, and elevated WBCs (691 on [**3-9**]), as well as
persistant RBCs. Given significant leukocytosis, and persistant
funguria (>100K grown on [**3-11**] Urine Cx), with ongoing urinary
retention, pt was started on 2 week course of fluconazole on
[**3-13**].
.
.
# abdominal pain / urinary retention - pt with intermittent
episodes of abdominal discomfort with typically resolved
completely with bowel movements. however, she was then noted to
have 1L in bladder [**3-6**] in the setting of a voiding trial after
foley catheter had been removed. foley catheter replaced, with
improvement in abodminal pain. CT ABD/PELVIS obtained over
[**2192-3-3**] given recurrent abdominal pain without acute pathology.
most likely etiology was felt [**2-28**] constipation vs urinary
retention, however symptoms typical resolved without
intervention. she was discharged to rehab with an agressive
bowel regimen (senna, colace, bisacodyl, lactulose, miralax).
second attempt was made to discontinue foley and attempt voiding
trial on [**3-9**], which was again unsucessful, as pt had 350cc on
post-void residual.
.
most likely etiology of retention is narcotic usage, and
deconditioning. pt will be discharged with foley catheter in
place x 7 days, then should attempt third voiding trial. she
should have intermittent straight cath performed Q6HRs, and if
>200cc in bladder, she should continue with ISC and have
follow-up appointment with urology. An appointment was made for
her given the presence of hematuria (which may have been
secondary to coagulopathy, and foley placement), and smoking
history, however this may be cancelled should these symptoms
resolve.
.
.
# coagulopathy - INR elevated to 4.2 on discharge, coumadin dose
of 2mg po qdaily was therefore discontinued. given that she is
being started on fluconazole, her INR should be followed daily,
and coumadin restarted on therapeutic (2.0-3.0).
.
# OSA - continued BiPAP. per pulmonary service, important for
pt to continue BiPaP both for sleep apnea, and also to help with
tracheobronchomalacia. when pt lethargic during day, ABG and
VBGs obtained showed stable PCO2 in 30s, however, pt encouraged
to wear BiPaP during day when able. Her settings for BiPaP
were:
Nasal CPAP w/PSV (BIPAP) Inspiratory pressure: 8 cm/h2o
Expiratory pressure: 5 cm/h2o to maintain SpO2 to >88 and <92
.
.
# DM2 - pt covered with sliding scale insulin throughout her
course, on [**3-11**], pt noted to have lower finger sticks (60-90),
down to 50s overnight, pt asymptomatic, but eating poorly.
finger sticks improved with oral glucose, and she was started on
D5NS, which was subsequently discontinued. her lantus dose was
decreased from 44U QHS to 25U QHS, given her poor oral intake
and now reduced oral steroid dose. she was encouraged to eat.
she will need close follow-up of her finger sticks daily, with
adjustment of her insulin regimen as needed.
.
# HTN, benign - continued home regimen diltiazem, amlodipine.
# hypothyroid - continued on home regimen of synthroid.
# depression - continued on citalopram.
# GERD - continued PPI.
.
# FEN - pt with poor oral intake, which improved with
encouragement. she was discharged home on a diabetic, cardiac
diet, with instructions to remain well hydrated. her insulin
regimen was adjusted as above given her poor oral intake, felt
largely [**2-28**] lack of appetitite.
.
# osteoporosis - continued calcium, and calcitonin.
.
.
# ACESS - L UE midline was placed [**2-27**]. this was left in place
at the time of discharge to facilate IV acess, and to provide
IVF as needed. this should be discontinued within 3 days of
arrival at rehab unless she continues to have an indication for
midline access.
.
# CODE - discussed with patient, husband, daughter [**Name2 (NI) **], and pt
made DNR in the setting of pulseless event. however, should she
have a pure respiratory decompensation, pt and family would like
to pt to be intubated again.
Medications on Admission:
Amlodipine 5 mg Tab Oral daily
Calcitriol 0.5 mcg Cap Oral daily
Calcium Carbonate 1,000 mg Tab Oral [**Hospital1 **]
Chlorhexidine Gluconate 0.12 % Mouthwash Mucous Membrane [**Hospital1 **]
Citalopram 10 mg Tab Oral daily
Diltiazem 120 mg Tab Oral, 3 tabs daily
Docusate Sodium 100 mg Tab Oral [**Hospital1 **]
Ferrous Sulfate 325 mg (65 mg Iron) Tab Oral [**Hospital1 **]
Fexofenadine 60 mg Tab Oral [**Hospital1 **]
Furosemide 40 mg Tab Oral-3 Tablet(s) Once Daily at 6am
Furosemide 40 mg Tab Oral-2 Tablet(s) Once Daily at 2pm
Gabapentin 300 mg Tab Oral [**Hospital1 **]
Insulin Aspart -- Unknown Strength
Insulin Glargine 100 unit/mL Sub-Q Subcutaneous, 44 units at
9pm.
Levalbuterol HCl --TID
Levothyroxine 75 mcg Tab Oral-[**1-28**] Tablet(s) Once Daily at 7 am
Magnesium Oxide 400 mg Tab Oral [**Hospital1 **]
Montelukast 10 mg Tab Oral QHS
Multivitamin,Tx-Minerals Tab Oral daily
Nystatin -- Unknown Strength qid 5ml
Pantoprazole 40 mg Tab, Delayed Release Oral [**Hospital1 **]
Prednisone 10 mg Tab Oral, 3 tabs at 8am
Salmeterol 50 mcg/Dose Disk Device [**Hospital1 **]
Sitagliptin 50 mg Tab Oral daily
Spironolactone 25 mg Tab Oral, 3 tabs [**Hospital1 **]
Theophylline 200 mg Tab Oral [**Hospital1 **]
Tiotropium Bromide 18 mcg Caps with inhalation device daily
Warfarin -- Unknown Strength
Acetaminophen 325 mg Tab Oral-2 Tablet(s) Every 4-6 hrs
Albuterol Sulfate --
Alprazolam 0.25 mg Tab Oral QID
Guaifenesin DM 10 mg-100 mg/5 mL Syrup Oral-10mls Syrup(s) Four
times daily, as needed
Lactulose 20 gram Oral Packet Oral daily prn
Trazodone 50 mg Tab Oral daily QHS
Oxycodone-Acetaminophen 5 mg-325 mg Tab Oral-1 Tablet(s) Every
6-8 hrs, as needed
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Levothyroxine 75 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. Spironolactone 25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
12. Ipratropium Bromide 0.02 % Solution Sig: [**1-28**] Inhalation Q6H
(every 6 hours).
13. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q6h ().
14. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1)
PO BID (2 times a day).
15. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO BID (2 times a day).
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
17. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
18. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
19. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous TID (3 times a day).
20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
21. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abd pain, gas.
22. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
23. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for headache/pain.
24. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-28**] Inhalation Q6H (every 6 hours) as needed
for SOB.
25. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
26. Morphine 10 mg/5 mL Solution Sig: [**1-28**] PO Q4H (every 4
hours) as needed for pain, anxiety, dyspnea.
27. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
28. Insulin Glargine 100 unit/mL Solution Sig: as per attached
sliding scale Subcutaneous at bedtime.
29. 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.
30. 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.
31. 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.
32. 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.
33. Humalog 100 unit/mL Solution Sig: as per attached sliding
scale Subcutaneous three times a day.
34. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
primary:
- health care associated pneumonia
- severe COPD
- severe trachaelmalacia
- acute on chronic renal failure
- urinary retention
- constipation
- fungal urinary tract infection
- hematuria
secondary:
- obstructive sleep apnea
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Lethargic but arousable
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Activity Status:Bedbound
Discharge Instructions:
you were admitted to the hospital with bacterial pneumonia. you
were intubated in the emergency department and admitted to the
ICU. a bronchoscopy was performed which revealed pneumonia and
tracheobronchomalacia.
.
a stent was placed to treat your tracehobronchomalacia. after
discussion with your pulmonologist, and thoracic surgery, you
were not felt to have further options for treating your COPD and
tracheobronchomalacia at this time. you may be followed in the
thoracic surgery clinic to consider further options.
.
you continued to have symptoms of shortness of breath. these
were treated with narcotics to treat your sensation of shortness
of breath.
.
The following changes were made to your medication regimen:
1. you were started on an increaesd regimen of Albuterol &
Acetylcysteine nebs 3 x day to maintain trachael Silicone Y
stent patency
2. Mucinex 1200 mg twice daily indefinitely for Silicone Y
stent patency
3. your lasix regimen was held, given a rising creatinine, and
should be restarted within 2-3 days.
4. you were started on a regimen of morphine to treat your
sensation of shortness of breath.
5. you were started on [**2192-3-13**] on a 14 day course of
fluconazole for a fungal urinary infection.
Followup Instructions:
upon arriving home, you should contact your primary care
physician, [**Name10 (NameIs) **] arrange to be seen within 1 week of leaving
rehab.
.
you should discuss with your rehab physicians, and primary
physician the possibility of following up in the thoracic
surgery clinic regarding your severe tracheobronchomalacia,
although they did not feel that you would be a good surgical
candidate presently. please call ([**Telephone/Fax (1) 17398**] if you would
like to schedule a follow-up appointment.
.
.
you should follow-up in the urology clinic within 2 weeks
regarding your hematuria and urinary retention. an appointment
has been made for you with Dr. [**Last Name (STitle) **], on [**2192-3-21**] at 1PM. please
call ([**Telephone/Fax (1) 4376**] if you have any questions or concerns.
ICD9 Codes: 486, 5849, 5180, 2761, 4280, 5859, 2724, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3049
} | Medical Text: Admission Date: [**2131-12-22**] Discharge Date: [**2131-12-28**]
Date of Birth: [**2090-10-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Stab wounds to left chest
Major Surgical or Invasive Procedure:
left thoracotomy
History of Present Illness:
The patient is a 41 y/o male who presented from an outside
hospital with excessive bleeding from 2 stab wounds. At the
outside hospital, the patient was intubated and had one chest
tube placed and had an output of 1200cc of blood. The patient
was transferred to the [**Hospital1 18**] ED for further management. The
patient had an additional chest placed and was aggressively
volume resuscitated in the ED.
Past Medical History:
None
Social History:
The patient works in construction.
Family History:
Non-contributory.
Physical Exam:
T 97 P 92 BP 92/27 R 17 SaO2 100%
Gen - Intubated, sedated
Heent - No scleral icterus, pupils equal, round, and reactive to
light
Chest - 3 cm stab wound at the left midclavicular line at the T6
level and a 8 cm wound at the left flank
Lungs - Decreased breath sounds in left lung base
Heart - regular rate and rhythm
Abd - soft, nontender, nondistended, bowel sounds audible
Extrem - no lower extremity edema
Pertinent Results:
[**2131-12-22**] 06:35AM BLOOD WBC-21.5* RBC-3.00* Hgb-9.2* Hct-26.6*
MCV-89 MCH-30.8 MCHC-34.7 RDW-13.0 Plt Ct-264
[**2131-12-22**] 06:35AM BLOOD PT-14.4* PTT-34.2 INR(PT)-1.3*
[**2131-12-22**] 12:31PM BLOOD Glucose-130* UreaN-10 Creat-0.5 Na-141
K-3.6 Cl-116* HCO3-21* AnGap-8
[**2131-12-22**] 06:35AM BLOOD ASA-NEG Ethanol-47* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2131-12-22**] 06:35AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
With persistent bleeding, the patient was taken to the OR for a
left exploratory thoracotomy, repair of his lung and intercostal
laceration, and evacuation of his left hemothorax which the
patient tolerated well and was transferred to the ICU intubated
and in stable condition. The patient was able to be weaned from
sedation and extubated and had his apical chest tube d/c'd on
post-op day 1. His basilar chest tube was left to water seal.
This chest tube was eventually discontinued. He was transferred
to the floor on post-op day 2. Post-operatively, an aspiration
pneumonitis that was noted on bronchoscopy in the exploratory
thoracotomy led to oxygen desaturation and the patient was
started on Levoquin. He also had bilateral pleural effusions
and was diuresed for this. He was kept on supplemental oxygen
to keep his SaO2 up. Ophthalmology was consulted on post-op day
4 when the patient complained of seeing shadows from his right
eye. He will follow up with them as an outpatient. He was
transfused 2 units of packed red blood cells on post-op day 4
for a Hct of 19.7. The patient was able to be weaned off
supplemental oxygen and was discharged on post-op day 6
tolerating a regular diet with pain well controlled.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*70 Tablet(s)* Refills:*0*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
left thoracotomy for repair of lung laceration
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 71207**] office [**Telephone/Fax (1) 170**] if you develop fever,
chills, chest pain, redness or drainage from your incision
sites.
You may shower. No tub baths or swimming for 3-4 weeks.
No lifting greater than 10 pounds for 6 weeks.
Followup Instructions:
call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] for a follow up
appointment
ICD9 Codes: 5070, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3050
} | Medical Text: Admission Date: [**2162-9-24**] Discharge Date: [**2162-9-28**]
Date of Birth: [**2093-3-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Mild exertional dyspnea
Major Surgical or Invasive Procedure:
[**2162-9-24**] s/p AVR (#21mm St.[**Male First Name (un) 923**] epic)/Asc ao replacement
History of Present Illness:
This is a 69 year old female with
known aortic stenosis since [**2158**]. She has experienced a slight
increase in exertional dyspnea. She was recently assessed by an
exercise tolerance test and echocardiogram which revealed more
severe aortic stenosis. At times, the patient is aware of brief
flutters which occur at night without lightheadedness,
dizziness,
presyncope or syncope. She denies effort related chest pain. She
remains very active, and performs routine daily activities
without difficulty. She was seen by Dr. [**Last Name (STitle) **] in [**Month (only) 116**] for
surgical discussion. She presents today for preadmission testing
for an aortic valve replacement with possible ascending aorta
replacement [**2162-9-20**] with Dr. [**Last Name (STitle) **].
Past Medical History:
Aortic Stenosis
History of Mitral Valve Prolapse
Hypertension
Dyslipidemia
Obesity
Pernicious Anemia
Hypothyroidism
Osteoarthritis
Peripheral Neuropathy
Chronic Back Pain, Degenerative Scoliosis
Lumbosacral radiculitis - prior thoracic block
Past Surgical History:
- Lap Cholecystectomy
- Multiple Lumbar and Thoracic spine fusions(approx nine) One
c/b
likely MRSA
- Left Cataract Surgery, (Right cataract scheduled for [**6-15**])
- Fibroid Removal
- Mohs
Social History:
Last Dental Exam: [**2162-1-10**]
Race: Caucasian
Lives with: Husband
Occupation: Retired, very active golfer
Cigarettes: Never
ETOH: < 1 drink/week [] [**2-16**] drinks/week [] >8 drinks/week [x]
Illicit drug use: Denies
Family History:
non-contributory
Physical Exam:
Physical Exam:
Pulse: 70 Resp: 18 O2 sat: 100% room air
B/P Right: 129/95 Left: 138/87
Height: 65 inches Weight: 197lbs
General: WDWN female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Murmur [x] grade 3/6 SEM radiating to carotids
Abdomen: Soft, non-distended, non-tender with NABS
Extremities: Warm [x], well-perfused [x]
Edema: None
Varicosities: None
Neuro: Grossly intact
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: transmitted murmurs
Pertinent Results:
Echocargiogram [**2162-9-24**]:
Pre-Bypass:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler.
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 ascending aorta is mildly dilated. There are simple atheroma
in the ascending aorta, aortic arch, and descending thoracic
aorta.
The aortic valve is bicuspid. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-11**]+) mitral regurgitation is seen.
There is very small pericardial effusion.
Post-Bypass:
The patient is on a phenylephrine infusion s/p aortic vavle and
ascending aortic plication.
There is a well seated #21 bioprosthetic aortic valve. There are
no perivalvular leaks. Peak and mean gradients are 14/7 with a
cardiac output of 3.6.
Left ventricular function is preserved with estimated EF-55%
Mitral regurgitaion appears slightly worse (mild-mod MR).
Tricuspid Reguritaiton remains [**1-11**]+.
There is no echocardiographic evidence or aortic dissection
post-decannulation.
.
[**2162-9-28**] 06:09AM BLOOD WBC-6.8 RBC-2.73* Hgb-8.7* Hct-26.0*
MCV-95 MCH-31.8 MCHC-33.4 RDW-14.7 Plt Ct-136*
[**2162-9-27**] 04:48AM BLOOD WBC-7.9 RBC-2.82* Hgb-8.9* Hct-27.4*
MCV-97 MCH-31.7 MCHC-32.7 RDW-15.0 Plt Ct-115*
[**2162-9-28**] 06:09AM BLOOD Glucose-114* UreaN-10 Creat-0.8 Na-134
K-4.1 Cl-98 HCO3-32 AnGap-8
[**2162-9-27**] 04:48AM BLOOD Glucose-127* UreaN-13 Creat-0.8 Na-135
K-4.2 Cl-100 HCO3-30 AnGap-9
[**2162-9-28**] 06:09AM BLOOD Mg-1.7
[**2162-9-27**] 04:48AM BLOOD Mg-2.3
Brief Hospital Course:
The patient was brought to the Operating Room on [**2162-9-24**] where
the patient underwent Aortic Valve(#21mm St.[**Male First Name (un) 923**] epic
tissue)/Ascending Aortic replacement . Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. She arrived AP over SB and was hypertensive
required nitro gtt. She was initially hypoxic and required extra
vent support, she eventually extubated without difficulty. POD 1
found the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable, weaned from the Nitro. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. She became hypoglycemic after receiving
Lantus per ICU protocol and remained in the unit one extra day
for monitoring. She was hypotensive and beta blocker was
adjusted. The patient was transferred to the telemetry floor on
POD#2 for further recovery. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 4 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged home with VNA
in good condition with appropriate follow up instructions.
Medications on Admission:
ATORVASTATIN 40 mg daily, LEVOTHYROXINE 100 mcg daily, ASPIRIN
325 mg daily, CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] 1,000
mcg daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
6. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
7. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
8. Potassium Chloride (Powder) 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth daily
Disp #*7 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Stenosis
History of Mitral Valve Prolapse
Hypertension
Dyslipidemia
Obesity
Pernicious Anemia
Hypothyroidism
Osteoarthritis
Peripheral Neuropathy
Chronic Back Pain, Degenerative Scoliosis
Lumbosacral radiculitis - prior thoracic block
Past surgical history:
Lap Cholecystectomy
Multiple Lumbar and Thoracic spine fusions(approx nine) One c/b
likely MRSA,
Left Cataract Surgery, (Right cataract scheduled for [**6-15**])
Fibroid Removal
Mohs
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Edema +1
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
[**Hospital 409**] Clinic [**Telephone/Fax (1) 170**] Date/Time:[**2162-10-7**] 10:30
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2162-10-27**] 1:00
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9751**] [**Telephone/Fax (1) 9752**], [**2162-10-14**] at 1:00p
Please call to schedule an appointment
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4541**] [**Telephone/Fax (1) 7164**] in [**1-11**] weeks
Completed by:[**2162-9-28**]
ICD9 Codes: 4241, 4280, 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3051
} | Medical Text: Admission Date: [**2158-10-20**] Discharge Date: [**2158-10-29**]
Date of Birth: [**2081-5-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
shortness of breath and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 yo Greek-speaking female with PMH of HTN, A Fib, CAD
presented to the ED with 3-day history of shortness of breath
and abdominal pain. Patient, speaking through her son, reported
worsening dyspnea, orthopnea, PND, and bilateral lower extremity
pitting edema, which has been a chronic problem for her. Her
functional status has been worsening, now only able to climb a
few steps before tiring. Reported a dry cough for 1-2 weeks.
Patient reported good medication compliance and no recent
changes in her diet. Patient also complained of abdominal
pain/bloating with early satiety and constipation. Stated
radiation of pain/burning up her chest. Denied vomiting,
diarrhea. Also complained of intermittent lower back pain
described as "somebody hitting her."
Patient presented to the ER with O2Sat=86% on RA. She received
nitro and lasix (20mg IV x 1) and ASA as well as steroids
(solumedrol 125mg x 1) given history of underlying interstitial
pulmonary disease. Sent for CT angiogram to rule out PE and then
transferred to the MICU. In the MICU, she was placed on a nitro
gtt and diuresed with IV lasix. When oxygen was weaned to 4L NC
with sats in the mid-90s, the patient was transferred to the
floor.
.
ROS: The patient denied any fevers, chills, weight change,
vomiting, diarrhea, melena, hematochezia, chest pain, urinary
frequency, urgency, lightheadedness, gait unsteadiness, focal
weakness, headache, rash or skin changes.
Stated recent retinal reattachment procedure.
Past Medical History:
Atrial fibrillation with progression to torsades during last
admission-s/p dofetilide with DCCV ? [**6-9**]
HTN
DMII
Mild COPD
Interstitial lung disease
Hyperlipidemia
AR
Social History:
Lives with her son and his family. Very functional at baseline
walking [**4-15**] blocks with no DOE. No EtoH or smoking history.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Vitals: T: 98.2 BP: 197/64 HR: 64 RR: 22 O2Sat: 96% on 2.5L
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, Dry MM, OP Clear
NECK: JVP 12-13cm, carotid pulses brisk, s/p R CEA, no carotid
bruits
COR: RRR, normal S1 and S2, + S4, SEM @ RUSB w/o radiation, and
[**2-15**] HSM at LLSB varied w/ inspiration
PULM: good air movement, bibasilar rales, expiratory wheezes
ABD: BS - , soft, NT, ND, no masses/organomegaly, no bruits
appreciated
BACK: No CVAT. Lipoma over lumbar spine. Nontender.
EXT: 3+ pitting edema to lower thighs, bilaterally symmetric and
venous stasis changes evident
NEURO: grossly normal
Pertinent Results:
[**2158-10-21**] 04:31PM BLOOD WBC-9.7 RBC-3.27* Hgb-9.9* Hct-28.8*
MCV-88 MCH-30.2 MCHC-34.3 RDW-15.8* Plt Ct-225
[**2158-10-21**] 03:41AM BLOOD Neuts-75.7* Lymphs-19.6 Monos-4.5 Eos-0.1
Baso-0.2
[**2158-10-21**] 03:41AM BLOOD PT-17.3* PTT-30.0 INR(PT)-1.6*
[**2158-10-21**] 04:31PM BLOOD Glucose-143* UreaN-36* Creat-1.7* Na-138
K-3.8 Cl-99 HCO3-32 AnGap-11
[**2158-10-21**] 03:41AM BLOOD LD(LDH)-185 CK(CPK)-13* TotBili-0.3
DirBili-0.1 IndBili-0.2
[**2158-10-20**] 08:01PM BLOOD Lipase-15
[**2158-10-21**] 03:41AM BLOOD CK-MB-2 cTropnT-0.02*
[**2158-10-20**] 08:01PM BLOOD CK-MB-3 cTropnT-0.02*
[**2158-10-20**] 10:40AM BLOOD cTropnT-0.03*
[**2158-10-20**] 10:40AM BLOOD CK-MB-NotDone proBNP-6228*
[**2158-10-21**] 04:31PM BLOOD Iron-31
[**2158-10-21**] 03:41AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.9
[**2158-10-21**] 04:31PM BLOOD calTIBC-243* Ferritn-84 TRF-187*
[**2158-10-20**] 10:40AM BLOOD TSH-23*
[**2158-10-20**] 08:01PM BLOOD Free T4-1.3
CTA Chest [**2158-10-20**]:
IMPRESSION:
1. Allowing for respiratory motion, no evidence of pulmonary
embolism seen.
2. Scarring and bronchiectasis in left upper lobe consistent
with history of interstitial lung disease. Prior studies, if
available, would be useful for comparison.
3. There is likely superimposed mild interstitial edema, with
small-to-
moderate right and small left pleural effusions and related
compressive
atelectasis. Numerous scattered sub-4-mm nodular opacities may
be related to early alveolar edema.
4. Evidence of prior granulomatous disease.
Renal U/S [**10-22**]:
1. Inability to perform full Doppler analysis to evaluate for
underlying
renal artery stenosis due to patient inability to breath-hold.
If high
clinical concern, a dedicated MRA could be performed.
2. Well-defined hyperechoic peripheral 1-cm left lower pole
lesion most
suggestive of a benign renal angiomyolipoma. Probable but not
definite 1-cm
right renal cyst. If not characterized by cross sectional
imaging, can get
follow up ultrasound in 6 months to confirm expected stability.
TTE [**10-24**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) LV diastolic dysfunction. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
([**1-11**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**1-11**]+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a small
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Left atrial dilation with mild diastolic LV dysfunction. Mild to
moderate aortic regurgitation. Mild to moderate mitral
regurgiation. Moderate pulmonary hypertension. Dilated ascending
aorta.
Compared with the prior study (images reviewed) of [**2157-6-27**],
degree of diastolic LV dysfunction, as well as mitral and aortic
regurgitation has increased. Pulmonary hypertension is now
identified. The other findings are similar.
EKG [**10-29**]:
Sinus rhythm with first degree A-V block with a P-R interval of
0.52. Left
anterior fascicular block. Non-specific intraventricular
conduction delay. Left
ventricular hypertrophy with ST-T wave changes. Poor R wave
progression could
be due to left anterior fascicular block and/or left ventricular
hypertrophy.
Non-specific ST-T wave changes are probably due to left
ventricular hypertrophy
but cannot exclude ischemia. Compared to the previous tracing of
[**2158-10-28**] the
ventricular rate is faster such that the P wave is generally
within the
T wave, except in leads V2-V3. The P wave can be seen at the
tail end of the
T wave and then there is one early beat such that the R-R
interval is longer
and you do see the P wave with the P-R interval of 0.52.
Brief Hospital Course:
77 year-old Greek-speaking female with a history of HTN, A Fib,
CAD, DMII, and ILD who presented with hypertensive urgency and
acute on chronic diastolic CHF exacerbation.
.
# HYPERTENSION: The patient has a history of hypertension, LVH
on EKG, diastolic dysfunction on her echo 1 year ago. Her blood
pressures in the ED peaked at 250/110. It was unclear whether
or not the patient had been taking her medications
appropriately. She denied recent dietary changes or increased
salt consumption. The patient was also felt to have a high
pretest probability of renal artery stenosis. She had renal
ultrasound completed but doppler could not be completed due to
technical difficulties. While awaiting MRA, the patient
developed acute on chronic renal failure.
Her initial home antihypertensive regimen was toprol xl 100mg
daily, benicar 40mg daily (max dose). Her meds were titrated up
with resolution of her hypertension and SBPs in the 120s-130s
range. When she developed ARF with eosinophilia, several meds
were stopped and she remained normotensive. She was discharged
on amlodipine, clonidine patch, and isosorbide and instructed to
follow up for an outpatient work up of potential RAS.
.
# CHF - This patient has acute on chronic diastolic dysfunction
with a preserved EF on an echo 1 year ago, 1+ AI and 1+ MR. She
was diuresed with IV lasix until near euvolemia and then placed
back on her home regimen of bumex 2mg daily. Bumex was stopped
in setting of what was thought to be drug-induced ARF as noted
above. The patient was clinically mildly hypervolemic and was
therefore started on a maintenance regimen of lasix 60mg PO
daily with return to euvolemia.
.
# 1st degree AV block: The patient's PR interval was noted to be
progressively longer up to .550 sec. Her amiodarone and
metoprolol were held and all other nodal agents were avoided.
She was asked to follow up as an outpatient for continued
management of this AV block in the setting of a history of PAF.
.
# Acute on Chronic Renal Insufficiency - Creatinine peaked at
2.5 with baseline 1.4-1.6. Her creatinine was trending down
prior to discharge. She had both a peripheral eosinophilia and
urine eos and was thereofre thought to likely have AIN [**2-11**] bumex
vs hydral vs protonix. These meds were stopped and replaced with
resolution of eosinophilia and downward trending creatinine.
.
# Normocytic Anemia: Hct ranging from 29 to 36, stable. BM guiac
negative. Non-localizing exam. Labs suggested some degree of
iron deficiency, no hemolysis. Iron held in setting of concern
for constipation. Suggested outpatient follow up with PCP.
.
# Hypothyroidism: Elevated TSH with normal T4. Patient takes
levothyroxine 125 mcg daily at home. Discussed with endocrine
who thought labs were c/w sick euthyroid syndrome and suggested
weighing benefit of addit levothyrox agaist risk of causing AF
to return. The patient was continued on her home dose of
levothyroxine and encouraged to follow up with her PCP.
.
# CAD: The patient has a history of 2VD, TTE with progression of
diastolic and valvular dysfunction. ASA 81mg and pravastatin
40mg daily were continued.
.
# Paroxsysmal Atrial Fibrillation: The patient remained in
normal sinus rhythm during her hospitalization. Her metoprolol
and amiodarone were held in the setting of both PR and QTc
prolongation. While PR interval remained prolonged, QTc returned
to normal range. The patient was continued on coumadin and
instruced to follow up as an outpatient.
.
#. ILD/COPD: Patient had oxygen saturations in the upper 90s
both sitting and with ambulation prior to discharge.
.
# NIDDM: HA1C 6.6. The patient is maintained on home oral
hypoglycemics which were held in favor of sliding scale insulin
during this hospitalization. She was instructed to restart oral
meds at time of discharge.
.
On [**10-29**], the patient was discharged to home in good condition
with stable vitals on room air with plan for follow up arranged.
Medications on Admission:
Glipizide 10mg po daily
Toprol 100mg po daily
Bumex 2mg po daily
Pravastatin 20mg daily
Clonidine 0.2mg po bid
Benicar 40mg po daily
Amiodarone 200mg po daily
ASA 81mg daily
cirpo 500mg daily (last dose 10/10)
coumadin 2.5mg daily except [**Month/Year (2) 766**] no coumadin and Wed / Friday
5mg daily
Levothyroxine 125mcg daily
calcium
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*90 Tablet(s)* Refills:*2*
6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
7. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal weekly ().
[**Month/Year (2) **]:*8 Patch Weekly(s)* Refills:*2*
8. Polyethylene Glycol 3350 100 % Powder Sig: One (1) capful PO
as needed as needed for constipation: Available over the
counter. .
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
[**Month/Year (2) **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (WE,FR).
12. Outpatient Lab Work
Please have your INR and your kidney function checked on
Wednesday. Please have these results faxed to Dr. [**Last Name (STitle) 11139**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Hypertensive Crisis
Acute on Chronic Dyastolic Congestive Heart Failure
Acute on Chronic Renal Failure
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: 1.5 liters
You were admitted to the hospital because your blood pressure
was very high and you developed fluid back up to your tissues
and your lung. You were given blood pressure medications to
reduce your blood pressure and were given medications to help
remove the extra fluid from your body. You were waiting to have
an MRI of the blood vessels that supply your kidneys to
determine if a blockage in those vessels (called Renal Artery
Stenosis) could account for your very high blood pressures.
While you were waiting to have this done, your labs showed that
your kidney was functioning abnormally. It seems as though your
kidney had a reaction to one of the medications you were on
previously. The main possibilities are: bumex or hydralazine or
pantoprazole. These medications were stopped and your kidney
function began to trend back towards normal. You should not take
these medications until otherwise instructed by Dr [**Last Name (STitle) 11139**] or Dr
[**Last Name (STitle) **].
You were started on a medication called Lasix which will help
remove extra fluid bluild up. (This replaces Bumex).
Your metoprolol and amiodarone were stopped because your EKG
showed changes suggesting the electrical system of your heart
was moving more slowly than we would want. The medications can
cause or worsen this and so you should continue to not take
these medications.
Medication Changes: As long as you can seperate what youre
taking from what you [**Last Name (un) 5497**] taking, you should keep the
medications you have at home in the case that your heart and
kidney function improve so that your doctor can safely
reintroduce the medications that can help you.
Stop taking Toprol 100mg daily
Stop taking Bumex 2mg daily
Stop taking Benicar until otherwise instructed.
Stop taking amiodarone.
Your pravastatin dose was increased from 20 to 40mg daily.
Your clonidine was changed from a pill to a patch and the dose
was increased from 0.2 to 0.4 mg.
New medications which you should continue to take: amlodipine,
isosorbide mononitrate sustained release, and lasix 60mg daily.
Please call Dr. [**Last Name (STitle) 11139**] or go to the emergency room if you
experience chest pain, shortness of breath, palpatations,
confusion, decreased urination, progressive swelling in your
legs, stomach, or hands, or any other concerning symptoms.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 11139**] within the next week.
Please have your blood drawn on Wednesday to check your INR and
your kidney function. You should also follow up with Dr. [**Last Name (STitle) 11139**]
regarding your thyroid function as lab work suggested your
thyroid was not functioning entirely normally. This could be
secondary to simply being in the hospital or it could warrent
adjustments in your levotyroxine dose.
You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 3632**] on
[**Telephone/Fax (1) 766**] [**11-13**] at 12:45 PM. Please call for confirmation,
any questions, or to change your appointment.
ICD9 Codes: 5849, 4280, 5859, 496, 4241, 4168, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3052
} | Medical Text: Admission Date: [**2128-10-16**] Discharge Date: [**2128-10-26**]
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Sepsis/UTI
Major Surgical or Invasive Procedure:
PICC line placement, Pacer Interrogation
History of Present Illness:
HPI: [**Age over 90 **]M with PMH notable for CAD, CHF (EF 20-25%) was brought
to the ED this morning by his family with whom he lives. Prior
to this morning, the pt was at his baseline, and had taken a
number of day trips with his fmaily over the past 2 weeks. This
morning, the pt's granddaughter went to his basement apt to look
in on him (his son and son's famly live upstairs) and found that
he was trembling and a bit confused. The pt's son then assessed
his father, and gave him Benadryl (1 tab) for the shaking. He
was sweating and clammy, but his temp later was >102 po The pt
then took his usual am meds with Glucerna, but vomited a frothy
emesis. He was then transported to the ED.
.
Per the pt's family, he had been feeling fine prior to this
morning. he had not complained of cough or SOB, nor had he
mentioned difficulty voiding or dysuria. His son empties a
bedside commode in the am for him, and has identified past UTIs
by malodorous urine, which he did not identify today. He had not
complained of CP or SOB. No GI sx, no bowel changes, no previous
fever/chills/malaise. He had not c/o HA or neck stiffness, or
pain of any kind. Pt had no recent exotic travel or known sick
contacts.
.
In the ED, the pt was initially stable but satting 84% RA. ON MD
exam, sat improved (?on NC), but temp was 104 with HR 60s, BP
134/61. He was minimally responsive (s/p benadryl) and exam was
notable for bibasilar rales. Because he was obtunded and had
ememis in ED with ?aspiration, he was intubated for airway
protection and quickly became hypotensive (BP min 105/50 prior
to sedation). He received 5L NS boluses (levophed started after
3L), as well as 2 g CTX, 1 gm vanc, 500 mg metronidazole, 1 g
tylenol, etomidate, succinylcholine, 10 mg dexamethasone, 2mg
midazolam x 2, levophed gtt, propofol gtt. He was subsequently
transferred to the [**Hospital Unit Name 153**] for further therapy and monitoring.
Past Medical History:
CAD - s/p MI in [**2109**] tx with lytic therapy and rescue
angioplasty
CHF - EF 20-25%
DM2
History of PAF
S/p PPM
Status post permanent pacemaker insertion.
Hypertension
Hypercholesterolemia
L hip replacement [**2119**] c/b femur fx with "slipped prosthetic"
[**2127**]
Past UTIs, most recently with proteus mirabalis (ctx sensitive,
fluoroquinolone resistant)
S/p TURP
Social History:
Pt is [**Age over 90 **] yo male who lives in basement of sons house. Wife
passed away last year. Retired plumber who worked here at [**Hospital1 18**].
Had been ambulating with a walker since leaving rehab,
participates in home PT few times a week.
Family History:
non-contributory
Physical Exam:
Upon arrival to [**Hospital Unit Name 153**]:
Gen: Elderly man, sedated and unresponsive
HEENT: B/l arcus, no scleral icterus, secretions around ETT
Neck: Large, no LAD
Heart: RR, no
Lungs: Coarse breath sounds b/l, no rales appreciated
Abd: Full with palpable spleen, not form or appreciably
distended, scan BS, soft
Ext: Thin, 1+ DPs, no c/c/e
Skin: No jaundice, icthyosison feet b/l
Pertinent Results:
[**2128-10-16**] 11:22AM BLOOD Lactate-3.4*
[**2128-10-18**] 03:21AM BLOOD Lactate-0.7
[**2128-10-17**] 03:01AM BLOOD Carbamz-4.0
[**2128-10-16**] 11:20AM BLOOD Cortsol-61.7*
[**2128-10-20**] 06:15AM BLOOD calTIBC-229* VitB12-328 Folate-11.0
Ferritn-188 TRF-176*
[**2128-10-16**] 11:20AM BLOOD cTropnT-<0.01
[**2128-10-16**] 06:09PM BLOOD CK-MB-4 cTropnT-0.02*
[**2128-10-16**] 11:20AM BLOOD ALT-21 AST-27 CK(CPK)-47 AlkPhos-129*
Amylase-77 TotBili-1.0
[**2128-10-16**] 11:20AM BLOOD Glucose-334* UreaN-29* Creat-1.1 Na-140
K-3.8 Cl-98 HCO3-27 AnGap-19
[**2128-10-24**] 06:15AM BLOOD UreaN-14 Creat-0.8 Na-134 K-3.7 Cl-99
HCO3-27 AnGap-12
[**2128-10-16**] 11:20AM BLOOD WBC-35.0*# RBC-4.03* Hgb-12.7* Hct-37.0*
MCV-92 MCH-31.5 MCHC-34.3 RDW-13.3 Plt Ct-235
[**2128-10-24**] 06:15AM BLOOD WBC-11.8* RBC-3.38* Hgb-10.5* Hct-32.0*
MCV-95 MCH-31.0 MCHC-32.7 RDW-13.8 Plt Ct-252
[**2128-10-16**] 11:20AM URINE RBC->50 WBC->50 Bacteri-OCC Yeast-NONE
Epi-0
[**2128-10-16**] 11:20AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
[**2128-10-16**] 11:20AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.019
.
[**2128-10-16**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2128-10-16**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {BETA
STREPTOCOCCUS GROUP B}; ANAEROBIC BOTTLE-FINAL {BETA
STREPTOCOCCUS GROUP B} EMERGENCY [**Hospital1 **]
[**2128-10-16**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL {BETA STREPTOCOCCUS GROUP B} EMERGENCY [**Hospital1 **]
.
Echo [**10-19**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe
regional left ventricular systolic dysfunction with akinesis of
the distal half of the ventricle. Basal segments are
hypokinetic. No masses or thrombi are seen in the left
ventricle. Tissue velocity imaging E/e' is elevated (>15)
suggesting increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened. Aortic stenosis is not suggested. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**10-20**] Hip Film:
AP film of the pelvis plus two added views of the left hip and
proximal left femur. There is a bipolar left hip
hemiarthroplasty with cemented femoral stem. A poorly visualized
fracture of the proximal femoral shaft has been fixated by
apparent large osseous allografts with associated cerclage wires
and long lateral plate (with four screws below the tip of the
femoral stem). Overall appearances are unchanged from [**2128-10-8**] with no focal bone destruction or evidence of hardware
loosening. The right hip and SI joints are normal.
.
IMPRESSION: No short interval change. No radiographic evidence
infection or loosening.
.
[**10-22**] LLE U/S
UNILAT LOWER EXT VEINS LEFT
Reason: please image left hip and thigh to rule out fluid
collection
.
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with grp B strep bacteremia with history of left
hip fracture last year, hardware in place.
REASON FOR THIS EXAMINATION:
please image left hip and thigh to rule out fluid collection
INDICATION: Left leg swelling. Evaluate for deep venous
thrombosis.
.
LEFT LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler
son[**Name (NI) 1417**] of the left common femoral, superficial femoral, and
popliteal veins were performed. There is normal flow,
augmentation, compressibility, and waveforms. Intraluminal
thrombus is not identified.
.
IMPRESSION: No evidence of deep venous thrombosis.
.
Brief Hospital Course:
Hospital Course, by Problem:
.
# Grp B strep septicemia: this was felt to be likely due to GU
source given active urinalysis, though urine cx negative. A TTE
negative was negative for any vegetations adherent to the
patients valves or pacer wires. The patients' family wished to
defer a TEE. ID was consulted and recommended 4 weeks IV CTX as
well as
rechecking ESR/CRP in 2 weeks to see if rising. Of note, a Left
hip plain film and LLE u/s to r/o fluid collection showed no
significant findings. The longer course was recommended by ID
as the exact source of the bacteremia was unclear and
endocarditis was not fully ruled out.
.
#CVS
Ischemia: the patient had several sets of CE during this
admission which were negative, despite lateral TWI on the
patients ECG.
Pump: the patient was slightly overloaded after fluid
resusciation in the ICU. He was diuresed and then restarted on
his home Lasix dose. Of note, repeat Echo during this admission
showed an EF of 25% with (worsening) 2+ MR. His amlodipine and
long-acting nitrate were discontinued during this admission d/t
hypotension.
Rhythm: the patient was continued on Sotalol, as was
intermittently in A fib. Per the family, the patient has a
history of several falls. Further discussion of the
risks/benefits of AC will be deferred to the patient's PCP.
[**Name10 (NameIs) 2351**] his ICU admission, given relative bradycardia, he had his
pacer interrogated and the settings were modified to increase
his baseline HR. Per EP, pt should follow-up in pacemaker
clinic after his discharge.
Prevention: the patient was kept on Aspirin. The patient would
likely benefit from the addition of a statin as an outpatient.
.
#Confusion: the patient was noted to be intermittently confused
during his hospitalization. During the morning of [**10-25**], the
patient was almost obtunted and barely responsed to sternal rub.
At this time, CT head/ABG/ECG/Fingerstick/CXR were all
unrevealing. Later in the day the patient was noted to be
incredibly more alter and conversing with his family memebers.
Per discussion with his sons, the patient gets extremely
confused during most hospital admissions. Detrol was
discontinued d/t possibility for anticholingeric effects.
.
#Hypoxia/COPD: on the day of discharge the patient was noted to
be slightly hypoxic (88-92RA). CXR from the day earlier did not
show over CHF but did show small (B) effusions. Given the
patient's immoblitiy, a CT scan was ordered which did not show a
PE, but only RLL atelectasis and evidence of emphysema. The
patient was amublated and did not desat (and in fact, O2 sats
improved to 92-94RA). The etiology was felt to be from
atelectasis and immobility. Upon discharge, the patient was
started on a Flovent Inhaler along with Atrovent given the CT
findings. The patient would likely benefit from outpt PFTs to
characterize the degree of his obstructive lung disease.
Medications on Admission:
1. Carbamazepine 200 mg Tablet Sig: 0.5 Tablet PO BID
2. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS prn
4. ? Nexium filled in [**7-19**]. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY
6. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
7. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
9. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID
10. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (in d/c
summary but never filled in pharmacy)
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Potassium 20 mEq po qd
Discharge Medications:
1. Carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
2. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*15 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) grams Intravenous Q24H (every 24 hours) for 4 weeks:
through [**2128-11-16**].
Disp:*46 grams* Refills:*0*
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia/agitation.
Disp:*30 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Weekly CBC w/ diff, ALT, AST, BUN, and creatinine to be faxed to
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**], Fax: [**Telephone/Fax (1) 1419**]
11. Outpatient Lab Work
ESR and CRP to be drawn [**2128-11-4**].
Fax to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**], Fax: [**Telephone/Fax (1) 1419**]
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
13. Atrovent 18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
four times a day as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*0*
14. Flovent 44 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
Primary Diagnoses:
Group B strep bacteremia, source unknown but likely [**3-18**] UTI
Delirium
Systolic congestive heart failure, resolved
Paroxysmal atrial fibrillation
Bradycardia
Secondary Diagnoses:
h/o of coronary artery disease
Type 2 diabetes
Hypertension
Hypercholesterolemia
L hip replacement [**2119**] c/b femur fx with "slipped prosthetic"
[**2127**]
Discharge Condition:
good: afebrile, wbc improved
Discharge Instructions:
Please monitor for temperature > 101, rash, shortness of breath,
or other concerning symptoms.
Stop taking your tolterodine (detrol), norvasc (amlodipine) and
isosorbide dinitrate (isordil).
Please avoid taking benadryl, as this can worsen your confusion.
Please take the trazodone or haldol instead, as prescribed.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] from infectious diseases
on [**2128-11-23**] at 10:30 AM. Phone: ([**Telephone/Fax (1) 4170**].
Please follow-up with Dr. [**Last Name (STitle) 1007**] within 1-2 weeks to discuss
starting coumadin. His phone number is [**Telephone/Fax (1) 10492**].
If you do not see someone regular for assessment of your
pacemaker, please schedule a follow-up appointment with our
pacer clinic within 3 months. Phone: [**Telephone/Fax (1) 59**].
ICD9 Codes: 5990, 4280, 4240, 2720, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3053
} | Medical Text: Admission Date: [**2143-8-30**] Discharge Date: [**2143-9-7**]
Date of Birth: [**2096-10-7**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old
gentleman with diabetes mellitus, acute myocardial infarction
on [**8-28**], found to have 3-vessel disease, after
presenting to [**Hospital 1474**] Hospital for chest tightness,
shortness of breath, nausea, and diaphoresis.
Upon transfer to [**Hospital1 69**], the
patient was pain free. No diaphoresis, nausea, or shortness
of breath.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. Hypercholesterolemia.
3. Hypertension.
MEDICATIONS ON TRANSFER:
1. Zocor 20 mg p.o. q.d.
2. Aggrastat.
3. Lopressor 25 mg p.o. b.i.d.
4. Glucotrol 5 mg p.o. b.i.d.
5. Nitrostat.
6. Aspirin.
7. Diamox 500 mg p.o. t.i.d.
8. Ambien p.o. q.h.s.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were
temperature of 98.4, pulse was 68, blood pressure was 100/70,
oxygen saturation of 96% on room air, respiratory rate
was 18, blood sugar was 146. Cardiovascular examination
revealed a regular rate and rhythm. No murmurs. Respiratory
was clear to auscultation bilaterally. The abdomen was soft,
nontender, and nondistended. Extremities were warm and well
perfused. No edema.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 7.1, hematocrit
was 38.7, platelets were 208. INR was 1.1. Potassium
was 3.5, blood urea nitrogen was 10, creatinine was 0.8.
Troponin was 150. CK/MB was 161.
HOSPITAL COURSE: The patient was admitted to the Medicine
Service. Preoperatively, the patient remained pain and
symptom free, afebrile, vital signs were stable.
The patient was taken to the operating room on [**2143-9-2**] where a coronary artery bypass graft times four was
performed with left internal mammary artery to left anterior
descending artery, saphenous vein graft to diagonal,
saphenous vein graft to obtuse marginal, saphenous vein graft
to right coronary artery.
The operation went without complications. In addition,
mediastinal chest tubes were placed intraoperatively. The
patient was transferred to the Surgical Intensive Care Unit
in stable condition.
On postoperative day one, the patient was extubated without
complications. He was afebrile. Vital signs were stable.
The patient was transferred to the floor.
On postoperative day two, the patient was afebrile. Vital
signs were stable. He had some tachycardia and responded
appropriately to Lopressor. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultation was
obtained for the patient's poorly controlled diabetes; with a
request from his wife. The patient was started on insulin
[**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations.
On postoperative day three, the patient was afebrile. Vital
signs were stable. He was ambulating and working with
Physical Therapy well. Blood sugars were controlled. No
issues. No concerns at this point.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: The patient was to be discharged to home.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) **] in four weeks for postoperative checkup. The
patient was to follow up with the [**Last Name (un) **] for blood sugar
control. The patient was to make an appointment.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. b.i.d. (times seven days).
2. Potassium chloride 20 mEq p.o. b.i.d. (times seven
days).
3. Enteric-coated aspirin 325 mg p.o. q.d.
4. Motrin 400 mg p.o. q.8h. p.r.n.
5. Ranitidine 150 mg p.o. b.i.d.
6. Percocet one to two tablets p.o. q.4-6h. as needed.
7. Docusate 100 mg p.o. b.i.d.
8. Glipizide 5 mg p.o. b.i.d.
9. Simvastatin 20 mg p.o. b.i.d.
10. Lopressor 50 mg p.o. b.i.d.
11. Insulin Glargine 12 units at bedtime plus sliding-scale
(see attached sheet).
DISCHARGE DIAGNOSES:
1. Diabetes mellitus.
2. Coronary artery disease.
3. Status post coronary artery bypass graft times four.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) 15509**]
MEDQUIST36
D: [**2143-9-5**] 14:06
T: [**2143-9-5**] 14:27
JOB#: [**Job Number 44234**]
ICD9 Codes: 4240, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3054
} | Medical Text: Admission Date: [**2112-9-8**] Discharge Date: [**2112-9-14**]
Date of Birth: [**2041-7-25**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 6209**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 yo female extensive PMHx admitted with hypotension and
hypoxia most likely due to RML/RLL pneumonia. Pt in usual state
of health until night before admissin when experienced flare of
asthma and no improvement on albuterol, continued mild SOB,
chest tightness, but no cough. Pt also experienced subjective
fevers and chills. Remainder of ROS neg. In the ED SBP 70s,
transiently on dopamine and then levophed; pressors off on
arrival in MICU. (Pt had angina and lateral ST segment
depressions on dopamine.) Central line placed (right IJ), given
stress dose steroids, on MUST protocol.
Past Medical History:
CAD s/p MI in 94, PVD (s/p aorto-fem bypass and L femoral
endarterectomy), L Breast CA s/p mastectomy, presumbed diastolic
disfunction, colon adenocarcinoma '[**08**] s/p LAR with Chemo and
XRT, SBO s/p XLap with LOA in [**3-20**], asthma, hypothyroidism,
hyperlipidemia, osteoporosis, ORIF R tibia, bilateral THR [**2110**],
recurrent UTI
Social History:
no tobacco, alcohol, IVDA
lives with husband
Family History:
not obtained
Physical Exam:
100.5, (63-89)/(34-52), 82-91, 20, 92% on 5Lnc
Gen chronically ill appearing, NAD, AOx3
HEENT: dry MM, 2+carotids, unable to appreciate JVD
CV S1, S2 regular but tachycardic
Pulm bibasilar crackles, [**Month (only) **] BS on Right, Right base e to a,
Right base fremitus
Abd soft nt, nd, guaiac neg
Ext no edema
Pertinent Results:
[**2112-9-8**] 03:00AM WBC-10.1 RBC-4.29 HGB-12.7 HCT-37.7 MCV-88
MCH-29.7 MCHC-33.8 RDW-14.0
[**2112-9-8**] 03:00AM CK-MB-2 cTropnT-<0.01
[**2112-9-8**] 03:00AM GLUCOSE-117* UREA N-19 CREAT-0.9 SODIUM-132*
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-20* ANION GAP-16
[**2112-9-8**] 03:20AM LACTATE-2.2*
[**2112-9-8**] 07:38AM PT-15.2* PTT-35.0 INR(PT)-1.5
[**2112-9-8**] 07:38AM CORTISOL-22.4*
[**2112-9-8**] 07:38AM cTropnT-<0.01
[**2112-9-8**] 07:38AM ALT(SGPT)-25 AST(SGOT)-28 CK(CPK)-142* ALK
PHOS-93 AMYLASE-34 TOT BILI-0.4
[**2112-9-8**] 07:43AM LACTATE-1.3
[**2112-9-8**] 09:57AM WBC-10.1 RBC-3.54* HGB-10.6* HCT-30.7* MCV-87
MCH-30.1 MCHC-34.6 RDW-13.9
[**2112-9-8**] 10:27AM LD(LDH)-173
[**2112-9-8**] 04:21PM FDP-40-80
[**2112-9-8**] 04:21PM FIBRINOGE-582*
Brief Hospital Course:
1. Hypoxia: Most likely due to RML/RLL pneumonia. Started on
ceftriaxone and azithromycin in the ED, continued in the MICU.
No PE on CT-A. No evidence of CHF on exam; TTE with LVEF 50-55%
and likely anterior fat pad vs loculated pericardial effusion
(less likely). Continued baseline nebs for COPD. Legionella
urine neg, sputum/ blood cultures with no growth. Pt stable on
MICU to floor transfer on 2Lnc. Should have outpatient PFTs to
evaluate for amio-induced lung toxicity. Pt switched to PO
azithromycin and cefpodoxime to complete 10 day course of abx
finishing on [**2112-9-17**].Pt had evidence of pulmonary edema on CXR
consistant with h/o diastolic CHF. Pt was diuresed with IV
lasix, which improved her respiratory status. She was given 20
mg. PO lasix upon discharge to move her toward euvolemia.
2. Hypotension: Most likely due to pneumonia-induced sepsis. On
MICU transfer, pt was normotensive and off pressors after fluid
resuscitation since arrival to MICU on HD 1. [**Last Name (un) **] stim was
appropriate, no steroids indicated. Pt had no problems with low
BPs on the floor and was discharged on home HTN meds.
3. CAD: Cycle cardiac enzymes given ST segment changes on
admission EKG. Repeat EKG morning of [**9-9**]. Continued telemetry
until r/o MI complete HD 2. Continued ASA, atorvastatin. Held
metoprolol [**1-18**] recent hypotension and normotensive pressures in
MICU. TTE; LVEF 55%, ant fat pad vs ?loculated peric effusion.
4. Right hip cellulitis: pt with underlying ORIF of R hip,
ultrasound demonstrated only subcutaneous edema consistent with
cellulitis, no evidence of fluid collection. Pt for Keflex
course 500 QID x 5 days. This was completed prior to discharge.
5. Hypothyroid: pt continued on home synthroid
6. Paroxysmal AFib: pt continued on Amio. Normal sinus rhythm
while in MICU. Question of lack of outpatient Coumadin in
patient with h/o AF AND pvd AND multiple malignancies; for
followup with primary care physician Dr [**Last Name (STitle) 6210**] on this subject.
Medications on Admission:
albuterol prn
flovent prn
advair
metoprolol 12.5 [**Hospital1 **]
amio 200 ad
bisocodyl
protonix
colace
lasix 20 [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Community acquired pneumonia
Diastolic CHF
Sepsis
Discharge Condition:
fair
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 liters
Followup Instructions:
Provider: [**Name (NI) 1039**] HARRIER, PT Where: [**Hospital6 29**]
REHABILITATION SERVICES Phone:[**Telephone/Fax (1) 2484**] Date/Time:[**2112-9-20**]
10:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2322**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2112-11-2**] 2:20
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2112-11-14**] 2:00
ICD9 Codes: 0389, 486, 4280, 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3055
} | Medical Text: Admission Date: [**2147-7-14**] Discharge Date: [**2147-7-31**]
Date of Birth: [**2078-6-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3 (LIMA to Diag, SVG to LAD, SVG
to RCA) and RCA Endarterectomy [**2147-7-17**]
History of Present Illness:
Mr. [**Known lastname 67785**] is a 69 y/o male w/ h/o HTN who p/w chest discomfort.
He saw his cardiologist and had EKG done that showed new TWI in
anterior leads. Pt. referred to cardiac catheterization. Cath
revealed 3VD.
Past Medical History:
Hypertension, Sleep Apnea with CPAP, s/p Bilat. Cataract Surgery
Social History:
Married w/ 3 kids, retired, works as a tailor. Denies tobacco
use. Rare ETOH.
Family History:
Brothers w/ CAD -died in 60s, Dad w/ CAD -died at age 70
Physical Exam:
VS: 52 20 139/62 5'5" 83.9
General: WD/WN male in NAD
Skin: Unremarkable, w/d
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR, -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, wel-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, Non-focal
Pertinent Results:
Cardiac Cath [**7-14**]: Selective coronary angiography of this right
dominant system demonstrated two vessel CAD. The LMCA had a
distal 30% stenosis. The LAD had a 50% proximal stenosis and
tandem stenosis of 99% and 90% in mid LAD. The large D1, which
had a very proximal take-off had 95% mid stenosis. The LCX had
mild diffuse disease. The RCA had a 50% mid stenosis and a PDA
that came off early and had a 95% proximal stenosis. The large
PLV branch had a proximal 90% stenosis. Left venticulography
demonstrated anterio- and infero-apical hypokinesis with LVEF
calculated to be 57%. Limited resting hemodynamics demonstrated
markedly elevated filling pressures with LVEDP=34 mHg.
Echo [**7-17**]: Pre-CPB: There are simple atheroma in the descending
thoracic [**Month/Year (2) 5236**]. There is no aortic valve stenosis. The mitral
valve appears structurally normal with trivial mitral
regurgitation. Post-CPB: Preserved LV systolic fxn. No AI, no
MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. Prior to weaning from bypass, RV dysfunction
was obvious, so Epi + NTG started prior to separation. RV
systolic fxn moderately depressed. Trace TR.
Echo [**7-17**]: Left ventricular cavity size is somewhat small with
focal inferior septal hypokinesis. The remaining segments
contact well and overall systolic function is preserved
(LVEF>55%). The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. Compared with the
prior transthoracic study (images reviewed) of earlaier in the
day on [**2147-7-17**], the RV is now markedly enlarged with severe
global hypokinesis.
Abd U/S [**7-18**]: There are no gallstones. There is no
pericholecystic fluid and the gallbladder wall is not thickened.
Small amount of free fluid in the right lower quadrant.
Echo [**7-20**]: The left atrium is mildly dilated. The left
ventricular cavity size is normal. LV systolic function appears
depressed. Overall left ventricular systolic function cannot be
reliably assessed. Compared with the prior study (images
reviewed) of [**2147-7-17**], LV and RV function are probably reduced.
[**7-30**] HCT 29, K 4.0, BUN 35, Creat 0.9
Brief Hospital Course:
Admitted [**7-14**] with 3 weeks of exertional angina and underwent
cardiac cath with results above. Received a 600 mg dose of
plavix then, and Dr. [**Last Name (STitle) **] elected to wait several days to let
this wear off. Underwent cabg x3, RCA endarterectomy, and repair
of ascending [**Last Name (STitle) 5236**] on [**7-17**]. Transferred to the CSRU in stable
condition on epinephrine, nitroglycerin and propofol drips.
Emergent TEE was done at the bedside later that evening after he
suffered a sudden VFib arrest. He was shocked into SR and IABP
placed with cardiac output of 5.0. TEE showed poor RV function,
CCO Swan placed and continued on epinephrine,dobutamine, and
amiodarone drips. Acidemia improved on POD #1, but LFTs and
creatinine continued to rise. RUQ US showed patent CBD, no
gallstones or evidence of cholecystitis. UTI treated with
levaquin. IABP and chest tubes removed as vent wean continued.
Epinephrine weaned off. Extubated on POD #4. Renal consulted to
evaluate renal failure with probable ATN. NTG drip started for
better BP management.On POD #7,levaquin started and pancultured
on [**7-24**].Creatinine improved and transferred to the floor on POD
#9 off all drips. Creatinine continued to improve and the renal
team signed off. He was seen by wound care for the LLE
wound/blister who recommended cleansing with saline and applying
adaptic QD. Mr. [**Known lastname 67785**] was ready for rehab and was discharged on
[**2147-7-31**].
Medications on Admission:
Atenolol 75mg qd, Aspirin 81mg qd, HCTZ 12.5mg qd, Hydralazine
25mg qd, Klor-Con 20meq qd, Plavix 75mg (stopped [**7-14**])
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 and
RCA Endarterectomy
PMH: Hypertension, Sleep Apnea with CPAP, s/p Bilat. Cataract
Surgery
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incisions with water and gentle soap.
Gently pat dry. Do not take bath or swim.
Do not apply lotions, creams, ointments or powder to incisions.
Do not drive for 1 month.
Do not lift more than 10 pounds for 2 months.
If you develop a fever or notice redness or drainage from
incisions, please contact office immediately.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks.
Dr. [**Last Name (STitle) 5686**] in [**3-3**] weeks.
Dr. [**Last Name (STitle) **] in [**1-30**] weeks.
Completed by:[**2147-7-31**]
ICD9 Codes: 4111, 9971, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3056
} | Medical Text: Admission Date: [**2150-10-5**] Discharge Date: [**2150-10-20**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
SOB/DOE
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 with a left internal mammary
artery graft to the left anterior descending and reverse
saphenous vein graft to the right coronary artery, marginal
branch, and first diagonal branch of the left anterior
descending
History of Present Illness:
Ms. [**Known lastname 62909**] is an 82-year-old female with worsening symptoms of
dyspnea on exertion and chest tightness who underwent cardiac
catheterization that showed left main and three-vessel disease.
She is presenting for revascularization.
Past Medical History:
Arthritis
Hypertension
Gout
Gastroesphageal Reflux Disease
Chronic renal insufficiency (creatinine 1.6)
Degenerative Joint Disease
Diverticulosis
Anemia
Venous insufficiency
Social History:
Patient denies smoking, occasional ETOH
Physical Exam:
Neuro: Grossly Intact, Awake and alert
Lungs: Clear to auscultation bilaterally -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS -r/r/g
Ext: Warm, no edema
Pertinent Results:
[**2150-10-20**] 06:20AM BLOOD WBC-14.0* Hct-28.8*
[**2150-10-19**] 09:20AM BLOOD WBC-13.1* RBC-3.19* Hgb-9.7* Hct-30.9*
MCV-97 MCH-30.5 MCHC-31.6 RDW-15.4 Plt Ct-487*
[**2150-10-20**] 06:20AM BLOOD UreaN-37* Creat-1.6* K-3.9
[**2150-10-19**] 09:20AM BLOOD UreaN-35* Creat-1.6* K-3.8
[**2150-10-19**] 08:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
[**2150-10-19**] 08:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
The patient was admitted to the hospital and taken to the
operating room the following day. The patient underwent a
coronary artery bypass graft x 4. She tolerated this procedure
well. For full operative details, please see operative note. The
patient was transferred to the CSRU immediately after surgery in
stable condition. Later on op day, pt was weaned from mechanical
ventilation and sedation and extubated. On post-op day #1, the
patient's chest tube and central lines were removed. On post-op
day #2, her diuresis and b-blockers were continued, she was
weaned off supplemental oxygen and was transferred to the floor
in stable condition. On post-op day #3, pt appeared to be slowly
improveing, epicaridal pacing wires were removed, and the
patient was encouraged to get oob and ambulate. Pt. was
recovering well and awaiting rehab placement from POD #[**5-15**].
During this time though, her WBC started to trend upwards (w/out
increase in temp) and on POD #9 serosang. drainage was noticed
coming from her sternal incision. Appropriate cultures were
taken and pt was placed on antibiotics. PICC Line was placed on
POD #10 and antibiotics (Vanco/Levo) were cont. for the rest of
her hopsital course. B-blocker was adjusted for maximal BP
control and diuretics titrated until pt was at pre-op wt. From
POD #[**11-18**] pt's WBC was trending down and pt appeared she would
be transferred to rehab facility. On POD #13 though, her WBC was
once again elevated, a CXR and UA were negative and her
midsternal incision was clean and dry. Subsequently her WBC fell
to 13, and she was ready for discharge.
Medications on Admission:
1. Celebrex 200mg PO QDaily
2. Maxide
3. Toprol XL 50mg PO BID
4. Norvasc 20.mg PO QDaily
5. Lisinopril 40mg PO QDaily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain for 30 doses.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
6. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q48H (every 48 hours) for 7 days.
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 7 days.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2203**] [**Hospital **] Nursing Home - [**Location (un) 2203**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 4
Hypertension
Gastroesophageal Reflux Disease
Chronic Renal Insufficiency
Discharge Condition:
Stable
Discharge Instructions:
[**Month (only) 116**] shower, wash incision with mild soap and water and pat dry.
No baths, lotions, creams or powders.
Call with temperature more than 101.4, redness or drainage from
incisions, or weight gain more than 2 pounds in one day or five
in one week.
No lifting more than 10 pounds or drivig until follow up with
surgeon.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Follow up with Dr. [**First Name (STitle) **] in 2 weeks.
See Dr. [**Last Name (STitle) 13175**] in 2 weeks
Completed by:[**2150-10-20**]
ICD9 Codes: 4019, 2749, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3057
} | Medical Text: Admission Date: [**2162-8-5**] Discharge Date: [**2162-8-9**]
Date of Birth: [**2085-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr [**Known lastname **] is a 79 y/o M w h/o DM2, CAD (s/p MI), asthma, and
recurrent DVTs in RLE, who is transferred from the MICU after
admission for hypoglycemia and hypoxemia thought to be [**1-23**] poor
PO intake.
.
Patient initially presented to his [**Month/Day (2) 3390**] with somnolence and was
found to be profoundly hypoglycemic w undetectable glucose on FS
and hypoxic to 85% at rest and 82% with ambulation. He had
missed breakfast but taken his usual insulin and he recently ran
out of his asthma meds. He was given glucose tabs and was
brought to the ED.
.
In the ED, his vitals were T=95.6, HR=67, BP=143/79, RR=16, and
SaO2=92% on RA. He had wheezes on exam at bases and peak flow of
250. His ABG on 3L O2 by NC showed respiratory acidosis
(pH=7.25, pCO2=82) and hypoxemia (pO2=83). He was treated with
levo and ceftriaxone for possible PNA; he received dexamethasone
for possible asthma exacerbation; and he was started on BiPAP
temporarily, but ABG/somnolence worsened. Since, he improved
clinically, he was observed on O2 by NC. His blood sugar slowly
normalized with dextrose and glucagon and the pt began eating
normal food. Because of concern about his respiratory acidosis
he was admitted overnight to the MICU, where he was treated for
reactive airway disease.
.
On admission to the floor, the pt has no complaints. Denies
CP/SOB. Denies HA/dizziness/visual problems. Denies abd
pain/N/V/Drh/constip. Has reg BM, non-bloody, non-tarry.
Past Medical History:
# CAD, s/p MI in [**2144**]; last p-MIBI in [**2156**] with inf wall fixed
defect/hypokinesis and EF 50%. Echo on [**2162-4-23**] showed LVEF of 70%
and pulmonary hypertension.
# Asthma: Last PFTs in [**2152**] showed FVC 2.86 (86% pred), FEV1 =
1.44 (59% of pred), FEV1/FVC = 50. Has required hospitalization
and has been intubated in the past (per pt; not in our records).
Frequent symptoms, has nebulizer at home. Post treatment peak
flow after last hospitalization was 300. Late onset of asthma.
# DM2 - A1C 7.2 in [**5-30**]
# Recurrent DVT of RLE in [**4-/2162**]--on warfarin, frequently
subtherapeutic. Prior hypercoagulable workup reportedly normal.
# Hypercholesteremia: Calculated LDL 54 in [**5-30**]
# Bipolar disorder; depression
# Status post right hemicolectomy in [**2152**] for large benign
villous adenoma that couldn't be removed endoscopically
# Status post umbilical hernia repair
# S/p MVA [**1-28**]
# Cervical stenosis/spondylosis (since MVA)
# recurrent cellulitis
Social History:
Pt is originally from [**Male First Name (un) 1056**] but has lived in this country
for many years. He is married, has 8 children, 16 grandchildren.
Home: [**Hospital1 1474**], MA (~10 years)
Occupation: retired welder
EtOH: none
Drugs: none
Tobacco: none
Family History:
Non-contributory
Physical Exam:
T-97.1, BP-145/65, HR-77, RR-20, SaO2=90% on 1L O2 by NC
Gen: elderly, obese Hispanic man sitting in chair in NAD
HEENT: EOMI, PERRL, clear OP, MMM
NECK: supple, no LAD
CV: RRR. Nl S1, S2. No m/r/g
LUNGS: CTAB, No W/R/C
ABD: Soft, obese, NT. NABS.
EXT: R leg > L leg (chronic). 2+ DP pulse on L, 1+ on R. WWP, no
TTP
SKIN: chronic hyperpigmented skin changes on R > L
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact.
Pertinent Results:
LABS ON ADMISSION: ([**2162-8-5**])
.
[**2162-8-5**] 12:50PM WBC-7.0 RBC-3.70* HGB-10.9* HCT-36.2* MCV-98
MCH-29.4 MCHC-30.1* RDW-17.6* PLT COUNT-226
[**2162-8-5**] 12:50PM NEUTS-74.1* LYMPHS-17.8* MONOS-4.9 EOS-2.7
BASOS-0.5
.
[**2162-8-5**] 12:50PM GLUCOSE-53* UREA N-25* CREAT-1.0 SODIUM-145
POTASSIUM-5.7* CHLORIDE-105 TOTAL CO2-34* ANION GAP-12
[**2162-8-5**] 12:50PM CALCIUM-8.7 PHOSPHATE-3.4 MAGNESIUM-2.6
[**2162-8-6**] 03:48AM BLOOD ALT-21 AST-18 LD(LDH)-285* AlkPhos-88
TotBili-0.2
.
[**2162-8-5**] 12:50PM TSH-1.7
[**2162-8-5**] 12:50PM CK-MB-6 proBNP-209
[**2162-8-5**] 12:50PM cTropnT-0.01
[**2162-8-5**] 03:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2162-8-5**] 03:10PM URINE RBC-[**2-24**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
.
[**2162-8-5**] 11:34PM TYPE-ART PO2-143* PCO2-81* PH-7.25* TOTAL
CO2-37* BASE XS-5
[**2162-8-6**] 08:00AM BLOOD Type-ART Temp-36.5 pO2-66* pCO2-75*
pH-7.31* calTCO2-40* Base XS-7 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
.
.
LABS ON DISCHARGE ([**2162-8-10**]):
.
[**2162-8-9**] 06:40AM BLOOD WBC-7.0 RBC-3.96* Hgb-11.8* Hct-37.5*
MCV-95 MCH-29.9 MCHC-31.5 RDW-16.6* Plt Ct-282
.
[**2162-8-9**] 06:40AM BLOOD PT-17.5* PTT-30.6 INR(PT)-1.6*
.
[**2162-8-9**] 06:40AM BLOOD Glucose-96 UreaN-22* Creat-1.1 Na-143
K-5.1 Cl-101 HCO3-39* AnGap-8
[**2162-8-9**] 06:40AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.3
.
.
MICROBIOLOGY:
Blood Cultures/Urine culture - negative
.
.
CARDIOLOGY:
EKG:
Sinus rhythm. Non-specific slight infero-apical ST segment
elevation.
Non-specific T wave changes in leads I and aVL
.
.
RADIOLOGY:
CXR portable ([**2162-8-5**]):
1. Atelectasis within both lower lobes.
2. Small amount of fluid within the right minor fissure.
.
CTA ([**2162-8-6**]):
1. No pulmonary embolism.
2. Slight interval increase in size of bilateral pleural
effusions, right
greater than left, compared to [**2162-4-24**].
3. Mild bibasilar bronchiectasis, essentially unchanged.
4. Persistent compression deformity involving a lower thoracic
vertebral
body, not significantly changed compared to study of [**2161-9-11**].
5. Mediastinal lymphadenopathy of uncertain etiology, stable.
[**2-25**] month CT
follow-up is recommended.
Brief Hospital Course:
In summary, Mr [**Known lastname **] is a 79 y/o M w h/o DM2, CAD (s/p MI),
asthma, and recurrent DVTs in RLE, who is transferred from the
MICU after admission for hypoglycemia, hypoxemia and acute on
chronic respiratory acidosis.
.
.
# Respiratory failure/Acute on chronic respiratory acidosis in
the setting of acute hypoglycemia. Pt's respiratory failure did
not seem to be due to either asthma or COPD given his relatively
normal pulmonary exam, radiological imaging and his lack of
pulmonary symptoms. PE was ruled out by CTA. Most likely
explanation is obesity-related hypoventilation (Pickwickian)
syndrome which could potentially have been exacerbated in the
setting of worsened hypoventilation from hypoglycemia/confusion.
Possible underlying lung dz suggested by bronchiectasis. Sleep
consult recommended nighttime CPAP. Pt is recommended to follow
up with pulmonary and sleep clinics. Discharged on
bronchodilators (advair, albuterol) and home O2 with activity
(pt's O2 dropped to 85% on RA with ambulation, setting in 90%'s
at rest).
.
.
# DM2/Hypoglycemia: Pt has DM2 with HgbA1c=7.2 (6/[**2161**]). He
presented with severe hypoglycemia in the setting of taking
insulin while fasting. Hypoglycemia resolved, glucose=227 on
transfer. Half of the home dose 70/30 insulin (20 units AM, 20
units PM) was given in the hospital and sliding-scale for
breakthrough hyperglycemia. The pt's glucose was in the
normoglycemic range at first, then in the mildly hyperglycemic
(150s-170s) range. Metformin was held, given that blood sugars
were in the normo-mildly elevated range. Pt was asymptomatic,
eating well, and discharged on the half-dose regimen and the
prior home sliding-scale, with follow-up in Dr[**Name (NI) 25189**] clinic.
.
.
# Hyperkalemia: Unclear etiology, though likely secondary to
acute on chronic respiratory acidosis. Hypoglycemia/insulin
should cause hypokalemia. No evidence of cell breakdown or ARF.
No EKG changes. Treated with calcium gluconate, kayexalate,
albuterol and insulin in MICU. Resolved.
.
.
# Hypertension: treated with metoprolol 12.5mg PO BID, switched
to Toprol XL 25mg daily. ACEI/[**Last Name (un) **] was not started, but should be
considered.
.
.
# H/o CAD: EKG unremarkable. Trop = 0.01, CKMB = 6. BNP = 209 on
admission. Continued home regimen: aspirin, metoprolol,
simvastatin.
.
.
# H/o DVT: Pt on warfarin anticoagulation with INR goal of [**1-24**],
INR=2.5 on transfer from MICU, but dropped to 1.6 by the time of
discharge even though no change was made in the regimen - home
warfarin 12mg PO daily was continued. Pt's INR has notoriously
been difficult to control in the past, so [**Date Range 3390**] followup and
titration is recommended.
Medications on Admission:
Warfarin 12 mg PO DAILY
Aspirin 81mg PO DAILY
Metoprolol Succinate (ToprolXL) 25mg PO daily
Simvastatin 40 mg PO DAILY
Metformin 500mg PO DAILY
Insulin (HuSC 70:30, 40units [**Hospital1 **]
Insulin (Humalog) SS
budesonide-formotorol (Symbicort) HFA Aerosol Inhaler
160-4.5mcg: 2 puff using inhaler [**Hospital1 **]
fluticasone-salmeterol (Advair Diskus) 250/50 1 INH IH [**Hospital1 **]
Albuterol 0.083% Neb Soln 1 NEB IH Q4H
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN
Ipratropium Bromide Neb 1 NEB IH Q6H
Aripiprazole 5 mg PO DAILY
Mirtazapine 30 mg PO HS
Escitalopram Oxalate 10 mg PO DAILY
Divalproex (Depakote) 500 mg PO HS
Divalproex (Depakote) 250 mg PO QAM
Calcium Carbonate 500 mg PO TID
Pantoprazole 40 mg PO Q24H
Docusate Sodium 100 mg PO BID
Cyanocobalamin 100 mcg PO DAILY
Vitamin D 800 UNIT PO DAILY
Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Warfarin 6 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QAM.
9. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 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. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours.
18. Insulin 70/30
Please take 20units @ breakfast and 20 units @ dinner.
19. Insulin Sliding-Scale
Please continue insulin sliding-scale at your previous schedule.
20. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation q2h:PRN as needed for
shortness of breath or wheezing.
22. Home O2
Pt needs home O2 with activities.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary diagnosis:
hypoxemia likely secondary to acute on chronic obstructive
pulmonary disease and hypoventilation secondary to obesity
.
Secondary diagnosis:
# coronary artery disease
# asthma
# diabetes mellitus 2
# recurrent deep venous thrombosis
# bipolar disorder
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
hypoglycemia. We think your shortness of breath was likely
related to sleep apnea and breathing problems secondary to your
weight. We would recommend that you follow-up in the sleep
clinic to schedule a sleep study. We also recommend that you see
a pulmonologist to evaluate your lung function. You are
scheduled for a lung evaluation on [**2162-8-10**] @1pm in the
Pulmonary Function Lab (see below). You should use O2 at home
with your activities.
.
Your blood sugar was also quite low on admission. We think this
was due to taking insulin on an empty stomach. You should
continue your insulin regimen at half-dose and follow up with Dr
[**Last Name (STitle) **] on Wednesday ([**2162-8-11**]) @ 1:30pm (see below).
.
We have changed your medications as follows:
1. Please take your half-dose 70/30 insulin (20units @breakfast,
20 units @ dinner) + sliding-scale at your previous schedule
2. Please use O2 with your activities.
.
If you experience fever, dizziness, blurry vision, chest pain,
shortness of breath, or if your blood sugars are consistently
<90, please seek medical care emergently.
Followup Instructions:
Provider: [**Name Initial (NameIs) 3390**] ([**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **]) @ [**Telephone/Fax (1) 3581**] - appointment on
Wednesday [**2162-8-11**] @ 1:30pm.
.
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2162-8-10**] 1:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2162-8-10**] 1:00
.
Please call the outpatient sleep clinic for appointment within
1-2 weeks of your discharge - [**Telephone/Fax (1) 107415**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
.
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2162-9-13**] 1:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2162-8-11**]
ICD9 Codes: 2762, 2767, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3058
} | Medical Text: Admission Date: [**2201-4-5**] Discharge Date: [**2201-4-11**]
Date of Birth: [**2201-4-5**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 2716**] is a former 31
week male infant admitted with hypotonia, respiratory
distress, and issues of prematurity.
The infant was born to a 24 year old gravida IV, para [**Name (NI) 1105**],
mother, estimated date of confinement [**2201-6-6**].
Prenatal screens - Blood type O positive, antibody negative,
RPR nonreactive, hepatitis B surface antigen negative.
Prenatal course significant for preterm labor with
spontaneous rupture of membranes on [**2201-4-3**] at 1600
hours. Mother was treated with clindamycin, then ampicillin
and erythromycin. During this pregnancy, prior preterm
laboratory treated with magnesium sulfate and betamethasone
on [**2201-3-26**]. Past medical history significant for
maternal depression treated with Klonopin, Prozac and Vicodin
p.r.n. for migraine, taking 1 every day. Normal fetal survey
per patient. Of note, mother has lactate allergy.
The infant delivered on [**2201-4-5**], at 7:27 a.m. with
Apgar of 6 at 1 minute, 8 at 5 minutes. The NICU team arrived
at about 3 minutes of age with infant receiving bag and mask
ventilation, was pink with some respiratory effort with
stimulation, continued recovering with blow by O2 only with
good respiratory effort and then pink in room air.
Unknown GBS. No maternal fever, rupture of membranes [**2201-4-3**], at 1600 hours. Maternal antibiotics since [**2201-4-3**], at [**2226**] hours.
PHYSICAL EXAMINATION: On admission, the infant on CPAP of 6
in room air with mild respiratory distress. Heart rate 140s,
respiratory rate 40s, blood pressure mean 33, oxygen
saturation 98%. Head circumference 30.5 centimeters, 75th to
90th percentile, length 42 centimeters, 50th to 75th
percentile, weight 1780 grams, 75th to 90th percentile.
Discharge weight 1620 grams, down 20 from previous day.
Minimal spontaneous activity, is responsive during
examination. Anterior fontanelle is open and flat. Facial
features not well assessed due to CPAP but in place and
currently notable for small chin. Ears normal size. Slightly
webbed neck. Breath sounds decreased bilaterally. Normal S1
and S2, no murmur. Bowel sounds present. Abdomen soft,
nontender, nondistended. Extremities with decreased
perfusion, tone decreased throughout. Testes descended
bilaterally. Patent anus.
HOSPITAL COURSE: Respiratory - The patient remained on CPAP
for the last 24 hours, transitioned to room air, has had no
further respiratory distress, has had no apnea or bradycardia
of prematurity. Baseline respiratory rate 30s to 60s,
bilateral breath sounds clear and equal.
Cardiovascular - The baby initially had a normal saline bolus
of 10 ml/kg for a marginal blood pressure, has had no further
blood pressure issues, did not require any pressor support.
Baseline heart rate 140s to 160s. Baseline blood pressure 50s
over 30s to 40s with mean in the 40s. The baby has no murmur.
Fluids, electrolytes and nutrition - The baby initially had
double lumen UVC inserted, was started on maintenance fluids
and parenteral nutrition at 80 ml/kg/day. Enteral feedings
were introduced on day of life 1 and advanced without issue
to full enteral feedings. The baby is currently eating breast
milk or special care 20 calories per ounce with a plan to
increase caloric density per routine. Double lumen UVC was
discontinued on [**2201-4-10**]. The baby achieved full enteral
feedings. He had electrolytes at 24 hours of age with sodium
138, potassium 3.9, chloride 105, bicarbonate 24. Last
electrolytes on day of life 3 with sodium 137, potassium 4.6,
chloride 103, bicarbonate 25. The baby is voiding and
stooling without issue. Initial Dextrostix was 96, all
Dextrostix have been greater than 60, no issues.
Gastrointestinal - The baby had a peak bilirubin on day of
life 3 of 7.3/0.3. Phototherapy was discontinued on day of
life 4 for a bilirubin of 4.9/0.3, rebound bilirubin on [**2201-4-10**], was 5.9/0.3. This issue has been resolved.
Infectious disease - On admission, the baby had a CBC and a
blood culture sent with a white count of 5.9, polys 4, bands
3, lymphocytes 80, platelet count 382,000, nucleated red
blood cells 6 with an ANC of 413. The baby was started on
ampicillin and gentamicin at 48 hours of age. The baby looks
clinically well. The antibiotics were discontinued and there
have been no further issues.
Neurology - The baby initially was hypotonic. This was
thought to be related to some of the maternal medications.
The baby's tone quickly improved and currently has normal
tone for gestational age. The baby is thought to be
nondysmorphic with neurological examination appropriate for
gestational age. The plan was to do a head ultrasound around
day [**7-19**] to rule out any intraventricular hemorrhage. This
has not been done at the time of transfer.
Sensory, audiology - Hearing screening has not been
performed. The plan would be to screen prior to discharge.
Ophthalmology - Examination has not been done at the time of
transfer. Because of gestational age of less than 32 weeks,
it would be indicated to do an ophthalmology examination.
Psychosocial - The parents look forward to [**Known lastname 518**] moving
closer to home. Of note, maternal history, mother had a 34
week in [**2199**], had preterm labor at 30 weeks with that
pregnancy and that baby is alive and well. She has had 2
subsequent normal spontaneous vaginal deliveries.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To [**Hospital 1474**] Hospital. Primary pediatrician, Dr.
[**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **], [**Hospital1 1474**], [**State 350**].
CARE RECOMMENDATIONS:
1. Continue to advance enteral caloric density.
2. Medications - None at the time of transfer. Would
recommend considering iron supplementation.
3. Car seat position screening has not been done at the time
of transfer.
4. State Newborn Screen - An initial screen was sent on [**4-8**], [**2201**], results are pending with plan to repeat at day
of life 14 per routine.
5. Immunizations received - None at the time of transfer.
6. Immunizations recommended - Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following three criteria: Born at less
than 32 weeks, born between 32 and 35 weeks with two of
the following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings or 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.
FOLLOW UP: With primary care pediatrician per routine. Early
intervention referral - Infant follow-up program referral.
Consider visiting nurse visit upon transition home.
DISCHARGE DIAGNOSES: Former 31 week preterm male.
Status post respiratory distress syndrome, probably transient
tachypnea of newborn.
Status post rule out sepsis with antibiotics.
Status post hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 58754**]
Dictated By:[**Doctor Last Name 60575**]
MEDQUIST36
D: [**2201-4-11**] 11:43:14
T: [**2201-4-11**] 13:25:11
Job#: [**Job Number 60576**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3059
} | Medical Text: Admission Date: [**2156-12-21**] Discharge Date: [**2156-12-29**]
Date of Birth: [**2087-6-25**] Sex: F
Service: [**Hospital Ward Name 332**] Intensive Care Unit
CHIEF COMPLAINT: Transfer to Intensive Care Unit for chronic
obstructive pulmonary disease flare requiring frequent
nebulizers.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant
69-year-old female with a past medical history significant
for chronic obstructive pulmonary disease who is on home
oxygen (never required chronic steroids, nebulizers, or
intubation) who was transferred to the [**Hospital Ward Name 332**] Intensive Care
Unit for respiratory distress/chronic obstructive pulmonary
disease flare.
The patient was transferred from the [**Hospital Ward Name 517**] regular
Medicine [**Hospital1 **].
The patient had initially presented to the Emergency
Department complaining of shortness of breath and was
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2156-12-29**] 13:03
T: [**2156-12-29**] 14:14
JOB#: [**Job Number 106425**]
ICD9 Codes: 486, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3060
} | Medical Text: Admission Date: [**2123-4-11**] Discharge Date: [**2123-4-16**]
Date of Birth: [**2051-8-20**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Transient aphasia and right sided weakness
Major Surgical or Invasive Procedure:
Cerebral angiography with intra-arterial thrombolysis x2
History of Present Illness:
71 yo RH male with hx of CAD s/p stent [**8-24**] and HTN who
presented to ER today c/o transient speech problems and right
sided weakness. He was in his usual state of excellent health
today until 12:30-12:45 PM when he was sitting at a table with
friends when he had the sudden onset of difficulty speaking.
According to witnesses, he was enganged in conversation with
friends when he suddenly grabbed his right arm. When asked
questions he did not respond and had a "blank stare". He did not
speak at all. He tried to get up from the table and nearly fell.
Family says that he was not moving his right arm and appeared to
be weak in his LE. They did not notice any facial droop. He did
not respond to questions or follow commands. EMS was called and
the patient was taken to [**Hospital1 18**] ER where he arrived at 1:50PM. By
the time he arrived, his speech and strength were back to
baseline. On questioning at this time, the patient says that he
remembers being unable to talk or think of the words that he
wanted to say. He says that he did understand what was being
said to him, but had difficulty responding. He says that both
his right leg and arm seemed weak (perhaps arm more than leg).
He did not have any change in his vision, facial droop,
dysphagia, vertigo, numbness/tingling.
On review of symptoms, he denies F/C, headache, cough, SOB, CP,
palpitations, or dysuria. He says that he has been feeling well.
He went to his primary care doctor last week who found him to be
in "good health". He has noted some increased fatigue,
particularly late in the day since starting atenolol. He
excercised this AM as usual and had no difficulties prior to the
onset of symptoms at 12:30
Past Medical History:
1. HTN
2. CAD -s/p PTCA [**8-24**] at [**Hospital1 2025**]
3. Polio as a child with residual left leg weakness and atrophy
4. No hx of prior stroke/TIA, DM, or high cholesterol
Social History:
Lives with his wife. Italian, came to US in [**2083**]. He is
completely independent and very active. He is a former smoker,
but quit in the [**2087**]'s. Occasional EtOH. No drugs. Retired x
10yrs, formerly worked as a casket maker.
Family History:
Mother had stroke in her 80's. Father died in 50's of cancer
(?type)
Physical Exam:
PE: T-98 BP-130/68 HR-40-50 RR-18 O2 Sat 98%
(at 2:15PM)
Gen: Well nourished male, pleasant, appears well
HEENT: NC/AT, oropharynx clear, moist oral mucosa
Neck: supple, normal ROM, No carotid briut
CV: RRR, S1/S2, 2/6 SEM radiating to carotid
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema, left leg shorter than right, decreased bulk
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and time. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact to high frequency items, but has
difficulty with low frequency words such as cactus, hammock, and
lapel in both English and Italian. No dysarthria.
[**Location (un) **]/Writing
intact. Registers [**1-21**], recalls [**12-24**]. Able to perform basic
calculations. No evidence of apraxia or neglect.
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally. Visual fields are full to confrontation; accuity
20/20 ou
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V: Sensation intact V1-V3
VII: No facial asymmetry.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palate elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements
Motor:
Decreased muscle bulk in left leg. Tone normal. No adventitious
movements. No drift.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick and vibration and
proprioception.
Reflexes:
B T Br Pa Ach
Right 2 2 2 2 2
Left 2 2 2 2 2
Grasp reflex absent
Toes were downgoing bilaterally
Coordination: normal on finger-nose-finger and heel to shin
bilaterally. RAMs slowed on right hand.
Gait was normal based, walks with limp due to shorter left leg
Romberg was negative
Pertinent Results:
[**2123-4-11**] 11:58PM GLUCOSE-136* UREA N-13 CREAT-0.6 SODIUM-143
POTASSIUM-3.4 CHLORIDE-113* TOTAL CO2-21* ANION GAP-12
[**2123-4-11**] 11:58PM CK(CPK)-71
[**2123-4-11**] 11:58PM cTropnT-<0.01
[**2123-4-11**] 11:58PM TRIGLYCER-44 HDL CHOL-35 CHOL/HDL-2.3
LDL(CALC)-38
[**2123-4-11**] 11:58PM NEUTS-83.0* LYMPHS-13.9* MONOS-2.8 EOS-0.2
BASOS-0.1
[**2123-4-11**] 11:58PM WBC-7.5 RBC-3.56* HGB-11.5* HCT-32.8* MCV-92
MCH-32.3* MCHC-35.1* RDW-13.3
[**2123-4-11**] 11:58PM PLT COUNT-159
[**2123-4-11**] 11:58PM PT-13.5* PTT-43.6* INR(PT)-1.2
[**2123-4-11**] 04:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2123-4-11**] 04:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2123-4-11**] 04:50PM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0
[**2123-4-11**] 01:50PM ALT(SGPT)-23 AST(SGOT)-18 CK(CPK)-81 ALK
PHOS-73 AMYLASE-54 TOT BILI-0.6
[**2123-4-11**] 01:50PM LIPASE-31
[**2123-4-11**] 01:50PM cTropnT-<0.01
[**2123-4-11**] 01:50PM CALCIUM-9.4 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2123-4-11**] 01:50PM NEUTS-59.1 LYMPHS-34.5 MONOS-4.9 EOS-1.2
BASOS-0.3
[**2123-4-11**] 01:50PM PLT COUNT-197
[**2123-4-11**] 01:50PM PT-12.9 PTT-24.8 INR(PT)-1.1
[**4-11**] MRI (pre angio #1)
No evidence of cortical infarction at this time. Absence of flow
signal is observed in the left middle cerebral arterial branches
at and beyond the bifurcation of this vessel. This is suspicious
for the presence of a thrombus in this location. Cerebral
angiography immediately followed this study.
[**4-12**] MRI (post angio #1)
1. MRI of the brain, demonstrating new area of slow diffusion
within the
right temporal-occipital lobe region, consistent with
infarction.
2. MR [**First Name (Titles) 20827**] [**Last Name (Titles) 4059**] normal signal intensity within the
intracranial arterial vasculature. Specifically, no significant
area of stenosis is identified.
[**4-14**] CTA chest (PE protocol)
No evidence of acute pulmonary embolus.
Brief Hospital Course:
71 yo CAD, high chol, and HTN who developed aphasia and right
sided weakness at 12:30PM [**4-11**]. Deficits completely resolved in
one hour. CT neg. At 4pm (while in ED), developed worsening
speech (fluent aphasia) and right facial droop. Exam fluctuated
over next hour. Was taken for emergent MR which showed a left M2
occlusion. He was immediately taken for intra-arterial
t-PA-given at 7:40PM. After angio and t-PA with resolution of
LMCA clot and improved sx, developed visual problems-unclear if
field cut or blurred vision. Had a repeat CT which was negative
for bleed, and taken back for repeat angiogram which showed
right PCA (P2) occlusion! Was intubated during procedure due to
agitation. Extubated shortly thereafter, in ICU until [**4-13**],
then transferred to the floor.
Hospital Course on the floor
1. NEURO:
His exam was notable only for a dense left field cut. PT
evaluated him and found him to be safe for home, as his gait was
stable. A Repeat MRI/MRA was performed on [**4-12**] that showed no L
MCA stroke and patent MCA, with R PCA infarct (medial occip
lobe, sparing pole). Stroke workup included TEE that showed no
ASD, no thrombus, but large complex atheroma in aorta
(descending, ascending, arch). Lipid panel normal. Carotids on
angio showed no evidence of stenosis. Because of the atheroma
and hx of two embolic strokes, he was started on coumadin for
anticoagulation and continued on ASA for secondary stroke
prevention. Upon discharge he was on day 3 of coumadin 5 mg,
INR 1.1.
2. Pulm
He was stable until [**4-14**] when he developed a new O2 requirement
and some tachypnea, chest CTA showed no evidence of PE and he
was quickly weaned off of O2. CXR follow up showed no evidence
of pneumonia.
3. CV:
He initially ruled out for MI with serial enzymes. He was kept
off of his atenolol initially because of low BP, but restarted
on lopressor upon transfer to the floor. As an outpatient he may
be restarted on his atenolol. His PCP may also consider starting
an ACE inhibitor as secondary stroke prevention upon discharge.
Early in the morning on [**4-16**] he developed some feeling of chest
pressure, he was given nitroglycerin without any relief. His
cardiac enzymes were cycled x3 again and they were negative,
EKG's unchanged. He was discharged after being cleared from the
cardiac perspective. Of note, when he was placed back on
telemetry at the time of his chest pain he was noted to
intermittently be in atrial fibrillation, not wiht rapid
ventricular response. This data just made the team more certain
about continuing anticoagulation.
4. GI: Cardiac diet
5. ID:
On [**4-14**] overnight he spiked a fever and workup was initiated
that showed normal CXR and U/A and urine culture and blood
culture were sent that are pending. He also underwent PE workup
that was negative.
6. Heme:
He was discharged on coumadin and ASA. His INR will need every
other day checks until therapeutic at 2-3. His PCP is aware of
this plan.
7. Ppx: Boots, PPI
Medications on Admission:
ASA 325 qd
Plavix 75mg qd
Atenolol ? dose
Lipitor ?20mg qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
R MCA territory stroke (likely cardioembolic), with aphasia and
L sided weakness, succssfully thrombolysed with subsequent R PCA
occlusion and L PCA territory infarction.
Discharge Condition:
much improved, only with a L sided field cut.
Discharge Instructions:
Please call your PCP and arrange to have your INR drawn on
Sunday.
Please make sure you take your aspirin and coumadin every day.
Because of your stroke, you will need to make lifestyle
modifications:
1. exercise at least 30 minutes 3-4 times per week
2. do not smoke
3. eat a low saturated fat, low cholesterol diet
Followup Instructions:
Please call [**Telephone/Fax (1) 657**] to schedule a follow up in [**11-22**] months
with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3061
} | Medical Text: Admission Date: [**2175-9-24**] Discharge Date: [**2175-10-19**]
Date of Birth: [**2124-12-16**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / [**Hospital1 **] Tylenol Plus / Sunflower Oil /
Clindamycin
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
nausea / vomiting
Major Surgical or Invasive Procedure:
transjugular liver biopsy
History of Present Illness:
50M with tea colored urine, nausea, mild epigastric pain, and
vomiting x1 on [**9-24**] to the ER, then admitted to the floor. Pt
transfered to MICU on Day 2. Pt has a hx HBV cirrhosis s/p OLT
in [**2156**] ([**Hospital1 1774**]), ESRD ?s/p IgG nephtropathy vs. tacro tox
resulting in kidney transplant [**2166**] ([**Hospital1 18**]). Pt currently
denies fevers and chills or frank [**Hospital1 **] in the urine or stool,
but endoeses dysuria and describes epigastric pain as "buring",
constant, non-radiating. In the ED received Unasyn for concern
of cholangitis, RUQ u/s showed patent portal vasculature, no
ascites, normal echotecture of liver, and no intra- or
extra-hepatic biliary dilitation. However, LFT markedly
elevated above baseline. Pt admited to floor and underwent an
ERCP today under GA (fenatyl, midaz, propofol, and paralytics),
distal part of bile duct is "completely excluded" from proximal
biliary tree, pt has a hepato-jujenostomy, normal pancreatogram,
and they performed a sphincterotomy. Pt was hypotensive in PACU
and during the procedure. Pt received 1400cc in the PACU
without response (SBP in 80's baseline 115). On the floor the
pt continued to be lethargic, at times confused, and c/o
lightheadedness. On the floor the SBP remained in the 80's
despite 1L NS bolus, and was associated with poor urine output,
persistently poor mental status, and an ABG was 7.32/37/98 with
lactate 1.7, with WBC 19.7 up from 5.5 in AM, Cr up to 2.3 from
1.6, LFT still elevated, bili up to 6.5, while pt afebrile, not
complaining of pain, no nausea or vomiting. Pt received
cefazolin during procedure and was received cipro/flagyl on
floor for ?cholangitis, and was started on vancomycin [**9-25**] to
expand coverage. ERCP fellow recomends IR guided perc
transhepatic drainage. Transplant surgery was consulted for
their input whether the pt needs an operation.
Past Medical History:
* LBP -- [**2173-12-28**] MRI with heterogeneously enhancing L5 lesions
* L brachiocephalic AV fistula aneurysm c/b hematoma now s/p
repair
* Liver Cirrhosis ? [**2-1**] Hepatitis B
* End Stage Liver disease s/p orthotic liver transplant ([**3-/2157**])
* ESRD s/p LRRT [**2-1**] cyclosporine-tacro toxicity ( [**6-2**]) @ [**Hospital1 1774**]
* Renal osteodystrophy with osteoporosis
* s/p multiple hernia repairs
* s/p splenectomy
* HTN
* Hyperlipemia
* GERD
* Depression
* Hematuria
* Colonic polyps
* OSA on CPAP
Social History:
Drugs: denies
Tobacco: denies
Alcohol: denies
Other: Lives alone. Single. No children.
Family History:
Two brothers with IgA nephropathy; one brother with cirrhosis;
both deceased
Physical Exam:
Admission PE:
VS: 97.4, 137/93, 68, 20, 99RA
GENERAL: Well-appearing man in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: olt scars well healed, tender to palpation in the
epigastrium, non-tender in the right upper quadrant, Soft/ND, no
masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions. No spider angiomata.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-4**] throughout, sensation grossly intact throughout, no
asterixis.
Discharge PE:
VS: Tc 97.6 Tm 98.2 145/78 (131-156/74-86) 73 (73-104) 22 97 on
3L
8h: 1100 out/120+100 IV in
24h: 2175 out/420+600 IV in
Gen: jaundiced, ill-appearing, weak, lethargic, falling in and
out of sleep during interview
HEENT: dry mucous membranes, icteric sclerae
CV: RRR, S1, S2 no murmurs/rubs/gallops appreciated
lungs: limited lung exam, worsening crackles b/l, [**3-3**] the way
up lung fields, decreased breath sounds at the bases, resps
unlabored
abdomen: horizontal abdominal scar, increasing distension and
tympany today; with R sided abdominal tenderness, no
rebound/guarding
ext: warm, well perfused, 2+ DP pulses, trace LE edema
Neuro: AAO x3, but very lethargic
Pertinent Results:
Admission labs:
.
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] WBC-10.6 RBC-4.49* Hgb-14.4 Hct-43.7
MCV-97 MCH-32.1* MCHC-32.9 RDW-14.0 Plt Ct-243
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] WBC-5.1# RBC-3.14*# Hgb-10.3*# Hct-36.3*
MCV-116*# MCH-32.8* MCHC-28.4*# RDW-15.3 Plt Ct-131*
[**2175-9-25**] 10:50AM [**Month/Day/Year 3143**] WBC-20.8*# RBC-4.24*# Hgb-13.8*# Hct-40.9
MCV-97# MCH-32.5* MCHC-33.7# RDW-14.9 Plt Ct-194
[**2175-9-25**] 07:50PM [**Month/Day/Year 3143**] WBC-19.7* RBC-3.83* Hgb-12.8* Hct-37.4*
MCV-98 MCH-33.4* MCHC-34.2 RDW-14.4 Plt Ct-208
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] PT-32.0* PTT-35.0 INR(PT)-3.2*
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] PT-33.8* PTT-40.3* INR(PT)-3.4*
[**2175-9-25**] 10:50AM [**Month/Day/Year 3143**] PT-33.5* PTT-37.7* INR(PT)-3.3*
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] Glucose-101* UreaN-18 Creat-1.6* Na-140
K-3.9 Cl-108 HCO3-24 AnGap-12
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] Glucose-679* UreaN-16 Creat-1.3* Na-132*
K-3.8 Cl-104 HCO3-18* AnGap-14
[**2175-9-25**] 10:50AM [**Month/Day/Year 3143**] Glucose-116* UreaN-20 Creat-1.6* Na-138
K-4.6 Cl-109* HCO3-20* AnGap-14
[**2175-9-25**] 07:50PM [**Month/Day/Year 3143**] Glucose-196* UreaN-27* Creat-2.3* Na-134
K-5.1 Cl-108 HCO3-21* AnGap-10
[**2175-9-26**] 02:33AM [**Month/Day/Year 3143**] Glucose-99 UreaN-30* Creat-2.5* Na-137
K-4.5 Cl-108 HCO3-22 AnGap-12
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] ALT-302* AST-245* LD(LDH)-275*
AlkPhos-276* Amylase-118* TotBili-3.8* DirBili-2.7* IndBili-1.1
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] ALT-233* AST-189* LD(LDH)-258*
AlkPhos-214* Amylase-82 TotBili-3.8*
[**2175-9-25**] 10:50AM [**Month/Day/Year 3143**] ALT-261* AST-204* LD(LDH)-316*
AlkPhos-253* Amylase-83 TotBili-5.2* DirBili-4.0* IndBili-1.2
[**2175-9-25**] 07:50PM [**Month/Day/Year 3143**] ALT-217* AST-163* AlkPhos-199*
TotBili-6.5*
[**2175-9-26**] 02:33AM [**Month/Day/Year 3143**] ALT-170* AST-118* LD(LDH)-220
AlkPhos-164* TotBili-6.8*
[**2175-9-27**] 03:30AM [**Month/Day/Year 3143**] ALT-151* AST-86* AlkPhos-128 TotBili-7.3*
DirBili-1.6* IndBili-5.7
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] Albumin-3.0* Calcium-7.8* Phos-2.0*
Mg-1.6
[**2175-9-25**] 10:50AM [**Month/Day/Year 3143**] Albumin-3.3* Calcium-9.2 Phos-2.2* Mg-1.7
[**2175-9-25**] 07:50PM [**Month/Day/Year 3143**] Albumin-3.0*
[**2175-9-26**] 02:33AM [**Month/Day/Year 3143**] Calcium-8.3* Phos-2.7 Mg-1.5*
.
LFT trends:
.
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] ALT-302* AST-245* LD(LDH)-275*
AlkPhos-276* Amylase-118* TotBili-3.8* DirBili-2.7* IndBili-1.1
[**2175-9-25**] 05:20AM [**Month/Day/Year 3143**] ALT-233* AST-189* LD(LDH)-258*
AlkPhos-214* Amylase-82 TotBili-3.8*
[**2175-9-30**] 06:58AM [**Month/Day/Year 3143**] ALT-112* AST-118* AlkPhos-163*
TotBili-7.0*
[**2175-10-1**] 04:01AM [**Month/Day/Year 3143**] ALT-105* AST-127* AlkPhos-172*
TotBili-7.6*
[**2175-10-1**] 06:00PM [**Month/Day/Year 3143**] ALT-100* AST-123* LD(LDH)-281*
AlkPhos-182* TotBili-8.3*
[**2175-10-2**] 03:21AM [**Month/Day/Year 3143**] ALT-97* AST-125* AlkPhos-197*
TotBili-9.3*
[**2175-10-3**] 06:15AM [**Month/Day/Year 3143**] ALT-90* AST-138* AlkPhos-244*
TotBili-11.7*
[**2175-10-8**] 03:44AM [**Month/Day/Year 3143**] ALT-45* AST-78* AlkPhos-171*
TotBili-14.4*
[**2175-10-9**] 04:50AM [**Month/Day/Year 3143**] ALT-39 AST-65* LD(LDH)-255* AlkPhos-152*
Amylase-34 TotBili-17.5*
[**2175-10-10**] 02:41AM [**Month/Day/Year 3143**] ALT-36 AST-64* LD(LDH)-240 AlkPhos-139*
TotBili-18.5* DirBili-14.6* IndBili-3.9
[**2175-10-11**] 04:52AM [**Month/Day/Year 3143**] ALT-44* AST-71* AlkPhos-132*
TotBili-19.5*
[**2175-10-12**] 06:33AM [**Month/Day/Year 3143**] ALT-54* AST-90* AlkPhos-129 TotBili-23.4*
[**2175-10-13**] 05:47AM [**Month/Day/Year 3143**] ALT-70* AST-104* AlkPhos-147*
TotBili-24.5*
[**2175-10-14**] 06:30AM [**Month/Day/Year 3143**] ALT-79* AST-105* AlkPhos-141*
TotBili-23.7*
[**2175-10-15**] 05:15AM [**Month/Day/Year 3143**] ALT-110* AST-129* AlkPhos-157*
TotBili-24.4*
[**2175-10-16**] 06:50AM [**Month/Day/Year 3143**] ALT-123* AST-138* AlkPhos-146*
TotBili-25.3*
[**2175-10-17**] 05:35AM [**Month/Day/Year 3143**] ALT-152* AST-153* AlkPhos-152*
TotBili-31.1*
[**2175-10-18**] 04:08AM [**Month/Day/Year 3143**] ALT-172* AST-151* AlkPhos-164*
TotBili-32.2*
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] ALT-174* AST-132* AlkPhos-171*
TotBili-34.6*
.
Discharge Labs:
.
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] WBC-20.3* RBC-2.68* Hgb-8.9* Hct-27.3*
MCV-102* MCH-33.1* MCHC-32.4 RDW-20.5* Plt Ct-210
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] PT-17.9* INR(PT)-1.6*
[**2175-10-18**] 04:08AM [**Month/Day/Year 3143**] Glucose-191* UreaN-98* Creat-2.7* Na-139
K-4.8 Cl-110* HCO3-16* AnGap-18
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] Glucose-168* UreaN-114* Creat-3.3* Na-138
K-5.0 Cl-108 HCO3-14* AnGap-21*
[**2175-10-18**] 04:08AM [**Month/Day/Year 3143**] ALT-172* AST-151* AlkPhos-164*
TotBili-32.2*
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] ALT-174* AST-132* AlkPhos-171*
TotBili-34.6*
[**2175-10-18**] 04:08AM [**Month/Day/Year 3143**] Albumin-3.5 Calcium-9.9 Phos-5.1* Mg-2.7*
[**2175-10-19**] 04:25AM [**Month/Day/Year 3143**] Albumin-3.3* Calcium-9.8 Phos-6.4*
Mg-2.8*
[**2175-9-24**] 07:35PM [**Month/Day/Year 3143**] HBsAg-NEGATIVE
[**2175-9-27**] 03:10PM [**Month/Day/Year 3143**] IgM HAV-NEGATIVE
[**2175-9-29**] 04:23AM [**Month/Day/Year 3143**] HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE IgM HBc-NEGATIVE
[**2175-10-3**] 10:28AM [**Month/Day/Year 3143**] Smooth-POSITIVE A
[**2175-10-16**] 07:16PM [**Month/Day/Year 3143**] AMA-NEGATIVE Smooth-POSITIVE *
[**2175-10-3**] 10:28AM [**Month/Day/Year 3143**] [**Doctor First Name **]-NEGATIVE
[**2175-10-5**] 01:59PM [**Month/Day/Year 3143**] CEA-2.9 PSA-0.3
[**2175-10-6**] 05:27AM [**Month/Day/Year 3143**] CRP-29.0*
[**2175-10-16**] 07:16PM [**Month/Day/Year 3143**] [**Doctor First Name **]-NEGATIVE
[**2175-10-3**] 06:15AM [**Month/Day/Year 3143**] IgG-1082
[**2175-10-16**] 07:16PM [**Month/Day/Year 3143**] IgG-887 IgM-26*
.
RUQ u/s [**2175-9-24**]
IMPRESSION: Normal transplant liver ultrasound. Major
intrahepatic vessels
patent with appropriate flow. No ascites.
.
CT abdomen [**2175-10-11**]
Coiling of pigtail catheter in between the liver capsule and the
internal
thoracic wall might be causing irritation and abdominal pain.
Pulling of the catheter back is recommended.
2. A right-sided pleural effusion is mildly increased in size
with respect to [**2175-10-6**]. Bilateral bibasilar
moderate-to-severe atelectasis is
stable.
3. Diffuse pancreatic calcifications are unchanged with respect
to prior CT.
4. Ascites has decreased in size with respect to prior CT.
5. Stable moderate cardiomegaly.
.
[**2175-10-11**]
IMPRESSION: Successful removal of a biliary catheter. No
immediate
complication.
.
[**2175-9-27**]: transcutaneous liver biopsy
A. Liver, allograft, transjugular needle core biopsy:
1. Moderate portal mononuclear inflammation with foci of
lymphocytic bile duct damage and focally prominent plasma cells.
2. Bile ductular proliferation with associated neutrophils and
moderate hepatocellular and canalicular cholestasis.
3. No definite endothelialitis is seen.
4. Trichrome stain shows increased portal fibrosis with some
periportal extension (Stage 2 fibrosis, in this limited sample;
definitive staging deferred given the limitations of transvenous
sampling).
5. Iron stain shows no stainable iron.
6. Reticulin stain is pending evaluation and will be reported in
an addendum.
B. Liver, allograft, transjugular needle core biopsy:
Minute fragments of liver parenchyma measuring up to 0.3 cm in
greatest dimension demonstrating:
1. Bile ductular proliferation with associated neutrophils and
moderate hepatocellular and canalicular cholestasis.
2. No definite endothelialitis.
3. Mildly increased portal fibrosis with some periportal
extension seen on Trichrome stain.
4. Fragments of venous wall with subendothelial
lymphoplasmacytic inflammation.
5. No stainable iron on iron stain.
Note: The above biopsies show two distinct histologic patterns
of injury; one with bile ductular proliferation with intraductal
neutrophils and cholestasis which suggests ascending cholangitis
or sepsis, and the other with portal, predominantly lymphocytic
inflammation with occasional foci of prominent plasma cells,
lymphocytic bile duct injury, and lobular apoptotic hepatocytes.
The latter findings in a patient nearly 20 years following liver
transplantation suggest a possible immune-mediated hepatitis, or
alternatively, a component of treated acute cellular rejection.
Given the lymphocyte-predominant pattern of portal inflammation
and the setting of immunosuppression, workup by the
Hematopathology consult team to rule out a post-transplant
lymphoproliferative disorder is warranted and will be reported
in an addendum. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was notified of the findings by
telephone by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7017**] on [**2175-9-28**].
ADDENDUM #1:
Reticulin stain shows normal plate thickness and distribution in
the limited trans-venous sample.
Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/rna
Date: [**2175-9-30**]
Hematopathology Addendum: T-cell dominant mixed lymphoid
infiltrate, favor reactive, see note.
Note: Sections of the specimen reveal mixed periportal
inflammation composed of lymphocytes, neutrophils and rare
plasma cells. By immunohistochemistry the cells express CD3,
CD5 and CD20 confirming that there is a mixed population of
B-cells and T-cells. CD138 highlights occasional plasma cells;
however kappa and lambda stain cannot be interpreted due to high
background staining. MIB-1 stains occasional hepatocytes and
lymphocytes. LMP stain is negative.
[**2175-10-10**]
DIAGNOSIS:
Liver, allograft, needle core biopsy:
1. Moderate portal and mild lobular mixed inflammation
including prominent neutrophils with associated bile duct
proliferation and focally prominent plasma cells.
2. Severe hepatocellular and canalicular cholestasis.
3. Focal lymphocytic cholangitis and bile duct damage seen.
4. No steatosis is seen.
5. Focal areas of centrivenular mononuclear cell infiltrate
with prominent plasma cells.
6. Trichrome stain shows increased portal/periportal fibrosis
with focal septal formation (Stage 2 fibrosis).
7. Iron stain shows no increase in stainable iron.
Note: The presence of plasma cells, particularly in the area of
centrivenular region and focal lymphocytic cholangitis is
consistent with an immune-mediated process. The differential
diagnosis includes acute cellular rejection vs. post-transplant
chronic immune mediated hepatitis. However, the prominent
neutrophilic infiltrate is unusual and a concurrent biliary
obstruction and sepsis cannot be entirely excluded. Compared to
the prior biopsy, there is an increase in the degree of
inflammation, particularly the neutrophilic and plasma cell
components. Evaluation is limited by technical artifact due to
processing. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] was notified of the preliminary
findings on [**2175-10-11**] by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 10165**].
ADDENDUM:
An immunohistochemical stain for C4d is negative. Satisfactory
controls were obtained.
Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/tkb
Date: [**2175-10-16**]
Clinical: 50 year old with history of liver transplant in [**2156**],
now with worsening liver function tests of unclear etiology.
Gross: The specimen is received in one formalin filled
container, labeled with the patient's name "[**Known lastname 16229**], [**Known firstname **]"
and the medical record number. It consists of a tan yellow to
focally green liver core biopsy measuring 1.7 cm in length x
(0.1) cm in diameter, entirely submitted in cassette A.
.
EGD: [**2175-10-1**]
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum:
Other slow bleeding at the ampulla was seen.
Impression: Slow bleeding at the ampulla was seen.
Otherwise normal EGD to second part of the duodenum
.
EGD: [**2175-10-1**]
Limited exam showed grade [**2-2**] varices at the lower esophagus.
There was no evidence of active bleeding.
Limited exam showed mild portal hypertensive gastropathy. There
was no evidence of active bleeding.
There were both fresh bleeding and a large clot at the ampulla.
At both upper corners of the major papilla, it was injected with
1:10,000 epinephrine with a total of 6 cc. The clot was
partially dislodged with the injection needle and bipolar probe
and the sphincterotomy site was exposed. The apex of the
sphincterotomy site was cauterized with the bipolar probe with
good hemostasis. There was no bleeding at the end of procedure.
Otherwise normal EGD to third part of the duodenum.
Recommendations: Avoid anticoagulation for at least the next
48-72 hrs, and longer if possible.
If any abdominal pain, recurrent bleeding, fever, or any other
concerning symptom please call oncall ERCP fellow or Dr. [**First Name (STitle) 908**].
Serial H/H.
.
EGD: [**2175-10-8**]
Varices at the lower third of the esophagus
Mosaic appearance in the stomach compatible with portal
hypertensive gastropathy
Ulcer with adherent clot in the area of the papilla - no active
bleeding was noted. Ulcer is at the base of the sphincterotomy.
(injection)
Otherwise normal EGD to third part of the duodenum
Recommendations: Given absence of active bleeding or visible
vessel, h/o recent cautery to papilla, and presence of severe
portal HTN, decision was made not to further cautherize the
papilla. There is a high likelyhood that this lesion with heal.
High dose PPI. Keep INR < 1.5.
Return patient to hospital [**Hospital1 **].
Brief Hospital Course:
Mr. [**Known lastname 16229**] is a 50M w history of Hep B cirrhosis s/p liver
transplant [**2156**], IgA nephropathy s/p renal transplant in [**2166**]
who initially presented with epigastric pain, abnormal LFTs, AP,
INR, and TBili, initially s/p ERCP for a working diagnosis of
cholangitis with septic shock, was started on broad spectrum
antibiotics and later had PTC placed with no subsequent change
in LFTs. Course further complicated by increasing LFTs s/p 3
liver biopsies, melena s/p 3 EGDs, renal failure, and
respiratory distress, and course of high dose steroids for
autoimmune hepatitis versus rejection.
.
# Acute liver failure: The patient initially presented with
possible cholangitis, despite no evidence of bile duct dilation
on imaging; received 1 dose Unasyn in ED, but has allergy so
that was stopped and patient was covered with Cipro/Flagyl. The
patient went for ERCP and during which bile duct was NOT
cannulated given patient hepatojejunostomy s/p liver transplant.
After procedure, pt was hypotension, bolused, and antibiotics
broadened and sent to unit out of concern for sepsis. In spite
of treatment for presumed cholangitis, the patient's LFTs did
not improve. The patient's LFTs worsened throughout his course
and in total he underwent three biopsies. The initial biopsies
showed evidence of bile duct proliferation which could be c/w
obstruction, as well as a second immune mediated process.
Because of the possible concern for obstruction, the patient was
kept on antibiotics and a PTC was placed. However, in spite of
biliary decompression, the patient's LFTs continued to trend up.
.
In order to rule out a secondary process like PTLD (as there was
some lymphocytic proliferation on initial biopsies, as well) the
patient underwent PET scan, which was negative. During this
time, the patient's LFTs were continuing to increase. Repeat
biopsies showed similar bile duct proliferation, but the second
biopsy also showed more evidence of an autoimmune process,
either an autoimmune hepatitis versus a rejection picture.
Because of this, the patient was started on 125 mg methylpred
pulse steroids. 500 mg methylpred was not used because of the
suspicion of underlying infection; the patient was also
continued on broad spectrum antibiotics during the pulse steroid
treatment. In spite of the pulse dose steroids, the patient's
LFTs continued to rise. An extensive work up was pursued for
viral etiologies of her liver failure and he was found to be
[**Doctor First Name **], anti-mitochondial negative, Hep B core ab postive with Hep
B viral load <40, anti-smooth muscle titer 1:20, normal IgG,
negative EBV, CMV, negative Hep D ab and PCR, negative HSV,
Varicella, LCMV negative, among others.
.
After receiving the pulse dose of steroids, the patient
underwent a third liver biopsy which showed some decrease in
inflammation, with evidence of possible chronic rejection;
however, no definite diagnosis could be made based on biopsy, as
pathology not completely consistent with rejection. At this
point the patient's LFTs were continuing to trend up, with
Tbilis in the 30s. The option of retranplanting the patient
came up, but before a full pretransplant evaluation began, the
patient declined the option. The next possible option for him
was ATG. However, given the patient's worsening condition,
volume overload, and worsening creat, as well as his desire to
just go home, it was decided to not go ahead and give the
patient ATG. Instead, he was discharged to home with hospice.
.
# s/p renal and liver transplant: The patient was kept on his
home immunosuppressive agents (tacrolimus and MMF), with his
tacrolimus dose adjusted according to AM tacro levels. While in
the MICU for the first time, his tacr level was found to be ~
19, and his tacro was held for a few days and then restarted at
a lower dose. The patient's tacrolimus levels were adjusted to
0.5 mg [**Hospital1 **] and towards the end of his hospitalization, his MMF
was increased to 1000 mg [**Hospital1 **]. It is unclear whether the patient
worsening LFTs were due to rejection, as his biopsy results were
never clearly indicative of rejection. Moreover, his acute
renal failure may also have been related to rejection, but a
biopsy was never done (see below).
# melena: After getting the first ERCP, the patient reported
having some melena. He was scoped on [**2175-10-1**] and found to have
oozing from ampulla, s/p epinephrine injection and coag of site.
The patient continued to have melena after this procedure and
also had a crit drop, which prompted rescoping him on [**2175-10-8**].
On this endoscopy, found portal hypertensive gastropathy and
ulcer with adherent clot in the area of the papilla and was
given 2 injections of epinephrine. Because no definite source
of bleeding was found, the patient underwent colonoscopy, which
was negative for any sources of bleeding, and a capsule
endoscopy.
.
# hypoxia: During this hospitalization, the patient developed
an oxygen requirement. Initially, it was thought to be [**2-1**]
fluid overload, as during his first MICU stay, he was very net
fluid positive. He was also found to be very crackly on lung
exam, and had improved breathing with Lasix. CRXs at this time
also showed evidence of pulmonary edema. Lasix was also used
cautiously, as he was also in acute renal failure and his creat
was trending up during the hospitalization. However, as the
hospitalization progressed and the patient't liver failure
worsened, his respiratory status also worsened. By the time of
discharge, he was on 4-6L NC, and it is likely that
hepato-pulmonary syndrome was also a component to this new O2
requirement. The patient also had a TTE with bubble study done
that showed evidence of a small PFO vs. pulmonary AV fistula.
The patient's oxygen requirement did not improve and he was
discharged to home hospice with home O2 for comfort.
.
# [**Last Name (un) **] in setting of Renal Transplant: Initially, the patient'
creat was 1.6 (baseline around 1.3-1.5), then began to trend up.
Was initally thought to be [**2-1**] prerenal azotemia, and creat
improved with fluids. Of note, the patient also had a
tacrolimus level that peaked ~19, and tacrolimus toxicity was
also on the differential. The option of renal biopsy was also
considered, but since his creat responded to fluids initially,
it was never pursued. The patient's creat began to trend up
again, and given the possibility of cirrhosis based on imaging,
the possibility of HRS was considered. The results of the third
liver biopsy showed that the patient did not have cirrhosis and
the possibilty of rejection of his kidney was raised, as HRS was
less likely at this time. However, given patient's
decompensation at this point and his desire to go home, kidney
biopsy was not pursued. During the hospitalization, medications
were renally dosed and nephrotoxic drugs avoided.
.
# ileus: The patient developed an ileus during the
hospitalization, unclear etiology. His lytes were repleted
aggressively, and the pt was on bowel rest when severe. KUBs
showed dilated loops of bowel without any evidence of free air.
Initially, the ileus resolved, and diet was advanced as
tolerated. However, it recurred again and the patient was kept
NPO again. An NGT was attempted, but the patient could not
tolerate it.
.
# Hepatitis B: The patient was not on any antiviral therapy as
an outpatient. His Hep B viral load was less than 40, and he was
initially started on 100 mg daily, which was then switched to 50
mg daily given his worsening renal function.
.
#. History of SMV Thrombosis: The patient was diagnosed with SMV
thrombosis a few months ago and was on coumadin at home. Early
on in the hospitalization he was on a heparin drip. However,
when he started having melena, all anticoagulation was held.
.
# goals of care: The patient was initially full code on
admission, however towards the end of the hospitalization, we
had a goals of care conversation with the patient and his
family, as his liver enzymes continued to increase in spite of
our treatment efforts. During these conversations, the patient
made it clear he was not willing to undergo another liver
transplant and he decided he wanted to be DNR/DNI. The patient
also declined the option for AGT and decided that he wants to go
home. The patient was set up for home hospice.
.
# L arm swelling: The patient has some L arm swelling early on
during the admission. A ultrasound was done showing a clot in a
superficial vein. Warm compresses were used and Tylenol (less
than 2 grams daily) was used for pain. pain
.
#HTN: The patient's home antihypertensive medications, including
amlodipine, metoprolol, and lisinopril were held.
.
#Hyperlipemia: Given the patient's liver injury, his home
simvastatin was held.
.
#GERD: The patient's omeprazole was also held as it can cause
cholestasis.
.
#Depression: The patient's cymbalta was also held as it can
cause cholestasis.
.
#OSA on CPAP: The patient was kept on CPAP at night.
.
Transitional Issues:
.
# home with hospice: The patient will be discharged to home
with hospice.
Medications on Admission:
oxycodone sr 20mg [**Hospital1 **]
compazine 5mg qam prn
risedronatre 35mg weekly
simvastatin 20mg daily
tacrolimus 2mg [**Hospital1 **]
tmp-smx ss mwf
asa 325mg daily
coumadin 5mg daily
amlodipine 10mg daily
duloxetine 60mg daily
lisinopril 5mg daily
lorazepam .5mg tid
metoprolol tartrate 150mg daily--this is per the patient; last
d/c summary says metop succ 100mg daily
mycophenolate mofetil 500mg [**Hospital1 **]
omeprazole 20mg [**Hospital1 **]
oxycodone 5mg qid prn
Discharge Medications:
1. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
2-20 mg PO q1 hour as needed for pain, SOB, anxiety: please take
sublingually (under tongue).
Disp:*30 mL* Refills:*0*
2. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
4. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itchiness.
Disp:*30 Tablet(s)* Refills:*0*
5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itchness.
Disp:*1 bottle* Refills:*0*
6. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itchiness.
Disp:*30 Capsule(s)* Refills:*0*
7. oxygen, 2-6 L NC as needed for comfort
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
primary diagnosis:
liver failure, possibly acute on chronic rejection
status post liver transplant for Hepatitis B cirrhosis
status post kidney transplant for IgA nephropathy
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Mental Status: Clear and coherent.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 16229**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted because you were having abdominal
pain and your urine was rust colored. We initially treated your
infection with antibiotics, but there was no improvement in your
condition and your condition and liver enzymes continued to
worsen. We also placed a drain into your bile ducts so that we
could decompress them and drain all of the infected fluid, but
that also did not improve your liver enzymes.
.
You underwent three liver biopsies in total, and there is still
no clear explanation for why your liver is failing right now.
The biopsies showed that you some evidence of obstruction, as
well as an immune mediated process that could be rejection. We
started you on steroids, but there was no improvement on the
steroids either.
.
In addition to the worsening liver enzymes you also had a
problem with [**Name2 (NI) **] in your stools. We think that this started
after you had an endoscopy to look at your bile ducts. Because
of this bleeding, you had mutiple endoscopies that were looking
for a bleeding source, including a colonoscopy and a capsule
endoscopy (where you swallowed a camera pill).
.
Your kidney function also suffered while you were here. We
think that it was initially related to not having enough fluid
going to your kidneys. Your kidneys initially responded to
fluids, but then continued to worsen.
.
Your breathing was also affected while you were in the hospital.
We initially thought this was due to getting too much fluid to
help perfuse your kidneys better. You responded to medications
that helped take some of this extra fluid off, but this
medication also affected your kidney function. As your liver
failure progressed, we think that your worsening respiratory
status was due to the liver failure itself.
.
We are discharging you home with hospice care.
.
We made the following changes to your medications:
STOP all of your home medications
START medications for your comfort only, including morphine,
ativan, sarna lotion, benadryl, atarax, oxygen, and oxycodone as
needed
Followup Instructions:
CMO
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2175-10-19**]
ICD9 Codes: 0389, 5845, 2851, 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3062
} | Medical Text: Admission Date: [**2174-6-26**] Discharge Date: [**2174-8-6**]
Date of Birth: [**2094-3-8**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
Transfer from nursing home [**2-9**] hypoglycemia and unresponsiveness
Major Surgical or Invasive Procedure:
[**2174-7-6**]- Angioplasty and stent of left external iliac artery.
[**2174-7-14**]- Right femoral to plantar artery bypass graft
History of Present Illness:
Ms. [**Known lastname **] is an 80 year-old female with a past medical history
remarkable for DM type 2, chronic renal insufficiency (baseline
unknown), hypertension, and chronic anemia, brought to the ED
from [**Hospital3 **] after being found unresponsive and
hypoglycemic.
Per report, the patient was found unresponsive this AM at 0545
at the nursing home. The blood sugar at that time was reportedly
23, and she was given 3 mg of Glucagon. EMS called, upon arrival
blood sugar 53. A peripheral IV was placed, and she was given 1
amp of D50 with rise in blood sugar to 309. The patient then
became awake and alert, and she was brought to the ED for
further evaluation. Per nursing home notes, she had a similar
episode of hypoglycemia the day prior, which was treated with
Glucagon.
In the ED, T 94.8, BP 240/108, HR 92, Sat 98% on room air. Blood
sugar stable. She was given HCTZ 12.5, Lasix 29, and Coreg 6.25.
On examination, she was noted to have bilateral foot ulcers, and
a right foot X-ray showed probable osteomyelitis, and received
Unasyn 1.5 gm IV. She is being admitted for further management.
Upon further questionning, Ms. [**Known lastname **] reports poor appetite over
the past few days. No URI symptoms, no chest pain, no SOB, no GI
or GU complaints. She notes that she has had the right heel
ulcer since [**Month (only) 958**], and does not recall previous therapy. + Pain,
no fever or chills.
Past Medical History:
1. Diabetes mellitus type 2, on Glipizide, with triopathy. Per
report, multiple prior episodes of hypoglycemia.
2. Hypertension
3. Congestive heart failure, EF unknown
4. Chronic renal insufficiency, baseline creatinine 2.3 in
[**4-/2174**]
5. Chronic anemia, with normocytic indices, Hct 36 in [**3-/2174**]
6. Peripheral neuropathy
7. Diabetic retinopathy and bilateral cataracts. She is legally
blind.
Social History:
She was previously in [**State 108**], and recently moved to [**Location (un) 86**] in
[**Month (only) 958**]. She has been at [**Hospital3 **] since [**Month (only) 958**]. She has 4
children in the area. She is a non-smoker, no EtOH, no illicit
drug use.
Family History:
Non-contributory.
Physical Exam:
Deceased
Pertinent Results:
On admission
EKG: NSR, normal axis, normal intervals, LVH by voltage criteria
with NSSTT changes. P pulmonale. No prior for comparison.
CXR [**2174-6-26**]: Increased thickening of septal lines, with
cardiomegaly, suggestive of chronic CHF. Markedly tortuous
aorta. Degenerative changes of the left shoulder, with previous
avascular
necrosis of the proximal humeral head.
[**2174-6-26**] Right foot X-ray: Bony alignment is satisfactory. No
fractures are identified. There is a soft tissue defect seen in
the lateral aspect of the calcaneus. There is a large amount of
associated soft tissue swelling. Additionally, the cortical
border of the calcaneus demonstrates loss of cortical uniformity
in that region, suggesting osteomyelitis in this region.
[**2174-6-27**] PVR/ABI: Pulse volume recording showed amplitudes of
35, 18, 14 and 7 mm in the right low thigh, calf, ankle and
metatarsal. On the left, these amplitudes were 24, 12, 7 and 15
mm.
Noninvasive measurement showed a systolic pressure of 157 mmHg
in the left brachial artery. The segmental limb pressure indices
dropped from 1.30 in the right distal thigh to 0.75 in the right
calf and _____ in the right ankle. On the left side, the index
was 0.73 in the distal thigh, 0.61 in the calf and 0.52 in the
dorsalis pedis artery.
CONCLUSION: Significant peripheral arterial obstructive disease,
starting at the aortobiiliac level, and likely associated with
superimposed bilateral infrapopliteal disease (left worse than
right).
[**2174-6-28**] RENAL U/S: Slightly echogenic kidneys, consistent with
medical disease. 4 mm nonobstructing stone within the left
kidney. Small simple cyst of the right kidney.
[**2174-6-28**] ECHO: Mild symmetric left ventricular hypertrophy with
moderate global hypokinesis. Mild mitral regurgitation. EF 35%.
[**2174-7-8**]
PMIBI
SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
milligram/kilogram/min. Two minutes after the cessation of
infusion, Tc-[**Age over 90 **]m
sestamibi was administered IV.
The image quality is adequate. The left arm is suboptimally
positioned.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal normal tracer uptake
throughout the myocardium.
Gated images reveal mild global hypokinesis.
The calculated left ventricular ejection fraction is 48%.
IMPRESSION: Normal myocardial perfusion. Mild global hypokinesis
with LVEF 48%.
[**2174-8-6**] 12:37 AM
GB DRAINAGE,INTRO PERC TRANHEP; GUIDANCE PERC TRANS BIL DRAINA
Reason: acute cholecystitis in septic pt in icu. please place
perc
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman with PVD, sepsis, ARF
REASON FOR THIS EXAMINATION:
acute cholecystitis in septic pt in icu. please place perc chole
tube
INDICATION: Septic patient with suspected cholecystitis
clinically and by ultrasound.
RADIOLOGISTS: Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **], the attending
radiologist, was present for the entire procedure.
DESCRIPTION OF PROCEDURE: The procedure, its indications, risk,
benefits and alternatives were discussed at length with the
patient's daughter-in-law, [**Name (NI) **] [**Name (NI) 108119**]. Verbal consent was
obtained by telephone. A preprocedure timeout was performed. The
patient was prepped and draped in sterile fashion. 1% lidocaine
was used for local anesthesia.
Initial limited ultrasound of the right upper quadrant
demonstrated a distended gallbladder with wall thickening, as
seen in the formal right upper quadrant ultrasound earlier in
the day.
There was no active patient cooperation with the procedure, and
patient motion made the procedure more difficult. Ultrasound
guidance was used to place an 8- French [**Last Name (un) 2823**] catheter into
the gallbladder, yielding bilious fluid by aspiration. After
attempt at deployment of the catheter, there was irregular
return of fluid suggestive of malposition. A second attempt was
used using a TLA needle and guidewire. After successful
aspiration of fluid, there was difficulty deploying the wire
within the gallbladder lumen. A third attempt was made with a
single stick technique using an 8-French [**Last Name (un) 2823**] catheter. While
fluid was aspirated, this third attempt was also unsuccessful in
deployment of the catheter and the catheter coiled in adjacent
ascites.
Some of the bilious fluid was sent to the lab for analysis. The
technical challenges of this procedure including patient motion
and inability to keep the catheter deployed within the
gallbladder lumen were discussed with the surgical services
caring for the patient. At this time, it was decided to await
results of the fluid analysis and then clinically decide whether
additional intervention is needed. There were no immediate
complications to the procedure, although the patient's blood
pressure remained relatively low throughout the procedure.
IMPRESSION: Technically unsuccessful percutaneous
cholecystostomy placement under ultrasound guidance.
[**2174-8-5**]
LIVER OR GALLBLADDER US
RIGHT UPPER QUADRANT ULTRASOUND: The gallbladder is markedly
distended with wall thickening and edema. The wall gets very
thin at areas raising the possibility of wall necrosis. There is
sludge layering within the gallbladder. There is ascites and
pericholecystic fluid. There is a right- sided pleural effusion.
IMPRESSION: Distended gallbladder with wall thickening and
edema, consistent with cholecystitis.
[**2174-8-3**] 2:44 PM
CAROTID SERIES COMPLETE
REASON: Stroke.
FINDINGS: Duplex evaluation was performed of both carotid
arteries. Minimal plaque was identified.
On the right, peak systolic velocities are 65, 139, 279 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 0.5.
This is consistent with less than 40% stenosis.
On the left, peak systolic velocities are 87, 109, 115 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 0.8.
This is consistent with less than 40% stenosis.
There is antegrade flow in the right vertebral artery. The left
vertebral artery was not visualized.
IMPRESSION: Minimal plaque with bilateral less than 40% carotid
stenosis.
Brief Hospital Course:
80 year-old female with long-standing DM with triopathy,
admitted with hypoglycemia and bilateral diabetic ulcers with
probable right foot osteomyelitis. Her hospital course will be
reviewed by problems. Pt Deceased.
.
1) Bilateral foot ulcers osteomyelitis: Physical examination on
admission was remarkable for bilateral foot ulcers with dry
gangrene, with one ulcer on the left hallux and a larger ulcer
on the right heel, with monophasic pedal pulses and poor
vascular supply. A foot x-ray was obtained which revealed
probable osteomyelitis of the right calcaneus. Vascular surgery
/ Podiatry was consulted. She was started on broad antibiotic
coverage with Unasyn IV and Vancomycin for coverage of
polymicrobial infection +/- MRSA, with the latter dosed for
level <15. A wound swab was sent to evaluate the patient's skin
flora and returned positive for MRSA, prompting continuned use
of Vancomycin. Pt taken to the OR for is schemic infected right
heel wound, status post a femoral to plantar artery bypass
graft. Pt wound was debrided, a vac was placed. This was
followed by non-invasive vascular studies ([**6-27**]), It showed an
ABI 0.58 and 0.52 on the right and left respectively. An MRA was
also done, this showed diffuse disease. Patient was transferred
to the vascular surgical service on [**2174-7-16**]. Pt then
underwent a an angiogram. Pt was given mucomyst and bicarb to
protect the kidneys. This showed severe deseased distally to
the prior graft site. It was thought that the patient could not
benefit from another lower extremity bypass graft. The patient
then underwent a debridement of right foot soft tissue and
calcaneus by podiatry. Pt tolerated the procedure well. There
were no complications. After this procedure pt had a graft
survellance which indicate a widely patent right lower extremity
bypass graft. There was, however, moderate-to-severe disease
within the native distal vessel, as exemplified by a peak
systolic velocity of over 300 cm/sec. Vascular surgery then
considered a BKA at this point, after all efforts were exhausted
to save the leg.
.
2) DM type 2: Per report, Ms. [**Known lastname **] has had multiple episodes of
hypoglycemia, likely secondary to Glipizide and poor PO intake.
Glipizide was discontinued in hospital, and she was placed on a
regular insulin sliding scale. BS were stable throughout her
hospital stay.
.
3) Hypertension / Hypotension: Ms. [**Known lastname **] was hypertensive in the
ED, with SBP up to 200. She also has evidence of LVH on EKG.
Lasix and HCTZ were both held on admission given her acute renal
failure. Blood pressure was modestly controlled using increased
titrations of Coreg, Imdur and hydralazine and fluid bolus for
bout's of hypotension. Pt, required Vasopressors / max levophed
s/p GB DRAINAGE,INTRO PERC TRANHEP, and GUIDANCE PERC TRANS BIL
DRAINAGE for SBP less then 60. Pt deseased following this
procedure.
.
4) Congestive heart failure: Clinically, she appeared euvolemic
to hypovolemic on admission, with normal JVP and clear breath
sounds. A TTE was obtained on [**6-28**], which revealed EF 35%,
symmetric LVH and global LV hypokinesis, felt secondary to mixed
ischemic and hypertensive cardiomyopathy. She was continued on
Coreg, and Lasix was held given her acute renal failure as
noted. She had a p-MIBI prior to transfer to surgery which
estimated LV EF at a much higher 55%.
5) Acute renal failure on chronic renal insufficiency: Per
report, her creatinine was 2.3 in [**2174-4-8**]. Her creatinine on
admission was 4.4. She was given gentle hydration, with minimal
improvement in her renal function. Urine lytes were sent and
revealed FeNa 2% and FeUrea 55%, not suggestive of a pre-renal
etiology. Urine microscopy was without casts. A renal U/S was
also obtained on [**6-28**], which revealed echogenic kidneys
consistent with medical disease and a small non-obstructing
stone in the left kidney. Renal was consulted, and the etiology
of her severe renal disease remains unclear. [**Name2 (NI) 17781**]/UPEP were
negative. Creatinine was monitored and patient was gently
hydrated with isotonic bicarnbonate as well as NS. Her
creatinine steadily climbed [**Name2 (NI) 33970**] out the hospital course to
a high of 4.8. Pt kidney function was a problem [**Name (NI) 33970**] the
hospital course. Strict guidlines were adhered to. Renal was
consulted. There guidelines were used. Pt did end up recieving
HD. for ARF.
.
6) Anemia: Per report, hematocrit was 36 in 03/[**2174**]. Iron
studies were sent in hospital with iron 28, TIBC 163 and
ferritin 893, with iron/TIBC >16% not suggestive of iron
deficiency but rather consistent with anemia of chronic disease.
TSH normal at 1.0. Her hematocrit slowly trended down in
hospital, and she was transfused 1 unit of PRBCs on [**6-28**] for
Hct 24.8, with a good response. Stools guaiac negative on [**6-28**].
Per renal, she was started on Epo [**Numeric Identifier 961**] units 3X/week. Her HCT
was monitered with serial blood tests.
.
7) Leukocytosis: WBC count 28 on admisson, presumed secondary to
osteomyelitis. As noted above, and infectious work-up was
otherwise unremarkable with negative U/A, negative CXR and
blood/urine cultures negative to date. Her wounds were cx as
mentioned above. She was treated with IV antibiotics. These were
tailored toward her sensitivities.
.
8) Nuero: Pt mental status began to wax and [**Last Name (un) **]. Nuerolgy was
consulted. It was thought that the pt had suffered from a
stroke. A CT scan was obtained which showed multiple low density
areas, including left frontal lobe, right occipital lobe, and
left caudate head, these may have represented multiple
infarctions or metastatic lesions with edema. This evaluation
was limited on this non-contrast head CT, and therefore, further
evaluation by brain MRI with diffusion-weighted images and
Gadolinium was obtained. Unfortunantly the MRI was virtually
uninterpretable study due to gross patient motion. She had
several episodes of twitching post MRI,
which may have been seizure activity. Alternatively, this muscle
twitching could have been myoclonus. Given her multiple reasons
to seize: focal lesions on CT (?stroke vs infection vs mass
lesions), metabolic abnormalities, ongoing infection,
medications which lower seizure threshold (i.e. Flagyl), one has
to assume
that these events were likely epileptic in nature were treated
accordingly. Pt recieved a EEG. This was an abnormal EEG due to
the focal slowing in the left anterior quadrant with associated
sharp waves as well as left temporal sharp
waves, a slow background, and bursts of generalized slowing. The
last
two abnormalities indicate a widespread encephalopathic process
affecting both cortical and subcortical structures. Carotid US
were done, these showed <40% bilateral carotid stenosis.
.
9) Increase LFT's: Pt c/o abdominal pain, Pt did have an
increase in [**Name (NI) 53324**], pt undwent a GB DRAINAGE,INTRO PERC TRANHEP,
and GUIDANCE PERC TRANS BIL DRAINAGE - this was a technically
unsuccessful percutaneous cholecystostomy placement under
ultrasound guidance. They did send CX's, these were negative. Pt
did not tolerate this procedure. She required IV vasopressors
and levophed post procedure for SBP 60's. It was thought that
the pt would benefit from open CCCY. The family was contact[**Name (NI) **].
The prefered not to intervene. Pt deceased.
.
Medications on Admission:
Glipizide 2.5 mg PO QD
HCTZ 12.5 mg PO QD
MVI 1 tab PO QD
Coreg 6.25 mg PO BID
Colace 100 mg PO BID
Lasix 20 mg PO BID
Oscal 250/Vit D 2 tabs PO TID
Ferrous sulfate 325 mg PO QD
Ultram 25 mg PO BID
? Bactrim DS 1 tab PO BID X 10 days?
Discharge Medications:
N/A pt deceased
Discharge Disposition:
Extended Care
Discharge Diagnosis:
N/A - pt deceased
Discharge Condition:
N/A - pt deceased
Discharge Instructions:
N/A - pt deceased
Followup Instructions:
N/A - pt deceased
Completed by:[**2174-8-23**]
ICD9 Codes: 5845, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3063
} | Medical Text: Admission Date: [**2138-11-25**] Discharge Date: [**2138-12-3**]
Date of Birth: [**2075-9-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
bronchoscopy
Interventional Radiology embolization
History of Present Illness:
63yo M tob smoker with no significant PMHx (because he never
goes to the doctor) was in his usual state of health until this
PM when he had an episode of hemoptysis. The hemoptysis was
described as approximately a tea spoonful of bright red blood
which was coughed up through mouth and nose. The pt
subsequently had 10 episodes of hemoptysis within 30 min. The
pt was subsequently taken to [**Last Name (un) 4068**] via Ambulance where he
continued to have hemoptysis all day. The pt denies any previous
episodes of hemoptysis or nose bleeds. The pt denies any
trauma. The pt also denies any past jail time or IVDU. The
only significant travel outside the US is to the carribean. The
pt reports he has never been homeless in the past. The pt denies
any cp, palpitations, sob, cough, sputum production, night
sweats, trauma. The pt believes he weights 127lbs and denies
any recent weight loss. The pt reports good appetite and energy
levels. He is unable to give any conclusive thoughts re:
fatigue or exercise tolerance.
Past Medical History:
club foot as child
Social History:
The pt lives with his wife in [**Name (NI) 620**] and does not have any
children. The pt denies any exposure to toxins, heavy metals,
leads, asbestos. The pt was previously a postal worker where he
handled mail. He is currently retired.
1. Tob: 1ppd x 44years
2. EtOH: denies
3. Illicit drug use: denies
Lives with mentally retarted wife, he cares for her, in federal
housing.
Family History:
1. Father: recently deceased from lung CA (+ remote tob)
2. Mother: A+W
3. Brother: muscular dystrophy? currently wheel chair bound.
Physical Exam:
VS: 97.5, 98, 130/80, 14, 97% RA
GEN: Cachectic appearing elderly male in NAD. conversing
fluently in full sentences.
HEENT: PERRL, EOMI, + temporal wasting, op clear, mmm
Neck: supple
Lymph node: no posterior auricular, posterior cervical, anterior
cervical, supraclavicular, or axiallary lymph nodes appreciated
on palpation
Chest: [**Month (only) **]. BS with diffuse rhonchi, pectus excavitum with flat,
erythematous rash over midline chest
CV: RRR, s1, s2, no m/r/g
Abd: soft, NT, ND, BS+, no rebound, guarding
Back: no CVA tenderness
Ext: wwp, no c/c/e
Pertinent Results:
[**2138-11-25**] 09:05PM PT-12.1 PTT-25.1 INR(PT)-1.0
[**2138-11-25**] 09:05PM WBC-7.8 RBC-5.06 HGB-15.2 HCT-44.0 MCV-87
MCH-30.1 MCHC-34.6 RDW-14.1 PLT COUNT-265
[**2138-11-25**] 09:05PM NEUTS-75.3* LYMPHS-19.5 MONOS-2.9 EOS-1.8
BASOS-0.5
.
cxr: No acute cardiopulmonary abnormalities identified.
.
Chest CT at [**Last Name (un) 4068**] [**2138-11-25**]: Emphysema, RML peripheral
opacities, LLL cavitary lesion
.
High-Res CT:
Brief Hospital Course:
63m with history of tobacco abuse admitted for hemoptysis, now
post IR embolization and extubation.
.
#Hemoptysis:
Patient underwent bronchoscopy that showed active bleeding in
the right upper lobe. He was intubated and taken to IR where an
embolectomy stopped the blood flow. A follow-up bronchoscopy
showed old blood without active bleeding and no obvious lesion.
AFB neg on BAL. BAL was also negative for malignant cells and
infection. Chest CT at OSH showed some ground glass but was
poor quality so a high-resolution. High resolution CT was done
to look for bronchiectasis and it showed resolving hemorrhage
and minimal right apical bronchiectasis. Recoommended follow up
CT in 2 months. Pt continued to have small amounts of hemoptysis
throughout his hospital stay but his hct was stable in the low
30s and he remained hemodynamically stable. On discharge, he has
no further hemoptysis
.
#Leukocytosis: Pt was admitted with an elevated WBC likely
reaction to blood in lung. Pt remained afebrile and no
antibiotics were started.
.
#Anemia: Baseline hct of 40 which dropped to 30 following the
hemoptysis. It remained stable around 30 without the need for
transfusion.
Medications on Admission:
none
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis:
1. Hemoptysis
2. Tobacco abuse
Secondary Diagnosis
1. Club Foot
Discharge Condition:
good
Discharge Instructions:
Please go to all follow-up appointments (see below)
Please call your PCP or go to the ED if you experience any of
the following symptoms: coughing up more blood, dizziness, chest
pain or anything else that concerns you.
Followup Instructions:
Please make an appointment to see Orthopedics to be fitted with
orthodics to help you walk. Call ([**Telephone/Fax (1) 2007**] to make an
appointment.
Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Date/Time:[**2138-12-10**] 10:00
THis is pulmonary function test. You need to have that before
you are seen in pulmonary clinic
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2139-2-2**] 11:00.
THis is a follow up CT of your chest. Please do not have any
food 3 hours prior to the test
Pulmonary clinic will be giving you a call within the next 2
weeks. You will be scheduled to see Dr. [**Last Name (STitle) **]. If you do not hear
from them, please call ([**Telephone/Fax (1) 513**]
Completed by:[**2138-12-30**]
ICD9 Codes: 3051, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3064
} | Medical Text: Admission Date: [**2168-7-20**] Discharge Date: [**2168-7-26**]
Date of Birth: [**2137-6-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Diarrhea/Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
31F with history of Crohn's on asacol/imuran and migraines
transferred to [**Hospital1 18**] from [**Hospital3 4107**] with c. difficile
colitis in setting of possible crohn's flare. Presented to
[**Hospital3 4107**] with 3 weeks of progressively worsening
abdominal pain. Patient thought initially to have crohn's flare
and started on IV steroids. Stool samples then came back
positive for c. Diff, steroids discontinued and oral vancomycin.
Due to bloody diarrhea, stool samples sent to state lab -
positive for e. coli (unable to differentiate), shiga toxin.
Cultures at [**Hospital1 **] were negative for salmonella, shigella and E.
coli 0157. Patient recieved Levoquin and flagyl initially for
the e. coli, however, this was discontinued on ID
recomendations. BM's slowly improved on PO vancomycin. 3 days
prior to transfer, developed fevers to 101-102, consistent
leukocytosis. Developed SBP to low 90's, responsive to 3L IVF.
Due to GI concerns for concomittant crohn's flare, was started
on hydrocortisone IV on day of transfer. Transfer requested due
ID and GI disagreement on treating E. Coli at OSH and higher
level of care. Intermittant low back and neck spasms treated
with muscle relaxants.
.
On the floor, patient has some abdominal pain, no nausea or
lightheadedness.
Past Medical History:
Crohn's Disease with last flare requiring hospitalization 2
years ago.
Migraines
Social History:
Social History: Lives in [**Location 18296**], TX. Here for job training.
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
no history of IBD. Father with defibrillator.
Physical Exam:
Admission Exam:
Vitals: T: 101.7 BP:111/68 P: 97 R: 18 O2: 95%RA
General: Alert, oriented, no acute distress, lying in bed
HEENT: Sclera anicteric, dry mucous membranes, 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, tender to palpation in all 4 quadrants,
non-distended, hypoactive bowel sounds, no rebound tenderness or
guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: round indurated lesion overlying left tibia, painful to
palpation, no sign of infection.
.
Discharge Exam:
AVSS
GEN: NAD
Abdomen: Mild periumbilical tenderness without rebound or
guarding.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2168-7-25**] 09:33 5.8 3.42* 10.1* 30.1* 88 29.4 33.5 14.6 845*
[**2168-7-24**] 08:30 7.1 3.41* 9.9* 29.8* 88 29.0 33.1 14.2 798*
[**2168-7-23**] 06:36 6.2 3.33* 9.7* 29.2* 88 29.2 33.3 14.3 718*
[**2168-7-22**] 06:35 7.9 3.69* 10.7* 32.3* 88 29.1 33.2 14.8 591*
[**2168-7-21**] 04:49 9.8 3.55* 10.5* 31.6* 89 29.6 33.3 14.0 641*
[**2168-7-20**] 21:04 14.4* 3.36* 9.7* 29.2* 87 28.9 33.2 14.5
505*
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2168-7-25**] 09:33 881 5* 0.5 140 3.9 104 29 11
[**2168-7-24**] 08:30 871 4* 0.6 140 3.9 105 29 10
[**2168-7-22**] 11:00 139 3.7 103
[**2168-7-22**] 06:35 801 2* 0.6 135 6.2*2 102 27 12
GROSSLY HEMOLYZED SPECIMEN
[**2168-7-21**] 04:49 951 3* 0.6 139 3.8 105 24 14
[**2168-7-20**] 21:04 104*1 2* 0.6 135 3.6 100 26 13
.
ENZYMES & BILIRUBIN ALT AST LDH AlkPhos Amylase TotBili
[**2168-7-24**] 08:30 14 22 64 0.1
[**2168-7-22**] 06:35 131 47 67 0.2
[**2168-7-20**] 21:04 9 14 178 73 48 0.3
.
HEMATOLOGIC calTIBC Hapto Ferritn TRF
[**2168-7-20**] 21:04 160* 462* 164* 123*
.
HIV SEROLOGY HIV Ab
[**2168-7-21**] 12:13 NEGATIVE
.
OTHER ENZYMES & BILIRUBINS Lipase
[**2168-7-20**] 21:04 55
Brief Hospital Course:
31 with Crohn's disease and occassional migraines that presented
as a transfer from [**Hospital3 **] for management of bloody
diarrhea, fever and hypotension and was treated for C. Diff
Colitis and Shiga-toxin producing E.Coli.
.
ACTIVE ISSUES:
# Infectious Colitis (C. Diff and EHEC): Ms. [**Known lastname **] initially
presented to [**Hospital3 4107**] for a chief complaint of bloody
diarrhea. Upon presentation, c diff toxin screens were positive,
but other stool studies including E. Coli 0157:H7 were negative.
State screen for shiga toxin was positive, however. Treatment at
[**Hospital1 **] for enterohemorrhagic E. coli was deferred, and she was
treated with PO vancomycin 500mg four times daily for C diff.
Upon presentation to [**Hospital1 18**], IV flagyl and PO vancomycin were
begun and ID/GI consults agreed. ID/GI consultants also agreed
with treatment with Cipro to cover for E. coli as well as a
possible Crohn's flare. Per GI, a crohn's flare was less likely
due to the location of the inflammation (transverse colon on OSH
CT). Held off on IV steroids as Crohn's flare was seen to be
less likely. Per ID, continue PO vanc x1wk after cessation of
other abx.
- The pt was dischared with 13 days of PO Cipro/Flagyl and 20
days of PO Vancomycin 125mg four times daily. She is due to
follow-up with her GI physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 88832**]. This plan was
discussed with Dr. [**Last Name (STitle) 88832**] over the phone on [**2168-7-25**].
.
# Normocytic Anemia: Ms. [**Known lastname 40412**] Hct on admission was 30 which
is approximately her Hct at the OSH. Iron studies demonstrated a
low TIBC and an elevated ferritin consistent with anemia of
chronic disease.
# Fever: Ms. [**Known lastname **] was febrile on admission to 102F.
Blood/Urine Cx were obtained in addition to repeat stool Cx.
Cultures were no growth to date.
# Pain Control: Ms. [**Known lastname **] was on a PCA at the OSH 1mg Morphine
q10mins. Initially treated here with morphine 1mg IV q4hr,
increased to 2mg IV q4h. The patient was discharged with a
script for oxycodone 5mg as needed for 20 total doses. The pt
was explicitly told not to drive while on this medication, or to
take the medication at night with ativan.
.
# Migraines: The pt was treated with fiorcet with good relief
PRN. She was provided a ten day script for occasional headaches.
.
# Crohns: No signs of active Crohns flare. The pt was maintained
on Mesalamine 1600mg [**Hospital1 **]. Azathioprine 100mg QHS was restarted
on [**2168-7-25**].
.
# Reactive Thrombocytosis: Following the infection the pts plts
continued to climb to 800K. This is likely a reactive
thrombocytosis to her infection. This should be followed up as
an outpatient.
.
# Coagulopathy: The pt presented to [**Hospital1 18**] with an INR of 2.4.
This improved with three doses of vitamin K and thus was likely
nutritional and not DIC. INR was normalized on discharge.
.
INACTIVE ISSUES:
# Hepatic Hemangioma: Incidentally found on outside hospital
imaging. This should be followed up as an outpatient.
.
TRANSITIONAL ISSUES: The pt is due to follow-up with her GI
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 88832**] on [**2168-8-16**] (appointment made). Patient
currently does not have a PCP and was told to establish care
with a PCP in [**Name9 (PRE) 18296**]. The pt also has a pain-specialist she
follows up with.
Medications on Admission:
Forvatriptan Succinate 2.5 mg daily prn
Seasonique 1 tab daily
Mesalamine 400 mg DR 1600 mg PO BID
Azathioprine 100 mg qhs
Zofran 8 mg q6h prn nausea
Hyrocodone-Acetaminophrn 10-324 TID prn pain
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for abdominal pain: Do not drive or operate
heavy machinery while taking this medication.
Disp:*20 Tablet(s)* Refills:*0*
2. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
3. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 20 days.
Disp:*80 Capsule(s)* Refills:*0*
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 13 days.
Disp:*26 Tablet(s)* Refills:*0*
5. metronidazole 250 mg Tablet Sig: One (1) Tablet PO four times
a day for 13 days.
Disp:*52 Tablet(s)* Refills:*0*
6. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day for 10 days.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0*
7. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q8H (every 8 hours) as needed for Migraine for 10
doses.
Disp:*10 Tablet(s)* Refills:*0*
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twenty-four(24)
hours.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
# Infectious colitis; including C.difficile and shiga toxin
producing bacteria
.
Secondary Diagnoses:
# r/o Crohn's flare
# Coagulopathy, likely nutritional
# possible hepatic hemangioma: incidentally found, will need
outpatient follow-up
# Anemia; likely combination of iron deficiency and anemia of
chronic disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted in transfer from [**Hospital3 **] with bloody
diarrhea. You were found to have multiple bacteria in your
stools contributing to your symptoms. You were followed by
Gastroenterology and Infectious Disease, and you were
successfully treated with antibiotics. Please complete the
course of antibiotics as prescribed, even if you feel all
better. We have written you for three new antibiotics in
addition to pain and anti-nausea medications:
1) Ciprofloxacin 500mg twice daily for 13 days
2) Flagyl 500mg four times daily for 13 days
3) Vancomycin 125mg four times daily for 20 days
.
- You have also been given scipts for pain medication that you
CANNOT drive on (Oxycodone 5mg daily).
- You have been given a script for fiorcet for headaches and
zofran for nausea.
- You have also been given a script for low dose ativan to be
taken at night. DO NOT take this medication at the same time as
oxycodone.
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 88832**] - Gastroenterology
[**Location 88833**] # 706
[**Location (un) 18296**], [**Numeric Identifier 88834**]
([**Telephone/Fax (1) 88835**]
Tuesday, [**8-16**], 8am
ICD9 Codes: 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3065
} | Medical Text: Admission Date: [**2189-12-9**] Discharge Date: [**2189-12-13**]
Date of Birth: [**2128-7-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2189-12-9**] CABGx3 (LIMA to LAD, SVG to Diag, SVG to OM)
History of Present Illness:
Mr. [**Known lastname **] is a 61 year old gentleman who has a history of
coronary artery disease s/p an RCA stent. He recently developed
exertional chest pain and subsequently had an abnormal stress
test. A cardiac catheterization revealed coronary artery dsease
and he therefore was referred from cardiac surgery.
Past Medical History:
Mr. [**Known lastname 75473**] past medical history is significant for a silent
MI in [**2180**] s/p an RCA stent, GERD, hypertension,
hypercholesterolemia, and hemorrhoids. His surgical history
includes a hernia repair, unspecified backsurgery, tonsillectomy
and adenoidectomy, and surgery on his left foot secondary to
infection.
Social History:
Mr. [**Known lastname **] works with the [**Hospital1 1474**] sewer department. He quit
smoking 8 years ago, he smoked 40 pack years.
Family History:
Mr. [**Known lastname **] has a brother who was diagnosed in his 50s with
coronary artery disease.
Physical Exam:
On physical exam at discharge Mr. [**Known lastname **] was awake, alert, and
oriented. Auscultation of his lungs reveal scattered rales. His
heart was of regular rate and rhythm. His sternum was stable
and his sternal incision was clean,dry, and intact. His abdomen
was soft and non-tender. His extremities were warm with trace
lower extremity edema. The left leg vein harvest site was
clean, dry, and intact.
Pertinent Results:
[**2189-12-11**] 12:43AM BLOOD WBC-12.4* RBC-3.05* Hgb-10.1* Hct-28.5*
MCV-93 MCH-33.1* MCHC-35.5* RDW-13.5 Plt Ct-211
[**2189-12-11**] 12:43AM BLOOD Glucose-118* UreaN-20 Creat-1.0 Na-135
K-4.0 Cl-101 HCO3-29 AnGap-9
Brief Hospital Course:
On [**2189-12-9**] [**Known firstname **] [**Known lastname **] underwent a coronary artery bypass
graft time 3 (LIMA to LAD, SVG to DIAG, SVG to OM). The
procedure was performed by Dr. [**First Name (STitle) **] [**Name (STitle) **]. He tolerated this
procedure well and was able to be transferred in critical bt
[**Last Name (un) 2677**] condition to the surgical intensive care unit. He was
extubated by on post-operative day one, his pressors were
weaned, and his chest tubes removed. By post operative day two
he was transferred to the step down floor. He was seen in
consultation by the physical therapy service. By post operative
day three his wires were removed and he was weaned from his
oxygen. pt stable for DC om POD # 5.
Medications on Admission:
aspirin 162mg
felodipine 2.5mg
lipitor 20mg
omeprazole 20mg
plavix 75mg
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. 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*
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: [**12-23**]
Tablets PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day
for 10 days.
Disp:*10 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease
GERD
Hemorrhoids
Silent MI [**2180**] s/p RCA stent
Hypertension
Hypercholesterol
Discharge Condition:
good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-23**] weeks.
Please see Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**3-27**] weeks.
Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] in [**12-23**] weeks.
Completed by:[**2189-12-13**]
ICD9 Codes: 4111, 412, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3066
} | Medical Text: Admission Date: [**2185-9-7**] Discharge Date: [**2185-9-23**]
Date of Birth: [**2100-1-5**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin / Morphine / Zosyn
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Pulmonary edema, intubation
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
85 y/o with hx of CVA in the past and baseline left sided
weakness who initially presented to [**Hospital1 **]-[**Location (un) 620**] with abdominal
pain. CT scan at BIN revealed uncomplicated diverticulitis, and
was started on zosyn. She received 600cc of fluid in setting of
IV contrast (pt w/ Cr of 2.2 at BIN) and developed respiratory
distress with BP of 209/90 per report. This was thought to be
flash pulmonary edema, and was treated with 60mg IV lasix and
nitro paste. Also received ASA. Pt was sedated with propofol
as well as receiving several doses of ativan and was intubated.
No ABG obtained at that time. Pt then apparently developed
hypotension, possibly in setting of lasix, nitro and propofol,
and was started on levophed at 0.03. R IJ and 2 18's were
placed, and transferred to [**Hospital1 18**].
On arrival to [**Hospital1 18**] propofol ggt was stopped and started on
fent/versed. On admission, vitals were BP: 99/69, HR: 74, RR
23. Lactate 2.7. Vent settings were AC: TV-500, 5 PEEP, 100%
FiO2. ABG was 7.32/45/171 on these settings.
Pt also had EKG at BIN which showed Lateral ST depressions, and
upright T waves. Repeat at [**Hospital1 18**] showed TWI in AVL, V5-V6.
Troponin noted at 1.51 on admission.
Vitals on transfer to ICU: T:99.0, HR: 81, BP: 144/72, RR: 16,
100% on vent. On 0.02 of levophed.
Past Medical History:
-Right caudate CVA presumptively embolic
-GERD
-Hypertension
-Gait ataxia
-Low back pain with history of laminectomy
-History of pneumonia
-Trigeminal neuralgia
Social History:
Patient has daughter ([**Name (NI) **]) who is NICU RN involved in care and
son who is a Rabbi [**First Name8 (NamePattern2) **] [**Name (NI) **]. Patient is divorced. Recently
moved from [**Location (un) **] to [**Hospital3 4103**] nursing facility. She does not
smoke or drink alcohol. No history of illicit drug use. Prior to
hospitalization, she was ambulating well with a walker.
Family History:
Notable for congestive heart failure. Mother died at 74. Father
died at 72 from pulmonary embolism. Sister at 82 with myasthenia
[**Last Name (un) 2902**]. Brother 84 with heart disease. There is a family
history of diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T:99.0, HR: 81, BP: 144/72, RR: 16, 100%
General: Intubated, sedated, non responsive to verbal or tactile
stimulation
HEENT: Sclera anicteric, PERRLA, neck supple, no JVD
Lungs: Bilateral coarse breath sounds
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly distended. No tenderness illicited, bowel
sounds present
GU: foley
Ext: Bilaterally inverted feet, cool feet, 2+ pulses, trace
edema
DISCHARGE PHYSICAL EXAM:
Tm 97.8 120-140/52-70 60-76 20 95-97% on RA
.
EXAM:
General: Chronically ill appearing. Awake, oriented x 3; NAD,
conversant this AM
HEENT: Sclera anicteric, oropharynx with dry mucous membranes,
no thrush, PERRL, EOMI
Neck: supple, no LAD, JVP is difficult to assess
Lungs: Improved. Scattered crackles at bases bilaterally; no
wheezing
CV: Regular rate and rhythm, normal S1 + soft S2, +[**1-22**] murmur
heard best at LUSB, radiates to carotids - pulsus tardus
present, no rubs or gallops
Abdomen: soft, mildly tender in RUQ, non-distended, normoactive
bowel sounds present, no rebound tenderness or guarding, no
organomegaly; bruises from subQ heparin
Ext: Muscle wasting in all limbs; Warm, well perfused, 1+
pulses, no clubbing, cyanosis or pitting edema
Neuro: PERRL, EOMI, L arm and leg significantly weaker than on R
but able to perform hand grip and lift leg off bed; babinski's
downgoing, sensation intact, reflexes brisk on L
Access: PIVs
Pertinent Results:
Labs/Studies:
[**2185-9-23**] 05:42AM BLOOD WBC-14.5* RBC-3.39* Hgb-10.9* Hct-33.6*
MCV-99* MCH-32.1* MCHC-32.4 RDW-16.5* Plt Ct-538*
[**2185-9-23**] 05:42AM BLOOD PT-33.2* PTT-31.0 INR(PT)-3.4*
[**2185-9-22**] 06:03AM BLOOD PT-34.1* PTT-29.0 INR(PT)-3.5*
[**2185-9-23**] 05:42AM BLOOD Glucose-116* UreaN-47* Creat-1.8* Na-135
K-3.9 Cl-99 HCO3-26 AnGap-14
[**2185-9-8**] 11:00AM BLOOD CK-MB-9 cTropnT-1.16* proBNP-[**Numeric Identifier **]*
[**2185-9-19**] 03:23AM BLOOD CK-MB-4 cTropnT-0.34*
[**2185-9-23**] 05:42AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
[**2185-9-8**] 02:35AM BLOOD calTIBC-166* VitB12-528 Folate-13.6
Hapto-139 Ferritn-577* TRF-128*
[**2185-9-12**] 06:39AM BLOOD Triglyc-215*
[**2185-9-16**] 05:02PM BLOOD TSH-4.2
.
[**9-21**] C.diff negative
[**9-19**] blood cultures x 2: NGTD
.
[**9-22**] CXR:
Pulmonary edema has resolved. There are low lung volumes with
bibasilar
atelectasis. There is no pneumothorax or pulmonary effusions.
Cardiomegaly
is stable. There are no new lung abnormalities.
.
[**9-21**] TTE:
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 moderately thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
Mild (1+) 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 a
very small pericardial effusion.
peak velocity: 3.3 m/s; peak gradient 44; valve area 1.1 cm2
.
[**9-19**] EKG:
Possible ectopic atrial rhythm. Left axis deviation may be due
to left anterior
fascicular block, although is non-diagnostic. Anterolateral lead
ST-T wave
changes are non-specific. Since the previous tracing of [**2185-9-17**]
ectopic atrial
rhythm and further ST-T wave changes are both now present.
.
[**9-21**] Swallow:
IMPRESSION: Penetration and aspiration with thin barium.
.
[**9-23**] Swallow: Much improved but still some degree of aspiration
of thin liquids.
Brief Hospital Course:
85F yo F p/w diverticulitis c/b shock and respiratory failure
after receiving IVF. She was intubated for presumed pulmonary
edema c/b post-intubation/lasix hypotension and elevated cardiac
biomarkers in the setting of critical AS.
.
# Shock: Likely both cardiogenic and septic - secondary to IVF
followed by lasix, nitro paste in the setting of critical AS and
patient being volume depleted from diverticulitis and having a
UTI. Pt was weaned off pressors. Pt was then started on lasix
ggt with good output and stable BPs. Patient likely pre-load
dependent given critical AS. She completed a 7-day course of
cefepime, flagyl, and vancomycin - which provided coverage for
UTI, pneumonia, and diverticulitis.
.
# Critical AS, improved to Moderate AS: Valve area 1.1 cm2 on
TTE [**9-21**], consistent with moderate AS once she was no longer
septic. Likely cause of pulmonary edema and subsequent
hypotension in setting of fluid shifts. Pt had hypertensive
episode and had acute pulmonary edema secondary to aortic
stenosis. Cardiology was consulted and patient was not
considered for replacement valve or valvuloplasty at that time
because of her critical condition at the time. She was
scheduled for follow-up with cardiology - Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **].
.
#Respiratory failure: Flash pulmonary edema with xray showing
bilateral pleural effusions and edema. Likely secondary to
critical AS. The patient was diuresed with lasix ggt to optimize
volume status before extubation. Goal diuresis of negative [**11-20**]
liters was met on multiple days and pt respiratory status
improved. Her RSBI score gradually decreased and she was able
to tolerate PSV settings while being weaned off of sedation. Pt
was eventually extubated, but shortly after extubation, she
began to have stridor. We administered racemic epi, and heliox,
but ultimately pt was reintubated. She was given 48 hours and
then another trial of extubation occured, this time with
steroids given 12 hours prior to extubation and then Q4hrsx3
after extubation. Pt was successfully extubated. She
subsequently had episodes of subjective respiratory distress,
but all the while was satting in the high 90's and without
stridor. These symptoms were best controlled with seroquel to
calm her down. Pt continued to diurese and she was eventually
transitioned to PO lasix. He respiratory status stabilized and
was ready to be called out of the [**Hospital Unit Name 153**]. On the floor, the
patient was diuresed with 40 mg PO Lasix per day with good
response. Her pulmonary edema improved - by clinical exam and
Xray and the patient was thought to be nearly euvolemic on the
day of discharge. The patient was not discharged on diuretics
because of her dependent on preload given moderate-severe aortic
stenosis.
.
#Hypertension: The patient was very hypertensive in the ICU and
upon transfer to the floor. Her BP regimen was changed to
captopril 12.5 mg tid and her pressures normalized. She was also
on metoprolol 75 mg tid for atrial fibrillation with rapid
ventricular response.
.
#Anemia: Required 4 units PRBCs throughout admission with last
being on [**9-8**]. with goal to keep Hct >30. Likely related to
elevated coags. Anemia work up showed iron 9, tibc 166, ferritin
577, TRF 128. B12/folate/hapto are wnl. These indicate likely
iron deficiency anemia with component of anemia of chronic dz.
Her Hct was stable ~34 on the days leading up to discharge.
.
#Diverticulitis: Pt presenting to OSH with abdominal pain found
to have diverticulitis of the left colon. Likely explained her
leukocytosis as high as 28 (trended down to 14.5), as well as
her hypotension. Abdomen was soft on the day of discharge. She
was tolerating prethickened liquids and soft foods on the 2 days
leading up to discharge.
.
#Renal failure: Per family, baseline is 1.3-1.6, and on
admission to [**Hospital1 18**] is 2.1 but has trended up to 2.7 - thought to
be [**12-21**] to contrast nephropathy. Creatinine was at her baseline -
1.8 on the day of discharge.
.
#Elevated troponin: Though to be demand ischemia given sepsis,
blood loss, and fluid shifts in the setting of critical AS.
Trops peaked at 1.37 on [**9-8**] but now trended downward. She was
discharged on aspirin 81 mg qday and metoprolol.
.
#History of Afib: Per discussion with family, patient does not
really have history of afib. Coumadin was started for hx of CVA.
The patient had episodes of Afib w/RVR that required an esmolol
or dilt drip. After transfer to the floor, the patient remained
in sinus rhythm with infrequent, spontaneously remitting
episodes of tachycardia - possibly Afib w/ RVR - though appeared
regular and could have represented AVNRT. She was discharged on
metoprolol 75 mg tid and coumadin. She became supratherapeutic
on coumadin and her dose was held on [**9-22**] and [**9-23**] - on the day
of discharge, INR was 3.4. She is to restart coumadin on Sunday,
[**9-25**] at 1 mg qday. She should have her INR checked on Tuesday,
[**9-27**].
.
#Trigeminal Neuralgia: Not taking tegretol at home per records
we have available.
.
#Nutrition: The patient was eating soft solids on the day of
discharge. She had 2 swallow studies which showed aspiration of
thin liquids and she was received nectar pre-thickened liquids.
Her second swallow showed much improvement and she will need
repeat eval at rehab.
.
#The patient received subQ heparin before she was therapeutic on
coumadin. On the day of discharge, INR was 3.4. The patient
remained full code after her transfer from the ICU. Long family
discussions were held and they are still in the process of
finalizing their thoughts. At this time, the patient is FULL
CODE.
.
Communication was primarily with the patient's daughter [**Name (NI) **]
[**Name (NI) 6311**] at [**Telephone/Fax (1) 103000**] ([**Telephone/Fax (1) 103001**]).
Medications on Admission:
(Per [**Hospital **] [**Hospital 620**] clinic note on [**8-15**], doses unknown)
Atenolol 75 mg daily
Pantoprazole 40 mg daily
Benicar 40 mg daily
Multivitamin daily
Acetaminophen 1g QID
Warfarin 2mg QMTWRF, 1mg Q sat and sun
Senna 2 tabs daily
Vitamin D 400 units
Tegretol 100mg PO BID -- unable to find this med listed
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. trazodone 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3
times a day) as needed for pain, fever.
6. metoprolol tartrate 50 mg Tablet [**Month/Year (2) **]: 1.5 Tablets PO TID (3
times a day).
7. captopril 12.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times
a day).
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2
times a day) as needed for constipation.
10. benzonatate 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID (3
times a day) as needed for cough.
11. multivitamin Oral
12. Coumadin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
Please hold dose on [**2185-9-24**]. Restart on Sunday, [**2185-9-25**] with INR
check on Tuesday, [**2185-9-27**].
13. Vitamin D-3 400 unit Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet,
Chewable PO once a day.
14. Outpatient Lab Work
Please check INR on Tuesday [**9-27**].
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary:
Aortic Stenosis - moderate
Hypoxic Respiratory failure - s/p intubation
Hospital-acquired pneumonia
Diverticulitis
Atrial fibrillation with rapid ventricular response
Acute pulmonary edema
Non-ST elevation myocardial infarction
.
Secondary:
Hypertension
Cerebrovascular accident
Chronic kidney disease stage III
Discharge Condition:
Mental Status: Clear and coherent - hard of hearing, confused
sometimes about details of history but oriented
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 6311**],
It was a pleasure caring for you at [**Hospital1 827**]. You were initially admitted for diverticulitis,
however, you became hypertensive and, with IV fluids, had fluid
accumulate in your lungs. You were intubated for this condition
and you were on a ventilator for several days. Your hospital
course was complicated by pneumonia and atrial fibrillation with
rapid ventricular response (an abnormal, fast heart rhythm). You
improved with antibiotics and we worked to get the fluid out of
your lungs with a medication called furosemide (Lasix). You will
need close follow-up for a condition we discovered, which is
known as aortic stenosis. This is a narrowed heart valve. We
have made a follow-up appointment with an excellent [**Hospital1 18**]
Cardiologist, Dr. [**Last Name (STitle) **]. This appointment information is listed
below. We also performed 2 swallow studies, which showed that
you did have a problem swallowing thin liquids - the second
study showed improvement, however. You will be followed up for
this condition at the Rehab facility.
.
We made the following changes to your medications:
We stopped Atenolol and STARTED Metoprolol 75 mg three times per
day for heart rate
We stopped Benicar and STARTED Captopril 12.5 mg three times per
day for blood pressure
We STARTED Aspirin 81 mg once per day
We CHANGED pantoprazole to lansoprazole once per day for
heartburn
We STOPPED Tegretol (carbamazepine) because it was not clear you
were taking this for trigeminal neuralgia.
We CHANGED your Coumadin dosing; you will restart coumadin on
Sunday, [**9-25**] at 1 mg per day - you will need your INR checked on
Tuesday [**9-27**] and may need your coumadin adjusted to 2 mg if your
INR is too low
.
Your follow-up information is listed below.
Followup Instructions:
Department: [**Last Name (un) 12214**] [**Doctor Last Name **] MED GRP
When: THURSDAY [**2185-10-20**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD [**Telephone/Fax (1) 5068**]
Building: [**Location (un) **] ([**Location (un) 86**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 486, 5845, 5990, 2760, 4241, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3067
} | Medical Text: Admission Date: [**2187-9-3**] Discharge Date: [**2187-9-6**]
Date of Birth: [**2131-10-29**] Sex: M
Service: MEDICINE
Allergies:
Beta-Adrenergic Blocking Agents / Shellfish
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
CC:[**CC Contact Info 5995**]
Major Surgical or Invasive Procedure:
Upper endoscopy
Colonoscopy
History of Present Illness:
HPI: This is a 55 yo Male with a hx afib, HTN who had BRBPR
tonight then syncopized in the bathroom. Denies LOC or trauma to
his head. The patient denies CP/Abd Pain/dyspnea or other
symptoms. Weak x2days and 1 episode of loose stool yesterday.
Does report abdominal cramping. No history of prior GIB. Never
had colonscopy in past. No NSAID use; does take aspirin daily.
Denies nausea or vomiting.
In the ED, vitals were 98.9, HR 115, 105/48, 14, 100%4LNC.He had
2 large bore [**CC Contact Info **]'s placed, he was t&s, underwent NG lavage. He
had been given 1 L NS. His BP subsequently began to drift down
and pt had large 750cc bright red clot from below; pt
subsequently became bradycardic to 10 and vomited x1 (not blood
per report), appeared less responsive x30 seconds but then came
to. Pt was subsequently emergently given 2U prbcs, 10mg IV
Vitamin K. In addition, a head CT was also performed which was
negative for acute bleed (given his syncopal episode and
coumadin use).
He reports minimal abdominal tenderness, denies chest pain,
palpitations, lightheadedness, headache. ROS otherwise as listed
below. He was recieving 1 U prbcs on arrival (3rd unit).
Past Medical History:
Past Medical History:
Asymptomatic Atrial Fibrillation s/p failed cardioversion [**1-6**];
now rate controlled and on coumadin.
hypertension
obstructive sleep apnea -on cpap at night
Childhood asthma
Achilles tendon surgery
h/o thyroid disease in the mid 70s treated with radioactive
iodine
Social History:
Social History: Patient is married with one child. He is
employed
as a dentist. Denies current ETOH, tobacco or drug use.
Family History:
Family Medical History: mother who died at age 84 secondary to
trauma, and father who had an MI at age 65 and then died of
complications of a large MI in his late 70s. He has two younger
brothers and a sister, all of whom are healthy to his knowledge.
Physical Exam:
Physical Exam:
Vitals: T: 97 BP:121/65 HR: 100 RR:21 O2Sat: 100%RA
GEN: Middle aged male, no acute distress,
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear
NECK: No JVD, no cervical lymphadenopathy
COR: irregularly irregular, no M/G/R, normal S1 S2
PULM: Lungs clear anteriorly, no W/R/R
ABD: Soft, NT, ND, +BS, no rebound/guarding
EXT: No C/C/E
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.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
========
GI
========
Colonoscopy Impression: Diverticulosis of the descending colon
and splenic flexure One of the diverticulum had evidence of clot
present. This one was located near the splenic flexure.
Otherwise normal colonoscopy to cecum
EGD Impression: Erythema at the GE junction, question of
Barrett's esophagus. Erosions in the antrum and stomach body No
source of GI bleed found Otherwise normal EGD to second part of
the duodenum
========
RADIOLOGY
========
Bleeding Scan INTERPRETATION: Following intravenous injection of
autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow
images and dynamic images of the abdomen for 90 minutes were
obtained. A left lateral view of the pelvis was also obtained.
Blood flow images show physiologic distribution of blood flow.
Dynamic blood pool images show no evidence of gastrointenstinal
system bleed.
IMPRESSION:
No evidence of GI bleed.
.
NON-CONTRAST HEAD CT: There is no evidence of infarction,
hemorrhage, edema, shift of normally midline structures or
hydrocephalus. The density values of the brain parenchyma are
within normal limits. The [**Doctor Last Name 352**]-white matter differentiation is
preserved. The soft tissues and surrounding osseous structures
are not remarkable.
IMPRESSION: Normal study.
========
ECG
========
Atrial fibrillation with mean rate of 96. Compared to the
previous tracing
ST segment changes are less pronounced.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
96 0 84 368/431 0 52 54
=========
LABS
=========
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2187-9-5**] 06:20AM 6.0 3.73* 11.2* 32.3* 86 29.9 34.6 14.6
126*
[**2187-9-4**] 09:25PM 31.0* 125*
[**2187-9-4**] 10:49AM 32.3*
[**2187-9-4**] 04:30AM 5.7 3.50* 10.8* 30.3* 87 30.8 35.6* 15.1
100*
[**2187-9-4**] 12:32AM 31.2* 101*
[**2187-9-3**] 08:54PM 31.8*
[**2187-9-3**] 03:53PM 29.5*
[**2187-9-3**] 12:34PM 33.0* 109*
[**2187-9-3**] 06:09AM 27.5*
Source: Line-[**Year (4 digits) **]
[**2187-9-3**] 04:11AM 10.3 3.39* 10.3* 29.3* 87 30.3 35.1* 14.4
121*
[**2187-9-3**] 12:57AM 10.5 3.72*# 11.4*# 33.5*# 90 30.5 34.0
14.2 172
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2187-9-3**] 04:11AM 91.3* 0 6.5* 1.9* 0.2 0.1
[**2187-9-3**] 12:57AM 72.0* 22.4 3.0 2.1 0.4
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2187-9-3**] 04:11AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2187-9-5**] 06:20AM 126*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2187-9-5**] 06:20AM 99 9 1.2 140 3.6 107 28 9
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2187-9-3**] 12:57AM Using this1
Using this patient's age, gender, and serum creatinine value of
1.6,
Estimated GFR = 45 if non African-American (mL/min/1.73 m2)
Estimated GFR = 55 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 50-59 is 93 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2187-9-4**] 04:30AM 19 42* 164 48 73 2.1*
[**2187-9-3**] 12:57AM 85
OTHER ENZYMES & BILIRUBINS Lipase
[**2187-9-4**] 04:30AM 19
CPK ISOENZYMES CK-MB cTropnT
[**2187-9-3**] 12:57AM <0.011
[**2187-9-3**] 12:57AM NotDone2
<0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2187-9-5**] 06:20AM 8.3* 2.8 2.0
[**2187-9-4**] 04:30AM 3.5 8.0* 2.6* 1.9
[**2187-9-3**] 08:54PM 2.2* 2.0
[**2187-9-3**] 04:11AM 3.1* 7.2* 2.2* 1.8
ADD ON
PITUITARY TSH
[**2187-9-5**] 06:20AM PND
Brief Hospital Course:
1) GIB: Pt was admitted for BRPR. He has had a significant drop
in his hct from a baseline of 48 to 27.3 The pt had one more
bright red stool in the ED. NG lavage was negative. Pt receieved
7 U PRBC, 6 U FFP and Vitamin K. He was placed on an IV PPI.
Coumadin and Aspirin were held in the stting of a GIB.
Colonoscopy was significant for extensive diverticulosis with
the presence of clot. EGD was negative for bleeding, but
suspicious for Barrett's esophagus. The patient's Hct remained
stable in the low 30s and he was transferred to the medicine
floor. He had a normal stool before d/c and did not have any
further BRBPR.
.
2) Afib: Pt rate controlled at home on verapamil. This was
stopped in the setting of GIB. Pt required some prn Lopressor
in the MICU for rate control. Once pt was hemodynamically stable
his Verapamil was restarted. The pt triggered soon after he was
sent to the Medicine floor for HR >140. ECG demonstrated A fib.
Pt required Lopressor IV 5 mg x 1. His verapamil was titrated up
to his home dose and he remained rate controlled, but he did not
remain rate controlled. His dose was increased to 180 mg [**Hospital1 **] and
he was rate controlled thereafter. In the setting of a GIB, the
patient's coumadin and aspirin were stopped. He was given an
appointment with his cardiologist to decide whether these
medications should be restarted as an outpatient.
.
3) Syncope: likely from hypovolemia from blood loss. Recent
cardiac stress testing was good, showing no structural heart
disease. One set of cardiac enzymes were negative and EKG is
unchanged from priors. CT head negative.
.
4) Acute on chronic renal failure: last year, patient's
creatinine started to trend upwards to 1.3, today it is 1.6.
Likely prerenal azotemia in the setting of chronic renal
failure. With appropriate volume resusication, Cr trended down
to 1.2 on day of d/c.
.
# HTN: Initially home anti-HTN were held in the setting of
hemodynamic instablity. These were restarted in the MICU, and pt
had stable VS in the MICU and on the medicine floor.
.
# OSA: Pt on home CPAP. Pt was kept on CPAP during this
hospitlization.
.
# FEN: Diet was advanced as tolerated and tolerated fulls before
d/c
.
# Access- 2 Large bore PIVs; will get 3rd [**Last Name (LF) **], [**First Name3 (LF) **] need to
consider CVL
.
# PPx:pneumoboots given GI bleed, IV ppi
Medications on Admission:
verapamil 120 mg b.i.d.
warfarin per INR.
aspirin 325mg daily
MVI
Discharge Medications:
1. Verapamil 180 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Blood Loss Anemia secondary to gastrointestinal bleed
requiring blood transfusion and fresh frozen plasma
Anemia
Atrial Fibrillation
Acute Renal Failure
Hypertension
Obstructive Sleep Apnea
Discharge Condition:
stable, normal vital signs
Discharge Instructions:
You presented to the hospital with GI bleeding. In the ED you
syncopized and were found to have a heart rate of 10. You
received 10 units of red blood cells and 6 units of fresh frozen
plasma. Your blood counts were below your baseline but stable
thoughout your hospitilization. An upper endoscopy revealed
Barrett's esophagus, but no upper sources of bleeding. A
colonoscopy revealed extensive diverticulosis that were likely
the source of your bleed. There were no active lesions, but some
clot was observed. Your experienced some fast heart rates which
were likely secondary to stopping your at home Verapamil You
were transferred to the medical floor and your at home dose of
Verapamil was restarted. Your heart rate was well controlled at
this dose.
In the setting of a GI bleed, your coumadin and aspirin were
stopped. Please continue to hold these medications until you
follow up with your outpatient physicians.
Please seek immediate medical attention if you experience any
bleeding, diarrhea, abdominal pain, chest pain, shortness of
breath, palpitations, dizziness, syncope or any change in your
condition
Followup Instructions:
Please f/u with your Cardiologist Dr. [**Last Name (STitle) **] on [**9-14**] pm at
2:20 pm. Please f/u with Dr. [**Last Name (STitle) 4539**] (gastroenterology) on [**9-18**] at
2:30 pm. Please f/u with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**2187-10-3**] at 3:40
pm. If you need to see your PCP sooner, please call for an
urgent care appointment.
Completed by:[**2187-9-7**]
ICD9 Codes: 5849, 2851, 5859, 2875, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3068
} | Medical Text: Admission Date: [**2139-12-1**] Discharge Date: [**2139-12-8**]
Date of Birth: [**2098-10-13**] Sex: F
Service:
CHIEF COMPLAINT: Bacteremia.
HISTORY OF THE PRESENT ILLNESS: This is a 41-year-old
Caucasian female with a history of short gut syndrome
secondary to total colectomy who was admitted for [**State 43537**] [**Hospital1 107**] on [**2139-12-1**] for workup of
Staphylococcus epidermidis bacteremia. She was originally
admitted to [**State 1558**] [**Hospital1 107**] on [**2139-11-22**]
with complaints of one day of nausea and vomiting and
abdominal pain with laboratories notable for severe
dehydration including hyponatremia, acute renal failure, and
metabolic acidosis.
Ms. [**Known lastname 1557**] was also noted to have leukocytosis and fever.
Per the patient's story, she has self-discontinued TPN one
day prior to admission and was using D5W with potassium as
substitution. At the outside hospital, she was given 2
liters of normal saline with 1 amp of bicarbonate. TPN was
restarted and she was continued on her vancomycin,
approximately 750 mg p.o. q. 24 hours. Of note, she
describes having been on a stable dose of 1 gram q. 24 hours
but was then told by her primary care physician to decrease
her dose to 750 mg q. 24 hours. Shortly after, she began to
have fevers, chills, and whole body aches.
At the outside hospital, she was also noted to have a
question of a UTI and was started on Levaquin which was
continued for three days. She continued to spike fevers
throughout her hospital stay with positive blood cultures
containing gram-positive cocci which was later identified as
Staphylococcus epidermidis sensitive only to vancomycin. She
was seen by ID there on [**2139-11-30**] and at that time Rifampin
was added at 300 mg IV b.i.d.
Finally, Surgery was consulted and recommended the change of
her tunneled cath in the right IJ position but it was decided
that it would be the safest at the [**Hospital6 649**] where the catheter was placed to begin with.
She now presents at this time for further evaluation. She
feels unchanged from her presentation except that her nausea
is now improved.
Of note, her ABG on admission showed a pH of 7.25, PC02 28,
P02 100. Her bicarbonate then was 11.6.
REVIEW OF SYSTEMS: Positive for myalgias and arthralgias and
previously decreased urine output.
PAST MEDICAL HISTORY:
1. Hyponatremia.
2. Metabolic acidosis.
3. Staphylococcus epidermidis line infection diagnosed in
[**2139-9-25**] at the outside hospital and being treated
with vancomycin.
4. History of [**Location (un) 976**] syndrome, status post colectomy in
[**2124**] with resultant short gut syndrome.
5. Chronic TPN.
6. History of SVC syndrome and multiple DVTs, status post
multiple stents, approximately [**11-5**] in total, by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
FAMILY HISTORY: Significant for [**Location (un) **] syndrome.
Approximately six out of eight siblings have this disease.
Her father also died of the disease and per report many
uncles have the disease as well.
ALLERGIES: Demerol causing seizures, Compazine and Reglan
causing a rash, IVP dye causing a rash and nausea, tape, and
Betadine which caused blisters.
ADMISSION MEDICATIONS:
1. Duragesic patch 100 micrograms change q. 72 hours
topical.
2. Tylenol p.r.n.
3. Paxil 20 mg p.o. q.d.
4. Protonix 40 mg p.o. q.d.
5. Dilaudid 5 mg p.o./IM q. 4-6 hours.
6. Zofran 8 mg p.o./IV q. six hours p.r.n.
SOCIAL HISTORY: She denied tobacco or alcohol use. She
denied IV drug use. She lives at home with her mother.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.9, pulse 86, blood pressure 98/50, respiratory rate 16,
saturating 93% on room air. General: This is a
well-nourished Caucasian female lying in bed in no acute
distress. HEENT: The pupils were equal, round, and reactive
to light. The extraocular movements were intact. Anicteric
sclerae. The mucous membranes were moist. No
lymphadenopathy. Cardiovascular: Regular rate and rhythm,
no rubs, murmurs, or gallops. Lungs: Decreased breath
sounds bilaterally, approximately one-half up with
accompanied with decrease to percussion. Abdomen:
Normoactive bowel sounds, nontender, nondistended. There was
an ileostomy bag in place without erythema around the site.
Extremities: No clubbing, cyanosis or edema. There were 2+
DP pulses.
LABORATORY DATA ON ADMISSION: Sodium 133, potassium 4.4,
chloride 101, bicarbonate 21.5, BUN 14, creatinine 0.8, blood
sugar 113, calcium 7.4, phosphate 4.1. The CBC showed a
white count of 6.4, hematocrit 23.3, platelets 86,000. Her
MCV was 90.
HOSPITAL COURSE:
1. INFECTIOUS DISEASE: Ms. [**Known lastname 1557**] was treated with
vancomycin and gentamicin per ID recommendations. It was
thought that Rifampin would be held until she is known to be
resistant to gentamicin as a synergistic [**Doctor Last Name 360**]. Ms. [**Known lastname 1557**]
was afebrile throughout her medical hospitalization.
ID consultation was done. Possible sources on admission
included a line infection, infected DVT, possible infected
stent. However, blood cultures were done to rule out
continued bacteremia as well as a U/A for question of
continued urinary tract infection. A chest x-ray was also
done to rule out pneumonia. Of note, her chest x-ray was
notable for bilateral pleural effusions, left greater than
right which will be discussed at a later time.
She also [**Known lastname 1834**] a transthoracic echocardiogram to rule out
endocarditis. This was negative for any vegetations on the
right or left-sided valves. Transesophageal echocardiogram
was held because the patient was afebrile throughout her
stay.
On [**2139-12-3**], Ms. [**Known lastname 1557**] was taken to the OR by Interventional
Radiology. Her right tunneled IJ catheter was removed
initially and a temporary catheter was placed. She was noted
to have a new clot within her SVC and TPA was administered.
A femoral line was also placed temporarily. At the end,
another right IJ catheter was placed through the same tunnel.
Again, she has had no leukocytosis and no fever since her
admission. Her blood cultures were also negative for any new
bacteremia. However, at the outside hospital, her blood
cultures were positive up until [**2139-11-30**].
2. PULMONARY: Ms. [**Known lastname 1557**] [**Last Name (Titles) 1834**] CTA to rule out
pulmonary embolus given her relative hypoxia. CTA was
negative for pulmonary embolus; however, she was noted to
have these new pleural effusions, left greater than right, on
chest x-ray and again on CT. On [**2139-12-3**], she [**Date Range 1834**]
thoracentesis by the Interventional Pulmonary Service. Her
effusion was noted to be transudative in nature and had
normal pH and no organisms.
Repeat chest x-ray the next day showed resolution of both the
right and left pleural effusions and no further thoracenteses
were warranted.
3. HEMATOLOGY: Ms. [**Known lastname 1557**] had a hematocrit of 23 and
platelets of 80,000 on admission. All heparin products were
held secondary to a possible heparin-induced
thrombocytopenia. HIT antibody eventually was negative. Her
platelets continued to improve throughout her stay and at
current are approximately 600,000. Her thrombocytopenia was
likely secondary to Cimetidine or some other medicinal side
effect. Her hematocrit has remained stable between 22-26.
She is asymptomatic from her anemia. Prior studies from
[**2139-8-25**] showed normal iron and repeat iron studies
here were also within normal limits.
Ms. [**Known lastname 1557**] was continued on heparin starting on [**2139-12-6**] for
chronic DVTs.
4. FLUIDS, ELECTROLYTES, AND NUTRITION: TPN was restarted
on [**2139-12-6**]. In the meantime, electrolytes were repleted per
IV. She continued to take p.o. with increased output from
her ostomy.
5. PROPHYLAXIS: Ms. [**Known lastname 1557**] was continued on Protonix during
her hospital stay. She will require heparin for DVT
prophylaxis.
DISPOSITION: Ms. [**Known lastname 1557**] will be discharged home. She will
need VNA services for IV antibiotics twice a day.
DISCHARGE DIAGNOSIS:
1. Staphylococcus epidermidis bacteremia, likely secondary
to line infection.
2. Chronic deep venous thromboses secondary to chronic
indwelling lines.
3. History of [**Location (un) 976**] syndrome, status post colectomy with
short gut syndrome.
4. Total parenteral nutrition requirement.
5. History of superior vena cava syndrome, status post
multiple stents.
DISCHARGE MEDICATIONS:
1. Vancomycin 750 mg IV b.i.d.
2. Fentanyl patch 100 micrograms per hour topical q. 72
hours.
3. Pantoprazole 40 mg p.o. q. 24 hours.
4. Paxil 20 mg p.o. q.d.
5. Tylenol 650 mg p.o. q. 4-6 hours p.r.n.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 111663**], M.D.
Dictated By:[**Name8 (MD) 8073**]
MEDQUIST36
D: [**2139-12-7**] 03:30
T: [**2139-12-10**] 10:37
JOB#: [**Job Number 111664**]
ICD9 Codes: 7907, 2875, 5119, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3069
} | Medical Text: Admission Date: [**2132-2-12**] Discharge Date: [**2132-2-19**]
Date of Birth: [**2084-3-22**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Cardiac surgery was consulted by
Dr. [**First Name11 (Name Pattern1) 919**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 911**] of cardiology to see this 47-year-old male
with a 3-week history of atypical chest pain. His symptoms
began on [**1-17**] with epigastric pain that radiated to
his back. He had diaphoresis and shortness of breath. He
initially attributed this to indigestion, but retrospectively
apparently he has been having these persistent symptoms since
then. He was cathed in [**2132-2-2**] - the day of admission
- which showed a normal ejection fraction of 50%, with a 70%
LAD lesion, an occluded OM2, and serial 80% to 95% RCA
lesions, with a large right PL. He was referred to Dr.
[**Last Name (STitle) 70**] for evaluation for coronary artery bypass grafting,
but this was not undertaken immediately as he was evaluated
and stabilized over the next day.
PAST MEDICAL HISTORY:
1. Elevated cholesterol.
2. Status post repair of an Achilles tendon rupture in [**Month (only) 116**] of
[**2130**].
3. Left forearm phlebitis 15 years ago.
4. Thrombocytopenia and anemia several years ago; the patient
states he underwent a hematology workup including a bone
marrow biopsy but no cause was identified.
5. Question of a history of kidney stones and a renal cyst.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. once a day.
2. Toprol 50 mg p.o. once a day (started 2 days prior to
evaluation).
3. Lipitor 10 mg p.o. once a day.
4. Heparin was started intravenously at the outside hospital
prior to his transfer into to [**Hospital1 18**].
HABITS: The patient admits to drinking 1 bottle of wine per
day, but denied direct EtOH abuse. He also admits to smoking
5 to 6 cigarettes per day.
PHYSICAL EXAMINATION ON ADMISSION: He is 6 feet, weighing
276 pounds, and was in no apparent distress. His heart was
regular in rate and rhythm without any murmurs, rubs or
gallops. His lungs were clear bilaterally. His abdomen was
soft, obese, nontender, and nondistended. He had no obvious
varicosities. He had a right femoral sheath in place when he
was examined by cardiac surgery. His extremities had no
cyanosis, clubbing, or edema. He had 2+ carotid pulses, 2+
radial pulses, 2+ femoral pulse on the left and a dressing on
the right, and 2+ bilateral DP and PT pulses. A left forearm
[**Doctor Last Name **] test was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with 3- to 4-second
refill time with either a radial or ulnar occlusion.
PREOPERATIVE LABORATORY DATA: White count of 5.5, a
hematocrit of 43.7, a platelet count of 132,000. PT of 13.4,
PTT of 31, and INR of 1.1. Sodium of 139, K of 4.1, chloride
of 105, bicarbonate of 25, BUN of 13, creatinine of 0.8, with
a blood glucose of 204. ALT of 49, AST of 27, LDH of 148,
alkaline phosphatase of 80, total bilirubin of 0.9. ALT of 43
and AST of 25 on repeat labs. Albumin of 4.8. HbA1C of 5.3%.
RADIOLOGIC STUDIES: A preoperative chest x-ray showed no
significant abnormalities with some atelectasis versus scar
in the left base.
HOSPITAL COURSE: He was referred to Dr. [**Last Name (STitle) 70**] of cardiac
surgery and was seen and evaluated. The plan was discussed
with CMI attending, and it was determined that his benefits
would be far greater with bypass grafting. The following
morning, on [**2-14**], he underwent coronary artery bypass
grafting x 3 with a LIMA to the LAD, a vein graft to the PDA,
and a left radial artery to the OM. He was transferred to the
cardiothoracic ICU in stable condition on a propofol drip at
40 mcg/kg/min, and Neo-Synephrine drip at 0.5 mcg/kg/min, and
a nitroglycerin drip at 0.5 mcg/kg/min for coverage of is
radial artery.
On postoperative day 1, the patient removed on a Neo-
Synephrine drip at 1.5 and nitroglycerin drip at 0.8. He was
started on aspirin therapy. He was hemodynamically stable
with a postoperative hematocrit of 31.2 and a creatinine of
0.8. He had some sinus tachycardia and some ectopy, but these
both normalized by the end of the day. The patient was
successfully extubated. He had been started briefly on
Levophed, and this was weaned off on postoperative day 2. He
began beta blockade with Lopressor and Lasix diuresis.
On postoperative day 2, he was transferred out to the floor.
He had some sinus tachycardia to 114 with a stable blood
pressure. He continued on Lasix diuresis. His beta blockade
was increased to 75 p.o. twice a day and then switched over
to Toprol XL 100 later that day. His creatinine remained
stable. He was saturating 94 percent on room air. He began to
work with the nurses and physical therapist. His chest tubes
were removed later on postoperative day 3.
On postoperative day 4, he had a low-grade temperature
overnight. It was 101.2 in the morning. His Toprol was
increased to 125 p.o. once a day. He continued to ambulate.
Percocet was switched over to Dilaudid, and repeat labs were
drawn. He did complain of some pain with movement, and he was
instructed on splinting and continued to receive p.o. pain
medications. He was alert and oriented, and he was strongly
encouraged to use in incentive spirometer and work on
pulmonary toilet. His incisions were clean, dry, and intact.
On postoperative day 5, he was restarted on his Lipitor. He
continued to progress very well and did a level 5 later in
the day and was discharged to home with VNA services. He was
also seen and evaluated by case management prior to his
discharge to VNA services.
LABORATORY DATA ON DISCHARGE: White count of 4.1, hematocrit
of 30.2, platelet count of 132,000. K of 4.0, BUN of 18,
creatinine of 0.8. His urinalysis from the 17th - the day
prior when he had a low-grade temperature - was negative. His
sternum was stable. The incisions were clean, dry, and
intact. His left radial artery incision was clean, dry, and
intact. His pacing wires and chest tubes had been removed.
DISCHARGE INSTRUCTIONS: The patient was instructed to follow
up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 3 to 4 weeks postoperatively and to
see Dr. [**Last Name (STitle) 70**] in the office in 6 weeks for his
postoperative surgical visit. The patient was also instructed
to follow up in the [**Hospital 409**] Clinic on [**Hospital Ward Name 121**] Two 2 weeks post
discharge.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x 3.
2. Pancytopenia in [**2125**].
3. Renal cyst with a question of renal calculi.
4. Elevated cholesterol.
5. Left forearm phlebitis 15 years ago.
6. Obesity.
7. Status post Achilles tendon repair.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. once a day (x 10 days).
2. Enteric coated aspirin 81 mg p.o. once daily.
3. Potassium chloride 20 mEq p.o. once a day (for 10 days).
4. Colace 100 mg p.o. twice daily.
5. Lipitor 10 mg p.o. once a day.
6. Metoprolol sustained release 100 mg p.o. once daily.
7. Dilaudid 2-mg tablets 1 tablet p.o. q.4-6h. p.r.n. (for
pain).
CONDITION ON DISCHARGE: He was discharged in stable
condition on [**2132-5-19**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2132-6-18**] 15:07:22
T: [**2132-6-20**] 10:56:48
Job#: [**Job Number 59296**]
ICD9 Codes: 4111, 2875, 3051, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3070
} | Medical Text: Admission Date: [**2116-5-3**] Discharge Date: [**2116-5-11**]
Date of Birth: [**2062-12-24**] Sex: M
Service: CCU
CHIEF COMPLAINT: Shortness of breath
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old man
with a history of coronary artery disease, insulin dependent
diabetes mellitus for 40 years and a renal transplant in [**2103**]
who presented who presented with an increased dyspnea on
exertion and shortness of breath at rest, increased over a
chronic baseline level. The patient noted symptoms acutely
worsened one day prior to admission prompting an Emergency
Room visit. In the Emergency Room the patient denied chest
pain, palpitations, nausea, vomiting or diaphoresis as well
as fever and chills. The patient did note that his usual
dose of Lasix was not working. In the Emergency Room he was
found to be sating high 90s on 2 liters after 80 mg of Lasix.
He was admitted to the [**Hospital Unit Name 196**] floor he was found to have a low
saturation. He was put on 100% nonrebreather, sating in the
mid 90s. Respiratory rate was 30s to 40s. The patient was
given 40 plus 40 of intravenous Lasix without any increased
urine output. On the nitroglycerin drip and Morphine the
patient was able to diurese 200 cc. The patient's
respiratory rate decreased to the 20s. The patient's
examination had improved. the patient was taken to the
Catheterization laboratory where he was found to be 80% on
100% nonrebreather. The patient was also found to have
lateral electrocardiogram changes. He was diaphoretic and
not complaining of chest pain but noting paroxysmal nocturnal
dyspnea and orthopnea.
PAST MEDICAL HISTORY: 1. Insulin dependent diabetes
mellitus for 40 years with triopathy; 2. Status post renal
transplant [**2103**]; 3. Status post bilateral below the knee
amputation; 4. Coronary artery disease, with three vessel
disease with poor touchdowns, not a surgical candidate with
recent in-stent stenosis of the left anterior descending
stent treated with brachytherapy; 5. Recent admit for right
knee ulcer to [**Hospital3 **].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Pravachol 20 mg p.o. q.d.; Aspirin
325 mg p.o. q. day; Lasix 60 mg p.o. q. day; Enalapril 20 mg
p.o. b.i.d.; Lasix 75 mg p.o. q. day; Isordil 20 mg p.o.
t.i.d.; Prednisone 10 mg p.o. q.o.d.; Sandimmune 100 mg p.o.
q. AM and 50 mg p.o. q. PM; Imuran 50 mg p.o. q. day; Ativan
2 to 4 mg p.o. q. 4 to 6 hours prn; NPH 20 units
subcutaneously in the morning and 14 units subcutaneously in
the PM; regular insulin sliding scale; Toprol XL 12.5 mg p.o.
q. day.
SOCIAL HISTORY: The patient is full code. He lives alone.
His wife had died recently. The patient quit smoking tobacco
20 years ago. He denied any alcohol use.
FAMILY HISTORY: Significant for gastrointestinal and breast
cancer.
PHYSICAL EXAMINATION: The patient's pulse was 95, blood
pressure was 125/38 with MAP 67, respiratory rate 22 and
oxygen saturation 97% on 100% nonrebreather. On general
examination the patient was a very chronically ill appearing
man in no apparent distress who was bolt upright in bed. On
head, eyes, ears, nose and throat examination the patient had
pupils which were nonreactive. Neck examination revealed no
lymphadenopathy and a central venous pressure of
approximately 10 cm of water. Cardiac examination revealed a
regular rate and rhythm, normal S1 and S2 with no murmurs,
rubs or gallops. There was presence of an S3. Pulmonary
examination revealed rales up to [**1-19**] of the lung fields with
bilateral pleural effusions. On abdominal examination the
patient's belly was soft, nontender, nondistended with normal
bowel sounds. Extremity examination reveals bilateral below
the knee amputations, 2+ edema. There was a left Stage 3
decubitus ulcer of the patella region.
LABORATORY DATA: Pertinent laboratory findings revealed a
white blood cell count of 9.4, hematocrit 40, platelets 291.
The patient had a BUN of 31, creatinine 1.4. The patient's
CK was trending downwards.
Electrocardiogram revealed normal sinus rhythm at 75 with
normal axis, left atrial abnormality, ST elevations V1
through V4, 1 to 3 mm. There were also small Q waves in 3
and F. Chest x-ray showed congestive heart failure with
bilateral pleural effusions. [**2115-11-16**], stress MIBI,
the patient with reversible moderate inferior and anterior
and septal wall defect.
Echocardiogram performed [**2116-5-6**], revealed sinus
tachycardia with no anxiety, abdominal aortic aneurysm, ST
increased V2 to V4, the patient also had biphasic T in V6.
Cardiac catheterization, the patient had ejection fraction of
20 to 30% with 100% proximal right coronary artery lesion,
95% recurrent in-stent mid left anterior descending lesion.
This focal lesion was dilated successfully.
HOSPITAL COURSE: The patient is a 53 year old man with a
history of coronary artery disease, myocardial infarction and
renal transplant as well as insulin dependent diabetes
mellitus and congestive heart failure.
1. Cardiovascular - From the cardiovascular standpoint the
patient presented in acute decompensated heart failure in the
setting of ischemic heart disease.
From a coronary artery disease standpoint the patient has
severe three vessel disease. Multiple interventions
including recent percutaneous transluminal coronary
angioplasty and brachiotherapy to the left anterior
descending now presented with recurrent in-stent left anterior
descending
stenosis, status post percutaneous transluminal coronary
angioplasty. The patient was ruled out for myocardial
infarction. He was evaluated by Cardiac Surgery who felt
that the patient was not a coronary artery
bypass candidate. He was continued on Aspirin, Plavix and
Beta blockers as well as Pravachol.
From a myocardial standpoint the patient had an ejection
fraction of 20% with severe hypokinesis, left ventricular
hypertrophy, and diastolic dysfunction. He presented with
decompensated heart failure. He ruled out for myocardial
infarction, however, his congestive heart failure was felt to
be secondary to ischemic heart disease. The patient was
diuresed with Lasix and eventually a combination of Diuril
and Lasix. The patient was started on Natrecor which
initially caused some hypotension but then the patient
reported improvement in his shortness of breath. He had
augmented diuresis while on the Natrecor. The patient was
considered for Aldactone although with his history of
hyperkalemia this was deferred. Plan was to use BiPAP if the
patient were to have further acute pulmonary edema. Post
cardiac catheterization the patient had an episode of acute
pulmonary edema which was responsive to Morphine and Lasix.
The patient was continued on his outpatient heart failure
regimen which included Enalapril, Isordil, and Toprol.
From a conduction standpoint the patient remained in sinus
rhythm and was continued on his Beta blocker.
From an endocrine standpoint the patient presented with a
history of insulin dependent diabetes mellitus and was
maintained on a regimen of NPH and regular insulin sliding
scale as per his outpatient regimen.
From a renal standpoint the patient is status post renal
transplant on an immunosuppressant regimen. He presented at
his baseline creatinine. However, with fingerstick diuresis
the patient's creatinine climbed from 1.4 to approximately
1.8. His Cyclosporin level of 113 was within normal limits.
The renal transplant team followed the patient. His
creatinine gradually began to trend down at the end of the
[**Hospital 228**] hospital course.
Infectious disease - The patient presented with a left knee
ulcer near the site of the left below the knee amputation.
Vascular surgery was consulted and felt the patient should be
on Levofloxacin and Flagyl. They debrided the ulcer. The
patient was continued on Levofloxacin and Flagyl for
approximately a course of 14 days. The patient had a swab
that grew Enterobacter as well as Stenotrophomonas.
Infectious Disease was contact[**Name (NI) **] regarding the treatment of
his Stenotrophomonas. Given the marked clinical improvement
in the ulcer, the feeling was that the Stenotrophomonas was a
colonizer and that there was no need to add additional
coverage. Vascular Surgery recommended the patient follow up
with his vascular surgeon at [**Hospital3 **].
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient was discharged to follow up
with Dr. [**Last Name (STitle) **] in Heart Failure Clinic in approximately one
to two weeks. The patient will also follow up with his
vascular surgeon at [**Hospital3 **] in approximately one week.
Due to high likelihood of repeat LAD in-stent stenosis,
elective relook angiography with standby for PTCA will be
considered in 4 months. DISCHARGE MEDICATIONS:
1. Tylenol 650 mg p.o. q. 4-6 hours prn
2. Pravachol 20 mg p.o. q. day
3. Plavix 75 mg p.o. q. day
4. Cyclosporin 100 mg p.o. q. AM and 50 mg p.o. q. PM
5. Azathioprine 50 mg p.o. q. day
6. Metoprolol XL 2.5 mg p.o. q. day
7. Colace 100 mg p.o. b.i.d.
8. Aspirin, enteric coated 325 mg p.o. q.d.
9. Ativan 0.5 to 1 mg p.o. q. 4-6 hours prn anxiety
10. Flagyl 500 mg p.o. t.i.d. for nine days
11. Levofloxacin 500 mg p.o. q. day for nine days
12. Prednisone 10 mg p.o. q.o.d.
13. Enalapril 20 mg p.o. b.i.d.
14. Lasix 80 mg p.o. q. day
15. Isordil 20 mg p.o. t.i.d. prn
16. Regular insulin sliding scale, NPH 20 units
subcutaneously q. AM and 14 units subcutaneously q. PM
DISCHARGE INSTRUCTIONS: The patient is to have dry sterile
dressings b.i.d. to his left lower extremity ulcer. He will
also need daily weights at home with a sitdown scale. Case
management was contact[**Name (NI) **] to obtain a sitdown scale for the
patient. [**Hospital6 407**] Services will aid the
patient in the dressing changes.
DISCHARGE DIAGNOSIS:
1. Congestive heart failure
2. Coronary artery disease with three vessel disease status
post percutaneous transluminal coronary angioplasty
3. Insulin dependent diabetes mellitus
4. Sepsis, recent
5. Status post bilateral below the knee amputations
6. Left knee ulcer
7. Renal transplant with chronic immunosuppression.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2116-5-10**] 13:33
T: [**2116-5-10**] 15:41
JOB#: [**Job Number 21048**]
cc:[**Last Name (NamePattern1) 21049**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3071
} | Medical Text: Admission Date: [**2107-12-10**] Discharge Date: [**2107-12-15**]
Date of Birth: [**2043-12-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
found unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
63yo man with history of hypertension, hyperlipidemia, and
bipolar disorder found on bathroom flor prone and incontinent of
urine/stool. Initially, he was arousable to verbal stimuli with
eye opening and incomprehensible verbal response. Vitals at
this point were 102/64, 90, 24, and 96%. There was a question
of right facial asymmetry. Hereafter, there was decreasing
level
of mental status with no response to verbal or pain.
In ED, vitals were 101.2, 98, 70/30, 20, and 100% on NRB. After
2L NS bolus, blood presure increased to 110. Narcan was given
with no effect. He was intubated with etomidate and
succinylcholine. He was given 50mg of charcoal by OG tube. He
was given vanco, ceftriaxone, and flagyl. Neosynephrine was
started with BP from 99/54 to105/57.
Discussion with his sister confirms the history and also adds
that he has had 3-4 months of leg cramps for which he has been
taking quinine. She also states that she counted all his pills
at home and that these were accurate.
Past Medical History:
-hypertension
-bipolar disorder, no h/o suicidal ideation or attempts
-hypercholesterolemia
-no known history of CAD
-GERD
-hip surgery one year ago
Social History:
-lives with 37 yo son (who has MR)
-wife in [**Name (NI) **] with [**Name (NI) 5895**]
- 45 pckXyear smoking history
- no etoh or drugs
Family History:
no family history of DM or CAD
Physical Exam:
101.2, 86, 137/67, 27, 100% on
AC (500X16, 0.5, 5)
gen: intubated, responding to voice, squeezing hands
heent: pupils equal, reactive
strabismus with outward/downward deviation of right eye
CV: RRR, no m/r/g
resp: CTA bilaterally
abd: soft, NT, good bowel sounds
extr: 2+ pitting edema bilaterally
petechial rash at bilateral heels/lower extremities
Pertinent Results:
[**2107-12-10**] 11:00AM CEREBROSPINAL FLUID (CSF) PROTEIN-47*
GLUCOSE-71
[**2107-12-10**] 11:00AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1*
POLYS-10 LYMPHS-90 MONOS-0
.
[**2107-12-10**] 07:01AM TYPE-ART TEMP-38.4 PO2-259* PCO2-35 PH-7.35
TOTAL CO2-20* BASE XS--5
[**2107-12-10**] 07:01AM LACTATE-1.1
[**2107-12-10**] 07:01AM O2 SAT-97 CARBOXYHB-0.3 MET HGB-1.5
.
[**2107-12-10**] 07:15AM GLUCOSE-135* UREA N-16 CREAT-0.8 SODIUM-138
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-21* ANION GAP-11
CALCIUM-7.0* PHOSPHATE-2.7 MAGNESIUM-1.8
.
[**2107-12-10**] 07:15AM ALT(SGPT)-25 AST(SGOT)-35 ALK PHOS-60
AMYLASE-303* TOT BILI-0.6 ALBUMIN-2.8* [**2107-12-10**] 07:15AM
LITHIUM-LESS THAN
[**2107-12-10**] 07:15AM VALPROATE-5*
[**2107-12-10**] 05:45AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
.
[**2107-12-10**] 05:30AM ALT(SGPT)-13 AST(SGOT)-14 CK(CPK)-15* ALK
PHOS-36* AMYLASE-205* TOT BILI-0.3
[**2107-12-10**] 05:30AM LIPASE-344*
.
[**2107-12-10**] 05:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
.
[**2107-12-10**] 05:30AM WBC-8.4 RBC-3.78* HGB-12.0* HCT-34.5* MCV-91
MCH-31.7 MCHC-34.8 RDW-13.8 PLT COUNT-310
[**2107-12-10**] 05:30AM NEUTS-62 BANDS-3 LYMPHS-15* MONOS-15* EOS-0
BASOS-0 ATYPS-3* METAS-2* MYELOS-0
[**2107-12-10**] 05:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
.
[**2107-12-10**] 05:30AM PT-14.0* PTT-27.4 INR(PT)-1.2
.
[**2107-12-10**] 06:23PM SED RATE-72*
CTA:
1. No evidence of pulmonary embolism.
2. Small amount of opacity at both lung bases representative of
either atelectasis or infiltrate.
ct a/p:
1) Dependent atelectasis/consolidation. This could represent
aspiration.
2) Cholelithiasis without evidence of cholecystitis.
3) Probable simple cyst in the kidney.
4) Periportal adenopathy.
ct spine:
IMPRESSION: No evidence of cervical spine fracture.
ct head w/o contrast:
1) No intracranial hemorrhage or mass effect.
2) Small vessel ischemic change.
cxr: Satisfactory positioning of the ET tube. No pneumothorax.
Patchy atelectasis in the left lower lobe. Pneumonia cannot be
excluded.
MR HEAD W/O CONTRAST, MRA BRAIN W/O CONTRAST, MRA
CAROTID/VERTEBRAL W/O CONTRAST:
1. No evidence of acute stroke.
2. Nonspecific hyperintensity in the periventricular white
matter most likely due to chronic small vessel infarction.
3. The MRA of the brain and neck are markedly limited by motion.
For further evaluation of the extracranial carotids, a carotid
ultrasound is recommended.
TTE:
1. The left atrium is mildly dilated. The left atrium is
elongated.
2 Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The ascending aorta is mildly dilated. The aortic arch is
mildly dilated.
5.The aortic valve leaflets (3) are mildly thickened. There is
mild aortic
valve stenosis. No aortic regurgitation seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7.There is no pericardial effusion. There is an anterior space
which most
likely represents a fat pad, though a loculated anterior
pericardial effusion
cannot be excluded.
MICRO:
negative urine, blood and csf cultures; ruled out for influenza
by negative direct antigens a and b. viral culture preliminarily
also negative.
Brief Hospital Course:
63 yo male w/ pmhx htn, hyperlipidemia, restless legs, bipolar
d/o found to have altered mental status and fever of unclear
etiologies, hypotension and mild pancreatitis, status post
extubation, having NSVT's while in ICU.
ICU course:
During ICU course, he defervesced, was extubated, weaned off
levophed, and antibiotics were discontinued. Workup for syncope,
seizure, stroke, meningeal or other infections negative to date.
TTE and viral cultures ordered and were pending. ICU course c/b
two episodes of asymptomatic NSVT. Transferred to floor on
hospital day #3.
Overall Hospital course, by problem:
1. Altered Mental Status/Unresponsiveness: An extensive workup
was begun in the ICU. Quinine was considered a possible
etiology as this can lead to prolonged QTc interval. However,
he had a normal EKG and has no known history of cardiac disease.
He was ruled out for an MI. His TTE showed only mild AS.
Infectious etiology was considered. He had a lumbar puncture
with CSF showing normal protein and glucose and 1 WBC and 1 RBC.
Blood, CSF, and urine cultures remained negative. He was ruled
out for influenza by direct antigen testing and his viral
cultures were preliminarily negative. Neurology was consulted.
A neurologic workup included a negative head MRI and MRA,
although the latter was limited by his motion. His depakote
level was low, although per his VA psychiatrist, his level the
week before was 40s. He had an EEG which was obtained while he
was on propofol that did not show lateralizing or epileptiform
abnormalities. The propofol was turned off during EEG and there
was a slight increase in the background activity. Neurology did
not believe that a seizure was responsible for his initial
state. His tox screen was positive only for benzodiazepenes.
It is possible that a benzo overdose may have led to his altered
mental status although per his sister, all his pills are
accounted for at home. A metabolic workup revealed initially
profound hypocalcemia and hypokalemia. At TSH and free T4 were
normal; however his PTH was slightly elevated which is
consistent with a calcium deficiency. It is possible that
hypocalcemia was a cause of a neurologic disturbance or
undetected seizure as he appeared symptomatic from the
hypocalcemia with a reported history of muscle cramps.
Malabsorption and malnutrition were considered given his low
albumin. However his calcium rose appropriately with
supplementation and his coagulation profile was normal. He did
appear initially dehydrated, with hypotension responding to
fluids. This could have led to a syncopal event but does not
explain the prolonged and profound altered mental status.
Although we are still unclear as to the cause of his change in
mental status, we presume that it is the result of some sort of
metabolic insult. His mental status has improved significantly.
However he still appears mildly delerious. He is hypomanic at
times, reports tearfulness, and per nursing is at times
inappropriate verbally. It is unclear what his baseline is
however. We are holding his quinine, as well as his olanzapine
and depakote.
2. NSVT: He had two episodes of asymptomatic NSVT while his
electrolytes were not fully repleted while in the ICU. He has
no known history of CAD and ruled out for MI by serial cardiac
enzymes. He had an echo that showed normal ventricular function
without wall motion abnormalities.
3. Hypotension: This was likely hypovolemic as he responded to
fluid boluses
and was then weaned from the neosynephrine. After pressors were
weaned, he remained normotensive and required no further IVF
boluses. It is also possible that he was overmedicated with
atenolol. He reportedly had an urgent care visit at the VA
recently for hypotentsion with a pressure of 90/30s. We kept
him off atenolol and his blood pressure remained normotensive.
4. Pancreatitis: This may have been a medication side effect
from valproic acid. Per his VA psychiatrist, he had a level in
the mid 40's the week prior to admission.
[**Last Name (un) **] score on presentation was low (< 2) which was consistent
with mild pancreatitis with low risk of mortality. His
pancreatic enzymes continued to trend downward, and he remained
free of any abdominal pain. He was able to tolerate po's
without difficulty after being extubated.
5. Petechial rash on bilateral lower extremities: He was not
thrombocytopenic. A vasculitis was considered as a potential
etiology; Dermatology was consulted, and felt that these changes
represented stasis changes secondary to his venous insufficiency
rather than vasculitis; decided against biopsy. The rash
resolved on its own.
6. bipolar disorder: Previously on Zyprexa and depakote. These
were held on presentation, and psychiatry was consulted for
recommendations regarding re-instituting these medications after
he was successfully extubated and alert/oriented. They
recommended that he remain off these until his delerium
completely resolves.
7. Diarrhea/LLQ pain-He had mild left lower quadrant pain and
watery black guaiac negative diarrhea. A CT did not show
diverticulitis or other potential source of pain/fever. Other
possibilities include infectious gastroenteritis/colitis from a
bacterial or viral etiology. It was thought that diarrhea is
from activated charcoal given in ED. This resolved on its own.
He was given one dose
8. Fever-no cultures have been positive so far. He appears to be
defervescing. There was a question if this is truly from an
infectious etiology as he does not appear to be symptomatic
other than with diarrhea, which is new in comparison to the
fever. Atelectasis or chemical pneumonitis [**1-24**] to aspiration
during his fall could be possible, however the latter without an
elevation in his white count is not usual. It could be that he
had an accounted for viral illness, that appears to be resolving
on its own.
9. Venous stasis-likely chronic; leg elevation was done with
good resolution.
10. leg cramps-He was no longer symptomatic once calcium was
repleted.
11. anemia-folate, b12 levels are normal. Low iron in setting of
low transferrin and TIBC with elevated ferritin does not provide
a clear etiology. This could be conssistent with anemia of
chronic disease. He is currently hemodynamically stable, with
hematocrit stable and guaiac negative. We would transfuse for
HCT <28; he has no h/o CAD but likely has COPD given 45py
smoking history. He may need outpatient colonoscopy given his
age. We started an iron supplement.
10. Fluids, Electrolytes, Nutrition-much of his initial
presentation may be attributable to dietary deficiencies. We
repleted his electrolytes and put him on an MVI, calcium and
vitamin D supplements. We encouraged him to drink plenty of
water and maintained him on a cardiac healthy diet. He was kept
on an insulin sliding scale.
Medications on Admission:
-depakote
-omeprazole 20 qD
-atenolol 50 qD
-quinine 325 qD
-simvastatin 40 qD
-gemfibrozl 600 [**Hospital1 **]
-olanzapine 10 HS
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: qs Injection
ASDIR (AS DIRECTED): USE RISS.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 25750**]
Discharge Diagnosis:
Unresponsiveness requiring intubation, now resolved.
Delerium of unknown etiology
Hypocalcemia
Hypokalemia
Hypophosphatemia
Hypoalbuminema
Anemia
Bipolar disorder
Hypertension
Hypercholesterolemia
GERD
Discharge Condition:
stable, afebrile
Discharge Instructions:
You are being transferred to continue acute medical care at [**Hospital 10050**] [**Hospital6 **].
Followup Instructions:
continue acute medical and psychiatric care at [**Hospital 1268**] [**Hospital 59525**].
ICD9 Codes: 2765, 2768, 2930, 4271, 496, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3072
} | Medical Text: Admission Date: [**2114-9-17**] Discharge Date: [**2114-10-15**]
Date of Birth: [**2057-11-29**] Sex: F
Service: NEUROLOGY
Allergies:
Percodan / Percocet / Cerebyx / Phenytoin
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Right facial droop, left face and arm numbness
Major Surgical or Invasive Procedure:
-Status post tracheostomy
-Status post PEG
-Status post dental extraction of 3 teeth
History of Present Illness:
Patient is a 56 year old right handed female with pastmedical
history of breast cancer 10-15 years ago, pleural effusion, DVT
and PE who presented to [**Hospital1 18**] on [**2114-9-17**] for evaluation of left
face and arm numbness and right facial
droop.
Patient was in her usual state of health until about one week
ago when she reports having "the flu". She then had several days
of nausea and vomiting and malaise. Two days prior to admission
her daughter her right eye was "droopy". On evening prior to
admission, her whole right face was drooped. Then, on morning of
admission, she awoke at 6am with left arm and face numbness.
This
was associated with a vertiginous sensation as well. Daughter
noted that her speech was slurred. No nausea or vomiting,
headaches, blurry vision, double vision, lightheadedness,
paresthesias, weakness or incoordination. She went to [**Hospital1 56809**] for evaluation. Head CT there with pontine
hemorrhage.
Transferred to [**Hospital1 18**] for further evaluation. On initial arrival,
heart rate 70-80s and sinus, BP 138/90, oxygen 93/RA and 98%/2L.
While in ED, she received 2 units of FFP. However, she reported
that her symptoms worsened. She felt that her speech was more
slurred, she was having difficulty managing her saliva and
secretions, and had vertical diplopia. Repeat head CT showed
interval worsening in the size of her bleed, from 8-12 mm. While
in ED, she went into atrial fibrillation with rapid ventricular
response; Diltiazem 20mg IV resulted in rate control.
After arrival to the neurology floor, she continued having
difficulty managing her secretions. On several occasions, her
oxygen saturation drooped into the 80s. She was transferred to
the ICU for closer monitoring. She received Factor VIIa. She was
electively intubated in early am on [**9-18**].
Past Medical History:
1. Breast cancer status post right mastectomy and chemotherapy
15
years ago
2. Pleural effusion
3. DVT and PE 7 years ago
Social History:
Married, with 3 children. Lives with husband,daughter, son and
grandchildren. She is a homemaker. No tobacco,valcohol, drug
use.
Family History:
Mother with stroke in her 70s. Sister with history of breast
cancer, died from brain mets.
Physical Exam:
Tm: 99.0 Tc: 98.4 BP: 97/69 (97-150/66-87) HR: 78 (76-140s)
Vent AC 600x12 ([**11-14**]) with FiO2 0.40
Gen: WD/WN, sitting up in bed comfortably, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: Decreased breath sounds over right hemithorax. Coarse
breath sounds on left. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Sleepy but arousable. Cooperative with exam. Able
to follow simple midline and appendicular commands. Able to make
needs known by writing on pad of paper.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: On neutral gaze, eyes are deviated to the left with
right beating nystagmus. On right lateral gaze, eyes do not
cross midline. Upgaze impaired with vertical nystagmus, some
rotatory component.
V, VII: Unable to fully assess with ETT but appears to have
right UMN palsy. Decreased sensation left hemiface.
VIII: Unable to fully assess.
IX, X: Unable to assess with ETT.
[**Doctor First Name 81**]: Shoulder shrug strong.
XII: Tongue to right around ETT.
Motor: Normal bulk and tone. No abnormal movements or tremors.
Strength full.
Sensation: Decreased to light touch over left hemibody.
Reflexes: B T Br Pa Ac
Right 1 1 1 0 0
Left 1 1 1 0 0
Grasp reflex absent. Right toe upgoing. Left toe equivocal.
Coordination: Slowed but accurate on left FNF. Dysmetric right
FNF.
Gait: Unable to assess.
Pertinent Results:
[**2114-9-17**] 12:20PM WBC-8.1 RBC-4.15* HGB-12.1 HCT-35.0* MCV-84
MCH-29.1 MCHC-34.5 RDW-14.1
[**2114-9-17**] 12:20PM NEUTS-74.4* LYMPHS-21.2 MONOS-3.5 EOS-0.5
BASOS-0.5
[**2114-9-17**] 12:20PM PLT COUNT-258
[**2114-9-17**] 12:20PM PT-18.9* PTT-29.3 INR(PT)-2.2
[**2114-9-17**] 12:20PM GLUCOSE-107* UREA N-15 CREAT-0.6 SODIUM-141
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-32* ANION GAP-12
[**2114-9-17**] 12:20PM CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-1.9
-----
CT head w/o contrast [**2114-9-17**]: A rounded hyperdensity is again
noted in the right pontomedullary junction. This is slightly
larger than on the prior study, now measuring 12 x 11 mm in
size. In addition, this extends slightly more superiorly into
the pons and slightly more inferiorly into the medulla. No new
areas of hemorrhage are identified. Streak artifact is again
identified within this area which limits evaluation of
surrounding edema. There is no mass effect or hydrocephalus.
[**Doctor Last Name **]-white matter differentiation remains preserved. The osseous
structures are normal.
-----
MRI head w/o contrast and MRA head [**2114-9-17**]: Multiplanar T1 and
T2W images of the brain was obtained. MRA of the Circle of
[**Location (un) 431**] was performed. Correlation is made to the CT examination
dated [**2114-9-17**]. As seen on the CT examination, there is
a small 1 cm lesion of increased T2 signal along the right
pontomedullary junction which demonstrates magnetic
susceptibility on gradient echo images suggestive of a small
cavernoma or a calcified lesion due to the increased density
seen on the CT exam and magnetic susceptibility. FLAIR images
demonstrate a similar but smaller lesion near the left middle
cerebellar peduncle. Additional evaluation of the brain with
Gadolinium enhanced MRI in both axial and coronal planes would
be recommended. The ventricular system is symmetrical without
hydrocephalus. The 4th ventricle is in the midline. There is
normal signal flow void within the intracranial portions of the
carotid and basilar arteries. MRA of the Circle of [**Location (un) 431**]
demonstrates patent distal vertebrobasilar circulation. No
aneurysms are seen along the posterior circulation. The
visualized anterior, middle, and posterior cerebral arteries are
patent. The exam is insensitive to detect tiny aneurysms less
than 3 mm in diameter.
-----
CT Chest, Abdomen, Pelvis [**2114-9-20**]:
CT OF THE CHEST WITH IV CONTRAST: There are multiple enlarged
lymph nodes in the left supraclavicular and prevascular regions,
the largest is in the left supravicular region measuring
approximately 12 x 19 mm. The patient is intubated. The trachea
and left main stem bronchi and its tributaries are widely
patent. There is obstruction within the central right airways
with complete opacification of the more distal airways and the
entire right lung. There is a mixed low and high attenuation
density of the collapsed right lung. There is a small loculated
effusion at the posterior inferior right thoracic cavity with a
thickened wall. The distal right main pulmonary artery is
obstructed. Posterior atelectatic changes are noted within the
left lung. At the superior aspect of the superior segment of the
left lower lobe there is a pleural based nodular density
measuring approximately 6 x 10 mm. The patient is status post
right mastectomy and surgical clips are noted in the right
axilla consistent with lymph node dissection. A porta cath is
noted in the superior left chest wall.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver, pancreas, spleen,
adrenal glands, kidneys, ureters, and small/large bowel loops
are unremarkable. There is layering high attenuation material
within the gallbladder suggestive of layering sludge. There is
gallbladder wall thickening or gallstones. There is no
lymphadenopathy or free fluid.
CT OF THE PELVIS WITH IV CONTRAST: The uterus, adnexa, sigmoid
colon, rectum, distal ureters, and urinary bladder are
unremarkable. Surgical clips are noted adjacent to the uterine
fundus. There is no lymphadenopathy or free fluid.
There are no suspicious lytic or sclerotic osseous lesions.
-----
MRI head with and without contrast [**2114-9-22**]: Since the previous
MRI study there is now evidence of subacute hemorrhage with
increased T1 and decreased T2 signal identified in the right
side of the pontomedullary junction. The previously seen
surrounding edema has also increased which involves now the
medulla and the posterior portion of the pons. No distinct
enhancement is seen in this region. A second area of increased
T2 signal with subtle enhancement is identified in the left
middle cerebral peduncle which is unchanged from the previous
study. No midline shift or hydrocephalus is seen. There are no
other distinct areas of abnormal enhancement noted. IMPRESSION:
Interval new hemorrhage with subacute characteristics in the
right pontomedullary junction with increased edema. No distinct
enhancement is seen in this region given the presence of blood
products. However in the presence of a second small enhancing
lesion in the left middle cerebral peduncle, and given the
patient's clinical history, these findings are suggestive of
metastatic lesions. No hydrocephalus is seen.
Brief Hospital Course:
Patient is a 56 year old female with past medical history of
breast cancer 15 years ago, DVT/PE admitted on [**2114-9-17**] after 2
day history of right facial droop, left hemibody numbness. Exam
with left gaze preference, impaired right lateral gaze with
nystagmus, impaired upgaze with vertical and rotatory nystagmus,
right central 7th palsy, altered palatal and gag function,
diminished sensation over left hemibody and right dysmetria. In
terms of localization, her findings point to lesion in right
lower pons/upper medulla. Indeed, she has hemorrhage at right
pontomedullary junction, 12x11mm. In light of location and
history of breast ca, hemorrhagic transformation of underlying
mass was a concern.
She was admitted to the Neurology/Neurosurgical ICU. Neuro
checks were performed every hour. Initially, she was started on
Mannitol and Decadron. These were both weaned [**2114-9-19**]. Goal
systolic blood pressure was <130. All antiplatelets and
anticoagulant agents were held. Repeat MRI with gadolinium to
assess for underlying mass demonstrated enhancement of
hemorrhagic mass and second enhancing lesion in cerebellum.
Oncology was consulted. Patient actively refusing chemotherapy
and/or radiotherapy but is actively discussing other treatment
options with Oncology.
On hospital day #1, she was intubated for inability to protect
airway and difficulty handling secretions. Chest XRay showed
opacification of right hemithorax and mediastinal shift. She
underwent flexible and rigid bronch with tissue biopsies samples
taken. Chest CT demonstrated multiple enlarged lymph nodes,
collapsed right lung and left sided pleural based density
concerning for malignancy. Pathology from her right mainstem
tumor mass was consistent with metastatic adenocarcinoma of
breast origin. We were unable to wean patient from ventilator,
likely related to collapsed right lung and poor lung volumes.
Tracheostomy was performed [**2114-9-25**]. Patient continues to rely
on mechanical ventilation.
While on telemetry monitoring, patient was noted to have
intermittent rapid atrial fibrillation alternating with sinus
bradycardia. She was seen by cardiolgoy. Esmolol or diltiazem
was recommended as needed for rate control. TSH was within
normal limits.
PEG tube was placed [**2114-9-26**]. Due to location of her hemorrhagic
tumor, patient is likely to have difficulties with swallowing
and speech function as she has decreased palatal, tongue, and
gag functions.
In terms of infectitious disease issues, patient spiked a
temperature on [**2114-9-26**]. Sputum culture showed S. Aurea. Urine
culture had gram positive bacteria. She was started on
Vancomycin empirically while identification and sensitivities
were pending on cultures.
The day prior to discharge she was started on a right eye patch
to be used intermittently to alleviate her diplopia. She also
has a right conjunctivitis that is being treated with drops.
We discussed the patient's disposition with oncology, who stated
that they had had a lengthy conversation with the patient and
her daughter on [**9-28**], at which time the patient had adamantly
refused any chemotherapy or further therapeutic interventions.
Arimidex or tamoxifen are not therapeutic candidates because
they have already been used in her treatment regimen in the
past. Oncology requested that she make a follow up appointment
with Dr. [**Last Name (STitle) **] if she is interested in further therapy.
Medications on Admission:
1. Coumadin 10 mg po qHS
2. Arimidex 1 mg po qd
3. Lasix 40 mg po qd
4. Potassium KCL
Discharge Medications:
1. Vancomycin 1000 mg iv q12
2. Reglan 10 mg po qid
3. senna 1 tab po bid prn constipation
4. prochlorperazine 10 mg IV q6 hours prn nausea
5. magnesium sulfate 2 gm IV qday prn Mg<2
6. Potassium chloride 40 meq IV qday prn K<3.5
7. Tocopheryl 400 ml pg qday
8. Esmolol 25 mcg/kg/min titrate to HR<110
9. Dulcolax 100 mg po bid
10. Insulin sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Metastatic breast cancer, with hemorrhage in right
pontomedullary junction, likely secondary to metastasis.
Discharge Condition:
Stable
Discharge Instructions:
Neuro: Neuro checks, supportive care
Onc: Pt should follow up with oncology (Dr.[**Name (NI) 8949**] office)
as an outpatient if she wishes to pursue therapy
Optho: Pt needs eye patch on R eye intermittently to alleviate
diplopia, also eye drops for conjunctivitis
CV: Continue esmolol for rate control. Pt has hx of intermittent
rapid atrial fibrillation, but has been stable from that
perspective for many days
Resp: Follow O2 sats, continue ventilation through trach
ID: Continue vancomycin x14 day course (last day will be [**10-10**]),
recommend reculturing if she spikes
HEME: follow hematocrit, transfuse for hematocrit <30, last
transfusion was [**9-28**]
GI: continue PEG tube feeds, follow electrolytes
Prophylaxis: pneumoboots, insulin sliding scale, proton pump
inhibitor
Followup Instructions:
Follow up with oncology: Call Dr.[**Name (NI) 8949**] office at
[**Telephone/Fax (1) 6568**] to schedule appointment
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 5180, 5990, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3073
} | Medical Text: Admission Date: [**2191-8-15**] Discharge Date: [**2191-8-21**]
Date of Birth: [**2106-12-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Fall, with gait instability
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname **] [**Known lastname **] is an 84 y.o woman with a history of HTN who
presents with multiple falls, with recent associated
orbital/facial fractures, found to have a small SDH and
hyponatremia following a subsequent fall leading to this
admission.
.
She was first admitted to [**Hospital1 18**] on [**2191-7-28**] after a mechanical
fall down an escalator, approximately 20 feet. Fall was
unwitnessed but does not recall what happened before the fall;
lost conciousness and woke up in the hospital. CT Max/sinus
obtained during that admission revealed multiple facial
fractures including fractures of the right orbital floor,
lateral wall, lamina papyracea, right zygoma, all walls of the
right maxillary sinus, lateral portion of the right glenoid
fossa, and right lateral pterygoid. She returned for plastic
surgery to repair the fractures on [**2191-8-8**], and had a ORIF Right
Lefort III and closed reduction nasal fracture.
.
She then fell again at home on [**2191-8-15**], when she was walking in
front of her daughter while carrying a plate. Per daughter, the
patient may have caught her foot and fallen, no observed
convulsions. Patient reports no memory of the fall, but denies
any CP, SOB, palpitations, lightheadedness, confusion after the
fall, tongue biting, or urinary incontinence. No history of
seizures. Daughter reports history of multiple falls over the
past ~2 years, always associated with tripping or instability.
The patient has very little memory of these events and is unable
to explain what she experienced during them. 1.5 years ago she
tripped while alone at home; also tripped while walking up
stairs in 11/[**2190**]. Daughter feels she is having more trouble
lifting up her feet, particularly when she is tired. Currently
does not use walker or cane to ambulate. Daughter reports she is
followed by cardiologist [**First Name9 (NamePattern2) 25495**] [**Last Name (un) 112352**] in [**Location (un) 47**] and had 24
hour monitor (likely Holter), unrevealing.
.
Daughter also reports a history of episodes of "spacing out"
which last a few minutes; have been occuring for the past year
or so. After spacing out, she has an exaggerated yawn and then
"passes out" followed 1-2 minutes later by needing to have a BM.
Reports she had an EEG about 2 years ago at [**Location (un) 47**] [**Hospital1 **]
which was unrevealing.
.
At an OSH she was found to have a small SDH, which has been
stable on serial CT head imaging. On the floor, the patient is
comfortable, denies any pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
.
Past Medical History:
ORIF Right Lefort III, closed reduction nasal fracture
HTN
GERD
Benign lump removed from neck
Multiple cystic lesions removed from breast in past, told she
has fibrocystic disease
Arthritis of knees, hands, shoulders, and feet
Social History:
Two children ([**Doctor First Name **] and [**Doctor First Name **]), 2 grandchildren. Lives with
daughter. Denies any smoking history; no EtOH, no illicits.
Family History:
non-contributory
Physical Exam:
On Admission:
O: T: 97.8 BP: 159/65 HR: 74 R 18 O2Sats 98%
Gen: WD/WN, comfortable
HEENT: Pupils: Right edema with irregular pupil.Left: [**5-3**].
Significant right orbital edema
EOMs no difficulty with left eye
Neck: non tender
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils: Right edema with steri strips, not assessed.Left:
[**5-3**].
III, IV, VI: Extraocular movements intact left without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Deltoid assessment limited by ROM, [**Hospital1 **]/Tri/Grip and LE's
[**6-4**]. Good sensation. No [**Doctor Last Name 937**] sing, no clonus.
Sensation: Intact to light touch.
Coordination: Exam limited but decreased ROM of L shoulder and
edematous R eye. Dysmetria Bilaterally, L>R. Impaired R rapid
alternating movements, heel to shin
On Discharge:
Vitals: T: 97.4 BP: 132/55 P: 79 R: 18 O2: 97% RA
FSBG: 111, 122, 101, 116, 110
General: Alert, oriented, no acute distress
Skin: No rashes or jaundice
HEENT: Right eye swollen but continuing to improve, eye now more
open, conjunctival injection of right eye; EOM intact
bilaterally; sclera anicteric, MMM, oropharynx clear
Neck: supple, no masses
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
Ext: Warm, well perfused, no clubbing, cyanosis or edema, right
second toe overlapping first toe
Neuro: A&Ox3, strength 5/5 in upper and lower extremities;
sensation intact; CN grossly intact
Pertinent Results:
CBC:
Admission: [**2191-8-15**] 10:21PM BLOOD WBC-11.5* RBC-3.87*#
Hgb-11.9*# Hct-34.7* MCV-90 MCH-30.8 MCHC-34.3 RDW-14.3 Plt
Ct-428
Diff: [**2191-8-15**] 10:21PM BLOOD Neuts-84.2* Lymphs-10.3* Monos-4.0
Eos-0.7 Baso-0.7
Discharge: [**2191-8-21**] 08:20AM BLOOD WBC-7.3 RBC-3.75* Hgb-11.6*
Hct-34.6* MCV-92 MCH-30.8 MCHC-33.4 RDW-14.0 Plt Ct-385
Coags: [**2191-8-15**] 10:21PM BLOOD PT-11.0 PTT-26.0 INR(PT)-1.0
Electrolytes:
Admission: [**2191-8-15**] 10:21PM BLOOD Glucose-106* UreaN-22*
Creat-0.8 Na-125* K-4.7 Cl-87* HCO3-27 AnGap-16
[**2191-8-16**] 05:30AM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.7 Mg-1.8
Discharge: [**2191-8-21**] 08:20AM BLOOD Glucose-109* UreaN-23*
Creat-0.8 Na-134 K-4.7 Cl-99 HCO3-24 AnGap-16
[**2191-8-21**] 08:20AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.0
TSH: [**2191-8-17**] 08:04AM BLOOD TSH-4.4*
Cortisol: [**2191-8-17**] 08:04AM BLOOD Cortsol-15.3
PTH: [**2191-8-16**] 05:30AM BLOOD PTH-75*
Vit D: [**2191-8-17**] 02:03AM BLOOD 25VitD-26*
Urine:
[**2191-8-16**] 03:52PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2191-8-16**] 05:04AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR
[**2191-8-16**] 03:52PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2191-8-16**] 05:04AM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-2
TransE-<1
[**2191-8-16**] 05:04AM URINE Hours-RANDOM Na-41 K-99 Cl-47
[**2191-8-16**] 03:52PM URINE Hours-RANDOM Creat-15 Na-58 K-22 Cl-47
[**2191-8-16**] 05:04AM URINE Osmolal-505
[**2191-8-16**] 03:52PM URINE Osmolal-233
Micro: MRSA SCREEN (Final [**2191-8-18**]): No MRSA isolated.
EKG: [**2191-8-18**]: Sinus rhythm, rate 76. Left axis deviation,
likely due to left anterior fascicular block. Compared to the
previous tracing of [**2191-7-30**] the axis is more leftward. The other
findings are similar.
IMAGING:
[**2191-8-16**] Portable CT w/o contrast:
COMPARISON: CT head without IV contrast performed [**2191-8-15**].
FINDINGS: Evaluation of the brain tissue is slightly limited
due to the
patient's motion.
There is a 7-mm subdural hematoma in the temporoparietal region
as well as a
right 4-mm subdural hematoma located in the occipital region,
both slightly
decreased in size compared to prior study.
The patient is status post open reduction and internal fixation
of right orbital fractures. Surgical mesh is seen in the right
orbit. There is no evidence of herniation of muscle or fat
through the inferior orbital wall. The multiple fractures
involving the right orbit, axilla and zygomatic process are
better seen and detected on prior studies. There is persistent
soft
tissue swelling around the right orbit. The globes are intact
bilaterally. There is bilateral opacification of the maxillary
sinus. There is opacification of the ethmoid air cells on the
right.
Normally midline structures are unremarkable. The basal cistern
appears patent and there is preservation of [**Doctor Last Name 352**]-white
differentiation. The mastoid air cells and middle ear cavities
are clear. There is no significant change and no new findings
compared with the prior study.
There is calcification in the basal ganglia bilaterally and in
the dentate nuclei of the cerebellum bilaterally consistent with
possible Fahr's disease or hyperthyroid dysfunction, that is
unchanged compared to prior study.
IMPRESSION: Multiple fractures including the right orbital
floor, maxilla and zygomatic process, unchanged from prior
studies with persistent soft tissue swelling around the right
orbit. There is no significant change compared to prior study
and no new findings.
[**2191-8-18**] CT w/o contrast:
FINDINGS: The right occipital subdural hematoma is now barely
visible and the larger right parietal subdural hematoma has also
decreased in size, with a maximum depth of 7 mm. There is
persistent minimal mass effect from the subdural hematoma in the
form of regional sulcal effacement. There is no shift of
normally midline structures. The ventricles and sulci are
otherwise normal in size and configuration. Bilateral corona
radiata, basal ganglionic
and cerebellar dentate nuclear mineralization is most consistent
with underlying Fahr disease or, less likely, hyper- or
hypoparathyroidism, as before. There is no evidence of acute
vascular territorial infarction. Multiple fractures of the
right orbit, maxilla, and zygomatic process appear stable. The
mastoid air cells and middle ear cavities are clear.
IMPRESSION:
1. Interval decrease in size of right convexity subdural
hematoma due to redistribution/resorption.
2. No new acute intracranial process to explain patient's
clinical decline is identified.
3. Likely underlying Fahr disease; correlate with clinical
evidence of movement disorder.
EEG: [**2191-8-17**]: FINDINGS:
ABNORMALITY #1: Background activity over the left hemisphere
consists of predominantly mixed [**6-6**] Hz theta with some delta
activity. During the awake state, the maximum alpha rhythm on
the left hemisphere is [**8-7**] Hz.
ABNORMALITY #2: There is absence of posterior rhythm over the
right hemisphere. There is continuous low amplitude slowing on
the right hemisphere with attenuation of faster frequencies.
BACKGROUND: Background activity over the left hemisphere
consists of predominantly mixed [**6-6**] Hz theta with some delta
activity. During the awake state, the maximum alpha rhythm on
the left hemisphere is [**8-7**] Hz. There is absence of posterior
rhythm over the right hemisphere. There is continuous low
amplitude slowing on the right hemisphere with attenuation of
faster frequencies.
HYPERVENTILATION: Is not performed due to portable study.
INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation is
not performed due to portable study.
SLEEP: Sleep is not recorded.
CARDIAC MONITOR: A single EKG channel shows a generally regular
rhythm with an average rate of 100-120 bpm.
IMPRESSION: This is an abnormal waking EEG because of due to
slow posterior dominant rhythm, continuous focal slowing, absent
alpha rhythm, and attenuation of faster frequencies over the
right hemisphere indicative of focal cortical and subcortical
dysfunction on the right likely secondary to subdural hematoma.
In the left hemisphere, there is mild to moderate diffuse
background slowing indicative of mild to moderate diffuse
cerebral dysfunction which is etiologically non-specific. No
epileptiform discharges or electrographic seizures are present.
Brief Hospital Course:
This is an 84 y.o woman with a history of HTN who presents with
multiple falls of unknown etiology, orbital/facial fractures,
found to have a small SDH and hyponatremia. She is also
confirmed to have bilateral brain calcifications in the basal
ganglia and cerebellum seen on her recent admission, which are
concerning for Fahr's disease and could at least partially
explain the patient's reported gait abnormalities and recurrent
falls. Decreased oral intake in the setting of her recent facial
fracture, as well as now-discontinued HCTZ likely contributed to
the fall leading to this admission, as well.
.
# Falls: As noted, there is a strong suspicion that the
patient's falls may be related to the calcifications noted on
imaging, and the clarification of the diagnosis will require
close neurology follow-up. We discussed with the patient and her
HCP that we do not yet have a prognosis associated with the
possible diagnosis, but that this should be forthcoming as her
outpatient work-up continues. Per the patient's and her
daughter's story of the falls, they appear to be due to a
worsening unsteady gait leading to mechanical falls. The
patient has little recollection of the falls, but per her
daughter she does not lose consciousness prior to falling. The
unsteady gait may be associated with the significant basal
ganglia and cerebellum calcifications, likely representing
Fahr's disease, as noted below. She was evaluated by neurology
who did not note a clear movement disorder or ataxia. While
inpatient, cardiac causes for falls were ruled out with a normal
EKG and no events on telemetry. She had an EEG which did not
have evidence of epilepsy; however, given her daughter's
descriptions of "spacing out" seizures remain possible. While
inpatient, she was maintained on [**Month/Day (3) 13401**] largely due to the
subdural hematoma (see below), but will continue this until her
outpatient neurology follow up in a month. While inpatient she
also worked with physical therapy to build up her strength and
was given a walker to use at home; she will continue with
outpatient physical therapy at home and will be re-evaluated by
neurology in one month to reassess her gait.
.
# Calcifications in basal ganglia and cerebellum: Noted on CT,
likely Fahr's disease. She had a metabolic work up to
determine other causes of calcification, which revealed a mildly
elevated PTH determined to be due to vitamin D deficiency, but
this was not felt adequate to explain the degree of
calcifications. She was started on vitamin D repletion, per
below. Per neurology, if the calcifications do represent Fahr's
disease, there may not be a specific treatment to reverse this
condition.
.
# Vitamin D deficiency: Normal Ca and Phos, mildly elevated PTH,
consistent with secondary hyperparathyroidism due to vitamin D
deficiency, will likely resolve with repletion of vitamin D.
Started on vitamin D [**2179**] units daily, to be continued on
discharge.
.
# Hyponatremia: Given urine electrolytes and euvolemia, likely
secondary to SIADH associated with the SDH, in the setting of
recently-started HCTZ. Improved from 125 to 135 with a 1200 cc
fluid restriction, which was then stable on the last day despite
liberalizing the restriction to [**2179**] cc daily. Her HCTZ was
also held, as this was likely contributing to the hyponatremia,
and we suggested that this [**Doctor Last Name 360**] not be restarted in the future
to the patient and family.
.
# SDH: Right occipital SDH and right parietal SDH initially
visualized at an OSH. Most recent head CT on [**2191-8-18**] showed that
"the right occipital subdural hematoma is now barely visible and
the larger right parietal subdural hematoma has also decreased
in size, with a maximum depth of 7 mm." She had no focal
deficits or evidence of seizure. She was started on [**Date Range 13401**] 750
mg [**Hospital1 **] for seizure ppx and will continue for one month after
discharge.
.
# Right eye injury: The patient had a recent facial/orbital
fracture with repair and plate placement by plastic surgery on
[**2191-8-8**]. She was seen by plastic surgery on this admission, who
noted no new fractures and confirmed that the plate remained in
place. She was also seen by ophthalmology in the ED. She was
continued on dorzolamide eye drops throughout her admission, and
her right eye improved significantly, with improvement both in
swelling and in vision.
.
# HTN: Has been on atenolol and more recently added losartan and
HCTZ at home. In hospital, HCTZ stopped due to hyponatremia.
Losartan was continued on her home dose. Her atenolol was also
decreased to 12.5 mg daily because her blood pressure had been
running low; now with SBP in the 120s-130s on day of discharge.
.
# Hyperlipidemia: Stable, continued home atorvastatin.
.
# GERD: Stable, continued home omeprazole.
.
# RUL pulmonary nodule: Incidental finding on CT at last
admission; patient reminded of this finding and encouraged to
follow up with PCP.
.
# Left breast mass (incidental finding): Incidental finding on
CT at last admission; patient reminded of this finding and
encouraged to follow up with PCP.
.
# Goals of care: Confirmed full code. Primary contact is
daughter [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 112353**] or cell [**Telephone/Fax (1) 112354**]; second
contact is [**Name (NI) **] [**Name (NI) **] [**0-0-**] (ok to leave messages)
.
# Transitions
1) Sodium to be rechecked outpatient [**2191-8-23**]
2) Home PT, new assistive device (walker)
3) Follow up with neurology in 1 month for further discussion of
potential diagnosis and prognosis.
4) Now on [**Month/Day/Year 13401**], likely will be able to discontinue this
medication in 1 month at neurology follow up
5) Blood pressure medications decreased to continue home
losartan, continue atenolol but at lower dose (12.5 mg daily),
and stop HCTZ given hyponatremia
6) On continued fluid restriction at [**2179**] cc daily; will need to
be monitored by PCP
7) Incidental findings on CT at last admission that need follow
up: left breast mass and RUL pulmonary nodule
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Atenolol 25 mg PO BID
2. Atorvastatin 20 mg PO HS
3. losartan-hydrochlorothiazide *NF* 100-25 mg Oral Daily
4. Omeprazole 20 mg PO DAILY
5. cefaDROXil *NF* 500 mg Oral Q 12 hrs
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE [**Hospital1 **]
Discharge Medications:
1. Outpatient Lab Work
Please check sodium on [**8-23**] and fax results to [**Telephone/Fax (1) 46473**].
Icd-9 code: hyponatremia
2. Atenolol 12.5 mg PO DAILY
Hold for SBP < 110, HR < 60
3. Atorvastatin 20 mg PO HS
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE [**Hospital1 **]
5. Omeprazole 20 mg PO DAILY
6. LeVETiracetam 750 mg PO BID
7. Vitamin D [**2179**] UNIT PO DAILY
8. Losartan Potassium 25 mg PO DAILY
Hold for SBP < 110
9. Senna 1 TAB PO BID:PRN Constipation
10. Docusate Sodium (Liquid) 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Right Acute Subdural Hematoma
Hyponatremia
Bilateral Basal Ganglia Calcifications
Bilateral Cerebellar Calcifications
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 participating in your care at [**Hospital1 18**]. You were
admitted after a fall in which you hit your right eye. As you
recently had surgery for repair of a facial fracture in the same
location, you were seen by your plastic surgeon. You do not
have any new fractures, and the surgical plate is still in the
right place.
As a result of the fall, you were found to have a small bleed in
your brain called a subdural hematoma, which has remained stable
throughout your hospital stay. You were started on [**Last Name (LF) 13401**], [**First Name3 (LF) **]
anti-seizure medication, to prevent seizures that sometimes
occur when people have blood in the brain. You should continue
this medication until you follow up with your neurologist in
about one month. You did have an EEG while you were here which
did not show any evidence of seizures.
As a result of the bleed in your brain, you developed low sodium
in the blood. This improved with daily fluid restriction to 2
L. Please continue this when you go home until you see your
primary care physician, [**Name10 (NameIs) 10139**] you should discuss this with them.
We also stopped your HCTZ, which was likely contributing to the
low sodium. You will need to have your sodium rechecked
outpatient on [**2191-8-22**].
You were also found to have calcifications in your brain located
in the basal ganglia and cerebellum, which are areas of the
brain involved with movement and balance. This may be something
called Fahr syndrome, and these may be contributing to your
falls. The neurology team evaluated you and did not note
significant problems with your ability to walk and no other
movement disorders; however, they would like to follow up with
you in one month to re-evaluate how you are walking. You will
have home physical therapy to help gain your strength back to
help prevent future falls.
You were also evaluated for other causes of falls, and you did
not have any sign of a cardiac cause for the falls such as an
arrhythmia. You did not drop your blood pressure when standing,
which can be a cause for falls.
Also please remember to follow up with your primary care doctor
about the lung nodule and breast mass that were identified
incidentally on imaging.
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Use an over the counter stool softener (such as Colace), as
narcotic pain medicine can cause constipation.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2191-8-22**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3074
} | Medical Text: Admission Date: [**2136-9-30**] Discharge Date: [**2136-10-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Transfered to [**Hospital Unit Name 153**] for monitoring of respiratory status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82yo nursing home resident who presented with increased
secretions, restlessness, epsiodes of vomiting and suspected
aspiration, O2 Sats 81-84%, with cyanotic extremities. He did
not improve on Abx regimen (Flagyl, cetriaxone, levaquin) that
was given in the NH. He was brought to the ED where he was found
to be febrile to 104.2, tachypneic, hypoxic and dehydrated. His
saturations were improving on 100% NRB-mask initially and O2 was
weaned down to 50%. A CXR showed b/l LL infiltrates. The pt was
started on Vancomycin and Zosyn and was transfered to the [**Hospital Unit Name 153**].
Past Medical History:
h/o CVA- baseline aphasic
CAD
h/o CHF
Schizoaffective d/o
Dementia
Hypercholesterolemia
Aspiration risk- on honey thickened liquids
Chronic back pain
Social History:
Independent with feeding per NH. Nonverbal at baseline.
Ambulates with walker. Pt has a guardian- [**Name (NI) **] [**Name (NI) 29768**] ([**Telephone/Fax (1) 42014**]
Family History:
Non-contributory
Physical Exam:
T 98.6 BP 167/75 RR 23 O2sats 94% RA
Gen: Moaning, thrashes to stimulation, no verbal response
HEENT: PERRLA, EOMI, scelar anicteric, clear OP, dry mm
Neck: no JVD
Lungs: Crackles at bases b/l
Heart: RRR, no m/r/g
Ext: no c/c/e, peripheral dorsal pulses b/l not perceived
Neuro: aphasic at baseline, commmunicates through hand gestures.
Moving all 4 extremeties.
Pertinent Results:
[**2136-9-29**] 11:55PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2136-9-29**] 11:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-7.0 LEUK-SM
[**2136-9-29**] 11:55PM URINE RBC->50 WBC-[**4-21**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2136-9-29**] 11:55PM URINE MUCOUS-FEW
[**2136-9-29**] 11:41PM COMMENTS-GREEN TOP
[**2136-9-29**] 11:41PM LACTATE-1.7 K+-3.2*
[**2136-9-29**] 11:35PM GLUCOSE-105 UREA N-15 CREAT-0.9 SODIUM-151*
POTASSIUM-3.3 CHLORIDE-116* TOTAL CO2-25 ANION GAP-13
[**2136-9-29**] 11:35PM CK(CPK)-154
[**2136-9-29**] 11:35PM cTropnT-0.01
[**2136-9-29**] 11:35PM WBC-14.6* RBC-4.30* HGB-12.8* HCT-37.2*
MCV-87 MCH-29.7 MCHC-34.3 RDW-15.6*
[**2136-9-29**] 11:35PM NEUTS-87.3* LYMPHS-9.6* MONOS-2.6 EOS-0.5
BASOS-0.1
[**2136-9-29**] 11:35PM PLT COUNT-190
[**2136-9-29**] 11:35PM PT-16.5* PTT-38.6* INR(PT)-1.8
Brief Hospital Course:
Per history from the nursing home the patient had an aspiration
event and which was followed by severe respiratory problems. [**Name (NI) **]
was started on Flagyl, cetriaxone, levaquin for aspiration
pneumonia but did not respond to the regimen. The pt was then
brought to the [**Hospital1 18**] emergency department where he presented
with fever to 104.2, tachpneia, hypoxemia and dehydration.
Patient was found to have bilateral lower lobe infiltrates on
CXR and was placed on Vancomycin and Zosyn for broad coverage.
On admission to the [**Hospital Unit Name 153**] the patient was found to be hypoxic and
hypercarbic which was attributed to a severe pneumonia together
with a component of mild CHF. As the patient did not improve
under therapy with Zosyn and Vancomycin, Vancomycin was switched
to Linezolid for better lung penetration. Zosyn was continued in
the setting of respiratory failure with a precipitating
aspiration event although sputum cultures were only positive for
MRSA. All blood cultures were negative. The patient was also
diuresed mildly for possible CHF. The pt' respiratory status
continued to deteriorate despite aggressive therapy and he
required 100% on a NRB mask in addition to oxygen by nasal
canula. He was uncomfortable, tachycardic and tachypneic. The pt
was hard to approach as his level of understanding was unclear.
[**Name2 (NI) **] did not follow commands when he was addressed by a
translator. He became agitated when invasive procedure, such as
blood draws, were performed. His understanding of the necessity
of these procedures was unclear. His agitation was initially
controlled with Haldol but Haldol had to be stopped as it lead
to a prolongation of the QT interval. As the patient became more
and more tachypneic and uncomfortable, control of is agitation
was only possible with increasing doses of morphine and
lorazepam, which surpressed his respiratory drive further. He
required frequent suctioning which led to further agitation. As
the pt was DNR, DNI intubation was not an option. The family as
well as the legal guardian were approached and were explained
the severity of his condition. It was explained that aggressive
treatment and comfort of the pt were not compatible and the
family as well as the legal guardian agreed on having the pt on
comfort measures only. Abx were withdrawn an the pt was made
comfortable with a Morphin-drip and Ativan. A scopolamine patch
was applied to decrease respiratory secretions. The patient
expired on [**2136-10-6**].
Medications on Admission:
depakote 500 am/375 pm,
protonix 40mg qday,
risperidone 0.5mg qhs,
trazadone 50mg qhs,
asa 325mg qday,
lasix 40mg [**Hospital1 **],
motrin 200mg tid prn,
lipitor 10mg qday,
atenolol 25mg qday
Discharge Medications:
None
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4657**] - [**Location 1268**]
Discharge Diagnosis:
Expired [**2136-10-6**]
Discharge Condition:
Expired
ICD9 Codes: 5070, 4280, 2760, 2765, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3075
} | Medical Text: Admission Date: [**2185-5-31**] Discharge Date: [**2185-6-3**]
Date of Birth: [**2161-3-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Fever, flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
24 year old woman presents with 2 days of dysuria, frequency and
1 day of fever and nausea and flank pain which radiated to her
left shoulder. Has had 2 uncomplicated UTIs in past 4 years. Pt
was seen in [**Hospital 191**] clinic on [**5-30**] for UTI sx and was prescribed
Bactrim. Also took Cipro x1 today prior to presentation.
In the ED, initial VS were: 103.4 123 94/62 18 98%/RA. Labs were
notable for: Urine HCG - neg, UA - nitrite+, 18 WBCs, WBC of
16.5. Ceftriaxone was administered. Blood cultures and urine
cultures were sent. Tylenol and ibuprofen were administered. Pt
received 6L NS with improvement of MAP's to the 70's. CT ab and
pelvis showed striated enhancement of the left kidney,
compatible with pyelonephritis. Pt was admitted to the ICU for
pyelonephritis and presumed sepsis.
On the floor, vitals 98.9 90 85/61 14 100%RA. Pt is
comfortable, requesting a diet, with reduction in her pain and
symptoms.
Past Medical History:
Previously healthy
Social History:
Works as a research coordinator at [**Hospital1 112**]
- Tobacco: None
- Alcohol: Minimal social
- Illicits: None
Family History:
non-contributory
Physical Exam:
Admission PE:
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, minor tenderness in LLQ and suprapubic area,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly, + CVA tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge PE as above, except no longer had any CVA tenderness
Pertinent Results:
Admission labs:
[**2185-5-31**] 03:04PM BLOOD Lactate-1.4
[**2185-6-1**] 02:19AM BLOOD Albumin-3.1* Calcium-6.6* Phos-2.5*
Mg-1.5*
[**2185-5-31**] 03:00PM BLOOD Glucose-99 UreaN-9 Creat-0.8 Na-136 K-3.6
Cl-106 HCO3-19* AnGap-15
[**2185-5-31**] 03:00PM BLOOD Plt Ct-189
[**2185-6-1**] 02:19AM BLOOD PT-15.4* PTT-31.5 INR(PT)-1.3*
[**2185-5-31**] 03:00PM BLOOD WBC-16.5*# RBC-4.35 Hgb-13.2 Hct-36.5
MCV-84 MCH-30.3 MCHC-36.0* RDW-13.0 Plt Ct-189
[**2185-5-31**] 03:00PM BLOOD Neuts-93.2* Lymphs-4.0* Monos-2.6 Eos-0.1
Baso-0.2
Labs prior to discharge:
...
Micro:
URINE CULTURE (Final [**2185-6-1**]): ESCHERICHIA COLI. >100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
ESCHERICHIA COLI
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Imaging:
[**2185-5-31**] Abd CT: 1. Striated appearance of the left kidney,
concerning for pyelonephritis in the setting of fever and
dysuria. No fluid collections or abscesses are detected. 2.
Trace bilateral pleural effusions.
[**2185-5-31**] CXR: Low lung volumes with streaky opacities in lung
bases, likely
reflective of atelectasis. Small bilateral pleural effusions.
RENAL ULTRASOUND [**2185-6-3**]:
IMPRESSION: Normal renal ultrasound. In particular, no evidence
to suggest
an inflammatory process involving either kidney. Please note
that ultrasound
is insensitive for pyelonephritis overall.
V/Q SCAN [**2185-6-3**]: preliminary read negative, final read pending
Brief Hospital Course:
24F previously healthy p/w dysuria, urgency, fever and flank
pain found to have pyelonephritis secondary to E. coli. She was
treated with ciprofloxacin 500 mg twice daily. However, she was
slow to improve and continued to be febrile on hospital day #3.
Given this, she will be given a 14-day course of ciprofloxacin.
Of note, she was significantly tachycardic on admission, with
improvement with intravenous fluids but never completely
resolved. She hovered in the 90's to 100's. Given the elevated
heart rate, a TSH was checked, which was within normal limits.
A D-dimer was checked which was elevated. Given this, a V/Q
scan was performed and this was negative. At the time of
discharge, her heart rate was in the 90's.
#Sepsis/pyelonephritis/E. Coli urinary tract infection: Most
likely due to pyelonephritis as above. Initially tachycardic,
febrile to 102.5 with a leukocytosis (16.5). She was initially
treated with IV ceftriaxone and then changed to oral
ciprofloxacin. As above, given the slow clinical response, she
was prescribed a 14-day course of antibiotics.
#Tachycardia: As above, this was mostly due to her infection
and SIRS physiology. She improved with IV fluids but remained
in the 90's to 100's. A TSH was checked and was normal, a
d-dimer was noted to be elevated, a V/Q scan was negative
however.
***
TRANSITIONAL ISSUES:
- check heart rate
Medications on Admission:
Birth control
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with pyelonephritis (a kidney
infection). You were treated with IV fluids and antibiotics.
You improved with treatment. You will need to complete your
course of ciprofloxacin (through [**2185-6-14**]).
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2185-6-7**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15675**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2762, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3076
} | Medical Text: Admission Date: [**2118-3-31**] Discharge Date: [**2118-4-20**]
Date of Birth: [**2071-11-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
fluid overload
Major Surgical or Invasive Procedure:
ultrafiltration
paracentesis
pleurocentesis
History of Present Illness:
46 yo F with history of CHF, atrial fibrillation, DMII, HTN who
presented to the ED with dyspnea.
*
Ms. [**Known lastname **] states that she was originally diagnosed with CHF, as
well as afib and DM while hospitalized at NEBH in [**2114**]. She
reports no prior ETT or catheterizations, though was begun on
beta-blocker and lasix. The mechanism of her CM is unknown, and
she denies any pregnancies, ETOH use, or IVDU. She is unsure of
her dry weight, though notes that she has weighed as little as
180lbs last fall. She has not weighed herself recently, though
believes that she has gained significant weight recently
(reports '[**63**] lb weight gain over 1 week', though has not weighed
herself). She noted increased abdominal girth approximately 2
months ago, and was seen by her PCP/cardiologist, Dr. [**Last Name (STitle) 9751**], who
doubled her lasix dose from 160 QD -> [**Hospital1 **]. However, despite the
increased lasix dose, she has experienced worsening dyspnea on
exertion progressively, with worsening abdominal distension, LE
edema and PND (has stable 2 pillow orthopnea), early satiety and
decreased PO intake. SHe has not experienced any chest
discomfort or nausea. She has noted LH recently, and self d/c'd
her atenolol several days ago.
*
ED course notable for administration of lasix IV, as well as
administration of nitropaste. She was also noted to have afib
with RVR, with rates in the 100-130 range, though was not given
beta-blocker out of concern for further decompensating her CHF
Past Medical History:
CHF - diagnosed [**2114**]
CM - RV/LV systolic dysfunction, etiology unknown. No prior ETT
or Cath.
afib diagnosed [**2114**], s/p cardioversion (reamined in SR for 24
hrs), chronically anticoagulated on coumadin
obesity
Social History:
denies smoking/ETOH
Family History:
h/o pancreatic CA
Physical Exam:
T97 BP 80-90s/40-60s HR 70
Gen-sitting in chair eating breakfast in no acute distress
HEENT-anicteric, oral mucosa moist, neck supple,JVD to ear
CV-rrr, no r/m/g
resp-slight decreased breath sounds R base, no wheezes/rhonchi
[**Last Name (un) 103**]-distended, +ascites, active bowel sounds, nontender
extremites-no femoral bruit, no peripheral edema, DP
1+bilaterally, small ulcers on distal LE in bandages, bilateral
inguinal 2cm nontender LAD, no axillary or cervical LAD
skin-no rash or lesions
GU-pelvic exam: no cervical motion tenderness or visible
lesions. normal external anatomy. no masses on bimanual exam. no
breast masses.
Pertinent Results:
Admission Labs [**2118-3-31**]:
PT-15.5* PTT-25.9 INR(PT)-1.5
WBC-8.2 RBC-6.04* HGB-10.4* HCT-36.2 MCV-60* MCH-17.3*
MCHC-28.8* RDW-20.0*
NEUTS-78* BANDS-0 LYMPHS-10* MONOS-10 EOS-1 BASOS-1 ATYPS-0
METAS-0 MYELOS-0 PLT COUNT-379
GLUCOSE-208* UREA N-77* CREAT-2.1* SODIUM-130* POTASSIUM-3.3
CHLORIDE-84* TOTAL CO2-30* ANION GAP-19 CALCIUM-10.0
PHOSPHATE-5.5* MAGNESIUM-2.6
ALT(SGPT)-10 AST(SGOT)-19 CK(CPK)-46 ALK PHOS-128* AMYLASE-83
TOT BILI-1.2
LIPASE-85* LD(LDH)-188
CK(CPK)-38 CK-MB-NotDone cTropnT-0.03*
URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 RBC-14* WBC-0
BACTERIA-NONE YEAST-NONE EPI-<1 BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG OSMOLAL-305 UREA N-301 CREAT-35 SODIUM-32
%HbA1c-6.4*
TSH-5.3* Free T4-1.2
calTIBC-484* VIT B12-705 FOLATE-7.5 FERRITIN-29 TRF-372* RET
MAN-1.0
Hb Electropheresis: Hgb A-96.9 Hgb S-0 Hgb C-0 Hgb A2-2.1* Hgb
F-1.0
.
Discharge Labs:
[**2118-4-20**] 08:46AM BLOOD WBC-7.7 RBC-5.01 Hgb-9.2* Hct-33.0*
MCV-66* MCH-18.4* MCHC-28.0* RDW-22.0* Plt Ct-488*
Glucose-96 UreaN-27* Creat-1.2* Na-136 K-4.1 Cl-97 HCO3-26
AnGap-17
Calcium-9.9 Phos-2.8 Mg-1.9
.
Other:
HIV Ab-NEGATIVE
SPEP-NO SPECIFIC ABNORMALITIES SEEN
UPEP-MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING. NO
MONOCLONAL IMMUNOGLOBULIN SEEN. NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN
CEA-5.3* AFP-2.8 CA125-632* CA [**32**]-9=18
[**Doctor First Name **]-POSITIVE Titer-1:40
.
C.CATH Study Date of [**2118-4-19**]
1. One vessel coronary artery disease. . The LAD had a total
occlusion of the distal vessel with the apical LAD filling by
left to left collaterals
2. Moderately elevated right and left sided filling pressures.
3. Moderately elevated pulmonary arterial hypertension.
4. Depressed cardiac output. Cardiac index was low (at 2.2
L/min/m2).
.
STRESS Study Date of [**2118-4-13**]
No anginal symptoms or ECG changes from baseline. Left
ventricular enlargement with depressed EF calculated at 32% with
regional wall motion abnormalities as above involving the
septum, apex and inferior walls. No reversible defects
identified.
.
ECHO Study Date of [**2118-3-31**]
LA/RA/LV/RV dilated. LVEF 20-30%. Severe apical akinesis and
midventricular HK. Abnormal septal motion/position consistent
with right ventricular pressure/volume overload. Branch
pulmonary arteries are dilated. There is a small pericardial
effusion subtending the right atrial free wall, without evidence
of cardiac tamponade. PA systolic pressure is significantly
elevated. 3+MR, 3+TR.
.
Pleural Fluid Cell Block [**2118-4-18**]: Negative.
Peritoneal fluid cell block/cytology [**2118-4-11**]: Negative.
.
EGD [**2118-4-14**]:
Duodenal mucosa with chronic inactive duodenitis and mild
villous shortening. Chronic inactive duodenitis with Brunner
gland hyperplasia and gastric mucous cell metaplasia.
.
CT ABDOMEN W/O CONTRAST [**2118-4-11**]
1) No sign of fistulous communication between the bowel and
intrabdominal ascites.
2) Large amount of slightly hyperdense intra-abdominal ascites,
possibly representing high proteinaceous contents vs small
blood.
3) 6.0 x 3.4 cm Spigelian hernia in right abdominal subcutaneous
tissue.
4) Possible omental carcinomatosis vs. fat-stranding in RLQ.
5) Left 8th old rib fracture.
6) Diffuse diverticulosis without evidence of acute
diverticulitis.
.
US ABD LIMIT, SINGLE ORGAN [**2118-4-5**]
1) Patent intrahepatic vasculature, as discussed above. Dilated
hepatic veins and IVC consistent with right heart failure.
2) Cholelithiasis.
3) Large right pleural effusion. Moderate abdominal ascites.
4) Mild splenomegaly.
.
PELVIS, NON-OBSTETRIC [**2118-4-12**]
Normal pelvic ultrasound without evidence of ovarian or adnexal
masses. Ascites.
.
UNILAT UP EXT VEINS US RIGHT [**2118-4-2**]
Thrombosis of the right IJ and right subclavian vein.
.
CXR [**2118-4-12**]: Pleural effusion associated with compression
atelectasis of the right lower lobe and the right middle lobe
w/free layering. Several healing rib fractures on the left side
are noted. Primarily involving left fifth, sixth, and seventh
ribs laterally.the right upper lobe and the entire left lung are
clear. No evidence of pneumothorax.
.
Micro
Blood, Urine, Ascites, and Pleural Fluid cultures with no growth
Brief Hospital Course:
46 year old female with CHF, atrial fibrillation, DMII, HTN, and
asthma presents with CHF exacerbation (compaint of dyspnea in
the ED) refractory to increased home lasix dosages. Admitted to
the CCU for tailored therapy after failing nesiritide on the
floor.
*
Cardiovascular
Echocardiogram revealed global chamber dilation with
estimated EF 20-30%. The apex was akinetic. Additionally, there
was severe hypokinesis of the midventricular segments and right
ventricular. Valvular abnormalities included 3+MR and 3+TR.
Persantine-MIBI stress testing reported left ventricular
enlargement with depressed EF calculated at 32%. Regional wall
motion abnormalities involved the septum, apex and inferior
walls. No reversible defects were noted. No angina or ECG
changes were seen. Diagnostic cardiac catheterization showed
single vessel disease with a discrete distal LAD 100% lesion
with collateral supply.
A large differential for dilated cardiomyopathy was
possible; including ischemic cardiomyopathy, infectious
cardiomyopathy (viral cardiomyopathy, HIV infection, Chagas'
disease, Lyme disease), toxic cardiomyopathy(Alcohol, Cocaine,
Medications,Trace elements, familial dilated cardiomyopathy,
inherited disorders(Hereditary hemochromatosis, neuromuscular
diseases, left ventricular noncompaction, sideroblastic anemias
and thalassemias, peripartum cardiomyopathy,
tachycardia-mediated cardiomyopathy, takotsubo cardiomyopathy,
SLE, Sarcoidosis, or nutritional deficiencies. Tests indicated
the following: TSH normal, ferritin normal, HIV negative, [**Doctor First Name **]
negative. The patient was enrolled in the UNLOAD trial and
randomized to Ultrafiltration, enabling removal of over 28L of
fluid. In conjunction with diuresis, paracentesis, and
pleurocentesis over 35L of fluid was lost over the hospital
visit. A fluid restricted, low Na diet was followed. She was
discharged on a diuretic regimen including aldactone and lasix.
Follow up in Dr.[**Name (NI) 23312**] clinic was arranged.
For coronary artery disease, the patient received ASA,
metoprolol, atorvastatin, and lisinopril. For atrial
fibrillation diagnoses in [**2115**] in addition to a right internal
jugular venous thrombus discovered this hospital visit, she
received IV heparin per sliding scale while an inpatient. Rate
was controlled with metoprolol. She was discharged on coumadin
with lovenox bridging. She was monitored on telemetry
continuously revealing chronic atrial fibrillation with
occasional tachycardia (with nebulizer therapy) and PVCs.
.
Pulmonary
The patient had history of obstructive sleep apnea and COPD. She
had chronic cough improved after nebulizer therapy. She was
started on atrovent, fluticasone inhalation, and singulair. The
patient had persistent right pleural effusion most likely due to
CHF. Pleurocentesis was performed by interventional pulmonology
service and appeared as a transudative fluid with the same
consistency as the ascites.
.
Gastrointestinal
The patient had chronic ascites with high CA-125 in 600s,
prompting an extensive oncologic workup (see below).
Pracentesis on [**4-6**] removed approximately 3L ascitic transudate
lacking malignant cells. Approximately 5L bloody fluid was
removed by paracentesis on [**4-11**] and was similarly transudative.
However, the source of the blood was unclear. Fluid cultures and
gram stains were all negative. Thus, an abdominal CT with oral
contrast was performed that did not reveal a bleeding source.
The right lower quadrant appeared to have possible omental
carcinomatosis versus fat stranding. Abdominal ultrasound
revealed no venous occlusion, dilated hepatic vein consistent
with heart failure, cholelithiasis, large right pleural
effusion, moderate ascites, and mild splenomegaly. Endoscopic
gastroduodenoscopy gastritis and 2 nonbleeding anterior gastric
ulcers. The biopsy was consistent with chronic inactive
duodenitis with Brunner gland hyperplasia and gastric mucous
cell metaplasia. No sprue was seen. Colonoscopy noted
diverticulosis and hemorrhoids. She did not have transaminitis
or hyperbilirubinemia.
.
Endocrine
The patient followed a routine regimen including glargine and
insulin per sliding scale for diabetes. Thyroid function tests
were normal.
.
Hematology
Hematocrit was stable with baseline in the low 30s. She had
microcytic anemia with iron deficiency. She was treated with
iron supplementation and vitamin C. HbA2 was reduced on
electropheresis and should be rechecked after iron stores are
replenished in order to evaluate for alpha thallesemia trait.
SPEP/UPEP was negative. No active bleeding source was found on
colonoscopy or EGD; however, a small bowel source could not be
exluded.
.
Oncologic Workup
The patient had elevated ca-125 and slightly increased CEA. She
also had microcytic anemia and a thrombotic disorder. On exam,
bilateral inguinal lymphadenopathy was present and the firm 2cm
mobile nodes were occasionally tender. No other lymphadenopathy
was found and the abdominal CT did not show enlarged mesenteric
nodes. Ovaries appeared normal on ultrasound. Cytology from
fluid samples were negative for malignant cells. The markers
tested have limited specificity and can be elevated
nonspecifically in ascites. Serum CA19-9 level was normal. The
patient was recommended to aggressively continue preventative
screening measures, including repeat pelvic exam/pap smear,
baseline mammogram, and routine skin and breast exams. She will
follow up with gynecology as an outpatient.
.
Renal
The patient had chronic renal insufficiency with baseline
creatinine near 1.6. She had transient acute failure likely
prerenal (low FeUrea) from decreased perfusion from CHF
exacerbation and diuresis with lasix.
.
Skin
Self-excoriations improved on benadryl, triamcinolone, and sarna
lotion. Alopecia resulted from trichotillomania that the patient
has had since a teenager.
.
Wellbutrin was prescribed to assist with both tobacco abuse and
mood.
Medications on Admission:
Singulair, pantoprazole, insulin , atrovent, iron gluconate 300
mg p.o. [**Hospital1 **],
digoxin, aspirin, metoprolol, atorvastatin 40 mg, furosemide
160mg [**Hospital1 **], coumadin
Discharge Medications:
1. Folic Acid 1 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. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
11. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) Units
Subcutaneous at bedtime: Take 30 units every evening as
directed.
Disp:*1 vial* Refills:*0*
12. 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:*0*
13. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
Disp:*20 injections* Refills:*0*
14. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*15 Tablet(s)* Refills:*0*
16. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
17. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily).
19. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for pruritis: (Benadryl).
20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
21. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
22. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
23. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
24. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*2 MDI units* Refills:*0*
25. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical TID (3 times a day).
26. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig:
One (1) Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*2 vials* Refills:*0*
27. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
28. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
Disp:*15 Capsule, Sustained Release(s)* Refills:*0*
29. Insulin Syringe Syringe Sig: use as directed Miscell.
as directed: Disp one box (100 count).
Disp:*1 box* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Decompensated congestive heart failure, with EF 25%
iron deficiency anemia
hypercholesterolemia
Discharge Condition:
good
Discharge Instructions:
Please take all your medications as described on the next page.
Weigh yourself each day and call your doctor if you gain more
than 3 pounds. It is very important that you adhere to a low
salt diet (less than 2 grams of sodium per day.) Consume no more
than 1.5 liters of liquids per day.
Followup Instructions:
Be sure to follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 9752**]
within 2 weeks.
Please follow up with Dr. [**Last Name (STitle) **]. Call for appointment
([**Telephone/Fax (1) 3512**]) within 1 week.
You must have your INR (coumadin effect level) measured on
Friday [**4-22**]. At that time they will adjust your coumadin dose if
needed.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
ICD9 Codes: 4280, 5849, 4254, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3077
} | Medical Text: Admission Date: [**2189-12-7**] Discharge Date: [**2189-12-11**]
Date of Birth: [**2133-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
? Sepsis
Major Surgical or Invasive Procedure:
Removal of HD catheter
History of Present Illness:
56M ESRD:PD here w/ lethargy and low blood pressure. Pt has had
fairly difficult course with multiple failed HD access as well
as cath infections, recently started on peritoneal dialysis with
occasional HD for fluid removal. Combined HD/PD therapy has been
instituted for the last two months, which is when patient's wife
noted that he was becoming relatively hypotensive. USOH of this
health until ~ 2 weeks ago, developed increasing lethargy, worse
over last two days. In addition, noted to have lower BP 60s-
100s, and notably more lethargic following hemodialysis and
during hypotensive sessions. Otherwise, was told to increase
sodium intake outside of dialysis with some good effect on blood
pressure, but recurrent lower extremity edema - which is primary
measurement of fluid status.
In addition, over last two days, has developed diarrhea, as well
as nausea and vomiting today. Furthermore, low grade fever, but
no chills over last day. Otherwise, no CP, abdominal pain,
occasional shortness of breath, especially today, recent
development of non-productive cough over last day, states having
decreased appetite. Of note, did not have HD last week.
Past Medical History:
1. ESRD: [**2-5**] anti-GBM disease, on HD since [**3-7**], then PD since
[**9-9**]
2. DM2
3. HTN
4. Chronic low back pain [**2-5**] herniated discs
5. CHF
6. Peripheral neuropathy
7. Anemia
8. h/o nephrolithiasis
9. s/p cervical laminectomy; ?osteo in past
10. h/o depression
11. h/o MSSA bacteremia ([**3-9**]-infected HD catheter), E. coli
bacteremia
12. s/p L AV graft: [**7-7**]
13. h/o [**12-7**] of L4-5 diskitis, osteo, epidural abscess
14. MRSA cath tip infection
Social History:
Lives w/ wife, son, daughter-in-law, and three grandchildren in
[**Location (un) 86**] area, has been unemployed [**2-5**] disability, smokes tobacco
1 ppd x45 years, past alcohol, no recreational drug use.
Family History:
NC
Physical Exam:
VS T 99.5 BP 116/53 HR 93 RR 24 O2Sat 100% on 2L
Gen: NAD, AAOx3
HEENT: NC/AT, PERRLA, mmm, pale conjunctiva
NECK: no LAD, JVD at 6cm
COR: S1S2, regular rhythm, no r/g, [**1-9**] high pitched murmur over
precordium non radiating
PULM: CTA b/l, no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, mild tenderness over lower
abdomen, no rebound or guarding
Skin: warm extremities, no rash, multiple small ecchymosis over
the chest and arms
EXT: 2+ DP, no edema/c/c
Neuro: moving all extremities, following commands, PERRLA
Pertinent Results:
[**2189-12-7**] 03:00PM GLUCOSE-86 UREA N-35* CREAT-11.1*# SODIUM-138
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-21
[**2189-12-7**] 03:00PM estGFR-Using this
[**2189-12-7**] 03:00PM ALT(SGPT)-9 AST(SGOT)-18 LD(LDH)-220
CK(CPK)-181* ALK PHOS-115 TOT BILI-0.2
[**2189-12-7**] 03:00PM CK-MB-7 cTropnT-0.67* proBNP-[**Numeric Identifier **]*
[**2189-12-7**] 03:00PM ALBUMIN-3.3*
[**2189-12-7**] 03:00PM HAPTOGLOB-306*
[**2189-12-7**] 03:00PM PT-32.4* PTT-43.4* INR(PT)-3.5*
[**2189-12-7**] 03:00PM D-DIMER-1027*
[**2189-12-7**] 01:41PM LACTATE-2.4* NA+-142 K+-5.0 CL--104
[**2189-12-7**] 01:30PM WBC-6.7 RBC-3.85* HGB-12.2* HCT-38.3*
MCV-100*# MCH-31.6# MCHC-31.7 RDW-19.9*
[**2189-12-7**] 01:30PM NEUTS-80.6* BANDS-0 LYMPHS-10.4* MONOS-5.8
EOS-2.4 BASOS-0.8
[**2189-12-7**] 01:30PM PLT SMR-NORMAL PLT COUNT-288
TTE [**5-9**]: EF 70%-80%, Moderate to severe [3+] TR. Moderate PA
systolic hypertension.
.
[**9-9**] MIBI: EF 59% Resting and stress perfusion images reveal a
moderate reversible inferior and inferolateral defect.
.
[**12-7**] CXR:
The heart size is borderline normal. Once again, a right
subclavian central venous line is visualized with its tip within
the distal SVC. Once again seen are multiple linear and discoid
atelectases of the left mid zone and right lung base. There
could be small bilateral pleural effusions. The lungs are
otherwise clear. The patient is noted to be status post cervical
fusion with hardware unchanged compared to previous exam.
Brief Hospital Course:
56M ESRD HD/PD, admitted with hypotension, found to have coag
negative staph line infection.
.
#ID: 1. Coag negative staph from line x 2 bottles. Sensitivities
pending. Hypotension appears to be due to dialysis rather than
sepsis. On Vanco (by level) for line infection; will continue on
Vanco IP 2 grams with PD by level as an outpatient for a 2 week
course (goal trough 15-20).
2. PNA- The patient was thought to possibly have pneumonia by
CXR, as well as a new O2 requirement and cough; therefore he was
initially treated empircally with levofloxacin then ceftriaxone
([**Date range (1) 101716**]). However, repeat CXR was not suggestive of PNA;
pt's pulmonary symptoms most likely due to volume overload;
therefore ceftriaxone was discontinued. At discharge the patient
was satting 91% on room air. [**Female First Name (un) **] team is deferring possible
pulmonary function tests to his PCP, [**Name10 (NameIs) **] his long history of
smoking.
.
# Hypotension/lethergy- likely due to intravascular volume
depletion (despite total body fluid overload); correlates with
timing of peritoneal dialysis. SBP at home reportedly as low as
60's (per pt's wife); during hospitalization SBP ranged from
75-130's. Pt feeling better overall at the time of discharge,
with systolic blood pressure of 100-110.
.
* ESRD: Continue peritoneal dialysis, renal meds per renal. Pt
on transplant list.
.
* Mental status: Etiology of recent MS changes unclear, ddx
includes Uremia, infection, hypotension; some improvement with
improvement in SBP to >80 per patient's wife. Currently at
baseline upone discharge.
.
* h/o DVT- anticoagulated on Coumadin 5mg, follow INR.
.
* Chronic pain: Continue methadone and oxycodone.
.
* FEN: Renal diet, PD
.
* Prophylaxis: PPI, anticoagulated
Medications on Admission:
Neurontin 300mg/600mg
Methadone 10mg
Seroquel 25
Metoprolol 12.5 TID
Norvasc 5
Warfarin 5
Mirtazapine 15
Protonix 40mg
Renagel 1200 TID
Sensipar 30mg
Oxycodone 10 QID
Paxil 20
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed.
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Methadone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed: Take as needed to maintain 2 bowel movements
daily.
Disp:*1 bottle* Refills:*0*
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
11. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
12. Vancomycin
Vancomycin: dose by level. Give 2 grams IP if level is equal to
or less than 15. Last day: [**2189-12-21**].
13. Outpatient Lab Work
Vancomycin Level. Please check every other day until [**2189-12-21**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
Primary: Line infection, Hypotension, ESRD
Discharge Condition:
Good. BP stable, satting well (91% on RA), afebrile, blood
cultures negative, appropriate followup arranged.
Discharge Instructions:
During this admission you have been treated for an infection of
your dialysis catheter and low blood pressure.
*Please continue to take all medications as prescribed. You are
being treated with Vancomycin (an antibiotic); this medication
will be given via peritoneal dialysis for a total of 2 weeks.
*Please call your doctor or come to the emergency room if you
experience lightheadedness or dizzyness, confusion, fevers,
chills, worsening cough, or any other concerning symptoms.
Followup Instructions:
Follow up with [**Doctor First Name 3040**] in Peritoneal Dialysis. She will arrange
for your Vancomycin to be given (dosed by level).
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-12-17**]
8:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2189-12-17**] 10:00
ICD9 Codes: 7907, 486, 5856, 4280, 3572, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3078
} | Medical Text: Admission Date: [**2196-7-16**] Discharge Date: [**2196-7-17**]
Date of Birth: [**2154-5-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Anaphylaxis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
42 year old female with a history of depression and allergy to
tree nuts presenting with choking sensation and nausea after
eating a sunflower seed. She had 2 prior ED admissions over the
past 3 years for similar reactions after eating some type of
nut, for which she quickly responded to steroid therapy. On the
day of admission, she ate a sunflower seed at Cosco, and
immediately felt a choking sensation with nausea. She did not
report CP, SOB, rashes, or uticaria at the time. On EMS
arrival, she was given benadryl, 2 doses of epi (0.3mg + 0.5mg),
and IV solumedrol 125mg.
.
In [**Name (NI) **], pt [**Name (NI) 4650**] initially but began complain of chest pain. EKG
showed T-wave depression in V3-5, with no prior EKG for
comparison. CXR showed no acute cardiopulmonary process, and
cardiac enzymes were neg x1. Pt became hypotensive from SBP 120s
to 90s, and was given Epinephrine 1mg, along with IV solumedrol
125mg, famotidine 20mg, and Lorazepam 1mg. Pt also developed
diffuse erythematous rashes and hives with uticaria on her face
and limbs.
Past Medical History:
1. Depression
2. Pulmonary tuberculosis with hilar LAD as a child.
Social History:
works in lab w/ microscope
married w/ 4 yr old son; husband in same lab
denies tobacco, alcohol, IVDA
sexually-active with husband only
Family History:
M w/ anxiety; F w/ DM;
no heart disease or cancer in family
Physical Exam:
VS: T 97.1 BP 128/55 HR 65 RR 32 O2Sat 100%RA
.
Exam:
Gen: lying in bed comfortably in NAD
Skin: diffuse erythematous rashes and hives on forearms and
thighs b/l; no jaundice
HEENT: NC/AT, sclera anicteric, MMM
Neck: supple w/o thyromegaly or LAD, no JVD
CV: RRR, nl S1+S2, no M/G/R
Pulm: CTA B
Abd: S/NT/ND, +BS, no HSM
Ext: no C/C/E, 2+ rad/PT pulses b/l
Neuro: A+Ox3, appropriately interactive; no tremors
.
Discharge exam: rash resolved, otherwise as above.
Pertinent Results:
[**2196-7-15**] 10:05AM TSH-1.7
[**2196-7-16**] 09:30PM CK(CPK)-64
[**2196-7-16**] 09:30PM CK-MB-NotDone cTropnT-<0.01
[**2196-7-16**] 03:00PM GLUCOSE-164* UREA N-16 CREAT-0.8 SODIUM-141
POTASSIUM-3.1* CHLORIDE-108 TOTAL CO2-18* ANION GAP-18
[**2196-7-16**] 03:00PM CK(CPK)-77
[**2196-7-16**] 03:00PM CK-MB-NotDone cTropnT-<0.01
[**2196-7-16**] 03:00PM WBC-14.5*# RBC-4.06* HGB-11.6* HCT-34.4*
MCV-85 MCH-28.6 MCHC-33.8 RDW-15.4
[**2196-7-16**] 03:00PM NEUTS-37* BANDS-0 LYMPHS-60* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2196-7-16**] 03:00PM PLT SMR-NORMAL PLT COUNT-386
.
CXR: No acute cardiopulmonary process.
Brief Hospital Course:
1. Anaphylaxis: expected etiology is from the sunflower seed
ingestion. The patient remained hemodynamically stable and her
rash resolved quickly with the antihistamine therapy. She was
discharged to complete a three day course of oral steroids and
was given a prescription for an epipen. She will follow up with
an allergist for formal testing and with her PCP.
.
2. Chest pain: in the setting of epinephrine and associated with
ST depressions in the lateral leads. This raises the question
of coronary disease, for which she will follow up with her PCP.
.
3. Depression: continued on her outpatient Celexa
.
4. Disposition: the patient improved quickly and was discharged
home with steroids to complete a three day course and close PCP
follow up. She was given a prescription for an epipen, which she
was told to carry with her at all times. She was full code.
Medications on Admission:
Celexa 40 mg daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
2 days: Start tomorrow ([**2196-7-18**]).
Disp:*4 Tablet(s)* Refills:*0*
3. Epinephrine 0.15 mg/0.3 mL Pen Injector Sig: One (1)
injection Intramuscular ONCE as needed for Throat swelling,
hives, or other signs of severe allergic reaction for 1 doses.
Disp:*1 pen* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Anaphylaxis
Discharge Condition:
stable
Discharge Instructions:
Please continue prednisone treatment, 40mg once daily, for 2
more days starting [**2196-7-18**] after discharge. Please see your
primary care doctor, Dr. [**Last Name (STitle) 9006**], for follow-up regarding allergies
and referral to allergist. Would also recommend a cardiac
stress test due to question of EKG changes following your
episode of chest pain.
Followup Instructions:
Please see your primary care doctor, Dr. [**Last Name (STitle) 9006**], for follow-up
regarding allergies and referral to allergist. Would also
recommend a cardiac stress test due to question of EKG changes
following your episode of chest pain.
ICD9 Codes: 2762, 2768, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3079
} | Medical Text: Admission Date: [**2106-10-21**] Discharge Date: [**2106-10-31**]
Date of Birth: [**2106-10-21**] Sex: M
Service: NEONATOLOG
HISTORY OF PRESENT ILLNESS: This is the 2.515 kg product of
a 34 [**1-28**] week gestation born to a 30 year old G2 P1-2 mother.
Prenatal screen was notable for maternal blood type B
positive, antibody negative, rubella immune, RPR nonreactive,
hep B surface antigen negative, group G strep unknown.
receive beta. Mom presented in preterm labor. Child was
delivered by spontaneous vaginal delivery. Child emerged
with decreased tone and no spontaneous respiratory effort.
He was given bag mask ventilation for 30 seconds and then
recovered. Apgars were 7 at one minute and 8 at five
minutes.
1. Respiratory. The child was able to be maintained in room
air without any other respiratory support. At time of
dictation he is breathing comfortably in room air.
2. Cardiovascular. The child always had good blood
pressure.
3. FEN. The child had initial low D-stick. An umbilical
venous line was placed and D10 was given. Repeat D-sticks
were fine. He was rapidly weaned from IV fluids and advanced
on feeds. At time of dictation he is tolerating full enteral
feeds of 24 calorie formula. He is able to tolerate the full
volume if it is at q.three hour volume. Weight at time of
dictation is 2.46 kg.
4. He had mild hyperbilirubinemia that was treated with
phototherapy. At the time of dictation his bilirubin was
within normal limits.
5. Infectious disease. He had initial CBC and blood
culture. He was started on antibiotics. Cultures remained
negative and he finished a course of amp and gent for 48
hours.
PHYSICAL EXAMINATION: He is an alert infant with fontanelle
open and soft. Mildly jaundiced. Breath sounds are clear
bilaterally. Cardiovascular exam is within normal limits
with no murmur. Abdominal exam is soft and nondistended. He
has normal male genitalia. Exam is otherwise unremarkable.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home.
DISCHARGE INSTRUCTIONS: Recommendation is that he receive
Synagis since he is mildly premature and he has a sibling in
preschool. He will also continue on 24 calorie formula.
DISCHARGE DIAGNOSES:
1. Mild prematurity.
2. Hyperbilirubinemia.
3. Rule out sepsis.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Doctor Last Name 44592**]
MEDQUIST36
D: [**2106-10-29**] 16:49
T: [**2106-10-29**] 17:10
JOB#: [**Job Number 44593**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3080
} | Medical Text: Admission Date: [**2191-10-16**] Discharge Date: [**2191-10-18**]
Date of Birth: [**2127-1-9**] Sex: F
Service: MEDICINE
Allergies:
Adhesive
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Transfer from outside hospital for bilateral Pulmonary Emboli,
elevated troponins and ST elevations in inferolateral leads
(found to be similar to old ekg changes)
Major Surgical or Invasive Procedure:
Bilateral lower extremity dopplers: The bilateral common
femoral,
superficial femoral, greater saphenous, and popliteal veins are
widely patent and demonstrate normal compressibility,
augmentation, and phasic flow. No evidence of intraluminal
thrombus.
History of Present Illness:
Mrs. [**Known lastname 70644**] is a 64 year old female nurse with a history of
smoking and thrombophlebitis who presents with an intense left
chest pain. On Friday, patient noticed an increased pain in her
right thigh and a decrease in sensation in her right fingers.
Patient woke up on Saturday ([**2191-10-15**]) to a [**9-13**] pain that
began on the top of her left shoulder and radiated down to her
midline. She describes the pain as a ??????vice-like?????? tightening as
it traveled down. Nothing seemed to make it better or worse and
she claimed she had done nothing unusual the day before. She
has not been on any prolonged trips, had any recent surgeries,
been immobilized recently, and has never felt a pain similar to
this one. She has no dyspnea, cough, hemoptysis, tachypnea,
tachycardia, nausea, emesis, dizziness, fevers, or chills
associated with this chest pain. She believed it was
??????neuromuscular?????? pain and tried to ignore it. Her husband drove
her to the local [**Hospital 18**] [**Hospital3 **] two hours later. She
was found to have ST elevations on her EKG, which were
consistent with previous findings, a positive D-dimer, and an
initial Troponin of 0.8. A CT angio showed bilateral pulmonary
emboli. She was given aspirin and started on heparin for
anticoagulation and nitroglycerin for prophylaxis. She was then
transferred to the [**Hospital1 18**] main campus for further workup. In the
emergency room, she was given a bedside echo and seen by
cardiology.
Past Medical History:
1.)Thrombophlebitis
2.)Gastritis
Social History:
Patient is a former operating room nurse with a 10 pack-year
history of smoking. She still smokes off and on but has not had
a cigarette in the past two weeks. She occasionally drinks
alcohol. She has no history of blood transfusions or illicit
drugs. She has two children, both married with one child each.
Patient has some financial concerns and helps small businesses
out to make ends meet. Her husband is an electric engineer who
still works three days a week. She really enjoys [**Location (un) 1131**].
Family History:
She believes one of her aunt had a ??????clot??????, probably a venous
thromboembolism. Her mother had extensive heart disease and
died of a myocardial infarction at 65. Her other aunt had a
dissected cerebral aneurysm. She states that there is an
extensive cancer history in her family.
Physical Exam:
General:
Vitals:
Temp: 98.8
BP: 111/51
HR: 79
RR: 13
Oxygen Sat: 98 on room air
HEENT:
Eyes: Visual fields are normal, extraocular muscles are normal,
fundoscopic exam not performed
Ears: Hearing intact bilaterally to whispering, Otoscopic exam
not performed.
Nose: Septum is in the midline. No swollen turbinates.
Mouth: No tongue deviation. Teeth and tongue are normal
Throat: Bilateral palatal elevation
Neck: No swollen nodes, no thyroidmegaly
Cardiac:
Carotid, radial, and DP Pulse all 2+
Midclavicular PMI along the 5th costal-vertebral line.
Normal S1 and S2 clear, no murmurs
Respiratory:
Wheezes are auscultated in bilateral lungs, more so on the right
base.
No cyanosis, clubbing, no increased AP diameter
No fremitus
Normal resonance
No egophony
Abdominal Test:
Abdomen not distended
Auscultation demonstrates increased bowel sounds
Percussion demonstrates no enlarged organs.
No CVA tenderness
Cranial Nerves:
I: Not tested
II: Peripheral vision normal
Pupils reactive
III, IV, VI: Extra-ocular movements are fully intact
Lid elevation normal
Pupillary reaction normal to light
V: Jaws clench well, unable to be opened
Pin prick to three regions of face are normal and symmetrical
VII: Facial expressions are normal and symmetrical
VIII: Can hear finger rubbing bilaterally
IX, X: Uvula elevates symmetric
[**Doctor First Name 81**]: Shrug normal
Can turn head against resistance well to both side
XII: Tongue protrudes in the midline. Tongue can push out checks
Neurological Exam:
Muscle bulk and tone are normal symmetrically
No fasciculations or tremors.
Strength test: [**4-8**] bilaterally on all extremities
Sensory of sharp versus dull normal
Joint Position sense is normal bilaterally
Light touch is normal on each side
Pertinent Results:
[**2191-10-16**] 11:48PM CK(CPK)-134
[**2191-10-16**] 11:48PM CK-MB-8 cTropnT-1.01*
[**2191-10-16**] 11:48PM PT-12.8 PTT-55.2* INR(PT)-1.1
[**2191-10-16**] 03:45PM GLUCOSE-118* UREA N-11 CREAT-0.8 SODIUM-137
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15
[**2191-10-16**] 03:45PM CK(CPK)-141*
[**2191-10-16**] 03:45PM cTropnT-0.96*
[**2191-10-16**] 03:45PM CK-MB-11* MB INDX-7.8*
[**2191-10-16**] 03:45PM WBC-10.5 RBC-3.85* HGB-12.5 HCT-35.4* MCV-92
MCH-32.4* MCHC-35.2* RDW-13.5
[**2191-10-16**] 03:45PM NEUTS-69.9 LYMPHS-23.5 MONOS-4.7 EOS-1.7
BASOS-0.1
[**2191-10-16**] 03:45PM PLT COUNT-201
[**2191-10-16**] 03:45PM PT-13.5* PTT-133.7* INR(PT)-1.2*
[**2191-10-18**] 05:40AM BLOOD WBC-7.9 RBC-3.59* Hgb-11.4* Hct-34.1*
MCV-95 MCH-31.8 MCHC-33.5 RDW-13.3 Plt Ct-227
[**2191-10-18**] 05:40AM BLOOD Glucose-97 UreaN-7 Creat-0.9 Na-143 K-4.1
Cl-106 HCO3-28 AnGap-13
[**2191-10-17**] 02:21PM BLOOD CK(CPK)-106
[**2191-10-18**] 05:40AM BLOOD CK(CPK)-23*
[**2191-10-17**] 07:19AM BLOOD CK-MB-5 cTropnT-0.96*
[**2191-10-17**] 02:21PM BLOOD CK-MB-4 cTropnT-0.86*
[**2191-10-18**] 05:40AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.4
Brief Hospital Course:
Patient was transferred from [**Hospital1 **] [**Location (un) 620**] for bilateral pulomonary
emboli seen on CTA and elevated troponins in the setting of ST
elevations in the inferolateral leads (found to be consistent
with old ekg's). The patient was on a heparin gtt and nitro
gtt.
In the ED at [**Hospital1 18**], a bedside echo was performed and did not
show significant heart strain. (ED ECHO: The left atrium is
normal in size. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction. 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 appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The left ventricular inflow pattern suggests
impaired relaxation. The estimated pulmonary artery systolic
pressure is normal. There is an anterior space which most likely
represents a fat pad.)
The patient was admitted to the MICU for continued nitro and
heparin gtt. Cardiology recommended telemetry, trending of the
troponins, discontinuing nitro drip on hospital day 2 and if
asymptomatic, transfer to the floor.
The patient tolerated the discontinuation of nitro without
complaints. She was transferred to the floor on HD 2. Her
heparin gtt was continued. On HD 3 she was bridged to lovenox,
bilateral lower extremity ultrasounds showed no evidence of
clots, and she was prepared for discharge.
Important outpatient issues discussed with the primary MD:
outpatient stress test recommended by cardiology, outpatient
hypercoaguability workup (protein c and S and free protein S),
follow up with Thoracic surgery at scheduled appointment for
workup of right upper lobe 6mm spiculated nodule.
Medications on Admission:
Aspirin 81mg PO qDay
Calcium
Discharge Medications:
1. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day.
Disp:*14 syringes* Refills:*0*
2. Coumadin 5 mg Tablet Sig: One (1) Tablet PO 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Right upper lobe 6 mm spiculated pulmonary nodule
Bilateral pulmonary emboli
Discharge Condition:
Stable, Improving
Discharge Instructions:
Follow up at your scheduled appointments with thoracic surgery
and Dr [**Last Name (STitle) 5292**]. (dates specified below). You should continue to
take the lovenox injections twice a day for the next three days.
Also, you should take one tablet (5mg) of coumadin every night.
You should follow up with Dr [**Last Name (STitle) 5292**] on Friday to determine if
your coumadin level is therapeautic.
Followup Instructions:
You have an appointment scheduled with Dr [**Last Name (STitle) **], a
thoracic surgeon, on [**10-25**] at 10 AM to discuss the right
lung nodule that was seen on CT scan. His office is located in
the [**Hospital Ward Name 23**] building on the [**Location (un) **]. This appointment is very
important. If you should have a conflict, please call the
office at [**Telephone/Fax (1) 11763**].
Follow up with Dr [**Last Name (STitle) 5292**] on Friday at 1PMat [**Street Address(2) **] [**Apartment Address(1) 70645**], [**Location (un) 620**] MA. An outpatient stress test should be scheduled
and a future hypercoaguability workup should be completed. Dr
[**Last Name (STitle) 5292**] will also follow up with the lab tests ordered in the
hospital (protein C, S and free protein S).
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2191-10-25**] 10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5294**]
[**2194-10-21**] 1:00PM
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3081
} | Medical Text: Admission Date: [**2156-1-19**] Discharge Date: [**2156-1-22**]
Date of Birth: [**2106-9-7**] Sex: M
Service: CARDIOTHORACIC
Mr. [**Known lastname **] is a direct-admission to the operating room and a
postoperative admission to the cardiothoracic service.
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 49-year-old
man, with known mitral regurgitation status post bacterial
endocarditis in [**2146**] secondary to dental work. He has been
entirely asymptomatic and physically active. A routine echo
done in [**2155-8-20**] revealed a dilated left ventricle with
4+ MR. [**Name13 (STitle) **] presented on [**11-6**] for a cardiac
catheterization as part of his preop evaluation for mitral
valve replacement. The cardiac catheterization revealed
normal coronaries, and he was scheduled for mitral valve
replacement with Dr. [**Last Name (Prefixes) **].
PAST MEDICAL HISTORY: Severe mitral regurgitation.
PAST SURGICAL HISTORY: None.
MEDS PRIOR TO ADMISSION: Enalapril 5 mg qd.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Married. Works as a construction worker.
No tobacco and rare alcohol use.
REVIEW OF SYMPTOMS: No CVA, seizures, syncope, or headaches.
No asthma, cough, or upper respiratory infections. No GERD,
GI bleed, diarrhea, or constipation. No dysuria. No
diabetes. No thyroid issues. No hematological issues. No
bleeding in the past. No infectious disease issues, and no
claudication.
PHYSICAL EXAM: Neurologically grossly intact. Pulmonary -
lungs are clear to auscultation bilaterally. Cardiac - S1,
S2, with a IV/VI systolic ejection murmur. Abdomen is soft,
nontender, nondistended with active bowel sounds.
Extremities are warm and well-perfused with 2+ pulses
throughout. He has no clubbing, cyanosis or edema.
LAB DATA: White count 6.7, hematocrit 43.0, platelets 209,
INR 1.1, sodium 141, potassium 4.2, chloride 104, CO2 30, BUN
18, creatinine 1.0. UA is negative. Chest x-ray shows no
cardiopulmonary diseases.
HOSPITAL COURSE: As stated previously, the patient was
directly admitted to the operating room on [**1-19**], where he
underwent mitral valve repair via a right thoracotomy using
the Heartport system. Please see the OR report for full
details. In summary, he had a mitral valve repair with a #30
annuloplasty ring. His bypass time was 133 minutes with a
crossclamp time of 117 minutes. He tolerated the operation
well and was transferred from the operating room to the
Cardiothoracic Intensive Care Unit. The patient did well in
the immediate postoperative period. His anesthesia was
reversed. He was successfully weaned from the ventilator and
extubated. His blood pressure was maintained with low-dose
Neo-Synephrine infusion.
On postoperative day #1, the patient remained hemodynamically
stable. His Neo-Synephrine infusion had been weaned to off
during the night of his operative date. He was begun on oral
beta blockers, as well as diuretics, and transferred to the
floor for continuing postoperative care and cardiac
rehabilitation.
On postoperative day #2, the patient's chest tube and
temporary pacing wires were removed. He remained
hemodynamically stable. His activity level was increased
with the assistance of the nursing staff and physical therapy
staff. On postoperative day #3, it was decided that the
patient was stable and ready to be discharged to home.
At the time of this dictation, the patient's physical exam is
as follows: VITAL SIGNS - temperature 99, heart rate
95--sinus rhythm, blood pressure 108/68, respiratory rate 18,
O2 sat 98% on room air. Weight preoperatively 72.4 kg and at
discharge is 76 kg.
LAB DATA: White count 6.6, hematocrit 29.8, platelets 151,
sodium 141, potassium 4.4, chloride 104, CO2 31, BUN 17,
creatinine 0.9, glucose 108.
PHYSICAL EXAM: Neurological - alert and oriented x 3, moves
all extremities, follows commands. Respiratory - clear to
auscultation bilaterally. Cardiac - regular rate and rhythm,
S1, S2, with no murmur. Abdomen is soft, nontender,
nondistended with active bowel sounds. Extremities are warm
and well-perfused with 1+ edema bilaterally. Right groin
incision with Steri-Strips, open to air, clean and dry.
Right thoracotomy site with Steri-Strips, open to air, clean
and dry.
DISCHARGE MEDICATIONS:
1. Enteric-coated aspirin 325 qd.
2. Colace 100 mg [**Hospital1 **].
3. Metoprolol 25 mg [**Hospital1 **].
4. Ibuprofen 400-600 mg q 6 h prn.
5. Percocet 5/325, 1-2 tablets q 4-6 h prn.
DISCHARGE DIAGNOSES: Status post mitral valve repair with a
#30 annuloplasty ring.
DISPOSITION: The patient is to be discharged to home.
FO[**Last Name (STitle) **]P:
1. He is to follow-up in the [**Hospital 409**] Clinic in 2 weeks.
2. Follow-up with his primary care doctor, Dr. [**Last Name (STitle) 99760**], in
[**12-23**] weeks.
3. Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2156-1-22**] 10:47
T: [**2156-1-22**] 10:52
JOB#: [**Job Number 99761**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3082
} | Medical Text: Admission Date: [**2116-8-29**] Discharge Date: [**2116-8-31**]
Date of Birth: [**2038-8-26**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2071**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2116-8-28**]
History of Present Illness:
The patient is a 78 yr old female with PMH significant for
hyperlipidemia who presented to the outside hospital with
substernal non-radiating chest pain that began at 4:15 am [**8-29**].
She denied any associated nausea, vomiting, shortness of breath,
or diaphoresis. Her symptoms started shortly after she was woken
up by thunderstorm and nearby lightning strike. She called the
ambulance at 4:50 am and arrived to the ER shortly thereafter.
At the OSH the patient was found to be hypotensive with BP 82/44
and bradycardic HR 42-47. She was also noted to be lightheaded
and diaphoretic. Her low blood pressure responded to 1L NS
bolus. EKG showed ST elevations in V3-V6, I, and Q waves with [**Street Address(2) 13234**] elevations in inferior leads. Pt received aspirin,
integrillin, nitroglycerin and heparin drips and then
transferred to [**Hospital1 18**] for catheterization.
Past Medical History:
1. Hyperlipidemia, on lipitor
2. Chronic sinusitis, on prednisone 5 mg q M,W,F
3. s/p hysterectomy
4. s/p cholecystectomy
Social History:
Lives alone with a dog. Daughter liver nearby and is an ER
physician.
[**Name10 (NameIs) **] history of tobacco use.
Family History:
Autoimmune disorders, including SLE and Raynaud's in the family.
Physical Exam:
Physical examination following arrival to CCU after
catheterization:
Afebrile, BP 110/70, HR 110, RR12, O2 sat 99% on 2L NC
General: alert and oriented x 3, NAD
HEENT: NC, AT, PERRLA, EOM intact, sclera white, MM moist
Neck: no elevated JVP, no thyromegaly, no carotid bruits
Pulm: CTA bilaterally
CV: regular S1S2, no m/g/r
Abd: +BS, soft, NT, ND
Extr: no c/c/e, DP pulses strong and symmetric bilaterally
R groin: no ecchymosis, no hematoma, no bruit
Pertinent Results:
[**2116-8-31**] 06:40AM BLOOD PT-12.7 PTT-81.0* INR(PT)-1.0
[**2116-8-29**] 09:35AM BLOOD CK(CPK)-411*
[**2116-8-29**] 05:02PM BLOOD CK(CPK)-330*
[**2116-8-29**] 11:45PM BLOOD CK(CPK)-281*
[**2116-8-30**] 05:44AM BLOOD CK(CPK)-239*
[**2116-8-29**] 09:35AM BLOOD CK-MB-25* MB Indx-6.1* cTropnT-1.40*
[**2116-8-29**] 05:02PM BLOOD CK-MB-17* MB Indx-5.2 cTropnT-0.86*
[**2116-8-29**] 11:45PM BLOOD CK-MB-13* MB Indx-4.6
[**2116-8-30**] 05:44AM BLOOD CK-MB-11* MB Indx-4.6 cTropnT-0.59*
[**2116-8-29**] 09:35AM WBC-8.0 RBC-3.60* HGB-11.8* HCT-32.4* MCV-90
MCH-32.7* MCHC-36.3* RDW-12.4
[**2116-8-29**] 09:35AM PLT COUNT-215
[**2116-8-29**] 09:35AM NEUTS-76.2* LYMPHS-17.8* MONOS-3.6 EOS-2.0
BASOS-0.5
[**2116-8-29**] 09:35AM GLUCOSE-105 UREA N-15 CREAT-0.6 SODIUM-143
POTASSIUM-3.7 CHLORIDE-109* TOTAL CO2-27 ANION GAP-11
[**2116-8-29**] 09:35AM CALCIUM-8.1* PHOSPHATE-3.0 MAGNESIUM-1.9
IRON-102 CHOLEST-135
[**2116-8-29**] 09:35AM calTIBC-285 VIT B12-369 FOLATE-GREATER TH
FERRITIN-55 TRF-219
[**2116-8-29**] 09:35AM TRIGLYCER-79 HDL CHOL-75 CHOL/HDL-1.8
LDL(CALC)-44
[**2116-8-29**] 09:35AM TSH-2.5
[**2116-8-29**] 09:35AM [**Doctor First Name **]-NEGATIVE
[**2116-8-31**] 06:40AM BLOOD Glucose-100 UreaN-14 Creat-0.7 Na-142
K-3.7 Cl-107 HCO3-29 AnGap-10
Cardiac catheterization [**2116-8-29**]:
PA mean 9 mmHg; RV 30/11 mmHg; PA 30/13/19 mmHg; PCW mean 15
mmHg; LV 110/20 mmHG; aorta 110/70/19 mmHG; CO 5.0 L/min; CI 2.9
L/min/m2; SVR 160; PVR 64; [**MD Number(3) 57781**] 72%.
Right dominant; LMCA was free of obstructive disease; LAD had
mild proximal plaquing; LCx no angiographically significant
disease; RCA no disease.
Left ventriculography revealed extensive anteroapical and
inferoapical akinesis, with hyperdynamic function of the
anterior and inferior bases. The calculated ejection fraction
was depressed at 33%. No significant mitral regurgitation was
visualized.
FINAL DIAGNOSIS:
1. Coronary arteries are free of angiographically-significant
CAD.
2. Moderate systolic ventricular dysfunction.
3. Mild diastolic ventricular dysfunction.
4. EKG evidence of anterolateral ST elevation with extensive
apical
akinesis and non-obstructive coronary artery disease. Possible
explanations include transient apical ballooning syndrome, MI
with
recanalized artery, focal myocarditis, coronary vasospasm.
Transthoracic echocardiogram [**2116-8-31**]:
LA is normal in size. LV wall thicknesses and cavity size are
normal. There is mild regional left ventricular systolic
dysfunction (ejection fraction 45%). There is
hypokinesis of the entire apex/distal [**1-11**] of the left ventricle.
Right
ventricular chamber size and free wall motion are normal. 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.
Mild (1+) mitral regurgitation is seen. There is mild pulmonary
artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Brief Hospital Course:
The patient was admitted to the CCU service. Differential
diagnoses for abnormal LV function in the setting of EKG changes
and normal coronary arteries included acute coronary syndrome
s/p spasm or s/p auto-lysis, eosinophilic cardiomyopathy, and
Takotsubo Apical Ballooning Syndrome. Given her history,
presentation, and clinical findings, Tokotsubo Apical Ballooning
Syndrome was thought to be most likely.
1. CAD - The patient received integrillin x 18 hours following
catheterization. Cardiac enzymes peaked CK 440 and CKMB at 25
and had been trending down. Then she was started on heparin b/o
low EF with wall motion abnormalities. After echo was obtained,
the patient was started on coumadin. She was discharged with INR
1.0, on Lovenox to bridge her to oral anticoagulation until her
INR will become therapeutic. She will continue Coumadin 5 mg po
qhs and she was given prescription for INR check to be done in 3
days. The results will be called to her primary care physician
who will manage her coumadin. Lovenox teaching was done prior to
the patient's discharge. She should remain on oral
anticoagulation for at least 2 months depending on improvement
of LV function with goal INR 2.0-3.0. The duration of her
anticoagulation therapy will be decided by her cardiologist. The
patient was also started on aspirin, low dose beta-blocker, and
ACE inhibitor that were titrated up as BP and HR tolerated.
Prior to discharge, the patient's beta-blocker and ACE inhibitor
were changed to longer acting once-a-day formulations. Her BP
was stable with SBP in 110's on the day of discharge on her
outpatient regimen.
2. Cardiomyopathy - Again, this was thought to be due to
Takotsubo Apical Ballooning Syndrome. Echocardiogram was done on
HD #3 and revealed EF 45%. TSH, iron studies, and [**Doctor First Name **] were
checked and were all within normal limits. The patient was
started on the Ace inhibitor and beta-blocker.
3. Sinusitis - the patient was continued on her outpatient
regiment of prednisone 5 mg po 3x/week. The possibility of
adrenal insufficiency was entertained in the patient presenting
with hypotension, but was felt to be unlikely with small doses
of steroids and every other day dosing.
Medications on Admission:
Calcium 1500 mg po qd, Lipitor 10 mg po qd, Prednisone 5 mg po
3x/week (Monday, Wednesday, Friday), Oxybutynin, Zantac 150 mg
po bid
Discharge Medications:
1. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours) for 4 days: Please contact
your primary care physician regarding when you should stop
taking Lovenox. .
Disp:*8 * Refills:*0*
2. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
Disp:*15 Tablet(s)* Refills:*2*
6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*10 Tablet(s)* Refills:*0*
7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Aspirin 81 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*
9. Zantac 150 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed.
11. Outpatient Lab Work
Please draw serum K, Mg levels and PT-INR on Thursday [**2116-9-3**].
Please call results to Dr.[**Name (NI) 57782**] ([**Telephone/Fax (1) 57783**]. Thanks.
Discharge Disposition:
Home With Service
Facility:
Diversified VNA [**Location (un) 1157**]
Discharge Diagnosis:
1. Probable Takotsubo Apical Ballooning Syndrome
2. Hyperlipidemia
3. Sinusitis
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as prescibed. Please contact
you primary care physician for you coumadin monitoring and dose
adjustment. Please have you blood drawn for INR, K, Mg level.
The results will be called to your primary care physician, [**Last Name (NamePattern4) **]. [**Name (NI) 57784**] ([**Telephone/Fax (1) 57783**].
In addition to your medications listed on this discharge form,
you may continue taking your inhalers as you did prior to this
admission.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Followup Instructions:
1. Dr.[**Name (NI) 57782**] (primary care physician) [**2116-9-4**] at 10 am
([**Telephone/Fax (1) 57783**]
2. Dr. [**First Name (STitle) 732**] (cardiologist) [**2116-9-29**] at 12 noon
([**Telephone/Fax (1) 57785**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]
Completed by:[**2116-9-12**]
ICD9 Codes: 4240, 4254, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3083
} | Medical Text: Admission Date: [**2194-12-8**] Discharge Date: [**2194-12-17**]
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Metastatic Lung Cancer
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo M with a past medical history significant for CAD and AAA
repair, with a very recent diagnosis of NSCLC with intracranial
and bony metastasis, presents today to the ED after wife noted
increased lethargy and decreased PO intake beginning Saturday (2
days prior to presentation). He was brought first to an OSH
where no intervention was made prior to coming to [**Hospital1 18**]. His
wife reports some abdominal distention but denies n/v/f/c. He
has not had a BM in three to four days and is passing no flatus
currently.
In the ED, the patient was tachycardic to the 120's and was
febrile to 101, lactate 1.3. He was given 2L NS and a dose of
levo/flagyl for possible aspiration. Hct stable at 34. He was
evaluated for SBO by the general surgery team, who felt that
based on imaging and physical exam that this was gastric
distention, no surgery recommended at this time and advised iv
ppi and NGT for decompression. An NGT was placed to suction and
about 600cc+ of liquid black gastric contents was drained. At
this time, GI was consulted and felt that this was not evidence
of UGIB and that there was no acute indication for EGD. He was
guaiac negative. He is admitted to the MICU for further
monitoring in the setting of gastric distention secondary to
possible gastric outlet obstruction with tachycardia.
His oncologic history as noted above is a very recent diagnosis
of metastatic NSCLC with mets in cerebellum and bone. He was
diagnosed after experiencing pleuritic chest pain (different
from his stable angina) and a CT on [**11-23**] showed a spiculated
mass in the right upper
lobe,pretracheal and precarinal right hilar lymph nodes. The
patient subsequently experienced severe LBP and an MRI of
L-spine showed multi-level metastatic disease with no
compression of spinal cord or cauda equina.
Radiation Oncology has now begun palliative treatment to brain
and back, first xrt on back was due the day of admission, [**12-9**].
Past Medical History:
AAA repair (asymptomatic 6.1cm AAA) [**12-22**]
Hyperlipidemia
CAD, h/o IMI
Stable angina
Cross fem bypass for claudication [**1-22**]
HTN
BPH
h/o hemorrhoidal bleeding
Social History:
Stopped smoking 15 years ago. Smoked 3-4 packs a day for 50
years. He is retired. He and wife are financially responsible
for their son, who is unable to work secondary to psychiatric
problems. They have undergone quite a lot of psychologic stress
secondary to this and resultant financial harships.
Family History:
non-contributory
Physical Exam:
VS: Temp: 98.6 BP: 98/64 HR: 117 RR: 17 O2sat 95% Ra
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions. NGT
in place
NECK: no supraclavicular or cervical lymphadenopathy, carotids
with sharp upstroke, no carotid bruits, no JVD no thyromegaly or
thyroid nodules
RESP: decreased bs at the right base, otherwise, clear.
CV: Tachycardic, S1 and S2 wnl, no m/r/g
ABD: moderately distended, but soft, +b/s, nontender. no masses.
No rebound/guarding. Tympanitic to percussion.
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: Arousable, but lethargic. Ox3. Cn II-XII intact. [**4-20**]
strength throughout. 2+DTR's, downgoing babinski bilaterally.
Random movements and picking noted.
Pertinent Results:
CT ABDOMEN W/O CONTRAST [**2194-12-8**] 9:14 PM
1. No acute intra-abdominal pathology including no evidence of
gastric outlet obstruction.
2. Patchy bibasilar opacities are concerning for pneumonia
and/or aspiration.
3. Cholelithiasis.
4. Monoiliac-type aortic graft with known occlusion of the left
common iliac artery and fem-fem bypass graft.
5. Prostatic enlargement.
6. Lumbar metastases, better visualized on recent MR of the
L-spine of [**2194-12-4**].
Portable TTE (Complete) Done [**2194-12-10**] at 10:45:50 AM
FINAL
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Atleast moderate
mitral regurgitation. Pulmonary artery systolic hypertension.
Mild aortic regurgitation.
Brief Hospital Course:
A/P: 84 yo M with h/o of CAD and recent diagnosis of stage IV
NSCLC with metastases to his brain and bone presents with
delirium, concern for aspiration pneumonia, and NSTEMI from
demand ischemia.
# Delirium: Initially felt to be secondary to possible pneumonia
vs. over sedation from opiates, yet poor mental status persisted
despite treatment of pneumonia and pulling back on pain
medication. Other contributing factors included hypernatremia
(resolved), ICU psychosis, and untreated pain from bone
metastases. Known brain metastases likely another contributing
factor. Despite treatment of all possible reversible
etiologies, continued to have decreased mental status. Given
poor prognosis and failure to resume noteworthy function,
patient was made DNR/DNI and later CMO. He expired [**2194-12-17**] due
to cardiopulmonary arrest.
# Non-small cell lung cancer: At initial diagnosis was stage IV
with metastatic lesions to his brain and bones. Oncology
consulted initially on admission and later met with family [**12-16**]
and informed them that he is not a candidate for chemotherapy
because of his medical illness and poor performance status.
Rad/onc was also consulted concerning possible palliative
treatment but determined that he was too unstable for further
intervention. Ultimately Palliative Care was consulted and
assisted in the transition to CMO status.
# Respiratory Distress/Pneumonia: While inpatient he had
episodes of respiratory distress that probably resulted from
several factors, including his underlying pneumonia, difficulty
clearing secretions, pain, and anxiety. Leukocytosis and
infiltrates persisted despite treatment with Flagyl and
ceftriaxone. Later Zosyn and vancomycin were started to cover
possible nosocomial pathogens. Respiratory distress continued
to be progressive despite antibiotics and suctioning. Once CMO
status, his pain and distress with treated with morphine as
needed until he expired.
# Demand Ischemia/Tachycardia: Upon admission was found to be
actively having a NSTEMI from demand ischemia in setting of
tachycardia. Cardiology was consulted and recommended medical
management given his tenuous status. Troponins were followed
until they peaked. Tachycardia remained and appeared to be
multifactorial including pain and agitation. He was treated
with gentle IV fluids, morphine for pain and Lopressor as
tolerated until he expired.
# Hematuria: Noted while inpatient and thought to be due to
trauma associated with Foley placement/patient tugging on Foley.
Urology was consulted and replaced his Foley. He was also
treated with continuous bladder irrigation intermittently. Once
CMO status was determined, bladder irrigation was discontinued
for patient comfort.
# Renal Failure: Cr slowly increased during his
hospitalization, likely associated with pre-renal etiology. His
lisinopril was held for this reason. He was treated with IVF
and his Cr was monitored until he was made CMO status, at which
point further labs were not drawn.
# Pain control: Patient with significant pain, likely secondary
to known bone metastates. While inpatient, was started on a
fentanyl patch and given IV morphine as needed for breakthrough
pain. He was continued on morphine and fentanyl for comfort
until he expired.
Medications on Admission:
Lopressor 25mg [**Hospital1 **]
ASA 81mg
Simvastatin 40mg
Cilostazol 200mg qdaily
SLNTG
Morphine/oxycontin (recently prescribed)
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Nonsmall Cell Lung Cancer, Metastatic
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 5849, 5070, 5990, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3084
} | Medical Text: Admission Date: [**2185-12-16**] Discharge Date: [**2185-12-17**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Ciprofloxacin
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Transferred from [**Location (un) 62562**] Hospital for repeat
bronchoscopy for possible tracheal stenosis.
Major Surgical or Invasive Procedure:
Rigid bronchoscopy with replacement of the tracheostomy tube
History of Present Illness:
89yoF with h/o CHF, ?COPD, s/p aortic valve replacement in [**2181**],
PAF, s/p trach for failure to wean on chronic ventilator support
who presented to [**Location (un) 62562**] Hospital on [**2185-12-15**] with
hypoxemia and high peak airway pressures. Per OSH admission
history and physical, her ventilator started alarming on
[**2185-12-14**] for "high pressure." Her daughter called the
ventilator company who instructed her to attempt "some
maneuvers" which apparently did not stop the vent from alarming.
Thus, she presented to OSH thereafter.
.
In the ED at OSH, respiratory staff [**Date Range 4351**] had difficulty
bagging her and initially suspected mucous plug, however they
were unable to suction significant secretions and peak pressures
remained high. She was admitted to the ICU there where she is
apparently well known for multiple admissions. She underwent
brochoscopy this am, however, they were unable to pass the
bronchoscope beyond the trach (distal portion of trach with 1/3
occlusion) thought to be obstructed by either mucous plug or
more likely granulation tissue. She is now being transferred
for IP procedure.
.
Additionally of note, at OSH, WBC count was noted to be elevated
to 20.7 and she was started on zosyn for unclear source,
presumably respiratory. Per her daughter, she has been "in and
out of the hospital" recently; she was discharged from [**Hospital **]
rehab in [**2185-8-20**] on trach collar during the day and AC
overnight. She was again admitted to [**University/College 23925**] [**Location (un) **] for 2
months (discharged [**2185-10-19**]) for CHF ?in the setting of a.fib
with RVR at which time she was discharged to home on chronic AC
mechanical ventilation. She was again admitted last week for
chest pain at which time her daughter reports workup was
negative. Also, her daughter notes that she has grown both MRSA
and pseudomonas in her sputum and doctors have told [**Name5 (PTitle) **] this was
[**1-21**] to colonization, not infection although her daughter
apparently requested course of ciprofloxacin x 1 week (stopped 2
days early by daughter [**1-21**] "rash" on back).
.
Currently denies fevers/chills, no rigors. She does endorse
perhaps some mild increase in secretions which she reports she
is able to clear well on her own (daughter needs to suction
infrequently and does not believe secretions are significantly
increased), no hemoptysis, no shortness of breath. No chest
pain, palpitations.
.
Further ROS: Denies HA, changes in vision. No changes in
weight. No N/V/diarrhea. No blood in stool. No
dysuria/hematuria. No rashes, joint pain. She reports chronic
diffuse weakness and rigidity since her CVA and since being
bedbound. Wears hearing aid.
Past Medical History:
Past Medical History:
Respiratory failure requiring mechanical ventilator support
Tracheal stenosis
Chronic kidney disease on hemodialysis
Diabetes mellitus (per OSH H+P, daughter denies)
COPD (per OSH H+P, daughter denies)
Hypertension, but now requires midodrine to maintain BPs
s/p CVA (per OSH H+P, daughter denies)
Aortic stenosis s/p aortic valve replacement in [**2181**]
Hypothyroidism per OSH record however pt. recently on
methimazole
Paroxysmal atrial fibrillation
CAD
Dementia (given med list although daughter denies)
Hyperlipidemia
CHF
Osteoarthritis
.
Past surgical history:
CABG in [**2181**] w/ AVR; mosaic porcine valve
AVR [**2181**]
Hip surgery
Hemodialysis catheter placement placed [**10/2184**] at [**Hospital 1281**]
Hosp,[**Location (un) **], MA
Social History:
No smoking, no alcohol, no drug use. Lives with daughter, bed
bound.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp: 97.4 BP: 157/51-->117/49 HR: 124-->105 RR: 14 O2sat:
97%; AC 420/12 PEEP 5.0, FiO2 0.30
GEN: nods/answers questions appropriately, appears comfortable
HEENT: left pupil 2mm, right pupil 4mm; neither responsive to
light (patient's daughter states chronically), [**Name (NI) 3899**], anicteric,
MMM, OP without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: rhonchorus anteriorly and mildy laterally, no wheezes, no
rales appreciated, unable to assess posterior lung fields
CV: sinus tachy, harsh systolic murmur heard throughout
precordium > at LUSB
ABD: nd, +b/s, soft, nt, +umbilical hernia
EXT: no c/c/e, warm, 2+ DP/PT pulses bilaterally; bilateral
upper and lower extremities rigid with flexion with limited
range of motion, no cogwheeling appreciated; moves all 4s
spontaneously, reports sensation to soft touch intact throughout
SKIN: Left anterior shin with large well healed scar, ? skin
graft
NEURO: Alert, unable to fully interpret, but pt. is oriented to
place as hospital, me as MD (can't assess for date and exact
hospital location). Diffusely weak LE and UE ([**2-21**] biceps, hip
flexor and symmetric). No sensory deficits to light touch
appreciated. Downgoing toes bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2185-12-16**] 08:56PM BLOOD WBC-8.7 RBC-5.30 Hgb-13.8 Hct-44.5 MCV-84
MCH-26.1* MCHC-31.1 RDW-18.1* Plt Ct-220
[**2185-12-16**] 08:56PM BLOOD Neuts-93.4* Bands-0 Lymphs-3.4* Monos-2.8
Eos-0.2 Baso-0.3
[**2185-12-16**] 08:56PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+
[**2185-12-16**] 08:56PM BLOOD Plt Smr-NORMAL Plt Ct-220
[**2185-12-16**] 08:56PM BLOOD PT-12.5 PTT-27.2 INR(PT)-1.1
[**2185-12-16**] 08:56PM BLOOD Glucose-168* UreaN-34* Creat-2.5* Na-141
K-4.3 Cl-97 HCO3-29 AnGap-19
[**2185-12-16**] 08:56PM BLOOD Calcium-9.7 Phos-4.5 Mg-2.0
[**2185-12-16**] 08:56PM BLOOD TSH-0.18*
[**2185-12-16**] 11:32PM BLOOD Type-ART Rates-[**12-2**] Tidal V-420 FiO2-40
pO2-106* pCO2-47* pH-7.44 calTCO2-33* Base XS-6 -ASSIST/CON
Urine Analysis
[**2185-12-17**] 12:03AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.019
[**2185-12-17**] 12:03AM URINE Blood-LG Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2185-12-17**] 12:03AM URINE RBC-95* WBC->1000* Bacteri-FEW Yeast-NONE
Epi-0
[**2185-12-17**] 12:03AM URINE WBC Clm-MANY
[**2185-12-17**]: UCx- NGTD; BCx- NGTD
EKG: Sinus tachy to 114, normal axis, borderline 1st degree
delay, QTc 452, LVH, <1mm ST depression V3-V6, o/w without
significant ST/TW changes.
[**2185-12-16**] CXR:
1. Possible mild CHF.
2. Small-to-moderate left effusion with underlying collapse
and/or consolidation.
[**2185-12-17**] Trachea/Chest CT: final report pending
[**2185-12-17**] Rigid Bronchoscopy: see report
Brief Hospital Course:
# Chronic Ventillator-Dependent Respiratory Failure:
Ms. [**Known lastname 4318**] is chronically on mechanical ventilation since [**2183**]
and has failed mutliple attempts at weaning. The underlying
etiology of her respiratory failure is not entirely clear;
however, her daughter reports CHF and the patient's records give
a history of COPD (although her daughter denies this history,
and the patient has no history of smoking).
Bronchoscopy the morning of [**2185-12-16**] at [**Doctor Last Name 62565**]
Hospital showed an obstruction distal to the ET tube, thought to
be either a mucous plug, granulation tissue or other mass. She
was transiently hypoxic with O2 sats in the high 80s just after
arrival to [**Hospital1 18**], but her oxygen saturations quickly increased
to the mid to high 90s on assist-control mode at 40% FiO2. On
[**2185-12-17**] at [**Hospital1 18**], she underwent a rigid bronchoscopy, which
showed tracheomalacia just distal to the end of the tracheostomy
tube (there was no evidence of granulation tissue). Her
original tracheostomy tube was exchanged for a longer tube (size
7, advanced 9.5 cm) that ended distally to the tracheamalacia;
no stent was placed.
# Leukocytosis:
Ms. [**Known lastname 4318**] [**Last Name (Titles) 4351**] had a WBC of 21,000 at [**Doctor Last Name 62565**]
Hospital, although she was without a fever. The H&P from the
OSH reported that she was to receive Zosyn, although she did not
have a medicine administration record listing antibiotics and it
is unclear whether she actually received this at the OSH.
Supposedly, per her daughter, Ms. [**Known lastname 4318**] has a history of
sputum cultures positive for MRSA and pseudomonas in past.
Moreover, the source for the leukocytosis was unclear, as her
cultures were negative and there was no evidence of pneumonia on
CXR.
WBC at [**Hospital1 18**] was normal throughout admission, and she remained
afebrile and normotensive. She was not continued on
antibiotics. Urine analysis on [**2185-12-17**] showed many WBC's and
RBC's, although few bacteria and negative nitrites; antibiotics
were deferred while urine cultures were pending. Blood cultures
were drawn on [**2185-12-16**] and urine culture was sent on [**2185-12-17**];
all cultures have been no growth to date thus far.
# Chronic Renal Failure requiring Hemodialysis:
Ms. [**Known lastname 4318**] usually has dialysis Monday-Wednesday-Fridays, and
her last session was on [**2185-12-16**] at the OSH prior to admission.
Electrolytes and volume status were stable throughout the
admission, and no dialysis was performed at [**Hospital1 18**].
# Diabetes:
According to her daughter, Ms. [**Known lastname 4318**] has no formal diagnosis
of diabetes; however, DM was listed on the medical record from
the OSH and her blood glucose was 168 on admission to [**Hospital1 18**].
She was placed on sliding scale insulin.
Medications on Admission:
Medications on transfer (listed in H+P):
DuoNeb
Lipitor
Aricept
Folate
Prevacid
Nephrocaps
Nystatin powder
Rythmol 150mg via G tube q8h
Namenda
Midodrine 5mg PO tid
.
Home medications:
Aspirin 81mg daily
Folic acid 800mcg daily
Prevacid 30mg daily
Namenda 5mg [**Hospital1 **]
Midodrine 5mg qid at 9am, noon, 5pm if SBPs <120, hs if SBPs <90
Rythmol 150mg [**Hospital1 **]
Nephrocaps daily
Lipitor 10mg daily
Aricept 10mg daily
Combivent 6puffs tid
Tums tid with meals
Nepron 2 cans daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) ml PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
5. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Memantine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO bid ().
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
9. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6)
Puff Inhalation QID (4 times a day).
11. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
12. Midodrine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
13. Donepezil 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at
bedtime).
14. Propafenone 150 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
15. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
16. insulin [**Last Name (STitle) **]: Sliding scale insulin Intramuscular four
times a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
Tracheomalacia
Chronic ventillator-dependent respiratory failure
Secondary Diagnoses:
Diabetes mellitus
Chronic renal failure requiring hemodialysis
Discharge Condition:
Stable-- peak ventillator pressure around 20; oxygen saturations
in the upper 90's on 40% FiO2 with Assist Control ventillatory
mode.
Discharge Instructions:
You are being transferred back to [**Location (un) 62562**] Hospital,
where they will continue to care for you until you are able to
go home.
Followup Instructions:
You will have continued care at [**Location (un) 62562**] Hospital.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
ICD9 Codes: 5856, 4280, 2724, 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3085
} | Medical Text: Admission Date: [**2165-5-22**] Discharge Date: [**2165-6-3**]
Service: [**Doctor Last Name **]
CHIEF COMPLAINT: Hypotension, status post fall.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
gentleman with a past medical history significant for
coronary artery disease (status post coronary artery bypass
graft, aortic valve replacement) and prostate cancer (status
post transurethral resection of prostate) who presented to
the Emergency Department status post a fall with generalized
weakness, tachypnea, and fever.
The patient was reportedly in his usual state of health until
approximately one week prior to admission when he reports
progressive lethargy and fatigue with three to four days of
dyspnea on exertion. He also reports a several week history
of low back pain for which he was recently started on
Neurontin.
The patient was seen by his primary care physician one day
prior to admission and was found to have a white blood cell
count of 22 and a left shift with normal chemistries, liver
function tests, and hematocrit. The patient was planned for
an outpatient chest x-ray and blood cultures on the day of
admission when he reportedly fell secondary to lower
extremity weakness without loss of consciousness or head
trauma.
The patient was found by his son-in-law on the floor with an
increased respiratory rate and labored breathing; awake,
alert, and without complaints. The patient denied chest
pain, headache, melena, bright red blood per rectum, as well
as dysuria. However, the patient did report a 1-day history
of fevers with nausea, vomiting, and increased urinary
urgency with poor oral intake.
Of note, one week prior to admission, the patient was able to
walk two miles per day.
In the Emergency Department, the patient was found febrile to
101.5, with a systolic blood pressure of 68/30 (from an
initial blood pressure of 108/38), heart rate was 70s to 80s,
with an oxygen saturation of 100% on room air. The patient
was awake and mentating adequately at the time. The patient
was started on dopamine, intravenous fluids, and broad
spectrum antibiotics (ceftriaxone, Flagyl, and levofloxacin)
and transferred to the Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post myocardial
infarction in [**2149**] with subsequent coronary artery bypass
graft.
2. Status post porcine aortic valve replacement.
3. History of peptic ulcer disease; status post Billroth II.
4. Status post prior cerebellar stroke.
5. History of prostate cancer; status post transurethral
resection of prostate.
6. History of carotid stenosis; bilateral.
7. Peripheral neuropathy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o. once per day.
2. Zocor 40 mg p.o. once per day.
3. Norvasc 5 mg p.o. once per day.
4. Neurontin 300 mg p.o. twice per day.
5. Atenolol 25 mg p.o. once per day.
6. Prevacid 15 mg p.o. once per day.
SOCIAL HISTORY: The patient is widowed and lives alone with
a supportive family. The patient denies tobacco, alcohol, as
well as illicit drug use.
FAMILY HISTORY: Family history was noncontributory.
REVIEW OF SYSTEMS: The patient denies melena, focal
weakness, paroxysmal nocturnal dyspnea, lower extremity
edema, orthopnea, and hematuria.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 101.5, blood pressure
was 98/60, heart rate was 97, respiratory rate was 24, and
oxygen saturation was 96% on 4 liters nasal cannula. In
general, the patient was a thin elderly male who appeared
tachypneic and in mild distress. Head, eyes, ears, nose, and
throat examination revealed normocephalic and atraumatic.
Pupils were equally round and reactive to light and
accommodation. Sclerae were anicteric. Mucous membranes
were dry. Edentulous. The oropharynx was clear. Neck
examination revealed supple with no lymphadenopathy or
jugular venous distention. Pulmonary examination revealed
bibasilar crackles; right greater than left. No egophony or
wheezing appreciated. Cardiovascular examination revealed a
regular rate and rhythm with a 3/6 systolic murmur at the
left lower sternal border radiating to the axilla with
well-healed midline sternal scar. Abdominal examination
revealed abdomen was soft with normal active bowel sounds.
No hepatosplenomegaly. No masses appreciated. Extremities
were warm and well perfused with 2+ dorsalis pedis and
posterior tibialis pulses. No edema. Neurologic examination
revealed awake and oriented times three. Diffusely weak, but
no focal weakness appreciated. Strength was 4+/5 throughout.
Sensation was intact with slightly decreased sensation in the
lower extremities bilaterally with 1+ symmetric reflexes.
Gait examination was deferred.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed complete blood count with a white blood
cell count of 37.6 (44% polys, 43% bands, 5% lymphocytes, and
5% monocytes), hematocrit was 32, mean cell volume was 87,
and platelets were 214. Chemistry-7 revealed sodium was 136,
potassium was 4.1, chloride was 105, bicarbonate was 16,
blood urea nitrogen was 46, creatinine was 2.4, and blood
glucose was 191. Prothrombin time was 16, INR was 1.7, and
partial thromboplastin time was 44.1. Total bilirubin was
0.3, ALT was 19, AST was 45, and alkaline phosphatase was 72.
Creatine kinase was 1261 with a negative MB and negative
troponin I. LDH was 280. Urine electrolytes with a urine
sodium of less than 10. Microbiology of data obtained from
admission with blood cultures times two on [**5-22**] and [**5-23**]
were without growth for the duration of the hospitalization.
Urine culture from [**5-22**] also without growth during the
hospitalization.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray on admission with
a new right lower lobe consolidation with air bronchograms.
No significant effusions were noted.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for management of hypotension with
presumed right lower lobe community-acquired pneumonia.
The patient was aggressively volume resuscitated with 6
liters of intravenous fluids for hypotension secondary to
presumed dehydration with possible sepsis. With intravenous
hydration, the patient's blood pressure normalized and the
patient was quickly weaned off dopamine.
The patient was noted to have elevated creatine kinase levels
(peak of 1893) with a negative MB index and was ruled out for
a myocardial infarction with three sets of cardiac enzymes.
On hospital day two, after intravenous hydration, the
patient's chest x-ray demonstrated a right lower lobe
infiltrate, and the patient was continued on broad empiric
antibiotics for presumed community-acquired pneumonia. The
patient continued with a 4-liter oxygen requirement on
transfer to the medicine floor.
On transfer to the medicine floor, the patient remained
afebrile on broad empiric antibiotics with no growth on
sputum, urine, as well as blood cultures. The patient
continued with a large oxygen requirement with continued
right lower lobe infiltrate.
Two days out of the Medical Intensive Care Unit, the patient
developed new onset atrial fibrillation with a rapid
ventricular rate to the 120s. The patient remained
normotensive; however, developed congestive heart failure in
the setting of rapid atrial fibrillation and required Lasix
diuresis. The patient was started on heparin as well as a
beta blocker which was titrated for rate control.
The Cardiology Service was consulted with recommendations for
a transesophageal echocardiogram and direct current
cardioversion given poorly tolerated atrial fibrillation.
The patient underwent a transesophageal echocardiogram
without evidence of intracardiac thrombus and subsequent
direct current cardioversion. The patient converted to a
sinus rhythm with one shock at 200 joules. However, shortly
thereafter, the patient was again found in atrial
fibrillation with a rapid ventricular rate.
The Electrophysiology Service was consulted who recommended
amiodarone loading and titration of Lopressor for improved
rate control. Despite efforts to adequately rate control the
patient with medications, the patient's rate remained
persistently elevated with continued dyspnea and oxygen
requirement.
A repeat chest x-ray demonstrated evidence of worsening
pneumonia with a question of the development of acute
respiratory distress syndrome.
On [**6-1**], after much discussion with the patient and the
patient's family, the patient was made comfort measures only.
The patient was started on morphine intravenously as needed
and eventually a morphine drip titrated for patient comfort.
The patient died peacefully on [**2165-6-3**].
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2165-6-11**] 15:04
T: [**2165-6-13**] 19:50
JOB#: [**Job Number **]
ICD9 Codes: 486, 5849, 2765, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3086
} | Medical Text: Admission Date: [**2110-7-14**] Discharge Date: [**2110-7-21**]
Date of Birth: [**2043-3-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
adhesive tape
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2110-7-17**]
1. Urgent coronary artery bypass graft x3: Left internal
mammary artery to left anterior descending artery and
saphenous vein grafts to obtuse marginal and posterior
descending arteries.
2. Endoscopic harvesting of the long saphenous vein.
[**2110-7-16**]
Cardiac catheterization
History of Present Illness:
Patient is a 67yo M with PMHx of HTN and HLD who presented to
the ED from his PCP's office with complaints of CP found to have
positive stress test in the ED after being observed.
Patient reports that since watching the Celtics in the playoffs
he had noticed a chest discomfort in his chest that was relieved
when turning off the TV. Over the weekend, he had 2 episodes of
chest pain associated with exertion. He was walking [**2110-7-12**] for
[**3-7**] miles and started noting chest pain across the chest. The
chest pain was quantified as [**6-12**]. He did stop and after approx
5 minutes the pain resolved. He walked again on the day prior to
presentation (Sunday)and it was quantified as [**7-13**]. The patient
states that the pain resolved with rest. His pain is not
associated with diaphoresis, shortness of breath, abdominal
pain, nausea, vomiting, dizziness, or lightheadedness. The
patient saw his PCP regarding his symptoms, who then referred
him to the ED for further evaluation.
The patient had a stress test done at [**Location (un) 2274**] that was stopped due
to leg fatigue in [**2110-3-5**]. He had no symptoms during this test
and was noted to be hypertensive during his study. He was chest
pain free during this ETT with no EKG changes.
In the ED, initial vitals were 99.1 92 169/91 16 100% 3L. He
received 325mg ASA in the ED. The patient's troponins in the ED
were negative times 2. He was observed in the ED and had an ETT.
Exercise stress test was positive with ST-depressions
inferolateral leads, ST elevation in AVR, V1, and chest pain
with SBP drop from 190 to 160. Nuclear imaging showed fixed
perfusion deficits but no inducible ischemia. He was admitted to
cardiology for cardiac catheterization.
On arrival to the floor, patient is currently chest pain free.
REVIEW OF SYSTEMS:
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He reports exertional leg pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
PRIMARY DIAGNOSIS:
Coronary artery disease
SECONDARY DIAGNOSIS:
Hypertension
Hyperlipidemia
Myocardial Infarction [**2088**]
Social History:
Originally from [**Location (un) 3156**]. Married.
# Tobacco: Former smoker. Quite 4 months ago. Prior to quitting
patient smoked [**2-3**] ppd; patient endorses a smoking history of
1ppd or more 20 years ago
# Alcohol: Drinks socially.
# Illicit: Denies
Family History:
Father with CAD, MI (age >60 years) and PVD. Mother with stroke
at age 82; HTN. Maternal grandmother CAD and PVD.
Physical Exam:
Admission physical exam:
VS: T 97.7, BP 160/100, HR 60, RR 17, SpO2 99% on RA
Weight: 82.3kg
GENERAL: WDWN sitting at the side of the bed in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Xanthalesma
present on the eyes.
NECK: Supple with no JVD.
CARDIAC: R, 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.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Varicose veins appreciated on the LE
bilaterally.
NEURO: CN II-XII tested and intact, strength 5/5 throughout,
sensation grossly normal. Gait not tested.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
Intra-op TEE [**2110-7-17**]:
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF = 65%).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. There are complex (>4mm) atheroma in the aortic arch.
The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results at time
of surgery.
POST-BYPASS: The patient is in sinus rhythm. The patient is on a
phenylephrine infusion. Biventricular function is unchanged.
Mitral regurgitation is unchanged. The aorta is intact
post-decannulation.
.
[**2110-7-21**] 04:30AM BLOOD WBC-6.1 RBC-3.64* Hgb-11.2* Hct-33.1*
MCV-91 MCH-30.7 MCHC-33.9 RDW-14.9 Plt Ct-161
[**2110-7-20**] 03:57AM BLOOD WBC-7.9 RBC-3.81* Hgb-11.9* Hct-34.1*
MCV-90 MCH-31.3 MCHC-34.9 RDW-14.9 Plt Ct-170
[**2110-7-21**] 04:30AM BLOOD Glucose-89 UreaN-28* Creat-0.9 Na-136
K-3.7 Cl-98 HCO3-30 AnGap-12
[**2110-7-20**] 03:57AM BLOOD Glucose-100 UreaN-26* Creat-1.1 Na-136
K-4.0 Cl-99 HCO3-32 AnGap-9
Brief Hospital Course:
Patient is a 67yo M with PMHx of HTN and HLD who presented to
the ED from his PCP's office with complaints of CP who was found
to have positive ETT after observation in the ED found to have
2-vessel coronary artery disease on cardiac catheterization.
CARDIOLOGY FLOOR COURSE
# 2-vessel coronary artery disease: Patient presented with
symptoms of angina; he was not started on a heparin drip upon
admission. Nuclear stress images show fixed moderate basal
inferior wall perfusion defect and a fixed moderate inferoapical
perfusion defect with normal ejection fraction. Patient
underwent cardaic catheterization [**2110-7-16**] showing extensive
disease in LAD and RCA. The patient was started on aspirin 81mg
daily and his home simvastatin was continued. Cardiac surgery
was consulted in light of cardiac catheterization findings, and
it was recommended that the patient undergo revascularization
surgery. Patient was taken for CABG [**2110-7-17**]. Chest tubes,
foley and pacing wires were removed in the usual fashio. PT saw
patient. Pt stable for home. No sequele from the procedure.
# Hypertension: Managed with hydrochlorathiazide 25mg daily as
an outaptient only; patient has not been taking atenolol as an
outpatient. Upon admission, patient's systolic blood pressure
was 160, with diastolic 100. The patient was started on
lisinopril 5mg daily, at the time of his CABGE this was [**Name (NI) 1788**] pt
currently on lopressor 50 TID. He is tolerating this dose. He
will arrange to see his PCP [**Last Name (NamePattern4) **] [**3-8**] weeks.
# Hyperlipidemia: Patient on simvastatin as an outpatient. Most
recent LDL of 95. Simvastatin 10mg daily was continued during
the hospitalization.
# Kidney function: Review of Atrius records shows that the
patient's serum creatinine has ranged from 1.1-1.4. Patient
received [**Doctor Last Name 1567**] hydration prior to catheterization and after
catheterization. This remained stable during this hospital stay.
.
POST-OP COURSE:
The patient was brought to the Operating Room on [**2110-7-17**] where
the patient underwent CABG x 3 with Dr. [**First Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD **** 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:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Acetaminophen 650 mg PO Q4H:PRN fever, pain
3. Aspirin EC 81 mg PO DAILY
4. Bisacodyl 10 mg PR DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. OxycoDONE-Acetaminophen Elixir [**6-12**] mL PO Q4H:PRN pain
RX *Roxicet 5 mg-325 mg/5 mL every four (4) hours Disp #*300
Milliliter Refills:*0
7. Metoprolol Tartrate 50 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *Lopressor 50 mg three times a day Disp #*90 Tablet
Refills:*0
8. Atorvastatin 20 mg PO DAILY
RX *atorvastatin 20 mg daily Disp #*30 Tablet Refills:*0
9. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Coronary artery disease
SECONDARY DIAGNOSIS:
Hypertension
Hyperlipidemia
Myocardial Infarction [**2088**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Dr.[**Name (NI) 11272**] office: Phone:[**Telephone/Fax (1) 170**], [**2110-7-29**]
10:15
Surgeon Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 170**], [**2110-8-19**]
1:00
Cardiologist -- the office will call you with an appt.
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 90382**] in [**5-8**] 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**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2110-7-21**]
ICD9 Codes: 4111, 2859, 2875, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3087
} | Medical Text: Admission Date: [**2170-2-22**] Discharge Date: [**2170-3-5**]
Date of Birth: [**2108-9-28**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
non-traumatic SAH
Major Surgical or Invasive Procedure:
[**2170-2-22**] - cerebral arteriography and coiling of left PICA
aneurysm
History of Present Illness:
61 yo F who was in her usual state of health, worked her
shift as cleaner in hospital from 5 pm to 2 am. when she got
home, she sudenly started screamin in pain, occipital
headache/post neck pain grade [**10-26**] in intensity and
nausea/retching. She was brought by her husband to [**Name (NI) 8641**]
Hospital where she had a NCHCT that showed SAH and report
commneted on "nonspecific subtle low density area R parietal
lobe
? ischemia" so she was transferred her for further treatment.
EKG
nsr, high T waves but nml K at 3.7. Initial BP was 209/105.
Past Medical History:
-EtOH pancreatitis
-lumbar disc disease
-bursitis
Social History:
lives with husband, no children, works as cleaner in a
hospital, priro heavy EtOh use, now only "occasional", tobacco
intake 12 cigs/day.
Family History:
brother had a brain tumor, no aneurysms or ICH
Physical Exam:
On admission:
PHYSICAL EXAM
T: 96.6 BP: 148 / 60 HR: 72 nsr RR 18 O2Sats 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: meningismus
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
NEURO
drowsy but arouses to loud voice, oriented to "[**Hospital 8641**] Hospital"
and "beginning of winter [**2170**]" with repeated prompting, no
dysatrhria, comprehension intact to simple commands, PERRL 1.5
to
1 bilat, EOMI without nystagmus, blinks to threat bilat, facies
symmetric, tongue midline, no pronator drift or adventitious
movement, nml bulk and tone, strength full throughout, DTRs 2 +
and symmetric, R plantar upgoing, L plantar equivocal, sensation
intact to light touch bilat, no obvious dysmetria on FTNT.
Pertinent Results:
[**2170-3-3**] 08:00AM BLOOD WBC-8.3 RBC-3.44* Hgb-10.0* Hct-30.4*
MCV-88 MCH-29.1 MCHC-33.0 RDW-14.4 Plt Ct-509*
[**2170-3-3**] 08:00AM BLOOD PT-11.7 PTT-39.7* INR(PT)-1.0
[**2170-3-3**] 08:00AM BLOOD Glucose-136* UreaN-6 Creat-0.7 Na-133
K-4.4 Cl-96 HCO3-28 AnGap-13
[**2170-3-3**] 08:00AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.2
[**2170-3-3**] 08:00AM BLOOD Phenyto-17.8
[**2-22**] CTA head
1. Subarachnoid hemorrhage with signs of obstructive
hydrocephalus and intraventricular blood.
2. Normal CTA of the neck.
3. Left posterior inferior cerebellar artery aneurysm with the
neck not definitely separable from the origin of posterior
inferior cerebellar artery. Correlation with cerebral
angiography is recommended. Other changes as above.
[**2-23**] CT head
Persistent diffuse subarachnoid hemorrhage without any new
hemorrhage. Very slight increase in hydrocephalus despite
intraventricular drain.
[**2-25**] CTP
IMPRESSION: Sequelae of subarachnoid hemorrhage persists
involving cerebellar infarcts, greater on the left than the
right. This CTA is consistent with recent left PICA coiling and
stent, without other abnormalities. Perfusion study at the
level of the MCA is normal.
[**2-28**] CT head
IMPRESSION:
1. Status post ventricular drain removal with small residual
intraparenchymal right frontal hemorrhage. No new hemorrhage is
identified.
2. Stable appearance of evolving left cerebellar infarction.
Brief Hospital Course:
Pateint was intubated and had an EVD drain placed emergently in
the ED. ICPs were monitored and maintained below 25mmHg. She
was taken to the angio suite for angiography and coiling of L
PICA aneurysm. Tolerated the procedure well. Was extubated in
the PACU. Had heparin drip overnight in PACU and was given asa.
Tx to ICU on POD 1. Was started on nimodipine and dilantin was
held for elevated level. Patient's neurologic status gradually
improved and imaging was stable. On [**2-27**] EVD drain was removed
and patient tolerated it well. [**3-1**] patient was transferred to
the floor and staples removed. Had residual drainage so another
stitch was placed at drain site. On [**3-4**] nimodipine was d/c'ed.
PT evaluated patient and recommended home for disposition.
Patient with no neurologic deficits at discharge and pain
controlled.
Medications on Admission:
Ultram, Vicodin
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Docusate Sodium 100 mg Capsule Sig: [**1-17**] Capsules PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
6. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day) for 4 weeks.
Disp:*168 Tablet, Chewable(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
Weekly Lab draw:
Dilantin level
Please fax results to Dr. [**Last Name (STitle) **] office.
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Discharge Condition:
Neurologically stable
Discharge Instructions:
Call or come back to ED in if you are experiencing headache,
increasing pain, difficulty speaking, changes in your ability to
think, increased pain, fevers, chills, nausea, vomiting, or any
other concerns.
It is okay to shower. Do not soak incisions sites. You need
your suture removed on [**2170-3-9**]. Your PCP can do this or Dr. [**Name (NI) 78096**] nurse.
Take dilantin for one month. You should have your blood drawn
weekly for Dilantin levels to be checked. Have the results sent
to Dr.[**Name (NI) 935**] office.
Do not drive while taking pain medications. Take stool
softeners to prevent constipation.
Followup Instructions:
You should follow up with Dr. [**First Name (STitle) **] in one month with
non-contrast head CT. Please call ([**Telephone/Fax (1) 88**] to set up an
appointment.
ICD9 Codes: 2768, 3051, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3088
} | Medical Text: Admission Date: [**2113-7-13**] Discharge Date: [**2113-7-25**]
Date of Birth: [**2035-5-25**] Sex: M
Service: NEUROLOGY
Allergies:
Ativan
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
CODE STROKE
Major Surgical or Invasive Procedure:
Lumbar puncture
Transesophageal echocardiogram
History of Present Illness:
78 yo RHM [**Location 7972**]/Portuguese speaking only PMH
dementia, right PCA stroke, essential thrombocytosis, htn,
hyperchol and seizure disorder who presents as CODE STROKE.
Called at 9:50am at bedside within minutes. History provided by
wife with translator at bedside.
Patient awoke this morning his usual self and saw his wife
before
going to take a shower. After ~10 minutes, he came out of the
shower complaining of right arm weakness and numbness and she
noted his speech was more dysarthric from his baseline and he
had
a right facial droop.
Last seen well @9am.
Onset of symptoms @9:10am.
NIHSS
1a. alert 0
1b. LOC questions 2
1c. LOC commands 0
2. Gaze 0
3. Visual 0
4. Facial palsy 1
5. Motor L arm 0
5. Motor R arm 1
6. Motor L leg 0
6. Motor R leg 1
7. Limb ataxia 0
8. Sensory 1
9. Best language 1
10. Dysarthria 1
11. Extinction 0
NIHSS Total 8
Head CT performed at 10:02AM without obvious signs acute bleed.
It did show right sided dural thickening associated with old
subdural hemorrhage. No obvious signs of acute infarct. Labs
INR 1.1, Cr 1.6 (b/l 1.5) and FS 110.
Given seizure history, patient was taken for stat MRI which was
suggestive of restricted diffusion in the left pons, limited T2
scan due to movemennt.
Patient was given IV TPA at 11:54, witin the 3 hour window. He
was given 7mg IV TPA bolus and started on 62.6 mg drip over one
hour.
ROS: No recent fevers/chills. Per wife, has had right facial
"drooping" of corner of mouth intermittently in the past but
never had right arm or leg symptoms before. In [**11-23**], patient
presented to ED with R UMN facial and dysarthria, MRA was
performed which was negative for clot. Unfortunately, DWI was
not obtained. W/u also included an EEG and toxic infectious w/u
which was negative. At discharge, patient was thought to have
had a TIA.
Past Medical History:
1) essential thrombocytosis
2) stroke, right pca territorial
3) htn, and hypercholesterolemia
4) presumptive seizure disorder (According to wife per prior [**Name (NI) **]
notes, his eyes roll back into head and he is unresponsive to
his
name for 2-3 min. No adventitious movements, oral-buccal
movements. No lethargy, tongue lac or incontinence. There was
no weakness/ paralysis/ or sensory changes associated with the
episode.
5) dementia (no normal w/u)
6) Subdural hematoma s/p evacuation
7) h/o GIB
8) h/o C diff colitis
Followed by Dr. [**First Name (STitle) 3322**] [**Name (STitle) **] as an outpatient.
Social History:
Lives at home with wife both of whom speak [**Name (NI) 7972**] only.
Lives with wife, needs assistance with ADLs. Completed 2nd
grade. Used to work on a farm. No tobacco, EtOH or drugs.
Family History:
Brother with stroke age 86. No hx of seizures
Physical Exam:
Exam: With [**Location 7972**]/Portuguese translator present
T- 96.4 BP- 179/75 HR- 60 RR- 21 96 O2Sat RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: no carotid bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, follows simple commands.
Oriented to person, +[**Hospital3 **] hospital but not to month or
year. Speech [**1-21**] words with moderate dysarthria. Normal
comprehension. Naming intact. Cannot read.
Cranial Nerves:
Pupils equally round and reactive to light, 2.5 to 2 mm
bilaterally. Visual fields are full to confrontation(?).
Extraocular movements intact bilaterally, no nystagmus.
Sensation
intact V1- V3. Facial movement symmetric. Hearing intact to
finger rub bilaterally. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. Right pronator drift and leg drift towards bed. Arms
antigravity for 10 seconds and legs also antigravity for 5
seconds bilaterally.
Sensation: Decreased to light touch on the right arm and leg.
No
extinction to DSS.
Reflexes:
+2 and symmetric throughout.
Toes upgoing bilaterally.
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: deferred.
Romberg: deferred.
Pertinent Results:
UA and Utox neg
140 107 20 98
----------------
4.2 25 1.6
CK: 74 MB: Notdone Trop-T: <0.01
ALT: 7 AP: 75 Tbili: 0.4 Alb: 4.2
AST: 14 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
MCV 114
3.6 >12.6< 402
34.6
PT: 12.4 PTT: 28.0 INR: 1.1
A1c: 5.4
LDL: 214
Imaging
CT Head [**7-13**]:
1. No hemorrhage.
2. Mild hypodensity within the left pons.
MRI [**7-13**]:
Focus of increased signal on diffusion images in the upper pons
on the left side could be due to acute infarct or T2
shine-through.
TTE:
The left atrium is mildly dilated. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
mildly thickened but with good leaflet excursion. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a fat pad.
TEE:
Mild to moderate aortic regurgitation with mildly thickened
leaflets, but no vegetations or abscess. Mild mitral
regurgitation.
CTA: Question of minor stenoses involving branches of the left
middle cerebral artery beyond the M1 segment.
Brief Hospital Course:
Mr. [**Known lastname 3586**] is a 78-year-old right-handed man with a history of
right PCA stroke, essential thrombocytosis, hypertension, and
hypercholesterolemia who presented with right facial droop and
weakness. His brief hospital course by problem is as follows:
1. Neuro: Stroke. Given the severity of his presenting symptoms,
he was given IV tPA after discussing the risks carefully with
his family. His right sided weakness did improve after the tPA.
MRI showed a left pontine stroke. However, he developed aphasia.
Followup CT showed no hemorrhage. There was some question as to
whether the aphasia in fact was his baseline. Since he did have
a waxing and [**Doctor Last Name 688**] mental status, further investigations were
pursued. EEG showed no focal epileptiform discharges. An echo
showed new aortic regurgitation concerning for endocarditis,
thought to perhaps explain his mental status. However,
subsequent TEE showed no vegetation and blood cultures were
negative. LP was attempted at the bedside but was unsuccessful;
it was later performed under fluoroscopic guidance, which
revealed bony abnormalities around the L3-L4 interspace. CSF was
not consistent with meningitis; several viral PCR studies were
pending at the time of discharge.
Routine work-up revealed an LDL > 200, and so he was started on
a statin. His goal LDL is <70. His A1c was appropriate at 5.4%.
CTA to look for stenosis or embolic source showed no clear
etiology.
2. Heme: Essential thrombocytosis. His anagrelide and
hydroxyurea were held for 24 hours after tPA and then restarted,
although he was not always able to take the hydroxyurea PO.
3. FEN: NG tube was attempted several times; each time he pulled
it out despite restraints. Ultimately, his mental status
improved sufficiently so that he could take oral nutrition.
4. CODE: FULL
5. Dispo: He was discharged to rehab with neurology follow-up.
Medications on Admission:
- anagrelide 0.5mg TID
- asa 81mg QD qMon
- folic acid 1mg QD
- hydroxyurea 1000mg QMON, THURS and 500mg QTUES, WED, FRI, SAT,
SUN
- lamictal 175mg [**Hospital1 **]
- Lopressor 75mg TID
- Norvasc 5mg QD
- Vitamin B12 2000mcg QD
ALL: Ativan (agitation)
Discharge Medications:
1. LaMOTrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Take with 25 mg tablet for total of 175 mg.
2. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO twice a day:
Take with 150 mg dose for total of 175 mg. .
3. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Insulin Regular Human 100 unit/mL Solution Sig: AS DIR
Injection ASDIR (AS DIRECTED): Standard sliding scale.
6. Anagrelide 0.5 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 5X/WEEK
([**Doctor First Name **],TU,WE,FR,SA).
8. Hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO 2X/WEEK
(MO,TH).
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever>101.0.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times 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. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12
hr Sig: One (1) Cap PO twice a day.
14. Polyethylene Glycol 3350 17 g (100%) Powder in Packet Sig:
One (1) Powder in Packet PO once a day as needed for
constipation.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
19. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
21. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): apply to erosions.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11729**] Home - [**Location (un) 686**]
Discharge Diagnosis:
Primary:
1. Ischemic Stroke of the left pons
Secondary:
1. Hypertension
2. Hyperlipidemia
3. Essential thrombocytosis
Discharge Condition:
Good condition. Neuro exam notable for inattention and aphasia,
with poor comprehension. 5/5 strength throughout.
Discharge Instructions:
You have been evaluated for right sided weakness and difficulty
speaking. You were found to have had a stroke. You have been
started on a medication called Aggrenox to help prevent another
stroke. You have also been started on Lipitor for cholesterol
and metoprolol and lisinopril for blood pressure. Please take
all medications as directed and keep all follow-up appointments.
If you should develop further weakness, loss of sensation,
difficulty swallowing, difficulty speaking, dizziness, chest
pain, palpitations, shortness of breath, or any other symptom
that is concerning to you, please call your PCP or your
neurologist or go to the nearest hospital emergency department.
Followup Instructions:
You have the following appointments scheduled:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2113-7-25**] 10:30
2. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2113-9-5**] 10:30
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2113-9-11**] 9:15
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
Completed by:[**2113-7-25**]
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3089
} | Medical Text: Admission Date: [**2122-9-3**] Discharge Date: [**2122-9-13**]
Date of Birth: [**2064-1-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2122-9-9**] Four Vessel Coronary Artery Bypass Grafting(LIMA to LAD,
SVG to OM1, SVG to OM2, SVG to PDA)
History of Present Illness:
This is a 58 year old male who was recently admitted to [**Hospital1 3325**] with substernal exertional chest pressure. He ruled out
for myocardial infarction. Stress test on [**2122-9-1**] was notable
for inferior ST changes while nuclear imaging revealed a mild to
moderate reversible inferior defect with an ejection fraction of
55%. Patient was subsequently transferred to the [**Hospital1 18**] for
further evaluation and treatment.
Past Medical History:
Hypercholesterolemia
History of Alcohol Abuse
Bilateral Knee Surgery
History of Vertigo
Social History:
Admits to drinking 8-12 beers per day. He denies tobacco. He is
married. He works in construction.
Family History:
Mother had MI at age 69.
Physical Exam:
Vitals: 166/92, 69, 12
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2122-9-3**] 02:48PM BLOOD WBC-7.3 RBC-4.43* Hgb-14.5 Hct-40.9
MCV-92 MCH-32.8* MCHC-35.5* RDW-12.7 Plt Ct-287
[**2122-9-3**] 09:05AM BLOOD INR(PT)-1.1
[**2122-9-3**] 02:48PM BLOOD Glucose-117* UreaN-14 Creat-0.8 Na-138
K-4.0 Cl-101 HCO3-27 AnGap-14
[**2122-9-3**] 02:48PM BLOOD ALT-34 AST-24 AlkPhos-63 TotBili-0.7
[**2122-9-3**] 02:48PM BLOOD %HbA1c-6.1*
[**2122-9-3**] Cardiac Cath: 1. Coronary angiography of this right
dominant system revealed 3 vessel coronary artery disease. The
LMCA was a short vessel with distal narrowing. The LAD had a
50% ostial stenosis. The LCx had an 80% ostial stenosis with a
50% stenosis of OM2. The RCA had serial 80% stenoses in its mid
and distal portions.
[**2122-9-4**] Echocardiogram: The left atrium is normal in size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 70%) 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 appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is no pericardial effusion.
[**2122-9-11**] Chest x-ray: In comparison with the study of [**9-9**], the
patient has taken a much better inspiration. The left chest tube
has been removed and there is no evidence of pneumothorax. The
endotracheal tube, right IJ catheter, and nasogastric tube both
have been removed. Some residual atelectatic changes are seen at
the bases.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted under cardiology and underwent cardiac
catheterization which revealed severe three vessel coronary
artery disease - please see result section. Cardiac surgery was
therefore consulted and further evaluation was performed.
Echocardiogram showed normal left ventricular function and
normal aortic and mitral valves - please see result section. His
preoperative course was otherwise unremarkable and he was
cleared for surgery. He remained pain free on medical therapy.
On [**9-9**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting surgery. See separate dictated operative note for
surgical details. Following the operation, he was brought to the
CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. His
CVICU course was uneventful and he transferred to the SDU on
postoperative day one. Chest tubes and pacing wires removed
without incident.Made good progress and cleared for discharge to
home on POD #4. Pt. is to make all follow-up appts. as per
discharge instructions.
Medications on Admission:
No meds at home. Hospital started Lopressor 12.5 mg [**Hospital1 **],
Nitropaste, Ativan prn
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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. 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*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Hypercholesterolemia
History of ETOH Abuse
Discharge Condition:
Stable
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.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-19**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 5310**] in [**1-17**] weeks, call for appt
Dr. [**First Name (STitle) 5936**] in [**1-17**] weeks, call for appt
Completed by:[**2122-9-14**]
ICD9 Codes: 4111, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3090
} | Medical Text: Admission Date: [**2181-10-15**] Discharge Date: [**2181-10-21**]
Date of Birth: [**2122-10-7**] Sex: M
Service: MEDICINE
Allergies:
Aldomet / Codeine Phos/Apap/Caff/Butalb / Hydralazine /
Aldactone / Effexor Xr / Lopid / Ciprofloxacin / Tricor /
Percocet / Vicodin
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
nausea and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 111187**] is a 59 yar old man with a PMH significant for ARF x
5, GIB, and cholestatic jaundice during his last admit who was
discharged 9 days prior to admission. He was in his usual state
of health until about 3 days prior to arrival when he developed
the onset of a headache, nausea, dry heaves. This is how he
feels when he has renal failure. He also noted increasing pedal
edema and thirst. He denies hematochezia, fevers, chills,
diarrhea, chest pain, dysuria, or hematuria. He says that his
sugars have been excellent lately. He has not taken lasix since
his last admit. He states that he last took 2 tablets of alieve
2 nights ago.
In the ED, he was found to be in acute renal failure with a
creatinine of 5.2 up from 1.6 six days ago. LENIS were negative
for DVT.
Past Medical History:
DM, COPD, "kidney failure" x 4, heart murmur since infancy,
apnea, veins "stipped" [**3-7**] varicose veins, appendectomy,
"tendency to bleed" since childhood.
Social History:
Lives w/ wife.
EtOH: denies after [**2160**]. Most prior to that would be "5 shots"
on any one night.
Illicits: denies past/present.
Tobacco: denies past/present.
Family History:
Mother died at 36 years old. Had DM, CHF.
Father died at 50 years old; had CAD.
Physical Exam:
95.1 - 62 - 128/36 - 14 - 99%ra
Gen: Morbidly obese body habitus; markedly jaundiced white male
in NAD lying flat on his back. Communicates in full sentences
and breathes comfortably.
HEENT: NC/AT. Sclera markedly icteric bilaterally, PERRL, EOMI.
Nares patent. Oropharynx: no erythema or exudate. Dry MM.
Pulm: cta b.
Back: no cvat.
CV: All heart sounds faint. rrr, S1, S2, II/VI holosystolic
murmur. Unable to assess JVD due to obesity. Pulses: [**3-9**]
bilateral radial.
Abd:+BS. Enormously distended but soft obese abd. No
organomegaly noted though exam limited by obesity. nontender.no
guarding.
Extr: [**3-7**] pitting edema of bilateral LE.
Skin: Violaceous discoloration of anterior tibial region
bilaterally. RLE had 4x2cm area of superficial ulceration that
is non-erythematous and non-draining. 1 dressing on tibial
aspect of right shin clean dry intact.
Pertinent Results:
[**2181-10-15**] 01:00AM WBC-9.3 RBC-3.21* HGB-10.8* HCT-33.3*
MCV-104* MCH-33.7* MCHC-32.5 RDW-17.6*
[**2181-10-15**] 01:00AM NEUTS-86* BANDS-2 LYMPHS-2* MONOS-5 EOS-1
BASOS-0 ATYPS-0 METAS-3* MYELOS-1*
[**2181-10-15**] 01:00AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL TARGET-1+
SCHISTOCY-OCCASIONAL BURR-OCCASIONAL STIPPLED-OCCASIONAL
TEARDROP-OCCASIONAL
[**2181-10-15**] 01:00AM PLT COUNT-222 PLTCLM-1+
[**2181-10-15**] 01:00AM PT-19.2* PTT-61.5* INR(PT)-2.6
[**2181-10-15**] 12:14AM GLUCOSE-150* UREA N-101* CREAT-5.2*#
SODIUM-132* POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-11* ANION
GAP-24*
[**2181-10-15**] 12:14AM ALT(SGPT)-68* AST(SGOT)-65* ALK PHOS-251*
AMYLASE-60 TOT BILI-34.4*
[**2181-10-15**] 12:14AM LIPASE-61*
[**2181-10-15**] 12:14AM proBNP-1472*
[**2181-10-15**] 12:14AM ALBUMIN-3.1* CALCIUM-8.7 PHOSPHATE-7.5*#
MAGNESIUM-2.0
.
CXR: bilateral effusions consistent with pulmonary edema (my
interpretation)
.
LENI negative but limited by habitus
.
U/S [**10-16**]
IMPRESSION:
1. Sludge-filled gallbladder without evidence for cholecystitis.
Common duct dilatation to 2 cm, etiology indeterminate.
2. Normal patency of the hepatic and portal venous vasculature.
3. Fatty liver.
4. Small ascites.
.
ECHO [**10-18**]
Conclusions:
The left atrium is markedly dilated. There is mild symmetric
left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
Overall left
ventricular systolic function is normal (LVEF 70 percent). No
masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect.
The aortic root is moderately dilated. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
The mitral valve leaflets are structurally normal. Mitral
regurgitation is
present but cannot be quantified. Tricuspid regurgitation is
present but
cannot be quantified. There is at least moderate pulmonary
artery systolic
hypertension. There is no pericardial effusion.
.
[**10-19**] U/S with dopplers
IMPRESSION:
1. Extremely limited study due to patient body habitus.
2. Distended gallbladder with sludge.
3. Fatty liver. Main and right portal veins are patent.
4. Increased ascites.
Brief Hospital Course:
.
# Oliguric Renal Failure: Initially patient was thought to be
prerenal vs HRS, and FENA was consistent with this. The patient
was hydrated with NaHCO, cautiously, and was started on
hepotorenal medications including octreotide, midodrine, and
albumin. Urine output transiently increased, but unclear if
this was d/t hydration or HRS treatment, as both occurred
simultaneously. Additionally, foley was found to be in urethra
on HD #2 and once this was replaced, urine output increased
transiently. However, the patient continued to have poor urine
output even in the setting of adequate BP. CVVH was started in
setting of uremia. Repeat FENA suggested ATN, but it was
questionable how accurate this was in the setting of CVVH.
There was some concern for right ventricular dysfunction in the
face of pulmonary hypertension, and an ECHO was performed. This
showed mod pulm HTN based on TR gradient of 45, but right
ventricle was not well visualized d/t patient's habitus. CXR
demonstrated a widened mediastinum that was concerning for
congestion. Because the patient's fluid status was not
completely clear and because there was some concern for hepatic
congestion by renal and total body fluid overload, 50cc/hr was
removed with CVVH. Cr intermittently trended down with CVVH but
then trended upwards. Treatment for HRS was continued, but
patient was unable to get midodrine for ~1day as he was
aspirating meds and it was very difficult to pass an NGT.
Patient remained oliguric until death.
.
# Transaminitis: Pt had evidence of non-alcoholic
steatohepatitis and presumed drug injury on previous biopsy and
demonstrated continued worsening of synthetic funtion based upon
INR and bilirubin. No clear etiology of acute liver
decompensation was found. Liver U/S from [**10-17**] showed no
thrombosis of portal or hepatic veins and little ascites, and
this was repeated with no change. There may have been a small
element of hepatic congestion, but this was not the cause of the
acute decompensation as the LFT's would have been more elevated.
Although the patient had already had a full workup for acute
liver disease, repeat workup was performed with CMV, EBV, and
Hep serologies, all of which were negative. No cause for acute
liver decompensation was determined, and the patient became
progressively more encephalopathic. He was treated with
lactulose for encephalopathy, but did not receive this for ~1
day d/t poor PO access. An arterial ammonia level was obtained
and was moderately elevated
.
# Septicemia - The patient did not have fevers or a white count
on presentation or for the majority of his ICU stay. Because
his mental status was deteriorating and white count jumped up,
blood cultures were taken on [**10-19**] which showed GPC in clusters,
which later grew out coagulase negative staph, and broad
spectrum antibiotics were started. However, over the course of
the following day he rapidly became hypotensive, febrile, and
tachycardic. He was found to by hypoxic with PaO2 78 and
adidemic with pH 7.1 and was intubated. His lactate trended
from 1.4 to 11.4 within 16 hours, and his hypotension progressed
to the point or requiring 3 different pressors to maintain MAPs.
A discussion was held with his wife and she made him [**Name (NI) 3225**] in the
face of rapid deterioration, overwhelming sepsis, acute
worsening liver disease of unknown etiology, and renal failure.
Pressors were withdrawn and the patient expired shortly
thereafter from cardiac and respiratory arrest.
.
# Cardiology - Last ECHO on record at [**Hospital1 **] with EF>50% in [**2178**]
with dilated LA and symmetric LVH, right heart not seen, and
cardiac cath in [**2179**] with normal coronary arteries and mild
pulmonary HTN (PCWP 20, PAP 20, RA 13). Repeat ECHO with mod
pulm HTN, LVH, normal EF. After initial resuscitation with
fluids, renal was consulted and started CVVH with goal to remove
50cc/hr in setting of ?right heart failure.
.
#FEN - The patient was found to aspirate liquids and meds, and
an NGT was placed and he was made NPO. A speech and swallolw
was planned but never obtained.
.
# Sleep Apnea: Used CPAP continuously, both at night and during
the day, until intubation.
.
# Type II Diabetes: Continued on outpatient NPH and sliding
scale with fingersticks.
.
# HTN: After fluid resuscitation remained normotensive until day
of death. Home dose of valsartan was held.
.
# Psych: History of anxiety, depression. Former alcoholic but
had not had drink in many years. Was continue lexapro 5 mg QPM.
.
Medications on Admission:
1. Ursodiol 600 mg Capsule QAM
2. Ursodiol 300 mg Capsule QPM
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-4**]
Puffs Inhalation Q6H PRN.
4. Metoprolol Tartrate 12.5 mg PO BID
5. Pantoprazole Sodium 40 mg Q24H
6. Hydroxyzine HCl 25 mg Tablet 1 Q4-6H PRN
7. Morphine 30 mg PRN
8. Diovan 40 mg Tablet Sig: [**2-4**] Tablet PO once a day.
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic Shock
Discharge Condition:
Deceased
Discharge Instructions:
None
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
ICD9 Codes: 5849, 0389, 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3091
} | Medical Text: Admission Date: [**2179-8-19**] Discharge Date: [**2179-8-19**]
Date of Birth: [**2114-7-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
fevers, hypotension
Major Surgical or Invasive Procedure:
R IJ line placed; d/c'ed prior to discharge
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname **] is a 65-year-old woman with
advanced pancreatic cancer undergoing systemic palliative
chemotherapy with weekly gemcitabine initiated on [**2179-7-22**] who
presented to the ED complaining of fevers/chills, dysuria and
cough 24 hours following treatment. She had been tolerating the
chemo well, aside from reports of significant weakness and
tiredness over the last few weeks as well as a possible skin
reaction to the chemo. Her third dose was held secondary to
ANC-740, plt-43,000. Her pain has been under control with
OxyContin 40 mg b.i.d. She
reports a fair appetite and her weight is stable. Her energy
level has been her chief complaint until now.
.
In the ED, she was found to be febrile to 105, slightly
disoriented, with a SBP in the 80's and sats in the low 90's.
She was fluid resuscitated with 3L of NS which brought her
pressure back up to the 110's and in the meantime, she was given
a dose of empiric stress dose steroids and a central line was
placed under ultra sound guidance. Her lactate was 1.1, she was
given doses of CTX and vanco. CXR, CTA and CT head were negative
for acute processes. Since being fluid resuscitated initially,
she has remained hemodynamically stable with sats in the mid
90's. She is admitted to the [**Hospital Unit Name 153**] for further management.
.
On ROS, the patient denies chest pain, shortness of breath,
abdominal pain. She denies having fevers, chills currently. She
notes having an episode of n/v after taking compazine yesterday,
prior to chemo, and afterwards, does not recall much of what
happened. She was told by her daughter that she was "shaking
like a leaf" and after waking from a nap, she was disoriented
and not making much sense. The patient also notes that she is
sleeping more and not taking in much PO as a result.
Past Medical History:
Metastatic Pancreatic Ca with multiple mets in liver and lungs
Hypercholesterolemia
?Lupus
AAA (incidentally picked up on a CT scan 3 years ago)
h/o Zoster
Social History:
The patient smoked for several years but has quit recently and
she also is a recovering alcoholic.
Family History:
Her mother died of lung cancer, although she was a smoker. She
also suffered from stroke and required a triple vessel CABG.
She has 3 children, all of whom are healthy. No remarkable
history of malignancies in her family.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION
Vitals: T 97.3 HR 70 BP 133/64 R 20 Sat 95% RA
General: 65 yo F, NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric, MMM, OP clear
Neck: supple, JVP @ 7cm
Chest: RRR II/VI SEM at LLSB radiating across precordium. No
rub.
Lungs: bibasilar rales. No wheeze/rhonchi
Abd: soft, NT/ND +BS
Ext: No e/c/c, warm and well perfused.
Neuro: CN II-XII in tact bilaterally. A&Ox3. Strength 5/5
bilaterally.
Skin: warm and well perfused, no lesions/rashes
Access: RIJ, PIV
foley in place
Pertinent Results:
LABS:
WBC RBC Hgb Hct MCV MCH MCHC
RDW Plt
[**2179-8-19**] 05:01AM 4.1 3.29* 10.6* 30.4* 92 32.1* 34.8
13.7 279
[**2179-8-18**] 08:20PM 6.2 3.44* 11.0* 30.6* 89 32.0
36.0*14.4 334
[**2179-8-18**] 09:50AM 6.3# 3.41* 11.0* 31.4* 92 32.2* 35.0
13.8 368
.
Neuts Bands Lymphs Monos Eos Baso Atyps
Metas
[**2179-8-19**] 05:01AM 85.3* 12.6* 1.9* 0.1 0.1
.
Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2179-8-19**] 05:01AM 164* 11 0.6 141 4.1 107 25
13
.
Lactate
[**2179-8-19**] 05:29AM 0.9
.
CARDIAC ENZYMES:
-CK 40; 38
-Tn-T <0.01 x2
.
MICRO:
-Blood cultures x4-pending
-Urine cultures pending
.
IMAGING:
-[**8-18**] CTA:
1. No pulmonary embolism or aortic dissection is noted.
2. Multiple bilateral pulmonary nodules are noted, the largest
nodules are seen within the left upper lobe and measure up to 7
mm in the short axis. These nodules could represent an atypical
or fungal infection. Followup is recommended to ensure
resolution.
3. Pathologically enlarged mediastinal nodes likely reactive.
.
-[**8-18**] HEAD CT:
IMPRESSION: No acute intracranial pathology including no
intracranial hemorrhage.
.
-[**8-18**] CXR:
IMPRESSION:
No acute intrathoracic process.
.
Brief Hospital Course:
1. Hypotension: It was responsive to fluid resusitation,
received a total of 3L in the ED. Initial episode of hypotension
was likely [**3-5**] recent poor po intake and insensible losses from
high fevers. On arrival to the [**Name (NI) 153**], pt's SBP 140's & she had
bibasilar rales with O2sats on RA in mid 90's. Recieved total of
Lasix 40mg IV for fluid overload, and maintained adequate BP
while in the [**Hospital Unit Name 153**].
.
2. Fevers: Most likely [**3-5**] chemotherapy; although infection is
certainly on the differential; however pt. remained afebrile
while admitted. Other etiologies include drug reaction, although
patient was premedicated with benadryl, decadron could also have
helped shut down a hypersensitivity reaction. CXR was
unremarkable for any infectious process. CTA done was negative
for PE. On-call covering heme-onc physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was
paged & agreed that this was most likely Gemcitabine reaction
since all work up was negative so far. Blood & urine cultures
were done and need to be followed up by outpt. PCP or
oncologist.
.
3. Dysuria: UA unremarkable. Foley was placed & d/c'ed prior to
discharge. Pt. denied further complaints.
.
4. Pancreatic Cancer: Pt of Dr. [**Last Name (STitle) **]; receiving weekly
gemcitabine. Continued supportive care of pt with anti-emetics &
anti-diarrheal agents. No new interventions for pt.
.
5. Code: DNR/DNI, confirmed with patient
.
Medications on Admission:
CHOLESTYRAMINE LIGHT 4 gram--1 packet by mouth before meals
COMPAZINE 10 mg--1 tablet(s) by mouth three times a day
LOMOTIL 2.5 mg-0.025 mg--1 tablet(s) by mouth 3-4 times a day as
needed for diarrhea
LORAZEPAM 0.5 mg--one tablet(s) by mouth every 6 hours as needed
MS CONTIN 30 mg--1 tablet(s) by mouth twice a day
OXYCONTIN 40 mg--1 tablet(s) by mouth twice a day
PANCREASE 20,000 unit-[**Unit Number **],500 unit-[**Unit Number **],000 unit--1 capsule(s) by
mouth three times a day
PERCOCET 5 mg-325 mg--[**2-2**] tablet(s) by mouth every 4-6 hours as
needed for pain
Discharge Medications:
1. Medications
Please resume all your home medications. We have not added or
changed any of your prior medations.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Fever
- Hypotension
.
Secondary Diagnosis:
- Pancreatic cancer
Discharge Condition:
Stable, afebrile, ambulating & tolerating po
Discharge Instructions:
1. Please take your medications as directed
.
2. Return to emergency department if you have fever greater than
101.5F, nausea, vomiting, lightheadedness, difficulty breathing,
chest pain or any other worrisome symptoms.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 4617**] [**Last Name (NamePattern1) 4618**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2179-8-25**] 10:30
Provider: [**First Name4 (NamePattern1) 4617**] [**Last Name (NamePattern1) 4618**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2179-9-1**] 9:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2179-9-15**]
1:30
ICD9 Codes: 2720, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3092
} | Medical Text: Admission Date: [**2162-1-30**] Discharge Date: [**2162-2-6**]
Service:
HISTORY OF PRESENT ILLNESS: This is as 86-year-old white
male on Coumadin, with a history of atrial fibrillation, who
fell on the day of admission and then developed a right-sided
subdural hematoma.
He was in his usual state of good health until approximately
5 p.m. on the day of admission when he fell on ice and a
positive loss of consciousness. He was taken to the [**Hospital 1474**]
Hospital Emergency Department and had a 2-cm left frontal
laceration sutured. His INR at that time was noted to
be 2.8. He was given 2 mg of vitamin K and 2 units of fresh
frozen plasma and admitted to the hospital floor at that
time. A head CT showed a 5-mm subdural hematoma at that
time. His examination was apparently normal at that time.
At approximately midnight they noted decreased alertness, and
a repeat head CT showed an increased size of the subdural
hematoma with new subarachnoid hemorrhage and left-sided
shift. He was transferred to the Coronary Care Unit and
intubated for airway protection, and hyperventilated, and
treated with mannitol and Decadron. A repeat INR was 2.4,
and a referral was made to the [**Hospital1 188**] at that time, and the patient was transported urgently
to the [**Hospital1 **].
PAST MEDICAL HISTORY: (Previous medical history includes)
1. A history of right hip replacement in [**2146**].
2. A history of coronary artery bypass graft times three
vessels in [**2150-5-12**].
3. A colostomy in [**2157**].
4. Hernia repair in [**2157**].
5. A left knee replacement in [**2158**].
6. A cataract repair on the right eye in [**2161-5-12**].
7. He has a positive history of hypertension.
MEDICATIONS ON ADMISSION: He currently takes the following
medications; Cardizem 240 mg p.o. q.d., Lasix, colchicine,
atenolol, allopurinol, Coumadin, Darvocet, Detrol, Protonix,
and Acufex.
ALLERGIES: He has an allergic history reaction to
PENICILLIN.
SOCIAL HISTORY: Social history included that he was a
retired married gentleman with a supportive family.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs at the
time of admission revealed he was intubated and on
synchronized intermittent mandatory ventilation with 50%
FIO2. Vital signs revealed a temperature of 95.6, blood
pressure of 151/83, heart rate of 105, oxygen saturations
100%. He appeared in no acute distress. There was a
cervical collar in place, and a left frontal laceration with
Steri-Strips was present. The chest was clear to percussion
and auscultation bilaterally. Heart rate was regular and
rhythmic without murmurs, gallops or rubs. Abdominal
examination was unremarkable. Extremities were without
clubbing, cyanosis or edema. Neurologic examination showed
the patient to be unresponsive with no spontaneous
extraocular movements or eye opening. Cranial nerve showed
the left pupil was minimally reactive from 2 mm to 1.5 mm.
There was positive doll's eyes and positive corneas. The
face was symmetric, and there a positive gag reflex. The
right eye showed a surgical nonreactive pupil. The muscle
examination showed normal tone and bulk throughout with
spontaneous movements only of the right upper extremity.
There was mild withdrawal to pain on the bilateral lower
extremities, and extension with pain to the left upper
extremity.
HOSPITAL COURSE: Due to the clinical findings, the patient
was admitted to the Neurosurgical Intensive Care Unit and was
followed closely for several days and provided extensive
supportive care. His INR was corrected with repeated fresh
frozen plasma. His hematocrit was elevated using 2 units of
packed red blood cells and 2 liters of crystalloid. However,
the patient remained minimally arousable and remained
intubated with cervical collar on throughout the remainder of
his hospitalization.
Due to the clinical findings, the patient was unable to be
extubated successfully and remained in critical condition
throughout the hospitalization. After an extensive
discussion with the family the decision was produced on
[**2-4**] to not consider cardiopulmonary resuscitation
should the patient have a cardiac event. Later that week, on
[**2-6**], the family decided to convert all care to comfort
measures only.
Subsequent to the decision to convert the patient's care to
comfort measures only, the patient later (on [**2162-2-6**]) showed no spontaneous activity and no response to
verbal or painful stimuli. The pupils were 6 mm and
nonreactive to light. There was no spontaneous respirations
observed, and no pulses palpable, and no heart beat was
auscultated, and the patient was pronounced dead at 9:08 p.m.
on [**2162-2-6**] with the family present and full aware.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Doctor Last Name 7311**]
MEDQUIST36
D: [**2162-5-31**] 17:11
T: [**2162-6-1**] 08:36
JOB#: [**Job Number 38529**]
ICD9 Codes: 7907, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3093
} | Medical Text: Admission Date: [**2197-2-17**] Discharge Date: [**2197-2-27**]
Date of Birth: [**2134-1-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2197-2-22**] Resection of left atrial mass with repair of inter
atrial septum with dacron patch
History of Present Illness:
This is a 63 y.o woman with past medical history significant
only for hypertension who presents with a 4 month history of
periodic chest pain. Note that the history was limited by
language and cultural barriers. The patient reports that she has
been having a "tightening" chest pain that comes and goes over
the past several months. This pain radiated up her neck and down
her right arm, and significantly worsened yesterday night,
waking her up from sleep. Her symptoms were concerning enough
that they came to the emergency room today, where a CTA of the
chest was performed to rule out dissection. The CTA found that
the patient had an extremely large left atrial myxoma that
occupied nearly the entire left atrium, measuring 3.7 x 3.3 cm
on CT. A bedside TTE performed by the cardiology fellow showed
the same mass but normal ejection fraction. She was evaluated by
CT surgery in the ED with potential plan for excision next week,
but with optimization and pre-op workup to be performed by
cardiology. She was admitted to the CCU for close observation.
Past Medical History:
hypertension
h/o sinusitis
hysterectomy for "fibroids"
Social History:
Originally from [**Country 2045**], moved here in [**2177**]. Works at [**Hospital1 18**] in
housekeeping.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T=97.4 BP=152/93 HR=108 RR=18 O2 sat=97% on RA
GENERAL: WDWN woman 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. 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, ND. Mild RUQ tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Radial and DP pulses 2+ bilaterally.
Neuro: anxious, but answers questions appropriately. CN II-XII
intact. Strength 5/5 in biceps, triceps, deltoids, hip flexors,
plantar and dorsiflexors of ankles bilaterally. Downgoing
babinski. Sensation grossly intact bilaterally.
Pertinent Results:
[**2197-2-22**] Echo: Pre-Bypass: The left atrium is mildly dilated. A
mass is seen in the body of the left atrium. The mass was
approximately 3.5 x 3 cm. The mass was attached to the
interatrial septum by a short stalk. During diastole the mass
did have movement toward the mitral valve without evidence of
significant obstruction to left ventricular inflow. The mass was
heterogenous with smooth edges. No spontaneous echo contrast is
seen in the left atrial appendage. The right atrium is dilated.
A patent foramen ovale is present. A left-to-right shunt across
the interatrial septum is seen at rest. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricle displays normal free wall
contractility. Interventricular septal motion is normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. There are simple atheroma in the ascending aorta. There
are simple atheroma in the aortic arch. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No
significant aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened.Trace to mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2197-2-22**] at
1030. Post-Bypass: The patient is being A-paced without
inotropic support. Overall biventricular systolic function is
unchanged from prebypass period. The left atrial mass is now
absent. A patch has been applied to the interatrial septum.
There is no evidence of left to right shunt across the
interatrial septum. Mitral regurgitation is improved
post-bypass, now with trace mitral regurgitation. The thoracic
aorta is intact post-decannulation. Findings have been discussed
in person with Dr. [**Last Name (STitle) **].
[**2197-2-20**] Cardiac cath: 1. Normal coronary arteries with evidence
of microvascular dysfunction. 2. Diastolic hypertension.
[**2197-2-17**] Chest CT: 1. Left atrial lesion measuring up to 3.8 cm
with apparent thin attachment to the interatrial septum, most
likely an atrial myxoma. Differential considerations include an
intraatrial thrombus. Correlation with echocardiography and
cardiac MR is recommended. 2. No pulmonary embolism or acute
aortic syndrome. 3. Two 2-mm pulmonary nodules. In the absence
of risk factors (ie. smoking, malignancy), there is no further
followup necessary. If there are risk factors, then a 12-month
followup chest CT [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] guidelines is recommended.
[**2197-2-26**] 10:00AM BLOOD WBC-13.1* RBC-3.54* Hgb-10.1* Hct-29.5*
MCV-83 MCH-28.5 MCHC-34.3 RDW-14.0 Plt Ct-316#
[**2197-2-17**] 01:30PM BLOOD WBC-7.7 RBC-5.04 Hgb-13.5 Hct-41.3 MCV-82
MCH-26.8* MCHC-32.6 RDW-13.3 Plt Ct-213
[**2197-2-22**] 12:54PM BLOOD PT-13.4 PTT-33.3 INR(PT)-1.1
[**2197-2-26**] 10:00AM BLOOD Glucose-124* UreaN-10 Creat-0.6 K-4.3
[**2197-2-17**] 01:30PM BLOOD Glucose-92 UreaN-9 Creat-0.6 Na-137 K-3.8
Cl-100 HCO3-28 AnGap-13
Brief Hospital Course:
[**2197-2-22**] Ms.[**Known lastname **] was taken to the operating room and underwent
resection of left atrial mass and repair of intra-atrial septum
(dacron patch). Cardiopulmonary bypass time=49 minutes. Cross
clamp time=37 minutes. Please refer to the operative report for
further details. She tolerated the procedure well and was
transferred to the CVICU intubated, sedated, in critical but
stable condition. She awoke neurologically intact and was
extubated without difficulty. All lines and drains were
discontinued in a timely fashion. Beta-Blocker/Asa/Statin/and
diuresis was initiated. She was transferred to the step down
unit for further monitoring. Physical therapy was consulted for
strength and mobility evaluation. Pathology revealed the mass
was an atrial myxoma with large fibrin thrombus. She continued
to slowly progress and was cleared for discharge to home with
VNA on POD# 5. All follow up appointments were advised.
Medications on Admission:
amlodipine 5mg qdaily
hydrochlorthiazide 25mg qdaily
fludrocortisone nasal spray
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
Disp:*1 * Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
6. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*10 Tablet Sustained Release(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: **Please take with FOOD.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Left atrial mass s/p resection
Past medical history:
hypertension
h/o sinusitis
hysterectomy for "fibroids"
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Recommended Follow-up:Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] on([**Telephone/Fax (1) 170**]) on [**2197-3-30**] at 1:15PM
Primary Care Dr. [**Last Name (STitle) **] [**12-31**] weeks
Cardiologist Dr. [**Last Name (STitle) 6512**] in [**12-31**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will
Completed by:[**2197-2-27**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3094
} | Medical Text: Admission Date: [**2196-4-3**] Discharge Date: [**2196-4-5**]
Date of Birth: [**2119-10-9**] Sex: M
Service: MEDICINE
Allergies:
A.C.E Inhibitors / Aspirin / Valsartan
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Coffee ground emesis
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy [**2196-4-4**]
History of Present Illness:
Patient is a 76 y/o M with a PMH of HTN, DM, CRI, and
hyperlipidemia who presents from home with emesis. The patient
reports that he was in his USOH yesterday until around 9pm when
he suddenly felt nauseated and vomited x1. He reports that he
had not eated anything since lunch time when he had two sausages
that he prepared at home. He reports that the emesis looked like
coffee grounds. Per the ED the patient's daughter felt that her
father "did not look good" and EMS was called. The patient had
another episode of coffee ground emesis in the ambulance. He
denies any fevers, chills, diarrhea or abdominal pain. He does
not know if he has had any melena as he "stopped looking at his
stools since he stopped taking iron 1 year ago". He denies any
h/o hematochezia. The patient denies any history of GI bleeding
in the past. He denies taking ibuprofen, however he did take one
aspirin yesterday for some L-sided neck pain despite being told
he should not take it.
.
In the emergency department initial VS were T 97.4 BP 125/64 HR
116 RR 20 O2 sat: 100% 4L. Hct was checked and was 31.6. He had
a melanic stool, guaiac positive. GI evaluated the patient in
the ED. An NGL was performed after long discussion with patient
which showed small flecks of old blood and no active bleeding.
BP remained stable. 2 PIVs were placed. He received 40mg
Protonix IV and 1L NS. He was admitted to the ICU for close
monitoring and EGD in am.
.
Currently the patient feels well but states he does not want to
be in the hospital. He denies any further nausea, emesis,
diarrhea or abdominal pain. He also denies chest pain, LH, SOB,
palpitations or other complaints.
.
ROS is otherwise negative for LE swelling, PND, orthopnea,
dysuria or difficulty urinating.
Past Medical History:
CKD, baseline Cr 3-3.5, followed by Dr. [**First Name (STitle) 805**]
DM2, last A1c 7.2 in [**1-15**]
HTN
Elevated PSA followed by Dr. [**Last Name (STitle) 106944**], s/p bx in [**9-11**]
showing chronic inflammation and no malignancy
Hyperlipidemia
? OSA
Chronic anemia, baseline Hct 35-38
Depression, not treated
L cerebellar CVA [**2180**]
Erectile dysfunction
Central vestibular vertigo
Social History:
Lives with his daughter. Widower, lost his wife 4 years ago.
Independant in ADLs, ambulates with cane. Smoked for 40 years,
quit 20 years ago. Retired post office worker. Denies EtOH.
Family History:
Father had CVA in 50s
Mother had DM and ? colon CA, died in 80s
Brother CVA age 31
Physical Exam:
GENERAL: Pleasant, alert, comfortable, well appearing, in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Tachy, regular, Normal S1, S2. No murmurs, rubs or
[**Last Name (un) 549**]. JVP= 6cm
LUNGS: CTAB, good air movement biaterally, no wheezes or rales
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, ext. warm and well-perfused
SKIN: No rashes, hyperpigmentation in upper anterior chest.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-8**]+ reflexes,
equal BL. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Labs on admission:
[**2196-4-3**] 10:52PM CK(CPK)-153
[**2196-4-3**] 10:52PM CK-MB-8 cTropnT-0.21*
[**2196-4-3**] 10:52PM HCT-29.0*
[**2196-4-3**] 10:52PM PT-14.2* PTT-22.4 INR(PT)-1.2*
[**2196-4-3**] 06:00PM URINE HOURS-RANDOM UREA N-726 CREAT-103
SODIUM-34
[**2196-4-3**] 06:00PM URINE OSMOLAL-436
[**2196-4-3**] 06:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2196-4-3**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2196-4-3**] 03:05PM GLUCOSE-216* UREA N-111* CREAT-4.1*
SODIUM-146* POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-25 ANION GAP-18
[**2196-4-3**] 03:05PM estGFR-Using this
[**2196-4-3**] 03:05PM ALT(SGPT)-18 AST(SGOT)-16 LD(LDH)-232
CK(CPK)-148 ALK PHOS-72 TOT BILI-0.1
[**2196-4-3**] 03:05PM CK-MB-9 cTropnT-0.15*
[**2196-4-3**] 03:05PM ALBUMIN-3.2* CALCIUM-8.1* PHOSPHATE-4.0
MAGNESIUM-2.1
[**2196-4-3**] 03:05PM WBC-8.5 RBC-3.03* HGB-9.0* HCT-26.9* MCV-89
MCH-29.7 MCHC-33.4 RDW-14.0
[**2196-4-3**] 03:05PM PLT COUNT-191
[**2196-4-3**] 10:31AM GLUCOSE-232* NA+-144 K+-4.5 CL--101 TCO2-23
[**2196-4-3**] 10:30AM WBC-9.5# RBC-3.48* HGB-10.7* HCT-31.6* MCV-91
MCH-30.8 MCHC-33.9 RDW-13.9
[**2196-4-3**] 10:30AM NEUTS-76.5* LYMPHS-17.1* MONOS-5.6 EOS-0.4
BASOS-0.3
[**2196-4-3**] 10:30AM PLT COUNT-248
.
Labs on discharge:
[**2196-4-5**] 05:25AM BLOOD WBC-7.3 RBC-3.08* Hgb-9.4* Hct-27.7*
MCV-90 MCH-30.4 MCHC-33.8 RDW-14.2 Plt Ct-139*
[**2196-4-5**] 05:25AM BLOOD Glucose-159* UreaN-87* Creat-3.7* Na-146*
K-4.3 Cl-113* HCO3-24 AnGap-13
.
Microbiology:
MRSA screen - negative
H pylori serology - pending
.
Imaging:
[**4-4**] ECHO:
The left atrium and right atrium are normal in cavity 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. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Technically suboptimal study. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function.
.
[**4-4**] EGD:
-Erosions in the gastroesophageal junction
-Nodularity and erythema in the fundus and stomach body
compatible with gastritis
-Ulcers in the pre-pyloric region
-Congestion in the duodenal bulb compatible with duodenitis
-Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
Patient is a 76 year old man with history of hypertension, DM
type 2, hyperlipidemia and chronic renal insufficiency who
presented from home with coffee ground emesis.
.
1.) Anemia/coffee ground emesis: EGD demonstrated several
pre-pyloric ulcers, likely etiology of presentation. Received a
total of 1 unit packed red blood cells, and was treated with [**Hospital1 **]
pantoprazole with stabilization of his hematocrit in the high
20's on discharge. H pylori serology was sent and is pending on
discharge, to be followed up as an outpatient and treated if
positive.
Otherwise patient was discharged on [**Hospital1 **] pantoprazole with
instructions to follow up with gastroenterology in [**4-11**] weeks
time.
.
2.) Hypertension, benign: Medications initially held on
admission, but all were restarted on discharge.
.
3.) Tachycardia: On presentation, now resolved with IV fluid
hydration.
.
4.) Abnormal EKG: Patient with noted new TWI on EKG, likely
from tachycardia above. Ruled out for MI. ECHO essentially
unremarkable.
.
5.) Hyperlipidemia: Continued statin
.
6.) Diabetes: Held outpatient regimen while NPO but restarted
on discharge.
.
7.) Chronic renal insufficiency: Baseline Creatnine [**First Name8 (NamePattern2) **] [**Last Name (un) **]
labs appears to be 3-3.5. Cr 4.1 on admission, decreased to
baseline by time of discharge.
.
8.) BPH: Continued tamsulosin
.
9.) History of CVA: Ticlid held on admission, restarted on
discharge.
Medications on Admission:
AMLODIPINE - 5 mg daily
ATORVASTATIN - 40 MG daily
DILTIAZEM HCL - 360 mg Sust. Release daily
DOXERCALCIFEROL [HECTOROL] - 0.5 mcg Capsule - 1 (One)
Capsule(s)
by mouth twice a day to maintain level of vitamin D
FUROSEMIDE - 40 mg, once a day on odd days, 2 tablets daily on
even days
INSULIN GLARGINE - 8 units sc once a day
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg daily
REPAGLINIDE - 1 mg twice a day
TAMSULOSIN [FLOMAX] - 0.4 mg daily
TICLOPIDINE - 250 mg twice a day
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Diltia XT 120 mg Capsule,Degradable Cnt Release Sig: Three
(3) Capsule,Degradable Cnt Release PO once a day.
4. Doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
5. Lasix 40 mg Tablet Sig: Two (2) Tablet PO on even days.
6. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous
once a day.
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Repaglinide 1 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
- Acute blood loss anemia, resolved
- Upper Gastrointestinal bleed, stable
Secondary
- Hypertension
- Diabetes, type II
Discharge Condition:
Afebrile, vitals stable
Discharge Instructions:
You were hosptialized because you had vomited blood. After a
thorough work up, the cause of your vomiting was from several
ulcers that have stopped bleeding. You recieved one unit of
blood and your hematocrit has been stable. You have been
started on a new medication called Protonix. Please take this
medication twice daily until you follow up with
gastroenterology.
Please avoid a class of medications called Non Steroidal
Anti-inflammatory medications and do not take them without first
discussing with your doctor. This includes Ibuprofen, motrin,
aspirin.
Please contact physician if develop more blood in vomit, blood
in stool, black colored stools or vomit,
lightheadedness/dizziness, chest pain/pressure, shortness of
[**Last Name (LF) 1440**], [**First Name3 (LF) 691**] other questions or concerns.
Followup Instructions:
Please follow up with gastroenterology Dr. [**Last Name (STitle) **] in [**4-11**] weeks
to arrange for a repeat endoscopy. Can call [**Telephone/Fax (1) 463**] to
schedule appointment.
Please follow up with these previously scheduled appointmentsP:
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. Date/Time:[**2196-4-8**] 1:30
.
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2196-4-20**] 11:40
.
Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2196-6-6**] 11:00
ICD9 Codes: 2851, 5859, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3095
} | Medical Text: Admission Date: [**2105-8-25**] Discharge Date: [**2105-9-1**]
Date of Birth: [**2073-1-20**] Sex: M
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Lumbar Puncture
Intubation
PICC line placement.
History of Present Illness:
32 yo male PMH IVDU, Hep C, unclear HIV diagnosis, recent
admission for MSSA bacteremia c/b septic pulmonary emboli and
presumed endocarditis who presents from rehab with altered
mental status for the past 3-4 days. Pt intubated on arrival to
ICU so history mainly from his mother. She reports pt "wasn't
acting like himself since last Friday." She reports that he was
febrile at rehab.Per OSH report pt lethargic [**8-25**] and given
narcan given concern for methadone overdose and then sent to ED.
His vitals at rehab were T 97.2 HR: 80 RR: 16 BP: 126/74 OSat
96% RA. Per rehab labs, Cr was 1.4 (above baseline of 0.9 on
[**2105-8-22**]).
.
At OSH ED initial ABG was 7.18/pCO2 45/pO2 520. Cr was 5.6. CK
1091. He received vancomycin and zosyn there.
.
In [**Hospital1 18**] ED VS were T: 99 HR:95 BP:100/80 RR:16 O2: 100%
intubated. He had CT Torso showing moderate bilateral pleural
effusions and question of discitis/osteomyelitis of T5/T6. A CT
Head showed Diffuse ethmoid air cell opacification with air-
fluid levels in the sphenoid sinuses He was given 3L NS
Past Medical History:
IV drug abuse
Bipolar d/o
ETOH abuse
HIV Negative
Social History:
Previously abused tobacco and Heroin
Family History:
Non-contributory
Physical Exam:
GEN: intubated, opens eyes and answers some questions
appropriately, follows commands
[**Hospital1 4459**]: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: regular, no murmurs
Pulm: anterior lung fields CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: no LE edema, PTs 2+.
Skin: no lesions
Neuro/Psych: 5/5 strength in U/L extremities.
Pertinent Results:
LABS:
[**2105-8-25**] 08:18PM LACTATE-0.8
[**2105-8-25**] 08:15PM GLUCOSE-112* UREA N-80* CREAT-4.8* SODIUM-136
POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-17* ANION GAP-16
[**2105-8-25**] 08:15PM CK(CPK)-1001*
[**2105-8-25**] 08:15PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2105-8-25**] 08:15PM WBC-2.7* RBC-3.23* HGB-9.6* HCT-28.2* MCV-87
MCH-29.6 MCHC-33.9 RDW-15.9*
[**2105-8-25**] 08:15PM NEUTS-45* BANDS-1 LYMPHS-36 MONOS-12* EOS-2
BASOS-1 ATYPS-1* METAS-1* MYELOS-1*
[**2105-8-25**] 08:15PM PLT SMR-NORMAL PLT COUNT-158
LABS DISCHARGE:
[**2105-8-30**] 05:30AM BLOOD WBC-6.2 RBC-3.89* Hgb-10.8* Hct-33.6*
MCV-86 MCH-27.8 MCHC-32.2 RDW-15.6* Plt Ct-271
[**2105-8-30**] 05:30AM BLOOD ESR-37*
[**2105-8-30**] 05:30AM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-140
K-3.1* Cl-109* HCO3-24 AnGap-10
IMAGING:
[**8-25**] Head CT: No acute intracranial process
[**8-25**] CT chest/abdomen/pelvis:
1. Moderate bilateral pleural effusions associated with
bibasilar opacities, likely reflective of atelectasis.
2. Irregular endplate changes involving the T5 inferior endplate
and T6
superior endplate. Given the history of bacterial endocarditis,
discitis and osteomyelitis are not excluded. If clinically
indicated, an MRI is suggested.
3. Retroperitoneal adenopathy.
[**8-28**] MRI T-spine:
1. Findings concerning for infection involving T4, T5 and T6
vertebral body,
more predominant at T5, T6 intervertebral space. No appreciable
epidural
collection, however limited evaluation due to absence of IV
contrast.
2. Worsening paraspinal soft tissue thickening and edema at T5-6
level.
3. Slightly worse bilateral pleural effusions.
ECHO([**2105-8-26**]): The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. No
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. IMPRESSION: No
valvular pathology or pathologic flow identified. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function.
Brief Hospital Course:
32 yo male with recent hospitalization for MSSA bacteremia,
presumed endocarditis and septic pulmonary emboli who presents
from rehab with altered mental status and found to have new
acute renal failure.
# ALTERED MENTAL STATUS: Intubated [**1-20**] AMS in outside hospital.
On HD 2 he was extubated with difficulty. His mental status did
not remain an issue while in the MICU. Likely etiology felt to
be secondary to uremia in setting of pre-renal ARF secondary to
significant diarrhea prior to admission. As his renal failure
improved, his mental status improved. Patient also continued to
receive renally cleared sedating medications prior to admission
which may have contributed to AMS even further. These
medications were initially held and slowly re-introduced.
Negative CT torso, negative trans-thoracic echo, negative
blood/urine cultures and negative lumbar puncture. Only
significant finding on LP was a slightly elevated filling
pressure of 25.5 mm Hg. Pt was found to have
osteomyelitis/discitis on T-spine MRI and was transitioned from
vanco/cefepime to nafcillin per ID recommendations to complete a
6 week course.
#. Osteomyelitis/Discitis T5/T6: Identified on MRI. Pt without
evidence of epidural abscess. No pain on exam or neurologic
deficit. Pt initially treated with Vanc/Cefepime and narrowed to
nafcillin given previous MSSA bacteremia prior to discharge. Pt
will complete a 6 week course of Nafcillin 2grams Q4hours.
Safety labs will be monitored by the ID outpatient clinic and
patient will follow up with ID in the coming weeks.
# ARF: Initially elevated to 4.8 on arrival with baseline of
0.9. ARF seems to have begun around [**8-22**]. Improved with IVFs
consistent with pre-renal etiology. Patient and family noted a
history of extensive diarrhea prior to hospitalization. Renal
function improved with hydration.
#. Diarrhea: Stool Cultures revealed Blastocystisi Hominis.
Diarrhea improved without therapy.
# H/O MSSA Bacteremia: Initial concern for re-infection.
Empirically started on vancomycin and cefepime. Blood cultures
negative for MSSA while in the MICU. Dental surgery was
consulted for assessment of tooth infections that patient did
not treat in the outpatient as was planned. It was not felt that
his infections had acutely worsened and not likely to be causing
his symptoms. He should follow up with dental in the outpatient
for extraction of infected teeth. The number to call:
[**Telephone/Fax (1) 68463**]. Blood cultures from OSH also negative;
osteo/discitis treated w/nafcillin, presumably [**1-20**] seeding from
bacteremia.
# Coffee Ground NG suction: Noted while intubated. Started on
protonix. Will need to f/u with GI as outpatient after discharge
from rehab hospital. Hematocrit stable during hospitalization
without evidence of bleeding.
# H/O IVDU: Initially held methadone given AMS, however
re-introduced on HD 3. Gabapentin held and gently reintroduced
beginning [**8-28**] and increased to 800mg three times daily.
Patient's last dose of methadone prior to admission was 40 mg
daily. No evidence of withdrawal during hospitalization; did not
require lorazepam for CIWA.
# BIPOLAR: Continued citalopram. Risperdol held and seroquel
decreased to 50mg QHS. Restarting Risperdol and uptitration of
seroquel should be addressed as an outpatient.
Medications on Admission:
Benadryl 25mg PO QHS
Methadone 40mg daily
Clonidine 0.1mg TID
Albuterol IH
Cymbalta 60mg daily
Docusate 100mg daily
Gabapentin 800mg TID
Ibuprofen 600mg TID
Risperdal 0.5mg qHS
Seroquel 100mg qHS
Tylenol
Hydroxyzine 50mg Q6:PRN agitation
Senna
ImmodiumAtivan 1mg PO Q4:PRN
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO DAILY (Daily).
3. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours): Last Dose [**2105-10-10**].
4. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for headache: take medication with food. .
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
8. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
10. Benadryl 25 mg Capsule Sig: One (1) Capsule PO at bedtime.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
12. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Primary:
- T5-T7 MSSA spinal osteomyelitis
- Toxic-metabolic encephalopathy
- Acute renal failure
- Respiratory failure
Secondary:
- Bipolar disorder
- Intravenous drug abuse
- Chronic alcohol abuse
- Hepatitis C
- MSSA endocarditis with septic emboli
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 75912**],
It was a pleasure caring for you while you were admitted at
[**Hospital1 18**] with altered mental status. We think that you became
dehydrated because of diarrhea and suffered kidney injury.
Because your kidneys weren't working properly your psychiatric
medications built up in your system and you became over-sedated.
Your mental status improved.
.
You were also found to have an infection in your spine
(discitis/osteomyelitis) during this hospitalization. We
started you on iv antibiotics, which you will need to continue
for 6 weeks at rehab. You should will be followed closely by the
infectious disease doctors as [**Name5 (PTitle) **] outpatient.
.
We made the following changes to your medications:
- START Nafcillin an antibiotic to treat infection.
- START Pantoprazole 40mg Daily
- DECREASE Seroquel to 50mg at night
- STOP Risperdol, Clonidine, Ativan, Hydroxyzine
Followup Instructions:
Please follow up with your scheduled infectious disease
appointments below:
.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2105-9-17**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2105-10-5**] at 9:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2105-11-9**] at 10:30 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5849, 2761, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3096
} | Medical Text: Admission Date: [**2138-7-18**] Discharge Date: [**2138-7-23**]
Date of Birth: [**2078-1-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Peanut
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2138-7-18**] Coronary bypass grafting x2 with the left internal
mammary artery to left anterior descending artery and a free
left radial artery graft to the first obtuse marginal artery
History of Present Illness:
60 year old male with known coronary artery disease, history of
stents to LCx/RCA in [**2126**], HTN, hyperlipidemia reports while
mowing the lawn a few weeks ago he developed anterior chest
tightness that radiated to his jaw and was relieved with rest.
He had a recurrance of this with similar activity several days
thereafter. He presents to OSH for further cardiac workup.
Cardiac cath reveals severe multivessel coronary artery disease.
He was transferred to [**Hospital1 18**] for evaluation of revascularization.
Past Medical History:
Coronary artery disease s/p stent LCX/RCA in [**2126**]
Hypertension
Hyperlipidemia
Asthma
Obstructive sleep apnea
Anxiety/depression
Restless leg syndrome w/ tremors
Benign prostatic hypertrophy
Chronic kidney disease
Past Surgical History:
s/p Laser prostatectomy [**2136**]/circumcision
Social History:
Race:white
Last Dental Exam:4months ago
Lives with:wife
Contact: [**Name (NI) **] Wife Phone #home:
[**Telephone/Fax (1) 34131**], Cell [**Telephone/Fax (1) 34132**]
Occupation:retired [**Company 22916**] packing engineer, works part time
for FEMA
Cigarettes: Smoked no [x]
ETOH:rare
Illicit drug use: None
Family History:
Father MI in 50s-expired in his 60s
Physical Exam:
Pulse:50 SB Resp: 14 O2 sat: RA 100%
B/P Right: 123/81 Left: 117/75
Height:5ft 7" Weight:97kg
General:
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit Right: None Left:None
Pertinent Results:
Echo [**2138-7-18**]: PRE BYPASS: No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. A 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. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results in the operating room at the time of
the procedure.
POST BYPASS: The patient is atrially paced. There is normal
biventricular systolic function. The mitral regurgitation is now
trace. The thoracic aorta is intact after decannulation.
Carotid U/S [**2138-7-18**]: There is less than 40% stenosis in the
internal carotid arteries bilaterally.
[**2138-7-23**] 04:57AM BLOOD WBC-5.2 RBC-2.81* Hgb-9.1* Hct-24.4*
MCV-87 MCH-32.4* MCHC-37.2* RDW-13.0 Plt Ct-150
[**2138-7-20**] 04:31AM BLOOD PT-12.4 INR(PT)-1.0
[**2138-7-23**] 04:57AM BLOOD Glucose-113* UreaN-38* Creat-1.8* Na-139
K-3.9 Cl-99 HCO3-30 AnGap-14
[**Known lastname **],[**Known firstname **] [**Medical Record Number 34133**] M 60 [**2078-1-16**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2138-7-22**]
11:51 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2138-7-22**] 11:51 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 34134**]
Reason: eval left ptx
Final Report
TECHNIQUE: Semi-erect portable radiograph of chest.
Comparison was made with prior radiographs through [**2138-7-18**].
INDICATION: 60-year-old man with status post evaluation of the
left
pneumothorax.
FINDINGS: Left apical pneumothorax is stable since [**2138-7-21**]. Basal lung
atelectasis is unchanged. There is no consolidation. Effusion if
any is
minimal bilaterally. Sternotomy sutures are intact. Heart size
is top normal.
The tip of right internal jugular is terminating into the SVC.
IMPRESSION: Stable minimal left apical pneumothorax since [**7-21**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 16988**] [**Name (STitle) 16989**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: WED [**2138-7-23**] 8:22 AM
Brief Hospital Course:
Mr. [**Known lastname **] was transferred from outside hospital after cardiac
cath revealed severe left main coronary artery disease. He was
initially admitted to the CVICU and underwent pre-operative
work-up. He was then brought to the operating room later on this
day where he underwent a coronary artery bypass graft x 2.
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 he was started on beta-blockers and diuretics and
diuresed towards his pre-op weight. Later this day he was
transferred to the step-down floor for further care. His Foley
was removed on post-op day one but he had failure to void and
was reinserted on post-op day two. Chest tubes and epicardial
pacing wires were removed per protocol. On POD# 4 he had a
successful voiding trial and he was discharged to home on POD#5
in stable condition. His discharge creatinine is 1.9 which is
elevated from preop creatinine of 1.3, but is has stabilized.
Medications on Admission:
Atenolol 50mg daily
Simvastatin 40mg daily
Aspirin 81mg daily
Celexa 40mg daily
Mirapex 0.125mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
8. isosorbide mononitrate 10 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily) for 3 months.
Disp:*90 Tablet(s)* Refills:*2*
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Mirapex ER 1.5 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
12. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 7 days.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 2
Past medical history:
s/p stent LCX/RCA in [**2126**]
Hypertension
Hyperlipidemia
Asthma
Obstructive sleep apnea
Anxiety/depression
Restless leg syndrome w/ tremors
Benign prostatic hypertrophy
Chronic kidney disease
Past Surgical History:
s/p Laser prostatectomy [**2136**]/circumcision
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 bilateral LE
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check [**Telephone/Fax (1) 170**] in [**Hospital Ward Name **] 2A on [**7-29**] at 11:15 AM
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**8-14**] at 1:15PM in the [**Hospital **]
medical office building [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2138-8-15**]@ 3:30 PM.
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 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:[**2138-7-23**]
ICD9 Codes: 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3097
} | Medical Text: Admission Date: [**2168-10-31**] Discharge Date: [**2168-11-3**]
Date of Birth: [**2094-3-23**] Sex: F
Service: MEDICINE
Allergies:
Lorazepam / Morphine / Penicillins / Zosyn
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
74 yr old female with hx of afib/flutter, tachy-brady syndrome
s/p [**First Name3 (LF) 4448**] in [**10/2168**], CHF (EF 20%), COPD s/p trach in [**8-/2168**]
who was sent to ED for evaluation of pacemker. In ED, EP
interrogated pacer and found that the pacer was functioning
properly. However, she was also found to have a fever to 101.4.
The pt was asymptomatic and is currently being treated with a
7-day course of augmentin for presumed sinusitis (given chronic
NGT) and UTI.
.
Also in [**Name (NI) **], pt was found to have different BP in each arm. A CT
of the chest was done to assess for subclavian vein stenosis but
it could not be assessed given the artifact from her pacer
wires.
.
On arrival to the ICU, pt's only complaint was a sore throat and
mild nausea. She denies chest pain, sob, vomiting, diarrhea, abd
pain, headache, dysuria, fevers or chills. She did not some
increased sputum from her trach tube.
Past Medical History:
* recent hx of enterococcal UTI and sinusitis, treated with
Augmentin
* Afib/Aflutter
* Tachy-brady syndrome s/p dual chamber [**Name (NI) 4448**] in [**10-12**]
* CHF (Echo [**2168-8-18**]: LV EF < 20%. Global hypokinesis. 3+ MR, 2+
TR
* HTN
* COPD/asthma s/p trach in [**8-/2168**]
* s/p bowel perforation in [**8-/2168**]
* remote hx of seizure
* h/o lower GI Bleed in [**8-/2168**]
Social History:
.
SH: lives at [**Hospital1 700**]; daughter is HCP
former [**Name2 (NI) 1818**], no EtOH/drug use
Family History:
noncontributory; no known hx of heart/lung dz
Physical Exam:
temp 99.3, BO 117/43, HR 103, R 12, O2 100%
Vent: AC 500x12x5x40%
Gen: NAD, awake and alert, answ questions
HEENT: trach collar in place with some purulent drainage; mild
tenderness over maxillary sinuses; oropharynx clear, no erythema
CV: RRR, no murmurs heard
Chest: diffuse exp wheezes, rhonci more pronounced in right
chest anteriorly
Abd: +BS, obese, soft, nontender, nondistended
Ext: no edema, 2+ DP; pain on palpation of distal feet
bilaterally
Neuro: CN 2-12 intact, moves all extremities
Pertinent Results:
admit labs:
.
ABG: PO2-126* PCO2-70* PH-7.39 TOTAL CO2-44*
.
Chem: GLUCOSE-122* UREA N-42* CREAT-0.6 SODIUM-143 POTASSIUM-4.1
CHLORIDE-96 TOTAL CO2-40* ANION GAP-11 LD(LDH)-240
.
CBC: WBC-16.8* RBC-3.29* HGB-10.4* HCT-31.4* MCV-95 PLT
COUNT-305
NEUTS-83.7* LYMPHS-7.2* MONOS-6.1 EOS-2.8 BASOS-0.2
.
COAGS: PT-12.6 PTT-24.6 INR(PT)-1.1
.
Urine:
[**2168-10-31**] 07:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
CT Chest:
1. No evidence of central upper extremity vascular stenosis in
this limited study.
2. Multifocal air space opacities within the right and left
upper lobes, consistent with pneumonia. Mediastinal
lymphadenopathy is likely reactive.
3. Six millimeter nodular density within the right upper lobe.
3-month followup CT of the chest is recommended to ensure
stability and/or resolution.
4. Enlarged central pulmonary arteries, consistent with
underlying pulmonary arterial hypertension.
.
CT Sinus: Probable retention cysts with incompletely imaged
maxillary sinuses.
.
** Micro:
sputum:
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 4 S
IMIPENEM-------------- 2 S
MEROPENEM------------- 0.5 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
.
Urine cx neg
.
Blood cx neg
.
Brief Hospital Course:
A/P: 74 yr old female with hx of afib/flutter, tachy-brady
syndrome s/p PCM, CHF, COPD s/p trach presents to [**Hospital Unit Name 153**] with
fever, diagnosed with psuedomonas pneumonia
.
1. Fever: CT of the chest and CXR showed RUL opacity and sputum
from admission grew out pseudomonas, pan-sensitive, except for
ciprofloxacin. Pt was given a dose of zosyn but developed hives
over her back and thighs so Zosyn was discontinued and she was
started on Aztreonam. Urine, blood ans stol cultures were all
negative. Given her chronic NGT a CT of the sinuses was done
and showed no signs of chronic sinusitis. On day of discharge,
pt had been afebrile x 48 hours. A PICC line was placed in
interventional radiology and pt should received 2 weeks of
Aztreonam for her pseudomonas pneumonia.
.
2. CHF: Pt has an EF of 20% on recent echo. Due to some
episodes of hypotension, her BP meds were held and she required
fluid boluses. Therefore, the pt remained positive during her
short hospital stay. On day of discharge, pt was hypertensive
and was tolerating her BP meds. She was started on
spironolactone and her hydralazine was stopped. Her dose of
Lasix may need to be decreased due to the addition of
Spironolactone. She was continued on metoprolol, lasix, ACE-I
and digoxin. Her digoxin level was therapeutic.
.
3. Tachy-brady syndrome s/p PCM: EP interrogated pacer on
admission and found that her [**Hospital Unit Name 4448**] was working properly.
Her device clinic appointment was cancelled as EP has already
since the patient.
.
4. COPD: Pt on chronic vent support. During her hospital stay,
pt was weaned and tolerated a pressure support trial of [**10-12**],
oxygenating well. Her flovent and combivent were continued.
.
5. BP difference: Per family, this is old. Cannot assess
subclavian stenosis on CT due to pacer wires.
.
6. Lung Nodule: On chest CT, pt was found to have a 6mm nodular
density within the right upper lobe that will need to be
followed with another CT in 3 months.
.
7. Anxiety: Pt's seroquel was continued and she was started on
prn seroquel.
.
8. FEN: Speech and swallow evaluated the patient and she passed
the bedside swallow exam. However, to further evaluate for
aspiration risk pt should have a video swallow.
.
8. Access: IR-placed PICC
.
9. Code: full
.
10. Ppx: SQ heparin.
Medications on Admission:
1. Augmentin 500mg po q8 x 7days (last dose on [**11-4**])
2. Bisacodyl 5mg prn
3. Digoxin 125 mcg qd
4. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
5. Acetaminophen 500mg q6 prn
6. Hydralazine 10 mg qid
7. Albuterol-Ipratropium 1-2 puffs q6
8. Furosemide 80mg [**Hospital1 **]
9. Metoprolol Tartrate 50 mg [**Hospital1 **]
10. Fluticasone 2puffs [**Hospital1 **]
11. Liquid Colace
12. Miconazole prn
13. Quetiapine 25 mg qhs
14. Lansoprazole 30 mg [**Hospital1 **]
15. Aspirin 81 mg qd
16. Lisinopril 20 mg qd
17. Heparin (Porcine) 5,000 tid
18. Phenol-Phenolate Sodium 1.4 % Mouthwash q4hrs prn
19. MgOx
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. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. Quetiapine 25 mg Tablet Sig: one-half Tablet PO twice a day
as needed for anxiety.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane Q4H (every 4 hours) as needed.
13. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO BID (2 times a day).
14. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-10**]
Puffs Inhalation Q6H (every 6 hours) as needed.
15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold for SBP<110 or P<60.
16. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-10**]
Puffs Inhalation Q4H (every 4 hours).
17. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q6H
(every 6 hours) as needed for pruritus for 1 weeks.
18. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
20. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
21. Aztreonam 1 g Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for 11 days.
22. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Pseudomonas pneumonia
....
COPD s/p trach
CHF with EF of 20%
tachy-brady syndrome s/p [**Location (un) 4448**]
Discharge Condition:
stable - afebrile and satting well on Pressure Support of 10,
PEEP 5, FiO2 of 40.
Discharge Instructions:
Please return if you experience fever >101.5, worsening
shortness of breath, hypoxia, or any other worrisome symptoms.
Please take all medications as directed. You have been
prescribed an antibiotic for pneumonia.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2168-11-15**]
10:30
.
Please follow-up with Dr. [**Last Name (STitle) 9022**] at [**Telephone/Fax (1) **] within [**1-10**]
weeks.
.
The patient needs a video swallow evaluation within the next
week to determine if the NG tube can be removed. She passed
bedside swallow evaluation.
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
ICD9 Codes: 4280, 496, 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3098
} | Medical Text: Admission Date: [**2178-9-12**] Discharge Date: [**2178-9-18**]
Date of Birth: [**2126-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
51M with COPD recently discharged day prior to admission is
referred from [**Hospital 100**] Rehab with hypercarbic respiratory failure.
Pt noted to have increased tachypnea and WOB today x 4 hours
with episodes of desaturation to 50s. Minute ventilation per
report 14L on ventilator but ABG 7.12/99/69/32 o2 sat 86% on AC
RR25 40%FiO2 PEEP 10. There was concern for air leak by rehab
pulmonologist. Prior to transfer, T 97.8 BP 90/60 HR 70 RR 25
99%. FS 105. He was given 1 amp bicarb then transferred to [**Hospital1 18**]
for further eval.
.
In the ED, initial VS:Afebrile SBP 90s/60s. HR 60s-70s RR 20s.
Initial ABG 7.04/132/135 on 50% FiO2. Patient was given 3L NS
with persistent low BP, SBPs 70s-80s. Right femoral TLC then
placed and he was started on Levophed 0.09mcg/kg/min. ID was
called regarding antibiotics and he was given Tobramycxin 120mg
IV x 1 and vanco 1g IV x 1.
.
On the floor, pt is trached and sedated but opens eyes to voice
and tracks. He denies pain by shaking head and is intermittently
coughing with cuff leak evident and loss of approximately 100cc
with each Vt.
.
Review of systems: Unable to obtain secondary to tracheostomy
and mental status.
Past Medical History:
COPD on oxygen
Obstructive Sleep Apnea and obesity hypoventilation
Anxiety on klonopin
Morbid Obesity
Chronic LLE DVT
ARF [**3-9**] AIN, recent baseline Cr low-mid 2's
Pseudomonas VAP
[**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 104697**] UTI treated with fluc
Sacral decubitus ulcer right flank
Chronic pain of unclear etiology-trach site ulceration
Constipation
AF
Anemia
Social History:
Patient was living at home with mother but was recently
discharged to [**Hospital 100**] rehab. He denies any history of tobacco,
etoh, or drug use. He was using motorized chair for most
mobility but has been immobile.
Family History:
Noncontributory
Physical Exam:
On Admission:
General: Awakens and opens eyes to voice, tachypneic, grunting
and cuff leak evident with breathing.
HEENT: Trach in place with cuff fully inflated. Sclera
anicteric, MM slightly dry, oropharynx clear
Neck: supple, unable to appreciate JVP, no LAD
Lungs: Coarse vented rhonchorous BS occ exp wheezes B/L
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. G
tube in place with dsg C/D/I
Ext: Warm, well perfused, 1+ pulses, trace edema, no clubbing,
cyanosis. Decub dsg. Right fem line with oozing. No erythema
Skin: Right flank sacral decub not observed but no s/s infection
per report
On discharge:
General: Awakens and opens eyes to voice, tachypneic, grunting
and cuff leak evident with breathing.
HEENT: Trach in place with cuff fully inflated. Sclera
anicteric, MM slightly dry, oropharynx clear
Neck: supple, unable to appreciate JVP, no LAD
Lungs: Coarse vented rhonchorous BS occ exp wheezes B/L
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. G
tube in place with dsg C/D/I
Ext: Warm, well perfused, 1+ pulses, trace edema, no clubbing,
cyanosis. Decub dsg. Right fem line with oozing. No erythema
Skin: Right flank sacral decub not observed but no s/s infection
per report
Pertinent Results:
[**2178-9-11**] 02:36AM BLOOD WBC-8.1 RBC-2.91* Hgb-7.7* Hct-26.1*
MCV-90 MCH-26.5* MCHC-29.6* RDW-20.3* Plt Ct-109*
[**2178-9-11**] 02:36AM BLOOD PT-28.0* PTT-46.4* INR(PT)-2.7*
[**2178-9-11**] 02:36AM BLOOD Glucose-85 UreaN-41* Creat-2.5* Na-139
K-3.5 Cl-104 HCO3-27 AnGap-12
[**2178-9-12**] 09:58PM BLOOD ALT-16 AST-30 LD(LDH)-356* CK(CPK)-38
AlkPhos-81 Amylase-38 TotBili-0.2
[**2178-9-11**] 02:36AM BLOOD Tobra-2.8*
[**2178-9-11**] 01:34AM BLOOD Type-ART pO2-107* pCO2-69* pH-7.25*
calTCO2-32* Base XS-0
[**2178-9-12**] 09:58PM BLOOD WBC-12.8* RBC-3.28* Hgb-8.7* Hct-30.0*
MCV-92 MCH-26.3* MCHC-28.8* RDW-19.7* Plt Ct-136*
[**2178-9-14**] 09:25PM BLOOD Hct-23.5*
[**2178-9-16**] 12:08PM BLOOD Hct-25.7*
[**2178-9-16**] 03:51AM BLOOD PT-30.0* PTT-44.4* INR(PT)-3.0*
[**2178-9-16**] 03:51AM BLOOD Glucose-97 UreaN-47* Na-150* K-3.7
Cl-112* HCO3-29 AnGap-13
[**2178-9-14**] 02:47AM BLOOD ALT-12 AST-24 LD(LDH)-305* AlkPhos-77
TotBili-0.3
[**2178-9-14**] 02:47AM BLOOD Albumin-2.5* Calcium-8.8 Phos-5.7* Mg-2.2
[**2178-9-14**] 04:21PM BLOOD Tobra-3.6*
[**2178-9-15**] 06:29AM BLOOD Type-ART Temp-36.1 Rates-28/ Tidal V-520
PEEP-8 FiO2-40 pO2-69* pCO2-66* pH-7.26* calTCO2-31* Base XS-0
Intubat-INTUBATED Vent-CONTROLLED
[**2178-9-17**] 6:37 pm JOINT FLUID Source: Knee.
GRAM STAIN (Final [**2178-9-17**]): 1+ (<1 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2178-9-20**]): NO GROWTH.
CT ABDOMEN AND PELVIS.
COMPARISON: [**2178-9-8**].
HISTORY: History of retroperitoneal bleed, on Coumadin, with new
hematocrit drop. Evaluate for worsening retroperitoneal bleed.
TECHNIQUE: CT axially acquired images through the abdomen and
pelvis were
obtained. No IV contrast was administered. Coronal and sagittal
reformats
were performed.
FINDINGS: Study is extremely limited due to extensive streak
artifact due to patient contact with gantry. Within the
limitations of a noncontrast exam, the lung bases demonstrate
severe ground-glass opacity with areas of focal consolidation,
most severe in the left lower lobe. Bilateral emphysematous
changes are also noted. this has worsened when compared to prior
exam. The spleen, liver, kidneys, adrenal glands, and pancreas
are unremarkable. The gallbladder contains high- density
material, which may represent small amount of sludge versus tiny
gallstones. There is no intrahepatic biliary dilatation. Small
bowel loops are normal in caliber. There is no free fluid or
free air. The patient is status post G- tube.
CT OF THE PELVIS: Again identified is expansion of the right
psoas and
iliacus muscle with high-density fluid consistent with a
retroperitoneal
hematoma. This measures approximately 9.6 x 17.8 cm (401B, 37)
and is
unchanged when compared to prior exam. No new areas of
retroperitoneal
hemorrhage are identified. A rectal tube is identified. The
rectum, sigmoid colon, and bladder are otherwise unremarkable.
Small foci of air within the bladder are noted and may be due to
recent Foley catheterization. The Foley catheter remains within
the bladder. There is no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic lesions
identified.
Degenerative changes of the thoracolumbar spine are noted.
IMPRESSION:
1. Stable appearance of large right iliacus and psoas muscle
retroperitoneal
bleed. No new areas of hemorrhage identified.
2. Bilateral lower lobe ground glass opacity with worsening
focal
consolidation of left lower lobe.
AP CHEST, 12:11 P.M. ON [**2178-9-16**]
HISTORY: COPD. Aspiration. Question pneumonia.
IMPRESSION: AP chest compared to [**9-3**] through [**9-14**].
Severe infiltrative pulmonary abnormality, probably largely
pulmonary fibrosis worsened only moderately since [**9-3**].
Aspiration pneumonia would not be appreciated. A component of
pulmonary edema, not necessarily cardiogenic is likely. Heart
size top normal, unchanged. Tracheostomy tube in standard
placement. No appreciable pleural effusion and no pneumothorax.
LENIs: No evidence of deep vein thrombosis in the left leg.
2-view knee: Study is limited due to difficulty in patient
positioning. There are no true AP or lateral views. Both of
these appear obliqued. Allowing for this, there are no
fractures. There is a knee joint effusion. There are
degenerative changes of the tibiotalar joint. No acute fractures
or dislocations are seen. There is some mild medial
compartmental joint space narrowing. If there is high clinical
concern for infection, MRI or joint aspiration should be
considered.
Brief Hospital Course:
This is a 51 y/o male with a history of severe mixed obstructive
and restrictive disease recently admitted with hypoxic and
hypercarbic respiratory failure, VAP and ARF now readmitted with
hypercarbic respiratory failure and elevated INR.
.
# Hypercabic respiratory failure: The patient has multifactoral
hypercarbic respiratory failure secondary to obstructive and
restrictive lung disease and obesity hypoventolation. The
patient had a tracheostomy placed [**2178-8-13**]. He presented to [**Hospital1 18**]
from [**Hospital 100**] Rehab with a rapidly worsening hypercarbia acidemia.
He had a audible sounds from his trach. Overall, the picture was
consistent with a cuff leak as the etiology of his worsening
hypercarbia. Upon arrival to the MICU the patient had loss of
100cc of tidal volumes due to the cuff leak. He had a
bronchoscopy on arrival and the trach was repositioned, which
led to a resolution of his cuff leak. He remained on AC
ventilation and albuterol, ipratroprium and beclomethasone. The
patient multiple ABG with goal PCO2 in the 70's. The patient had
a trial of pressure support, however, responded poorly with
tachypnea and anxiety. The patient was switched back to AC.
.
# Resistant pulmonary Pseudomonas VAP: The patient recently grew
resistant Pseudomonas on his sputum which persisted on a repeat
culture ([**2178-9-9**]) during a recent hospitalization. The culture is
sensitive to tobramycin and gent only. The patient currently is
being treated with tobramycin 150mg IV QOD. His course will end
[**2178-9-19**].
.
# Hypotension: The patient was initially normotensive on
presentation but became hypotensive with SBP to 70-80's in the
emergency department despite IVF. The etiology of his
hypotension was unclear. The patient did not have fevers or
leukocytosis which argued against infection, however, he had
many potential sources including Pseudomonas in his sputum,
decubitus ulcer and dirty UA. The patient also had a recent
psoas hematoma. His HCT was stable at admission and the patient
was not tachycardic. The patient was treated with levophed for a
goal of a MAP over 60 and was given fluid boluses as needed. The
patient was continued on his tobra. His hypotension resolved
with fluid boluses and levophed was stopped.
.
# Anemia: The patient had a falling hct during the
hospitalization of unknown etiology. During his prior admission
he was found to have a retroperitoneal bleed. He was transfused
a total of 2 units of pRBC and had a CT of his abdomen and
pelvis. The abdomen and pelvis scans showed a stable
retroperitoneal hematoma and no acute sources of bleed. The
patient had his coumadin stopped and vitamin K was given to
reverse his elevated INR. His hct was stablized during the
admission.
.
# Elevated INR: The patient had an INR of 7 which was likely
from an interaction from fluconazole and coumadin. The patient
was given vitamin K with a decrease in his INR to 2.4. His
coumadin was stopped due to his prior retroperitoneal hematoma
and hct drop during this hospitalization.
.
# Hypernatremia: Patient receiving D5W for hypernatremia. Will
adjustments to D5W IVF rate as needed.
.
# Renal failure: The patient had renal failure at his previous
admission. On admission his kidney function was resolving. Renal
was consulted and deferred dialysis due to improving kidney
function. The patient had his femoral HD line pulled without
complication.
.
# Atrial fibrillation: The patient developed intermittent Afib
during his last admission. Upon arrival he was normal sinus
rhythm and continued to be throughout the admission. The patient
was on metoprolol. His coumadin was stopped and not restarted
due to history of bleed.
.
# Left knee pain: The patient was noted to have L knee pain.
Three view x-ray were taken which failed to review etiology. The
joint fluid was aspirated and orthopedics was consulted. Ortho
thought unlikely to be septic joint, possible gout.
.
# H/O DVT: The patient had his coumadin stopped during this
admission. SC heparin was given.
.
# Constipation: The patient was continued on his home bowel
regimen.
.
# Code: Full code.
Medications on Admission:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
Disp:*QS MDI* Refills:*2*
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-20 Puffs Inhalation Q4H (every 4 hours).
Disp:*QS MDI* Refills:*2*
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*60 ML(s)* Refills:*2*
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*QS * Refills:*2*
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*QS * Refills:*2*
6. Senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day).
Disp:*300 ML(s)* Refills:*2*
7. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
Disp:*QS * Refills:*2*
8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
9. Sodium Chloride 0.9% and heparin. Flush 10 mL IV PRN line
flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline and
heparin daily and PRN.
10. Pantoprazole 40 mg PO Q24H
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
13. Fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*QS Patch 72 hr(s)* Refills:*2*
14. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
15. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM.
Disp:*90 Tablet(s)* Refills:*2*
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash/puritis.
Disp:*QS * Refills:*0*
18. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
21. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
One (1) Inhalation twice a day.
Disp:*QS MDI* Refills:*2*
22. Tobramycin: Dosed based on level
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SO or
wheezing.
Disp:*QS * Refills:*0*
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*QS * Refills:*2*
3. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) Inhalation [**Hospital1 **] (2 times a day).
Disp:*QS * Refills:*2*
4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for pain.
Disp:*QS Patch 72 hr(s)* Refills:*0*
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 7500 (7500)
units Injection TID (3 times a day) as needed for DVT proph.
Disp:*QS * Refills:*0*
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q6H (every 6 hours) as needed for wheeze.
Disp:*qs * Refills:*0*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*QS Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qS Tablet(s)* Refills:*2*
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*QS * Refills:*2*
11. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constipation.
Disp:*QS * Refills:*0*
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
Disp:*QS Tablet(s)* Refills:*0*
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
[**2-6**] Adhesive Patch, Medicateds Topical DAILY (Daily).
Disp:*QS Adhesive Patch, Medicated(s)* Refills:*2*
15. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
Disp:*30 Recon Soln(s)* Refills:*2*
16. Hydromorphone (PF) 1 mg/mL Syringe Sig: [**2-6**] Injection Q4H
(every 4 hours) as needed for pain.
Disp:*QS * Refills:*0*
17. Tobramycin Sulfate 40 mg/mL Solution Sig: Seven (7)
Injection ONCE (Once) for 1 doses: 280mg IV, To be given if
tobramycin level <2.
Disp:*QS * Refills:*0*
18. Outpatient Lab Work
Daily coag, CBC, chem 10. Results to be reviewed by MD.
19. Outpatient Lab Work
of D5W IVF.
20. Methadone 5 mg Tablet Sig: 2.5 Tablets PO four times a day:
total of 12.5 mg po QID.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Inhalation Lung Injury
Hypoxic and Hypercarbic Respiratory Failure
Pseudomonas Pneumonia
Acute Renal Failure requiring Hemodialysis
Gastrointestinal Bleed
Atrial Fibrillation
Hypernatremia
L knee pain
Discharge Condition:
Fair
Discharge Instructions:
You were admitted to the MICU after experiencing respiratory
distress at your long term rehab facility. Upon admission, you
had a bronchoscopy which revealed poor placement of the
endotracheal tube. The tube was repositioned with immediate
improvement of your respiratory status. Because of your large
pain medication requirements, we change yor daily regimen to a
longer lasting medication called Methadone to be take three
times a day, with dilaudid to be given for breakthrough pain.
Lastly, your left knee pain appears due to bleeding into the
joint space. Aspiration of joint fluid showed no gout or
infection, and xray revealed no fracture. We've given you pain
medication to help with the pain, and we have reversed your
anticoagulation which should prevent further bleeding into the
joint space. Regarding your health issues prior to admission,
you sould continue on the ventilator for your respiratory
failure, uing the current Assist Control settings. These
settings may be weaned as tolerated. For your Pseudomonal
pneumonia, continue tobramycin for 3 more days. A tobramycin
level should be check prior to dosing, and a peak level should
be checked 1 hour after infusion stopped. His dose today will
be Tobramycicn 280mg IV if the tobramycin level comes back <2.
For your anemia, continue having hematocrit checked daily, and
transfuse for levesl less than 25. For your skin ulcerations,
continue current wound care. For hypernatremia, continue D5Wat
200cc/hr and check electrolytes [**Hospital1 **]. For renal failure,
continue to monitor urine output and BUN/Cr daily.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-10-13**] 2:30
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2178-11-24**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-12-14**] 10:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5849, 2851, 2760, 2762, 496, 2875, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3099
} | Medical Text: Admission Date: [**2132-12-9**] Discharge Date: [**2132-12-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Hypoxemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname **] is an 86 yo woman with 3V CAD s/p MI and multiple
coronary interventions, DM2, HTN, dementia and a h/o DVT who
presents from her nursing home with hypoxemia.
.
She had reportedly had symptoms c/w an upper respiratory tract
infection for a week prior to desaturating to the high 70s on 2
LNC. Her O2 sat improved to the 90s with 5L by NC. At the time,
she was normotensive, but tachycardic to the 140s and tachypneic
to the 40s.
.
In the ED, her initial VSs were 99.8, 120, 73/58, 18, 97% 5LNC.
She spiked a temp to 101.4. A CXR was suggestive of pulmonary
edema and possible RLL pneumonia. Her blood pressure remained
low despite 1500 cc NS. She was given levofloxacin 750 mg PO x1,
vancomycin 1 g IV x1. A central line was inserted, and she was
transferred to the [**Hospital Unit Name 153**] for further management.
.
The pt is mildly demented, and had a difficult time presenting
any further history. She reports rhinorrhea and sinus congestion
and does report a cough currently that is nonproductive. She
denies chest pain, difficulty breathing, changes in bowel
habits. She denies leg swelling or calf pain.
.
She received the influenze vaccine about 2 weeks ago, she
reports. She received the Pneumovax in [**8-9**].
Past Medical History:
PMH:
Past Medical History:
# CAD (anteroseptal MI [**12-7**], inferior MI (old - 20yrs ago); LAD
STEMI [**6-8**] c/b post-stent dissection and in-stent thrombosis
requiring urgent PCI
# Recent C-diff colitis following antibiotic treatment for UTI
# RLE DVT [**10-7**]
# Depression
# GERD
# Glaucoma
# Asthma
# Facial droop (old per daughter)
# Claustrophobia
# diabetes mellitus, type 2
# Hypertension
.
Social History:
Social history is significant for the absence of current tobacco
use, former tobacco user. There is no history of alcohol abuse.
The patient lives at [**Hospital1 599**].
Family History:
Non contributory
.
Physical Exam:
Vitals: T: 97.3 BP: 96/56 P: 100 R: 24 SaO2: 100% 4LNC
General: Awake, alert, NAD, pleasant, appropriate, cooperative
HEENT: EOMI, no scleral icterus, MMM, no lesions noted in OP
Neck: no cervical LAD, JVP not visible while upright
Pulmonary: Lungs with rales bilaterally, decreased breath sounds
at R base, no wheezes or ronchi
Cardiac: borderline tachy, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, 1+ DP pulses b/l
Skin: no rashes or lesions noted.
Pertinent Results:
LABS ON ADMISSION
[**2132-12-9**] 04:30AM WBC-11.5*# RBC-4.53 HGB-12.2 HCT-37.6 MCV-83
MCH-27.0 MCHC-32.5 RDW-16.1*
[**2132-12-9**] 04:30AM NEUTS-91.6* LYMPHS-5.7* MONOS-2.3 EOS-0.1
BASOS-0.2
[**2132-12-9**] 04:30AM PLT COUNT-293
[**2132-12-9**] 04:30AM GLUCOSE-270* UREA N-24* CREAT-1.1 SODIUM-143
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-31 ANION GAP-16
[**2132-12-9**] 04:40AM LACTATE-2.3*
[**2132-12-9**] 09:49AM LACTATE-1.4
[**2132-12-9**] 09:49AM TYPE-[**Last Name (un) **] PO2-47* PCO2-56* PH-7.38 TOTAL
CO2-34* BASE XS-5 COMMENTS-GREEN TOP
STUDIES
Port CXR [**12-9**] - Mild to moderate pulmonary edema with a small
right effusion likely secondary to heart failure. More confluent
opacity in the right lung base may represent confluent edema
although underlying pneumonia cannot be excluded. Repeat
radiographs following diuresis recommended.
TTE [**12-10**] - EF 25%, The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate to severe regional left ventricular systolic
dysfunction with mild aneurysm of the basal inferior wall and
apex and near akinesis of the inferior wall, and distal half of
the anterior septum and anterior wall, apex and distal lateral
wall. No masses or thrombi are seen in the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
is normal with focal hypokinesis of the apical free wall. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2132-9-2**],
the distal half of the anterior septum and anterior wall, apex,
and distal inferior wall dysfunction is new c/w interim ischemia
(mid-LAD distribution) with underlying multivessel CAD. Moderate
pulmonary artery systolic hypertension and increased LVEDP are
now identified.
Chest Xray [**2132-12-14**]- New left lower lobe infiltrate, reduction in
size of right effusion.
Port CXR [**12-15**] - This is compared with the prior from [**2132-12-14**]. The NG tube is in the proximal stomach. There is minimal
interval change in the pleural effusions bilaterally. The
pulmonary edema is somewhat improved. There is interval removal
of the right subclavian line.
IMPRESSION: NG tube in standard position. Improvement in
pulmonary edema, effusion unchanged.
LABS ON DISCHARGE
[**2132-12-17**] 04:18AM BLOOD WBC-9.9 RBC-3.77* Hgb-9.8* Hct-30.7*
MCV-82 MCH-26.0* MCHC-31.9 RDW-15.7* Plt Ct-368
[**2132-12-17**] 04:18AM BLOOD Glucose-132* UreaN-18 Creat-0.9 Na-146*
K-3.8 Cl-99 HCO3-38* AnGap-13
[**2132-12-15**] 08:33PM BLOOD CK-MB-4 cTropnT-0.56*
[**2132-12-15**] 08:33PM BLOOD CK(CPK)-50
[**2132-12-17**] 04:18AM BLOOD Albumin-3.1* Calcium-9.1 Phos-3.5 Mg-2.0
[**2132-12-15**] 08:33PM BLOOD Vanco-25.0*
[**2132-12-15**] 06:28PM BLOOD Type-ART pO2-239* pCO2-71* pH-7.40
calTCO2-46* Base XS-15
Brief Hospital Course:
ASSESSMENT/Plan: 86 yo woman with 3V CAD, DM2, HTN, dementia
presents with respiratory distress, fever, SIRS likely [**1-3**]
pneumonia with course c/b pulmonary edema, and elevated cardiac
enzymes likely [**1-3**] demand ischemia.
1) Respiratory distress/hypoxia: Initially admitted withHad
episodes of transient desaturation, but appeared asymptomatic
overnight on the day of presentation. This was likely due to
pulmonary edema, CHF, and pneumonia. The patient was initially
treated broadly with vancomycin and zosyn which was changed to
vancomycin and levaquin, of which a 7 day course was completed.
The patient was ruled out for influenza and all blood cultures
were no growth. She was diuresed with IV lasix successfully with
improvement in her respiratory status. At the time of discharge,
the patient was sating 94-98% on 2 L NC and was no longer
tachypneic.
2) Systolic Heart failure/CAD - The patient was noted to have
new dysfunction of anterior septum and inferior wall as well as
new aneurysmal dilation, which was new compared to a prior TTE
from [**9-8**]. This was felt to be secondary to interval stent
closure. EKGs did show non-specific inverted T waves
precordially which were concnering for ongoing ischemia in the
setting of volume overload. Cardiac enzymes were checked and
were significant for troponin-T 0.42, CK 134, CK-MB 18, and MB
index 13.4. Cardiology was consulted who felt that her symptoms
of nausea, diaphoresis, and elevated cardiac enzymes were likely
due to demand ischemia rather than ACS. A heparin gtt was not
started to due unlikely ACS and the patient was not sent to the
cardiac cath lab as her enzymes began to trend down rapidly in
the setting of decreased symptoms and hemodynamic stability. She
was continued on aspirin, plavix, simvastatin, and metoprolol
and she was started on lisinopril, which was gradually titrated
up during the course of hospitalization. She was discharged on
lisinopril 5mg po daily with goal of eventually uptitrating to
10mg daily. In addition, she should be changed to long acting
beta-blocker such as toprol xl as soon as her volume status is
stabilized. Her home dose of lasix 20mg daily was also
restarted and she should be followed closely with daily weights.
Dry weight on discharge is 55.1kg. She should follow a low
sodium diet.
3)DM2 - Held po hypoglycemics and placed on ISS. Started on
ACE-I as above. She usually takes glyburide 5mg daily. This
was not restarted on discharge as she was not taking regular po
intake.
4) Anxiety - Takes ativan prn for baseline anxiety, which was
used carefully in the setting of tenous mental status in setting
of infection and demand ischemia. Three days prior to discharge
ativan was stopped completely and held for the remainder of her
hospital stay due to concern for contribution to altered mental
status.
5) Depression - She was continued on her outpatietn regimen of
paroxetine and olanzapine qhs.
6) Glaucoma - Continued eye drops.
7) Nutrition: At the time of discharge pt was not taking in
adequate POs. An NG tube was placed. Tube feed were not
started given plan for transfer within several hours of
placement, however goal is for her to be started on tube feeds
at [**Hospital 100**] Rehab MACU. She was given 250cc free water bolus for
hypernatremia prior to transfer.
8)Electrolytes - She will require daily chem 7 check and likely
daily repletion of K, with goal K 4-4.5.
9)Code status - DNR/DNI, discussed with family
Medications on Admission:
Aspirin 325 mg
Clopidogrel 75 mg
Lisinopril 5 mg
Metoprolol Tartrate 37.5 tid
Simvastatin 80 mg
Glyburide 5 mg
Furosemide 40 mg
Paroxetine HCl 30 mg
Olanzapine 2.5 mg qhs
Pantoprazole 40 mg
Docusate Sodium 100 mg [**Hospital1 **]
Prednisolone Acetate 1 % Drops [**Hospital1 **]
Naphazoline-Pheniramine 0.025-0.3 % Drops qid
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: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: [**12-3**] PO BID (2 times a
day).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Naphazoline-Pheniramine 0.025-0.3 % Drops Sig: One (1) Drop
Ophthalmic QID (4 times a day).
8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): See insulin Sliding Scale.
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**4-11**]
MLs PO Q6H (every 6 hours) as needed for cough.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis: Respiratory distress due to congestive heart
failure and pneumonia
Secondary Diagnosis:
# CAD (anteroseptal MI [**12-7**], inferior MI (old - 20yrs ago); LAD
STEMI [**6-8**] c/b post-stent dissection and in-stent thrombosis
requiring urgent PCI
# Recent C-diff colitis following antibiotic treatment for UTI
# RLE DVT [**10-7**]
# Depression
# GERD
# Glaucoma
# Asthma
# Facial droop (old per daughter)
# Claustrophobia
# diabetes mellitus, type 2
# Hypertension
Discharge Condition:
At the time of discharge, the patient was sating 94-98% on 2
Liters Nasal Cannula and was no longer tachypneic
Discharge Instructions:
You were admitted to the hosptial with low oxygen levels. This
was due to a combination of pneumonia and congestive heart
failure. You were treated for pneumonia with antibiotics, which
you completed while in the hosptial. You where treated for the
congestive heart failure with diuretics.
.
You are to eat a low salt diet.
.
Check you weight daily. At the hospital, your weight was 55.1
kg. This is a good weight for you. If you weight starts to
increase it may indicate that your heart is not working as well
as it should and you should call the cardioulgy office at
[**Telephone/Fax (1) 5003**].
.
If you have any symptoms of shortness of breath, chest pain,
fevers, cough, or any other concerning symptoms you should come
to the hospital immediately
.
Please take all of your medications as prescribed.
.
Please keep all of your appointments as scheduled.
Followup Instructions:
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (PRE) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2133-1-9**] 9:00
ICD9 Codes: 486, 4271, 2760, 4280, 2859, 4589, 4019, 412 |
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