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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3100
} | Medical Text: Admission Date: [**2186-6-7**] Discharge Date: [**2186-6-11**]
Date of Birth: [**2124-11-5**] Sex: M
Service: [**Hospital Ward Name **] ICU
CHIEF COMPLAINT: "Black stools" x one day.
HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old
male with a history of ischemic cardiomyopathy with an EF of
30 to 35%, status post left anterior descending coronary
artery stent [**2182**], history of colonic polyps in [**2177**] status
post resection, history of recurrent left lower extremity
deep venous thrombosis on chronic anticoagulation who was in
his usual state of health until two days prior when he noted
onset of fatigue, nausea, loss of appetite. Yesterday one
day prior to admission he had one episode of black stool. He
denies any abdominal pain. He denies any vomiting or bright
red blood per rectum. Of note, he had a light bowel movement
on the day prior. He denies any history of heavy alcohol use
or non-steroidal anti-inflammatory drugs use. No prior
retching. No back pain. He does have a history of abdominal
aortic aneurysm repair. He denies any changes in his
Coumadin dosing. No lightheadedness. No loss of
consciousness. The patient came to the clinic for a
scheduled phlebotomy for his hemochromatosis at which time
his systolic blood pressure was 88. He reported having black
stool and was sent to the Emergency Room. In the Emergency
Room he was OB positive. Nasogastric lavage was performed,
which returned clear fluid. He was given 2 liters of saline
intravenous with no improvement in systolics. His hematocrit
was 31 initially and dropped to 24. INR was 2.3. He was
given 2 mg of po vitamin K and sent to the [**Hospital Ward Name 332**] Intensive
Care Unit.
REVIEW OF SYSTEMS: He denies any fevers or chills. He
denies any abdominal pain. He does admit to taking Dilantin
200 mg in [**Doctor Last Name 2434**] of his usual 300 dose of one to two weeks.
He also admits to persistent reflux symptoms for several
years, but it has been untreated. He uses Rolaids prn.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post non Q wave myocardial
infarction in [**2180**] with left anterior descending coronary
artery [**Last Name (un) 2435**]. Status post myocardial infarction in [**2182**] with
percutaneous transluminal coronary angioplasty to left
anterior descending coronary artery stent.
2. History of congestive heart failure with an EF of 30 to
35%.
3. Hemochromatosis with early cirrhosis requiring q 3 month
phlebotomies.
4. Noninsulin dependent diabetes mellitus.
5. Status post abdominal aortic aneurysm repair in [**2178**].
6. History of recurrent left lower extremity deep venous
thrombosis now on anticoagulation.
7. History of seizure disorder.
8. Status post L4-L5 discectomy in [**2181**].
9. History of benign colonic polyp resection in [**2177**].
MEDICATIONS AT HOME:
1. Aspirin 81.
2. Atenolol 50.
3. Zestril 10.
4. Lipitor 10.
5. Coumadin 5 Tuesday to Sunday, 7.5 on Monday.
6. Metformin 1000 twice a day.
7. Glyburide 20 twice a day.
8. Folate one.
9. Dilantin 300.
ALLERGIES: The patient admits to an allergy to intravenous
dye many years ago. The reaction was some bumps on his hand.
No shortness of breath or choking.
SOCIAL HISTORY: The patient lives with his wife in
[**Name (NI) 2436**]. He is retired from the furniture upholstery
business. He smoked 35 years times half a pack a day. Quit
in [**2182**]. Very rare alcohol. No non-steroidal
anti-inflammatory drugs or Ibuprofen use.
PHYSICAL EXAMINATION: The patient's temperature was 98.4.
Heart rate 76 to 79. Blood pressure 90/50. Respirations 15.
Sat 94 to 99% on 2 liters. In general, well appearing and in
no acute distress. Pupils are equal, round and reactive to
light. No scleral icterus. Oropharynx is clear.
Conjunctiva were slightly pale. No lymphadenopathy. No
bruits. JVP approximately 8 cm. Chest rales at the right
base. Cardiac regular. S1 and S2. No murmurs. Abdomen was
benign, soft, nontender. Good bowel sounds. He had a
midline ventral hernia, which was soft. Liver was palpated 2
cm below the costal margin. The patient was OB positive in
the Emergency Department. Extremities revealed 1+ pedal
edema with venostasis changes bilaterally. Skin examination
had no rashes. The patient s alert and oriented times three
with a chronic left foot drop.
INITIAL LABORATORIES: White blood cell count 6.3, hematocrit
31.4, which then dropped to 24.3, baseline is 41. Platelets
138. SMA 7 notable for a sodium of 136, K of 4.7, bicarb 24,
BUN 32, creatinine 0.5, glucose 158, INR 2.3. Dilantin level
was 3.0. ALT 35, AST 51, alkaline phosphatase 203. Total
bilirubin .5, LDH 215, albumin 3.0. Enzymes were cycled,
which were negative. The patient's electrocardiogram
revealed normal sinus rhythm, PR prolongation at 206. Left
axis deviation, inferior Qs, all of which were old. There
were some new T wave flattening in V2 to V6.
HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient
was admitted with melena likely an upper gastrointestinal
bleed given history of abdominal aortic aneurysm, question of
enteric fistula. Given history of hemochromatosis and early
cirrhosis, question of varices, given history of reflux
symptoms, question of esophagitis, gastritis. The patient
was again admitted with gastrointestinal bleed and was typed
and crossed. He was initially transfused 2 units for a
hematocrit of 24. He had two peripheral intravenouses in
place. INR was corrected with vitamin K 2 mg and 4 units of
fresh frozen platelets and hematocrit revealed a change from
24 up to 26 after 4 units. INR corrected to 1.7. The
patient was also started on Protonix 40 intravenous b.i.d.
Aspirin and Coumadin were held. The patient underwent an
esophagogastroduodenoscopy on the following morning, which
revealed grade 1 esophageal varices and mild gastritis
esophagitis as well as portal gastropathy. There was no
active bleeding at any site. The patient then underwent an
abdominal CT, which was negative for aortic enteric fistula.
On the following day the patient underwent a colonoscopy,
which was normal up until the ascending colon. However, they
were not able to go all the way to the cecum and recommended
virtual colonoscopy in the future and the patient had then
underwent a repeat esophagogastroduodenoscopy with banding
times four to the esophageal varices. The patient will need
a repeat banding procedure in ten days. After the banding
the patient was started on Sucralfate 1 gram q.i.d. and was
continued on Protonix. Again aspirin and Coumadin were held
throughout. After 4 units hematocrit stabilized from 24 up
to 32 and remained stable at 32 upon discharge.
2. Hypotension: The patient was initially in the systolics
in the 90s likely hypovolemic in the setting of a
gastrointestinal bleed. However, given the history of
cardiac disease the patient's enzymes were cycled times
three, which were negative. He was resuscitated with fluid,
fresh frozen platelets and packed red cells and blood
pressure remained stable throughout. After the
esophagogastroduodenoscopy the Atenolol was switched to
Nadolol given the history of cirrhosis and varices and
Zestril was held up until discharge due to low blood
pressures.
3. Coronary artery disease: Patient with a history of
myocardial infarction in [**2180**] and [**2182**] and is status post
stent of the percutaneous transluminal coronary angioplasty
in [**2182**]. Enzymes were cycled, which were negative. Aspirin
and Coumadin were held due to gastrointestinal bleed. Beta
blocker and ace were initially held due to low blood
pressures. Lipitor was held secondary to new cirrhosis. The
patient was restarted on Nadolol upon discharge, however,
aspirin, Coumadin, Zestril and Lipitor were held prior to
discharge to be restarted by primary care physician at his or
her discretion.
4. Deep venous thrombosis: Patient with recurrent left
lower extremity deep venous thrombosis, but admitted with
gastrointestinal bleed. INR 2.3, Coumadin was held due to
multiple procedures and held upon discharge. The patient
will undergo repeat banding in ten days after which time the
patient may or may not resume anticoagulation per primary
care physician.
5. Hemachromatosis: The patient with hemachromatosis for
long standing, now with evidence of cirrhosis on examination.
The patient will continue with further phlebotomies as per
Dr. [**Last Name (STitle) **] and may need further workup for cirrhosis.
6. History of abdominal aortic aneurysm: Patient ruled out
enteric fistula with negative abdominal CT.
7. Seizure disorder: The patient was given additional dose
of Dilantin 400 times one and then restarted on his regular
does of 300 and will continue on his regular dose. No
further seizure activity.
8. Diabetes: The patient was initially held NPO diabetic
medications due to NPO status. Was covered with a sliding
scale. Sugars remained stable and can restart Glyburide upon
discharge. Metformin held secondary to cirrhosis.
DISCHARGE DIAGNOSES:
1. Esophageal varices s/p banding.
2. Portal gastropathy.
3. Gastritis esophagitis.
4. Hemachromatosis with early cirrhosis.
5. Coronary disease.
6. Recurrent deep venous thrombosis.
7. Congestive heart failure.
8. Diabetes.
9. s/p abdominal aortic aneurysm repair.
10. Seizure disorder.
MEDICATIONS ON DISCHARGE:
1. Nadolol 20 q.d.
2. Sucralfate one q.i.d. times seven days.
3. Protonix 40 po q.d.
4. Dilantin 300.
5. Folate 1.
MEDICATIONS HELD:
1. Aspirin.
2. Coumadin.
3. Lipitor.
4. Zestril.
5. Atenolol switched to Nadolol.
FOLLOW UP: The patient will follow up with primary care
physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**]. Follow up with hematologist [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] and follow up with liver specialist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for repeat
banding in ten days. At the time of follow up, the timing for
resuming anticoagulation should be addressed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36
D: [**2186-6-12**] 03:36
T: [**2186-6-19**] 08:59
JOB#: [**Job Number 2440**]
cc:[**Last Name (NamePattern4) 2441**]
ICD9 Codes: 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3101
} | Medical Text: Admission Date: [**2177-5-15**] Discharge Date: [**2177-5-16**]
Date of Birth: [**2135-1-14**] Sex: M
Service: .
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This is a 42 year old man with
an anterior myocardial infarction on [**4-30**], status post left
anterior descending PCI at [**Hospital6 **], who
presented to his primary care physician's office on the
morning of admission with complaints of left substernal chest
pain. The symptoms began at 9 a.m. with chest pain,
diaphoresis, nausea and some dizziness. The pain was slow in
onset. It radiated to the left shoulder; no shortness of
breath. Similar in location and character to anginal pain
but less severe, seven out of ten as opposed to ten out of
ten with myocardial infarction, not relieved by sublingual
Nitroglycerin. The pain was also different in that it was
exacerbated by motion, pleuritic in nature.
The patient denies shortness of breath, has two to three
pillow orthopnea which is stable. No paroxysmal nocturnal
dyspnea. The patient reports loosing weight since discharge
from hospitalization on [**5-5**]. He has mild intermittent
lower extremity edema but no progressive edema. The patient
was transferred to [**Hospital1 69**] and
underwent cardiac catheterization.
The cardiac catheterization demonstrated a patent left
anterior descending stent, serial 40% lesions in obtuse
marginal 2, 80% right coronary artery lesion with left to
right collaterals from the left anterior descending, PAP
pressures 43/20.
The patient was transferred to the cardiac care unit for
concerns of elevated pulmonary capillary wedge pressures post
procedure.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
4. Gastroesophageal reflux disease.
5. History of alcohol.
6. Status post right knee surgery.
7. Status post tummy tuck in [**2173**].
MEDICATIONS:
1. Aspirin.
2. Plavix.
3. Lipitor 80.
4. Warfarin 5.
5. Lisinopril 10.
6. Atenolol 50 p.o. q. day.
7. Mirtazapine 30 p.o. q. day.
8. Zoloft 100 mg q. day.
9. Neurontin 1500 mg p.o. q. day.
10. Protonix 40 mg p.o. q. day.
11. Lorazepam 0.5 mg p.o. three times a day.
12. Azolitmin nasal spray.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Attends [**State 1558**] as a
student. Works at [**Doctor First Name 47672**] Pantry. Quit tobacco one week;
prior one pack per day times 35 years. History of heavy
alcohol use; quit eleven months ago. No illicit drug use.
No intravenous drug use.
FAMILY HISTORY: No early coronary disease in the family;
father with alcohol abuse.
PHYSICAL EXAMINATION: Blood pressure 121/66; pulse 56;
respirations 15, O2 saturation 98%. PA-pressure 36/16 with
mean of 23. In general, a middle aged man in no acute
distress. HEENT: Extraocular muscles are intact. Moist
mucous membranes. Neck supple. No jugular venous
distention. Cardiovascular is regular rate and rhythm,
positive S3. Pulmonary clear to auscultation bilaterally.
Abdomen soft, notable for ecchymosis across the lower
abdomen. Mildly tender around area surrounding bruise. No
hematomas, not distended. Positive obesity. Extremities
with no edema. Two plus dorsalis pedis pulses bilaterally.
Neurological: Alert and oriented, appropriate, non-focal.
LABORATORY: White blood cell count 10.8, normal
differential. Hematocrit 40.8, platelets 372. Sodium 137,
potassium hemolyzed, chloride 100, bicarbonate 25, BUN 21,
creatinine 0.6, glucose 88. CK 159, troponin less than 0.3,
MB 2.0.
Coagulation studies were INR 2.1.
EKG normal sinus rhythm at 70, normal axis and intervals. ST
elevation in V1 through V4 with Q waves V1 through V3
consistent with evolving old infarction.
HOSPITAL COURSE: Mr. [**Known lastname **] was admitted to the Cardiac
Care Unit for monitoring overnight. His hemodynamics
remained stable. He was negative approximately two liters
post cardiac catheterization and his wedge pressure returned
to [**Location 213**]. His arterial and Swan-Ganz catheter were removed
by morning.
The patient underwent echocardiogram which demonstrated no
pericardial effusion. Ejection fraction 30 to 35% on early
depressed overall left ventricular systolic function.
The patient was started on aspirin 650 mg four times a day
times seven days for treatment of post myocardial infarction
pericarditis. The patient's Telemetry monitoring
demonstrated no arrhythmia and the patient will continue to
follow-up for further electrophysiology studies as planned
through [**Hospital6 **].
DISCHARGE MEDICATIONS:
1. Aspirin 650 mg p.o. four times a day times seven days,
then return to aspirin 325 mg p.o. q. day.
2. Plavix 75 mg p.o. q. day.
3. Lipitor 80 mg p.o. q. day.
4. Warfarin 5 mg p.o. q. h.s.; INR measured at 2.6 on
[**2177-5-16**].
5. Lisinopril 10 mg p.o. q. day.
6. Atenolol 50 mg p.o. q. day.
7. Mirtazapine 30 mg p.o. q. day.
8. Zoloft 100 mg p.o. q. a.m.
9. Neurontin 1500 mg p.o. q. day.
10. Protonix 40 mg p.o. q. day.
11. Lorazepam 0.5 mg p.o. three times a day p.r.n.
12. Azolitmin spray 137 micrograms, two sprays q. nostril
h.s.
13. Percocet one to two tablets q. six hours p.r.n., dispense
twenty.
14. Nicotine transdermal 21 patch q. day.
DISCHARGE INSTRUCTIONS:
1. Follow-up as previously planned with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) 1617**].
2. Follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3265**].
3. Appointment with Dr. [**Last Name (STitle) **] on [**6-25**] at 03:00 p.m. with
appointment with Dr. [**Last Name (STitle) 1617**] to follow.
PLEASE SEND CARDIAC CATHETERIZATION REPORT AND ECHOCARDIOGRAM
REPORT WITH CARBON COPIES.
DISCHARGE DIAGNOSES: Pericarditis.
CONDITION ON DISCHARGE: Good.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2177-5-16**] 16:27
T: [**2177-5-16**] 22:20
JOB#: [**Job Number 47673**]
CC.: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 **], [**Location **],
TELEPHONE NUMBER [**Telephone/Fax (1) 47674**].
DR. [**Last Name (STitle) **], [**Hospital1 2177**] CARDIOLOGY, TELEPHONE NUMBER [**Telephone/Fax (1) 47675**]
ICD9 Codes: 4271, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3102
} | Medical Text: Admission Date: [**2195-12-25**] Discharge Date: [**2195-12-29**]
Date of Birth: [**2123-7-8**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
male with a history of ischemic cardiomyopathy with a known
EF of 15%, diabetes mellitus, hypertension,
hypercholesterolemia, peptic ulcer disease who was admitted
to [**Hospital3 417**] Hospital on [**12-19**] for congestive heart
failure. The patient reports one week prior to admission he
began experiencing increased shortness of breath, dyspnea on
exertion, orthopnea and PND. This was also associated with
the production of green sputum. The patient was started on
Levaquin and admitted for increasing shortness of breath.
The patient ruled out for MI by three normal sets of enzymes
at the outside hospital. Subsequently a nuclear stress test
was obtained which demonstrated a lateral ischemic area with
a fixed septal defect and an EF of 14%. The patient was
diuresed and treated with antibiotic therapy. However, prior
to his discharge, the patient had a run of non sustained V
tach and was therefore transferred to [**Hospital1 190**] for catheterization with potential
revascularization as well as for consideration of an EP
study.
Catheterization performed at time of admission demonstrated a
wedge of 30, PA sat 50%, right dominant, PA pressure 52/27,
no NCA, normal LAD, 90% stenosis of the focal mid region,
left circumflex normal, RCA 100% with good collaterals. A
stent was placed in the LAD which resulted in dissection of
V1 and a stent was also placed in V1. Final result of the
catheterization revealed an LAD of 0%, mid LAD 10%, D1 10%.
The patient demonstrated a PA sat of 39% towards the end of
the procedure and a balloon pump was placed.
The patient was then transferred to the cardiac care unit for
further management.
PAST MEDICAL HISTORY: 1) Ischemic cardiomyopathy with a
catheterization in [**2193-3-28**] demonstrating normal LM, normal
left circumflex, normal LAD, RCA 100% with an EF of 47%. 2)
Congestive heart failure with an EF of 15%. 3) Hypertension.
4) Diabetes mellitus. 5) Hypercholesterolemia. 6) Peptic
ulcer disease.
MEDICATIONS: Aspirin 325 mg po q d, Lasix 40 mg po q d,
Diovan 80 mg po q d, Atenolol 25 mg po q d, Glipizide 5 mg po
q d, Prevacid 30 mg po bid, Pravachol 40 mg po q d, Metformin
500 mg po q d, Levaquin 250 mg po q d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives at home with his wife and
is able to perform all ADLs. He denies any tobacco or
alcohol history.
FAMILY HISTORY: The patient reports [**7-8**] siblings suffer
from coronary artery disease.
PHYSICAL EXAMINATION: Vitals, afebrile, heart rate 80,
respiratory rate 20, blood pressure 112/68, PA pressure
58/27, oxygen saturation 100% on non rebreather. General,
comfortable. HEENT: Extraocular movements intact,
conjunctiva clear, oropharynx clear. Neck, brisk carotid
upstrokes. Cardiovascular, regular rate and rhythm, normal
S1 and S2, no S3 or S4, no murmurs. Lungs, good aeration
bilaterally, minimal crackles at the left base. Abdomen,
positive bowel sounds, soft, nontender, non distended, no
hepatomegaly. Groin, right groin reveals Swan and
intra-aortic balloon pump placement. Extremities, no edema,
2+ DP/PT.
LABORATORY DATA: At outside hospital, white blood cell count
7.8, hematocrit 35.8, platelet count 171,000, sodium 136,
potassium 4.6, chloride 100, CO2 23, BUN 45, creatinine 1.8,
glucose 180, calcium 8.7, albumin 3.2, AST 54, ALT 88.
At [**Hospital1 69**], white blood cell
count 8.9, hematocrit 34.6, platelet count 174,000, sodium
133, potassium 4.4, chloride 100, CO2 21, BUN 49, creatinine
1.4, glucose 227, ALT 79, AST 62, alkaline phosphatase 106,
total bilirubin 0.6, CK 87, albumin 3.3, calcium 8.4,
magnesium 2.1, phosphorus 5.2.
EKG, normal sinus rhythm, minimal left axis deviation, Q's in
leads 3 and AVF, LVH by criteria.
HOSPITAL COURSE: The patient is a 72-year-old white male
with a history of ischemic cardiomyopathy and an EF of 14%
who presented to the [**Hospital3 417**] Hospital with congestive
heart failure and pneumonia. The patient was diuresed and
entered into non sustained V tach and catheterization showing
90% in LAD with a stent placed complicated by failed V1 and 2
dissections as well as complicated by low cardiac index and
hypotension and placement of an intra-aortic balloon pump.
1. Cardiovascular: The patient had one stent placed in his
LAD and two stents were placed for dissection. He was
treated with initial IV fluid hydration as per post cath
protocol. An intra-aortic balloon pump was placed during the
procedure secondary to low EF and PA sats of 39%. Following
admission to the CCU the patient underwent aggressive
diuresis with a Lasix drip, titrated as needed to maintain
appropriate urine output. Anti-hypertensive meds were held
and a Heparin drip was initiated given the placement of the
intra-aortic balloon pump. In addition, the patient was
maintained on telemetry with the intent to consult
electrophysiology consult after improvement of his basic
cardiac status.
The patient was continued on Aspirin and Plavix and
Integrilin was stopped as per protocol with Heparin being
initiated for the intra-aortic balloon pump. Cholesterol
profile was checked which demonstrated a total cholesterol of
40, LDL of 79 and HDL of 28. The patient was continued on
Pravachol which she was on for hypercholesterolemia as an
outpatient.
The patient was successfully diuresed with IV Lasix which was
titrated down to his usual daily dose of 40 mg po q d. On
hospital day #3 the patient was started on Captopril 12.5 mg
which he tolerated well and following which the intra-aortic
balloon pump was weaned and removed. ACE inhibitor dosing
was titrated to Captopril 12.5 mg tid and then switched over
to Zestril 5 mg po q d. In addition, prior to discharge the
patient was started back on his beta blocker of Atenolol 25
mg po q d. Aspirin and Plavix will also be continued as an
outpatient as well as Pravachol.
The patient remained hemodynamically stable and was
transferred to the floor where he did well. He tolerated his
anti-hypertensive medications, maintaining his systolic blood
pressure in the 90's. The issue of his non sustained
ventricular tachycardia was revisited by electrophysiology
who recommended that the patient follow-up with Dr. [**Last Name (STitle) 37577**]
within the next 1-2 weeks for initiation of an EPS study.
The patient was hemodynamically stable at time of discharge
and will follow-up with his cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
2. Pulmonary: The patient demonstrated significant
congestive heart failure at time of admission which responded
well to IV Lasix. The patient was diuresed quickly at the
beginning of the hospital stay and his Lasix was titrated
down to his usual daily dose of 40 mg po q d. The patient's
oxygen requirements were also titrated until he was able to
maintain saturations over 96% on room air. At time of
discharge the patient had a normal pulmonary exam. He
completed a 7 day course of Levaquin for a presumed pneumonia
which was started at the outside hospital.
3. Renal: The patient had an initial creatinine of 1.8
which was likely secondary to receiving 500 cc of dye during
his catheterization procedure. The patient was treated with
two doses of Mucomyst and his creatinine fell to within
normal limits by the end of the hospital stay.
The patient maintained excellent urine output over the course
of the hospital stay and had no further renal issues.
4. Infectious Disease: The patient was diagnosed with a
pneumonia at the outside hospital and started on Levaquin.
This was continued to complete a 7 day course. The patient
remained afebrile with a normal white blood cell count over
the course of the hospital stay and did not demonstrate any
other signs of infection.
5. Gastrointestinal: The patient was placed on Protonix for
GI prophylaxis. He quickly began to tolerate a regular diet
and had no further gastrointestinal issues over the course of
the hospital stay.
6. Hematological: The patient's hematocrit was followed and
remained stable over the course of the hospital stay. He was
on a Heparin drip initially with placement of intra-aortic
balloon pump which was discontinued after discontinuation of
the pump. The patient was not placed on any further
anticoagulation.
7. Endocrine: The patient has a history of diabetes
mellitus and was placed on a regular insulin sliding scale.
His oral hypoglycemics were held during hospital stay
secondary to her acute issues. The patient is to resume his
usual diabetic regimen at time of discharge.
8. Prophylaxis: The patient was maintained on IV Heparin,
subcu Heparin as needed until the patient was fully
ambulatory. He was also maintained on Protonix for GI
prophylaxis.
CONDITION ON DISCHARGE: The patient was discharged to home
in stable condition.
FOLLOW-UP: The patient is to call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
office on the morning after discharge at [**Telephone/Fax (1) 3183**] to
obtain an appointment within 7 days. He is also to contact
Dr. [**Last Name (STitle) 37577**] within the next 1-2 weeks to set up a time for
EPS study.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q d, Plavix 75 mg
po q d times 30 days, Zestril 5 mg po q d, Protonix 40 mg po
q d, Pravachol 40 mg po q d, Lasix 40 mg po q d, Glipizide 5
mg po q d, Metformin 500 mg po q d, Atenolol 25 mg po q d.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2195-12-29**] 16:39
T: [**2196-1-4**] 21:33
JOB#: [**Job Number 37578**]
ICD9 Codes: 4280, 4271, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3103
} | Medical Text: Admission Date: [**2195-12-18**] Discharge Date: [**2195-12-23**]
Date of Birth: [**2135-12-21**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 19908**]
Chief Complaint:
bladder cancer
Major Surgical or Invasive Procedure:
cystectomy with ileal conduit
History of Present Illness:
59yM s/p radical cystectomy, ileal conduit
IVF: 5.0L EBL:800cc
PMH: CAD s/p MI x 3, CABG, CHF with EF 40%, DM diet, HTN, lipid
Meds: ASA 81, Atenolol 12.5, Cristor 20, Lopid 600 [**Hospital1 **]; NKDA;
+TOB
Plan:
MSO4 PCA; if UOP good later can give Toradol
EKG, Lop 5q4
IS
NPO/NGT/Pepcid; KUB for stents
D5LR at 150; lytes
RISS
SCH3
Ancef/Flagyl x48hrs
R IJ, L art line, NGT, stoma with labelled stents, JP
PT consult
Brief Hospital Course:
Patient was admitted to the Urology service after undergoing
radical cystectomy and ileal conduct. No concerning
intraoperative events occurred; please see dictated operative
note for details. Patient received perioperative antibiotic
prophylaxis and deep vein thrombosis prophylaxis with
subcutaneous heparin. With the passage of flatus, patient's diet
was advanced. The patient was ambulating and pain was controlled
on oral medications by this time. The ostomy nurse saw the
patient for ostomy teaching. At the time of discharge the wound
was healing well with no evidence of erythema, swelling, or
purulent drainage. The ostomy was perfused and patent. Patient
is scheduled to follow up in one weeks time with in clinic for
wound check.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
bladder cancer
Discharge Condition:
stable
Discharge Instructions:
-Please resume all home meds
-Do not drive while taking oxycodone. Please take Tylenol in
addition to oxycodone, and transition to Tylenol as pain
improves.
-You may shower, but do not immerse incision, no tub
baths/swimming.
-Small white steri-strips bandages will fall off in [**6-17**] days,
you may remove at that time if irritating.
-Call if incision becomes markedly more red, swollen, or begins
to drain purulent fluid, or for fever more than 101.5.
-Please refer to visiting nurses (VNA) for management of the
ileal conduct.
Followup Instructions:
1-2 weeks
Completed by:[**2195-12-23**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3104
} | Medical Text: Admission Date: [**2125-7-11**] Discharge Date: [**2125-8-29**]
Date of Birth: [**2060-8-9**] Sex: F
Service: LIVER TRANSPLANT SURGERY
CHIEF COMPLAINT: The patient comes in after a fall.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
woman, status post autologous liver transplant on [**2125-6-27**]
for primary sclerosing cholangitis, diabetes type II. She
came in for a visit at the [**Hospital 1326**] Clinic Center today,
one day after falling on the floor at home landing on her
ribs and forehand. The patient reports no loss of
consciousness, lightheadedness, chest pain, shortness of
breath at this time. She did report that her legs have been
feeling very weak lately. The patient was helped to her feet
by her brother and the patient resumed her activities for the
day without complaint. Today, the patient complained of
significant pain in her left lower ribs. The patient also
reports having decreased appetite since discharge. No nausea
or vomiting, positive flatus, positive bowel movement,
describes "not liking the sight of food".
The patient has a recent hospital admission on [**2125-6-27**] to
[**2125-7-5**]. The patient's diagnosis was end-stage liver
disease, status post orthotopic liver transplant followed by
duplex ultrasound revealing normal arterial and venous flow,
cholangiogram revealing no stricture or lesion of the biliary
system. Condition at the time of discharge was stable. She
was discharged to home without services. At the time, she was
on MMF 1,000 b.i.d., prednisone 15 q d, Inderal 275 b.i.d.
PAST MEDICAL HISTORY: Status post autologous liver
transplant 06/[**2125**]. Primary sclerosing cholangitis, status
post stents. Diabetes type 2. Hyperthyroidism.
Gastroesophageal reflux disease. Diverticulosis. Laminectomy.
Appendectomy. Cholecystectomy. Ulcerative colitis. BRCA
status post mastectomy and chemotherapy.
MEDICATIONS ON ADMISSION:
1. Ativan 0.5 mg p.r.n.
2. Fluoxetine 60 mg q d.
3. Levothyroxine 150 mg q d.
4. Multivitamin, one q d.
5. Alendronate 70 mg q week.
6. Bactrim SS, one q d.
7. Fluconazole 400 mg q d.
8. Lispro, one unit q.i.d. SS.
9. Lantus 12 units q p.m.
10. MMF 1,000 [**Hospital1 **]
11. Protonix 40 mg q d.
12. Valcyte 450 b.i.d.
13. Prednisone 15 q d.
14. Neoral 275 b.i.d.
15. Furosemide 20 q d.
PHYSICAL EXAMINATION: On admission, she was in no apparent
distress. She was alert and oriented times three. Cranial
nerves II-XII were intact. Pupils equal, round and reactive
to light. Extraocular movements intact. Moist mucous
membranes. Regular rate and rhythm with 1-2/6 diastolic
rolling murmur. Clear to auscultation bilaterally.
Exquisitely tender along the left lateral lower costal
margin. Abdomen was nondistended, normal abdominal
examination, soft, nontender, well healing incision with
staples in place, no erythema or signs of drainage.
Extremities: Dorsalis pedis was present, no edema. Vital
signs on admission: Temperature 97.1, blood pressure 123/65.
LABORATORY DATA: Hematocrit 28.5, white blood cell count
14.9, platelets 419, sodium 131, potassium 6.7, chloride 98,
bicarbonate 20, BUN 59, creatinine 2.2, glucose 308, calcium
9.6, phosphate 5.4, magnesium 2.7, ASG 28, ALT 44, alkaline
phosphatase 148, total bilirubin 3.5, PT 13.3, PTT 25.5, INR
1.2, fibrinogen 504. Her first cyclosporin level for the next
day was 1,330. She was continued on prednisone 15 q d. She
was put on 275 b.i.d. for the first two doses and after the
level, she was held one dose and then started on 200. The
repeated mostly held with occasional dosing with levels
slowly declining from 1,000 to 540 by [**2125-7-21**].
HOSPITAL COURSE: Status post fall. The patient came with
confusion. She developed respiratory insufficiency and
decreasing mental status with changes. She required
intubation. She had developed ascites and hydrothorax, which
were drained. Despite a normal ultrasound on admission,
magnetic resonance imaging showed portal vein thrombosis.
She received TPA times three and Wall stenting of the portal
vein and flow was reestablished.
There was still some clot in the superior mesenteric vein.
Her symptoms decreased and she improved clinically. Her
ascites resolved as she became ambulatory while requiring
tube feeds presently. It is possible that she no longer will
require the tube feeds. Pain is well controlled on oral
medication. Regarding cultures, on [**2125-7-15**], she had a
blood culture that is negative. On [**2125-7-16**], she has a BAL
that was negative. She received several methicillin resistant
Staphylococcus aureus screenings, which were negative on
[**2125-7-23**]. On [**2125-7-24**], cultures through her hospital stay
have failed to grow anything or show anything of clinical
significance.
On [**2125-7-29**], the patient received MR [**First Name (Titles) 151**] [**Last Name (Titles) **]
contrast MRCP so she had the MR of the abdomen with and
without contrast and reconstruction for indications status
post recent liver transplant and elevated alkaline
phosphatase. Impression was portal vein thrombosis from
confluence of the IMV this point being higher up, mild to
moderate intrahepatic biliary ductal dilatation with no fixed
filling defect and no strictures seen.
The patient was discharged to the [**Hospital1 **] , which is an
extended care facility.
DISCHARGE INSTRUCTIONS: They are to monitor her for the
following: Fevers, chills, nausea, vomiting, inability to
tolerate food or drink. If any of these occurs, they are to
contact the physician immediately or their in-house physician
if they are unable to reach.
FINAL DIAGNOSES: Portal vein thrombosis, hydrothorax, thorax
respiratory insufficiency requiring intubation.
COMORBIDITIES: Diabetes type 2, hypothyroidism, ulcerative
colitis, gastroesophageal reflux disease, diverticulitis,
cholecystectomy, laminectomy, appendectomy, breast cancer
status post chemotherapy and mastectomy.
FOLLOW UP: Liver [**Hospital 1326**] Clinic [**2125-9-3**] at 10:20 a.m.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] [**2125-9-11**] at 2:10 p.m. Liver [**Hospital 1326**] Clinic
[**2125-9-17**] at 9:20 a.m. Phone number for the clinic is [**Telephone/Fax (1) 28347**] and the same for Dr. [**Last Name (STitle) 816**].
PROCEDURES PERFORMED: Chest tube and intubation.
CONDITION ON DISCHARGE: Afebrile and tolerating a regular
diet. Pain well controlled on oral medications.
DISCHARGE MEDICATIONS:
1. Levothyroxine sodium 150 mcg tablets, one tablet p.o. q d.
2. Alendronate 70 mg tablets, one tablet p.o. q week Fridays.
3. Bactrim SS tablets, one tablet p.o. q d.
4. Multivitamin.
5. Lansoprazole 30 mg capsules delayed release, one capsule
p.o. q d.
6. Artificial tear ointment.
7. Polyvinyl alcohol drops.
8. Albuterol nebs.
9. Fluconazole 200 mg tablets, one tablet p.o. q 24 hours.
10. Visicol 10 suppository h.s. as needed.
11. Ipratropium bromide nebs as needed.
12. Docusate 100 mg, one capsule p.o. b.i.d.
13. Valganciclovir 450 mg tablets, one tablet p.o. q d.
14. Spironolactone 25 mg tablets, one tablet p.o. q d.
15. Acetaminophen.
16. Lorazepam 0.5 mg tablets p.o. b.i.d. as needed for
anxiety.
17. Fluoxetine HCL 20 mg capsules, one capsule p.o. q d.
18. Sliding scale insulin.
19. Warfarin. She should take 0.5 mg every day.
20. Mycophenolate mofetil 200 suspension for
reconstitution 2.5 p.o. q d four times a day, which is 500
mg four times a day.
21. Prednisone 5 mg tablets. Take two tablets p.o. q d,
which is 10 mg every day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 46274**]
MEDQUIST36
D: [**2125-8-29**] 14:09:03
T: [**2125-8-29**] 15:19:26
Job#: [**Job Number 52365**]
ICD9 Codes: 5119, 5849, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3105
} | Medical Text: Unit No: [**Numeric Identifier 76230**]
Admission Date: [**2155-10-9**]
Discharge Date: [**2155-10-13**]
Date of Birth: [**2155-10-9**]
Sex: M
Service: NB
DATE OF TRANSFER TO NEWBORN NURSERY: [**2155-10-12**]
HISTORY: This is a full term infant with respiratory
distress admitted for NICU management. The infant was born at
38-3/7 weeks to a 36-year-old gravida 4, para 2, blood type
is 0 positive, antibody negative, GBS negative, hepatitis B
negative, RPR nonreactive woman.
PAST MEDICAL AND OBSTETRIC HISTORY: Reportedly unremarkable.
ANTEPARTUM HISTORY: Remarkable for advanced maternal age and
normal testing. Elective cesarean section under spinal
epidural anesthesia. Apgars were 9 and 9. The infant
initially did well in the recovery area, breast fed and later
had grunting, flaring and retracting noted and was
transferred to the NICU.
PHYSICAL EXAMINATION AT TRANSFER: The infant was in an open
crib and breathing room air. Breath sounds were equal and
clear. HEAD, EARS, EYES AND THROAT: Anterior fontanelle was
open and level. Sutures opposed. Positive root, positive suck
and positive Moro. [**Doctor First Name **] tone. RESPIRATORY: The infant's
breath sounds were equal and clear. No retraction.
CARDIOVASCULAR: Soft audible murmur on exam. Regular rate and
rhythm. The infant was pink and well perfused. GI: The
abdomen was soft and round without masses. Positive bowel
sounds. Cord on and dry. GU: Normal male genitalia. Testes
descended bilaterally. The infant's current weight upon
transfer was 2925. Birthweight was 2990.
SUMMARY OF COURSE BY SYSTEMS INCLUDING PERTINENT LAB RESULTS:
RESPIRATORY: Infant initially on nasal cannula 02 upon
admission to the NICU. Chest x-ray was consistent with TTN.
The infant transitioned to room air on day of life #2 and has
been stable on room air for over 24 hours.
CARDIOVASCULAR: The infant has been cardiovascularly stable.
Soft audible murmur on exam. Regular rate and rhythm. Blood
pressure stable at 74/54 with a mean of 61.
FLUIDS, ELECTROLYTES AND NUTRITION: The infant initially was
n.p.o. IV fluids of D10W at 60 mL/kg. Full breast feeding
began on day of life #2 and IV weaned successfully off with
stable D-sticks of 66 to 81. Set of electrolytes were done on
day of life #1: Sodium 137, potassium 4.8, chloride 101, and
bicarb of 23. Serum calcium was 7.2. Ionized calcium 1.05.
GI: Maximum bilirubin on day of life #3 was 8.4/0.4. The
infant has not required phototherapy. A repeat bilirubin is
ordered for day of life #4.
HEMATOLOGY: The infant's blood typing not done. The infant's
initial hematocrit upon admission was 44.1 with a platelet
count of 405,000.
INFECTIOUS DISEASE: Blood culture and CBC were performed
upon admission to the NICU. Initial white count was 16.7 with
68 polys and 6 bands. The infant was begun on ampicillin and
gentamicin for a 48-hour rule-out and his blood culture has
remained negative to date.
SENSORY: Passed BAERS b/l.
OPHTHALMOLOGY: The infant does not meet criteria for
ophthalmology exam.
CONDITION AT TRANSFER: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 17**] [**Last Name (NamePattern1) **],
([**Telephone/Fax (1) 76231**].
CARE AND RECOMMENDATIONS: Feeds at transfer: The infant is
ad lib breast feeding. The infant is currently not on any
medication. Car seat positioning screening: The infant does
not meet criteria. State screening has been sent [**2155-10-9**] per
protocol, results are pending. Immunizations received: Will
receive Hep B [**10-13**] prior to d/c. Follow-up
appointment schedule recommended with pediatrician, Dr. [**First Name8 (NamePattern2) **]
[**First Name8 (NamePattern2) 17**] [**Last Name (NamePattern1) **], 48 hours after discharge from the hospital.
DISCHARGE DIAGNOSIS:
1. Transient tachypnea of the newborn.
2. Sepsis evaluation.
3. Term AGA infant
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 71194**]
Dictated By:[**Last Name (NamePattern1) 71091**]
MEDQUIST36
D: [**2155-10-12**] 17:58:49
T: [**2155-10-12**] 20:07:52
Job#: [**Job Number 76232**]
cc:[**Last Name (NamePattern1) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3106
} | Medical Text: Admission Date: [**2103-12-10**] Discharge Date: [**2103-12-16**]
Date of Birth: [**2081-4-8**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8257**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
22 year-old Gravida 2 Para 0 at 21 weeks 2 days GA presented to
the ED with fever and flank pain. She reported bilateral flank
pain, mild nausea and denied any vaginal bleeding, contractions,
or leakage of fluid. She was feeling active
fetal movement.
.
Upon arrival to the ED she was found to have fever 101.1,
tachycardia to 120 and hypotension with blood pressure 80/50s.
Examination revealed CVA tenderness. Labs revealed a white blood
count of 18 and urinalysis had >50 WBC. The clinical picture was
consistent with pyelonephritis. Ceftriaxone was administered.
Given the persistent hypotension despite 4 Liters of IV fluid,
the decision was made to admit her to the [**Hospital Unit Name 153**].
.
Of note she has hyperthyroidism and had not be taking her PTU
for the last 2 weeks.
Past Medical History:
Prenatal Course:
1. Dating: estimated due date [**2104-4-19**]
2. Labs: A+/RI/HepB S Antigen -/RPRNR/HIV negative
3. Ultrasound: normal full fetal survey
4. Issues: Hyperthyroidism
.
Past Obstetric History: spontaneous abortion x 1
.
Past Gynecologic History:
-[**8-28**] Abnormal Pap->Colpo with normal biopsy
-h/o GC/chlamydia->negative [**12-30**]
.
Medical History: Hyperthyroidism ([**Doctor Last Name 933**])
.
Surgical History: Right eye surgery
Social History:
Patient denies any tobacco, alcohol or recreational drug use.
Prior to pregnancy, + alcohol
Family History:
Maternal Great Uncle had [**Name2 (NI) 933**] disease, mother has thyroid
dysfunction. No other family history of other autoimmune
diseases.
Physical Exam:
On Presentation:
V/S Tm: 100.7, Tc: 98.8, BP 90/44 - 109/33, HR 81-122, RR 22-42,
O2 92-96% 2L
Gen: Young woman in NAD
HEENT: Slight bilateral proptosis with very slight soft tissue
swelling in area of epicanthal fold over left eye. OP clear
without erythema or exudate.
Neck: Thyroid gland small, firm, slightly irregular on left,
without tenderness to palpation.
Pulm: Good respiratory effort with no audible wheezes, rhonchi,
or rales
CV: Tachycardic, nl s1/s2
Abd: Gravid, soft, non-tender, +BS
Back: No significant CVA tenderness
Skin: No acanthosis nigricans, no rashes, left forearm tattoo
Ext: Warm and well perfused without lower extremity edema
Pertinent Results:
[**2103-12-10**] WBC-18.0*# RBC-3.42* Hgb-10.9* Hct-30.1* MCV-88 Plt
Ct-268
[**2103-12-10**] Neuts-93.3* Lymphs-4.5* Monos-1.6* Eos-0.5 Baso-0.1
[**2103-12-10**] WBC-14.4* RBC-2.92* Hgb-9.2* Hct-25.9* MCV-89 Plt
Ct-209
[**2103-12-11**] WBC-11.7* RBC-2.57* Hgb-8.2* Hct-22.7* MCV-88 Plt
Ct-187
[**2103-12-11**] Neuts-85.9* Lymphs-10.1* Monos-3.8 Eos-0.1 Baso-0.1
[**2103-12-11**] Hct-28.9*#
[**2103-12-12**] WBC-10.3 RBC-2.88* Hgb-9.3* Hct-25.4* MCV-88 Plt Ct-206
[**2103-12-13**] WBC-6.2 RBC-3.08* Hgb-9.6* Hct-27.3* MCV-89 Plt Ct-207
.
[**2103-12-10**] PT-13.3 PTT-30.2 INR(PT)-1.1
[**2103-12-11**] PT-14.0* PTT-36.0* INR(PT)-1.2*
.
[**2103-12-10**] Glucose-123* UreaN-7 Creat-1.1 Na-136 K-3.1* Cl-102
HCO3-21*
[**2103-12-10**] Glucose-96 UreaN-7 Creat-0.7 Na-139 K-3.5 Cl-112*
HCO3-15* [**2103-12-11**] Glucose-97 UreaN-6 Creat-0.7 Na-130* K-3.8
Cl-100 HCO3-17* [**2103-12-11**] Glucose-89 UreaN-6 Creat-0.8 Na-140
K-3.4 Cl-110* HCO3-19*
[**2103-12-12**] Glucose-76 UreaN-5* Creat-0.8 Na-136 K-4.1 Cl-108
HCO3-19*
.
[**2103-12-10**] ALT-14 AST-21 AlkPhos-57 TotBili-0.6
[**2103-12-10**] ALT-13 AST-25 LD(LDH)-200 AlkPhos-47 TotBili-0.4
.
[**2103-12-10**] Albumin-3.0* Calcium-6.7* Phos-1.6* Mg-1.4*
[**2103-12-11**] Calcium-6.4* Phos-2.1* Mg-2.2 Iron-10*
[**2103-12-11**] Mg-1.7
[**2103-12-12**] Albumin-2.9* Calcium-8.3* Mg-1.9
.
[**2103-12-11**] calTIBC-179* Ferritn-129 TRF-138*
.
[**2103-12-10**] 11:49AM BLOOD TSH-0.19*
[**2103-12-10**] 11:49AM BLOOD T3-146 Free T4-0.86*
[**2103-12-10**] 09:17PM BLOOD T4-9.4 calcTBG-1.28 TUptake-0.78
T4Index-7.3
[**2103-12-12**] 04:54AM BLOOD PTH-16
[**2103-12-13**] 07:45AM BLOOD TSH-1.0
[**2103-12-13**] 07:45AM BLOOD T3-129 Free T4-0.96
.
[**2103-12-10**] Type-[**Last Name (un) **] Temp-39.1 pH-7.34* Comment-GREEN TOP
[**2103-12-12**] Type-[**Last Name (un) **] pH-7.43
.
[**2103-12-10**] URINE Blood-NEG Nitrite-POS Protein-30 Glucose-100
Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-MOD
[**2103-12-10**] URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE Epi-[**1-24**]
[**2103-12-11**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
URINE CULTURE (Final [**2103-12-13**]): ESCHERICHIA COLI. >100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
URINE CULTURE (Final [**2103-12-12**]): <10,000 organisms/ml.
.
Blood cultures 1/19, [**12-11**]: no growth
.
Echocardiogram [**12-11**]:
IMPRESSION: Normal LV cavity size with normal global and
regional biventricular systolic function. No diastolic
dysfunction or significant valvular disease seen. Small
pericardial effusion located posterior to inferolateral wall
without evidence of tamponade.
.
Chest X-Ray [**12-11**]:
Final Report
INDICATION: 22-year-old female who is pregnant with
pyelonephritis and
shortness of breath after fluid.
PA AND LATERAL CHEST RADIOGRAPHS: There is bilateral
predominantly lower lobe air space opacity with air
bronchograms. There is prominent azygos vein. The heart size is
normal. There are no pleural effusions on this frontal
radiograph. Findings are consistent with pulmonary edema.
.
Bilateral Lower Extremity Venous Doppler [**12-11**]:
CLINICAL HISTORY: Acute onset of shortness of breath, 21 weeks
pregnant.
Evaluate for deep vein thrombosis.
Normal flow and compressibility was present in the common
femoral, superficial femoral, and popliteal veins in both the
right and left side. No evidence of thrombus in either calf was
seen.
IMPRESSION: No evidence of deep vein thrombosis.
.
Renal Ultrasound [**12-11**]:
INDICATION: 21 weeks pregnant with pyelonephritis. Please assess
for
hydronephrosis or perinephric abscesses.
FINDINGS: The right kidney measures 11.7 cm. The left kidney
measures 10.6
cm. There is moderate bilateral hydronephrosis. No definite
stones are
identified in either kidney. Renal parenchymal abnormalities are
identified to suggest abscess. An intrauterine pregnancy is
present with fetal heart rate of 167 beats per minute.
IMPRESSION: Moderate bilateral hydronephrosis and small amount
of right
perinephric fluid with no son[**Name (NI) 493**] evidence for renal
abscesses. As no
renal stones are identified and the entire course of the ureters
is not
visualized, it is not possible to determine whether the
hydronephrosis present relates to pregnancy or other causes.
Brief Hospital Course:
MICU COURSE:
# Acute pyelonephritis: Treated with ampicillin and gentamicin
per OB recommendations. Renal ultrasound did not show
perinephric abscess. Continued to have intermittent low grade
fevers while in the ICU
.
# Hypotension: Patient met the criteria for sepsis, howevere per
prior OMR notes, blood pressures had been running in 90's, so
patient not hypotensive per her parameters.
.
# Tachycardia: Differential diagnosis includes hyperthyroidism
though per endocrine consult, felt that based on her labs, she
was likely hypothroid. However, may be a sign of early dilated
cardiomyopathy. Echocardiogram was normal. Was minimally fluid
responsive. Ruled out deep vein thrombosis with lower extremity
venous Dopplers.
.
# Oxygen desaturation: Oxygen saturation in the mid 80s% on
hospital day #2. Patient was approximately 9 liters positive.
Chest x-ray was consistent with pulmonary edema
.
# Pregnancy at 21 weeks: Fetal heart rate was reassuring on
admission. Continued prenatal vitamins. Had daily fetal heart
rate spot checks that were reassuring.
.
# [**Doctor Last Name 933**] Disease status post eye surgery: TSH is low at 0.19.
Free T4 is also low at 0.86. This may be a result of increased
thyroid binding globulin induced by hyper-estrogen state. Also,
patient had not been taking PTU for 2 weeks. The importance of
taking this medication for fetal well-being was explained to the
patient and she understood this conversation. Endocrinology
consult placed for recommendations regarding thyroid hormone
level normalization.
.
# Hypokalemia: Etiology unclear, was 3.1 on admission. Resolved
with repletion. Only 1 episode of diarrhea ~2 weeks ago. Kidney
function normal. Oral intake had been good until 3 days ago.
.
# Anemia: Likely dilutional and secondary to pregnancy, appears
to also have iron deficiency component. Recevied 1 unit packed
red blood cells for hematocrit of 22.
.
# Hypocarbia: Likely a hyperchloremic metabolic alkalosis
secondary to fluid resuscitation. [**Month (only) 116**] also be a consequence of
tachypnea.
.
.
The patient was called out of the ICU on hospital day #3.
Clinically she was stable with no oxygen requirement and stable
blood pressure. She continued on IV ampicillin and gentamicin
until she was afebrile for 48 hours on the evening of hospital
day #5. Her initial urine culture grew pan-sensitive E. Coli
and she was transitioned to oral Nitrofuantoin. She remained
afebrile and was discharged home on hospital day #6. She will
remain on suppression for the remainder of her pregnancy.
.
While hopsitalized, she was followed by the endocrine service.
Her thyroid function tests were normal off medication and they
believed her [**Doctor Last Name 933**] to be in remission and that she should
remain off the propylthiouracil that she had been taking. She
will follow up with endocrine as an outpatient.
Medications on Admission:
PNV
Propylthiouracil 100mg [**Hospital1 **] (has not taken for 2 weeks)
Discharge Medications:
1. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day): for 10 days, then once daily for
rest of pregnancy.
Disp:*50 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Discharge Condition:
Good
Discharge Instructions:
Take Antibiotics as prescribed - twice a day for 10 days, then
once a day for rest of pregnancy.
Call with abdominal pain, pain or burning with urination,
vaginal bleeding, or any other problems.
Followup Instructions:
Dr. [**Last Name (STitle) **] at [**Hospital1 **] on [**12-27**] as scheduled.
Endocrine: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2103-12-31**] 2:30
ICD9 Codes: 0389, 2762, 2761, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3107
} | Medical Text: Admission Date: [**2124-6-5**] Discharge Date: [**2124-6-9**]
Date of Birth: [**2037-8-15**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin / Pravastatin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Delerium and Hypoxia
Major Surgical or Invasive Procedure:
UF [**Last Name (NamePattern4) 2286**]
History of Present Illness:
Mr. [**Known lastname 10369**] is an 86 year-old man with wegener's c/b ESRD,
DM2, atrial fibrillation and chronic right pleural effusion who
was found to be delerious at [**Known lastname 2286**] today with hypoxia to 89%
on RA that corrected to 93% on 2L. Patient also complained of
loose stools for the past several days while at rehab. Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] referred the patient to the ED for further
evaluation. Of note, the patient was admitted from [**Date range (1) 10375**] for
the treatment of PNA.
In the ED, initial vitals were 98.5 120 128/76 24 95% 2L. Labs
notable for WBC 4.9 90.6%N, HCT 29.9, INR 2.9, proBNP [**Numeric Identifier 10376**],
Lactate 1.9, Vanco 28.2. Blood cultures were sent. CXR showed
pulmonary edema with persistence of RLL>RML,RUL opacities (also
seen was known R-sided effusion that has been worked up
extensively by Interventional
Pulmonology). Given concern for HCAP, patient already had a
therapeutic Vanco level and received ceftriaxone 1g IV,
azithromycin 500mg IV, and flagyl 500mg IV.
On arrival to the floor, patient was sleeping but easily
aroused and was able to answer questions appropriately. Denied
any
pain, felt comfortable. Coughing with ronchorous breathing and
slightly tachypnic.
Past Medical History:
- Wegener's Granulomatosis, dx [**12/2121**] c-anca + and bx +, on
cytoxan/steroids
- DM 2 on insulin since [**2082**], typical A1c around 7.5%
- ESRD on HD (M/W/F via LUE AVF)
- Monoclonal gammopathy most likely a smoldering multiple
myeloma
- HTN, well-controlled
- Bronchiectasis with baseline grossly abnormal CXR
- SSS with intermittent afib and bradycardia
- Mitral Regurgitation
- Chronic anticoag (indication: AF) on coumadin
- Prostate cancer --> radiation therapy [**2118**], normalized PSA
- Radiation proctitis with rectal bleeding --> laser rx
- GI bleed [**3-9**] radiation proctitis
- Malignant melanoma left thigh s/p excision
- Anemia attributed to CKD
- R ingunal hernia
- S/p appy
- S/p L inguinal hernia repair
- hyperlipidemia
- Fe deficiency
- TB: latent, Patient had a history of TB with treatment in
sanitarium in [**2052**]'s, h/o INH toxicity so no treatment of latent
TB
- MAC: Bronchoscopy with BAL was performed on [**12-23**], and AFBs
found on smear c/w MAC per lab results/ID consult. Patient opted
to forego MAC therapy
- hx of pericardial effusion, no drainage needed
- TIA [**2124-3-8**], no residual deficits
Social History:
Lives with wife who is his caregiver. [**First Name (Titles) **] [**Last Name (Titles) **] son. Retired,
was employed as an international business consultant, has a PhD
in industrial engineering. Born in Eastern [**Country 10363**]. Came to the
United States in [**2068**]. Very active individual before onset of
Wegener's in [**2120**] - former mountain climber, tennis player, and
skier.
- Tobacco history: during WWII, stopped [**2057**]
- ETOH: [**2-7**] glass of wine with dinner nightly
- Illicit drugs: none
Family History:
Grandmother: DM
Father: kidney infection
Sister: TIA x 2 (80s)
Physical Exam:
Physical Exam on Admission
GENERAL - Elderly man lying in bed, A&Ox3, NAD, AOx3
HEENT - NCAT EOMI MM dry OP clear
NECK - supple, JVP flat ~ 10cm H2O
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - decreased breath sounds bilateral bases; rhonchorous
left base; breathing unlabored, no apparent respiratory distress
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no CVAT
EXTR - cool, 2+ DP pulses; LUE AVF with bruit/thrill
SKIN - scattered ecchymoses
LYMPH - no cervical LAD
NEURO - AOX3 and although some responses are inappropriat
Physical Exam on Discharge
Expired
Pertinent Results:
Admission Labs
[**2124-6-5**] 07:05PM LACTATE-1.9
[**2124-6-5**] 07:00PM GLUCOSE-151* UREA N-19 CREAT-2.6*# SODIUM-145
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-31 ANION GAP-17
[**2124-6-5**] 07:00PM ALT(SGPT)-20 AST(SGOT)-43* CK(CPK)-158 ALK
PHOS-123 TOT BILI-0.6
[**2124-6-5**] 07:00PM LIPASE-42
[**2124-6-5**] 07:00PM CK-MB-6 cTropnT-0.21* proBNP-[**Numeric Identifier 10376**]*
[**2124-6-5**] 07:00PM VANCO-28.2*
[**2124-6-5**] 07:00PM ALBUMIN-3.1* CALCIUM-8.6 PHOSPHATE-2.7
MAGNESIUM-1.7
[**2124-6-5**] 07:00PM WBC-4.9 RBC-2.61* HGB-9.5* HCT-29.9* MCV-114*
MCH-36.3* MCHC-31.7 RDW-19.0*
[**2124-6-5**] 07:00PM NEUTS-90.6* LYMPHS-4.9* MONOS-4.3 EOS-0.2
BASOS-0
[**2124-6-5**] 07:00PM PLT COUNT-65*
[**2124-6-5**] 07:00PM PT-30.1* PTT-46.8* INR(PT)-2.9*
[**2124-6-5**] 03:00PM VANCO-13.0
[**2124-6-5**] 01:15AM PT-30.2* INR(PT)-2.9*
Pertinent Labs
[**2124-6-7**] 04:20AM BLOOD WBC-5.7 RBC-2.77* Hgb-9.5* Hct-31.9*
MCV-115* MCH-34.4* MCHC-29.9* RDW-18.3* Plt Ct-66*
[**2124-6-6**] 07:30AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+
Macrocy-3+ Microcy-OCCASIONAL Polychr-NORMAL Spheroc-OCCASIONAL
Ovalocy-3+ Schisto-1+ Burr-1+ Ellipto-OCCASIONAL
[**2124-6-7**] 10:18AM BLOOD PT-33.5* PTT-52.4* INR(PT)-3.3*
[**2124-6-6**] 07:30AM BLOOD ESR-110*
[**2124-6-8**] 04:44AM BLOOD Glucose-328* UreaN-48* Creat-3.6*# Na-137
K-5.3* Cl-94* HCO3-24 AnGap-24*
[**2124-6-6**] 04:18AM BLOOD CK-MB-5 cTropnT-0.21*
[**2124-6-8**] 04:44AM BLOOD Calcium-8.2* Phos-7.5* Mg-2.1
[**2124-6-6**] 12:14PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2124-6-6**] 05:00PM BLOOD CRP-212.4*
EKG [**2124-6-5**]
Minimally irregular supraventricular tachycardia, most likely
atrial fibrillation. Left axis deviation. Left anterior
fascicular block. QS deflection in leads V1-V2 consistent with
prior anteroseptal myocardial
infarction. 0.5 millimeter ST segment depression in leads V4-V6
with T wave inversion in lead aVL and to a lesser degree in lead
I. Compared to the previous tracing of [**2124-5-27**], ventricular rate
is much faster. T wave inversion is more pronounced in lead aVL
but less pronounced in leads V4-V5, with similar left precordial
ST segment depression. An ongoing lateral ischemic process
cannot be excluded. Clinical correlation is suggested.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
131 0 96 304/428 0 -55 173
CXR portable [**2124-6-5**]
FINDINGS: Single AP upright portable view of the chest was
obtained. The
right costophrenic angle is not included on the images. Again
seen is a large area of right mid-to-lower lung opacity which is
better assessed on prior CT from [**2124-5-29**]. There is a moderate
right pleural effusion with overlying atelectasis, an underlying
consolidation cannot be excluded. Streaky and fibrotic opacities
are seen in the right lung involving the upper, mid and lower
lung fields, most noted in the left mid lung field, also seen on
the prior study. Left apical pleural thickening and
calcifications are again seen, consistent with chronic change.
No large left pleural effusion is seen. There is no
pneumothorax. The cardiac and mediastinal silhouettes are
stable. Multiple old right-sided rib deformities/fractures are
again seen. A left sided [**Year (4 digits) 1106**] stent is again partially
imaged.
IMPRESSION:
1. Right costophrenic angle not fully included on the images.
Given this,
large area of right mid-to-lower lung opacity is again seen,
likely
representing combination of pleural effusion, atelectasis and
possible
underlying consolidation. Increased right perihilar opacity.
Areas of patchy and fibrotic opacities in the left lung again
seen, may be chronic.
TTE [**2124-6-6**]
The left atrium is mildly dilated. The right atrium is markedly
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened (?#). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. [Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2124-4-11**],
tricuspid regurgitation is now more prominent.
UE fistulogram
Patent AV fistula in the left upper extremity with areas of
aneurysmal
dilatations in the upper and mid portion of the left arm. The
arteriovenous anastomosis is patent however increased velocities
were noted. The peak systolic velocity at the level of the
arteriovenous anastomosis is 716 cm/sec. Within the fistula,
peak systolic velocities ranged between 120 and 143 cm/sec. In
the distal fistula there is a patent stent however increased
velocities were noted at the level of the proximal end of the
stent. Peak systolic velocities at this level were between 689
and 505 cm/sec. Within the stent, the peak systolic velocities
ranged between 58 and 244 cm/sec. Distally to the stent and
within the subclavian vein peak systolic velocities ranged
between 47 and 360 cm/sec. Peak systolic velocity in the
brachial artery proximal to the arteriovenous anastomosis was 47
cm/sec. Distally to the anastomosis, the peak systolic velocity
was 69 cm/sec.
IMPRESSION: Patent AV fistula in the left upper extremity with
increased peak systolic velocities at the level of the arterial
anastomosis and within the proximal margin of the stent.
Velocities were recorded up to 716 cm/sec in the arteriovenous
anastomosis.
Brief Hospital Course:
86M w/ wegener's, ESRD, Afib, DM2, recent TIA /w delirium,
presenting with delerium and hypoxia admitted for possible PNA,
expired on [**2124-6-9**]
# Dyspnea/SIRS- Patient was recently admitted from [**5-25**] to [**6-2**]
for the treatment of HCAP and was discharged on
Vanc/Levofloxacin. At HD today, patient was noted to be hypoxic
to 89% on RA and was referred to the ED for further evaluation.
In the ED, CXR showed continued evidence of right sided
opacities. WBC 4.9 is elevated from 3.5 on recent discharge.
Patient was tachycardic to the 110-120s (in the setting of Afib)
and tachypnic to the 20s with a concern for PNA confering the
diagnosis of sepsis. The patient had a therapeutic Vanc level in
the ED and received 1L NS, ceftriaxone, flagyl and azithromycin
for possible PNA. The antibiotics were continued overnight, but
then d/c'd on HD 2 after repeat CXR showed evidence of pulmonary
edema. Despite this finding that patient was relatively
euvolemic on exam and did not have elevated JVP or marked
periperal edema. It is possible that the patient has pulmonary
edema in the setting of AF with RVR. There is also the
possibility of worsening of GPA given recent discontinuation of
azathioprine and elevated ESR/CRP. Patient was unfortunately
unable to tolerate [**Month/Year (2) 2286**] given hypotension down to the 70s at
each subsequent session. His prednisone was increased with
rheumatology recommendation but respiratory status did not
improve significantly over the subsequent days. Midodrine was
started as patient's family did not wish to pursue any heroic
measures. Stress does steroid was not pursued because the
patient's family utlimately decided to transition patient to CMO
given his progressively worsening respiratory status and
hypotension.
# GPA/Wegner's granulomatosis. Patient was initially kept on
prednisone 10 mg daily and bactrim prophylaxis. However, given
the concern of vasculitis flare with recent discontinuation of
azathioprine, it was increased in the setting of his worsening
respiratory status as well as elevated CRP/ESR.
# Delerium: Patient was found to be delerious at HD on day of
admission and continued to have an element of delerium on
admission the to the MICU. Delirium improved slightly when
seroquel wore off. However, patient continued to have a degree
of delirium that is likely [**3-9**] underlying inflammatory process
and hypoxia.
# Afib. He initially did not require any rate control. He was
kept on home warfarin initially. However, he later required low
dose metoprolol for rate control. Patient does not require rate
control. Warfarin was discontinued given supratherapeutic
level.
# ESRD, HD-dependent: On HD qMWH, kidneys affected by Wegener's
vasculitis. Patient had very limited HD sessions given
hypotension.
# GOC. Patient and his family were updated daily. His
outpatient PCP, [**Name10 (NameIs) 10368**], and nephrologist were updated on
a regular basis. Palliative care was consulted. His HCP was
clear about no heroic measures for the patient and ultimately
decided that patient would transition to CMO given persistent
hypoxia and hypotension, inability to tolerate [**Name10 (NameIs) 2286**].
Patient passed away on [**2124-6-9**].
Chronic Issues:
# Chronic right pleural effusion. Stable on imaging.
# Diabetes. He was on insulin sliding scale.
# Elevated TropT, LFTs: Troponins and LFTs were downtrending
since recent discharge.
# Anemia: Patient with iron studies suggesting anemia of chronic
disease with macrocytosis likely multifactorial from ESRD
(though on epo), bactrim, MGUS, and aging marrow.
#. Hypothyroidism. He was continued on levothyroxine 137 mcg
daily & 25 mcg QOD
#. MGUS / smoldering myeloma: At baseline patient is
pancytopenic with WBC in the 3s and Hct low 30s with
macrocytosis (also noted to be on immunosuppression as described
above).
#. Hyperlipidemia. He was continued on statin and ASA.
Medications on Admission:
- senna 8.6 mg QHS
- docusate sodium 100 mg [**Hospital1 **]
- atorvastatin 40 mg daily
- pantoprazole 40 mg daily
- sulfamethoxazole-trimethoprim 800-160 mg 3X/WEEK (MO,WE,FR)
- aspirin 81 mg daily
- cholecalciferol 800 unit daily
- sevelamer carbonate 400 mg daily
- acetaminophen 1000 mg Q8H
- levothyroxine 137 mcg daily
- levothyroxine 25 mcg QOD
- prednisone 10 mg daily
- folic acid 1 mg daily
- warfarin 1 mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
End Stage Renal Disease
Wegner's granulomatosis
Delirium
Atrial fibrillation
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2124-6-9**]
ICD9 Codes: 486, 5856, 2930, 5119, 4589, 4240, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3108
} | Medical Text: Admission Date: [**2113-9-23**] Discharge Date: [**2113-9-28**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
nausea/vomiting, s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo F with Alzheimer's and recent admit for GI bleed from
gastritis and metaplastic pyloric mass presented with an episode
of nausea / vomiting / and a fall from her bed. She is a poor
historian, but records from [**Location (un) **] indicate that she had
vomited w/o blood x 1 around 2 pm on [**2113-9-23**], and possibly
fell/slid from bed. Pt denies F/C/abd pain/diarrhea/melena /
BRBPR. In ED, she had episode of vomiting with SBP 60's,
bradycardia to 30's --> given atropine.She was transferred to
the MICU for further mgmt.
Past Medical History:
Alzheimer's dementia
HTN
OCD
h/o recent GIB w/ EGD revealing
high grade duodenal dysplasia and intestinal metaplasia ([**8-9**])
EGD [**9-9**] with ulcerating pyloric mass increased in size.
Social History:
She lives at [**Hospital3 **] facility). Has a
remote history of tobacco use, quit 40 years ago. No EtOH.
Family History:
NC
Physical Exam:
O: V: T96.4 BP 114/84 P74 R20 94% 2L
Gen: NAD
HEENT: OP clear, NG tube in place
Resp: lungs coarse bilaterally
CV: distant, RRR
Abd: soft NTND +BS
Ext: no edema
Neuro: A+Ox1 (to person), oriented to season and general place
Pertinent Results:
[**2113-9-23**] 03:45PM BLOOD WBC-7.7 RBC-2.07*# Hgb-6.4*# Hct-20.5*#
MCV-99*# MCH-31.1 MCHC-31.4 RDW-18.9* Plt Ct-371#
[**2113-9-24**] 01:16AM BLOOD WBC-12.4*# RBC-3.01*# Hgb-9.5*#
Hct-28.7*# MCV-95 MCH-31.4 MCHC-33.0 RDW-18.7* Plt Ct-318
[**2113-9-24**] 05:59AM BLOOD Hct-29.0*
[**2113-9-24**] 02:54PM BLOOD Hct-31.7*
[**2113-9-24**] 09:05PM BLOOD Hct-35.9*
[**2113-9-25**] 05:35AM BLOOD WBC-14.7* RBC-3.63* Hgb-11.2* Hct-34.1*
MCV-94 MCH-30.8 MCHC-32.9 RDW-19.5* Plt Ct-264
[**2113-9-25**] 03:15PM BLOOD Hct-35.2*
[**2113-9-26**] 06:00AM BLOOD Hct-33.8*
[**2113-9-27**] 05:30AM BLOOD Hct-33.3*
[**2113-9-24**] 01:16AM BLOOD CK-MB-86* MB Indx-18.5* cTropnT-1.62*
[**2113-9-24**] 02:54PM BLOOD CK-MB-135* MB Indx-16.2* cTropnT-3.06*
[**2113-9-24**] 09:05PM BLOOD CK-MB-97* MB Indx-13.3*
[**9-23**] CT head - negative
[**9-23**] CXR - unremarkable
Brief Hospital Course:
1. Anemia - on admission her Hct was 20.3 so she received total
of 3 units PRBCs with an appropriate Hct bump to around 33-35.
She was given 2 L NS in ED. This was felt to be secondary to
bleeding from the pre-pyloric mass. GI was consulted and felt
that she would benefit from stent placement only if she was
nauseated/vomiting, but that it would not control the bleeding,
so she was tried on food and tolerated all foods well. Her PPI
was continued twice a day. It was discussed with her family that
a conservative/palliative approach will be pursued, with
symptomatic control with PPI twice a day, biweekly hct checks,
and likely no readmission if she has a massive GI bleed. This
will be conveyed to her [**Hospital3 **] facility, where she is
to return.
2. Cardiac ischemia: Her troponins/CK were elevated during
admission, likely secondary to ischemia from low hematocrit. As
pt has history of bleeding, anticoagulation with heparing was
contraindicated anyway. A betal blocker was added to her regimen
instead of her calcium channel blocker. She was monitored on
telemetry without any adverse events. As she is DNR/DNI, no
further enzymes will be drawn.
3. HTN: A beta blocker was substituted for her calcium channnel
blocker for its cardioprotective effects. Her BP was stable.
4. s/p fall: She was noted to have had a fall at the outside
hospital, but her head CT was negative for bleed and her mental
statyus
5. Nausea/vomiting: She tolerated clears then solid food in the
hospital without aspiration or vomiting. She did not need
antiemetics.
6. Code status: DNR/DNI - This was discussed with the family and
palliative care. Also no invasive procedures (i.e. cath, EGD for
massive GI bleed) should be done but will consider EGD/stent as
outpatient if gastric outlet obstruction develops. The family
will clarify her status further, with possible CMO, as an
outpatient, and may fill out a do not hospitalize plan.
Medications on Admission:
home meds:pantoprazole 40 mg PO BID, B-12 1000 mcg PO QD,
ferrous sulfate 5 g PO TID, folic acid 0.4 mg PO BID, diltiazem
(Tiazac) 240
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 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*
3. Fluoxetine HCl 10 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. B Complex-C Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
6. Multi-Vit 55 Plus Tablet Sig: One (1) Tablet PO once a
day.
7. Outpatient Lab Work
Please draw HCT every Monday and Thursday and send results to
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**0-0-**]
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Homecare Solutions
Discharge Diagnosis:
Pyloric mass with subacute bleeding
dementia
cardiac ischemia
Discharge Condition:
Pt was eating and drinking well. She was ambulating, and had no
complaints of pain.
Discharge Instructions:
Please administer her current medications, and give colace and
senna if constipated.
She may resume a normal diet.
Please have the nurse or laboratory draw her blood Monday [**10-2**], and each Thursday and Monday after that, with results sent
to Dr. [**Last Name (STitle) **].
If she has vomiting, nausea, bleeding or dark stools, please
contact Dr. [**Last Name (STitle) **]. Please do not hospitalize without contacting
her daughter first.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] early next week for check of
your blood count ([**0-0-**]).
Follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3815**] (GI) as needed, ([**Telephone/Fax (1) 8892**].
ICD9 Codes: 5789, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3109
} | Medical Text: Admission Date: [**2152-7-23**] Discharge Date: [**2152-7-29**]
Date of Birth: [**2098-3-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Motrin / Ibuprofen / Shellfish Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2152-7-23**] Placement of IABP
[**2152-7-25**] Urgent CABG x 4 on IABP(LIMA to LAD, SVG to DIAG, SVG to
OM, SVG to PDA)
History of Present Illness:
Mr. [**Known lastname 79662**] is a 54 year old male with history of coronary
artery disease since [**2147**]. Approximately one week prior to
admission, he was experiencing intermittent chest pain. He
eventually presented to [**Hospital3 **] ED. EKG showed ST elevations
in v2-v4. He ruled in for acute MI with elevated troponins. He
was urgently taken to the cath lab which revealed critical three
vessel coronary artery disease. He was started on intravenous
therapy and transferred to the [**Hospital1 18**] for urgent surgical
revascularization.
Past Medical History:
Coronary Artery Disease - s/p PCI/stenting to LAD in [**2147**]
Hypertension
Dyslipidemia
Social History:
Active smoker. Occasional ETOH. Currently lives with his wife.
Family History:
Denies premature coronary disease.
Physical Exam:
Admission
Vitals: 132/80, 85, 16
Slightly obese male in no acute distress
Oropharyx benign
Neck supple, no JVD
Lungs clear to auscultation bilaterally
Heart regular rate and rhythm, normal s1s2, no murmur or rub
Abdomen benign
Extermities warm without edema
Neurologically intact, no focal deficits noted
Distal pulses 2+, no carotid or femoral bruits noted
Discharge
VS T98 HR88SR BP 130/84 RR 16 O2sat 100-RA
Gen NAD
Neuro A&O, nonfocal exam
CV RRR, no murmur. Sternum stable incision CDI
Pulm dimminished bases bilat
Abdm soft, NT/+BS
Ext warm, 1+ edema bilat. Left SVG sites w/steris CDI
Pertinent Results:
[**2152-7-23**] 05:05PM BLOOD WBC-13.2* RBC-4.45* Hgb-13.2* Hct-38.1*
MCV-86 MCH-29.7 MCHC-34.7 RDW-12.3 Plt Ct-217
[**2152-7-23**] 05:05PM BLOOD PT-13.2 PTT-37.1* INR(PT)-1.1
[**2152-7-23**] 05:05PM BLOOD Glucose-124* UreaN-9 Creat-0.9 Na-133
K-3.7 Cl-97 HCO3-28 AnGap-12
[**2152-7-23**] 05:05PM BLOOD ALT-38 AST-76* CK(CPK)-668* AlkPhos-65
Amylase-30 TotBili-1.5
[**2152-7-23**] 05:05PM BLOOD CK-MB-59* MB Indx-8.8* cTropnT-0.48*
[**2152-7-25**] 07:19AM BLOOD %HbA1c-5.3
[**2152-7-27**] 04:15PM BLOOD WBC-10.4 RBC-3.62* Hgb-10.7* Hct-31.7*
MCV-88 MCH-29.5 MCHC-33.7 RDW-12.0 Plt Ct-153
[**2152-7-27**] 04:15PM BLOOD Plt Ct-153
[**2152-7-26**] 06:17AM BLOOD PT-13.6* PTT-28.2 INR(PT)-1.2*
[**2152-7-27**] 04:15PM BLOOD Glucose-112* UreaN-13 Creat-0.9 Na-137
K-3.7 Cl-97 HCO3-28 AnGap-16
[**2152-7-23**] EKG:
Sinus rhythm. ST segment elevation in the anteroseptal leads
suggestive
of myocardial infarction.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
79 154 88 358/391 40 2 52
[**Known lastname **],[**Known firstname **] P [**Medical Record Number 79663**] M 54 [**2098-3-31**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2152-7-26**] 1:09
PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2152-7-26**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79664**]
Reason: ?ptx after CT removal
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with
REASON FOR THIS EXAMINATION:
?ptx after CT removal
Final Report
CHEST RADIOGRAPH
INDICATION: Followup.
COMPARISON: [**2152-7-25**].
As compared to the previous examination, the mediastinal and
pleural drains
have been removed. The patient has also been extubated. The
pre-existing
small left-sided pleural effusion and the associated
retrocardiac atelectasis
have slightly increased in extent. Otherwise the chest
radiographic
appearance is unchanged. The Swan-Ganz catheter is in unchanged
position.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: WED [**2152-7-26**] 4:37 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 79665**] (Complete)
Done [**2152-7-25**] at 8:45:34 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2098-3-31**]
Age (years): 54 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Chest pain. Coronary artery disease. Left
ventricular function. Preoperative assessment.
ICD-9 Codes: 440.0
Test Information
Date/Time: [**2152-7-25**] at 08:45 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW5-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.6 cm
Left Ventricle - Fractional Shortening: *-0.15 >= 0.29
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV
free wall hypokinesis.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS
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>55%). The right ventricular cavity is moderately dilated
with mild global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
POST BYPASS
There is preserved left ventricular systolic function. The RV is
still moderately enlarged but now with normal systolic function.
The study is otherwise unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2152-7-25**] 10:58
Brief Hospital Course:
Mr. [**Known lastname 79662**] was admitted to the cardiac surgical service. Given
his critical coronary artery disease, he was brought to the
cardiac cath lab where an IABP was successfully placed without
complication. Surgery was delayed for several days given recent
Plavix dose, and he continued to remain pain free on intravenous
therapy. On [**7-25**], Dr. [**Last Name (STitle) **] performed four vessel
coronary artery bypass grafting. For surgical details, please
see seperate dictated operative note. Following the operation,
he was brought to the CVICU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated without
incident. On postoperative day one, the IABP was weaned and
removed without complication. He maintained stable hemodynamics
and transferred to the SDU on postoperative day two. The
remainder of his postoperative course was uneventful, on POD4 he
was discharged home with visiting nurses.
Medications on Admission:
Transfer meds: IV Heparin, Plavix, IV Nitro, Aspirin, Atenolol,
Lescol
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*14 Tablet(s)* Refills:*0*
2. Lescol 40 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*15 Tablet(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:*2*
5. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for 7 days.
Disp:*7 Tablet Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Preoperative Acute ST Elevation MI
Hyperlipidemia
HTN
History of LAD stent [**2147**]
Discharge Condition:
good
Discharge Instructions:
Shower daily, no baths or swimming
No creams, lotions, powders to incisions
No driving
No lifting more than 10 pounds for 10 weeks
Take all medications as prescribed
report any weight gain of greater than 3 pounds a week
Followup Instructions:
Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) in 4 weeks
Dr.[**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] in [**1-9**] weeks
Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) 4922**] in [**1-9**] weeks
Completed by:[**2152-8-1**]
ICD9 Codes: 5180, 2875, 2859, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3110
} | Medical Text: Admission Date: [**2179-12-25**] Discharge Date: [**2179-12-27**]
Date of Birth: [**2120-2-17**] Sex: M
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 male with DM2, HTN, schizophrenia was picked up by his
brother from [**Last Name (NamePattern1) 66721**]nursing home for a day trip. His brother
found him to be confused, and he felt dizzy and sweaty; he
called EMS. His finger stick was 13, and he was given IM
glucagon in the ambulance. In the ED he was found to still be
hypoglycemic and was given D50 and allowed to eat. He was also
hypothermic to 92.3. Per nursing home, his last temp on
[**2179-12-17**] was 97.4 oral.
.
He has had no changes in any of his psych meds since [**8-/2179**] when
he arrived at nursing home. Per nursing staff at [**First Name4 (NamePattern1) 10378**] [**Last Name (NamePattern1) **], his
BS had initially been difficult to control [**3-11**] dietary
non-compliance. He had been eating foods which would elevate his
BS. His last change in his diabetes management was on [**2179-11-29**],
which was an increase in his 70/30 insulin from 44 units to 48
units; and on [**2179-12-6**] metformin was added 500 mg qd.
.
He indicated that he has had hypoglycemic episodes 4x over the
past month; usually it occurs around noon, and he feels similar
to how he felt today. His brother indicated that it is always
the same nurse/aide that is on when this happens.
.
ED course: Initially in ED, bs 35 (p glucagon). Then he got 1
amp D5W --> 159. Repeat was 29 on chem 7, so given octreotide
out of concern for hypoglycemia related to sulfonylurea. After
that, his BS was 55, and he was encouraged to eat. One hour
after that his BS was 56, after which he was given another amp
of D5 and [**Location (un) 2452**] juice. He remained hypothermic to 92-93, and
was given a bair hugger. He was then admitted to MICU for closer
monitoring. Of note, his last dose of metformin was at 9am on
[**12-25**].
.
Review of Systems: He currently denies recent f/c/night sweats.
He denies cough, abdominal pain, diarrhea, constipation,
excessive thirst or urination, HA, change in vision, dysuria,
rash, or known sick contacts. [**Name (NI) **] has not had any orthopnea, DOE,
PND. At baseline, he walks independently, feeds himself. He is
incontinent of urine.
.
MICU course:
On arrival to MICU, pt had a bld sugar of 203. He was given 6U
of regular for a sugar of 245 at 6pm. Over the next 6 hours, his
blood sugar dropped into the 100s and then at 2am, it was found
to be 58. He was symptomatic with confusion and dizziness. He
was given [**2-8**] amp of D50 and it rose to 79 but then at 4am, it
was found to be 56. He was given another [**2-8**] amp of D50 and it
remained in the 70s-100s. At 10am, after breakfast, it rose to
251 and he was given 6units of regular. [**Last Name (un) **] was consulted.
Past Medical History:
Diabetes Mellitus type 2, on insulin
Scizophrenia
Hypertension
Scrotal cellulitis (rx with cephalexin in [**11-12**])
s/p hepatic tumor resection?
? Coronary artery disease (based on meds / ecg)
Social History:
Lives at [**Last Name (NamePattern1) 66721**]Nursing Home in [**Location (un) **]. He smokes 5
ciagarettes per day for the past year; he had quit the 10 years
previous to that. He denies EtOH use. He enjoys [**Location (un) 1131**].
Family History:
NC
Physical Exam:
(In ICU at admission)
94.5 169/90 81 20 99% 2L NC
Gen- NAD, pleasant, alert and oriented, lying in bed under
bairhugger
Heent- MMM, EOM intact, sclerae anicteric
Neck- JVP flat
Cor- RRR, nl S1/S2, no M/R/G
Chest- CTAB
Abd- soft, obese, nontender/nondistended; scars from chole and
hepatic resection
Ext- 4 small (<1cm) pressur ulcers around base of both feet; 1+
pitting edema bilaterally
Neuro- alert and oriented
Skin- no rashes, birthmark over right eyelid; scrotum without
erythema
Msk- full range of motion; strength 5/5 deltoids, biceps,
triceps
Pertinent Results:
[**2179-12-27**] 06:30AM BLOOD WBC-4.2 RBC-3.98* Hgb-11.6* Hct-33.6*
MCV-85 MCH-29.1 MCHC-34.4 RDW-15.0 Plt Ct-194
[**2179-12-25**] 01:00PM BLOOD WBC-5.3 RBC-4.06* Hgb-12.2* Hct-34.2*
MCV-84 MCH-30.1 MCHC-35.7* RDW-15.1 Plt Ct-225
[**2179-12-27**] 06:30AM BLOOD Glucose-144* UreaN-21* Creat-0.7 Na-137
K-4.6 Cl-103 HCO3-28 AnGap-11
[**2179-12-25**] 01:00PM BLOOD Glucose-29* UreaN-23* Creat-0.9 Na-134
K-4.4 Cl-97 HCO3-29 AnGap-12
[**2179-12-25**] 01:00PM BLOOD ALT-21 AST-27 CK(CPK)-199* AlkPhos-72
Amylase-45 TotBili-0.2
[**2179-12-25**] 01:00PM BLOOD Lipase-22
[**2179-12-26**] 03:30AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.1 Iron-42*
[**2179-12-25**] 01:00PM BLOOD CK-MB-10 MB Indx-5.0 cTropnT-0.04*
[**2179-12-26**] 03:30AM BLOOD calTIBC-289 Ferritn-57 TRF-222
[**2179-12-26**] 03:30AM BLOOD %HbA1c-6.6* [Hgb]-DONE [A1c]-DONE
[**2179-12-25**] 02:35PM BLOOD Lactate-1.1
[**2179-12-25**] 05:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2179-12-25**] 05:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
URINE CULTURE (Final [**2179-12-27**]): <10,000 organisms/ml
[**2179-12-25**] 4:15 pm BLOOD CULTURE #2.
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2179-12-25**] 2:30 pm BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
Brief Hospital Course:
Hypoglycemia / hypothermia: His hypoglycemia is most likely due
to his medical regimen. He has had 5 episodes this past month of
hypoglycemia, and his insulin regimen was increased just prior
to that, as well as the addition of metformin. [**Last Name (un) **] diabetic
consult swas called for and they changed the insulin regimen,
started glargine with an insulin sliding sacle. No further
episodes of hypoglycemia were noted. Metformin was stopped as
well.
He is recommended to follow up with [**Hospital **] clinic for better
titration of the sugars.
Hypoglycemia can also be accompanied by hypothermia. work-up for
infection was all negative at discharge. Blood cultures from
admission remained negative to date at the time of discharge.
His temp remained within normal range.
Hypertension: He has a history of hypertension, and his BP has
been adequately controlled. He is on lisinopril and labetolol.
There is concern of masking hypoglycemic awareness with
labetolol, but there was greater concern for rebound tachycardia
so this was continued. This may be readdressed by the PCP in
clinic.
Schizophrenia/Depression: Meds were continued
? Coronary disease: It is unclear if he has CAD or not - he
indicated that he had a cath done at [**Hospital3 **] several
years ago, though denies heart disease. His ECG shows q waves.
Continued ace inhibitor, bblocker, aspirin. His PCP is at [**Name9 (PRE) **] Medical center.
.
Anemia: unclear baseline or etiology.Continue ferrous sulfate.
GI evaluation should be addressed by PCP.
Hyperlipidemia: continued atorvastatin
The above information was converyed to the patient's nurse at
the NH prior to discharge.
Medications on Admission:
Insulin 70/30 48 units qam, 22 units qpm
Ferrous Sulfate 325 qd
ASA 81 qd
MVI qd
Lisinopril 5mg qd
Hytrin 5mg qd
Celexa 20mg qd
Vit c 500mg [**Hospital1 **]
Juven (nutrition)
Trazodone 50mg [**Hospital1 **]
Labetalol 100mg [**Hospital1 **]
Trilialafon 12mg [**Hospital1 **]
Lasix 40mg [**Hospital1 **]
Depakote 125mg tid
Glucophage 500mg qam (~9am)
Zyprexa 40mg qhs; prn agitation
Lipitor 40mg qhs
Zinc sulfate qd
Glucagon prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Perphenazine 8 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
14. Olanzapine 10 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
19. Insulin Glargine 100 unit/mL Solution Sig: One (1) 10
Subcutaneous at bedtime. 10
20. Insulin sliding scale
Please follow the insulin slidin scale (Humolog) as suggested
21. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (NamePattern1) 66721**]Nursing - [**Location (un) **]
Discharge Diagnosis:
Hypoglycemia - due to increased insulin dose
Hypothermia - possibly related to hypothermia
Secondary diagnoses:
Diabetes Mellitus type 2, on insulin
Scizophrenia
Hypertension
Scrotal cellulitis (rx with cephalexin in [**11-12**])
s/p hepatic tumor resection?
? Coronary artery disease (based on meds / ecg)
Discharge Condition:
stable
Discharge Instructions:
Your had very low sugar levels before admission to the hospital.
Your insulin regimen has been changed and is noted below.
Metformin was also stopped.
Please check your sugars 3-4 times before meals in the next [**3-13**]
week to make sure that the are not low (less than 60)
return to the emergency room or call you doctor if you notice
dizziness, sweating or any other symtoms concerning to you.
You are requested to make an appointment in the [**Hospital **] clinic
([**Hospital 982**] clinic). Please call [**Telephone/Fax (1) 2384**] to make an
appointment in the next 1 to 2 weeks.
You should also follow up with your primary care doctor in the
next 1 week.
Followup Instructions:
Follow up with your primary care doctor, Dr [**First Name (STitle) **] [**Name (STitle) 5404**]
[**Telephone/Fax (1) **] in the next 1 week.
[**Hospital **] clinic ([**Hospital 982**] clinic) - Please call [**Telephone/Fax (1) 2384**] to
make an appointment with Dr [**Last Name (STitle) 978**] in the next 1 to 2 weeks. If
an appointment is not available with Dr [**Last Name (STitle) 978**] in the next 2
weeks, you are advised to make an appointment with any available
medical provider.
ICD9 Codes: 5180, 2859, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3111
} | Medical Text: Admission Date: [**2192-11-6**] Discharge Date: [**2192-11-12**]
Date of Birth: [**2124-8-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2192-11-8**] Coronary artery bypass graft x 5 (left internal mammary
> left anterior descending, saphenous vein graft > obtuse
marginal 1, saphenous vein graft > obtuse marginal 2, saphenous
vein graft > distal right coronary artery > posterior descending
artery)
[**2192-11-6**] cardiac catheterization
History of Present Illness:
68 year old male with dyspnea on exertion for past 5 months
relieved with rest. Occasional chest tightness (GERD like)
symptoms with exertion. He is able to walk [**11-29**] mile before he
would experience shortness of breath and relieved almost
immediatly with rest. He had stress test at [**Hospital1 **] and
was interpreted as positive and was sent for cardiac
catheterization. He was found to have coronary artery disease
and is now being referred to cardiac surgery for
revascularization.
Past Medical History:
Borderline diabetes
Hypercholesterolemia
Glaucoma
Seborrheic keratosis
Social History:
Lives with:wife
Occupation:[**Name2 (NI) 92151**]/consultant
Cigarettes: Smoked no
Other Tobacco use:denies
ETOH:[**1-2**] drinks/week
Illicit drug use: denies
Family History:
Father MI in 70's
Physical Exam:
Pulse:71 Resp:18 O2 sat:98/RA
B/P 151/92
Height:5'9" Weight:200 lbs
General:NAD, alert, cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] No Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm []x, well-perfused [] Edema [] _____
Varicosities: None [] well healed wound left lateral lower leg
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:
Cardiac Catheterization [**2192-11-6**]:
1. Selective coronary angiography of this right dominant system
demonstrated three vessel coronary artery disease. The LMCA had
no
angiographically-apparent significant stenosis. The LAD had a
proximal
99% stenosis, 100% D1 stenosis. Right to left collaterals to LAD
and D1.
The LCX had a 60% OM1 stenosis, with a long 60% stenosis OM2.
The RCA
had a mid 70% stenosis, a 50% ostial and mid 90% PDA.
2. Limited resting hemodynamics revealed normal systemic
arterial pressures at the central aortic level 105/69 mmHg.
3. Left Ventriculography was deferred.
[**2192-11-8**] ECHO
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is A-Paced, on no inotropes.
Preserved biventricular systolic pressure.
Trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact.
[**2192-11-7**] Carotid Ultrasound
Impression: Right ICA no stenosis. Left ICA <40% stenosis
[**2192-11-11**] 11:22AM BLOOD WBC-12.5* RBC-3.86* Hgb-11.3* Hct-33.8*
MCV-88 MCH-29.3 MCHC-33.5 RDW-13.4 Plt Ct-210#
[**2192-11-12**] 04:41AM BLOOD UreaN-29* Creat-1.0 Na-140 K-3.9 Cl-102
[**2192-11-6**] 06:45PM BLOOD ALT-25 AST-24 AlkPhos-6* Amylase-58
TotBili-0.6
[**2192-11-12**] 04:41AM BLOOD Mg-2.5
[**2192-11-7**] 12:45PM BLOOD %HbA1c-5.9 eAG-123
[**2192-11-6**] 06:45PM BLOOD Triglyc-84 HDL-45 CHOL/HD-2.7 LDLcalc-58
Brief Hospital Course:
Mr. [**Known lastname 92152**] was admitted to the [**Hospital1 18**] on [**2192-11-6**] following a
cardiac catheterization which revealed severe three vessel
coronary disease. The cardiac surgical service was consulted and
he was worked up in the usual preoperative manner. A carotid
ultrasound was performed which showed a normal right and less
then 40% stenosis of the left internal carotid artery. On
[**2192-11-8**], Mr. [**Known lastname 92152**] was taken to the operating room where he
underwent coronary artery bypass grafting to five vessels.
Please see operative note for details. Postoperatively he was
taken to the intensive care unit for monitoring. Over the next
several hours, he awoke neurologically intact and was extubated
without complications. On post operative day one he was started
on betablockers and lasix for gentle diuresis. He continued to
progress and was transferred to the floor. Physical therapy
worked with him on strength and mobility.Chest tubes and pacing
wires removed per protocol. Continued to make good progress and
was cleared for discharge to home with VNA on POD #4. All f/u
visits were advised.
Medications on Admission:
LEVOTHYROXINE 88 mcg daily
METFORMIN 850 mg twice daily
SIMVASTATIN 40 mg daily
ASPIRIN 325 mg daily
CHOLECALCIFEROL 1,000 unit daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or fever .
Disp:*50 Tablet(s)* Refills:*0*
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
12. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO DAILY (Daily) for 1 weeks.
Disp:*7 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Diabetes Mellitus type 2
Hypercholesterolemia
Glaucoma
Seborrheic keratosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check [**11-20**] at 10:15am - Cardiac surgery office [**Hospital **]
medical building [**Hospital Unit Name **] [**Telephone/Fax (1) 170**]
Surgeon: Dr [**Last Name (STitle) 914**] [**Name (STitle) 766**] [**12-18**] at 1:30pm
Cardiologist: Dr [**First Name (STitle) **] [**Telephone/Fax (1) 2258**] [**12-6**] at 10:40am
Please call to schedule appointments with your:
Primary Care Dr. [**Last Name (STitle) 55544**] [**Telephone/Fax (1) 12775**] in [**2-28**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2192-11-12**]
ICD9 Codes: 4111, 2724, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3112
} | Medical Text: Admission Date: [**2102-3-7**] Discharge Date: [**2102-3-10**]
Service: [**Hospital1 **]
CHIEF COMPLAINT: This is a [**Age over 90 **]-year-old female admitted with
atrial fibrillation with a rapid ventricular response,
hypertension and electrocardiogram changes at Dialysis.
HISTORY OF PRESENT ILLNESS: On the day of admission, the
patient was at Dialysis and received two hours of treatment
when she became hypertensive and confused. She has a history
of similar complaints on an admission on [**2101-1-24**]. She
was brought to the Emergency Department. Heart rate was in
the 140s. Systolic blood pressure was 40. She was found to
be in irregular narrow complex rhythm and was given two
liters of normal saline. Attempts at cardioversion at 100,
200 and 360 joules failed to convert her to sinus rhythm.
Her blood pressure slowly rose to 95/50s with fluids and the
patient became increasingly response and interactive. An
attempt at a left subclavian line failed in the Emergency
Department. She was given 5 mg Lopressor intravenous for
persistent tachycardia without any change. Her blood
pressure became 70s/50s. She was given another liter of
normal saline for a total of 3 and transferred to the Medical
Intensive Care Unit.
PAST MEDICAL HISTORY:
1. End stage renal disease from nephrolithiasis with
obstruction. She is receiving hemodialysis at [**Location (un) 4265**] and has
a right AV fistula. She is dialyzed Tuesday, Thursday and
Saturday.
2. Ulcerative colitis status post colectomy with ileostomy,
remote.
3. Paget's disease.
4. Peptic ulcer disease, status post hemigastrectomy.
5. History of cholecystectomy.
6. Osteoporosis.
7. Admitted [**2101-1-24**] for atrial fibrillation with rapid
response and lateral ST depressions with troponin leak
attributed to demand ischemia and renal failure.
Echocardiogram was done and was normal except for delayed
relaxation. She had no stress test or cardiac
catheterization because patient and family did not desire
revascularization. She was started on aspirin at that time.
8. Severe memory deficit and dementia.
9. Recent fall, [**2102-3-3**] with staples to forehead
laceration.
MEDICATIONS: Epogen 10,000 units subcutaneously q.
hemodialysis, Tums 500 mg po t.i.d. with meals. She was
discharged on aspirin [**2101-1-24**] but apparently not taking,
Ferrlecit at hemodialysis.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives at home and has full time
[**Last Name (LF) 13222**], [**First Name3 (LF) **], who provides 24 hour care. She has a
distant tobacco history. She drinks one vodka tonic every
afternoon. Her cardiologist is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Patient had a son
nearby but he died within the last several years. Patient's
proxy is her [**Last Name (LF) 802**], [**Name (NI) 5627**] [**Name (NI) **], and she is closely
involved in her aunts care and transport.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 98.6. Heart rate 130.
Blood pressure 99/70. Respiratory rate 24. 100% on
nonrebreather. In general, patient is lying in bed in no
acute distress, staples to forehead, laceration clean, dry
and intact. Oropharynx is clear. Mucous membranes were dry.
Sclerae were anicteric. Neck was supple. Jugular venous
distention was 7-8 cm. Lungs were clear to auscultation
bilaterally. Cardiovascular: Irregular rhythm, tachycardic,
3/6 systolic ejection murmur blowing loudest at the apex.
Abdomen was soft with normal active bowel sounds, was
nondistended. There was a colostomy in place draining brown
stool, no edema. Extremities are warm. There was a fistula
in the right upper extremity. Neurologically, she was alert
and oriented times one and grossly nonfocal.
LABORATORIES ON [**3-3**]: White blood cell count 4.3,
hematocrit 35.3. Chem-7 notable for BUN of 28 and creatinine
of 5.7. Admission CK 45 with troponin of 1.1. Arterial
blood gases 7.39/35/87, lactate 3.1. CT of the head showed
no bleed or acute process. Chest x-ray showed no effusion
and no infiltrate. Electrocardiogram showed atrial
fibrillation at 150 with 1-[**Street Address(2) 1766**] depression in V4 to V6
which was new compared to [**2102-3-3**] except for the ST
depression in V4 which is old. After spontaneous conversion,
she was in normal sinus rhythm without ST depressions.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit with a diagnosis of hypertension and
atrial fibrillation resulting from the stress of
hemodialysis. She was given a 250 cc normal saline bolus, 20
mg of intravenous diltiazem and then placed on a drip at 8 mg
per hour, spontaneously converted to normal sinus rhythm at a
rate of 78 on the evening of the 12th. A right femoral line
was attempted but returned arterial blood and was removed
without complications. She was transferred to the [**Hospital1 139**]
Medicine Floor Team on [**3-8**]. She was seen by her
Cardiologist, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], that evening, who started her on an
amiodarone load hopefully to prevent recurrence of atrial
fibrillation at her next hemodialysis. Electrocardiogram
showed resolution of her ST depression after her atrial
fibrillation broke. CKs were elevated because of her
cardioversion with negative MB fractions and troponin.
She was stable throughout [**3-8**] and on [**3-9**] at
hemodialysis, she went back in atrial fibrillation with rapid
response, however, this time she held her blood pressure and
did not have mental status changes. She actually finished
the entire dialysis treatment. Back on the floor, systolic
blood pressure then dropped to 70s to 90s with a heart rate
in the 120s to 160s. After a long discussion with the
patient and her proxy, [**Name (NI) 5627**] [**Name (NI) **], the patient and proxy
desired the patient to be made "Do Not Resuscitate, Do Not
Intubate" with no CPR. This is in keeping with a decision
that she made previously when she was less demented. She is,
however, to be full care including shocks if she is not in
cardiac arrest. The patient at this point was then treated
with a total of 25 mg diltiazem in 5 mg intravenous boluses
and then placed back on diltiazem drip and again converted
back to normal sinus rhythm overnight.
The following morning she was at her baseline and was
receiving po diltiazem. She underwent echocardiogram
cardiography that morning which revealed new left ventricular
hypertrophy and 2+ mitral regurgitation plus ejection
fraction of greater than 60% and 2+ tricuspid regurgitation.
Prophylaxis throughout her stay was with Zantac and normal
diet and subcutaneous heparin, although, patient sometimes
refused the heparin despite explanation of its importance.
Because of her paroxysmal atrial fibrillation,
anticoagulation was considered but heparin was not initiated
and full dose aspirin is used instead because she is a frail
elderly patient with a history of recent fall with head
injury and because according to her proxy, comfort is her
primary goal. She is going home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Heart's
monitor to assess for recurrent atrial fibrillation and
monitor her q.d. amiodarone. Her home health aid and proxy
were advised that her nightly vodka tonic does place her at
risk for recurrent falls as the history is that she may have
fallen shortly after the vodka tonic.
DISCHARGE STATUS: "Do Not Resuscitate, Do Not Intubate" but
full care if not in cardiac arrest.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg po b.i.d. times two days, 400 mg q.d.
times two weeks and then 200 mg po q.d.
2. Nephrocaps 1 po q.d.
3. Aspirin 325 po q.d.
4. Epogen 10,000 units subcutaneous at hemodialysis.
5. Tums 500 mg po t.i.d. with meals.
6. Diltiazem 30 mg q.i.d. converting to 120 mg extended
release on [**3-11**] a.m.
DISCHARGE FOLLOW-UP:
1. VNA to do home safety evaluation. Assess for need for PC
and hopefully remove the staples from her head laceration in
about one week.
2. With [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] regarding Cardiology issues and the results
of her [**Doctor Last Name **] of Heart's monitor.
3. Hemodialysis on Tuesday, Thursday and Saturday. At her
next dialysis on [**2102-3-11**], she should be monitored
closely for recurrence as she has now had atrial fibrillation
with two consecutive dialyses.
DISCHARGE DIAGNOSES:
1. Paroxysmal atrial fibrillation with rapid response
triggered by hemodialysis.
2. Dementia.
3. End stage renal disease.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2102-3-14**] 14:34
T: [**2102-3-14**] 14:34
JOB#: [**Job Number **]
ICD9 Codes: 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3113
} | Medical Text: Admission Date: [**2184-9-25**] Discharge Date: [**2184-10-18**]
Date of Birth: [**2105-12-15**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin / Bactrim / Phenergan / Reglan
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Right arterial line placement [**9-26**]
Intubation [**9-27**], [**9-29**]
Central line placement (right IJ) [**9-27**]
Cardiac cath [**9-29**]
Left arterial line placement [**10-2**]
Cardiac cath and bare metal stent placement to RCA [**10-3**]
Tunneled Dialysis Line placement [**10-12**]
History of Present Illness:
78F PMH of type I DM complicated by nephropathy, neuropathy, and
retinopathy, osteoporosis, CKD (baseline Cr 2.0) and recent
NSTEMI in [**6-/2184**] who is presenting with recurrent syncope [**1-29**] to
short episdoes of asystole since this AM.
.
Patient has h/o of gastroparesis and chronic nausea and
abdominal dyscomfort. She was at her baseline state of health
until this morning. At noon after taking 2 bites of her
sandwiched, she developed sudden nausea and had wretching X1,
immediately there after she syncopized per her husband with some
irregular limb movements w/o incontinence or tongue bite.
Husband caught her she did not fall on the floor and did not hit
her head. She reacovered after 30 seconds and came to quickly.
She recalls feeling faint but otherwise denies any preceeding
palpitaions, chest pain or other symptoms except nausea and
wretching. After ~ 10 minutes she had another identical episode
at which point her husband call EMS. En route EMS noted episode
of 6s of asystole and patient becoming unresponsive.
.
Upon arrival to the ED VS: 98.2 59 140/53 17 100%RA,
transcutaneous pacer pads were placed on patient. During
observation in ED patient bradyed down to the 40's, then had
about 10 second pause with syncope which ended with junctional
beat then sinus took over in the 50's. Half a milligram of
atropine was given with HR increasing only to the 60's. Initial
Glu 100, but 50 on repeat for which she recieved IV D50% 50cc.
EKG showed new T-wave inversions in the inferior leads
Trop = 0.08 X1
WBC 3.8, Hct 26, PLT 105 all at recent baseline, cr/BUN 2.3/70
at baseline
CXR: (my read), AP film hyperinflation, prominent hili and
increased mildly interstitial markings which are not
significantly changed from prior.
.
Of note patient's recent history includes admission [**2097-7-17**] for
NSTEMI, at the time presented with chest pain new ST depressions
and positive biomarkers and had MIBI showing a moderate fixed
inferior wall defect without reversible defects. Echocardiogram
showed new inferior wall motion (compared to [**2178**] prior) with
LVEF 45%, mild left ventricular hypertrophy, mild mitral
regurgitation, and mod PHTN (PASP 52 mm Hg above RA pressure).
Given concern for her renal functions and no reversible defects
on MIBI she was medically managed with ASA 325mg, [**Year (4 digits) **] 300,
atorvastatin 80 and metoprolol tartrate PO. More recently she
was admitted [**2087-9-9**] for worsening peripheral tingling which
after neg head CT was attributed to natural progression of her
peripheral neuropathy. On this admission was also noted to be
hypertensive to the 200's and was started on amlodipine which
she had been taking in the evenings intermitently only if her
SBP's > 130. She has otherwise been stable at home, no other
recent med changes. No new complaints beyond fatigue and ongoing
chronic complaints as per ROS below.
.
REVIEW OF SYSTEMS
On review of systems:
+ for chronic dizziness, lightheadedness, word finding
difficulties. Also had several recent mechanical falls.
- denies cough, hemoptysis, black stools or red stools. denies
recent fevers, chills or rigors. No prior h/o syncope.
.
Denies chest pain since NSTEMI 2 months ago, denies paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations.
Past Medical History:
- Type 1 diabetes with renal insufficiency (Dr. [**Last Name (STitle) 978**] and Dr.
[**First Name (STitle) 10083**] at [**Last Name (un) **]), peripheral neuropathy, gastroparesis
- Anemia (~29-30), on Procrit BIW
- Prepatellar bursitis
- Bilateral foot drop
- Osteoporosis
- Hypothyroidism
- Hyperhomocysteinemia
- Likely acute interstitial nephritis from cephalexin/bactrim
[**11/2182**]
- Osteoarthritis
- Cholelithiasis without cholecystitis per RUQ US [**2182**].
- CAD: s/p NSTEMI [**6-/2184**] (presented with chest pain, inferior ST
depression, positive enzymes, MIBI showed non reversible perf
defects, managed medically, no revascularization procedure
undertaken.)
- Ischemic cardiomyopathy with inf wall hypokinesis and LVEF 45%
per echo [**6-/2184**] post NSTEMI, NYHA class I-II.
Social History:
Patient lives with husband. She denies use of tobacco, alcohol,
recreational drugs, or herbal medications. She use bilateral
foot braces for neuropathy and foot drop. She reports being
independent in ADLs but is having increasing difficulty with
ambulation without assistive device.
Family History:
Mother died at age [**Age over 90 **] of old age. Sister died of ovarian CA in
her 50's. Sister still alive at age [**Age over 90 **]. No family history of
stomach or esophageal cancer.
Physical Exam:
Admission exam:
GENERAL: thin, NAD. Oriented x3. Mood, affect appropriate.
HEENT: mild pallor, PERRL, EOMI. No jaundice
NECK: Supple with JVD to ear lobes. There's radiating murmur
over bil carotids but no bruits.
CARDIAC: RRR, distant heart sounds with faint SM at apex and LSB
heard best over carotids. No r/g. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: blacked based ulcer on palmar aspect of lateral
left foot unstagable but not deep. stage I-II ulcers on medial
left ankle and plantar right mid foot. Abrasion left knee. No
ROM limitation, pain or bony tenderness along BLE. No signs of
cellulitis or discharge. No c/c/e. Peripheral pulses are
palpable but faint. Also has OSA changes in fingers.
SKIN: ulcers and abrasion as above, no rash
Neuro: reduced sensory preception socks and gloves distribution,
mild bil intention tremor, A+O X3, very mild word finding
difficulty. otherwise grossly intact.
.
Discharge exam:
98.2 124/50 89 93%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric there is an ocular hemorrhage noted in
the left eye near the lateral canthus, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Chest: she has right tunneled dialysis line which is c/d/i
without induration
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, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Initial labs:
[**2184-9-25**] 02:00PM BLOOD WBC-3.8* RBC-2.66* Hgb-8.7* Hct-26.0*
MCV-98 MCH-32.7* MCHC-33.5 RDW-13.4 Plt Ct-105*
[**2184-9-25**] 02:00PM BLOOD Neuts-69.8 Lymphs-19.1 Monos-6.3 Eos-4.5*
Baso-0.3
[**2184-9-25**] 02:00PM BLOOD PT-11.9 PTT-30.2 INR(PT)-1.1
[**2184-9-25**] 02:00PM BLOOD Glucose-101* UreaN-70* Creat-2.3* Na-140
K-4.8 Cl-105 HCO3-29 AnGap-11
[**2184-9-25**] 02:00PM BLOOD ALT-25 AST-28 CK(CPK)-49 TotBili-0.4
[**2184-9-25**] 02:00PM BLOOD Lipase-19
[**2184-9-25**] 02:00PM BLOOD CK-MB-3
[**2184-9-25**] 02:00PM BLOOD cTropnT-0.08*
[**2184-9-25**] 09:30PM BLOOD CK-MB-3 cTropnT-0.06*
[**2184-9-25**] 02:00PM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2
[**2184-9-25**] 02:00PM BLOOD TSH-11*
[**2184-9-25**] 09:30PM BLOOD Free T4-1.3
.
Pertinant labs:
[**2184-10-18**] 06:15AM BLOOD WBC-4.7 RBC-2.35* Hgb-7.5* Hct-23.2*
MCV-99* MCH-31.9 MCHC-32.3 RDW-18.4* Plt Ct-117*
[**2184-10-8**] 07:05AM BLOOD PT-10.9 PTT-47.1* INR(PT)-1.0
[**2184-10-18**] 06:15AM BLOOD Glucose-413* UreaN-32* Creat-2.5* Na-132*
K-4.2 Cl-95* HCO3-31 AnGap-10
[**2184-9-29**] 05:09AM BLOOD CK-MB-20* MB Indx-6.1* cTropnT-2.06*
[**2184-9-29**] 10:30AM BLOOD CK-MB-22* MB Indx-7.5* cTropnT-2.71*
[**2184-9-29**] 04:10PM BLOOD CK-MB-39* MB Indx-8.9* cTropnT-3.89*
[**2184-9-29**] 10:38PM BLOOD CK-MB-45* MB Indx-11.8* cTropnT-3.78*
[**2184-9-30**] 05:58AM BLOOD CK-MB-42* MB Indx-13.9* cTropnT-3.41*
[**2184-10-18**] 06:15AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.9
[**2184-10-14**] 06:20AM BLOOD calTIBC-222* Ferritn-641* TRF-171*
[**2184-9-25**] 02:00PM BLOOD TSH-11*
[**2184-10-14**] 06:20AM BLOOD PTH-50
[**2184-10-14**] 06:20AM BLOOD 25VitD-23*
[**2184-9-29**] 08:00AM BLOOD Cortsol-40.1*
[**2184-10-13**] 06:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
.
Imaging:
CXR [**2184-9-25**]: mild bibasilar atelectasis
.
MR of head, MRA of head and neck, [**2184-9-28**]
FINDINGS: There is no evidence of infarct or hemorrhage. There
are scattered T2/FLAIR hyperintensities in the subcortical and
periventricular white matter, which are nonspecific but could be
seen as the sequelae of chronic microangiopathy. There is
prominence of the ventricles and extra-axial CSF spaces, stable
since the prior examination. There is no mass, midline shift, or
hydrocephalus. There is mucosal thickening of the frontal,
ethmoidal, sphenoid, and maxillary sinuses. A small amount of
fluid is visualized in the mastoid air cells.
.
MRA BRAIN: There is irregularity of the cavernous internal
carotid arteries due to atheromatous disease. The right A1
segment is smaller, probably hypoplastic. The anterior cerebral
arteries are otherwise patent with normal branching pattern. The
left M1 and bilateral M2 segments exhibit narrowing and
irregularity likely atheromatous disease.
There is narrowing of the V4 segment of the right vertebral
artery. The
basilar artery appears patent. The posterior cerebral arteries
are patent with normal branching pattern. There is no evidence
of aneurysm, or arteriovenous malformation.
.
MRA NECK: The origin of the common carotid and vertebral
arteries is not
included in the field of view. The cervical vertebral arteries
are patent. There is mild narrowing of the proximal right
internal carotid artery. Otherwise, both internal carotid
arteries are patent. The diameter of the proximal carotid
arteries is larger than the distal diameter, therefore, there is
no stenosis by NASCET criteria.
IMPRESSION:
1. No evidence of infarction or hemorrhage.
2. Mild narrowing of the cavernous carotid arteries, likely
related to atherosclerotic disease. No aneurysm or arteriovenous
malformation.
3. Unremarkable MRA of the neck.
.
ECHO [**2184-9-29**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
focal hypokinesis of the inferior wall, basal to mid
inferolateral wall, distal septal wall, and apex. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
with moderate global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. The mitral valve leaflets are mildly thickened. There
is severe mitral annular calcification. There is moderate
functional mitral stenosis (mean gradient 8 mmHg) due to mitral
annular calcification. No mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild left ventricular
hypertrophy. Focal regional left ventricular systolic
dysfunction consistent with multivessel CAD. Right ventricular
dilation and dysfunction. Moderate pulmonary artery
hypertension. Moderate functional [**Last Name (un) 22837**] stenosis from MAC.
Compared with the prior study (images reviewed) of [**2184-7-19**],
more extensive regional dysfunction is present with a decline in
ejection fraction. Right ventricular systolic dysfunction is now
present. There is a gradient across the mitral valve consistent
with functional mitral stenosis.
.
Cardiac Cath [**2184-9-29**]:
Assessment & Recommendations
1. Severe diffuse three vessel coronary artery disease with
subtotal occlusion of heavily calcified diffusely diseased RCA
2. Moderate pulmonary arterial hypertension with severe right
ventricular diastolic heart failure on pressor.
3. Moderate left ventricular diastolic heart failure.
4. Cardiogenic shock with SBP ranging from 60 mm Hg off pressor
to 180 mm Hg (with excellent cardiac index) on
pressor(norepinephrine)
5. Monitoring PA line left in place. As this is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 26900**], [**First Name3 (LF) **] NOT
advanced to PCW position or inflate balloon without fluoroscopic
guidance.
6. CCU team to evaluate the benefits and risks of RCA rotational
atherectomy and stenting given echocardiographic and hemodynamic
evidence of RV failure, but heavily calcified and diffusely
diseased RCA.
.
Renal US [**10-2**]:
IMPRESSION:
1. Findings consistent with bilateral abnormal renal arterial
circulation. No evidence of venous thrombosis. No stones or
hydronephrosis.
2. Right pleural effusion.
.
Cardiac Cath [**10-3**]:
Interventional details
Change for [**Doctor Last Name **]-0.75. Crossed with a ChoICE PT XS wire. Serial
dilations with 01.25 mm, 2.0 mm. 2.5 mm. 2.75 mm balloons.
Deployed a 2.5 x 18 mm Integriti stent and postdilated to 3.0
mm.
Used the 2.75 mm balloon to dilate the mid RCA. Final
angiography revealed normal flow, no dissection and 30% residual
ostial stent recoil in the RCA and 30% residual stenosis in the
mid vessel RCA. The distal RCA had diffuse unchanged disease.
Assessment & Recommendations
1.ASA 81 mg PO QD indefinitely
2.[**Doctor Last Name **] 75 mg PO QD x 30 days uninterrupted and preferably x 12
months.
3.Secondary prevention CAD.
.
VENOUS DUPLEX UPPER EXTREMITY [**2184-10-6**]
Duplex evaluation was performed of both upper extremities. Both
subclavian veins are patent and phasic. Thrombus is identified
in the right cephalic and the antecubital fossa as well as the
left cephalic vein. Left basilic vein is patent. Both brachial
and radial arteries are patent with calcifications.
IMPRESSION: Thrombus in both cephalic veins and antecubital
fossa on the
right. For diameters of patent veins as well as brachial and
radial arteries evaluate scan worksheet.
Brief Hospital Course:
78F PMH of type I DM (complicated by nephropathy, neuropathy,
and retinopathy), CKD (baseline Cr 2.0) and recent inferior
NSTEMI in [**6-/2184**] who presentd with recurrent syncope [**1-29**] to
short episdoes of asystole.
.
Acute issues:
# Bradycardia/Asystole/Syncope: Patient admitted following
multiple syncopal episodes preceded by nausea and retching. In
ambulance, noted to have 6 second asystolic pause. Had
additional 10 second pause in the ED and was given 0.5mg of
atropine. After admission to CCU, continued to have episodes of
bradycardia to the 30s-40s with associated hypotension. These
were often but not exclusively related to nausea and vomiting.
Concern for recurrent inferior MI but troponins and CK-MB
initially stable. Initially thought to be most likely secondary
to elevated vagal tone, but patient had progressive hypotension
and bradycardia as hospitalization progressed (see below
NSTEMI). Episodes of syncope resolved later in hospitalization,
with no events of significant symptomatic pauses noted on tele.
She did have several episodes of bradycardia to the 30s but was
asymptomatic during these events.
.
# Hypotention/Shock: Shock appeared cardiogenic in nature on
cath study but sepsis was highly considered given low SVR. On
day 2 of admission, patient became hypotensive to the 60s-80s
systolic, associated with bradycardia. She was started on
dopamine with good response. Patient also developed intermittant
fevers, so concern for sepsis. UA dirty, urine cultures were
negative to date except for one sample with staph aureus coag +,
pansensitive. [**12-31**] blood cultures grew gram positive cocci on
[**8-26**]. Patient given 1 dose vanc/zosyn, then switched to
vanc/cefepime. Cefepime was discontinued when urine culture
returned with staph and not GNR. Lactate 3.1 on [**9-27**], likely due
to hypoperfusion with low blood pressures, and eventually
normalized below 2 on repeat measurements. Patient with low
temperature and restarted on zosyn. Hemodynamically, pt required
pressor support on Hospital Day 8, pt remained on levophed gtt
with labile SBPs ranging from 90s to 150s intermittently. On
[**2184-10-3**] vanc and zosyn were discontinued as blood cultures were
no growth to date, and ID consulting team also recommended
discontinuing antibiotics. Patient was on lasix gtt to decrease
preload for cardiogenic shock and this was discontinued when CVP
goal of [**10-8**] was reached. Patient was weaned from pressors on
[**10-5**] and remained off pressors for remainder of hospital
course.
.
# Mental status changes: Patient with intermittant episodes of
unresponsiveness associated with hypotension, concerning for
seizure vs hypoperfusion. The first of these occurred following
dose of Phenergan and was associated with muscle rigidity,
attributed to medication reaction. However, patient continued to
have similar episodes throughout the day on [**9-27**]. After one
unresponsive episode, had sensation of falling. Also had periods
of hallucinations, picking at bedclothes, confusion more
consistent with acute delirium. Neurology consulted. MRI and MRA
of head/neck showed no infarct, just atherosclerotic disease in
cavernous carotid arteries. EEG showed no seizure activity.
Concern for encephalitis given low grade fevers, so LP done
which was unremarkable and viral PCR negative. The patient was
electively intubated to preform procedures and get imaging. She
remained intubated for some time given on pressors and going to
cath lab (see below). She was successfully extubated on [**10-5**].
After which her mental status was improved.
.
# Anuric Acute on Chronic Kidney Disease: Urine output decreased
to <10cc/hr on second day of admission. Cr increased from 2.2 on
admission to 3.4 the morning of [**9-27**]. FENa <1%, but no
improvement in UOP with fluid boluses or initiation of pressors.
Urine sediment suggestive of early ATN. Pt also with anion gap
metabolic acidosis which was most likely related to uremia and
lactic acidosis. In addition, delta/delta revealed underlying
non gap metabolic acidosis which could be related to RTA
secondary to diabetes. Renal consult suggested renal U/S, urine
lytes and urine eosinophils. Renal u/s showed R renal artery
parvus tardus suggestive of renal artery stenosis and poor
diastolic flow bilaterally. Cath study on [**10-3**] did not show
impressive stenosis of renal arteries and no interventions were
done. Urine lytes were consistent with ATN and urine eosinophils
were negative and thus made interstitial nephritis related to
cephalosporins (history of allergy) less likely. Following PCI
on [**10-3**], Cr continued to trend up with declining bicarb which
felt to be related to contrast induced injury. The patient's Cr
continued to increase and UOP only with diuretics. Per renal
recs home Epo was restarted, low phose diet, nephrocaps, and
sevelameer 800mg TID with meals started on [**10-12**]. Renal was
following and tunneled HD line was placed on [**10-13**]. Patient
underwent dialysis initiation once transferred to the floor and
will undergo MWF dialysis once discharged. She is largely
anuric at this point.
.
# CAD: Initially inferior wall STD + TWI similar to ECG changes
at the time of NSTEMI 2 months ago, but cardiac enzymes stable,
no chest pain. Continued home aspirin, [**Month/Year (2) 4532**], statin.
Metoprolol initially held due to bradycardia, hypotension,
pauses. Pt had troponinemia on [**9-29**] that peaked at 3.89 and
cath study showed 3VD - this was concluded to be demand NSTEMI
presentation. CAD was later intervened on [**10-3**] with high risk
PCI (after multiple family meetings regarding goals of care)
where the RCA was stented with BMS. Patient was restarted on
increased dose of metoprolol on [**10-7**].
.
# Nausea/Vomiting: most likely [**1-29**] to her chronic diabetic
gastroparesis but could also be manifestation of inferior
myocardial ischemia. Obstructive biliary issue is also on the
ddx given RUQ US showed cholelithiasis. LFTs on admission were
unremarkable and lipase negative. On day of demand NSTEMI LFTs
trended up slightly ALT 41, AST 64, AlkP 229, GGT 98, and TBili
normal. The patient continued to have nausea and emesis
intermitently throughout course. Low dose ativan was used to
control nausea given reactions to other medications as above.
This resolved by discharge, at which time the patient was
tolerating PO.
.
# Nutrition: Patient with poor PO intake on admission. Tube
feeds were initiated on [**10-2**] but rate could not be advanced
given high residual volume due to gastroparesis. A post-pyloric
tube was placed on [**10-5**] and tube feeds were resumed. The
patient continued to recieve tube feeds until she pulled out
tube on [**10-8**]. She resumed oral feeding on [**10-9**].
.
# ischemic cardiomyopathy: post NSTEMI echo in [**6-/2184**] showed inf
wall hypokinesis and LVEF 45%. No ACE-I were started given CKD.
NYHA class I-II. ECHO on this admission showed decreased LVEF to
35-40% likely secondary to additional cardiac insult this
admission. The patient was diuresed intermittently during
hospital course. Initially with IV lasix bolus. She was then
started on torsemide and metolazone with good response.
Diuretics were stopped on [**10-11**] secondary to low BPs and dry
volume status. Isordil was started for afterload reduction.
.
# Pancytopenia: this is long standing, unknown if worked up in
the past. Pt's thrombocytopenia worsened throughout course but
with normal coagulation panel which was not consistent with
DIC/TTP. Most likely this could be related to bone marrow
suppression related to stress/sepsis/shock/antibiotics.
Additionally patient on Epo at home, restarted on [**10-13**].
.
# Hypothyroidism: TSH elevated on presentation but with normal
FT4. Pt's home Synthroid was continued throughout course.
.
Transitional issues:
# Dialysis follow-up
# Cardiology follow-up
# Renal follow-up
# Patient's goal hematcrit should be >30% given her NSTEMI
during this admission. Patient recieved one unit of pRBC on the
day of discharge and total of 4unit pRBC during her hospital
stay.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Glargine 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 50 mcg PO DAILY Start: In am
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY Start: In am
8. Calcium Carbonate 500 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY Start: In am
10. Fish Oil (Omega 3) 1000 mg PO DAILY Start: In am
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Vitamin D 800 UNIT PO BID
13. Amlodipine 2.5 mg PO DAILY
patient has been taking this at home QHS:PRN SBP > 130.
14. Epoetin Alfa 0 UNIT IV ONCE Duration: 1 Doses Start: HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Vitamin D 800 UNIT PO BID
9. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
10. Isosorbide Dinitrate 10 mg PO TID
RX *isosorbide dinitrate 10 mg 1 tablet(s) by mouth Every 8
hours Disp #*90 Tablet Refills:*0
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
Every 8 hours Disp #*90 Tablet Refills:*0
12. Omeprazole 20 mg PO DAILY
13. Fish Oil (Omega 3) 1000 mg PO DAILY
14. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0
15. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
16. Glargine 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital1 8**]
Discharge Diagnosis:
Syncope
Non ST Elevation Myocardial Infarction
Renal Failure
Cardiogenic Shock
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 26898**],
It was a pleasure taking care of you during your recent
admission to [**Hospital1 18**]. You were admitted with fainting spells.
These were felt to be due to vasovagal episodes. These episodes
resolved and no pace maker was placed. However, your hospital
course was complicated by a heart attack which resulted in organ
damage and required you to be supported by a breathing machine
and medications to improve your blood pressure. A stent was
place in the site of the heart blockage. Unfortunately, the
heart attack resulted in significant damage to your kidneys. As
a result, you were started on dialysis. You improved once
dialysis was started and you were discharged to rehab. The
following changes were made to your medications.
STOP
Amlodipine
Iron Supplement
START
Nephrocaps
Multivitamin
Sevelamer
Folate
Isosorbide Dinitrate
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2184-11-2**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2184-10-18**]
ICD9 Codes: 5845, 5856, 2930, 2762, 3572, 4168, 4280, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3114
} | Medical Text: Admission Date: [**2114-11-29**] Discharge Date: [**2114-12-10**]
Date of Birth: [**2114-11-29**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**First Name4 (NamePattern1) 15406**] [**Known lastname 11622**] delivered at 35 weeks
gestation, birth weight 2775 grams, was admitted to the
Newborn Intensive Care Unit for management of prematurity and
respiratory distress.
estimated date of delivery [**2115-1-3**]. Prenatal screens
included blood type O positive, antibody screen negative,
Rubella immune, RPR nonreactive, and hepatitis B surface
antigen negative and group B strep positive. Pregnancy was
complicated by placenta previa noted on 18 week and 25 week
ultrasound and preterm contractions from 28 week gestation
managed with bed rest. Had intermittent vaginal bleeding.
spontaneous vaginal delivery under epidural anesthesia on
[**2114-11-29**] secondary to progressive preterm labor. Rupture of
membranes one hour prior to delivery. No maternal fever.
Received intrapartum antibiotics five hours prior to
delivery.
Infant emerged with a weak cry and well maintained heart
rate. Received oral and nasal bulb suctioning, tactile
stimulation and dried. Subsequently required brief positive
pressure ventilation for irregular respiratory effort.
Spontaneous regular respirations were established but the
infant was still pale with intermittent grunting and was
therefore grunting and was therefore transferred to the
Intensive Care Nursery from labor and delivery. Apgar scores
were 6 and 8 at one and five minutes respectively.
Examination of placenta at the delivery showed scattered old
clots without calcifications.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2775 grams (75th
percentile), length 50.5 cm (90th percentile), head
circumference 34 cm (90th percentile). A nondysmorphic pale
infant, palate intact, anterior fontanelle soft and flat,
moderate nasal flaring, moderate intercostal and subcostal
retraction, good breath sounds bilaterally with a few
scattered rales, well perfused with regular rate and rhythm,
femoral pulses present bilaterally, no murmur. Abdomen soft,
nondistended, no organomegaly, no masses, three vessel cord,
normal female external genitalia. Active alert infant with
tone slightly decreased moving all limbs symmetrically.
Normal reflexes. Hips stable.
SUMMARY OF HOSPITAL COURSE BY SYSTEM: Respiratory: Placed
on nasal CPAP 6 cm of water on admission for respiratory
distress. Highest oxygen requirement on CPAP 45 percent.
Weaned to nasal cannula oxygen on day of life two. Required
supplemental O2 by nasal cannula until day of life seven.
Has remained in room air since with comfortable work of
breathing, respiratory rate 30 to 50s.
Respiratory: Has had several episodes of apnea and
bradycardia or oxygen desaturations since admission. Last
oxygen desaturations on [**12-6**], last bradycardia episode on
[**12-4**] associated with feeding.
Cardiovascular: Received one bolus of normal saline for
pallor on admission. Has remained hemodynamically stable
throughout hospital stay. A soft murmur was audible through
the first few days of life that has subsequently not been
heard.
Fluids, electrolytes and nutrition: Was n.p.o. on admission
and receiving D10W by peripheral intravenous. Started
enteral feeds on day of life two, on all breast or bottle
feed by day of life four with weight gain. Discharge weight
Gastrointestinal: Peak total bilirubin 13.1, direct .4. Did
not require phototherapy.
Hematology: Hematocrit on admission 41 percent.
Infectious disease: Received Ampicillin and Gentamicin for
48 hours for rule out sepsis. Respiratory distress though
secondary to mild surfactant deficiency. Initial CBC was
benign. Blood culture was negative. Received initial dose of
Synagis RSV prophylaxis.
Neurology: Examination age appropriate.
Sensory: Hearing screening was performed of automated
auditory brain stem responses passed both ears.
CONDITION AT DISCHARGE: Stable preterm infant.
DISCHARGE DISPOSITION: Discharged home with parents. Name
of primary pediatrician: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24613**], [**Hospital 2312**]
Pediatrics, telephone number [**Telephone/Fax (1) 37109**].
CARE RECOMMENDATIONS:
1. Ad lib demand breast feeding, follow weight gain.
2. Medication: Fer-In-[**Male First Name (un) **] 0.2 cc p.o. q.d.
3. Car seat test passed.
4. Immunizations received: Received hepatitis B
immunization and Synagis on [**2114-12-7**]. Immunizations
recommended: Synagis RSV prophylaxis to be
considered from [**Month (only) 359**] to [**Month (only) 547**] for infants who
meet any of the following three criteria: 1) born at
less than 32 weeks, 2) born between 32 and 35 weeks
with plans for day care during RSV season, with a
smoker in the household, or with preschool siblings
or, 3) with chronic lung disease.
FOLLOW UP APPOINTMENTS: 1) Follow up appointment with
pediatrician following discharge. 2) [**First Name (Titles) 1587**] [**Last Name (Titles) 28085**] made to [**Location (un) 86**] [**Hospital6 1587**], telephone number [**Telephone/Fax (1) 37525**].
DISCHARGE DIAGNOSES:
1. AGA preterm female.
2. Respiratory distress syndrome resolved.
3. Rule out sepsis.
4. Neonatal jaundice.
5. Apnea of prematurity, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2114-12-9**] 04:69
T: [**2114-12-9**] 07:05
JOB#: [**Job Number 38966**]
ICD9 Codes: 769, 7742, 2765, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3115
} | Medical Text: Admission Date: [**2128-11-15**] Discharge Date: [**2128-11-24**]
Date of Birth: [**2082-1-24**] Sex: M
Service: [**Company 191**] MED
HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old man with
past medical history including hepatitis C (treated with PEG-
Interferon, Ribavirin, finished [**10/2127**] with viral load not
detected by PCR in [**1-/2128**]), who presented initially to [**Hospital 1263**]
Hospital for elective endoscopic retrograde
cholangiopancreatography. He complained of two-week history
of jaundice associated with intermittent vague abdominal pain
with some constipation. Denied recent nausea, vomiting,
diarrhea, fever, or chills. At [**Hospital 1263**] Hospital patient
underwent EGD on [**2128-11-11**] and was found to have
gastritis/gastroesophageal reflux disease. A recent
abdominal ultrasound showed a questionable focal lesion
(location not reported).
On [**2128-11-11**] he also underwent an ERCP that revealed common
bile duct stricture which was stented with a plastic stent.
Per report patient's bilirubin had been 23.8 on admission to
[**Hospital 1263**] Hospital and continued to remain elevated after
stenting. The patient underwent laparoscopic cholecystectomy
on [**2128-11-13**] at [**Hospital 1263**] Hospital with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain
left in place. On [**2128-11-15**] the patient was transferred to
the [**Hospital6 256**] for a repeat ERCP.
During ERCP procedure on [**2128-11-15**] patient received Versed,
Fentanyl, Phenergan and was reportedly very difficult to
sedate. The plastic common bile duct stent was removed, and
during procedure, patient went into respiratory arrest. He
became apneic with heart rates in the 30s, systolic blood
pressure to 81, and oxygen saturation to 40% very briefly. A
Code Blue was called and patient was given Flumazenil and
Narcan. Patient never lost his pulse. The patient's heart
rate increased to a rate of 150s with systolic blood pressure
to the 150s. Patient was bagged, ventilated, and was
witnessed to vomit brown material into the bag mask. He was
intubated by Anesthesia for airway protection and brought to
the [**Hospital Ward Name 12573**] Intensive Care Unit. He became agitated en route
to the Intensive Care Unit and vomited more brown material.
He was stabilized in the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Hepatitis C, viral load undetectable in 01/[**2128**].
2. Gastroesophageal reflux disease.
3. Hiatal hernia.
4. Gastritis.
5. Esophageal ring.
6. Gallstones.
7. Status post laparoscopic cholecystectomy on [**2128-11-13**].
8. Status post ERCP [**2128-11-11**] and [**2128-11-15**].
9. Trauma to neck at age 10 with tracheal and esophageal
reconstruction done at that time with permanent voice damage.
Patient has a permanent whisper.
MEDICATIONS UPON ADMISSION: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient quit tobacco smoking 15 years ago;
had a 15-pack-year history prior to this. Positive for
alcohol abuse; quit 16 years ago. Positive intravenous drug
use; quit 16 years ago.
PHYSICAL EXAMINATION: Temperature 98.3, heart rate 81, blood
pressure 121/61, oxygen saturation was 95% on AC mode, tidal
volume 700, respiratory rate 20, FIO2 of 100%, and a PEEP of
5. General: Patient was intubated, sedated, jaundiced
profoundly. HEENT: Icteric sclerae; pupils equal, round,
reactive to light; endotracheal tube in place; mucous
membranes moist. Neck: Supple; jugulovenous pressure at 6
cm at 45 degrees; no bruits; no lymphadenopathy; well healed
scar on anterior neck. Cardiovascular: Regular rate and
rhythm; normal S1, S2; no murmurs, rubs, or gallops. Chest:
Bibasilar rhonchi with upper airway congestion, otherwise
clear to auscultation. Abdomen: Obese; J-P drain at right
upper quadrant with 40 cc of serosanguinous fluid; site is
clean, dry, and intact without erythema; liver edge palpable
at 4 cm below midclavicular costal margin; no palpable
splenomegaly or pulsatile mass; soft, nondistended, good
bowel sounds. Extremities: Warm, dry, 1+ pedal pulses
bilaterally; no cyanosis, clubbing, or edema. Neuro:
Sedated; moving all extremities; good gag reflex. Derm:
Warm, dry, with bilateral palmar erythema.
LABORATORY DATA UPON ADMISSION: White blood cells 7.5,
hematocrit 34.3, platelets 169. Coagulation studies were
normal. Chemistry was normal with the exception of a
potassium of 2.9. ALT 36, AST 47, LDH 229, alkaline
phosphatase 240, total bilirubin 19.6, amylase 28, lipase 60,
CK 174, MB 5, troponin less than 0.01, albumin 2.3, calcium
7.7, ammonia 40. Blood gas on arrival to the Intensive Care
Unit: pH 7.25, PCO2 55, PO2 250, bicarbonate 25, lactate
3.0.
EKG: Sinus tachycardia with a rate of 104, normal axis, no
acute ST-T changes, no prior study available for comparison.
Portable chest x-ray showed the ETT at carina, diffuse patchy
infiltrates bilaterally, and no effusions.
HOSPITAL COURSE LISTED BY PROBLEM:
1. Respiratory arrest/respiratory failure: Likely due to
heavy sedation needed during ERCP. Patient with likely
aspiration pneumonia versus chemical pneumonitis. Patient
was started on Ampicillin, Levofloxacin, and Metronidazole
empirically. Patient was treated for a seven-day course. On
day two of ICU admission patient was extubated without
difficulty. He was quickly weaned to a nasal cannula and
subsequently was weaned to room air within a day of
extubation. Patient's white blood cell count decreased
during admission, and an initial fever after intubation to a
maximum of 102.2 resolved and patient was afebrile for last
eight days of admission. Patient was kept on p.r.n.
nebulizer treatments and remained with good saturation
2. Common bile duct stricture: On day two of admission a
percutaneous drain was placed by Interventional Radiology
with both internal and external draining of bile. The common
bile duct stent had been removed on ERCP upon admission. A
biopsy of the common bile duct was done at that time and
showed chronic inflammation and no evidence of tumor or mass.
Both PTC and CT of abdomen and MRCP were unrevealing for
extrinsic mass. However, this stricture was concerning for
malignancy. Patient's bilirubin continued to decline towards
normal during his admission, and on day of discharge
bilirubin was at 9. Patient's drain was capped on day prior
to discharge to ensure adequate internal drainage. Patient
was sent home with drain in place.
3. Gallbladder adenocarcinoma: Pathology from [**Hospital 1263**]
Hospital was returned during patient's admission. The final
pathology indicated a well differentiated invasive
adenocarcinoma of the gallbladder. The tumor invades the
muscular wall and extends into adjacent adipose tissue. The
cystic duct appeared free of malignancy, but the serosal
liver bed showed focal extension of tumor. There were also
scattered foci suspicious for lymphvascular invasion per the
report. The stage given was at least PT2N1MX. The patient's
pathology slides have been requested by the surgeons who
consulted on this patient and will be reviewed by our
Pathology Department in the coming weeks.
An Oncology consult was obtained at the time this report was
sent from [**Hospital 1263**] Hospital, and at this time Oncology has
requested the MRCP in addition to sending the bile fluid
draining for cytology. The cytology report came back
negative for malignant cells. Patient was seen by the
Surgery team headed by Dr. [**Last Name (STitle) **], who wishes for a wide
surgical resection of malignancy that would include a partial
liver lobectomy and removal of the ductal system.
Dr. [**Last Name (STitle) **] wishes for patient to follow up with him on
[**2128-12-10**] to allow his aspiration pneumonia and acute issues
to resolve. [**Name (NI) **] PTC drain will be assessed at that
time. Patient will also follow up with Dr. [**First Name (STitle) **] from
Oncology after his surgical treatment.
It is unclear at the time of this discharge whether the
common bile duct stricture is related to the adenocarcinoma
of the gallbladder or is simply just inflammation as the
pathology precludes. All of this will be assessed during the
surgical procedure planned by Dr. [**Last Name (STitle) **].
4. Pain management: Patient complained of abdominal pain
related to his drain placement. Patient has a history of
narcotic abuse and repeatedly requested minimal narcotics for
his pain control; however, these were needed during his
admission for relief of pain. Patient was given subcutaneous
Dilaudid as needed and was switched to p.o. Oxycodone upon
discharge. Patient felt good relief and improvement of his
pain throughout his admission.
5. Nutrition: Patient was tolerating p.o. diet with good
appetite during admission. He was started on supplemental
multivitamins, folate, and thiamine and will continue these
upon discharge.
6. Prophylaxis: Patient was started on pantoprazole and was
on Heparin during his admission for deep venous thrombosis
prophylaxis. Patient was ambulating without difficulty and
was cleared to go home with services. Other laboratory
values that were checked during admission include a CEA of
2.4, a CA of 19-9 of 58, bile fluid that grew Enterococcus
that was sensitive to both Ampicillin and Levofloxacin.
Patient's seven-day course of antibiotics, as explained
above, was seen to cover for this Enterococcus.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home with [**Location (un) 86**] VNA for drain care and
pain management.
DISCHARGE DIAGNOSES:
1. Adenocarcinoma of the gallbladder.
2. Common bile duct stricture.
3. Resolving aspiration pneumonia.
4. Hepatitis C.
5. Gastroesophageal reflux disease.
6. Gastritis.
7. Status post laparoscopic cholecystectomy.
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg p.o. q.d.
2. Folic acid 1 mg p.o. q.d.
3. Multivitamins, one, p.o. q.d.
4. Thiamine 100 mg tablets p.o. q.d.
5. Colace 100 mg b.i.d.
6. Ursodiol 300 mg q.d. p.r.n. itching.
7. Phenergan 25 mg tablets p.o. q. four to six hours p.r.n.
nausea.
8. Albuterol inhaler one to two puffs q. six hours p.r.n.
for shortness of breath or wheezing.
9. Oxycodone 5 mg tabs, take one to four tablets p.o. q.
four to six hours p.r.n. for pain. Patient given 60 pills,
no refills.
DISCHARGE INSTRUCTIONS:
1. Patient to see his primary care doctor, Dr. [**First Name (STitle) 5936**], at
[**Telephone/Fax (1) 25350**], on Wednesday, [**2128-12-1**], at 5:15 p.m.
Patient will have his chemistries and liver function tests
checked within two to three days of discharge by home nursing
to ensure trending downward of bilirubin.
2. Dr. [**Last Name (STitle) **] from Surgery on [**2128-12-10**] to plan for coming
operation.
3. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Hematology/Oncology on [**2128-12-22**] at
1 o'clock.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 9244**]
MEDQUIST36
D: [**2128-11-24**] 15:16
T: [**2128-11-25**] 14:27
JOB#: [**Job Number 37705**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3116
} | Medical Text: Admission Date: [**2103-8-13**] Discharge Date: [**2103-8-27**]
Date of Birth: [**2024-7-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amiodarone Analogues
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
redo sternotomy, aortic valve replacement (25mm St. [**Male First Name (un) 923**]
porcine) [**2103-8-14**]
History of Present Illness:
This 78 year old patient with complex past medical history s/p
Coronary Artery Bypass Graft x 4 in [**2090**]. Pt had a cardiac cath
at NEBH in [**12-8**]. The aortic area was 1.0 with a mean gradient
of 33 and an EF of 58%. Then [**12-9**] he
developed chest pain and ruled in for MI with a troponin of
6.5.He had a cardiac cath at [**Hospital1 18**] at that time which showed a
valve area of 0.8 with a mean gradient of 34 and an EF of 40%.
The study showed significant native CAD but all grafts were
patent.He declined intervention at that time because he was
going to [**State 108**] for the winter. When he returned this spring he
was complaining of increased dyspnea on exertion. He had a
cardiac cath [**2103-6-6**] at NEBH which showed severe aortic stenosis
and a calculated [**Location (un) 109**] of 0.6 cm2 and a mean gradient of 34-35
mmHg. This catheterization also showed severe 3 vessel native
CAD. The LIMA graft to the LAD was patent. The vein graft to the
PDA was patent with a significant lesion in the native vessel
downstream from
the graft. The vein graft to diagonal branch is patent with
distal native vessel severe disease and patent saphenous vein
graft to the obtuse marginal with diffuse attenuation of native
vessels. On [**2103-6-19**] he then underwent stenting of the PDA via
the SVG. He now presents for surgical evaluation for Aortic
valve replacement.
Past Medical History:
aortic stenosis
s/p redo sternotomy, aortic valve replacement this admission
PMH:
coronary artery disease, s/p CABG [**2090**]
chronic atrial fibrillation
non-insulin dependent diabetes mellitus
hypertension
hyperlipidemia
Social History:
The patient is a retired salesman and lives with his wife. [**Name (NI) **]
has a distant smoking history. He drinks an occassional glass
of wine, no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Physical Exam
Pulse: 78 Resp: 18
B/P Left: 110/70
Height: 5'[**05**]" Weight: 195lbs
General: WD/WN male, NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X], except left eye
Neck: Supple [X] Full ROM [X], -JVD
Chest: Lungs clear bilaterally [X], Healed midline scar from
CABG
Heart: RRR [X] Irregular [] Murmur[X] 2/6 SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None [X]
Healed RLE from groin to anke
Neuro: Grossly intact, A&O x 3
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:
[**2103-8-17**] 01:45AM BLOOD WBC-8.9 RBC-2.83* Hgb-9.6* Hct-27.2*
MCV-96 MCH-34.0* MCHC-35.4* RDW-13.3 Plt Ct-129*
[**2103-8-17**] 01:45AM BLOOD PT-16.2* INR(PT)-1.4*
[**2103-8-17**] 01:45AM BLOOD Glucose-132* UreaN-26* Creat-0.7 Na-136
K-4.2 Cl-104 HCO3-23 AnGap-13
[**2103-8-17**] 01:45AM BLOOD Mg-2.2
PRE-CPB:1. The left atrium is moderately dilated. The left
atrial appendage emptying velocity is depressed (<0.2m/s). A
left atrial appendage thrombus cannot be excluded.
2. A patent foramen ovale is present.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild to
moderate regional left ventricular systolic dysfunction with
inferior hypokinesis. There is mild global left ventricular
hypokinesis (LVEF = 40 %). Overall left ventricular systolic
function is moderately depressed (LVEF= 40 %).
4. The right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis.
5. There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation
is seen.
7. The mitral valve leaflets are mildly thickened. There is a
minimally increased gradient consistent with trivial mitral
stenosis. Mild to moderate ([**2-2**]+) mitral regurgitation is seen.
8. There is a moderate right pleural effusion.
9. There is a trivial/physiologic pericardial effusion.
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] were notified in person of the
results.
POST-CPB: On infusions of epinephrine and phenylephrine. AV
pacing. Well-seated bioprosthetic valve in the aortic position.
Trivial AI. No paravalvular leak. Mitral regurgitation is 1+. TR
is 1+. There is preserved biventricular systolic function on
inotropic support. The aortic contour is normal post
decannulation. The size of the left pleural effusion is
significantly reduced.
[**2103-8-27**] 05:00AM BLOOD WBC-11.0 RBC-3.07* Hgb-10.2* Hct-29.6*
MCV-96 MCH-33.1* MCHC-34.4 RDW-13.5 Plt Ct-594*
[**2103-8-27**] 05:00AM BLOOD PT-25.4* INR(PT)-2.4*
[**2103-8-27**] 05:00AM BLOOD Glucose-52* UreaN-22* Creat-0.8 Na-136
K-4.7 Cl-100 HCO3-23 AnGap-18
Brief Hospital Course:
Mr [**Known lastname 41819**] was admitted preoperatively for heparinization while
off Coumadin. On [**8-14**] he was brought to the operating room for
redo sternotomy and Aortic valve replacement with #25 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
Porcine valve. Cross clamp time=75 minutes.Cardiopulmonary
Bypass time=107 minutes. Please see Dr[**Last Name (STitle) **] operative
report for further details. He tolerated the operation well and
was transferred to the cardiac surgery ICU in stable condition
on Epinephrine and Neosynephrine for optimal hemodynamic
support. He was weaned from the ventilator and extubated on
POD#1. Upon extubation he was found to be restless and somewhat
agitated. This was initially felt to be from the narcotics he
had received however these symptoms persisted. The neurology
team was consulted and a head CT was done(A preliminary report
read "No hemorrhage or large territorial infarct. Ill-defined
low attenuation foci in the right frontal centrum
semiovale/corona radiata white matter (2:25-28), may represent
infarcts, age indeterminate). He was seen by Dr [**Last Name (STitle) 656**] who felt
the patient did not have a new infarct.
Over the next 48 hours his neurological exam improved
dramatically, all lines and drains were discontinued in a timely
fashion. Beta-blocker and diuresis was initiated. On POD3 he was
transferrred to the stepdown floor for continued post-op care
and recovery. Once on the floor he was noted to have a small
amount of serous drainage from the inferior aspect of his
sternal wound and was prophylactically started on Keflex. The
remainder of his hospital course was essentially uneventful.
Over the next several days he made slow but continuous progress
in his physical activity and on POD #12 he was cleared for
discharge by the cardiac surgery covering attendings, to home
with VNA. All follow up appointments were advised.
Medications on Admission:
Digoxin 250 MCG 1 tablet daily
Simvastatin 20 mg 1 tablet daily
Warfarin 2.5 mg 1 tablet daily, 2 tablets on Sunday
Lisinopril 10 mg daily
Metoprolol 25 mg twice a day
Plavix 75 mg daily
Glyburide 5 mg twice a day
Aspirin 325 mg daily
Nitro Patch PRN
Discharge Medications:
1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 1 weeks.
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
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. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO Q AM.
Disp:*60 Tablet(s)* Refills:*2*
5. Warfarin 1 mg Tablet Sig: adjust dose to target INR 2-2.5
Tablets PO DAILY (Daily): Pt to receive 2.5 mg on [**8-21**].
home regime preop was 2.5mg qd with 5mg on Sunday.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain/fever.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO three
times a day.
Disp:*45 Tablet(s)* Refills:*2*
14. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 10 days.
15. Glyburide 5 mg Tablet Sig: One (1) Tablet PO Q PM.
Disp:*60 Tablet(s)* Refills:*2*
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Facility:
tbd
Discharge Diagnosis:
aortic stenosis
s/p redo sternotomy, aortic valve replacement(25 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
porcine)
PMH:
coronary artery disease, s/p CABG [**2090**]
chronic atrial fibrillation
non-insulin dependent diabetes mellitus
hypertension
hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**keep a log of your blood sugars and present to your PCP [**Last Name (NamePattern4) **] 1
week visit**
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **],[**First Name3 (LF) 198**] [**Telephone/Fax (1) 14525**] in 1 week, Please resume
Coumadin/INR follow up with DR.[**Last Name (STitle) 7389**]
Neurology -Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**] -see in [**2-2**] weeks [**Telephone/Fax (1) 1694**]
Please call for appointments
Have INR drawn by VNA [**8-28**] with results to Dr. [**Last Name (STitle) 7389**] [**Telephone/Fax (1) 14525**]
Completed by:[**2103-8-27**]
ICD9 Codes: 4241, 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3117
} | Medical Text: Unit No: [**Numeric Identifier 72195**]
Admission Date: [**2190-4-24**]
Discharge Date: [**2190-5-25**]
Date of Birth: [**2190-4-24**]
Sex: M
Service: Neonatology
IDENTIFICATION: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 72196**] is a 31 day old former
29 and [**1-24**] week premature infant who is being transferred
from the [**Hospital1 69**] Neonatal
Intensive Care Unit to the special care nursery at [**Hospital 1474**]
Hospital.
HISTORY: Baby [**Name (NI) **] [**Known lastname 72196**] was born on [**2190-4-24**], as the
980 gram product of a 29 and [**1-24**] gestation pregnancy to a 23-
year-old gravida I, para 0 to I mother with [**Name (NI) 37516**] of [**2190-7-9**]. Prenatal laboratory studies included blood type B
positive, antibody negative, rubella immune, RPR nonreactive,
hepatitis B surface antigen negative and group B strep
unknown. Pregnancy was notable for 2 vessel cord noted on
ultrasound with otherwise normal ultrasound findings and a
normal quadruple screen. Pregnancy was complicated by
preeclampsia treated with magnesium, as well as a course of
betamethasone which was complete on [**2190-4-23**]. On the
evening of delivery, mother experienced worsening blood
pressures and then was noted to have a nonreassuring fetal
heart tracing. This prompted a C-section delivery. Rupture of
membranes was at delivery and there was no maternal fever or
intrapartum antibiotic prophylaxis given. At delivery, the
infant emerged with spontaneous cry requiring facial CPAP but
otherwise routine care. Apgars were 8 and 8 and the infant
was transferred to the NICU.
SOCIAL HISTORY: Notable for mother having fetal alcohol
syndrome, and currently living with her adoptive mother.
Father of the infant is not involved in this infant's care.
HOSPITAL COURSE: By systems:
Respiratory: On admission, the infant was noted to have
moderate respiratory distress due to hyalin membrane disease.
He was intubated and placed on mechanical ventilation and
treated with 2 doses of Surfactant. He was on conventional
ventilation with settings up to PIP of 25, PEEP 5 and rate of
25 and then gradually weaned over the next 48 hours. He was
extubated to CPAP by day of life 2 and subsequently weaned to
room air on day of life 7. Since weaning from CPAP, he has
required intermittent periods of nasal cannula support for
spells or work of breathing. Respiratory status has gradually
improved and the infant has been stable in room air since day
of life 17. He was treated with caffeine for apnea of
prematurity and this was discontinued on day of life 29. The
infant was also noted to have nasal congestion and he was
treated with several days of nose drops including
phenylephrine, dexamethasone and prednisolone from day of
life 14 through day of life 18 with improvement. He did complete
4 weeks of vitamin A treatment as well. By the time of discharge,
the infant is breathing comfortably in room air
with rare spells noted.
Cardiovascular: The infant has been hemodynamically stable
throughout hospitalization. A murmur was noted on day of life
[**3-21**]; echocardiogram on day of life 4 revealed normal anatomy with
a moderate patent ductus arteriosus with continuous left to right
flow. A patent foramen ovale with left to right flow was noted as
well. The infant was begun on a course of indomethacin with
resolution of the murmur. No further evidence of a PDA has
been noted and no further imaging studies have been
performed.
Fluid, electrolytes and nutrition: The infant was initially
maintained n.p.o. and was given parenteral nutrition. A
umbilical venous catheter was placed for the first week of
life at which point a PICC line was placed and the umbilical
venous catheter was removed. Enteral feedings were begun on
day of life 9 following treatment for the PDA with Indocin.
Enteral feeds were then advanced without difficulty reaching
full volume feedings by day of life 18. PICC line was removed
on day of life 19. Caloric density was gradually increased to
a maximum of 150 cc/kg/day of 28 calorie breast milk with
additional beta protein. At the time of discharge, the infant
continues on 150 cc/kg/day of breast milk supplemented to 28
calories with additional beta protein. Feeding is given via
gavage with occasional breast feeding attempts. Electrolytes
were normal throughout admission. The infant was noted to
have hypoglycemia on admission to the NICU but this resolved
with initiation of IV fluid and blood sugars have been normal
since that time. Electrolytes on day of life 16 included a
sodium of 136, potassium of 4.6, chloride of 107 and
bicarbonate of 22. Our plan was to check a set of
electrolytes along with nutritional laboratory studies of
calcium, phosphorus and alkaline phosphatase on day of life
34. The infant has maintained normal urine and stool output
throughout. Of note, gavage feedings are given over 1 hour
due to a history of small spits; no recent significant
spits have been noted. The infant is being treated with
vitamin E supplementation.
GI: The infant did develop hyperbilirubinemia requiring
phototherapy. Peak bilirubin was 6.1 on day of life 3. The
infant received phototherapy for approximately 3 days with
resolution of hyperbilirubinemia.
Heme: Initial hematocrit was 50.8. The infant was begun on
iron supplementation following full enteral feedings. Last
hematocrit was measured on day of life 17 and this was 40. Of
note, initial CBC at the time of delivery revealed a white
count of 4.0, with 20% polys, consistent with mild
neutropenia. A repeat CBC on day of life 2 showed a white
cell count of 5.5 with 40% polys, within normal range.
ID: CBC and blood culture were sent on admission. The infant
was treated with 48 hours of ampicillin and gentamicin
that were then discontinued with negative blood cultures and
benign clinical course. The infant did receive 48 hours of
oxacillin and gentamicin from day of life 17 to 19 for some mild
umbilical erythema for concerns of possible omphalitis. Blood cx
was negative and symptoms resolved, and course was not thought
consistent with omphalitis.
Neurology: The infant has maintained a normal neurologic
examination throughout admission. Head ultrasound on day of
life 6 and again on day of life 31 was normal. Initial eye exam
was performed on day of life 24 and this revealed immature retina
in zone 2 bilaterally with follow up recommended in 2 weeks; this
would be approximately [**2190-6-1**].
CONDITION ON DISCHARGE: The infant is breathing comfortably
in room air with occasional spells. The infant is receiving
full volume feedings of 150 cc/kg/day of breast milk
supplemented to 28 calories per ounce with additional beta
proteins given PG with occasional breast feeding. The infant
is being treated with iron and vitamin E. The infant is
maintaining stable temperatures in isolette.
DISCHARGE DISPOSITION: The infant is being transferred to
[**Hospital 1474**] Hospital.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 2174**] [**Last Name (NamePattern1) **], M.D. in [**Location (un) 1475**].
RHCM: Newborn screens were sent on [**4-27**], and [**5-9**]. First
hepatitis B vaccine was given on [**2190-5-24**].
PHYSICAL EXAMINATION: At discharge, weight is 1575 grams.
Vital signs are stable in room air. The infant is a small
premature infant who is active at exam. Fontanelles are soft
and flat. Ears and nares are normal. Palate is intact. Red
reflex is present bilaterally. Neck is supple. Chest is clear
to auscultation without grunting, flaring or retractions.
Cardiac is regular rate and rhythm without murmur. Abdomen is
soft with active bowel sounds without hepatosplenomegaly. GU:
Normal premature male with testes descended bilaterally. No
hernias are palpated. Anus is patent. Femoral pulses are 2+
and symmetric. Hips and back are normal. Extremities are warm
and well perfused without lesions. Tone and activity are
appropriate.
DISCHARGE DIAGNOSES:
1. Prematurity at 29 and 1/7 weeks.
2. Borderline growth restriction with weight percentile of
15th percent.
3. Respiratory distress syndrome.
4. Patent ductus arteriosus.
5. Hyperbilirubinemia.
6. Sepsis evaluation.
7. Apnea of prematurity.
8. Two vessel umbilical cord.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2190-5-25**] 13:20:54
T: [**2190-5-25**] 16:39:16
Job#: [**Job Number 72197**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3118
} | Medical Text: Admission Date: [**2183-10-15**] Discharge Date: [**2183-10-18**]
Service: MEDICINE
Allergies:
Aspirin / Nsaids
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Cc:[**CC Contact Info 108953**]
Major Surgical or Invasive Procedure:
ORIF
History of Present Illness:
.
HPI:
83M with PMH significant for CAD s/p CABG in [**2169**], MVR in [**2178**],
CHF, and COPD, presents to the ED after experiencing R hip pain
following a fall. He states that he was bending over, and became
dizzy with blurred visual after standing up abruptly. He fell on
his side. He denies LOC or head trauma. Films taken at his rehab
([**Hospital3 **]) demonstrated R femoral neck fracture, and he
was sent to [**Hospital1 **] ED. Of note, CXR at rehab on [**2183-10-10**] suggested
evidence of RLL and LUL infiltrate, and was started on
Levofloxacin 500mg PO qD x 10 days.
.
In the ED, initial VS were BP 134/69, HR 71, RR 18, SaO2 95% 2L
NC. Hip films confirmed R femoral neck fracture. Initial labs
significant for INR 5.4, on coumadin. CT head showed no evidence
of hemorrhage. He was seen by orthopedic surgery, who
recommended admission to medicine service for medical
optimization prior to likely ORIF surgery [**10-16**]. Mr. [**Known lastname **]
also complained of mild flank pain. A UA was ordered once he
reached the floor.
Past Medical History:
.
PMH:
CAD: s/p CABG [**2169**]
s/p MVR [**2178**]
s/p PPM, placed [**2178**] at time of valve surgery, V-paced
CHF - EF 40% on [**2178**] TTE
Pulmonary HTN by [**2178**] cath
Tracheomalacia following prolonged intubation
Restrictive lung disease with PFTs c/w neuromuscular disease,
possibly [**3-6**] diaphragmatic damage from previous cardiac
surgeries
h/o Endocarditis
h/o colon CA [**92**] yrs ago, resected
BPH
h/o GIB
Social History:
SOCIAL HISTORY: The patient denies history of intravenous
drug use or ethanol use. He has greater than 33 pack year
history of tobacco use, discontinued [**2178**]. His wife recently
died. His daughter died emphysema secondary to alpha I
antitrypsin
deficiency. The patient retired five years ago as a
[**Hospital **]medical Engineer.
.
Family History:
FAMILY HISTORY: Father died of an MI at age 82, mother died
of cancer at age 69. He is a carrier of alpha I antitrypsin
gene.
.
Physical Exam:
.
PE: TL 97.1F BP: 135/60, HR: 79, RR: 30, SaO2: 90% 2L (prior to
neb treatment).
Gen: Ill appearing gentleman, lying in bed, NAD
HEENT: PERRL, sclerae anicteric, OP clear
Neck: Supple, no LAD, previous orifice from trach visible
CV: RRR, II/VI SEM LUSB, mech valve click, +S3
Chest: Crackles R base, no w/r
Abd: Soft, NT/ND, +BS
Extr: R leg externally rotated, 2+ DPs bilaterally
Neuro: A&Ox3
Pertinent Results:
ECG [**2183-10-15**]: V-paced at 84bpm
[**2183-10-18**]: Atrial fibrillation. Right axis deviation. Compared to
the previous tracing of [**2183-10-15**] there is deep T wave inversion
in leads II, III, aVF and V3-V6 consistent with active ischemic
process. Rule out infarction. Clinical correlation is suggested.
.
Imaging:
CXR [**2183-10-15**]:
Cardiomegaly, s/p CABG and MVR, dual-lead PPM. Elevation of
right hemidiaphragm with volume loss and interstitial opacities
c/w CHF. Also focal opactiy over R lung zone and fluid in
fissure, could be c/w PNA. Small effusions, no PTX.
.
Head CT [**2183-10-15**]:
FINDINGS: There is no evidence of intra- or extra-axial
hemorrhage. The ventricles, cisterns and sulci are mildly
prominent, consistent with age-related involutional changes.
Multiple patchy areas of hypodensity in the white matter
consistent with chronic small vessel ischemic disease, and
include hypodensity which is more prominent, but unchanged
within the left subinsular cortex. A bony protuberance about the
ossicle may represent an osteoma which is unchanged or merely a
congenital variant.
IMPRESSION:
1. No evidence of intracranial hemorrhage.
2. Evidence of age related involutional changes and white matter
disease, unchanged.
.
Hip films: There is a comminuted right femoral neck fracture.
Subtle angulation is present. No other fracture is identified.
IMPRESSION: Right femur fracture.
.
[**3-9**] PFTs:
FVC 1.98L (51% predicted)
FEV1 1.25L (51% predicted)
FEV1/FVC: 63% (100% predicted)
.
[**1-2**] TTE:
EF 40%. 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. Overall
left ventricular systolic function is moderately depressed
secondary to severe inferior and posterior hypokinesis and mild
hypokinesis of the rest of the left ventricle; the ejection
fraction is approximately 40 percent. There is moderate global
right ventricular free wall hypokinesis. The number of aortic
valve leaflets cannot be determined. The aortic valve leaflets
are moderately thickened. There is no significant aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. A mitral valve annuloplasty
ring is present. There is moderate thickening of the mitral
valve chordae. Moderate
(2+) mitral regurgitation is seen. The mitral regurgitation jet
is eccentric. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
.
[**7-3**] Cath: (prior to MVR)
1. Coronary angiography in this right dominant system revealed
three
vessel CAD. The left main coronary artery had a 40% distal
stenosis. The LAD had an 80% mid-vessel stenosis, and there was
competitive flow from the LIMA in the distal LAD. The ramus
intermedius branch had a 40% proximal stenosis. The left
circumflex artery was totally occluded proximally. The RCA had a
diffusely diseased proximal segment and was totally occluded
after the first acute marginal branch.
2. Graft arteriography revealed a patent LIMA to the LAD. The
SVG to the rPDA was widely patent, and the rPDA distal to the
anastamosis had a 70% stenosis. The SVG to the obtuse marginal
branch was ectatic but without significant stenosis and the
marginal branch distal to the anastamosis supplied collaterals
to the right postero-lateral branch.
3. Resting hemodynamic measurements revealed severe pulmonary
hypertension witha PA systolic pressure of 92 mmHg. There was
increased right and left sided filling pressures with a mean RA
pressure of 16 mmHg, a mean PCWP of 28 mmHg and an LVEDP of 22
mmHg. The cardiac index was preserved at 2.3 L/min/m2.
4. Left ventriculography revealed global hypokinesis with
posterobasal wall akinesis and moderate-to-severe (3+) mitral
regurgitation. The calculated LVEF was 45%.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA and SVGs.
3. Moderate-to-severe (3+) mitral regurgitation.
4. Mild systolic ventricular dysfunction.
5. Severe pulmonary hypertension
[**2183-10-15**] 06:58AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2183-10-15**] 06:05AM CALCIUM-8.8 PHOSPHATE-2.6* MAGNESIUM-2.3
[**2183-10-15**] 06:05AM WBC-5.4 RBC-3.18* HGB-10.2* HCT-30.2* MCV-95
MCH-32.2* MCHC-33.9 RDW-16.7*
[**2183-10-15**] 06:05AM PT-43.8* PTT-37.1* INR(PT)-5.0*
[**2183-10-15**] 01:30AM GLUCOSE-90 UREA N-28* CREAT-1.1 SODIUM-138
POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-35* ANION GAP-12
[**2183-10-15**] 01:30AM CK(CPK)-39
[**2183-10-15**] 01:30AM cTropnT-0.02*
[**2183-10-15**] 01:30AM CALCIUM-8.9 PHOSPHATE-2.8 MAGNESIUM-2.2
[**2183-10-15**] 01:30AM WBC-6.3# RBC-3.33* HGB-10.7* HCT-31.6* MCV-95
MCH-32.3* MCHC-34.1 RDW-16.5*
[**2183-10-15**] 01:30AM PT-46.7* PTT-37.4* INR(PT)-5.4*
Brief Hospital Course:
Pt. was admitted for optimization of medical status prior to
operation for hip fx. stable until early [**10-17**] around 12:oo am
when began desatting to the high 80s on 2L NC. Vital signs o/w
at the time: T 97.3 BPs 90s-100s/30s-60s, HR 60s-70s, rr in the
high 20s. Pt was also noted to be increasingly somnolent and
unresponsive. Pt placed on 100% FM with improvement of sats. He
had been given MS contin 45 mg at 11 am the day prior and was
therefore given narcan 0.2 mg X1 and narcan 0.4 mg X1 several
hours later. He was given lasix 10 mg IV X3 o/n. Mental status
improved somewhat with the early dose of narcan. CXR checked at
the onset of the pt's change in status demonstrated worsened
bibasilar pna.
ABG trend o/n was as follows:
12:20 am 7.33/68/70
4:00 am 7.23/90/65
6:00 am 7.27/79/60
At time of MICU eval ABG was checked and demonstrated
7.05/139/125. Given worsening respiratory status pt transferred
to the unit. Code status confirmed with family to be DNR/DNI.
HCP felt that [**Name (NI) 108954**] would be an in-line with the pt's wishes.
Pt. EKG showed new Afib with ST changes worrisome for ischemia
and trop leak without elevation of CK in context of rapidly
progressive ARF. He was given trial of [**Name (NI) 108954**] overnight without
much improvement of MS. In discussion with pt.'s family, it was
decided to choose comfort care interventions. He was placed on
morphine drip and passed [**10-18**] with family around
Medications on Admission:
Meds:
Lopressor 25mg PO bid
Prilosec 20mg PO qD
Coumadin 3mg 5d/wk, 2mg 2d/wk
Azmacort 2 puffs tid
levaquin ([**10-19**] last dose - ?pnemonia)
lasix 10mg PO qD
lisinopril 5mg PO qD
Albuterol neb [**Hospital1 **]
Atrovent neb [**Hospital1 **]
Combivent 2 puffs qid
wellbutrin XL 150mg PO qD
Dulcolax 10mg PR prn
Remeron 7.5mg PO qHS
.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
hypercarbic respiratory failure
CAD: s/p CABG [**2169**]
Atrial fibrillation
Acute Renal Failure
Hip fracture
CHF
PNA
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 486, 0389, 4280, 5070, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3119
} | Medical Text: Admission Date: [**2156-6-4**] Discharge Date: [**2156-6-30**]
Date of Birth: [**2084-3-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Aleve / Codeine / Depakote
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hypotension after hemodialysis
Major Surgical or Invasive Procedure:
R IJ central line placement
Hemodialysis
History of Present Illness:
Chief Complaint:
Hypotension
.
History of Present Illness:
72F with a history of type II DM, ESRD on HD, GAVE, HTN, MR,
CAD, CHF w/ RV failure and seizure disorder with recent
hospitalization from [**5-5**] to [**6-3**] with culture negative sepsis
with MS change and c.diff colitis, who presents to the ED on
[**6-4**] for HD. Pt was discharged on [**6-3**] and was due for her HD
today per her MWF schedule. She was sent from rehab to the
[**Hospital1 18**] ED for HD due to her current diarrhea from c.diff colitis
and concerns about her volume status. She was seen in the ED
then sent for HD with 2.5 fluid removed. Prior to HD, in ED BP
131/76 RR 16 92% 4L.
.
Following her ultrafiltration, she returned to the ED for likely
discharge back to rehab. However, both during HD and on return
to the ED, she was noted to be hypotensive, to as low as SBP
60s. She received 2 L total IVF in ED with minimal response.
She had a RIJ placed for access. Her BP has since been labile
and she has had BP to 67/42 with HR 89 at time of transfer to
the floor. The only laboratory sent at the time of admission to
floor were CBC and chem 10.
.
Allergies: Aspirin / Aleve / Codeine / Depakote
Past Medical History:
* Chronic Gastric Angiodysplasia (GAVE)and consequent chronic
low-grade UGIB, and has therefore been advised not to take
aspirin or other antiplatelet agents.
* DM type II: c/b nephropathy and neuropathy - currently not on
diabetic meds, has hypoglyemia [**12-27**] poor nutritional stores
* ESRD: HD MWF has fistula L arm
* CAD
* CHF, R-sided, diastolic EF 50-55% with 4+ TR 2+ MR [**8-/2155**]
TTE
* Anemia: multifactorial (ESRD + iron deficiency [**12-27**] GIB)
* colon polyps (hyperplastic) [**7-/2153**] colonoscopy
* gastritis and duodenitis [**7-/2153**] EGD
* gout
* pleural effusion s/p thoracentesis [**8-/2153**] negative cytology,
.
Social History:
Pt lives at [**Location **]. No ETOH, tobacco, or drugs.
Pt has four children, all involved in her care. There were
several family meetings during this admission with all her
children. They are very supportive and close family. No health
care proxy is assigned at this time ([**2156-5-31**]). She is aware that
she needs to choose one.
.
Family History:
[**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. Her mother
had an MI in her 80s.
Physical Exam:
VS: T: 95 BP: 78/48 HR: 112 RR: 16
Gen: Elderly woman in apparent distress, intermittently
responsive and awake, at times combative and agitated
HEENT: NCAT. Mucous membranes slightly dry
Neck: Supple, no JVD, RIJ dressing c/d/i
CV: RRR normal s1 s2
Chest: Poor air movement
Abd: Soft, NT/ND. No HSM or tenderness. +BS, umbilical hernia
Pertinent Results:
[**2156-6-3**] 05:13AM BLOOD WBC-5.6 RBC-2.63* Hgb-9.5* Hct-30.8*
MCV-117* MCH-36.3* MCHC-30.9* RDW-25.9* Plt Ct-76*
[**2156-6-24**] 04:16AM BLOOD WBC-6.4 RBC-2.35* Hgb-8.5* Hct-27.3*
MCV-116* MCH-36.3* MCHC-31.3 RDW-20.3* Plt Ct-129*
[**2156-6-30**] 07:18AM BLOOD WBC-6.1 RBC-2.53* Hgb-8.9* Hct-28.3*
MCV-112* MCH-35.3* MCHC-31.5 RDW-18.8* Plt Ct-142*
.
[**2156-6-3**] 05:13AM BLOOD Glucose-70 UreaN-10 Creat-2.6* Na-141
K-3.9 Cl-102 HCO3-30 AnGap-13
[**2156-6-24**] 04:16AM BLOOD Glucose-161* UreaN-8 Creat-2.2* Na-133
K-3.6 Cl-97 HCO3-30 AnGap-10
[**2156-6-30**] 07:18AM BLOOD Glucose-85 UreaN-11 Creat-3.0* Na-133
K-3.6 Cl-95* HCO3-27 AnGap-15
.
[**2156-6-5**] 02:25AM BLOOD ALT-16 AST-32 AlkPhos-147* Amylase-59
TotBili-2.5*
[**2156-6-6**] 05:31AM BLOOD ALT-19 AST-44* LD(LDH)-439* AlkPhos-133*
TotBili-2.4*
[**2156-6-21**] 05:58AM BLOOD ALT-12 AST-29 LD(LDH)-309* TotBili-6.1*
DirBili-4.5* IndBili-1.6
.
[**2156-6-28**] 06:13AM BLOOD ALT-19 AST-50* AlkPhos-189* TotBili-9.6*
.
[**2156-6-5**] 05:16AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2156-6-5**] 11:49PM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2156-6-6**] 09:06PM BLOOD CK-MB-NotDone cTropnT-0.18*
.
[**2156-6-16**] 05:11AM BLOOD Ammonia-69*
[**2156-6-17**] 05:05AM BLOOD Ammonia-52*
[**2156-6-21**] 04:03PM BLOOD Ammonia-16
[**2156-6-23**] 06:12AM BLOOD Ammonia-53*
[**2156-6-14**] 04:22AM BLOOD Digoxin-0.9
[**2156-6-15**] 06:53AM BLOOD Digoxin-1.8
.
Imaging:
Echo - The left atrium is elongated. The right atrium is
moderately dilated. A secundum type atrial septal defect is
present. The estimated right atrial pressure is 10-15mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. There is
abnormal diastolic septal motion/position consistent with right
ventricular volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. The tricuspid valve leaflets
fail to fully coapt. Severe [4+] tricuspid regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
CT abdomen and pelvis -
CT OF THE ABDOMEN WITHOUT CONTRAST: There is a moderate-to-large
left
effusion, simple in attenuation, increased in volume from the
prior study.
There is a small right pleural effusion, also increased since
the prior exam.
There is bilateral lower lobe atelectasis versus consolidation.
There are
coronary artery calcifications and calcifications of the aortic
valve.
The non-contrast appearance of the liver, gallbladder, spleen,
pancreas and
adrenal glands is unremarkable. The known enlarged common bile
duct is not
well assessed on this examination. The kidneys are atrophic.
There is no
hydronephrosis. A moderate amount of ascites is again seen.
There is no free
intra-abdominal air.
There is circumferential wall thickening of the colon, most
marked from the
cecum through the hepatic flexure. The transverse, descending,
and sigmoid
colon is not well distended though it may be thickened to a
lesser degree.
Small bowel loops are normal in caliber and appearance, without
evidence of
obstruction. The abdominal aorta is normal in caliber, with
atherosclerotic
calcifications. Patency of the mesenteric vessels cannot be
assessed without
IV contrast; no air is seen within them. There is no mesenteric
or
retroperitoneal lymphadenopathy. There is extensive subcutaneous
edema
bilaterally, similar to that seen on the prior study. A 2.4 x
1.3 cm nodule
is seen in the subcutaneous fat of the left lower abdomen,
possibly related to
an injection.
CT OF THE PELVIS WITHOUT CONTRAST: Oral contrast reaches the
rectum, which is
normal in appearance. There are calcifications of the uterine
vessels. The
bladder is likely collapsed and not well assessed. There is a
moderate-to-
large amount of free pelvic fluid, slightly increased from the
prior exam. No
enlarged pelvic or inguinal nodes are seen. Again extensive
subcutaneous
edema is appreciated.
No suspicious osseous lesions are detected.
Multiplanar reformatted images were essential in delineating the
anatomy and
pathology in this case.
IMPRESSION:
1. Interim development of circumferential wall thickening of the
colon, most
pronounced in the cecum through the hepatic flexure. The
remainder of the
colon is likely thickened to a lesser degree. While
infectious/inflammatory
colitis such as C. Diff remain in the differential, ischemic
colitis is of
concern, given the vascular distribution of the findings (right
sided
predominance and elevated lactate) . The patency of the
mesenteric vessels was
not assessed on this non- contrast exam. No free air, portal
venous gas or
obstruction.
2. Extensive third spacing of fluid including subcutaneous
fluid, pleural
effusions and ascites.
3. Known enlargement of the common bile duct is not well
assessed on this
study. Followup imaging was advised on the prior exam.
4. Atrophic kidneys.
5. Moderate-to-severe atherosclerotic calcification of the
abdominal
vasculature.
6. Nodule of the subcutaneous fat of the left lower abdomen.
This could be
related to injections. Attention on followup studies will be
helpful.
Brief Hospital Course:
71 yo F with DM, ESRD on HD, GAVE, HTN, CHF w/ RV failure,
c.diff colitis and persistent diarrhea admitted for hypotension,
also noted to be persistently hypoglycemic. Was in the unit on
pressors, then was able to be weaned off. Waxing and [**Doctor Last Name 688**]
encephalopathy while on floor, contributing to hypoglycemia and
aggitation.
.
# Hypotension: Coagulopathy, thrombocytopenia, hypothermia and
hypotension was concerning for sepsis. Her BP was not
responsive currently to IVF, she received total of 1.5 L in ED
and 1 L on floor, she was started on neo (did not tolerate
levophed) and started on broad spectrum antibiotics including
vancomycin IV and cefepime IV as well as vancomycin po and
flagyl iv for her c.diff. There was also likely component of
hypovolemia in setting of diarrhea and poor POs. She as weaned
off of neo, but continue to have intermittent low blood
pressures to the high 80's and 90's. This is likely secondary to
her c.diff infection. She was mentating at her baseline
throughout these hypotensive periods. She received her usual
dialysis, but did not tolerate much fluid removal. She was
eventually weaned off of her pressors. For several dialysis
sessions, she was unable to have a high enough BP for adequate
fluid removal, but BPs started to improve and patient was
tolerated dialysis with approx 2-3L removal per session. When
transferred to the floor, patient had moderately low BPs while
she was in aflutter/afib. Patient evenutally converted with HRs
in 80-100s and BPs improved. Likely due to improved heart
function with slower rhythm. BPs on discharge in 120s and
stable.
.
# Atial tachycardia: Intermittent bursts of atrial tachycardia -
afib vs. aflutter. HRs in 120s-140s during these epsisodes.
Low BPs but had normal perfusion. Electrophysiologists were
consulted and started 4 week amiodarone load with 400 mg daily.
Then will start 200 mg amiodarone daily indefinitely. Also on
digoxin 0.125 mg every other day. Pt was not on beta blocker
during this time because blood pressure were unable to tolerate.
While on floor, after approx 1-1.5 weeks of amio load,
patient's aflutter/fib resolved. Was in NSR and telemetry was
discontinued. She was noted to have several runs of
asymptomatic NSVT to about 10 beats while on telemetry. Will
continue amio 400 mg until [**7-10**], then switch to 200 mg
daily.
.
# Encephalopathy - likely related to toxic metabolite buildup,
probably hepatic failure is biggest contributor. Would wax and
wane between confusion and lucidness. Would treat aggitation
with SL zyprexa. Avoided sedating meds. Pt was refusing
narcotics for pain control because she could feel herself not
thinking clearly. Upon discharge, patient has appropriate
mental status for several days and was able to understand her
situation. Likely has depression contributing at some level,
too. Often is sad and crying in the morning when family is not
around.
.
# Hypoglycemia: Pt has history of diabetes, but is no longer on
any diabetic meds because of these low blood sugars. Is likely
due to poor nutritional stores in setting of hepatic failure
with poor gluconeogenesis. Endocrinology was consulted during
previous admission and did not feel insulinoma was a
possibility. C peptide was likely only elevated because it is
renally cleared. Pt FS was as low as 15 while in the MICU. Pt
was able to resume her diet and then have appropriate blood
sugars. She does need encouragement to keep appropriate PO
intake. While on the general medicine floor, had a period ofo
altered mental status in which she was too somnolent to eat, and
to maintain sugars, we had her on a d10W gtt at 500cc/hr for
about 3 days. She became hyponatremic at that time. Her mental
status improved, we were able to stop the drip and keep her on
her normal PO diet and her sugars did much better. Her
hyponatremia also resolved. We started her on scheduled glucose
tabs, but she does not take them regularly because she does not
like the taste.
.
# ESRD/HD: On HD MWF. Needs to continue this schedule as an
outpatient.
.
# Thrombocytopenia/coagulopathy: Initially ther was concern for
DIC. She was given vitamin k initially, however her coagulopathy
is likely [**12-27**] to her hepatopathy [**12-27**] to right heart failure. Her
coags were followed as well as monitoring for signs of bleeding.
No further intervention was necessary. Her INR is high at 2.5.
She does not have any active signs of bleeding and has stable
anemia with a hemoglobin between 8 and 9.
.
# Hyperbilirubinimia: Thought to be associated with congestive
hepatopathy from RV hypokinesis. We monitored her liver
functions were showed increasing bilirubin. She became more
jaundiced throughout her stay. Her belly exam remained
intermittently tight and distended, worsening at time, but
improves often after dialysis. She is asymptomatic. We
discussed possibly doing a therapeutic paracentesis, but with
her his risk and lack of symptoms, we decided against it.
.
# Peripheral Vascular Disease - the patient developed what
appears to be arterial ulcers on her Bilateral big toes. They
do not seem infected, but she has symptoms of pain in her heels,
occassionally her hands. We did ultrasounds studies of her ABIs
which were 0.4 and 0.6 in R and L respectively. We tried to
control her pain with oxycodone, but patient refusing narcotic
meds. Tylenol up to 2 gms daily can be used for symptom relief.
.
# C.diff - was admitted with a c.diff infection. Was treated
with appropriate course of PO vanco and PO flagyl. Diarrhea is
now only mild and not voluminous like it previously had been.
Does not need any more treatment on discharge.
.
# Hx of siezures - on prior admission, had a seizure while
hypotensive and in the MICU. Is now on keppra for siezure
prophylaxis. Will continue keppra as outpatient. She has an
appointment with neurology is late [**Month (only) 216**] in which they may
cchoose to discontinue this med.
.
# Pleural effusions - patient has a stable pleural effusion,
unknown etiology. A thoracentesis was attempted previously, but
unsuccessful. There has been a question of possible lymphoma
seen on prior imaging studies, but no diagnosis has been made.
Her breathing is stable on room air and she is not dyspneic on
the mild exertion she is able to do.
.
# Deconditioning - has been in and out of the hosptial since
about [**Month (only) 956**], does not get out of bed much. Needs extensive
PT work to improve her strength.
.
# Code - patient is now DNR/DNI as CPR is not medically
indicated in her case. Palliative care knows the patient and
the family well. There were many family meetings during the
time of her care about the patient's poor prognosis.
.
# Contact: son [**Name (NI) **], [**Telephone/Fax (1) 13227**]
Medications on Admission:
Camphor-Menthol 0.5-0.5 % Lotion QID (4 times a day) as needed.
Omeprazole 40 mg Capsule PO DAILY
Metronidazole 500 mg PO TID for 10 days from [**6-3**]
Keppra 100 mg/mL 250 mg PO BID
Ergocalciferol (Vitamin D2) 50,000 unit PO 2X/WEEK (MO,TH) for 2
months
Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day: Start after 2 months of 50,000u twice weekly is completed.
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 10 days: Please finish taking amiodarone 400 mg daily until
[**7-10**]. Then start taking 200 mg daily.
4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed: Do not exceed 2 grams daily.
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day).
7. Dextrose (Diabetic Use) 300 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
PLEASE DO NOT START THIS DOSAGE UNTIL [**7-11**]. Thanks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**]
Discharge Diagnosis:
Primary diagnosis:
1. Hypotension
2. C. diff
3. Altered mental status secondary to multiorgan failure
4. ESRD on HD
5. Liver dysfunction
6. Right heart failure
7. Peripheral Vascular disease
8. Hypoglycemia
Discharge Condition:
vitals signs stable, SBPs in 110s-120s, HR 80s-90s. Afebrile.
Somewhat delerious, but waxing and [**Doctor Last Name 688**]. Continues to have
mild diarrhea 2-4x a day. Able to get from bed to chair with
assistance. Tolerating ground solids.
Discharge Instructions:
You were admitted for low blood pressures after a dialysis
session. You were in the MICU for several days on a vasopressor
medicine that kept your blood pressure at a high level. We had
a difficult time removing fluids from your body during dialysis
while you had this low blood pressure.
.
Eventually we were able to wean you off the vasopressors. You
were treated for a possible infection with strong antibiotics.
None of the cultures came back, so we do not know if there was
an infection causing you to have these low pressures.
.
These pressures also affected your mental status. Some days you
were very delerious from having low pressures and having toxic
metabolic buildup in your blood from your multiorgan failure.
We monitored your electrolytes and liver function tests. You
started to improve over time but still have some good days and
bad days.
.
You had a bowel infection called c.diff this whole time. It
causes chronic diarrhea. We treated you with anitbiotics called
vanco and flagyl, both of which are taken by mouth. You stopped
taking these medicines on [**6-24**].
.
You also had heart problems during this hospitalization. For a
while, you were in a rhythm called atrial flutter. It caused
your heart rate to go very high, which is unsafe for your body.
We were able to start controlling it with medicines called
digoxin and amiodarone. The electrophysiologists helped us
choose and then further manage these medicines.
.
You also had some problems keeping you blood sugars high enough,
especially on days when you were confused and not eating well.
We treated you with IV fluids that had sugar in them. You did
well and when your mental status improved, we were able to take
that off. You should continue to try and eat as much as
possible several times a day to help your nutrition and blood
sugars.
.
You continued dialysis MWFs while an inpatient.
.
You will be discharged to a rehabilitation facility to start
working on your strength. You will need to continue dialysis.
You should come back to the hospital for any chest pain,
shortness of breath, dizziness, fainting, or other concerns.
Followup Instructions:
Neurology:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2156-7-19**] 4:30
.
PCP:
[**Name10 (NameIs) 357**] call [**Known firstname 2048**] [**Last Name (NamePattern1) 4223**] at [**Telephone/Fax (1) 7976**] to make an
appointment as needed once at rehabilitation.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2156-6-30**]
ICD9 Codes: 0389, 5856, 4240, 2749, 4280, 3572, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3120
} | Medical Text: Admission Date: [**2140-2-22**] Discharge Date: [**2140-2-24**]
Date of Birth: [**2066-3-12**] Sex: M
Service: NEUROLOGY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
Endotracheal intubation
radial arterial line
intra-arterial MERCI clot retrieval
History of Present Illness:
Pt. is a 73 y/o w/ a hx of prior TIA and HTN who was
brought to [**Hospital3 **] by EMS for acute onset of unresponsiveness
this afternoon, found to have bithalamic infarct on MRI.
History
is per daughter and wife (daughter interprets for wife, who does
not speak English)
They report that at 3:30 he was well, and was taking care of his
baby granddaughter. At 4:00 his wife heard him grunt and came
into the room to check on him. She found him sitting on the
couch. His left eye was rolling up, and his right eye was
staring forwards and wide open. His neck seemed stiff. His
left
hand was rubbing his belly, and he was kicking his left leg
irregularly. His right hand was curled into his body and stiff,
and he was not moving his right leg. He seemed to be grunting
and trying to speak, but could not produce any words. He was
drooling and both sides of his face seemed to be drooping. He
did initially seem to understand his wife, because she went to
get an emergency chinese herbal rememdy, and he stuck out his
tongue when she asked. She called his daughter, who called EMS.
EMS arrived around 4:15. He was transferred to [**Hospital3 **].
On exam there he is described as snoring and unresponsive. His
pupils were 5 mm and minimally reactive. He had decorticate
posturing, and his toes were upgoing bilaterally.
Past Medical History:
Hypertension
CAD
TIA 6 years ago in [**Country 651**], treated with an "IV medicine," no
residual
Social History:
lives with wife, daughter, and son in law, emigrated from [**Name (NI) 651**]
last [**Month (only) **], no tobacco, rare EtOH
Family History:
wife thinks his mother may have had a stroke
Physical Exam:
T- 97.5 BP- 168/85 HR- 71 RR- 18 O2Sat- 100% on RA
Gen: Lying in bed, intubated
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral 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: intubated, sedated, does not respond to voice or
sternal rub
Cranial Nerves:
pupils 7 mm, non-reactive. No EOM with Dolls (horizontal or
vertical) No gag with manipulation of ETT, minimal gag with
deep
suction. No corneals R or L.
Motor:
Normal bulk bilaterally. Tone flaccid in bilat UE. Trace
decerebrate posturing in both arms, triple flexion in both legs
with pain.
Sensation: no response to pain in any extremity
Reflexes:
Trace throughout.
Toes upgoing bilaterally
Coordination: not assessed
Gait: not assessed
Pertinent Results:
Labs:
OSH labs:
Na 137 K 3.8 Cl 103 HCO3 23 BUN 17 Cr 0.6 Gluc 146
INR 1.0 PT 11.7
Hct 44.8 Plt 155 WBC 3.0 Hgb 15.6
Imaging
CTA head and neck: Tip of basilar artery does not opacify
consistent with occlusion. The PCAs do opacify however,
probably
from collaterals given no PCOMs identified.
Dominant left vert.
Hypodensity of bilateral thalamus possible acute infarcts. No
ICH. Old right parietal infarct with ex vacuo dilataton of right
occipital [**Doctor Last Name 534**]. old infarct of genu of left internal capsule.
Paranasal sinus disease.
CT HEAD W/O CONTRAST [**2140-2-23**] 12:26 AM
FINDINGS: New hyperdensity is noted throughout the basilar
cisterns and layering within the bilateral sylvian fissures.
Discrete foci of relatively greater hyperdensity are noted
within the interpeduncular cistern and right quadrigeminal
cistern which measures 6 and 16 mm in size, respectively. The
lateral ventricles have slightly increased in size compared to
the prior study at 21:13. There is no shift of midline
structures. The cerebral sulci are slightly less well defined.
Redemonstrated is the area of old right frontoparietal
infarction and ex vacuo dilatation of the occipital [**Doctor Last Name 534**] of the
right lateral ventricle. An old small lacunar infarct near the
genu of the left internal capsule is again seen. Subtle thalamic
hypodensity seen on the prior study is less apparent. There are
small fluid levels in the sphenoid sinus air cells. Maxillary
sinus mucosal thickening is worse on the right. There is mucosal
thickening of the ethmoid air cells. Mastoid air cells remain
clear.
IMPRESSION:
1. Extravasated contrast and hemorrhage within the subarachnoid
space as described.
2. Slight increase in size of the lateral ventricles.
3. Old right frontoparietal infarction.
4. Old lacunar infarct of the genu of the left internal capsule.
5. Possible acute infarct of the thalamus.
6. Paranasal sinus disease as described.
Brief Hospital Course:
Pt is a 73 w/ a hx of prior TIA and HTN who was brought to [**Hospital1 **] by EMS for acute onset of unresponsiveness this
afternoon, found to have bithalamic infarct on MRI. On exam his
pupils are 7 mm and unreactive, he has no corneals and a very
weak cough with deep suction, and no EOM with Dolls. He has
decerebrate posturing in his arms and triple flexion in his legs
with pain. His exam is consistent with a top of the basilar
syndrome, which is indeed confirmed on CTA here and MRI at [**Hospital3 **].
1) Top of the basilar artery infarction-
He was out of the window for IVtPA at presentation. The patient
had bilateral thalamic infarctions at presentation with evidence
for lethal injury without emergent intervention. Neurosurgery
was cosulted re: the possibility of angiogram and possible clot
retreival. He was immediately taken to the interventional
neuroradiology suite where MERCI clot retrieval device was used
with successful opening of basilar artery, complicated by
rupture of the left PCA. The patient had a large subarachnoid
hemorrhage. The patient had minimal brainstem reflexes
following, and within hours no longer had a gag reflex or any
other spontaneous movements. He had fluctuating hyperthermia
followed by hypothermia suggestive of hypothalamic injury. A
formal braindeath examination was performed on HD #2 and the
patient met all clinical criteria for brain death including
apnea test. The family wanted family members to arrive from
other countries prior to withdrawal of care. The patient expired
shortly after extubation.
Medications on Admission:
Herbal remedy for HTN
ASA 81 mg QD
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3121
} | Medical Text: Admission Date: [**2184-6-20**] Discharge Date: [**2184-6-25**]
Date of Birth: [**2107-8-16**] Sex: M
Service: OMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76yo M with h/o nonsmall cell lung cancer, metastatic to chest
wall, spinal cord, and brain p/w 2d h/o SOB, fever, and vough
productive of yellow sputum. Pt. is s/p a recent right frontal
craniotomy and resection of metastatic tumor ([**5-19**]). He is
currently on taxotere chemotherapy, most recent dose on [**6-17**].
The patient says that he has been recovering well since the
surgery. Over the last two days, he developed the above
symptoms, plus intermittent chills. No N/V/CP/dysuria/no abd
pain, no headache, no neck pain, no change in mental status.
Upon arrival to ED patient was noted to be hypoxic with an O2
sat of 86% on r/a, up to 97% on non rebreather mask. He was
febrile to 101.4 and tachycardic with a heart rate of 122. A
chest X-ray revealed a persistent opacities in the RUL and RLL
(the pt. is s/p XRT to RUL). The RLL infiltrate was noted to be
suspicious for pneumonia.
Past Medical History:
1) Nonsmall cell lung cancer, dx'd [**2-24**], metastatic to chest
wall, also causing cord compression. S/p steroid tx, chemotx,
and XRT. S/p right frontal craniotomy on [**5-19**] for
metastatectomy.
2) PUD
3) hearing loss (secondary to perforated tympanic membrane)
4) COPD
Social History:
SHx:
tob: 1.5ppd x 65 years, quit two years ago
EtOH:
retired painter - lives with wife, has three children
Physical Exam:
PE: V/S: T 99.0, bp 140/52, P 97, spO2 97% on 100% NRB, RR 35
Gen: Elderly male, +temporal wasting, in respiratory distress,
taking rapid shallow breaths
HEENT: OP dry MM, PERRL, EOMI
NECK: no JVD
PULM: coarse bronchial breath sounds with expiratory wheezes
bilaterally, prolonged I:E ratio
COR: tachycardic S1/S2, no murmurs appreciated
ABD: S/ND/NT, +BS
EXT: no CCE
Pertinent Results:
[**2184-6-20**] 09:45PM GLUCOSE-155* UREA N-18 CREAT-0.6 SODIUM-138
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15
[**2184-6-20**] 03:08PM PO2-67* PCO2-37 PH-7.42 TOTAL CO2-25 BASE
XS-0
[**2184-6-20**] 10:40AM WBC-9.4 RBC-4.19* HGB-12.7* HCT-37.6* MCV-90
MCH-30.3 MCHC-33.8 RDW-18.2*
Brief Hospital Course:
IMP: 76 yo male with h/o NSCLC with clinical pneumonia
(shortness of breath, hypoxia, fever, productive cough).
Likely postobstructive given lung masses.
PLAN:
1) Hypoxia: most likely secondary to combination of poor lung
substrate (COPD / lung cancer) + added insult of infection
(pneumonia). Will provide supplemental O2 to keep sp)2 > 90,
but less than 95% given h/o COPD. Would check ABG.
2) Pneumonia: likely postobstructive. Would treat with
levofloxacin as well as provide anaerobic coverage with
metronidazole. Obtain sputum for gram stain and culture. Obtain
blood cultures to monitor for dissemination.
3) Lung cancer: disseminated. Current plans are for head XRT.
Continue steroids.
4) Brain mets: s/p recent surgery. Pt. to be seen by
neurosurgery.
5) COPD: underlying lung disease. Would provide nebs prn.
Patient already on antibiotics and steroids.
6) PPx: hep sc, PPi (steroids)
7) CODE: DNR/DNI --> had long discussion with the patient, his
wife, and his son [**Name (NI) **] (cell# [**Telephone/Fax (1) 38091**]); they do not want
his life dependent on a ventilator, should it come to that.
Hospital Course:
[**6-28**] transferred from ICU, Chest CT showed increased ground
glass opacities and interstitial infiltrates bilaterally.
[**6-22**]: did well through the day, no issues
[**6-23**]-off respiratory precautions
[**6-24**]:Improved. Likely D/c to rehab tomorrow
Medications on Admission:
MEDS (on admission)
decadron 2mg po qd (as part of taper)
oxycontin 10mg po hs prn
percocet prn
FeSO4 tab 325mg po qam
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO QPM PRN () as needed for
pain.
Disp:*20 Tablet Sustained Release 12HR(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Courtyard - [**Location (un) 1468**]
Discharge Diagnosis:
pneumonia
Discharge Condition:
stable
Discharge Instructions:
Rehab facility
Followup Instructions:
please follow up with Dr. [**Last Name (STitle) **]
([**Telephone/Fax (1) 5562**]
Completed by:[**2184-6-25**]
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3122
} | Medical Text: Admission Date: [**2160-10-22**] Discharge Date: [**2160-10-25**]
Date of Birth: [**2092-2-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 female with h/o severe COPD on home O2, hypothyroidism who
presented to [**Hospital6 4620**] Tuesday with several days
of increasing lethargy, confusion, and oxygen requirement. She
arrived in [**Location (un) 86**] on Sunday to visit her son, and has been more
lethargic and confused than normal, feeling unsteady on her
feet, and complaining of shortness of breath. She has not used
any inhalers, and her son has been increasing the amount of
supplemental oxygen to 5-6L/min. She did not take her regular
medications on Monday, and it was noticed that she had 21
lorazepam tabs when she left NY, and now only has about 5 left.
Her son called her pulmonologist in NY, who thought this could
be due to hypercapnea or too much lorazepam, and recommended
going to the ED.
.
She is a poor historian, though it sounds as though her
respiratory status has gotten much worse in the past 6 months,
at which time she has been on home O2. There has then been a
subacute decline over the past two weeks, which was noted by her
daughter in [**Name2 (NI) **] and then her son in [**Name (NI) 86**]. She has not had any
other symptoms recently, including cough, sputum production,
fever, chills, myalgias, nasal congestion.
.
She was diagnosed with "severe COPD" several years ago, and has
required home oxygen over the past few months. She does not
regularly use any inhalers, though notes that when she does use
albuterol she gets some relief. She was recently prescribed
combivent, but her psychopharmacologist recommended against it
b/c it made her agitated.
.
NWH course: She was found to be hypoxic to the 80s, afebrile,
normotensive, confused. Her initial ABG was 7.25/96/130. Once on
BiPAP, her SaO2 improved to 95%, and RR was 24-36. She was given
solumedrol 125mg, nebs. Repeat ABG was 7.41/60/60. She was less
confused. Her pulmonologist was contact[**Name (NI) **] and said she has
baseline very severe COPD, and agreed with DNR/DNI status and
use of non-invasive ventilation. There were no ICU beds at NWH,
so she was transferred to [**Hospital1 18**].
.
Review of Systems: As above. No f/c/night sweats. No abdominal
complaints, URI sx, urinary sx. No chest pain, orthopnea.
Past Medical History:
- COPD (unknown PFTs; on home 4 L/min oxygen) - dx 4-5 years ago
- Hypothyroidism
- Anxiety / panic attacks
Social History:
Widowed x 2. [**Hospital 8735**] medical interpreter. She has two children.
Lives alone in an apartment across the street from her daughter;
uses home O2 4L/min, drives, and is independent of ADLs. She is
a former smoker (30 pack year, quit in [**2145**]); denies EtOH.
Family History:
non-contributory
Physical Exam:
Vs- 98.9 axillary 134/86 22 94% on 30% ventimask, hr 104
Gen- mildly labored breathing, using excessory neck muscles,
speaking in three word phrases
Heent- PERRL, EOM intact, MMM
Neck- JVP flat, no LAD
Cor- RRR, nl S1/S2, no M/R/G
Chest- poor inspiratory effort, poor air movement, no crackles,
wheezes
Abd- + BS, soft, NT/ND
Ext- cool, poor capillary refill >2 sec
Neuro- not oriented to time or place (did not know she was in
[**Location (un) 86**])
Skin- no rashes, lesions
Msk- no pitting edema
Pertinent Results:
[**2160-10-22**] 01:48PM TYPE-ART TEMP-37.0 RATES-/12 O2 FLOW-2
PO2-72* PCO2-58* PH-7.48* TOTAL CO2-44* BASE XS-16 INTUBATED-NOT
INTUBA VENT-SPONTANEOU COMMENTS-NASAL [**Last Name (un) 154**]
[**2160-10-22**] 04:30AM GLUCOSE-171* UREA N-19 CREAT-0.6 SODIUM-140
POTASSIUM-4.0 CHLORIDE-92* TOTAL CO2-39* ANION GAP-13
[**2160-10-22**] 04:30AM estGFR-Using this
[**2160-10-22**] 04:30AM CK(CPK)-32
[**2160-10-22**] 04:30AM CK-MB-3 cTropnT-<0.01
[**2160-10-22**] 04:30AM CALCIUM-9.6 PHOSPHATE-2.4* MAGNESIUM-1.9
[**2160-10-22**] 04:30AM TSH-1.0
[**2160-10-22**] 04:30AM WBC-9.2 RBC-4.34 HGB-12.8 HCT-39.2 MCV-91
MCH-29.4 MCHC-32.5 RDW-13.6
[**2160-10-22**] 04:30AM PLT COUNT-264
[**2160-10-22**] 03:38AM TYPE-ART PO2-61* PCO2-65* PH-7.44 TOTAL
CO2-46* BASE XS-16
.
pCXR: 1. Findings suggesting COPD.
2. Suspected pulmonary hypertension.
3. No evidence of focal consolidation or congestive heart
failure.
.
MRI/A Brain:
The ventricles and extraaxial spaces are normal in size. There
is no evidence of midline shift, mass effect, or hydrocephalus
seen. There is no evidence of significant subcortical white
matter ischemic disease or evidence of acute infarct seen on
diffusion images. A linear flow void is incidentally noted in
the right corona radiata extending to the margin of the right
lateral ventricle indicative of a developmental venous normally.
There are no chronic microhemorrhages visualized on
susceptibility images.
Small retention cysts are visualized in both maxillary sinuses.
IMPRESSION: No evidence of acute infarct.
MRA OF THE HEAD:
Head MRA demonstrates normal flow signal within the arteries of
anterior and posterior circulation.
IMPRESSION: Normal MRA of the head.
Brief Hospital Course:
1. COPD flare: Patient was believed to have COPD exacerbation
due to viral URI, though etiology unclear. She was intially
treated with IV solumedrol and then switched to PO prednisone.
She did not require bipap or antibiotics and her symptoms
improved. She had negative cardiac enzymes x2 - 1 set here and
1 set at the OSH. Patient was noted not to be taking any short
or long acting bronchodialators or steroids as an outpatient.
She was discharged on prednisone 40 mg daily, to complete a 3
week taper. She was discharged on O2 continuos 3L, to be
increased to [**3-5**] with walking.
2.word finding difficulty: Complained of having difficulty doing
crossword puzzle after admission. MRI/A head was normal with no
CVA and normal flow. Seemed to resolve at discharge.
3.hypothyroidism: Continued on levothyroxine
4.hyperglycemia:blood sugar elevated on admit, likely due to IV
solumedrol, this resolved as her prednisone was decreased.
Follow up blood sugar with PCP.
5. anxiety: Continued on paxil and ativan
6. Code status: DNR/DNI no central lines.
Medications on Admission:
- paxil 10 mg [**Hospital1 **]
- lorazepam 0.5 mg [**Hospital1 **], (and prn)
- synthroid 0.125 mg qd
- [**Location (un) **] [**Doctor Last Name **]
- fish oil 2000mg [**Hospital1 **]
- mucinex
- albuterol prn
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for excess secretions.
5. Omega-3 Fatty Acids 550 mg Capsule Sig: Two (2) Capsule PO
BID (2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Prednisone 10 mg Tablet Sig: as dir Tablet PO once a day:
Take 4 tabs daily for next week, then take 3 tabs daily for a
week, then take 2 tabs daily for a week, then take one tab daily
for a week, then stop.
Disp:*70 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q3-4H (Every 3 to 4 Hours) as needed.
14. Home O2
Please wear 3L Continuos O2 via NC at all times, and 4-5L with
walking. Keep O2 sat 92-98%
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
COPD Flare
Anxiety
Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
Take medications as listed below. Follow up with your PCP [**Last Name (NamePattern4) **] [**12-3**]
weeks after discharge from rehab. Please also follow up with
your pulmonologist in [**12-3**] weeks after discharge from rehab.
Followup Instructions:
1. Follow up with your PCP [**Last Name (NamePattern4) **] [**12-3**] weeks after discharge from
rehab.
2. Please follow up with your pulmonologist in [**12-3**] weeks after
discharge from rehab as well. You may need some follow up PFTs.
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3123
} | Medical Text: Admission Date: [**2106-1-16**] Discharge Date: [**2106-1-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
lower gastrointestinal bleeding
Major Surgical or Invasive Procedure:
flexible sigmoidoscopy x 2
central line placement
History of Present Illness:
This is an 88 yo Cantonese-speaking female who presented with 2
episodes of BRBPR and called EMS. She was found to have an SBP
of 90 in the field and brought to the ED. She was given 1 liter
LR, 1500 cc NS, 1 U pRBC and transferred to the ICU. Per the
Cantonese interpreter, she denied any abdominal pain, but has
had recent weakness. She has a hx of liver disease and
hepatocellular carcinoma and has been followed by Dr. [**Last Name (STitle) 79140**] at
[**Hospital1 336**]
Patient was admitted to the MICU where she was observed to have
BM c BRBPR on [**1-17**]. She underwent flexible sigmoidoscopy without
any intervention. Patient subsequently had additional episodes
of bleeding with BMs on [**1-18**] and became hypotensive. She was
transfused packed red blood cells and and was rescoped. This
time she had derma-bond to two bleeding lesions. Patient has not
had any additional bowel movements since that time. Hct has
remained stable and she has remained hemodynamically stable.
Past Medical History:
-Type II Diabetes Mellitus
-Hypertension
-Hepatocellular Carcinoma, followed by Dr. [**Last Name (STitle) 79140**] at [**Hospital1 336**]. Per
PCP patient not interested in treatment
-Cryptogenic Cirrhosis
-Knee Osteoarthritis
-Asthma
Social History:
(per PCP): Lives with her husband. [**Name (NI) **] children (unknown how
many) who are not involved in her care. No tobacco or ETOH.
Family History:
Unknown
Physical Exam:
Exam on Admission To Hepatorenal Floor from MICU
Vitals: T 97.1 BP 132/68 HR 85 RR 22 O2 Sat 97% RA
Gen: well appearing, no acute distress
HEENT: NC/AT, OP clear
Lungs: CTAB, no wheezes or crackles
Heart: RRR, s1/s2 present, -mrg
Abd: +BS, soft, non-tender, non-distended
Ext: no edema, cyanosis or clubbing
Pertinent Results:
ADMISSION LABS:
CBC:
[**2106-1-16**] 08:45PM BLOOD WBC-4.0 RBC-2.08* Hgb-6.7* Hct-20.0*
MCV-96 MCH-32.5* MCHC-33.7 RDW-16.8* Plt Ct-70*
[**2106-1-16**] 08:45PM BLOOD Neuts-59.0 Lymphs-26.9 Monos-8.6 Eos-5.1*
Baso-0.4
COAGS:
[**2106-1-16**] 08:45PM BLOOD PT-22.3* PTT-56.9* INR(PT)-2.1*
CHEMISTRIES:
[**2106-1-16**] 09:15PM BLOOD Glucose-216* UreaN-19 Creat-1.1 Na-146*
K-3.6 Cl-113* HCO3-24 AnGap-13
[**2106-1-18**] 03:24AM BLOOD Calcium-7.3* Phos-3.8 Mg-1.9
LFTs:
[**2106-1-16**] 09:15PM BLOOD ALT-12 AST-26 LD(LDH)-212 AlkPhos-75
TotBili-0.6
HEPATITIS PANEL:
[**2106-1-16**] 09:15PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
[**2106-1-16**] 09:15PM BLOOD HCV Ab-NEGATIVE
----
----
DISCHARGE LABS:
[**2106-1-21**] 04:49AM BLOOD WBC-12.1* RBC-3.37* Hgb-11.0* Hct-30.8*
MCV-91 MCH-32.6* MCHC-35.8* RDW-17.8* Plt Ct-67*
[**2106-1-21**] 04:49AM BLOOD Glucose-164* UreaN-30* Creat-0.9 Na-143
K-4.1 Cl-113* HCO3-21* AnGap-13
MICROBIOLOGY:
[**2106-1-21**] 3:57 am STOOL CONSISTENCY: SOFT Source: Stool.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Pending at time of
discharge)
----
----
IMAGING STUDIES:
ABDOMINAL U/S [**2106-1-17**]:
IMPRESSION:
1. Left hepatic mass measuring 2.9 x 2.4 x 2.5 cm is compatible
with the
reported history of hepatocellular carcinoma.
2. Cholelithiasis without evidence of cholecystitis.
3. Normal hepatic arterial and venous waveforms without evidence
of
thrombosis.
Brief Hospital Course:
This is an 88 year old female with a history of cryptogenic
cirrhosis, hepatocellular carcinoma who presented with bright
red blood per rectum found to be secondary to bleeding rectal
varices.
# Rectal Variceal Bleed: Patient observed to have bowel
movements with bright red blood per rectum on [**1-17**]. She
underwent flexible sigmoidoscopy by the liver service which on
first flex sig did not observe active bleeding and no
interventions performed. On [**1-18**] patient had additional episodes
of bright red blood per rectum and had a repeat flex sig. On the
second flex sig two large rectal varices with hemocystic spots
were observed and injected with dermabond. Patient had no
additional episodes of bleeding after this intervention. In
total the patient was transfused 6 units of packed red blod
cells given she presented with a Hct of 20. Patient was on an
octreotide drip and ciprofloxacin for 72 hours. Patient should
follow up for repeat flex sigmoidoscopy in [**12-29**] weeks. Team to
discuss whether patient will follow up at [**Hospital1 18**] or [**Hospital1 336**] with
outpt PCP who is at [**Hospital1 336**] and will contact patient with this
information.
# Hepatocellular Carcinoma: Patient followed by Dr. [**Last Name (STitle) 79140**] an
oncologist at [**Hospital1 336**]. Per patient's PCP patient has not been
interested in undergoing treatment for her known cancer. We
suggested that the patient make sure she understand all
available treatment options and discuss these options with her
oncologist and PCP.
# History of Hypertension: Diovan and Diltiazem were held
initially given blood loss and episode of hypotension while in
the MICU. Medications were not restarted given that patient's
blood pressure was in a normotensive range. Patient has PCP
follow up on [**2106-1-29**] at which time she should have her blood
pressure rechecked.
# Asthma: Respiratory status remained stable. Patient's atrovent
and albuterol inhalers were continued. Theophylline was held
given that patient was on cipro. Patient may restart
theophylline on discharge.
# DM: Blood sugars remained stable. Per patient's PCP, [**Name10 (NameIs) **]
is no longer on treatment for her diabetes.
Medications on Admission:
-Diltiazem 300 mg daily
-Loratadine
-Diovan 160 mg [**Hospital1 **]
-Theophylline 200mg [**Hospital1 **]
-Atrovent inhaler [**Hospital1 **]
-Albuterol
-Hydrocodone-Acet 5-500
-Omeprazole 20mg daily
-Diabetic Boost 1 can TID
Discharge Medications:
1. 3 in 1 commode
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for shortness of
breath, wheezing.
4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain: Do not take more than
4 per day since this medication takes acetaminophen which could
be toxic to your liver.
5. Loratadine Oral
6. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO twice a day.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. diabetic boost 1 can TID
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health
Discharge Diagnosis:
Primary: Lower gastrointestinal bleeding secondary to rectal
variceal bleed
Secondary: Hepatocellular carcinoma, Asthma, Hypertension
Discharge Condition:
hemodynamically stable
Discharge Instructions:
You were admitted to the hospital with lower gastrointestinal
bleeding. We determined that you have rectal varices, that are
related to your chronic liver disease, were responsible for the
bleeding. You bleeding resolved after we did a procedure that
put applied a material to the varices to make them stop
bleeding. Following this procedure you did not have any further
bleeding and your red blood cell counts remained stable.
You should have this procedure repeated within the next [**11-27**]
weeks in order to prevent further rectal bleeding. We will
discuss setting up this procedure with your primary care
provider to determine whether it would be more convenient for
you to have this procedure done at [**Hospital 4415**]
versus [**Hospital1 18**].
STOP TAKING:
Diltiazem
Diovan
If you experience any additional episodes of rectal bleeding,
not chest pain, shortness of breath or dizziness please contact
your primary care physician immediatley or come to the emergency
department for evaluation.
Followup Instructions:
We suggest that you have another flexible sigmoidoscopy in order
treat your rectal varices. You should have this within the next
2-3 weeks. We will talk with your doctor and discuss whether you
should return to our hospital to have this or go to [**Hospital 58906**], where you receive most of your care. Either us
or your doctor's office will contact you with this information.
You are scheduled to see your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1057**],
[**2106-2-2**] at 11:20 am.
Completed by:[**2106-1-21**]
ICD9 Codes: 5849, 4019, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3124
} | Medical Text: Admission Date: [**2179-7-26**] Discharge Date: [**2179-8-4**]
Date of Birth: [**2105-7-27**] Sex: F
Service: ORTHOPAEDICS
Allergies:
seasonal
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation L4-S1
History of Present Illness:
Ms. [**Known lastname 33813**] has a long history of back and leg pain. She has
failed conservative therapy and is electing to proceed with
surgical intervention.
Past Medical History:
HTN, barrett's espophagus, hypothyroid, hyperlipidemia
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2179-7-28**] 05:30AM BLOOD WBC-6.8 RBC-3.00* Hgb-9.5* Hct-26.7*#
MCV-89 MCH-31.5 MCHC-35.4* RDW-15.1 Plt Ct-136*
[**2179-7-27**] 09:00PM BLOOD Hct-21.1*#
[**2179-7-26**] 07:19PM BLOOD WBC-8.4 RBC-3.66* Hgb-11.6* Hct-32.7*
MCV-89 MCH-31.6 MCHC-35.3* RDW-12.8 Plt Ct-177
[**2179-7-28**] 05:30AM BLOOD Glucose-118* UreaN-18 Creat-1.4* Na-136
K-4.9 Cl-103 HCO3-25 AnGap-13
[**2179-7-28**] 03:03AM BLOOD Glucose-112* UreaN-18 Creat-1.5* Na-135
K-5.0 Cl-102 HCO3-26 AnGap-12
[**2179-7-26**] 07:19PM BLOOD Glucose-163* UreaN-19 Creat-1.1 Na-137
K-3.3 Cl-99 HCO3-23 AnGap-18
[**2179-7-28**] 03:03AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname 33813**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2179-7-26**] and taken to the Operating Room for L4-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. However, she developed new onset of right
leg weakness and absent peripheral pulses. CTA showed likely
left posterior tibial artery occlusion for which she was started
on heparin; she had a spontaneous return of pulse and heparin
was stopped. Initial postop pain was controlled with a Dilaudid
PCA.
.
The pt was scheduled for the posterior surgery [**7-28**] but became
combative, confused and tried to pull out her lines in the
pre-op area. The pt started to desat to the 70s and the
anesthesia team decided to intubate. CT of the head was taken to
rule out hemmorhage given recent use of heparin. CTA of chest
was taken, given pts suspected DVT and recent surgery and wet
read was negative for PE. In the PACU she also required norepi
pressor support. Her abdomen was noted to be distended, and
there was difficultly placing an OGT. She was transferred to the
MICU. She was started on Vanc/Zosyn given hypoxia, hypotension,
and small pleural effusions on CT chest, although she was
afebrile. General surgery was consulted for distended abdomen
and elevated bladder pressures, who did not believe she had
abdominal compartment syndrome. KUB showed ileus and there was
no obstruction on CT. RP hematoma had been seen on L spine CT
[**2179-7-28**] (5.8 x 3.5 cm), and was stable on CT [**2179-7-29**] (5.3 x 3.6
cm). Hct was stable. The cause of her acute delerium was
uncertain, but felt to be multifactorial given the Dilaudid PCA
and pt's regular EtOH use.
.
On [**2179-7-30**], she went back to the OR for the posterior approach.
Please see the operative notes for further details.
Post-operatively she developed a pneumonia and was placed on
Cipro. She continued to improve and was able to work with
physical therapy. She was discharged to rehab in good condition
and tolerating a regular diet.
Medications on Admission:
[**Doctor First Name 130**], atenolol 25, levothyroid 88, nexium 40, simvastatin 20
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. quetiapine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
6. pantoprazole 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. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: Began [**8-3**].
9. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Lumbar stenosis and spondylosis
Acute post-op delerium
Post-op pneumonia
Post-op acute blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: Activity as tolerated
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to change the dressing daily.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2179-8-4**]
ICD9 Codes: 486, 5185, 2851, 4019, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3125
} | Medical Text: Admission Date: [**2198-12-8**] Discharge Date: [**2198-12-31**]
Date of Birth: [**2198-12-8**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] "[**Name2 (NI) 333**]" [**Known lastname 37443**], Twin II, is a 34-2/7 week
gestation who was admitted to the NICU for management of
prematurity.
Mother is a 34-year-old Gravida 1, para 0 woman. Prenatal
surface antigen negative, RPR nonreactive, Rubella immune,
GBS unknown. Maternal history of infertility from
endometriosis. Pregnancy notable for invitro conception with
selective reduction of one (Triplets to twins). Mother was being
monitored by serial fetal ultrasounds, all reportedly okay.
Mother presented on [**2198-12-7**] with spontaneous, premature
evidence of chorioamnionitis. She was started on Ampicillin
and Erythromycin and allowed to labor. Labor was augmented
with Pitocin. Due to failure to progress, infants were delivered
by cesarean section. Clear fluid, no maternal fever.
This triplet emerged with good color and spontaneous crying.
Dried, suctioned and stimulated. Responded well. Apgars
were 7 at 1 minute and 8 at 5 minutes. He was shown to his
parents and then transported to the Neonatal Intensive Care
Unit for management of prematurity.
PHYSICAL EXAMINATION ON ADMISSION:
Weight 2670 grams (75 to 90 percentile), length 47 cm (75th
percentile). Head circumference 33 cm (75 to 90 percentile).
Active, alert, tone slightly decreased, anterior fontanel
open and flat. Palate intact, positive red reflex both eyes.
No respiratory distress. Bilateral breath sounds clear and
equal. No grunting, flaring or retracting. No murmur,
regular rate and rhythm, pink, pulses +2 and equal. Abdomen:
Soft, nondistended. No hepatosplenomegaly. Three vessel
cord, anus patent, spine intact, no dimple, hips stable,
normal male genitalia.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Infant did not require supplemental oxygen this
hospitalization. Infant has remained in room air with
respiratory rates 40 to 50. His last apnea and bradycardia was
on [**2198-12-25**]. Infant did not receive methylxanthine
therapy (caffeine) this hospitalization.
Cardiovascular: Hemodynamically stable throughout this
hospitalization. No murmurs. Heart rate 140 to 150.
Fluid, Electrolytes and Nutrition: Enteral feedings of
premature Enfamil 20 calories per ounce with iron was started
on date of delivery and advanced to 150 cc's per kilo per day
by day of life five. Infant tolerated feeding advancements
without difficulty, initally by gavage, then shifting to oral
feedings. Maximum caloric density was premature Enfamil 24
calories per ounce. Infant is currently on Enfamil 20 calories
per ounce p.o. taking a minimum of 150 cc's per kg per day. Most
recent weight is 3075 grams, head circumference 34.5 cm, length
50.8 cm.
Gastrointestinal: Most recent bilirubin from day of life
three was 7.2/0.2. Infant did not receive phototherapy this
hospitalization.
Hematology: Infant did not require blood transfusion this
hospitalization. Most recent hematocrit from the day of
delivery was 46.5, platelets 281, white blood cell count
10.2.
Infectious Disease: Infant received 48 hours of Ampicillin
and Gentamicin initially for rule out sepsis, blood cultures
have remained negative to date.
Neurology: Infant does not meet criteria for head ultrasound.
Audiology: Sensory audiology hearing screening was performed
with automated auditory brainstem responses. Infant passed
both ears.
Ophthalmology: Infant does not meet criteria for ophthalmology
exam.
Psychosocial: [**Hospital1 69**] social
work was involved with the family. The contact social worker
can be reached at [**Telephone/Fax (1) 8717**]. Parents involved.
CONDITION ON DISCHARGE: Former 34-2/7 week twin II now
37-4/7 weeks corrected,stable in room air.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7867**],
[**Telephone/Fax (1) 37440**], Fax #[**Telephone/Fax (1) 37444**].
CARE/RECOMMENDATIONS:
Feedings at discharge: Enfamil minimum 150 cc's per kg per
day 20 calories per ounce with iron p.o.
Medications: Fer-in-[**Male First Name (un) **] 2 mg per kg per day.
Car seat position screening: Infant passed car seat test.
State newborn screening status: State Newborn screen sent on
[**2198-12-11**] showed a slightly elevated 1708HP of 64.5. Repeat
newborn screen sent on [**2198-12-24**] was within normal range.
Immunizations: Infant received Hepatitis B vaccine on
[**2198-12-23**]. Infant does not meet criteria for Synagis RSV
prophylaxis.
FOLLOW-UP APPOINTMENT:
1. Primary pediatrician appointment on [**2199-1-1**].
2. Visiting Nurses Association.
DISCHARGE DIAGNOSIS:
1. Prematurity, 34-2/7 weeks, twin gestation.
2. Rule out sepsis.
3. Apnea of prematurity, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33795**], M.D. [**MD Number(1) 35944**]
Dictated By:[**Last Name (NamePattern1) 35945**]
MEDQUIST36
D: [**2198-12-31**] 15:23
T: [**2198-12-31**] 15:47
JOB#: [**Job Number 37445**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3126
} | Medical Text: Admission Date: [**2103-8-29**] Discharge Date: [**2103-9-25**]
Date of Birth: [**2021-5-20**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Worsening L heel/leg ulcers
Major Surgical or Invasive Procedure:
[**2103-9-6**] L BKA
History of Present Illness:
Patient is an 82 year old female who came into vascular clinic
for a routine follow up visit. She was examined in clinic
today,
the bandage was taken down and her left leg wound began bleeding
profusely. The bleeding was controlled and the wound was
rewrapped and she was admitted to the vascular surgery service.
This is an ulcer which has not been healing for many months now,
at least 4 months, possibly quite a bit longer. She had 3
months
ago, in clinic she was noted to have a 3 x 3 cm ulceration on
the
lateral aspect of her left tibia. She c/o bilateral foot pain.
With the right [**5-20**] and the left [**10-20**]. Both feet throb, non
radiating and constant. Pain alleviated with tylenol and
aggrivated by foot manipulation.
Past Medical History:
COPD, DM-2, HTN, CVA, hyperlipidemia, CAD, depression,
CHF, uterine prolapse, PVD, osteoarthritis, and had an
appendectomy in the distant past.
Social History:
Currently resides at [**Hospital3 537**].
Family History:
Non-contributory
Physical Exam:
97.4 72 112/70 15 95% RA
NAD
RRR
CTA B
S/NT/ND
wounds c/d/i. L BKA, staples intact
Right- staples medially, has hematoma all along the incision
line
Pulses:
dopplerable DP and PT signals on right
Pertinent Results:
[**2103-9-25**] 09:13AM BLOOD WBC-9.6 RBC-3.80* Hgb-10.9* Hct-34.4*
MCV-90 MCH-28.6 MCHC-31.6 RDW-16.5* Plt Ct-345
[**2103-9-25**] 09:13AM BLOOD Plt Ct-345
[**2103-9-24**] 08:24AM BLOOD Glucose-92 UreaN-8 Creat-0.5 Na-140 K-4.3
Cl-102 HCO3-32 AnGap-10
Cardiology Report
ECG Study Date of [**2103-9-4**] 5:22:40 AM
Sinus rhythm. Low QRS voltage is non-specific but clinical
correlation is
suggested. Since the previous tracing of [**2103-6-6**] right axis
deviation and
early precordial QRS transition are absent and generalized low
QRS voltage is now seen.
Radiology Report
FOOT AP,LAT & OBL LEFT Study Date of [**2103-8-29**] 5:22 PM
FINDINGS:
Three views of the left foot demonstrate osteopenia. There is
hallux valgus metatarsus and varus with mild degenerative
changes of the first MTP. There are mild degenerative changes of
the first TMT. There is subchondral sclerosis at both aspects of
the TMT joints. There is mild enthesopathy at the dorsal and
plantar calcaneal insertions. No frank osteomyelitis is
identified in the foot.
ART DUP EXT LO UNI;F/U LEFT Study Date of [**2103-8-30**] 9:15 AM
IMPRESSION: Patent left femoropopliteal bypass graft with low,
resistive
flow. The below-knee popliteal artery appears to occlude not far
below the
terminus of the bypass graft.
ART EXT (REST ONLY) Study Date of [**2103-8-30**] 9:15 AM
IMPRESSION: Severe bilateral lower extremity occlusive disease
without
Doppler flow below the knee. PVRs are aphasic in the calf levels
distally.
CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Study Date of
[**2103-8-31**] 12:32 PM
IMPRESSION:
1. Occlusion of left fem-[**Doctor Last Name **] bypass at its proximal end. Left
external iliac stent is patent. Occlusion of the left SFA and
portions of the left anterior tibial and left posterior tibial
arteries.
2. Occlusion of the right SFA at its mid portion. Areas of
occlusion in the mid course of the right anterior tibial and
right posterior tibial arteries.
3. Indeterminate bilateral low-attenuation adrenal nodules.
Differential
diagnosis includes adrenal adenomata, but they should be
monitored on follow up imaging.
CHEST (PRE-OP PA & LAT) Study Date of [**2103-9-4**] 10:53 AM
FINDINGS:
Since the previous study,the left lower lobe atelectasis is
unchanged. The
lungs are clear with no mass, consolidation or pneumothorax.
Cardiomediastinal silhouette is normal.
IMPRESSION: No acute cardiopulmonary findings
Brief Hospital Course:
[**2103-8-29**] Patient admitted for worsening LLE ulcers. Started on
braod spectrum antibiotics (Vanco, Cipro, Flagyl). NIAS
requested for LE's, foot x-ray, routine wound care.
[**2103-8-30**] HD1: Patient had episodes of hypoglycemia associated
with somnolence, with Metformin on hold, d/c'd Pioglitazone.
Continued routine wound care, and broad spectrum antibiotics.
Podiatry consulted re: L heel ulcer- will need LBKA if
circulation cannot be restored.
[**2103-8-31**] HD2: No acute events. Continued routine wound care, and
broad spectrum antibiotics. Patient had a CTA bilateral lower
extremities- demonstrated 1. Occlusion of left fem-[**Doctor Last Name **] bypass at
its proximal end. Left external iliac
stent is patent. Occlusion of the left SFA and portions of the
left anterior
tibial and left posterior tibial arteries. 2. Occlusion of the
right SFA at its mid portion. Areas of occlusion in the mid
course of the right anterior tibial and right posterior tibial
arteries, will need Right femoral-to-dorsalis pedis bypass with
in
situ saphenous vein graft in the future, to be done after L BKA.
8/22-24/09 HD3-5: No acute events. Continued routine wound care,
and broad spectrum antibiotics. Booked for LBKA on [**2103-9-4**]. Made
NPO, pre-oped, IV hydrated and consented for L BKA.
[**2103-9-4**] HD6: Day of proposed surgery, patient at the last minute
is refusing to have surgery (L BKA), procedure was re-booked for
[**2103-9-6**]. Family contact[**Name (NI) **] and made arrangements for someone to
be in w/ patient prior to going to the OR for her L BKA.
Continued routine wound care, and broad spectrum antibiotics.
[**2103-9-5**] HD7: No acute events. Continued routine wound care, and
broad spectrum antibiotics. Made NPO and IV hydrated for L BKA
the next day.
[**2103-9-6**] HD8: No acute events. Taken to OR and underwent L BKA.
Patient tolerated procedure, recovered in the PACU then
transferred back to [**Hospital Ward Name 121**] 5 floor. Diet and PO meds resumed. Pain
well controlled w/ current medications.
[**2103-9-7**] HD9/POD1: Hct is down to 25.4, transfused w/ 1 unit
PRBCs. Placed on BKA pathway. Physical therapy referral placed.
Rehab screening requested. Family and patient decided to go
ahead w/ plans for Right femoral-to-dorsalis pedis bypass to be
done during this admission. Booked for [**2103-9-14**].
[**Date range (1) 89694**]/HD10-16/POD6: Continued BKA pathway. Speech and swallow
evaluation to evaluate for aspiration and diet recs- continue
ground solids and thin liquids. Poor po intake calorie count x 3
days, started Megase. PICC placed for better access, placement
confirmed w/ CXR. Continued IV antibiotics. Lisinopril,
Mirtazipine and Furosemide discontinued for low BP. [**9-13**]
Pre-oped, consented, made NPO after MN, IV hydarted for Right
femoral-to-dorsalis pedis bypass.
[**2103-9-14**] HD17/POD7: Taken to OR for Right femoral-to-dorsalis
pedis bypass with in
situ saphenous vein graft. Patient tolerated procedure,
recovered in the PACU then transferred to VICU [**Hospital Ward Name 121**] 5. Routine
post BKA care. Restarted Heparin drip post-op. Placed lower
extremity bypass pathway.
[**2103-9-15**] HD18/POD7/1: Hct down to 27.8 <-31.5, transfused w/ 1
unit PRBC's. Fluid resuscitated. Pain managed w/ IV Morphine
prn. Continued IV antibiotics. Resume po meds and diet.
Continued LE bypass pathway.
[**2103-9-16**] HD19/POD8/2: Patient noted to have right unilateral upper
extremity swelling, Ultrasound was done and ruled out for UE
DVT. Continued IV antibiotics. Continued w/ Heparin drip. Pain
managed w/ IV Morphine prn. Fluid bolus for low urine output.
[**2103-9-17**] HD20/POD9/3: Hct down to 24.9 <-30.1, transfused w/ 1
unit PRBC's. Continued on LE bypass and BKA pathways. Continued
IV antibiotics and Heparin drip. Diet advanced.
[**2103-9-18**] HD21/POD10/4: WBC elevated, pan cultured, CXR
taken-possible basilar consilidation. First C-diff came back
negative. Urine cultures-negative, blood cultures still pending.
Heparin drip d/c'd. Electrolytes repleted.
[**2103-9-19**] HD22/POD11/5: WBC coming down. Poor PO intake,
reconsulted speech and swallow- recs ground solids and nectar
thickened liquids, supplements w/ every meal and calorie counts
for 3 days. Hct continue to fall now 24.3, transfused w/ 1 unit
PRBCs. Poor urine output since MN, IV fluid bolused after blood
transfusion. Urine lytes sent FENa 0.06%, Cr 0.4.
[**2103-9-20**] HD23/POD12/6: Continued LE bypass and BKA pathways.
Transfused 1 unit of PRBCs. Urine poutput remain marginal, good
response to low dose Lasix. Rehab screen requested.
[**2103-9-21**] HD24/POD13/7: No acute events. Given low dose lasix
again w/ good response. [**Hospital 25403**] rehab bed.
[**Date range (1) 95755**]: Patient did well over the weekend. No acute
events. Discharged to rehab in good consition on [**2103-9-25**].
Medications on Admission:
Meds: Lisinopril 10 mg daily
Atorvastatin 10 mg QHS
Atenolol 50 mg daily
Donepezil 10 mg QHS
Mirtazapine 30 mg QHS
Pioglitazone 15 mg DAILY
Acetaminophen 500 mg (2) Tablet PO Q 8H prn pain
Docusate Sodium 100 mg Capsule [**Hospital1 **]
Ipratropium Bromide 17 mcg/Actuation Aerosol 1-2 Puffs
Inhalation QID
Aspirin 325 mg PO DAILY
Oxycodone 5 mg 1 Q6H prn pain
Senna 8.6 mg Tablet [**Hospital1 **]
Bisacodyl 5 mg Tablet, Delayed Release (E.C.) 2 PO DAILY prn
constipation.
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Inhalation Q4H prn SOB.
Lasix 20 mg Tablet daily.
Metformin 500 mg Tablet PO twice a day.
Namenda 10 mg PO daily.
Humalog Insulin SC per Fingerstick
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for prn pain.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 1-2 Puffs
Inhalation QID (4 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 for
constipation.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB/wheezing.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily ().
12. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
13. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
14. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
16. Ipratropium Bromide 0.02 % Solution Sig: [**1-12**] Inhalation Q6H
(every 6 hours) as needed for wheezing.
17. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Skilled Nursing Center - [**Location (un) 1456**]
Discharge Diagnosis:
PVD w/ ischemic L leg/foot and failed bypass
Ischemic right leg
Acute anemia-related to operations-required blood transfusions
History of:
COPD
DM-2
HTN
CVA
hyperlipidemia
CAD
depression
CHF
uterine prolapse
PVD
osteoarthritis
PSH: [**2103-6-6**] L femAKpop w/NRSVG, L EIA stent, s/p appy
Discharge Condition:
Stable
Lasix on hold, rehab to determine need to resume
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Amputations Discharge Instructions
ACTIVITIES:
- no driving till FU
- may shower, no tub baths
- no stump shrinkers, may ace
- no pillows under hip/knee
WOUND:
- staples will remain till FU
- Keep wound dry and clean, call if noted to have redness,
draining, swelling, or if temp is greater than 101.5
DIET:
- Diet as tolerated eat a well balanced meal
- Your appetite will take time to normalize
- Prevent constipation by drinking adequate fluid and eat foods
[**Doctor First Name **] in fiber, take stool softener while on pain medications
- PATIENT WILL NEED LOTS OF ENCOURAGEMENT TO ENSURE ADEQUATE
NUTRITIONAL INTAKE
MEDICATIONS:
- Continue all medications as directed
- Take your pain medications conservatively
- Your pain will get better over time
Followup Instructions:
Call Dr.[**Name (NI) 1392**] office for FU appointment. Phone:
[**Telephone/Fax (1) 1393**]
follow up in [**2-13**] weeks
Completed by:[**2103-9-25**]
ICD9 Codes: 2851, 4280, 3572, 496, 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3127
} | Medical Text: Admission Date: [**2131-8-12**] Discharge Date: [**2131-8-24**]
Date of Birth: [**2061-5-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Aspirin / Lisinopril / Ibuprofen / Metoprolol Tartrate
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2131-8-20**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending
with vein grafts to obtuse marginal and PLV
History of Present Illness:
Mr. [**Known lastname **] is a 70 year old Russian speaking male with h/o 3
vessel coronary artery disease on cath [**2126**] s/p DES to mid LAD,
who presented to PCP [**Name Initial (PRE) 151**] 1 month of exertional angina. Pt sent
for stress test and it was stopped d/t fatigue and patient was
sent home. Shortly after the stress test, pt was called by a
doctor to return to the ED.
Past Medical History:
Coronary Artery Disease s/p stent mid LAD [**2126**]
Hypertension
Hyperlipidemia
Gastroesophageal reflux disease
Bilateral Knee pain
Chronic breathing problems/[**Name2 (NI) **] d/t Chernobyl - pt worked close
Social History:
Lives with: wife
[**Name (NI) **]: Caucasian
Tobacco: quit [**2108**], 22 pack year hx
ETOH: social
Family History:
denies
Physical Exam:
Pulse:72 Resp:16 O2 sat: 100% RA
B/P Right:180/85 Left: 160/85
Height:5'7" Weight:210 LBS, 95.3 KG
General: NAD, alert, cooperative
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] NO Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None [X]
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: NONE Left: NONE
Pertinent Results:
[**2131-8-13**] Cardiac Cath: 1. Selective coronary angiography in this
right dominant system demonstrated three vessel disease. The
LMCA had a distal 20% stenosis. The proximal LAD had 90% ostial
in-stent restenosis with mild luminal irregularities. There was
60% stenosis of the mid-LAD. The distal wraparound LAD was 30%
stenosed. The proximal LCx had a 90% lesion at the bifurcation
of OM1, the mid LCx had 60% stenosis. The OM2 was 90% occluded.
The RCA had 50% mid and 60% distal disease. The RPDA was
occluded at the origin and supplied by right to right
collateral. 2. Limited resting hemodynamics revealed a central
aortic pressure of 164/86mmHg. 3. Left ventriculography was
deferred.
[**2131-8-14**] Carotid Ultrasound: Less than 40% stenosis in the right
and left internal carotid arteries.
[**2131-8-15**] Echocardiogram: The left atrium is moderately dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic arch is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve 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 no pericardial effusion.
[**2131-8-23**] CXR: PA and lateral chest radiographs are compared to
[**2131-8-21**]. The cardiomediastinal contours are stable. Bilateral
pleural effusions are probably unchanged in size. Bibasilar
atelectasis and overall lung aeration compared to the
examination from two days prior have improved. Median sternotomy
wires appear vertically oriented and intact.
[**2131-8-12**] 11:30AM BLOOD WBC-8.1 RBC-4.25* Hgb-13.8* Hct-39.6*
MCV-93 MCH-32.4* MCHC-34.7 RDW-13.6 Plt Ct-237
[**2131-8-24**] 05:05AM BLOOD WBC-7.0 RBC-2.79* Hgb-9.0* Hct-26.1*
MCV-93 MCH-32.1* MCHC-34.4 RDW-13.9 Plt Ct-193
[**2131-8-12**] 11:30AM BLOOD PT-12.8 PTT-25.3 INR(PT)-1.1
[**2131-8-20**] 04:54PM BLOOD PT-15.8* PTT-63.8* INR(PT)-1.4*
[**2131-8-12**] 11:30AM BLOOD Glucose-105 UreaN-15 Creat-0.9 Na-139
K-4.3 Cl-106 HCO3-24 AnGap-13
[**2131-8-24**] 05:05AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-135
K-3.9 Cl-98 HCO3-28 AnGap-13
[**2131-8-14**] 06:40AM BLOOD ALT-13 AST-15 AlkPhos-81 TotBili-0.9
[**2131-8-13**] 06:30AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0
[**2131-8-23**] 05:46AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1
[**2131-8-14**] 10:05AM BLOOD %HbA1c-5.7
[**2131-8-24**] 05:05AM BLOOD WBC-7.0 RBC-2.79* Hgb-9.0* Hct-26.1*
MCV-93 MCH-32.1* MCHC-34.4 RDW-13.9 Plt Ct-193
[**2131-8-24**] 05:05AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-135
K-3.9 Cl-98 HCO3-28 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent cardiac catheterization
which revealed severe three vessel coronary artery disease - see
result section for details. Prior to catheterization, he
underwent Aspirin desensitization. Following cardiac cath he
underwent pre-operative work-up for bypass surgery. Prior to
surgery though he required Plavix washout. On [**2131-8-20**] 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
CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. On post-operative day one he was transferred to
the telemetry floor for further care. Chest tubes and epicardial
pacing wires were removed per protocol. He remained stable
during his post-operative course and was seen by physical
therapy for strength and mobility. There were no significant
post-op events besides a rise in his WBC that trended back down
to 7 by discharge. Also, all cultures taken were negative. On
post-operative day four he appeared to be doing well and was
discharged home with VNA services and the appropriate follow-up
appointments.
Medications on Admission:
Medications at home:
Nifedipine SR 60mg daily
Simvastatin 40mg qHS
HCTZ 25 mg qHS
Inhouse:
ASA (desensitized [**2131-8-13**])
Heparin SC TID
Colace PRN
Plavix 75 mg daily
Plavix - last dose:300mg [**8-12**] + 75 mg [**8-13**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*1*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease, s/p Coronary Arteyr Bypass Graft x 3
Hypertension
Dyslipidemia
Gastroesophageal reflux disease
s/p Stent placement to LAD [**2126**]
Bilateral knee pain
Chronic breathing problems/[**Name2 (NI) **] d/t living near Chernobyl
s/p Appendectomy
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns
Followup Instructions:
[**Hospital Ward Name 121**] 6 in 2 weeks for wound check
Dr. [**Last Name (STitle) **] in [**5-6**] weeks, call for appt
Dr. [**Last Name (STitle) 3357**] in [**3-6**] weeks, call for appt
Dr. [**Last Name (STitle) 52994**] in [**3-6**] weeks, call for appt
Completed by:[**2131-8-24**]
ICD9 Codes: 4111, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3128
} | Medical Text: Admission Date: [**2170-11-5**] Discharge Date: [**2170-11-27**]
Date of Birth: [**2130-9-30**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Bactrim Ds
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
right IJ placement
History of Present Illness:
40 M with HIV (CD 4=664 in [**2169**] and 189 on [**2170-11-5**]) but no
history of opportunistic infections who presents with 2 days of
fevers to 102 for which he took tylenol. He had a cough
productive of clear sputum and back pain secondary to a deep
cutaneous abscess. He presented to the ED on [**2170-11-5**] with fever
and abscess. The abscess was I&D'd and he was given fluids for
tachycardia and oxacillin for abscess. He then abruptly dropped
his BP to 60's, a sepsis protocol was initiated and a total of 5
L fluid were given. A central line was placed, vanc, ceftriaxone
and dilaudid were given in the ED. Admitted to the [**Hospital Unit Name 153**] for
closer monitoring of hypotension and tachycardia. Blood cultures
from [**2170-11-5**] grew MRSA x 2. Surgery following. ID consulted for
antibiotic therapy and ?indications for propylaxis given low
CD4.
Past Medical History:
1. HIV: diagnosed in [**2158**], on ZDV/3TC/nevirapine (per OMR note
but patient denies ever being on HAART), currently no meds,
followed by Dr [**Last Name (STitle) 4844**]
2. Seasonal allergies
3. Right hand tendonitis
4. s/p T and A
5. Right knee cellulitis (MSSA, [**3-21**])
6. H/o strep pharyngitis, HSV, skin abscesses (per OMR)
Social History:
Lives alone, currently single, smokes 1 ppd x 12 years, past
ecstacy and Ketamine use
Family History:
Non-contributory
Physical Exam:
Tm=102.1 Tc=98.6 P=95 (92-104) BP=110/65 (110/65-124/59)
RR=21 100% RA
Gen - Alert, no acute distress, lying on R side, unable to move
secondary to vac dressing
HEENT - PERRL, extraocular motions intact, anicteric, moist
mucous membranes, poor dentition
Neck - 10 cm JVD, no cervical lymphadenopathy, submandibular
lymphadenopathy
Chest - Right upper lobe crackles, decreased breath sounds at
the bases bilaterally R>L
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tenderness; lower back with vac
dressing draining 2 cm incised lesion
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**3-1**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Pertinent Results:
MRI [**11-19**]: Essentially stable appearance of soft tissue
edema/inflammation
without evidence of osteomyelitis or drainable abscess
collection. Slightly
heterogeneous signal within the dependent portions of the iliac
bones is non-
specific, and most likely represents hematopoietic marrow.
CT abdomen [**11-18**]: No intra-abdominal fluid collections.
CT chest [**11-14**]: Multiple nodular and focal patchy opacities
bilaterally of different sizes, many of which show evidence of
cavitation. The largest of these within the
right upper lobe although all lobes are affected. These findings
are
consistent with septic emboli. 2. Elevation of the right
hemidiaphragm. Tiny right-sided pleural effusion which is
layering posteriorly. 3. Gastric varices.
MRI Pelvis [**2170-11-7**]: No evidence of intraosseous infection.
CXR [**2170-11-7**] AP: Increased right pleural effusion with right
lower lobe atelectasis vs. PNA. Increased pulmonary edema vs.
diffuse infection.
CXR [**2170-11-6**] AP: Left upper lobe, right upper lobe infiltrates
suggestive of PMA. Diffuse intersitital opacities suggestive of
pulmonary edema vs. infxn
[**2170-11-5**] 07:35AM WBC-12.9* LYMPH-8* ABS LYMPH-1032 CD3-82
ABS CD3-845 CD4-18 ABS CD4-189* CD8-59 ABS CD8-613 CD4/CD8-0.3*
[**2170-11-5**] 07:35AM PLT COUNT-240
[**2170-11-5**] 07:35AM WBC-12.9* RBC-5.24 HGB-14.6 HCT-42.8 MCV-82
MCH-27.9 MCHC-34.1 RDW-12.1
[**2170-11-5**] 07:35AM NEUTS-84.4* LYMPHS-8.3* MONOS-6.6 EOS-0.4
BASOS-0.4
[**2170-11-5**] 07:35AM CORTISOL-25.6*
[**2170-11-5**] 07:35AM ALBUMIN-3.9 CALCIUM-9.0 PHOSPHATE-2.9
MAGNESIUM-1.5* URIC ACID-3.8
[**2170-11-5**] 07:35AM LIPASE-12
[**2170-11-5**] 07:35AM ALT(SGPT)-23 AST(SGOT)-21 LD(LDH)-147 ALK
PHOS-102 AMYLASE-28 TOT BILI-0.9
[**2170-11-5**] 07:35AM GLUCOSE-111* UREA N-11 CREAT-0.8 SODIUM-132*
POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-27 ANION GAP-15
[**2170-11-5**] 08:06AM LACTATE-2.3*
[**2170-11-26**] 10:31AM BLOOD WBC-4.1 RBC-4.34* Hgb-11.5* Hct-35.3*
MCV-81* MCH-26.5* MCHC-32.7 RDW-14.6 Plt Ct-419
[**2170-11-5**] 07:35AM BLOOD WBC-12.9* Lymph-8* Abs [**Last Name (un) **]-1032 CD3%-82
Abs CD3-845 CD4%-18 Abs CD4-189* CD8%-59 Abs CD8-613
CD4/CD8-0.3*
[**2170-11-21**] 05:00AM BLOOD WBC-3.7* Lymph-42 Abs [**Last Name (un) **]-1554 CD3%-91
Abs CD3-1408 CD4%-29 Abs CD4-454 CD8%-57 Abs CD8-888*
CD4/CD8-0.5*
[**2170-11-22**] 05:50AM BLOOD ALT-46* AST-30 CK(CPK)-20* AlkPhos-131*
TotBili-0.2
[**2170-11-19**] 10:06AM BLOOD ALT-57* AST-41* LD(LDH)-174 AlkPhos-127*
Amylase-39 TotBili-0.2
[**2170-11-25**] 03:28AM BLOOD Vanco-14.5*
Brief Hospital Course:
1. sacral abscess - Abscess was incised and drained in the ED.
Surgery consult obtained, and this was felt to be subcutaneous
abscess rather than pilonidal cyst. Wound cultures grew out
MRSA. Pt placed on vancomycin, ultimately for a 4-week course.
Wound vac was placed, with surgery following and doing dressing
changes. Wound vac discontinued prior to discharge per surgery
team; wet-to-dry dressings were performed, and eventually dry
gauze dressings. No evidence of further infection, with abscess
appearing to be healing well by discharge. Pt will follow up
with Dr. [**Last Name (STitle) **] in surgery in 4 weeks.
2. MRSA sepsis - Pt was admitted to the [**Hospital Unit Name 153**] from the ED on a
non-rebreather mask, hypotensive on a levophed drip which was
weaned off and the patient remained stable, transferred from
[**Hospital Unit Name 153**] to the floor on [**2170-11-8**]. On arrival, pt's CVP continued
to be low ([**4-23**]), with further fluid resuscitation resulting in
adequate BP. Levophed drip was stopped 48 hours later, and BP
remained stable throughout rest of course. Pt had multiple
further blood cultures for surveillance purposes, which were
negative. Last positive blood culture was on [**11-5**]. Pt on
vanco for 4 week course after first negative blood culture.
Vancomycin trough levels were persistently low, with continual
uptitrating of the dose, up to 1750mg IV q12, and then
ultimately was 1000mg IV q8h with a therapeutic trough level.
3. pneumonia - Pt noted to have multiple patchy opacities on
CXR and chest CT, some of these lesions were noted to be
cavitating. ID was involved early in the course of [**Hospital **]
hospital stay. 3 AFB smears were negative, PCP via sputum
induction was negative, Legionella urinary antigen was negative,
Cryptococcus negative. A PPD was placed, which was negative, as
well. CXR showed right pleural effusion with right lower lobe
atelectasis vs. pneumonia. This was evaluated with U/S probe and
it was determined that the fluid collection was too small to be
tapped. Findings on CT scan were consistent with septic emboli,
so a TTE and then TEE were performed, both of which were
negative for any vegetations. Per ID, it is thought that these
are septic emboli, likely of MRSA, from some intravascular
source but not valvular vegetations. The appearance of these
nodules, in their cavitations is consistent with Staph
pneumonia, possibly from hematogenous spread. Pt was placed on
4 week course of vanco, and he continued to improve overall,
feeling well by the time of discharge. He maintained good O2
sats and showed no respiratory distress. A followup CT scan was
arranged prior to discharge, and pt will follow up in [**Hospital **] clinic
to determine if the vancomycin may be discontinued.
4. fevers - fevers persisted even with the vancomycin on board.
Pt's cultures were consistently negative and no changes noted
on repeat chest imaging. Pt clinically was well-appearing in
the last week or so before discharge, but was still having
fevers. Other sources of fever were searched for: an abdominal
CT showed no fluid collections or occult abscesses; an MRI of
the sacral area near the abscess ruled out osteomyelitis. It
was thought that perhaps his subtherapeutic vanco dose might be
responsible for this. However, no further causes of infection
were found, and pt was clinically well. Pt remained afebrile
for > 4 days prior to discharge.
5. HIV - CD4 count low 189, but pt had an acute infectious
process going on. Repeat CD4 count when pt more stable was 454.
Bactrim prophylaxis was stopped. Pt will follow up with Dr.
[**Last Name (STitle) 4844**] in [**Month (only) 404**] of next year. No HAART while in house.
6. HSV - pt had some oral HSV and completed a 7-day course of
famciclovir with resolution of symptoms.
7. gastric varices - varices were found incidentally on CT
scan. LFTs were mildly elevated. Pt asymptomatic. Abd CT scan
did not comment on any liver abnormalities. An outpatient EGD
appointment was arranged to better assess these varices, as well
as a subsequent liver clinic appointment.
8. PPX: H2 blocker, SQ heparin
9. FULL CODE.
10. Dispo: Patient will be discharged to home with VNA for PICC
care, as well as help with dressing changes.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for insomnia.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
6. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
7. Vancomycin HCl 500 mg Recon Soln Sig: 1250 (1250) mg
Intravenous Q12H (every 12 hours) for 11 days: Last day of
treatment in [**12-6**]. Patient may need longer duration of therapy
to be determined by outpatient infectious disease doctor.
[**Last Name (Titles) **]:*22 doses* Refills:*0*
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous QD () as needed: to PICC.
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. saline heparin flushes per VNS protocol
11. PICC line care
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] HOME THERAPIES
Discharge Diagnosis:
Primary diagnoses:
MRSA sacral abscess
MRSA bacteremia
Septic Pulmonary Emboli
HIV
Secondary diagnoses:
Gastric Varices, seen on CT scan
Seasonal allergies
Right hand tendonitis
s/p T and A
Right knee cellulitis (MSSA, [**3-21**])
h/o strep pharyngitis, HSV, skin abscesses (per OMR)
Discharge Condition:
stable. pain well controlled. wound healing well.
Discharge Instructions:
Please call your doctor and return to the hospital for
fever/chills, increasing warmth, pain, redness, or swelling from
the abscess, general malaise, diarrhea, or any other concerns
you may have.
Please go to all of your appointments.
Followup Instructions:
You have the following appointments:
1) Provider: [**Name10 (NameIs) **] SCAN Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2170-12-1**] 10:15
This is on the [**Hospital Ward Name 517**]. Please do not eat any solid food 3
hours beforehand. ***Before this appointment, please call ([**Telephone/Fax (1) 26760**] to update your information.
2) MD Where: LM [**Hospital Unit Name 4337**] DISEASE
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2170-12-3**] 10:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9406**], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2170-12-3**] 10:30
3) Dr. [**Last Name (STitle) **] - surgery - to take a look at your abscess
[**2170-12-24**], 1:00PM; in [**Hospital Ward Name 23**] building (Surgical
Subspecialties); phone number ([**Telephone/Fax (1) 26761**]
4) [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**], Dr.[**Name (NI) 4864**] nurse practitioner
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], RNC Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2170-12-25**]
11:00
5) Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2171-2-7**] 9:50
6)Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX)
Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2170-12-20**] 10:00
***You need to arrive at 9 am.
Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Where: GI ROOMS
Date/Time:[**2170-12-20**] 10:00
This is for evaluation of your liver
7) Liver Clinic appointment: to follow up with liver scan
[**2171-2-26**] at 9 am [**Location (un) **] Dr. [**Last Name (STitle) 10924**]
ICD9 Codes: 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3129
} | Medical Text: Admission Date: [**2164-12-21**] Discharge Date: [**2164-12-23**]
Date of Birth: Sex:
Service:
ADMISSION DIAGNOSES:
1. Status post motor vehicle collision.
2. Anoxic brain injury.
3. Hypernatremia.
4. Cardiac contusion.
5. Subdural hematoma.
DISCHARGE DIAGNOSES:
1. Brain death secondary to anoxic brain injury.
2. Status post motor vehicle collision.
3. Anoxic brain injury.
4. Hypernatremia.
5. Cardiac contusion.
6. Subdural hematoma.
HISTORY OF PRESENT ILLNESS: [**Known firstname 46**] [**Known lastname 75745**] is a 23 year-old
gentleman who was in a high speed motor vehicle collision
with rollover and subsequent submersion into water on
[**12-21**] of [**2164**]. From the transferring hospital reports,
the time of submersion was at least 3 minutes before the
patient was extricated. The patient was immediately intubated
in the field and transferred via Life Flight from regional
hospital for management. The patient arrived to the [**Hospital1 1444**] on [**12-21**] intubated with
stable hemodynamics.
PAST MEDICAL HISTORY: His past medical history was unknown.
Upon the initial trauma survey, the patient was found to be
neurologically unresponsive. The only neurologically
suppressive medication he had been given prior to transfer
was succinylcholine for the intubation. He was found to be
unresponsive. Corneal, gag and cough reflexes were all
absent. No motor function was present in the extremities. His
pupils were fixed and dilated. His examination was otherwise
only remarkable for some superficial lacerations without
significant bleeding. His lab values upon admission were
notable for a hematocrit of 45.3. His sodium was 146. His
troponin value was 0.11. His lactate value was 4.1. It
should also be noted that the patient was normothermic on
admission. In terms of his imaging, review of imaging from
the referring hospital demonstrated a subdural hematoma which
was not causing significant mass effect or shift but there
was significant blurring of the [**Doctor Last Name 352**]-white matter interface.
His chest x-ray demonstrated diffuse alveolar opacities with
edema, consistent with his prior neurologic injury.
HOSPITAL COURSE: Upon initial presentation to the trauma
bay, there was significant evidence based on the patient's
mechanism of injury, examination and imaging that he had
suffered an irreversible injury. A neurosurgical
consultation was obtained as well. The neurosurgical service
concurred that the patient's major injury was likely anoxic
brain injury from his submersion. They felt that the
subdural hematoma was likely not contributing to his absence
of brain stem reflexes. Given these findings, there was no
role for any significant additional intervention. The family
arrived shortly after the [**Hospital 228**] transfer to the [**Hospital1 1444**]. Family meeting was held
immediately discussing his grave prognosis and the lack of
recoverable function. The family understood this and
requested some additional time for additional family members
to arrive. The patient remained intubated and was transferred
to the trauma surgical intensive care unit. The family had
been in discussion with the [**Location (un) 511**] organ bank and
supportive therapy was provided during the remainder of his
48 hour hospitalization until final decisions regarding organ
donation could be made, as well as arrival of additional
family members. During the course of his hospitalization, [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] brain scan was obtained. This showed no evidence of
perfusion to the cerebral cortex consistent with brain death.
The patient expired on [**2164-12-23**].
[**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 67332**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2165-7-1**] 17:23:39
T: [**2165-7-1**] 18:04:55
Job#: [**Job Number 75746**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3130
} | Medical Text: Admission Date: [**2147-12-1**] Discharge Date: [**2147-12-8**]
Date of Birth: [**2076-8-5**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 71 year-old
male with known coronary artery disease status post
myocardial infarction in [**2142**] with stents to left anterior
descending coronary artery and tissue plasminogen activator.
Since then the patient felt well. Over the past five to six
months he began to experience exertional angina. On the [**1-30**] the patient underwent ETT and was positive for
ischemic responses. Subsequently a catheterization showed
left main normal, left anterior descending coronary artery
80% mid occlusion, left circumflex 80% obtuse marginal one,
right coronary artery 80% proximal.
PAST MEDICAL HISTORY: Hypertension, diabetes, anterior wall
myocardial infarction in [**2142**] and benign prostatic
hypertrophy.
PAST SURGICAL HISTORY: Polyp removal and a deviated septum.
MEDICATIONS AT HOME: Norvasc 5 mg po q.d., Micronase 5 mg po
q.d., Ecotrin 325 mg po q.d., Imdur 30 mg po q.d., Lopressor
50 mg po b.i.d.
HOSPITAL COURSE: The patient was initially managed on the
Medicine Service and then on [**2147-12-4**] the patient
underwent coronary artery bypass graft times five, left
internal mammary coronary artery to left anterior descending
coronary artery, saphenous vein to left anterior descending
coronary artery, saphenous vein to obtuse marginal, saphenous
vein graft to PLV and saphenous vein graft to obtuse marginal
one by Dr. [**First Name (STitle) 10102**]. Postoperatively, the patient did well.
The patient was extubated and went off all drips in the
Intensive Care Unit and was transferred onto the floor on
postoperative day number two. Upon transfer to the floor the
only complications was that the patient developed atrial
fibrillation on [**2147-12-5**]. The rate was controlled
and the patient was subsequently started on Amiodarone. Also
on postop day number two the patient's Foley was discontinued
at midnight, however, the patient was unable to void
subsequently and the Foley catheter was reinserted and voided
approximately 1 liter of urine was drained out and it was
decided to leave the Foley catheter in.
Prior to discharge the patient was able to work with physical
therapy and was able to achieve a level five. He was able to
walk 300 feet and climb stairs.
DISCHARGE MEDICATIONS: Lopressor 75 mg po b.i.d., Lasix 20
mg po b.i.d. times ten days, potassium chloride 20
milliequivalents po b.i.d. times ten days, Micronase 5 mg po
q.d., Amiodarone 400 mg po t.i.d. times four days and then
400 mg po b.i.d. times a week and then 400 mg po q.d.
Percocet one to two tabs po q 4 to 6 hours prn, Colace 200 mg
po q.d.
CONDITION ON DISCHARGE: The patient was afebrile and vital
signs were stable. Chest was clear. Heart was a regular
rate and rhythm and in normal sinus. Sternum was stable.
Incision was clean, dry and intact. No drainage.
The patient will be discharged with a Foley catheter in and
the patient's daughter is a nurse and she stated that she can
take out the Foley 48 hours later and the patient will be
followed up by Dr. [**Last Name (STitle) 39819**], telephone number is
[**Telephone/Fax (1) 39820**] the urologist that the patient sees. His office
is already contact[**Name (NI) **] and aware of the plan and the patient is
also told to follow up with Dr. [**First Name (STitle) 10102**] in three to four
weeks.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 02-253
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2147-12-8**] 09:03
T: [**2147-12-8**] 09:15
JOB#: [**Job Number 39821**]
ICD9 Codes: 9971, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3131
} | Medical Text: Admission Date: [**2152-9-21**] Discharge Date: [**2152-9-26**]
Service: MEDICINE
Allergies:
Penicillins / Codeine / Sulfonamides / Aspirin / Valium /
Erythromycin Base / Ciprofloxacin / Biaxin / Acyclovir / Zestril
/ Egg / Oxycontin
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo F w/ ipf, chf, cad, sjogren's syndrome presenting c/o
severe shortness of breath for "many days." Pt reports that she
has shortnes of breath at baseline (no home O2). She was in her
usual state of health, which consists of chronic shortness of
breath and Left sided nonradiating chest pain, for which she
uses NTG 1-2 times a day. Pt is status post RCA stenting three
years ago, since then with recurrent chest pains but negative
nuclear tests, thus suggesting noncardiac origin of the chest
pains. Pt went to her cardiologist ([**Doctor Last Name **]) for routine
f/u today. She reported worsening shortness of breath, and on
exam she "appeared uncomfortable, shivering and tachypneic. The
respiratory rate is 40 per minute. Her blood pressure is 95/70
in both arms seated, pulse is 60 and regular." She was sent to
ER for respiratory distress and lower than normal pressure. She
reports 2 episodes of left sided nonradiating non-pleuritic
sharp chest pain with no diaphosesis at rest each lasting 10
minutes and resolving without intervention (once while in the
cardiologist's office and once while in the ED). She reports
that this chest pain is consistent with recurrent chest pain
that she has had at basline. ROS positive for chills and
rhinorhea and 2 pillow orthopnea; but no PND or leg edema, no
fevers, denies nausea/vommitting/diarrhea, no cough, no dysuria.
Per ED discussion with pcp- [**Name10 (NameIs) **] has had multiple episodes of
dyspnea with CP which is attributed to anxiety and then resolves
after r/o MI.
.
In the ED: T 97.0 HR 58 BP 106/69 RR 25 SzO2 95%2L. Pt given
ativan and rountine labs with CE, EKG, and CXR. EKG with no
change, first set of CE negative, and admitted to medicine.
Past Medical History:
-- CAD: s/p MI x2; s/p Cypher stent to RCA in [**2148**]; [**12-12**] P-MIBI:
Normal pharmacologic stress myocardial perfusion with normal
left ventricular cavity size and wall motion.
-- CHF: Echo [**2151-3-4**] EF >55%, 1+MR, 1+ TR, mild PA systolic
pressure
-- Hypertension
-- Diabetes mellitus
-- Atrial fibrillation - per history but currently in sinus. Not
on coumadin
-- Sjogren's syndrome / scleroderma.
-- squamous cell carcinoma
-- Interstitial lung disease
-- osteoporosis, with vertebral compression fractures.
-- GERD / esophageal dysmotility / peptic ulcer disease.
-- Macular degeneration
-- h/o DVT
-- s/p colectomy
-- s/p CVA x4
-- s/p TAH/RSO
-- s/p post appendectomy
-- h/o femoral hernia repair
Social History:
[**Hospital1 18**] employee x 36 years, widowed for 38 years, 2 children (58
and 67). Pt does not see family often as live in [**State **] and
[**State 4565**] Smoked for about 5 years 3 packs per day. Gave up
about 65 yrs ago. Her husband was a heavy smoker, no alcohol.
Walks with a cane, reports not leaving the house often (can walk
to [**Location (un) **] Corner, about [**12-7**] mile). Lives alone w/ VNA 2x per
week.
Family History:
One child died at age 60 of CAD/cancer. Father died at 52 of MI.
Physical Exam:
Vitals - T 98.4 BP 144/68 HR 64 RR 26 SaO2 100% on 3.5L NC
General - pt is elderly female in moderate distress, shivering,
and tachypnic
HEENT - Brige of nose with scabed over lesion, [**Name (NI) 3899**], Pt blind,
MMM, OP clear
Neck - no thyromegaly, no lad, jvp flat
CV - nml s1 s2 rrr no m/r/g
Lungs - cta bil no rales/rhonchi/wheeze
Abdomen - +bs, soft, ntnd, no hsm
Ext - no c/c/e
neuro: a&ox3, moving all extremities, nonfocal
Pertinent Results:
[**2152-9-21**] 02:34PM TYPE-[**Last Name (un) **] PO2-38* PCO2-23* PH-7.64* TOTAL
CO2-26 BASE XS-4 COMMENTS-GREEN TOP
[**2152-9-21**] 02:34PM LACTATE-3.4*
[**2152-9-21**] 02:30PM GLUCOSE-100 UREA N-18 CREAT-1.2* SODIUM-137
POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-23 ANION GAP-17
[**2152-9-21**] 02:30PM estGFR-Using this
[**2152-9-21**] 02:30PM CK(CPK)-75
[**2152-9-21**] 02:30PM cTropnT-<0.01
[**2152-9-21**] 02:30PM CK-MB-NotDone proBNP-4429*
[**2152-9-21**] 02:30PM WBC-14.2* RBC-4.23 HGB-13.7 HCT-38.0 MCV-90
MCH-32.4* MCHC-36.1* RDW-15.0
[**2152-9-21**] 02:30PM NEUTS-62.6 LYMPHS-27.3 MONOS-8.5 EOS-0.8
BASOS-0.6
[**2152-9-21**] 02:30PM PLT COUNT-195
[**2152-9-21**] 02:30PM PT-11.3 PTT-23.8 INR(PT)-1.0
.
.
Imaging:
[**2152-9-21**] CXR -
1. Evidence of pulmonary fibrosis, unchanged.
2. Stable cardiomegaly.
3. Overall no change since [**2152-8-14**].
Brief Hospital Course:
[**Age over 90 **] yo F w/ Sjogren's syndrome/Scleroderma, esophageal
dysmotility, CAD s/p MI X 2 and s/p RCA stent, "chest pain
syndrome" resulting in numerous admisssions and extensive
negative work-up, who presents with SOB.
.
# Shortness of breath/chest pain - Pt has presented with similar
symptoms multiple times in the past. Pt does have a hx of
coronary artery disease and is status post RCA stenting 3 years
ago, but has had recurrent chest pains on multipls occasions
since which have been worked up with negative nuclear tests,
thus suggesting noncardiac origin of the chest pains. She was
ruled out for MI w/ serial EKG's and cardiac enzymes. While on
the medical floor the patient became extremely anxious and
developed a respiratory alkalosis to 7.84 and transferred to the
MICU for observation. Anti-anxiolytics were used with good
effect. Geriatrics was consulted to assist in anxiety control
and recommended clonazepam 0.25 mg [**Hospital1 **] w/ lorazepam rescue. She
was also instructed in the use of a brown paper bag to control
anxiety -related SOB.
.
#Gout
Patient experienced an acute episode of gout in her right big
toe. This was treated w/ 2 days of PO prednisone 40 mg. She
will continue 3 more courses to complete 5 total days of 40 mg
daily prednisone.
.
# CAD
Patient was ruled out for MI as stated above. Her home dose of
beta blocker, statin, and aspirin were continued.
.
# HTN
Well controlled on home BP meds (valsartan, nifedipine,
metoprolol).
.
# DM
Patient is currently diet controlled. However, w/ prednisone
will continue sliding scale until she completes prednisone.
.
# Sjogrens/Scleroderma
Pt has history of IPF associated with connective tissue disease.
On no current therapy.
Medications on Admission:
Albuterol 1-2 Puffs Q6H PRN
Aspirin 81 mg daily
Calcium Carbonate 500 mg TID
Valsartan 160 mg daily
Nitroglycerin 0.3 mg PRN
Nifedipine 60 mg SR daily
Hexavitamin daily
Metoprolol 100mg [**Hospital1 **]
Atorvastatin 80 mg daily
Isosorbide Mononitrate 60 mg SR TID
Ipratropium inhalations QID
Fosamax 70 mg weekly
Protonix 20 mg daily
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO TID (3 times a
day).
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
12. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO at bedtime.
13. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED) for 3 days: See sliding scale.
15. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days.
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
21. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary: Non-cardiac Chest Pain, Gout
.
Sencondary:
- Coronary Artery Disease
- Anxiety disorder, NOS
- Congestive Heart Failure
-- Hypertension
-- Diabetes mellitus
-- Atrial fibrillation - Not on coumadin
-- Sjogren's syndrome / scleroderma.
-- squamous cell carcinoma
-- Interstitial lung disease
-- osteoporosis, with vertebral compression fractures.
-- GERD / esophageal dysmotility / peptic ulcer disease.
-- Macular degeneration
-- h/o Deep Venous Thrombosis
-- status post colectomy
-- status post CVA x4
-- status post Total Abdominal Hysterectomy /Right Salpingo
Ooporectomy
-- status post post appendectomy
-- status post femoral hernia repair
Discharge Condition:
Stable, chest pain resolved, SaO2 95% on RA
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
chest pain. You were monitored in the Medical Intensive Care
Unit because of your breathing. We think that your breathing
difficulty may be related to external stressors.
.
You also had a gout flare which was treated with prednisone.
Please continue to take this for the full course. If you have
continued fevers, worse pain in the toe or elsewhere, please let
your caretakers know or call your doctor.
.
If you have any symptoms of worsening shortness of breath, chest
pain, abdominal pain, nausea, vommiting, or any other concerning
symptoms please go to the emergency room.
Followup Instructions:
Provider PULMONARY BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2152-9-27**] 1:30
Provider [**Name9 (PRE) 1570**],INTERPRET [**Name Initial (PRE) **]/LAB NO CHECK-IN PFT INTEPRETATION
BILLING Date/Time:[**2152-9-27**] 1:30
Provider [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2152-9-27**] 2:00
Provider [**Name9 (PRE) **],[**First Name3 (LF) 251**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 250**] [**2152-10-3**] @ 12:20
ICD9 Codes: 4280, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3132
} | Medical Text: Admission Date: [**2142-10-5**] Discharge Date: [**2142-10-25**]
Date of Birth: [**2065-11-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Mental status change/Chest pain
Major Surgical or Invasive Procedure:
[**2142-10-10**] - CABGx3
History of Present Illness:
The patient is 76-year-old man who presented with increasing
angina and shortness of breath. Catheterization showed severe
left main and left-sided
coronary artery disease. Ejection fraction was preserved. He had
mild mitral regurgitation. It was elected to proceed with bypass
surgery.
Past Medical History:
Hypercholesterolemia
HTN
?Parkinson's disease vs. Alzheimers
BPH
NPH (hydrocephalus) s/p VP shunt
Back surgery
Social History:
Lives with wife. [**Name (NI) 4084**] smoked and drinks rarely.
Physical Exam:
GEN: Elderly man in NAD
HEENT: NCAT, PERRL, EOMI, OP benign
NECK: Supple No JVD
HEART: RRR, no murmur
LUNGS: Clear
ABD: Benign
EXT: 2+ pulses, no edema, no varicosities.
NEURO: Slowed speech, A+Ox3.
Pertinent Results:
[**2142-10-5**] 08:52PM PT-12.7 PTT-26.9 INR(PT)-1.1
[**2142-10-5**] 08:52PM PLT COUNT-352
[**2142-10-5**] 08:52PM WBC-14.7* RBC-4.36* HGB-13.5* HCT-37.3*
MCV-86 MCH-30.9 MCHC-36.1* RDW-13.3
[**2142-10-5**] 08:52PM %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE
[**2142-10-5**] 08:52PM ALT(SGPT)-57* AST(SGOT)-39 LD(LDH)-282* ALK
PHOS-202* TOT BILI-0.4
[**2142-10-5**] 08:52PM GLUCOSE-109* UREA N-18 CREAT-1.1 SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12
[**2142-10-24**] 06:30AM BLOOD WBC-17.0* RBC-3.08* Hgb-9.3* Hct-27.0*
MCV-88 MCH-30.3 MCHC-34.6 RDW-14.7 Plt Ct-543*
[**2142-10-24**] 06:30AM BLOOD Plt Ct-543*
[**2142-10-24**] 06:30AM BLOOD Glucose-85 UreaN-22* Creat-1.4* Na-137
K-4.4 Cl-103 HCO3-26 AnGap-12
[**2142-10-5**] CXR
1. No evidence of pneumonia or effusions.
2. Calcified pleural plaques bilaterally.
[**2142-10-16**] CXR
Decreased small left pleural effusion.
[**2142-10-22**] HEAD CT
1. Air fluid level in the partially visualized right maxillary
sinus which could represent sinusitis. Further evaluation could
be obtained with a sinus CT.
2. Possible disruption of the VP shunt catheter as it courses in
the posterior scalp. Comparison with prior outside exams is
recommended to exclude the possibility of shunt malfunction.
3. Moderate hydrocephalus, possibly related to #2.
[**2142-10-18**] Video Swallow
1. One trace aspiration event with nectar-thick liquid was
observed under fluoroscopy. Aspiration did not occur with other
consistencies.
2. The patient has a significant amount of retained material in
the valleculae following swallowing, especially with solids. He
is not aware of the retained material, and alternating solid and
liquid consistencies seen to be effective at clearing retained
material.
[**2142-9-20**] Chest CT
1. Bilateral pleural effusions and pericardial effusion.
2. Multiple calcified pleural plaques, consistent with prior
asbestos exposure.
3. Minimal soft tissue stranding adjacent to the sternum,
reflecting post- surgical change from recent sternotomy wire for
CABG. Additionally, there is focal soft tissue thickening at the
level of the aortic root, which also likely reflects
post-surgical change. No definite fluid collections are
identified adjacent to the sternum.
[**2142-10-12**] EKG
Sinus rhythm. Right bundle-branch block. Compared to the
previous tracing
of [**2142-10-11**] the rate is slower.
[**2142-10-22**] Head CT
1. Air fluid level in the partially visualized right maxillary
sinus which could represent sinusitis. Further evaluation could
be obtained with a sinus CT.
2. Possible disruption of the VP shunt catheter as it courses in
the posterior scalp. Comparison with prior outside exams is
recommended to exclude the possibility of shunt malfunction.
3. Moderate hydrocephalus, possibly related to #2.
Brief Hospital Course:
Mr. [**Known lastname 65399**] was admitted to the [**Hospital1 18**] on [**2142-10-5**] for surgical
management of his coronary artery disease. He was worked-up in
the usual preoperative manner by the cardiac surgical service.
The date of his case was postponed due to a catheterization lab
emergency. On [**2142-10-10**], Mr. [**Known lastname 65399**] was taken to the operating
room where he underwent coronary artery bypass grafting to three
vessels. Postoperatively he was taken to the cardiac surgical
intensive care unit for monitoring. On postoperative day one,
Mr. [**Known lastname 65399**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta
blockade, plavix and aspirin were resumed. He developed
leukocytosis and was pancultured. He was prophylactically
started on vancomycin, levofloxacin and fluconazole. His
cultures were negative except for MRSA in the sputum without
clinical findings of pneumonia. He developed rapid atrial
fibrillation which was treated with beta blockade and
amiodarone. Gentle diuresis was initiated. The physical therapy
service was consulted for assistance with his postoperative
strength and mobility. As Mr. [**Known lastname 65399**] was noted to cough with
feedings, a swallow evaluation was performed. As he did not show
clinical signs of aspiration when fully awake and alert, a
supervised regular diet was recommended. On postoperative day
five, Mr. [**Known lastname 65399**] was transferred to the step down unit for
further recovery. Given his continued leukocytosis, the
infectious disease service was consulted. a C. difficile toxin
was negative on several occasions. His fluconazole and
levofloxacin were discontinued. Mild serosanguinous drainage was
noted from his sternotomy. A chest CT was performed which was
not suggestive of mediastinitis. A head CT scan was suggestive
of sinusitis as well as possible disruption of the VP shunt
catheter as it courses in the posterior scalp (outside film
correlation was recommended) and moderate hydrocephalus. A
repeat speech and swallow consult was performed as Mr. [**Known lastname 65399**]
continued to display signs of difficulty swallowing. A video
swallow was obtained which showed functional oral and pharyngeal
swallowing ability for moist/ground solids and thin liquids if
he takes a sip after each bite. There was significant residual
in his throat that he was likely unable to feel thus sipping
after each bite was encourage. A diet of ground and pureed foods
with this liquids was recommended. A hematology/oncology consult
was obtained given his persistent leukocytosis to evaluate for a
malignancy. A blood smear was evaluated which suggested no
evidence of a hematologic malignancy. Follow-up was recommended
after discharge if his white cell count had not normalized. The
neurosurgery service was consulted to evaluate his VP shunt. A
CT shunt series was performed which showed the shunt to be
intact without signs of infection or failure. Over time, Mr.
[**Known lastname 65400**] white blood cell count slowly trended towards normal.
Stopped [**2142-10-24**]
Mr. [**Known lastname 65399**] continued to make steady progress and was discharged
to rehabilitation on postoperative day 15. He will follow-up
with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician
as an outpatient.
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. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
Disp:*60 Packet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs qs for one month* Refills:*2*
7. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*40 Tablet(s)* Refills:*2*
9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*qs qs 1 month* Refills:*2*
11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 7 days: Then one tablet po qd x 7 days.
Disp:*21 Tablet(s)* Refills:*0*
13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*qs qs one month* Refills:*2*
14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs qs one month* Refills:*2*
15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
16. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name 62491**]HealthCare
Discharge Diagnosis:
CAD
HTN
Hyperlipidemia
Acute MI
BPH
Hydrocephalus (NPH) with VP shunt
Leukocytosis
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These innclude
redness, drainage or increased pain.
2) Monitor vital signs. Report any weight gain of greater then 2
pounds in 24 hours or 5 pounds in 1 week.
3) No creams, lotions or powders to wound until it has healed.
4) No lifting more then 10 pounds for 10 weeks. No driving for 1
month.
5)
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month.
Follow-up with your cardiologist in 2 weeks.
Follow-up with your primary care physician [**Last Name (NamePattern4) **] 2 weeks.
Completed by:[**2142-10-25**]
ICD9 Codes: 2761, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3133
} | Medical Text: Admission Date: [**2168-2-1**] Discharge Date: [**2168-2-17**]
Date of Birth: [**2089-4-21**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
worst headache of life with right sided numbness and weakness.
nausea, vomiting, slurred speech
Major Surgical or Invasive Procedure:
Right Frontal EVD
Diagnostic cerebral angiogram
Tracheostomy
PEG placement
History of Present Illness:
This is a 78 year old male who at 9pm this evening was
ambulating to the bathroom when he "reeled" to the right side
and
then leaned to his right side. At the same moment he
experienced
right lateral neck pain and headache associated with numbness on
the right side of his body, slurred speech, and nausea and
vomiting. The pt denies any visual disturbance, bowel and
bladder incontinence, or hearing deficit at the time of the
event. The patient was brought to an outside hospital where he
had a Head Ct which was consistent with a posterior fossa
hemorrhage with hemorrhage in the ventricles as well. The
patient was transferred here for further management. The patient
denies taking aspirin, Coumadin, Plavix heparin or Lovenox
Past Medical History:
HTN, asthma, low back surgery, enlarged prostate
Social History:
lives at home with his wife. The patient has three
daughters who are at the bedside and one son who is flying in to
see the patient overnight.
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM:
O: T:97 BP: 136 / 66 HR:54 R: 18 O2Sats: 97% r/a
Gen: pt is lying on stretcher with eyes closed in no apparent
distress.
HEENT: Pupils:1mm EOMs: lateral bilateral nystagmus
Neck: supple
Extrem: Warm and well-perfused.
Neuro:
Mental status: pt lethargic, eyes open to voice, cooperative
with
exam with much prompting.
Orientation: Oriented to person, place, and date.
Recall:grossly intact
Language: Speech slow with good comprehension and repetition.
Naming intact.
Cranial Nerves:
I: Not tested
II: Pupils are 1 mm bilaterally. Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally with
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength on right 4- biceps/triceps/delts.left foot
drop
is reported as patients baseline. dorsiflexors/plantar flexors
[**1-21**].
Sensation: Intact to light touch.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements.
ON DISCHARGE
Exam fluctuates ; at best he will eye open to voice with tactile
stim. No tracking, + simple commands (sticks out tongue /
wiggle toes), Nods yest to name only (appropirate to challenge
of name), + right facial weakness, pupils 1.5mm to pinpoint/
reactive, attempts to localize to sternal rub/ + grimace, triple
flexion on lower ext.
Pertinent Results:
CT Head with and without contrast [**2168-1-31**]
1.Intracranial hemorrhage, centered in the superior vermis of
the
cerebellum, with extension to involve the subarachnoid and
intraventricular spaces. The extent of hemorrhage has increased
over the short-interval since the prior examination, with an
increase in the size of the ventricles, which is likely related
to the hemorrhage within the ventricular system resulting in
outflow obstruction.
Consideration may be given to external ventricular drainage.
2.Multiple small arterial feeding vessels extending towards the
cerebellar
vermian hemorrhage, with single prominent collecting vein,
draining directly into the vein of [**Male First Name (un) 2096**], concerning for a
vascular malformation. Given that there is no principal arterial
feeder or typical vascular nidus identified, and that there is a
close relationship of these multiple arteries to the tentorial
dura, these findings suggest an underlying dural arteriovenous
fistula, rather than a true arteriovenous malformation (which
would, in any case, be unusual in a patient of this age).
CT Head without contrast [**2168-2-2**]
1)New or increased bitemporal subarachnoid hemorrhage,
concerning for new or
continued bleeding from the cerebellar hemorrhagic focus.
2) Otherwise, stable appearance of cerebellar vermian hemorrhage
with unchanged vasogenic edema causing mild supratentorial
herniation. No midline shift. No increased mass effect.
3) Interval placement of a right frontal approach
ventriculostomy catheter terminating into the third ventricle.
No significant change in the degree of ventricular dilatation.
Stable appearance of blood products within third, fourth and
lateral ventricles, with some redistribution.
_
_
_
_
_
________________________________________________________________
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2168-2-3**] 12:36 AM
Final Report
HISTORY: 78-year-old man, with altered mental status, and large
cerebellar
intraparenchymal hemorrhage, with intraventricular extension to
the lateral, third and fourth ventricles. Now status post stent
placement. De-saturating in the 70% FIO2 and febrile. Assess for
pulmonary source.
COMPARISON: Limited comparison from prior chest radiographs with
the latest on [**2168-2-2**].
TECHNIQUE: MDCT images were acquired from the thoracic inlet to
the lung
bases before and after administration of IV contrast.
Multiplanar reformatted images were obtained for evaluation.
CTA CHEST: The study is moderately limited by suboptimal IV
bolus timing as the segmental and subsegmental branches of the
pulmonary arterial vasculature are insufficiently opacified.
There is no central pulmonary embolism. The study is further
limited by patient's inadvertent expiration during the
supposedly end-inspiratory phase, evident by posterior tracheal
wall bowing (2:16). The tracheobronchial tree remains patent.
Respiratory motions limits evaluation of the lower lobes, but no
suspicious lung masses or nodules are detected. There is
bibasilar dependent atelectasis. Bilateral simple pleural
effusions are small on the right and trace on the left. There is
no pneumothorax. There are scattered calcified lymph nodes, with
representative ones seen in the subcarinal station (2:26) and
the right hilum (2:27). None of the central lymph nodes are not
pathologically enlarged, ranging up to 6 mm in the right lower
paratracheal station (3:52). There is no hilar or axillary
lymphadenopathy.
The visualized thyroid is normal. Heart size is top normal, with
trace
physiologic pericardial effusion. The left main coronary artery
and the left anterior descending artery are partially calcified.
Calcified atherosclerotic plaques scatter along the aortic arch.
The aorta is otherwise normal in caliber and course, without
acute aortic pathology. The remaining great mediastinal vessels
are normal.
The study is not designed for subdiaphragmatic diagnosis. A 24 x
21 mm
hypodense left hepatic lesion (2:24) is compatible with a liver
cyst. The
right kidney is not imaged, but in the expected location of the
right upper pole, there is a hypodense lesion, likely represents
a exophytic renal cyst (2:56). The visualized spleen, adrenal
glands and pancreas are grossly unremarkable. There is a small
hiatal hernia.
BONE WINDOW: No suspicious osteolytic or blastic lesion is
noted. There are mild-to-moderate multilevel degenerative
changes.
IMPRESSION:
1. Suboptimal IV bolus timing limits assessment of subsegmental
and segmental pulmonary artery vasculature. No central pulmonary
embolism. No acute aortic pathology.
2. Bilateral small pleural effusions, right larger than left.
3. Partially calcified mediastinal and hilar lymph nodes. No
lymphadenopathy.
The study and the report were reviewed by the staff radiologist.
_
_
_
_
_
________________________________________________________________
[**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2168-2-3**]
12:36 AM
FINDINGS: The size of the cerebellar hemorrhage is similar to
the previous
study, measuring approximately 2.6 x 2 cm (AP x TRV). In
comparison to [**2168-2-2**], there is new/increased bifrontal
subarachnoid hemorrhage (2:24, 2:23). The amount and
distribution of subarachnoid hemorrhage in the temporal lobe is
similar to the most recent prior study. Blood again layers in
the occipital horns. The amount of vasogenic edema surrounding
the cerebellar hemorrhage is similar to the previous study, with
partial effacement of the right ambient cistern. The ventricles
have decreased in size. The right frontal approach
ventriculostomy catheter is unchanged, terminating at the level
of the foramen of [**Last Name (un) 2044**]. There is no shift of normally midline
structures. No new parenchymal hemorrhage is identified.
The visualized paranasal sinuses demonstrate minimal mucosal
thickening of the posterior ethmoid air cells on the right. The
paranasal sinuses and mastoid air cells are otherwise normally
pneumatized and aerated. A small focus of pneumocephalus
overlies the right frontal lobe, unchanged.
IMPRESSION:
1. New or increased bifrontal subarachnoid hemorrhage in
comparison to the
study of roughly 16 hours earlier, concerning for new or
continued bleeding, with extension of existing hemorrhage into
the subarachnoid spaces.
2. Otherwise unchanged appearance of the cerebellar hemorrhage
with
surrounding vasogenic edema resulting in mild upward
transtentorial
herniation.
3. Interval decrease in the size of the lateral and third
ventricles in
comparison to [**2168-2-2**], s/p EVD. Unchanged blood layering
in the
occipital horns.
COMMENT: Discussed by Dr. [**Last Name (STitle) 20059**] with [**Doctor First Name **] [**Doctor Last Name **] of
neurosurgery 5:00am, [**2168-2-3**].
The study and the report were reviewed by the staff radiologist.
_____________________________________________________________
[**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2168-2-8**]
3:54 PM
Final Report
INDICATION: 78-year-old man with cerebellar bleed.
Please evaluate.
COMPARISON:
Angiogram from [**2168-2-8**]. CT of the head from [**2168-2-6**], [**2-3**] and [**2168-2-5**]. Outside hospital CT from
[**2168-1-31**].
TECHNIQUE: Contiguous axial images were obtained through the
brain without IV contrast.
FINDINGS:
CT OF THE HEAD: Again seen is an intraventricular shunt
traversing the right frontal lobe and ending in the frontal [**Doctor Last Name 534**]
of the right lateral ventricle. In the interval, multiple
hyperdense streak artifacts are visualized at the level of the
superior vermis consistent with AVM embolization meterial. There
is unchanged, predominantly right-sided hemorrhage in the
superior vermis and superior cerebellar cistern. There is
unchanged trace subarachnoid hemorrhage, predominantly seen in
the right parietal lobe. There is significant decrease of the
previously described intraventricular hemorrhage of the lateral
ventricles and fourth ventricle. Unchanged periventricular and
subcortical bilateral white matter hypodensities likely
represent mixed small vessel ischemic disease. Unchanged mild
mucosal thickening of the ethmoid sinuses.
IMPRESSION:
1. Unchanged superior vermis, intraparenchymal and superior
cerebellar
cistern hemorrhage secondary to AVM.
2. In the interval, multiple hyperdense streak artifacts are
visualized at
the level of the superior vermis consistent with AVM
embolization.
3. Unchanged position of the right lateral ventricle drain.
4. Significant decrease of the intraventricular hemorrhage.
Unchanged right parietal lobe subarachnoid hemorrhage.
_
_
_
_
_
_
_
_
________________________________________________________________
[**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**]
Radiology Report UNILAT UP EXT VEINS US RIGHT PORT Study Date of
[**2168-2-7**] 10:16 AM
Final Report
INDICATION: 78-year-old man with new right arm swelling. Rule
out DVT.
COMPARISON: None.
FINDINGS: Grayscale, color, and Doppler evaluation of the right
internal
jugular vein, subclavian vein, brachial, cephalic, and basilic
veins were
performed. There is normal compressibility, flow, and
augmentation. There is no evidence of DVT.
IMPRESSION: No evidence of DVT in the right upper extremity.
The study and the report were reviewed by the staff radiologist.
_
_
_
_
_
_
________________________________________________________________
[**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**]
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2168-2-9**]
10:52 AM
Final Report
HISTORY: 78-year-old man, with pulmonary edema and possible
infiltrate in the left lower lobe. Assess for changes.
COMPARISON: CTA chest on [**2168-4-4**] and multiple chest
radiographs with the latest on [**2168-2-9**].
TECHNIQUE: Non-contrast MDCT images were acquired from the
thoracic inlet to the lung bases. Multiplanar reformatted images
were obtained in 5 mm and 1.25 mm slice thickness for
evaluation.
CT CHEST WITHOUT CONTRAST: Compared to the prior study six days
ago, there is interval increase to now small bilateral pleural
effusions. There are
relaxation atelectasis in the lower lobes, but superimposed
infection cannot be excluded. Evaluation of the underlying lung
lesions is limited in the setting of atelectasis and pleural
effusions but no gross mass or nodule are noted. A calcified
granuloma is noted in the right lower lobe (2:21). There is no
pneumothorax. The patient is intubated with the endotracheal
tube terminating 2.4 cm above the carina. A nasogastric tube
traversing the esophagus with the tip terminating in the
first/second portion of the duodenum.
The heart is mild-to-moderately enlarged but without significant
pericardial effusion. The unopacified great mediastinal vessels
are grossly within normal limits. Mild coronary artery
calcifications are most evident along the LAD. Scattered
mediastinal lymph nodes are not pathologically enlarged, and
likely reactive. There is no gross hilar or axillary
lymphadenopathy. Several partially calcified mediastinal and
hilar lymph nodes are indicative of old granulomatous disease.
The study is not designed for subdiaphragmatic diagnosis. The
2.7 cm
hypodense left hepatic lesion again seen, unchanged, likely
represents hepatic cyst (2:38). Bilateral multiple hypodense
renal lesions, incompletely evaluated but are likely to be renal
cysts. The remaining visualized abdomen is grossly normal.
BONE WINDOW: There is no osteolytic or blastic lesions
concerning for
malignancy. Lumbar spinal fusion hardware is noted in the scout
image (1:2).
IMPRESSION:
1. Interval increase of now small bilateral pleural effusions.
Bibasilar
relaxation atelectasis. Superimposed infection cannot be
excluded.
2. Stable mild-to-moderate cardiomegaly, without significant
pericardial
effusion.
The study and the report were reviewed by the staff radiologist.
_
_
_
_
_
_
_
_
________________________________________________________________
[**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**]
Neurophysiology Report EEG Study Date of [**2168-2-13**]
FINDINGS:
BACKGROUND: Is diffusely slow and disorganized consisting mostly
of
delta frequency slowing with occasional theta frequencies. There
are
fairly frequent generalized and multifocal (R>L) spikes and
sharps
occurring both in isolation as well as in brief semi-periodic
runs with
a frequency of around 1 Hz. There were no electrographic
seizures
noted.
HYPERVENTILATION: Could not be performed secondary to patient
being
intubated.
INTERMITTENT PHOTIC STIMULATION: Could not be performed
secondary to
the portable nature of this study.
SLEEP: No normal sleep architecture was seen on this recording.
CARDIAC MONITOR: A generally regular rhythm was noted; however,
there
were two distinct rhythms noted, one with a prolonged QRS
complex and
another with a narrow QRS complex.
IMPRESSION: This is an abnormal extended routine EEG due to a
diffusely
slow and disorganized background marked by fairly frequent
generalized
and multifocal R>L spikes and sharps. At times, these occurred
in brief
semi-periodic runs with a frequency of about 1 Hz. There were no
electrographic seizures noted. Overall, this background is
suggestive
of a sever encephalopathy. Amongst the most common causes of
encephalopathy are metabolic derangements, medications,
infection, and
anoxia.
[**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M 78 [**2089-4-21**]
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2168-2-16**]
7:25 AM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2168-2-16**] 7:25 AM
BILAT LOWER EXT VEINS Clip # [**Clip Number (Radiology) 109377**]
Reason: eval for dvt
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with cerebellar hemorrhage. prolonged bedrest
/ low frade temps
as of [**2168-2-15**]
REASON FOR THIS EXAMINATION:
eval for dvt
Provisional Findings Impression: DLrc TUE [**2168-2-16**] 11:31 AM
PFI: No evidence of bilateral lower extremity DVT.
Final Report
INDICATION: Patient is a 78-year-old male. With prolonged
immobilization.
Evaluate for deep venous thrombus.
EXAMINATION: Bilateral lower extremity DVT study.
COMPARISONS: None available.
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the bilateral
common femoral,
superficial femoral, and popliteal veins were performed. There
is normal
flow, compressibility and augmentation. In addition, normal flow
is
demonstrated within the post-bilateral posterior tibial and
peroneal veins.
Symmetric respiratory variability is demonstrated in the common
femoral veins.
IMPRESSION: No evidence of bilateral lower extremity DVT.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] LI
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2168-2-16**] 1:25 PM
Imaging Lab
CT scan +/- contrast this am - reviewed by Dr. [**First Name (STitle) **] as stable
without abcess. Final read pending.
Brief Hospital Course:
Patient presented to OSH after experiencing the worst headache
of his life. on the evening of [**2-1**]. he complained of right
sided head and neck pain as well as associated right sided
numbness and weakness, nausea, vomiting, and slurred speech. On
ehad Ct he was found to have a cerebellar hemorrhage most likely
secondary to an AVM. He was transferred to [**Hospital1 18**] for further
management and was placed in the ICU. Given his cerebellar
bleeding as well as his Head CT which showed that his hemmorhage
included both lateral ventricles as well as the third and fourth
ventricles, he was taken to the OR semi-urgently on the
afternoon of [**2-1**] for palcement of an EVD under anesthesia.
This procedure was uneventful and he came out of the OR with the
EVD at 20cm and clamped. He was stable overnight into the 16th
with the EVD clamped and ICP's ranging from [**3-6**]. His mental
status seemed to be slightly better on exam on [**2-2**] and he
underwent cerebral angiography for diagnostic purposes.
He later had ICP's that were slightly elevated with a headache
as well. His EVD was opened at 20cm. He spiked a temp and was
hypoxic as well. A fever workup ensued as well as a CTA of the
chest. PE workup was negative. Ultimiately CSF grew out gram
negative rods. It was re-sent and the gram stain was confirmed.
On the 18th the distal collection system was changed out and csf
was again sent off of the new system, the results were gram
negative rods once again. Patient's EVD was then clamped in
attemps to determine if EVD can be removed. ID is involved and
recommended that we continue current antibiotic regimen. An
echocardiogram was ordered.
On the morning of [**2-5**] he was quite lethargic on exam with
increased weakness right greater than left. This may be
secondary to his fevers. Hhe was mentating appropriately and
his EVD, which had been clamped overnight was working
effectively when opened to assess. He had minimal ICP issues
over night which did not require unclamping of his drain. A
Head CT with contrast was obtained as well which was planned.
CSF was obtained via the EVD in order to assess for any
progression of infection. He was switched to meropenem.
He had mental status changes and his EVD stopped working on
[**2168-2-6**]. A new catheter was placed by Dr. [**Last Name (STitle) **]. His exam
remained stable with the drain open at 20. The patient was
brought to the angio suite for emobolization on Monday [**2168-2-8**].
he underwent the procedure without issue. His BP was tightly
controlled 90-110 sys for approx. the first 24 hours. He was
due to be extubated the am of [**2168-2-9**] but he had upper extremity
twitching that was non suppressable, somewhat rhythmic and non
responsive to ativan.
An EEG was performed and the preliminary results were the he was
not having seizures
Stroke neurology was also consulted to assist in the assessment
of the possible seizure activity. They recommended starting
Keppra.
He remained intubated in the ICU with no eye opeing or ability
to follow commands and was subsequently trach and peged on
[**2168-2-13**].
on [**2-14**] the EVD had remained clamped for 48 hours and
subsequently removed. He was later weaned off of the ventilator
to trach collar. His transfer to step down was hindered x 24
hours only by increased secreations requiring frequent
suctioning.
He had lower extremity dopplers which were negative. His CT +/-
contrast was negative this am. He was deemed safe for d/c to
rehab.
Medications on Admission:
HCTZ 25mg Po daily, Monopril 40mg Po daily, Mevacor 10mg PO
daily, Hytrin 5mg Po Daily, Claritin 10mg PO prn, Relafen 750mg
PO prn, Ultracet 50mg PO prn
Discharge Medications:
1. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day).
2. Metoclopramide 10 mg IV Q6H:PRN TF residual > 200
Hold for elevated QTc
3. 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.
4. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for stop after last dose on [**2168-2-24**]
weeks.
5. HydrALAzine 15-25 mg IV Q3H:PRN SBP > 160
do not exceed the dose of 200mg/24hrs
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
10. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
13. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Four (4) Puff Inhalation Q4H (every 4 hours).
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for Wheezing.
15. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
16. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
17. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q 24H (Every 24 Hours)
as needed for back pain.
21. Lovastatin 20 mg Tablet Sig: 0.5 Tablet PO Daily ().
22. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
23. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
24. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
25. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
CEREBELLAR AVM
respiratory failure
dysphagia
altered mental status
CNS venrticulitis with Gram negative rod CNS infection
Discharge Condition:
Neuroligically improving.
Discharge Instructions:
Angiogram with embolization
Medications:
?????? Continue all medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please call the office at [**Telephone/Fax (1) **] to be seen by Dr. [**First Name (STitle) **]
/ Neurosurgery in 4 weeks - you will need a CT scan of the
brain with contrast at that time.
Completed by:[**2168-2-17**]
ICD9 Codes: 431, 2760, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3134
} | Medical Text: Admission Date: [**2109-10-8**] Discharge Date: [**2109-10-28**]
Date of Birth: [**2066-10-31**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Ceftazidime / Carbamazepine
Attending:[**First Name3 (LF) 848**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
-[**Location (un) **] t-tube removed and replaced with regular
tracheostomy tube
-Tunneled HIckman catheter
History of Present Illness:
40-year-old bed-bound, hemiplegic, minimally-to-non-verbal woman
with history of [**Doctor Last Name **] encephalitis (Dx at age 8), on 4x
AEDs at baseline, s/p Left partial (parietal) hemispherectomy in
[**2085**] (age 19) and s/p VNS placement, who now presents with
several break-through GTC seizures witnessed at a Neurosurgery
appointment for battery replacement surgical planning. She has
daily focal seizures at baseline -- primarily causing twitching
of her Right eyelind -- which are resistant to hemisphereotomy,
VNS placement, and four AEDs. She also has occasional
break-through GTC seizures. She also has a h/o episodes of
aspiration pneumonia requiring intubation, subsequent tracheal
stenosis, and is now s/p tracheostomy, then T-tube placement
[**2101**].
Her VNS battery was at 0.55 years of life remaining back in [**Month (only) 116**]
of [**2108**], but it could not be replaced at that time because the
venous access requested by Neurosurgery could not be established
at that time (Dr. [**Last Name (STitle) 739**] insisted on a port-a-cath,
placement of which in the OR by Thoracic was unsuccessful). On
the DOA [**10-8**], while she was at her Neurosurgery appointment (Dr. [**Name (NI) 14232**] office) for preoperative evaluation for her VNS battery
replacement, she had multiple seizures involving eye deviation
to the left, drooling, and cyanosis. Each seizure lasted less
than one minute. From 12:30 to 4:30pm, there were 15-20
seizures. In the past when she has had these seizures, it was a
sign that she had an underlying infection, such as aspiration
pneumonia, UTI, or G-tube site infection.
In the ED on admission, she received lorazepam 2mg IM and then
phenobarbital 60mg IV. Of note, her phenytoin dose was decreased
several weeks ago due to an elevated level of unclear cause. Her
phenobarbital level was good at that point (mid-30s), but her
phenytoin level of 7 was much lower than Dr.[**Name (NI) 3536**] goal of
20-25 in this patient, so she was bolused with 500mg IV
phenytoin.
ROS: The patient has chronic abdominal pain, which she continues
to have today. At baseline she understands speech and is
minimally verbal, with phonation (has T-tube since [**2101**],
replaced once here since) that is understood only by family, not
by her outpatient Neurologist/Epileptologist (Dr. [**First Name (STitle) 437**]. She
has a right hemiplegia, with contracted/flexed RUE. Does not
take PO (G-tube meal bolus feeds). No recent problems with
fever, vision, hearing, cough, vomiting, diarrhea, urination, or
new weakness.
Past Medical History:
1. [**Doctor Last Name **] encephalitis
2. Epilepsy
3. Partial left hemispherectomy at age 19 complicated by right
hemiparesis and partial aphasia
4. Mental retardation
5. Left thoracolumbar scoliosis
6. Vagal nerve stimulator implanted [**12-7**], needs battery change
7. h/o Aspiration pneumonias, now on scopolamine patch
8. S/p PEG placement using T tube
9. S/p tracheostomy
10. MRSA line infection in the past
11. Hx multiple UTIs, Urosepsis (enterococcus, VRE, other)
12. Difficult venous access requiring femoral sticks
13. Constipation
14. Mood disorder, on SSRI; also Zyprexa
Social History:
No history of tobacco, alcohol, illicit drug use. Lives in a
group home.
Family History:
Unremarkable. No h/o seizures or [**Doctor Last Name **]
Physical Exam:
On admission in the ED:
Gen: Lying in bed, NAD
HEENT: NC/AT
Neck: Supple
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Trach site c/d/i. Clear to auscultation bilaterally .
Wearing face mask.
Abd: +BS soft, nontender. G-tube site c/d/i.
Ext: no edema
Neurologic examination:
Mental status: Awake, alert. Follows commands. Tries to talk
and says a few words but dysarthric and difficult to understand.
Says her name but when asked where she is she points to her mom
and nurse to have them answer the question.
Cranial Nerves:
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V1-3: Sensation intact V1-V3.
VII: Right facial droop (baseline).
VIII: Hearing grossly intact.
Motor:
Tone is increased in the right arm, with the wrist and fingers
flexed on that side.
Delt; C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7
Left 5 5 5 5 5
Right 1 3 2 1 1
.
Legs withdraw to noxious, no spontaneous movement. The ankles
are plantarflexed at rest and do not fully dorsiflex to 90
degrees.
.
Deep tendon Reflexes:
.
Biceps: Tric: Brachial: Patellar: Achilles Toes:
Right 1 1 1 1 1 MUTE
Left 1 1 1 1 1 MUTE
.
Sensation: Intact to light touch on all extremities.
.
Coordination: Finger-nose-finger dysmetric on left; unable to
test other limbs due to weakness.
One seizure witnessed during the exam. The patient had eye
deviation to the left, drooling, and arrest of purposeful
movement for about 1 minute. She returned to baseline several
minutes after the episode.
Pertinent Results:
Labs on admission ([**2109-10-8**]):
[**2109-10-8**] 04:25PM BLOOD WBC-3.0* RBC-3.74* Hgb-11.6* Hct-35.6*
MCV-95 MCH-30.9 MCHC-32.5 RDW-15.0 Plt Ct-212
[**2109-10-8**] 04:25PM BLOOD Neuts-40.5* Lymphs-51.6* Monos-4.3
Eos-2.7 Baso-0.8
[**2109-10-8**] 04:25PM BLOOD PT-14.2* PTT-37.3* INR(PT)-1.2*
[**2109-10-8**] 04:25PM BLOOD Glucose-87 UreaN-18 Creat-0.6 Na-138
K-4.3 Cl-104 HCO3-26 AnGap-12
[**2109-10-11**] 08:24PM BLOOD ALT-28 AST-21 AlkPhos-175* TotBili-0.3
[**2109-10-10**] 02:09AM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.8 Mg-2.0
[**2109-10-9**] 01:54AM BLOOD TSH-4.5*
[**2109-10-9**] 01:54AM BLOOD Free T4-0.78*
[**2109-10-9**] 01:54AM BLOOD Cortsol-5.3 (AM cortisol morning after
admission)
[**2109-10-10**] 03:08PM BLOOD Cortsol-22.3* (baseline for Syntropin
stim test)
[**2109-10-10**] 03:55PM BLOOD Cortsol-29.4* (30min after ACTH)
[**2109-10-10**] 05:02PM BLOOD Cortsol-34.9* (60min after ACTH)
[**2109-10-8**] 04:25PM BLOOD HCG-<5
[**2109-10-9**] 10:41AM BLOOD Type-ART pO2-73* pCO2-41 pH-7.39
calTCO2-26 Base XS-0
[**2109-10-10**] 03:28PM BLOOD freeCa-1.20
***********
AED levels:
-Phenytoin/Phenobarbital:
[**2109-10-17**] 01:54AM BLOOD Phenyto-18.4
[**2109-10-16**] 02:11AM BLOOD Phenyto-19.1
[**2109-10-15**] 04:27AM BLOOD Phenyto-20.1*
[**2109-10-14**] 01:59AM BLOOD Phenyto-19.9
[**2109-10-13**] 01:12AM BLOOD Phenyto-20.2*
[**2109-10-12**] 02:51AM BLOOD Phenoba-31.2 Phenyto-19.4
[**2109-10-11**] 01:26AM BLOOD Phenyto-18.0
[**2109-10-10**] 02:09AM BLOOD Phenyto-17.7
[**2109-10-9**] 01:54AM BLOOD Phenyto-17.4
[**2109-10-8**] 04:25PM BLOOD Phenoba-36.4 Phenyto-7.0*
-Keppra:
[**2109-10-8**] 11:05PM BLOOD LEVETIRACETAM (KEPPRA)- 78.6 (uln
@1500bid=70)
-Zonisamide:
[**2109-10-8**] 11:05PM BLOOD ZONISAMIDE(ZONEGRAN)- 11.6 (10-40)
***********
[**2109-10-28**] 04:22AM BLOOD WBC-7.0 RBC-2.93* Hgb-9.3* Hct-27.5*
MCV-94 MCH-31.7 MCHC-33.7 RDW-15.3 Plt Ct-280
[**2109-10-28**] 04:22AM BLOOD Glucose-105* UreaN-9 Creat-0.5 Na-140
K-4.0 Cl-105 HCO3-29 AnGap-10
[**2109-10-27**] 06:08AM BLOOD ALT-15 AST-15
[**2109-10-28**] 04:22AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.8
[**2109-10-27**] 06:08AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.8 Mg-1.9
[**2109-10-13**] 05:23PM BLOOD Osmolal-272*
[**2109-10-19**] 09:53AM BLOOD TSH-3.9
[**2109-10-28**] 04:22AM BLOOD Phenoba-28.3 Phenyto-20.0
Brief Hospital Course:
Initial hospital/ICU course:
42 year old female with h/o [**Doctor Last Name **] encephalitis s/p left
hemispherectomy in [**2085**], presents with increased seizures. At
baseline, she has focal seizures involving right eye twitching,
but she presented with multiple breakthrough seizures involving
eye deviation to the left, drooling, and cyanosis. In the past
when she has had these seizures, it was a sign that she had an
underlying infection. Given the patient's history, the
presentation was concerning for underlying infection versus low
AED levels. Also of note, her AED battery was supposed to be
changed back in [**2109-4-6**], when it had only 0.55 year's power
remaining, so it is probably near-dead now, and this may have
contributed her seizures on DOA as well.
By system/problem:
Neuro/epilepsy:
Under Dr.[**Name (NI) 3536**] guidance, Ms. [**Known lastname **] was monitored on LTM-EEG
for nearly a week in the ICU, up until transfer to the floor. No
clinical or electrographic seizures, beyond the intermittent
occurrence of skew-deviation/eye-twitching/nystagmoid eye
movements clinically, and on LTM, her typical pattern of
left/frontocentral spike/spike-and-slow-wave baseline abnormal
EEG. Phenytoin level was subtherapeutic at 7 on admission (had
been taking 50mg tid), and came up to 19-20 after a few IV loads
of 100-500mg followed by increasing her baseline dose to 75mg
tid (albumin low at 3.1, so this corresponds to a dose in Dr. [**Name (NI) 10875**] target range of 20-25 if her albumin were normal). may
have Phenobarb remained stable and therapeutic in the mid-30s.
Zonegran came back therapeutic (10) on admission but was
incrased for better seizure control and Keppra was
supratherapeutic (76) c/w her dosing of greater than 3g/d.
Regarding her VNS replacement, this procedure was deferred until
[**11-7**] for complete replacement because wires were
cut/damaged as this was discovered during surgery. A venous
mapping study was performed by IR and a Hickman tunneled femoral
catheter was placed for her vns change.
Pulm/ID, Pneumonia:
Ms. [**Known lastname **] arrived with leukopenia, hypotension, and hypothermia.
Thus, she was treated for SIRS on clinical grounds. Initially,
no definitive infectious source was identified. Blood and
urinalysis/urine cultures were negative/no growth on admission
and afterwards. A c.diff a/b toxin screen sent later in her stay
was negative as well. She did have small bibasilar
consolidations, however, so she was started on linezolid (rather
than vanc, due to a remote h/o vancomycin-resistant
enterococcus) and cefepime and clindamycin was started to add
coverage for anerobes, with c/f aspiration pneumonia given her
recent breakthrough seizures and already tenuous
pulmonary/tracheal anatomy (tracheal stenosis with long-standing
T-tube). She was coughing frequently and a bronch was performed
by IP due to inability to pass a suction catheter through her
[**Location (un) **] T-tube. The bronch showed substantial obstruction
from granulation tissue within the T-tube, so it was removed,
the trachea was dilated, and the tube was replaced with a
regular tracheostomy tube. ID was consulted, and suggested
discontinuing first clindamycin and then all abx, and said pt OK
for nsgy battery replacement if stable for 24h off abx.
Subsequently, however, her first quality sputum cultures
(previous attempts were unsuccessful due to her tracheal
stenosis pre-dilation/tube-replacement) -- from a mini-BAL [**10-12**]
and BAL [**10-13**] -- each grew out pseudomonas (cefepime-sensitive),
so she was re-started for another 7d course of cefepime IV. She
completed her course of Cefepime but also developed a rash from
this. The rash cleared after discontinuation of the drug. Of
note she recieved her 7D course. She is deemed a colonizer of
pseudomonas.
CV/hypotension:
Ms. [**Known lastname **] was on a norepinephrine gtt intermittently for moderate
hypotension over the first several days of her stay in the ICU.
After 3-4d, she developed transient diabetes insipidus with UOP
of 3-500mL/h and serum Na of up to 147, which was treated with
vasopressin gtt, which incidentally allowed rapid weaning of the
norepi gtt. Two bedside TTEs were unremarkable/normal.
Endo/thyroid/HPA/DI:
An elevated TSH of 4 and slighly low free T4, along with
hypothermia and hypotension (in the setting of unclear ID
process or not) along with a serum cortisol of 5 (thought to be
inappropriately normal even at 2am in a patient thought to be
septic) all prompted an Endocrinology consult shortly after
admission. They recommended following up the thyroid studies
later, as an outpatient given their limited utility in the acute
setting. They also recommended an ACTH stim test the following
afternoon, which revealed a baseline daytime level of 22 (normal
/ appropriate), and a 60min post-ACTH stimulation level of 38,
also wnl. See above w.r.t. transient episode of DI, treated with
vasopressin gtt.
GI:
Patient fed via G-tube with continuous TFs.
After her ICU stay she was transferred to the floor where she
had an uncomplicated course. There were seizure breakthrough and
she was relaoded with dilantin IV for a level 20-25 uncorrected.
The group home was instructed and trained in proper trach and
catheter upkeep.
Medications on Admission:
Zyprexa 5 mg Tab
1 Tablet(s) via GT daily
Singulair 5 mg Chewable Tab
2 Tablet(s) via GT once daily
Fleet Enema 19 gram-7 gram/118 mL
([**Known lastname 65**] unavailable)
Keppra 500 mg Tab
3 Tablet(s) via GT in the am; 2 tabs at noon; and 3 tabs at
night
Zonisamide 100 mg Cap
3 Capsule(s) via GT q pm
DuoNeb 0.5 mg-2.5 mg/3 mL Neb Solution
1 vial vis neb every 4 hours while awake
Phenobarbital 30 mg Tab
1 Tablet(s) via GT q pm
Phenobarbital 60 mg Tab
1 Tablet(s) via GT in the am and 1 tab at 2p; and 1 tab po prn
for seizures per protocol
Tylenol 325 mg Tab
([**Known lastname 65**] unavailable)
Diazepam 10 mg Tab
1 Tablet(s) via GT 1 hour prior to medical/gyn exam
Potassium Chloride SR 20 mEq Tab, Particles/Crystals
1 Tab(s) via GT q am
Guaifenesin 100 mg/5 mL Oral Liquid
15cc GT Q6hr as needed for chest congestion
Simethicone 60 mg Tab
([**Known lastname 65**] unavailable)
Colace 100 mg Cap
1 Capsule(s) GT twice a day
Ducodyl 5 mg Tab
([**Known lastname 65**] unavailable)
Dilantin Infatabs 50 mg Chewable
1 Tablet(s) by mouth three times per day
Acidophilus Cap
1 Capsule(s) GT once a day
Scopolamine 1.5 mg 72 hr Transderm Patch
1 patch transdermally with change every 72 hours
Prevacid SoluTab 30 mg Rapid Dissolve
1 Tablet(s) via GT once a day
Miralax 17 gram/dose Oral Powder
1 tsp GT daily GT with 8oz of water
Fluoxetine 20 mg Cap
1 Capsule(s) by gt once daily
Feeds: Fibersource HN @50cc/hr, continuous
Discharge Medications:
1. montelukast 5 mg Tablet, Chewable [**Known lastname **]: Two (2) Tablet,
Chewable PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
2. levetiracetam 100 mg/mL Solution [**Known lastname **]: Fifteen (15) ml PO BID
(2 times a day): LeVETiracetam 1500 mg NG [**Hospital1 **]
Morning and evening dose
Order was filled by pharmacy with a dosage form of Solution and
a strength of 100 MG/ML .
Disp:*qs * Refills:*2*
3. levetiracetam 100 mg/mL Solution [**Hospital1 **]: Ten (10) ml PO DAILY
(Daily): LeVETiracetam 1000 mg NG DAILY
Afternoon dose
Order was filled by pharmacy with a dosage form of Solution and
a strength of 100 MG/ML.
Disp:*qs * Refills:*2*
4. phenobarbital 20 mg/5 mL Elixir [**Hospital1 **]: Fifteen (15) ml PO BID
(2 times a day): PHENObarbital 60 mg NG [**Hospital1 **] Morning and 2pm
doses Order was filled by pharmacy with a dosage form of Elixir
and a strength of 20 MG/5 ML .
Disp:*qs * Refills:*2*
5. phenobarbital 20 mg/5 mL Elixir [**Hospital1 **]: 7.5 ml PO QPM (once a
day (in the evening)): PHENObarbital 30 mg NG QPM Order was
filled by pharmacy with a dosage form of Elixir and a strength
of 20 MG/5 ML .
Disp:*qs * Refills:*2*
6. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) PO Q6H
(every 6 hours) as needed for Fever/Pain.
Disp:*qs * Refills:*0*
7. phenobarbital 20 mg/5 mL Elixir [**Hospital1 **]: Fifteen (15) ml PO DAILY
(Daily) as needed for Generalized seizure >5 minutes, or more
than 3 generalized seizures in one hour.: PHENObarbital 60 mg NG
DAILY:PRN Generalized seizure >5 minutes, or more than 3
generalized seizures in one hour. Do not use for focal seizures.
Order was filled by pharmacy with a dosage form of Elixir and a
strength of 20 MG/5 ML .
Disp:*qs * Refills:*0*
8. guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: Fifteen (15) ML PO Q6H
(every 6 hours) as needed for Chest congestion.
Disp:*qs * Refills:*1*
9. simethicone 40 mg/0.6 mL Drops, Suspension [**Hospital1 **]: One (1) PO
QID (4 times a day) as needed for Gas pains.
Disp:*qs * Refills:*2*
10. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2
times a day) as needed for constipation: Docusate Sodium 100 mg
PO BID
Give meds by GT only.
.
11. scopolamine base 1.5 mg Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
12. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*qs Tablet,Rapid Dissolve, DR(s)* Refills:*2*
13. fluoxetine 20 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO DAILY
(Daily): Fluoxetine 20 mg NG/peg DAILY
.
Disp:*qs * Refills:*2*
14. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
[**Last Name (STitle) **]: Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
Disp:*qs * Refills:*1*
15. olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
16. zonisamide 100 mg Capsule [**Last Name (STitle) **]: Four (4) Capsule PO QPM (once
a day (in the evening)).
Disp:*120 Capsule(s)* Refills:*2*
17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
Disp:*qs * Refills:*2*
18. phenytoin 50 mg Tablet, Chewable [**Last Name (STitle) **]: 1.5 Tablet, Chewables
PO TID (3 times a day) as needed for epilepsy.
Disp:*100 Tablet, Chewable(s)* Refills:*2*
19. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed for groin itching.
Disp:*1 * Refills:*0*
20. camphor-menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical
QID (4 times a day) as needed for rash/itching.
Disp:*1 * Refills:*0*
21. triamcinolone acetonide 0.1 % Ointment [**Last Name (STitle) **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for rash.
Disp:*1 * Refills:*0*
22. heparin, porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Heparin
Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g.Hickman), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
Dispense QS x 30 [**Last Name (un) 32460**]
.
Disp:*qs ML(s)* Refills:*3*
23. Outpatient Lab Work
[**2109-11-5**]: Lab: CBC with Diff. Chem 10.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
1. Epilepsy
2. Tracheal stenosis
3. Pseudomonas pneumonia
4. Autonomic/neuroendocrine abnormalities (hypothermia,
hypotension, and hypothyroidism, and transient diabetes
insipidus) of unclear etiology
Discharge Condition:
x
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Mental Status: Confused.
Discharge Instructions:
x
You were admitted for increase in seizures. You were treated for
this in the ICU. You were also treated for a pneumonia with
cefepime and ultimately found to have a chronic colonization of
the airways. For your seizures we gave you dilantin and
increased you zonegran. You were also found to have a broken VNS
which will be replaced in 2 weeks by neurosurgery. During your
stay you had a hickman catheter placed which should stay in
place at least until your surgery. You also had your trach tube
replaced for an updated one (#7 cuffed Portex Per-fit trache).
You will need a blood test done on [**11-5**]. you are to
call Dr [**Last Name (STitle) **] office with the results. YOu are to have your VNS
changed by Dr [**Last Name (STitle) **] (neurosurgery) on [**11-7**], his number
is [**Telephone/Fax (1) 3231**]
Followup Instructions:
x
-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**]: Neurology Time/date:Please call to make an
appointment in 4 weeks. The Phone#: ([**Telephone/Fax (1) 40691**]
-Dr [**Last Name (STitle) **]: Neurosurgery tentative OR appointment for [**11-7**]. Call [**11-5**] with lab results to Dr [**Last Name (STitle) **] office
[**Telephone/Fax (1) 3231**].
-Lab slip prescribed for [**2109-11-5**]. CBC w/ diff. Chem 10.
PT/PTT/INR.
Completed by:[**2109-10-28**]
ICD9 Codes: 0389, 5070, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3135
} | Medical Text: Admission Date: [**2172-12-8**] Discharge Date: [**2172-12-14**]
Date of Birth: [**2095-2-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2172-12-8**]
1. Aortic valve replacement with a 27 mm [**Company 1543**] Mosaic
Ultra aortic valve bioprosthesis model number 305,
serial number [**Serial Number 92202**].
2. Coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending coronary
artery; reverse saphenous vein single graft from aorta
to the ramus intermedius coronary artery; reverse
saphenous vein single graft from the aorta to the distal
right coronary artery.
3. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
77 year old male presented to ED today after found to have
abnormal stress test. On day prior to admission, he reported
left anterior chest, shoulder and upper arm
pain/pressure/numbness for 9 hours. He reports chest pain
started while he was working at his computer and persisted until
he went to bed that evening. He also says that over last few
months he has had occasional dyspnea on exertion. He saw his PCP
who recommended that he undergo an ETT. His exercise stress test
showed ST depressions in inferior and lateral leads. He was then
referred to [**Hospital1 18**] for a cardiac catheterization. He was found to
have aortic stenosis and coronary artery disease and is now
being referred to cardiac surgery for revascularization and an
aortic valve replacement.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
Mild aortic stenosis
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Anemia, vitamin B12 deficiency
Erectile Dysfunction
seborrheic keratosis
ocular hypertension
GERD
hypothyroidism
CKD
Social History:
Lives with significant other. Previously worked in
sales/marketing.
-Tobacco history: never smoked
-ETOH: occasional
-Illicit drugs: denies
Family History:
Father had pacemaker placed when 60.
Mother with hx of HTN and CVA
family hx also notable for colon cancer and diabetse
No additional family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
Admission Physical Exam
Pulse:58 Resp:20 O2 sat:100/RA
B/P Right:182/72 Left:201/63
Height:6'2" Weight:170 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [III/VI]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none - muscle
bulge on right mid shin (present x 60 years)
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left:transmitted murmur B/L
Pertinent Results:
[**2172-12-12**] 05:52AM BLOOD WBC-9.4 RBC-2.50* Hgb-7.8* Hct-22.4*
MCV-90 MCH-31.2 MCHC-34.9 RDW-13.2 Plt Ct-244
[**2172-12-8**] 02:30PM BLOOD WBC-12.1*# RBC-3.52* Hgb-10.6* Hct-31.3*
MCV-89 MCH-30.0 MCHC-33.8 RDW-13.3 Plt Ct-177
[**2172-12-9**] 02:07AM BLOOD PT-11.1 PTT-26.8 INR(PT)-1.0
[**2172-12-8**] 01:30PM BLOOD PT-12.9* PTT-32.9 INR(PT)-1.2*
[**2172-12-12**] 05:52AM BLOOD Glucose-108* UreaN-39* Creat-1.7* Na-132*
K-5.1 Cl-100 HCO3-27 AnGap-10
[**2172-12-8**] 02:30PM BLOOD UreaN-28* Creat-1.3* Na-139 K-4.9 Cl-110*
HCO3-24
[**2172-12-14**] 04:32AM BLOOD Hct-27.2*
[**2172-12-13**] 04:57AM BLOOD WBC-7.7 RBC-2.39* Hgb-7.4* Hct-21.8*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.4 Plt Ct-269
[**2172-12-14**] 04:32AM BLOOD UreaN-36* Creat-1.6* Na-136 K-4.8 Cl-102
[**2172-12-13**] 04:57AM BLOOD Glucose-91 UreaN-38* Creat-1.6* Na-135
K-4.5 Cl-103 HCO3-27 AnGap-10
[**2172-12-14**] 04:32AM BLOOD PT-24.8* INR(PT)-2.4*
[**2172-12-13**] 04:57AM BLOOD PT-11.1 INR(PT)-1.0
[**2172-12-9**] 02:07AM BLOOD PT-11.1 PTT-26.8 INR(PT)-1.0
[**2172-12-8**] 02:30PM BLOOD PT-12.6* PTT-33.0 INR(PT)-1.2*
Echocardiographic: [**2172-12-10**]
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Stroke Volume: 77 ml/beat
Left Ventricle - Cardiac Output: 4.67 L/min
Left Ventricle - Cardiac Index: 2.67 >= 2.0 L/min/M2
Left Ventricle - Peak Resting LVOT gradient: 7 mm Hg <= 10 mm
Hg
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *17 < 15
Aorta - Sinus Level: 2.7 cm <= 3.6 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *3.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *44 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 19 mm Hg
Aortic Valve - LVOT VTI: 27
Aortic Valve - LVOT diam: 1.9 cm
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 1.09
Mitral Valve - E Wave deceleration time: *291 ms 140-250 ms
TR Gradient (+ RA = PASP): 25 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2172-12-1**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). TDI E/e' >15,
suggesting PCWP>18mmHg. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. No 2D or Doppler evidence of distal arch coarctation.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
leaflets move normally. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR. Prolonged (>250ms) transmitral E-wave decel time.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis leaflets appear to move normally. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. Increased left ventricular filling pressure.
Well-seated, normally functioning aortic valve bioprosthesis
with borderline-elevated transaortic valvular mean pressure
gradients (19 mmHg). Normal pulmonary artery systolic pressure.
Compared with the prior study (images reviewed) of [**2172-12-1**], a
bioprosthetic aortic valve is now present. The pulmonary artery
systolic pressure has normalized.
CXR: IMPRESSION: [**2172-12-13**] Right apical pneumothorax is tiny and
unchanged. Small bilateral pleural effusions are stable and
bibasilar atelectasis has improved. Heart size is normal. Right
jugular line ends low in the SVC. No pulmonary edema.
Brief Hospital Course:
On [**2172-12-8**] Mr.[**Known lastname 23903**] was taken to the operating room and
underwent Aortic valve replacement(#27 mm [**Company 1543**] Mosaic Ultra
aortic valve bioprosthesis)/Coronary artery bypass grafting x3
(left internal mammary artery to left anterior descending
coronary artery; reverse saphenous vein single graft from aorta
to the ramus intermedius coronary artery; reverse saphenous vein
single graft from the aorta to the distal right coronary
artery) with Dr. [**Last Name (STitle) 914**]. Please see operative report for
further details.CARDIOPULMONARY BYPASS TIME: 144
minutes.CROSSCLAMP TIME: 123 minutes. He tolerated the
procedure well and transferred to the CVICU intubated and
sedated. He awoke neurologically intact and was extubated. He
weaned off pressor support and initially Beta-blocker was held
due to nodal rhythm. Statin/Aspirin and diuresis were
initiatited. All lines and drains were discontinued per
protocol. POD#1 he was transferred to the step down unit for
further monitoring. Physical Therapy was consulted for
evaluation of strength and mobility. POD#3 he went into rate
controlled atrial fibrillation/flutter. He was placed on
Beta-blocker and oral Amiodarone. Anticoagulation with Coumadin
was initiated. His INR went from 1.0->2.4->3.2 and he was given
0 mg Coumadin on [**2172-12-14**] with repeat INR on [**2172-12-15**] scheduled.
INR goal 2.0-3.0 - [**Hospital 2274**] [**Hospital3 271**] to provide
further Coumadin instructions. On [**2172-12-13**] he was transfused
with 2 units of PRBC for HCT of 21.8 which increased to Hct of
27.2. He was given Folic acid, iron and Vitamin C for post op
anemia. He continue to progress and on POD 6 he was cleared for
discharge to home with VNA services. All follow up appintments
were advised.
Medications on Admission:
Lisinopril 20 mg daily
Levothyroxine 50mcg po daily
Omeprazole 20mg po daily
Vitamin B12 1000mcg po daily
HCTZ 25mg po daily (sometimes halved dose or did not take)
Fish oil
Red yeast rice extract
Discharge Medications:
1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for PAIN/TEMP.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200 [**Hospital1 **] x 2 weeks then 200 mg daily x 1 month or seen by
cardiologist.
Disp:*60 Tablet(s)* Refills:*0*
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 2 months.
Disp:*60 Tablet(s)* Refills:*0*
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 months.
Disp:*60 Tablet(s)* Refills:*0*
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed for goal INR 2.0-3.0 - Take NO Coumadin on [**2172-12-14**].
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Severe critical aortic stenosis/Severe 3-vessel coronary
disease.
s/p AVR/CABG
Atrial Flutter
Secondary:
Dyslipidemia
Hypertension
Mild aortic stenosis
Anemia, vitamin B12 deficiency
Erectile Dysfunction
seborrheic keratosis
ocular hypertension
GERD
hypothyroidism
CKD (baseline Creat 1.3-1.5)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] - the office will call you with an
appointment for 1 month
[**Location (un) 2274**] office to call with appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2920**] or Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**University/College **] [**Location (un) 2274**] Center for the next [**1-16**]
weeks
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2172-12-17**] at 10:00
in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 17528**],[**First Name3 (LF) 17529**] [**Telephone/Fax (1) 17530**] in [**3-18**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Coumadin for Atrial Flutter: INR Goal 2.0-3.0
[**Hospital 2274**] [**Hospital3 **] to call with further Coumadin
instructions
Next INR draw Tuesday [**2172-12-15**]
Phone: [**Telephone/Fax (1) 17530**]
Fax: [**Telephone/Fax (1) 6808**]
Completed by:[**2172-12-14**]
ICD9 Codes: 4241, 2761, 9971, 2767, 5859, 2449, 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3136
} | Medical Text: Admission Date: [**2111-4-15**] Discharge Date: [**2111-4-25**]
Service: CARDIOTHORACIC
Allergies:
Azithromycin / Oxycodone / Calcitonin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2111-4-16**] Aortic valve replacement with a 21-mm St. [**Hospital 923**] Medical
Biocor tissue valve
History of Present Illness:
86 year old female has a history of hypertension,
hyperlipidemia, PAF, GERD and prior bacterial endocarditis. She
has been followed through the years for aortic stenosis which is
now severe (Peak gradient of 85mmHG/valve area of 0.82cm2). She
has noticed a decline in her activity tolerance over the past
year. She easily becomes extremely short of breath and
profoundly fatigued with as little as walking a few minutes.
Often when she is symptomatic, she feels extremely cold. She
also describes intermittent flutterings in her chest and
occasional "indigestion" type symptoms that can be felt when
lying down in bed or at times during the day, often resolving
with relaxation. She was found to have non-significant coronary
disease on cardiac catheterization.
Past Medical History:
Aortic stenosis
Hypertension
Hyperlipidemia
Paroxysmal atrial fibrillation
[**2087**] acute bacterial endocarditis/osteomyelitis
GERD/hiatal hernia, lower esophageal ring
[**2106**] syncope (due to dehydration per patient report)
Restless leg syndrome
Hx of [**Hospital1 15309**] neuroma of feet
Degenerative joint disease
Osteoporosis/Arthritis
[**2108**] diverticulitis/rectal bleeding
Hard of hearing (hearing aids bilaterally)
Past Surgical History:
s/p laminectomy
s/p Tonsillectomy
s/p Hysterectomy
s/p Appendectomy
s/p Hemroidectomy
Social History:
Race:Caucasain
Last Dental Exam:2 months ago, Dental clearance obtained in
chart
Lives with:is widowed with three children. She lives alone,
daughter is staying with her until surgery. She uses a cane
Occupation:retired
Tobacco:denies
ETOH:denies
Family History:
Mother with "enlarged" heart, Bother had MI
Physical Exam:
Pulse:57 Resp:18 O2 sat:98/RA
B/P Right:181/54 Left:189/76
Height:5' Weight:172 lbs
General: awake alert oriented
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 [**3-27**] harsh systolic ejection murmur with
radiation to carotid areas.
Abdomen: Obese, Soft [x] non-distended [x] non-tender [x]
+ bowel sounds
Extremities: Warm [x], well-perfused [x]
Trace Edema, some superficial varicosities on the right calf.
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid: bilateral carotid bruits
Pertinent Results:
[**2111-4-15**] 06:32PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2111-4-15**] 06:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2111-4-15**] 06:32PM URINE RBC-1 WBC-26* BACTERIA-FEW YEAST-NONE
EPI-3
[**2111-4-15**] 06:32PM URINE HYALINE-1*
[**2111-4-15**] 06:32PM URINE MUCOUS-RARE
[**2111-4-15**] 05:35PM GLUCOSE-104* UREA N-20 CREAT-1.1 SODIUM-136
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13
[**2111-4-15**] 05:35PM ALT(SGPT)-9 AST(SGOT)-19 ALK PHOS-74
AMYLASE-45 TOT BILI-0.3
[**2111-4-15**] 05:35PM LIPASE-29
[**2111-4-15**] 05:35PM ALBUMIN-4.3 MAGNESIUM-2.2
[**2111-4-15**] 05:35PM %HbA1c-6.0* eAG-126*
[**2111-4-15**] 05:35PM WBC-11.6*# RBC-4.15* HGB-12.2 HCT-35.1*
MCV-85 MCH-29.4 MCHC-34.7 RDW-13.6
[**2111-4-15**] 05:35PM PLT COUNT-252
[**2111-4-15**] 05:35PM PT-12.8 PTT-26.2 INR(PT)-1.1
CXR:
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Status post CABG, elevated white blood count.
Comparison is made with prior study, [**4-18**] and [**4-19**].
Pulmonary edema has markedly improved. Cardiomegaly is stable.
Widened
mediastinum is stable. Left PICC tip is in the cavoatrial
junction or upper right atrium. Moderate-to-large bilateral
pleural effusions are more
conspicuous than before and associated with bibasilar opacities,
left greater than right. These opacities could be due to
atelectasis, but superimposed infection cannot be excluded.
ECG:
Probable sinus bradycardia with A-V conduction delay. Unstable
baseline makes assessment difficult. Probable left atrial
abnormality. Delayed R wave progression is non-diagnostic. Since
the previous tracing of [**2111-4-15**] limb lead QRS voltage and
delayed R wave progression pattern are both less prominent.
Brief Hospital Course:
Mrs. [**Known lastname 75001**] was admitted one day before surgery for
heparinization prior to aortic valve replacement. She underwent
usual lab work-up. On [**4-16**] she was brought to the operating room
where she underwent an aortic valve replacement. Please see
operative report for surgical details. Following surgery she was
transferred to the CVICU for invasive monitoring in stable
condition. Later this day she was weaned from sedation, awoke
neurologically intact and extubated. She had atrial fibrillation
post-op (history of PAF) and was started on Amiodarone. In
addition to atrial fibrillation, she had respiratory issues
post-op with severe pulmonary congestion that required
aggressive diuresis and pulmonary toilet. Coumadin was started
for her atrial fibrillation. Due to these issues she remained in
the ICU until post-op day five when she was transferred to the
telemetry floor. While here she continued to receive beta
blockers and was diuresed towards her pre-op weight. Chest tubes
and epicardial pacing wires were removed per protocol. She
worked with physical therapy for strength and mobility post-op.
On POD #9, Mrs. [**Known lastname 75001**] is now ready for discharge to
rehabilitation center. Her INR is therapeutic at 2.6.
Medications on Admission:
AMOXICILLIN prior to dental visits
LANSOPRAZOLE 30 mg daily
METOPROLOL SUCCINATE ER 50 mg daily
PRAVASTATIN 40 mg daily
TYLENOL ARTHRITIS PAIN
Discharge Medications:
1. docusate sodium 100 mg Capsule [**Known lastname **]: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Known lastname **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. warfarin 1 mg Tablet [**Known lastname **]: 0.5 Tablet PO DAILY (Daily) for 1
doses: 0.5mg x 1 tonight then daily per HO.
Disp:*30 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet [**Known lastname **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
Disp:*30 Tablet(s)* Refills:*0*
5. magnesium hydroxide 400 mg/5 mL Suspension [**Known lastname **]: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*QS ML(s)* Refills:*0*
6. bisacodyl 10 mg Suppository [**Known lastname **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
7. lisinopril 10 mg Tablet [**Known lastname **]: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
8. pravastatin 20 mg Tablet [**Known lastname **]: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
10. tramadol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
11. amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times
a day) for 7 days: then decrease to 200mg by mouth [**Hospital1 **] x 1week,
then decrease to 200mg by mouth daily.
Disp:*28 Tablet(s)* Refills:*1*
12. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN flush
Peripheral IV - Inspect site every shift
14. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Aortic stenosis s/p Aortic valve replacement
Past medical history:
Hypertension
Hyperlipidemia
Paroxysmal atrial fibrillation
[**2087**] acute bacterial endocarditis/osteomyelitis
GERD/hiatal hernia, lower esophageal ring
[**2106**] syncope (due to dehydration per patient report)
Restless leg syndrome
Hx of [**Hospital1 15309**] neuroma of feet
Degenerative joint disease
Osteoporosis/Arthritis
[**2108**] diverticulitis/rectal bleeding
Hard of hearing (hearing aids bilaterally)
Past Surgical History:
s/p laminectomy
s/p Tonsillectomy
s/p Hysterectomy
s/p Appendectomy
s/p Hemroidectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) **]
PCP:[**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] MD
Cardiologist:[**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] MD
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication:Atrial Fibrillation
Goal INR:2-2.5
First draw
Results to phone fax
Completed by:[**2111-4-25**]
ICD9 Codes: 4241, 5990, 2761, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3137
} | Medical Text: Admission Date: [**2168-3-24**] Discharge Date: [**2168-5-26**]
Date of Birth: [**2168-3-24**] Sex: M
Service: NB
HISTORY: [**Known lastname **] [**Known lastname **] is a former 27-4/7 week gestational
age infant admitted to the Neonatal Intensive Care Unit for
prematurity and respiratory distress.
MATERNAL HISTORY: Mom is a 29-year-old gravida 2, para 0 now
1 woman with past OB history notable for TAB x1 approximately
10 years ago. Past medical history unremarkable, with
current medications including only acetaminophen and
ranitidine.
PRENATAL MATERNAL SCREENS: Blood type O positive, antibody
negative, RPR nonreactive, hepatitis B surface antigen
negative, rubella status pending, and HIV negative.
PREGNANCY HISTORY: Last menstrual period on [**2167-9-13**] for EDC of [**2168-6-19**] and estimated gestational age
of 27-4/7 weeks by dates and confirmatory ultrasounds.
Ultrasounds at 14, 22, 24, and 27 weeks normal and consistent
with dates. Pregnancy was complicated by first trimester
bleeding, presented with one week history of abdominal pain
with hypertension in obstetrician's office on date of
delivery. Subsequent evaluation consistent with HELLP
syndrome with maternal platelet count of 60,000.
Betamethasone was administered eight hours prior to delivery.
Mom proceeded to cesarean section under general anesthesia.
Membranes were ruptured at delivery yielding clear amniotic
fluid. No maternal fever or other signs of chorioamnionitis.
No preterm labor. The infant emerged hypotonic and apneic.
Was orally and nasally bulb suction, dried, and tactile
stimulation provided with onset of inconsistent respiratory
effort, but intermittent bradycardia from 90 to 100 beats per
minute. Bag mask ventilation for 3-4 minutes with resolution
of cyanosis, but continued poor respiratory drive. Infant
was intubated on initial attempt and the procedure was
tolerated well without complications. The infant was
subsequently pink and 100 percent FIO2 with moderate
intercostal retractions with spontaneous breath and well-
maintained heart rate. He was transferred uneventfully to
the Newborn Intensive Care Unit.
PHYSICAL EXAMINATION: Preterm infant with examination
consistent with 28 weeks gestation. Birth weight 962 grams
(25th to 50th percentile). Length 36 cm (50th percentile).
Head circumference 25.25 cm (25th to 50th percentile). Vital
signs: Rectal temperature 95.1, heart rate 138, respiratory
rate 52, and oxygen saturation in 100 percent FIO2 100, blood
pressure 45/18, and a mean arterial pressure of 28. Head,
eyes, ears, nose, and throat: Anterior fontanel is soft and
flat, nondysmorphic, palate intact, neck and mouth normal,
moderate facial bruising. Chest: Moderate retractions with
spontaneous breaths, good excursion with ventilated breaths,
fair breath sounds bilaterally, scattered coarse crackles.
Cardiovascular: Infant well perfused, regular, rate, and
rhythm, femoral pulses normal, S1, S2 normal, no murmur
auscultated. Abdomen is soft, nondistended, no organomegaly,
no masses, bowel sounds active, anus patent, three-vessel
umbilical cord. CNS: Active infant, responds to
stimulation, tone decreased in symmetric distribution, moving
all extremities symmetrically. Skin: Facial bruising,
otherwise unremarkable. Musculoskeletal: Normal spine,
limbs, hips, clavicles.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Known lastname **]
was intubated in the delivery room and transported to the
Newborn Intensive Care Unit and placed on conventional
mandatory ventilation. He received two doses of Survanta and
was subsequently extubated to CPAP by day of life two. He
received two bicarb boluses on day of life six for persistent
metabolic acidosis. He weaned to nasal cannula oxygen by
day of life 22, and then to room air by day of life 40.
Caffeine citrate was started on day of life two for apnea of
prematurity and discontinued on day of life 46. His last
bradycardic episode was on [**5-18**]. He has has several
desaturation episodes not associated with apnea or bradycardia
durign the weeks since his last apneic spell. These were felt
due to reflux and/or oropaharyngeal discoordination.
Persistence of these lead to starting od Enfamil AR on [**5-31**].
His last episode occured on [**5-29**].
Cardiovascular: [**Known lastname 49966**] blood pressure has been stable
throughout his hospitalization. No fluid boluses or pressors
were required. He received a course of indomethacin on day
of life three for a patent ductus arteriosus. A followup
echocardiogram on day of life five showed a small patent
ductus arteriosus felt to be clinically insignificant. A
louder murmur on day of life 18 prompted a repeat
echocardiogram, which showed a 1.5 mm patent ductus
arteriosus with left-to-right flow. He received another
course of indomethacin at that time.
A followup echocardiogram on day of life 20 showed a small
less than 1 mm patent ductus arteriosus with left-to-right
flow again felt to be clinically insignificant. He continues
to have a soft intermittent murmur.
Fluid, electrolytes, and nutrition: Umbilical arterial and
umbilical venous catheters were placed shortly after
admission to the Newborn Intensive Care Unit. IV fluids of
D5W were started at 100 cc/kg/day. Enteral feeds were
started on day of life nine after his course of indomethacin
and advanced to full volume feeds by day of life 15.
He was NPO again on day of life 18 for a second course of
indomethacin. He was back to full volume feeds by day of
life 25. Caloric density was increased to 30 calorie breast
milk with ProMod.
Transient hypoglycemia on day of life two and three requiring
several boluses of D10W. Last electrolytes on [**4-19**]
were a sodium of 137, potassium of 5.3, chloride of 100, and
bicarb of 26. On [**5-5**], he had a serum calcium of 10.4,
a phosphate of 6.1, and an alkaline phosphatase of 388. He
is now ad lib p.o. feeds of Enfamil 26 calories/ounce taking
180-210 cc/kg/day. His discharge weight is 2245 grams,
length 45 cm, head circumference 31.5 cm.
GI: Phototherapy was started on day of life one for a total
bilirubin of 6.2. Peak bilirubin of 8.1 on day of life nine.
Phototherapy was discontinued on day of life 26 for a
bilirubin of 5.0. Rebound on day of life 27 was 5.0.
Hematology: [**Known lastname 49966**] blood type is O positive. His
hematocrit on admission to the NICU was 50.8. He did not
receive any blood products during his hospitalization. His
last hematocrit on [**4-10**] was 26.8 with a reticulocyte
count of 20.4.
Infectious disease: A CBC and blood culture were drawn upon
admission to the Newborn Intensive Care Unit. He had a white
count of 2300 with a hematocrit of 50, platelet count of
148,000 with 24 percent neutrophils and 1 percent band. His
blood culture was negative. His leukopenia improved on day
of life one with a white blood cell count of 6,000. He
received 48 hours of ampicillin and gentamicin, and had no
further issues with infection.
Neurology: Head ultrasounds on day of life 4, day of life 8,
and day of life 33 were normal.
GU: [**Known lastname **] was circumcised on day of life 54. The
circumcision is healing nicely.
Sensory: A hearing screen was performed with automated
auditory brain stem responses. He passed in both ears.
Ophthalmology: [**Known lastname 49966**] eyes were most recently examined on
[**Month (only) 116**] 24thth and were found to be immature to zone 3. A
follow-up
examination should be scheduled three weeks from that exam
with Dr. [**Last Name (STitle) **] at [**Hospital3 1810**].
Psychosocial: [**Hospital1 69**] Social
Work has been involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **].
CONDITION AT DISCHARGE: Infant is stable, in room air, and
taking all p.o. feeds, stable temperature, and open crib.
DISCHARGE DISPOSITION: To home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 19419**] in [**Hospital1 1474**],
phone number [**Telephone/Fax (1) 53417**]. [**Known lastname **] will also be followed by
[**Hospital1 1474**] VNA, phone number [**Telephone/Fax (1) 36133**]. [**Known lastname **] will be
followed by [**Hospital3 **] [**Hospital 4189**] Health Center for early
intervention, phone number [**Telephone/Fax (1) 43398**]. [**Known lastname 49966**] first
pediatric appointment is scheduled for [**5-27**] at 11:30 a.m.
with Dr. [**Last Name (STitle) 19419**].
CARE RECOMMENDATIONS: Feeds at discharge: Ad lib demand
feeds of Enfamil enriched to 26 calories/ounce by
concentration and 2 calories/ounce corn oil.
Follow-up appointment with Dr [**Last Name (STitle) 54603**] for repeat eye exam in
three weeks.
MEDICATIONS: Ferrous sulfate 0.2 cc every day.
CAR SEAT POSITION SCREENING: [**Known lastname **] passed his car seat
test.
STATE NEWBORN SCREENING STATUS: [**Known lastname 49966**] last newborn
screening was sent on [**5-10**]. No abnormal results were
reported.
IMMUNIZATIONS RECEIVED: [**Known lastname **] received his first hepatitis
B vaccine on [**5-1**]. He will receive his two month
immunizations at his primary pediatrician.
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following
three criteria: 1. Born at less than 32 weeks, 2. Born
between 32 and 35 weeks with two of the following:
daycare during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school-age
siblings, or 3. With chronic lung disease.
1. Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for
household contacts and out of home caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity at 27-4/7 weeks gestation.
2. Respiratory distress syndrome.
3. Patent ductus arteriosus.
4. Hyperbilirubinemia.
5. Apnea of prematurity.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2168-5-26**] 05:11:15
T: [**2168-5-26**] 07:07:38
Job#: [**Job Number **]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3138
} | Medical Text: Admission Date: [**2175-8-6**] Discharge Date: [**2175-8-11**]
Date of Birth: [**2175-8-6**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**First Name4 (NamePattern1) 4813**] [**Known lastname 4027**] is the former
3.150-kilogram product of a 37-2/7-weeks gestation pregnancy
born to a 30-year-old G1, P0 woman. Blood type: O-positive,
antibody negative, rubella immune, RPR nonreactive, hepatitis
B surface antigen negative, group B Strep status unknown.
This was an uncomplicated pregnancy except for the twin
gestation. The infant was born by elective cesarean section.
Apgars were 8 at 1 minute and 8 at 5 minutes. He was admitted
to the neonatal intensive care unit from labor and delivery
suite for respiratory distress.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight is 3.150 kilograms which is 6 pounds 15 ounces,
length 19 inches, head circumference 35 cm. General:
Nondysmorphic near term male with grunting, flaring, and
retracting. Head, eyes, ears, nose, throat: Anterior fontanel
soft and flat, palate intact. Positive red reflexes
bilaterally. Chest: Breath sounds equal, slightly barrel-
shaped chest. Breath sounds: Clear. Cardiovascular: Regular
rate and rhythm, no murmur, normal S1, S2. Femoral pulses +2.
Abdomen: Benign. Genitalia: Normal. Testes: Descended. Anus:
Patent. Spine: Intact. Hips: Normal. Neuro: Nonfocal, age-
appropriate exam.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: A chest x-ray obtained shortly after
admission to the neonatal intensive care unit was
consistent with retained fetal lung fluid. [**Doctor First Name 4813**] required
nasal cannula oxygen and weaned to room air on [**8-9**], [**2174**]. At the time of discharge, he is breathing
comfortably on room air with a respiratory rate of 40s-
60s breaths per minute.
2. Cardiovascular: [**Doctor First Name 4813**] has maintained normal heart rates
and blood pressures. No murmurs have been noted.
3. Fluid, electrolytes, and nutrition: [**Doctor First Name 4813**] was initially
NPO and treated with intravenous fluids. Breast-feeding
was initiated on day of life #1. At the time of
discharge, he is breast-feeding or taking Similac 20
calorie per ounce formula. Weight on the day of discharge
is 2.815 kilograms which is 6 pounds, 3 ounces. Serum
electrolytes were checked in the 1st few days of life and
were within normal limits.
4. Infectious disease: Due to the unknown etiology of the
respiratory distress and the unknown group beta Strep
status of the mother, [**Name (NI) 4813**] was evaluated for sepsis upon
admission to the neonatal intensive care unit. His
initial complete blood count was within normal limits. As
he remained in oxygen at 24 hours of life, the complete
blood count was repeated and remained within normal
limits. A 2nd blood culture was sent, and intravenous
ampicillin and gentamicin were started. Blood culture was
negative, and antibiotics were discontinued after 48-hour
course.
5. Hematological: Hematocrit at birth was 43.6%.
6. Gastrointestinal: Peak serum bilirubin was on day of life
4, a total of 10.6 mg per deciliter. Repeat bilirubin on
the day of discharge is 12.2.
7. Neurology: [**Doctor First Name 4813**] has maintained a normal neurological
exam during admission, and there were no neurological
concerns at the time of discharge.
8. Sensory: Audiology: Hearing screening was performed with
automated auditory brainstem responses. [**Doctor First Name 4813**] passed in
both ears.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] (Ed) [**Doctor Last Name 60843**], [**Location (un) **], [**Location (un) 55**], [**Numeric Identifier 38804**]. Phone number [**Telephone/Fax (1) 60844**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: Breast-feeding or Similac 20.
2. No medications.
3. Car seat position screening was performed. [**Doctor First Name 4813**] was
observed in his car seat for 90 minutes without any
episodes of oxygen desaturation or bradycardia.
4. State newborn screen was sent on [**2175-8-9**] with
no notification of abnormal results to date.
5. Hepatitis B vaccine was administered on [**2175-8-10**].
6. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria: 1) born at less
than 32 weeks; 2) born between 32-35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities,
or school-age siblings; or 3) with chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS SCHEDULED OR RECOMMENDED: Appointment
with Dr. [**First Name (STitle) 60843**], primary pediatrician within 2 days of
discharge.
DISCHARGE DIAGNOSES:
1. Term gestation at 37-2/7-weeks gestation.
2. Twin #1 of twin gestation.
3. Transitional respiratory distress.
4. Suspicion for sepsis ruled out.
5. Status post circumcision.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2175-8-11**] 03:01:23
T: [**2175-8-11**] 04:32:48
Job#: [**Job Number 69172**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3139
} | Medical Text: Admission Date: [**2117-8-21**] Discharge Date: [**2117-9-6**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old
female with a history of rheumatoid arthritis and
hypertension who was in the process of preoperative
evaluation for a right knee replacement. She was found to
have a urinary tract infection on routine urinalysis on
[**8-11**]. She was therefore started on Bactrim. Since
then the patient reports nonspecific complaints including
increasing fatigue and occasional lightheadedness but denied
any chest pain, shortness of breath, nausea, vomiting, or
diaphoresis. She does report that her urine did become
[**Location (un) 2452**] in color. She experienced a decrease in urine output
times two days prior to admission without any dysuria or
hematuria.
She had laboratories drawn at an outside hospital on
[**8-18**] which demonstrated an increased white blood cell
count with 3 bands. In addition, her creatinine had
increased from a baseline of 1 to 2.7. While she was at her
primary care physician's office getting her laboratories
drawn she continued to complain of lightheadedness and
dizziness.
She was seen in the clinic on [**8-20**] for followup. She
was found to have a blood pressure of 110/64 and physical
examination revealed no bibasilar crackles. Her
electrocardiogram showed no acute changes, and a chest x-ray
was negative by report. Her creatine kinase enzymes and
creatinine were found to be elevated and she was sent to the
Emergency Department to evaluate for acute renal failure and
to rule out for myocardial infarction.
In the Emergency Department, the patient was afebrile with
stable vital signs. Her creatine kinases were cycled, and
her troponin was negative. Her second creatine kinase had an
elevated MB fraction. The patient was questioned again about
chest pain, angina, shortness of breath, nausea, vomiting,
diaphoresis; and she denied all. She was noted at that time
to have a maculopapular rash.
In the Emergency Department, she was given Lasix 20 mg, and
aspirin, as well as 1 unit of packed red blood cells. She
was admitted for further evaluation of her acute renal
failure and to rule out myocardial infarction.
PAST MEDICAL HISTORY:
1. Rheumatoid arthritis.
2. Osteoporosis.
3. Hypertension.
4. History of vertigo.
5. No history of coronary artery disease.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Atenolol 25 mg p.o. q.d.,
Bactrim 1-week total (to be completed on [**10-20**]),
Fosamax 10 mg p.o. q.d., Plaquenil 200 mg p.o. b.i.d.,
Ultra-Cal, Vioxx 25 mg p.o. b.i.d., meclizine 25 mg p.o. q.d.
p.r.n.
SOCIAL HISTORY: The patient lives alone is very independent.
She walks regularly for exercise. She denies any alcohol or
tobacco use. Her daughter is her contact at phone
number [**Telephone/Fax (1) 32941**].
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were blood
pressure 108/48, heart rate 58, respiratory rate 26, satting
97% on 2 liters oxygen. In general, pleasant, in no acute
distress. HEENT revealed extraocular muscles were intact.
Pupils were equal, round, and reactive to light. The
oropharynx was without lesions. Cardiovascular had a regular
rate and rhythm, a 2/6 systolic ejection murmur at the left
sternal border radiating to the axilla. No jugular venous
distention. Pulmonary revealed crackles appreciated at the
lower one-third on the left and lower one-half on the right.
Abdomen was distended and tympanitic with positive bowel
sounds, soft and nontender. No suprapubic tenderness. No
costovertebral angle tenderness. Foley in place with light
yellow urine. Extremities had 2+ pitting edema to the feet
bilaterally. Skin had maculopapular rash over the chest,
arms, legs; nonpruritic. Neurologically, nonfocal.
LABORATORY DATA ON PRESENTATION: White blood cell count 6.9,
hematocrit 27.5, platelets 154. Sodium 128, potassium 4.2,
chloride 95, bicarbonate 22, BUN 57, creatinine 3.5, glucose
of 111. ALT 15, AST 30, alkaline phosphatase 79, total
bilirubin 0.2. Creatine kinase 263 with an MB fraction
of 21, giving an index of 8%. Urinalysis was nitrite
negative, protein negative, blood negative, 5 red blood
cells, 1 white blood cell, no bacteria, 1 epithelial cell.
RADIOLOGY/IMAGING: Electrocardiogram revealed sinus rhythm
at 56 beats per minute, primary AV block, normal axis, T wave
inversions in leads III and aVF.
HOSPITAL COURSE: The patient is an 84-year-old female with
rheumatoid arthritis with a recent bump in her creatinine and
a new rash following initiation of Bactrim therapy, who was
also presenting with a complaint of malaise, positive
creatine kinases, negative troponin.
Her acute renal failure seemed likely secondary to Bactrim
initiation as well as possibly having been contributed by
dehydration and Vioxx therapy. The role of her positive
creatine kinase enzymes was unclear. She also seemed to be
demonstrating a mild congestive heart failure at the time of
admission.
The patient was ruling in by myocardial enzymes for a
myocardial infarction given her elevated enzymes. She was
therefore started on an aspirin and Lopressor, and her ACE
inhibitor was held. The patient was started on telemetry,
and serial electrocardiograms were followed.
The patient was also suffering nonoliguric acute renal
failure which was thought secondary to Bactrim, possibly
exacerbated by dehydration. Therefore, the Bactrim was held.
A Renal consultation was obtained, who said that the sediment
of the urine did show white cells. They felt like her
symptomatology could be consistent with Bactrim-induced renal
insufficiency. They recommended gentle hydration and
withholding of offending agents with consideration for
steroid treatment should her renal function worsen.
Over the course of the next few days the patient's creatinine
trended downward as the patient diuresed. The patient
remained cardiovascularly stable with creatine kinase enzymes
trending downward as well. She remained chest pain free over
the next few hospital days. Her beta blocker, aspirin, and
nitrates were continued.
However, the patient's pulmonary function continued to worsen
over the next few days. She continued to have low oxygen
saturations and required increasing amounts of oxygen to
maintain her saturation. In addition, she continued to have
rales on examination despite avid diuresis. Therefore, it
was felt that congestive heart failure was an unlikely reason
for the patient's pulmonary problems. A CT scan was obtained
which was not consistent with pulmonary embolus. As her
pulmonary situation continued to deteriorate, it was felt
that she was likely developing acute respiratory distress
syndrome. She was therefore evaluated by the Medical
Intensive Care Unit team for possible transfer.
By [**8-27**], the patient was requiring 10 liters to 15
liters by face mask to maintain oxygen saturations of greater
than 90%. As part of the workup of her hypoxia, an
echocardiogram revealed an ejection fraction of 50% with
moderate pulmonary hypertension, and her CT angiogram while
demonstrating no evidence of pulmonary embolus did
demonstrate increased interstitial infiltrates and areas of
ground-glass opacifications. She was therefore transferred
to the Medical Intensive Care Unit on [**8-27**] for
management of what appeared to be a noncardiogenic
interstitial infiltrate of unclear etiology. She was
continued on levofloxacin 250 mg p.o. q.d. and was started on
Solu-Medrol 60 mg intravenously q.8h.
A bronchoalveolar lavage was planned to evaluate for
infectious etiology of the patient's pulmonary issues as well
as to obtain a tissue sample for evaluation of possible
hypersensitivity pneumonitis. Pending these results, the
patient was continued on empiric antibiotic therapy as well
as empiric Pneumocystis carinii pneumonia coverage and
empiric steroids. Her saturations remained stable on a
nonrebreather over the next few days; however, the patient
did not show any improvement in her pulmonary situation.
Results from the bronchoalveolar lavage did not demonstrate
any etiology of the patient's pulmonary pathology.
Therefore, Thoracic Surgery was contact[**Name (NI) **] for evaluation for
possible open lung biopsy.
Over the course of the next few days the patient's pulmonary
situation continued to worsen. On [**8-30**], it was felt
that the patient was becoming fatigued and could not longer
support her own breathing. Therefore, she was intubated and
sedated to decrease her work of breathing. Levofloxacin and
Solu-Medrol were continued. The patient has remained
hemodynamically stable; however, after initiating sedatives
for placement of the endotracheal tube, her pressure dropped
and responded well to fluid boluses.
On [**9-1**], a central line was placed in preparation for a
lung biopsy. This resulted in a subsequent pneumothorax
which was treated with chest tube placement. The patient
tolerated the procedure without difficulty. A lung biopsy
was performed later that afternoon. Results from the lung
biopsy demonstrated extensive fibrosis with virtually no
pulmonary architecture remaining. Therefore, it was felt
that the patient was suffering end-stage fibrosis possibly
secondary to a usual interstitial pneumonitis versus an acute
interstitial pneumonitis.
Over the course of the next few days the patient's oxygen
requirements and ventilatory support need increased. A
family discussion was held to discuss the patient's poor
prognosis given the extent fibrosis found on lung biopsy. It
was determined that the only possible course of treatment
left was a short course of intensive high-dose steroids. The
patient's family agreed to this treatment, and the patient
was treated with 1 g of Solu-Medrol intravenously q.d. times
three days. Over the course of those three days, the patient
remained hemodynamically stable but with decreasing blood
pressure and had to be started on pressors. She also
required increasing ventilatory support and was kept sedated
as well as paralyzed. Serial blood gases demonstrated
increasing acidosis. In addition, the patient's peak
pressures increased to well over 40.
Therefore, at the end of three days of high-dose steroids it
was felt that the patient's pulmonary situation had not
improved. This was discussed at length with the patient's
family who agreed that in this situation the patient would
not want to be on a ventilator for the rest of her life.
Therefore, the focus of care was switched to comfort measures
only. The patient was provided with adequate sedation and
pain medication.
The patient was found to be unresponsive in the afternoon of
[**2117-9-6**]. Telemetry demonstrated no electrocardiac
activity. The patient was found to have pupils fixed and
dilated with absent reflexes, absent heart sounds, and absent
breath sounds. The patient was pronounced dead at 4:30 p.m.
on [**2117-9-6**]. The patient's family was in attendance
at the time of death. The attending, Dr. [**First Name (STitle) **], and the
patient's covering primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], were
contact[**Name (NI) **]. The patient deferred an autopsy at the time of
death.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2117-10-14**] 17:06
T: [**2117-10-17**] 10:08
JOB#: [**Job Number **]
(cclist)
ICD9 Codes: 5849, 5990, 2765, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3140
} | Medical Text: Admission Date: [**2200-11-11**] Discharge Date: [**2200-11-19**]
Service: CSU
.
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male
patient with history of coronary artery bypass graft in [**2191**]
and stenting in [**2199-3-23**]. He reports feeling well until
four weeks prior to admission, when he began developing
exertional angina and increase of episodes of atrial
fibrillation. An echo at the end of [**10-2**],
showed a new inferior wall abnormality. He was admitted to
an outside hospital for catheterization, showing occlusion of
his obtuse marginal graft. At that time, he was transferred
to the [**Hospital1 69**], on [**2200-11-23**] for
valve and possible redo coronary artery bypass graft. He had
been on Plavix for the stents he had placed in [**2199-3-23**]
and, for that reason, it was decided that he would be
discharged home off the Plavix for a week and return to have
his coronary artery bypass graft done. However, once home,
he again was experiencing some atrial fibrillation on the
morning of [**11-9**] and since he wasn't anticoagulated
preoperatively, his cardiologist advised that he be
readmitted. He was readmitted to [**Hospital1 190**] on [**2200-11-11**] for intravenous heparin and plans
for a coronary artery bypass graft/MVR later in the week.
PAST MEDICAL HISTORY: Coronary artery bypass graft in [**2191**]
with left internal mammary artery to the left anterior
descending; saphenous vein graft to obtuse marginal one and
obtuse marginal two, right coronary artery and left
circumflex. Chronic renal insufficiency. Diabetes type II.
Hypertension. Paroxysmal atrial fibrillation. Congestive
heart failure. Mitral regurgitation. Status post
tonsillectomy.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient lives in [**Hospital1 6930**] with wife,
retired. Very active, drives. No assistive devices.
Tobacco: Quit 40 years ago with a 20 pack year history. No
history of alcohol.
FAMILY HISTORY: Mother down with a heart attack at the age
of 55. Two brothers with coronary artery disease and
myocardial infarction, both deceased at 54 and 56 years of
age. One sister deceased of a myocardial infarction in [**2164**].
PHYSICAL EXAMINATION: On presentation, height was 5' 7".
Weight 168 pounds. Vital signs: Temperature 97.5; blood
pressure 152/78, heart rate 74 and sinus; respiratory rate
16. SP02 on room air 94%. General: The patient is sitting
up in bed, in no acute distress. Neurological: Alert and
oriented times three, appropriate. Respiratory: Positive
rales, bilateral bases, left greater than right.
Cardiovascular: Regular rate and rhythm, S1 and S2, 3 out of
6 systolic ejection murmur, loudest at the apex. GI: Soft,
round, nontender, nondistended, positive bowel sounds.
Extremities are warm, well-perfused, darker in color in the
calf area with no edema or varicosities.
LABORATORY DATA: Preoperative lab results from [**11-6**] and
[**11-7**] reveal white blood cell count of 6.3, hematocrit 35.8,
platelets 160, PT 13, INR 1.1, sodium 144, potassium 4.6,
chloride 107, CO2 28, BUN 31, creatinine 1.8, glucose 99, ALT
27, AST 19, LDH 168, alkaline phosphatase 79, amylase 53,
total bilirubin 0.8. Urinalysis was negative. Chest x-ray
on [**11-5**] showed no acute cardiopulmonary processes. He also
had carotid ultrasound preoperatively, showing less than 40%
bilateral stenosis and lower extremity vein mapping showing
the right greater saphenous vein patent throughout and left
greater saphenous vein harvested from his previous coronary
artery bypass graft.
HOSPITAL COURSE: Mr. [**Known lastname **] was brought to the hospital on
[**2200-11-11**]. IV heparin was given preop for his coronary artery
bypass graft/MVR. He had some renal insufficiency at
baseline. His creatinine was monitored here with a
creatinine of 1.7 preoperatively. He was taken to the
operating room on the morning of [**2200-11-13**] with Dr. [**Last Name (STitle) **]
and underwent a coronary artery bypass graft times two with
saphenous vein grafts to the obtuse marginal one and obtuse
marginal two. He also had a mitral valve repair with a 28 mm
[**Location (un) 55269**] Annuloplasty ring. Total cardiopulmonary bypass time
of 129 minutes. Cross clamp time was 82 minutes. The
patient was transferred to cardiac surgery recovery unit with
a mean arterial pressure of 89, CVP of 10, heart rate of 80
on Nitroglycerin, Dobutamine and Propofol drips. He was
extubated on the evening of his operation and his IV drip
medications were weaned as tolerated. He was transferred to
the inpatient floor on postoperative day one in stable
condition. His heart rate continued to vary between a normal
sinus rhythm and atrial fibrillation, which is the patient's
baseline. Chest tubes were discontinued on postoperative day
two without incident. His cardiac pacing wires were
discontinued on postoperative day number three, also without
incident. Mr. [**Known lastname **] was followed by the physical therapy
team throughout his hospital stay, with initial evaluation on
[**11-15**]. They continued to follow him throughout his stay and
on [**11-17**], they found that the patient was safe to return home
once medically stable, stating that all goals of the physical
therapy team were met. The remainder of Mr. [**Known lastname 1500**]
postoperative course was uneventful with a fairly chronic
atrial fibrillation postoperatively, that was known
preoperatively, treated only with rate control and Coumadin
which he was on preoperatively as well. The Coumadin was
restarted on [**11-17**] and will be continued at home. On [**11-19**],
it was found that the patient is medically stable for home
and will be discharged.
CONDITION ON DISCHARGE: Good. VITAL SIGNS: Temperature
98.2, pulse 83, sinus rhythm, varying with atrial
fibrillation. Respiratory rate of 18; blood pressure 119/54,
weight 78.3 kg.
LABORATORY FINDINGS: Pertinent laboratory results included
white blood cell count of 7.6; hematocrit of 30.0; platelets
112, Sodium 142; potassium of 3.6; chloride 103; C02 33; BUN
52; creatinine 1.6; glucose 88.
PHYSICAL EXAMINATION: Neurological: Alert, oriented,
nonfocal. Pulmonary: Lungs clear bilaterally. Cardiac
regular rate and rhythm, varying with atrial fibrillation.
Abdomen is soft, nontender, nondistended, with positive bowel
sounds. Extremities: 1+ edema. Sternal incision without
drainage or erythema. Leg incision clean and dry, no
drainage.
DISCHARGE STATUS: Home with visiting nurses.
DISCHARGE DIAGNOSES: Coronary artery disease.
Mitral stenosis.
Chronic renal insufficiency.
Diabetes type II.
Hypertension.
Paroxysmal atrial fibrillation.
DISCHARGE MEDICATION:
1. Amiodarone 400 mg p.o. daily for 7 days and then decrease
to 200 mg p.o. every day.
2. Colace 100 mg p.o. b.i.d.
3. Percocet 5/325 one to two tablets p.o. q. 4 hours p.r.n.
for pain.
4. Aspirin 325 milligrams p.o. every day.
5. Lasix 20 mg p.o. b.i.d. for 7 days.
6. Potassium chloride 20 mEq every day for 7 days.
7. Lopressor 50 mg p.o. b.i.d.
8. Terazosin hydrochloride 5 mg p.o. at bedtime
9. Coumadin 2.5 mg p.o. times one and then as directed by
physician.
10. Lentis insulin 100 units per ml 24 units
subcutaneously at bedtime and Humilog insulin
subcutaneously per sliding scale.
FOLLOW-UP: Appointment with Dr. [**Last Name (STitle) **] in four weeks. Make
an appointment with patient's primary urologist in one week
and appointment with Dr. [**Last Name (STitle) 55270**] in one to two
weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) 5898**]
MEDQUIST36
D: [**2200-11-19**] 17:16:55
T: [**2200-11-20**] 07:24:08
Job#: [**Job Number 55271**]
ICD9 Codes: 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3141
} | Medical Text: Admission Date: [**2164-10-22**] Discharge Date: [**2164-10-30**]
Date of Birth: [**2095-10-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2164-10-22**]: Emergency repair of type-A ascending aortic dissection
with ascending aortic and hemiarch replacement with a size-28
Gelweave graft.
History of Present Illness:
69 year old male woke up this am with acute epigastic pain,
chest pain, shortness of breath and diaphoresis. He called EMS
and was brought to ED and was found to have type A dissection
and is going emergently to OR with Dr.
[**First Name (STitle) **].
Past Medical History:
Hyperlipidemia
Hypertension
BPH
right superior cerebellar artery stroke
prostate cancer s/p brachytherapy 5 years ago
gout
Afib
Past Surgical History:
s/p lumbar laminectomy
s/p tonsillectomy
Social History:
Lives with wife, Ex [**Name (NI) 2570**], quit smoking 25 years ago, drinks a
glass of wine on occasions, no drug abuse
Family History:
Strokes in both parents
Physical Exam:
Admission:
Pulse:58 Resp:18 O2 sat:97
B/P 206/72
Height:6'1" Weight:220 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: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:
[**10-22**] Echo: Prebypass: No atrial septal defect is seen by 2D or
color Doppler. There is severe symmetric left ventricular
hypertrophy. There is mild regional left ventricular systolic
dysfunction with hypokinesia of the apical and mid portions of
the inferior wall.. Overall left ventricular systolic function
is mildly depressed (LVEF= 45%). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. A mobile density is
seen in the ascending aorta consistent with an intimal
flap/aortic dissection. A mobile density is seen in the aortic
arch consistent with an intimal flap/aortic dissection. A mobile
density is seen in the descending aorta consistent with an
intimal flap/aortic dissection. There are three aortic valve
leaflets. There is no aortic valve stenosis. Mild (1+) to
Moderate [2+] aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2164-10-22**]
at 1715. Post bypass: Patient is A paced. LVEF= 40%. 2+ aortic
insufficiency present. (2 jets seen - one central and the other
eccentric. Mild mitral regurgitation present.
[**10-22**] Chest CT: 1. Type A aortic dissection with involvement of
the entire thoracic aorta and abdominal aprta as well as
multiple abdominal aprtic branches, described in detail above.
No evidence of aortic rupture. 2. Infrahilar lymphadenopathy,
unclear etiology, may be reactive. 3. Multiple pancreatic
hypodense lesions. Recommend further evaluation with
non-emergent MRCP. 4. Pulmonary, hepatic, and splenic
calcifications suggestive of granulomatous disease. 5.
Diverticulosis without evidence of diverticulitis.
[**10-23**] Renal U/S: 1. No hydronephrosis. Simple bilateral renal
cysts. 2. Arterial and venous flow is seen bilaterally within
the kidneys.
[**2164-10-30**] 03:56AM BLOOD WBC-9.2 RBC-2.97* Hgb-8.9* Hct-26.5*
MCV-89 MCH-30.1 MCHC-33.7 RDW-15.4 Plt Ct-313
[**2164-10-29**] 03:43AM BLOOD WBC-10.2 RBC-2.96* Hgb-8.8* Hct-26.4*
MCV-89 MCH-29.8 MCHC-33.3 RDW-15.1 Plt Ct-245
[**2164-10-28**] 05:00AM BLOOD WBC-10.2 RBC-2.85* Hgb-8.7* Hct-25.4*
MCV-89 MCH-30.4 MCHC-34.1 RDW-14.9 Plt Ct-184
[**2164-10-30**] 03:56AM BLOOD PT-15.2* INR(PT)-1.4*
[**2164-10-29**] 03:43AM BLOOD PT-14.8* INR(PT)-1.4*
[**2164-10-28**] 05:00AM BLOOD PT-15.5* INR(PT)-1.5*
[**2164-10-27**] 05:12AM BLOOD PT-15.3* INR(PT)-1.4*
[**2164-10-30**] 03:56AM BLOOD Glucose-109* UreaN-66* Creat-2.2* Na-135
K-3.8 Cl-97 HCO3-29 AnGap-13
[**2164-10-29**] 03:43AM BLOOD Glucose-116* UreaN-70* Creat-2.6* Na-136
K-3.8 Cl-98 HCO3-29 AnGap-13
[**2164-10-28**] 05:00AM BLOOD Glucose-105* UreaN-61* Creat-3.1*# Na-135
K-4.0 Cl-97 HCO3-27 AnGap-15
[**2164-10-27**] 05:12AM BLOOD Glucose-131* UreaN-87* Creat-5.2* Na-134
K-4.4 Cl-97 HCO3-25 AnGap-16
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 2572**] was transferred to the ED by
EMS presenting with acute epigastric pain, chest pain, shortness
of breath and diaphoresis. He was found to have a type A aortic
dissection and was emergently transferred to the operating room
for repair. Please see operative note for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. He remained intubated for
several days due to respiratory failure and worsening
hypertension during extubation trial. Finally on post-op day two
he was weaned from sedation, awoke neurologically intact and
extubated. In addition on post-op day two, nephrology was
consulted for decreasing urine output and acute kidney injury.
He eventually required hemodialysis and was followed closely by
nephrology throughout his hospital course. Atrial fibrillation
was noted post-operatively (has history of) and he was
appropriately treated with beta-blockers and Amiodarone. Chest
tubes and epicardial pacing wires were removed per protocol. He
had a swallow study performed due to a history of CVA which he
passed for a regular diet, thin liquids. On post-op day four he
was transferred to the step-down unit for further recovery.
Blood pressure medications were titrated to keep SBP<140.
Coumadin was eventually started for his atrial fibrillation and
history of CVA and his home dose was resumed. He is to be
followed by the [**Hospital3 2576**] [**Hospital 197**] Clinic. Over the next
several days he remained stable while receiving hemodialysis.
Renal continued to follow, urine output slowly increased and
renal function was improved to a creatinine of 2.2 at the time
of discharge (peak cratinine 5.7.) Renal signed off with the
thought that renal function would continue to inprove, although
it may not return to baseline (1.5-1.6.) Physicial therapy
worked with him for strength and mobility. On POD 8 he was
ambulating without difficulty, tolerating a full oral diet and
his incisions were healing well. It was felt that he was safe
for discharge home at this time with VNA services.
Medications on Admission:
famotidine 20 mg [**Hospital1 **]
labetalol 200 mg- 2 Tablet(s) Twice Daily
Benicar 40 mg- 1 Tablet Once Daily
methocarbamol 750 mg- 1 Tablet TID
warfarin Unknown Strength 1 tablet daily
allopurinol 300 mg Daily
simvastatin 40 mg Daily
prednisone 5 mg Tab Oral PRN- last dose 1 week ago (has only
taken a few times for gout)
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed for INR goal 2.0-2.5.
Disp:*90 Tablet(s)* Refills:*2*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*100 Tablet(s)* Refills:*0*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*100 Tablet(s)* Refills:*0*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
12. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Aortic Dissection s/p Emergent repair
Past medical history:
Hyperlipidemia
Hypertension
Benign prostatic hypertrophy
Right superior cerebellar artery stroke
Prostate cancer s/p brachytherapy 5 years ago
Gout
Atrial fibrillation
s/p lumbar laminectomy
s/p tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Ultram
Sternal Incision - healing well, no erythema or drainage
Edema: 1+ LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**11-6**] at
10:45 AM in [**Hospital Unit Name **] [**Hospital Unit Name **]
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2164-11-27**] 1:30
Location: [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Cardiologist: Please get referral to cardiologist from Dr. [**Last Name (STitle) 2578**]
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 2578**] [**Telephone/Fax (1) 2579**] in [**2-21**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for Atrial Fibrillation
Goal INR: 2.0-3.0
First draw [**2164-10-31**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Mass [**Hospital 2580**] [**Hospital 197**] Clinic
Results to phone [**Telephone/Fax (1) 2581**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2164-10-30**]
ICD9 Codes: 5845, 2875, 2767, 4241, 2724, 2859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3142
} | Medical Text: Unit No: [**Numeric Identifier 54913**]
Admission Date: [**2200-1-27**]
Discharge Date: [**2200-4-18**]
Date of Birth: [**2200-1-27**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is a former 1.070
kg product of a 29-2/7 week gestation pregnancy born to a 41-
year-old G7, P2, now three woman. Prenatal screens: Blood
type O positive, antibody negative, RPR nonreactive, rubella
immune, hepatitis B surface antigen negative, group B Strep
status unknown.
The pregnancy was notable for in-[**Last Name (un) 5153**] fertilization
conception. The mother experienced increased blood pressures
and had 2 plus proteinuria. She was admitted on [**2200-1-10**]
for management of hypertension with magnesium sulfate. She
received betamethasone on [**1-10**] and [**2200-1-11**]. The mother
was monitored for ongoing concerns for restricted fetal
growth. The estimated fetal weight was at the 10th
percentile.
Prior obstetrical history is notable for spontaneous vaginal
deliveries in [**2183**] and [**2194**]. Also mother treated for
hypothyroidism with Synthroid.
Delivery was undertaken for concern for fetal heart rate
decelerations noted on monitoring. Delivery was by cesarean
section for breech positioning. Apgars were 7 at 1 minute
and 8 at 5 minutes. Baby required intubation in the delivery
room for respiratory distress and apnea. He was transported
to the Neonatal Intensive Care Unit for treatment of
respiratory distress and prematurity.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 1.070 kg, length 38 cm, head circumference 37
cm, all 25th percentile for gestational age. General:
Intubated preterm male, no obvious dysmorphisms. Head, eyes,
ears, nose, and throat: Anterior fontanel open and flat,
orally intubated, symmetric facial features. Palate intact.
Positive red reflex bilaterally. Chest: Equal breath sounds
with diffuse crackles, fair aeration. Cardiovascular:
Regular, rate, and rhythm without murmur, normal S1, S2,
femoral pulses plus 2. Abdomen is soft, nontender, no
masses. GU: Preterm male genitalia. Testes undescended.
Spine straight with intact sacrum. Moving all extremities.
Neurologic: Tone and reflexes consistent with gestational
age.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: [**Known lastname **] was treated with two doses of
Surfactant. His maximum ventilatory settings were a peak
inspiratory pressure of 24 over a positive end expiratory
pressure of 5, intermittent mandatory ventilatory rate of
25, and 40 percent oxygen. He weaned to low settings, and
was extubated to continuous positive airway pressure on
day of life two.
He required reintubation on day of life three for frequent
episodes of apnea. He remained on the ventilator through day
of life 12. He was extubated to continuous positive airway
pressure with supplemental O2 from day of 12 through 32. He
was on nasal cannula O2 from day of life 32 to 41, when he
weaned to room air. Date of his transition to room air was
[**2200-3-9**].
He was treated for apnea of prematurity with caffeine. His
caffeine was discontinued on [**2200-3-9**]. His last episode of
apnea occurred on [**2200-3-15**]. At the time of discharge, he
is breathing comfortably on room air with respiratory rates
40-60x/minute.
1. Cardiovascular: An intermittent murmur was noted from the
second week of life of approximately two months of age.
[**Known lastname **] was noted to have consistently elevated blood
pressures
with systolics greater than 100 mm Hg during the middle of
[**Month (only) **]. A cardiac
echocardiogram was performed on [**2200-4-7**] that showed
good biventricular function. A small patent foramen ovale
and otherwise structurally normal heart. A renal
ultrasound was performed, which was within normal limits.
He had a consultation with the Renal service from [**Hospital3 18242**]. He initially received several doses of
hydralazine, which was ineffective and he was changed to
captopril, which has required titration of is dosing. At the
time of discharge, he was on 0.2 mg orally 4x daily. On the
day of discharge this was increased to 0.3 mg 4x daily. The
goal
is to have his systolic blood pressures under 100 mm Hg. The
contact person with the Renal team is Dr. [**First Name (STitle) **] [**Name (STitle) 54914**], and he
can be reached through [**Hospital3 1810**] paging system, [**Telephone/Fax (1) 54915**], beeper number [**Pager number **] or office number is [**Telephone/Fax (1) 54916**].
VNA will be coming to the house to perform daily BP
measurements over the weekend. Dr [**Last Name (STitle) **] has been asked that
these be called to him for titration of medication dosing.
1. Fluid, electrolytes, and nutrition: [**Known lastname **] was initially
NPO and maintained on intravenous fluids. Enteral feeds
were started on day of life number three and gradually
advanced to full volume. He had a percutaneously inserted
central catheter for parenteral nutrition, which was
discontinued when he reached full feeds, which was on day
of life 15. He was advanced to a maximum of 30
calories/ounce with additional ProMod protein supplement.
At the time of discharge, he is ad lib feeding or breast
feeding taking in 400-500 cc daily.
Serum electrolytes were checked frequently during admission
and were all within normal limits. The most recent set were
checked on [**4-14**] and showed NA 141 K 4.8, Cl 104 HCO3 22, BUN
5 and creatinine 0.1.
His discharge weight is 3.165 kg with a length of 47.5 cm and
a head circumference of 37 cm, which notably is above the 90th
percentile. A HUS done on [**4-17**] was normal as were all previous
studies.
1. Infectious disease: Due to the unknown group B Strep
status and his respiratory distress, [**Known lastname **] was evaluated
for sepsis at the time of admission. A white blood cell
count was 4,700 with a differential of 22 percent polys, 2
percent bands. A blood culture obtained prior to starting
intravenous antibiotics was no growth and initial course
of antibiotics was stopped at 48 hours. He was noted to
have a reddened periumbilical area and was again
recultured on day of life 14. He received a seven day
course of oxacillin for presumed omphalitis. The blood
culture at that time was also no growth.
1. Hematological: Hematocrit at birth was 51.8 percent. He
did not receive any blood products during admission. His
low hematocrit was 28 percent on [**2200-3-26**]. Most recent
hematocrit was on [**2200-4-6**] at 31.2 percent with a
reticulocyte count of 2.4 percent.
1. GI: [**Known lastname **] required treatment for unconjugated
hyperbilirubinemia with phototherapy. His peak serum
bilirubin occurred on day of life three, a total of
7.8/0.3 mg/dl direct. He required phototherapy for
approximately one week. His phototherapy was discontinued
on day of life 10 with a rebound bilirubin of 3.7, total
over 0.4 mg/dl direct.
[**Known lastname **] also had bilateral inguinal hernias, which were repaired
at [**Hospital3 1810**] on [**2200-4-4**]. He had a circumcision
performed at that time also. Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 38447**] performed the
surgery.
1. Neurology: [**Known lastname **] has had four normal ultrasounds during
admission, most recently on [**2200-4-17**]. As noted with his
discharge growth parameters, his head circumference is 37
cm, which is greater than the 90th percentile. He has a
normal neurological exam at discharge and there are no
current neurological concerns.
1. Sensory: Audiology. Hearing screening was performed with
automated auditory brain stem responses. [**Known lastname **] passed in
both ears.
Ophthalmology. Eyes were most recently examined on
[**2200-3-12**] and retinas were found to be mature. Recommended
followup with Dr. [**Last Name (STitle) 36137**], [**Hospital3 1810**]
Ophthalmology is recommended at age eight months.
1. Psychosocial: [**Hospital1 69**] Social
Work was involved with this family. The contact person is
[**Name (NI) 5036**] [**Name (NI) 4467**], and she can be reached at [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents. The primary
pediatrician is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 54917**], [**Hospital 1411**] Medical Associates,
[**Location (un) **] [**Street Address(2) 54918**], [**Location (un) **], [**Numeric Identifier 54919**], phone
number [**Telephone/Fax (1) 8506**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: Feeding:
Ad lib breast feeding or expressed mother's milk ad lib p.o.
Medications: Ferrous sulfate 25 mg/mL dilution 0.6 mL p.o.
once daily, Poly-Vi-[**Male First Name (un) **] 1 mL p.o. once daily, captopril oral
suspension 0.3 mg p.o. 4x daily.
Car seat position screening was performed. [**Known lastname **] was observed
for 90 minutes in his car seat without any episodes of
bradycardia or oxygen desaturation.
State newborn screens were sent on [**4-6**], and
[**2200-3-20**] with no report of abnormal results.
Immunizations received: Hepatitis B vaccine on [**3-17**] and
[**2200-4-18**]. Diphtheria, acellular pertussis, Hemophilus
influenza B on [**2200-3-29**], and injectable polio vaccine and
pneumococcal 7-valiant conjugate vaccine on [**2200-3-30**].
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the three criteria: 1. Born at less than 32 weeks, 2.
Born between 32 and 35 weeks with two of three of the
following: daycare during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOW-UP APPOINTMENTS SCHEDULED OR RECOMMENDED: Renal, Dr.
[**First Name (STitle) **] [**Name (STitle) 54914**], office [**Telephone/Fax (1) 50498**] or page through [**Hospital3 18242**] [**Telephone/Fax (1) 38834**], beeper number [**Pager number **]. He should be
consulted if systolic blood pressure is consistently over 100
mm Hg. Planned followup in one month after discharge with
DMSA scan.
Serum electrolytes should be checked within one week of
discharge.
Primary pediatrician within five days of discharge.
Pediatric Ophthalmology at eight months of age.
[**Hospital6 407**] will be checking blood pressure
daily.
DISCHARGE DIAGNOSES: Prematurity at 29-1/7 weeks gestation.
Respiratory distress syndrome.
Suspicion for sepsis ruled out twice.
Apnea of prematurity.
Anemia of prematurity.
Omphalitis.
Bacterial conjunctivitis.
Unconjugated hyperbilirubinemia.
Hypertension of unknown etiology.
Macrocephaly.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2200-4-18**] 07:21:03
T: [**2200-4-18**] 08:13:14
Job#: [**Job Number **]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3143
} | Medical Text: Admission Date: [**2175-2-11**] Discharge Date: [**2175-2-18**]
Date of Birth: [**2131-1-26**] Sex: F
Service: EMERGENCY
Allergies:
Doxycycline / Tetracycline / Augmentin
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Shortness of breath, Chest pain
Major Surgical or Invasive Procedure:
[**2175-2-15**] Right heart catheterization
History of Present Illness:
Ms. [**Known lastname **] is a 44 year-old Chinese ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] dialect, related to
Cantonese, history) speaking female who presents for acute onset
of shortness of breath and palpitations. She has a complicated
PMH: is s/p L pneumonectomy for TB in [**2160**] that was c/b
post-pericardiotomy syndrome; has newly diagnosed pulmonary
hypertension, with chronic hypoxia on home 3L O2 and CPAP; and a
history of breast cancer s/p R mastectomy and chemo in
[**2170**]-[**2171**]. She says that she woke up this morning at 0500-0600
and felt a sharp pain over her heart, shortness of breath,
sweatiness, HA and blurry vision. She took hot milk and water,
and then felt worse, with a heart rate of 180. She says that she
felt like she was in "shock". The pain radiated down her arm and
into her shoulder and "liver region". Not associated with taking
deep breaths. She was taken to the ED and arrived around 0745.
She says this was similar to her symptoms last week when
admitted to [**Hospital1 18**], but the intensity of this episode was far
greater, especially with regard to her heart rate and SOB. She
denies cough, fevers, but + chills. She denies any recent sick
contacts. [**Name (NI) **] night sweats but + diaphoresis. Has had 3-4 days of
nausea and diarrhea, with 3-4 bowel movements/day (essentially
since discharge). She does not feeling generally short of breath
for a few months, with decreased appetite over the last 1 month
and a 2-lb weight loss. She felt well yesterday. Notably, she
did present to the ED on [**2-6**] with again similar complaints which
resolved after oxygen and observation. She did not keep her
cardiology appointment on [**2-7**].
Upon presentation to the ED, her VS were HR 124, and she was 77%
on 4L NC. She was put on a NRB and her O2sat improved to 100%.
VS prior to transfer were 98.1, HR 103, BP 107/69, RR 28, O2sat
99% on 4L NC.
A CXR was done and showed minimal change from [**2-6**]. EKG with
sinus tachycardia, no significant changes. Labs without
elevation in WBC, normal lactate, cardiac enzymes normal in ED x
1.
.
Currently she reports feeling at her baseline with no SOB or
chest discomfort. Still feels her heart rate is fast.
Past Medical History:
- TB S/p extrapleural left pneumectomy with mediastinal
repositioning and serrated mediastinal flap [**2160**] c/b
myopericarditis treated with ibuprofen, c/b pericardial effusion
and tamponade
- Pulmonary hypertension
- OSA/nocturnal hypoventilation
- Right-sided stage I breast cancer ER/PR neg, HER-2/neu
negative, diagnosed in [**5-7**]
--- s/p lumpectomy and sentinel node biopsy in [**6-6**] and s/p 4
cycles adriamycin and cytoxan on [**2171-10-9**]
--- s/p completion mastectomy was done on [**2172-3-12**] as radiation
would have compromised pulmonary function further
---s/p weeks of taxol c/b neuropathy
Social History:
The patient lives at home with her husband and son.
She does not work. She immigrated from [**Country 651**] in [**2154**]. She denies
any tobacco, alcohol, or illicit drug use.
Family History:
Her mother's sister was diagnosed with breast cancer at the age
of mid-40s. Her grandfather had diabetes. No family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory
Physical Exam:
VS: T 98.6, BP 95/66, HR 102, RR 24, O2sat 98%4L
GENERAL: Thin appearing female in NAD.
HEENT: PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of
the oral mucosa.
NECK: Supple, no JVD
CHEST: No chest wall tenderness. S/p R mastectomy with
well-healed incision.
CARDIAC: Tachycardic, normal S1, split S2 with loud P2. LUSB
II/VI systolic murmur, LLSB I/VI systolic murmur. No thrills,
lifts. No S3 or S4.
LUNGS: Transmitted BS in left lung but right lung clear with no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, mild TTP in epigastric area, otherwise nontender,
non-distended, no rebound or guarding. +BS.
EXTREMITIES: No LE edema. Pulses equal, [**12-3**]+ in both LEs
Pertinent Results:
CBC/diff:
[**2175-2-11**] 08:25AM BLOOD WBC-4.4 RBC-4.06* Hgb-10.3* Hct-34.9*
MCV-86 MCH-25.4* MCHC-29.6* RDW-14.0 Plt Ct-222#
[**2175-2-12**] 07:07AM BLOOD WBC-3.5* RBC-4.12* Hgb-10.4* Hct-35.9*
MCV-87 MCH-25.2* MCHC-28.8* RDW-13.7 Plt Ct-246
[**2175-2-11**] 08:25AM BLOOD Neuts-80.8* Lymphs-11.1* Monos-7.3
Eos-0.5 Baso-0.2
.
Coags:
[**2175-2-11**] 08:25AM BLOOD PT-11.4 PTT-25.3 INR(PT)-0.9
[**2175-2-12**] 07:07AM BLOOD PT-11.1 PTT-27.7 INR(PT)-0.9
.
Lytes
[**2175-2-11**] 08:25AM BLOOD Glucose-125* UreaN-10 Creat-1.0 Na-137
K-4.3 Cl-95* HCO3-36* AnGap-10
[**2175-2-12**] 07:07AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-139 K-4.7
Cl-92* HCO3-42* AnGap-10
[**2175-2-12**] 07:07AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9
.
Cardiac enzymes:
[**2175-2-11**] 08:25AM BLOOD CK(CPK)-36
[**2175-2-11**] 03:20PM BLOOD CK(CPK)-38
[**2175-2-11**] 08:25AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2175-2-11**] 03:20PM BLOOD CK-MB-NotDone cTropnT-<0.01
.
ABG [**2-12**]:
[**2175-2-12**] 02:43PM BLOOD Type-ART O2 Flow-4 pO2-116* pCO2-106*
pH-7.25* calTCO2-49* Base XS-14
.
ECHO [**2-13**]:
The left atrium and right atrium are normal in cavity size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. The right
atrial pressure is indeterminate. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is moderately dilated There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of [**2175-2-3**], the
image quality on the current study is suboptimal. Trace aortic
regurgitation is now seen. Biventricular cavity size and
systolic function are similar. The estimated PA systolic
pressure is now lower, but may be related to technical quality
rather than a true change. Intravenous saline contrast injection
does not suggest right-to-left shunt.
.
C. CATH [**2175-2-15**]:
COMMENTS:
1. Resting hemodynamics revealed moderate pulmonary
hypertension, with
PA systolic pressure of 70mmHg on room air, with normal to
mildly
elevated mean PCWP of 13 mmHg.
2. With 100% inhaled oxygen, the PA systolic pressure decreased
to
62mmHg from 70mmHg, and mean PA pressure decreased from 45mmHg
to
38mmHg, with a decrease in PVR from 730 dynes-s/cm5 to 645
dynes-s/cm5.
3. Inhaled nitric oxide caused no significant change in
pulmonary
pressures or PVR above 100% oxygen.
FINAL DIAGNOSIS:
1. Moderate pulmonary hypertension, responsive to 100% oxygen.
..
CXR [**2175-2-17**]:
As compared to the previous radiograph, there is no relevant
change. Left post-pneumonectomy chest with typical changes.
On the right, massive apical post-infectious, potentially
post-tuberculous
changes are seen with a retraction of the hilar and apical lung
parenchymal structures.In the remaining lung, extensive fibrotic
scars are seen. These, however, have not increased in extent as
compared to the previous examination. No newly appeared focal
parenchymal opacities in the right lung. The pre-existing
minimal pleural effusion has completely resolved.
Brief Hospital Course:
This is a 43 yo F with a history of TB s/p L pneumonectomy c/b
post-pericardiotomy syndrome, pulmonary hypertension, OSA, and R
stage I breast cancer s/p R mastectomy in [**2171**] presenting with
acute onset of shortness of breath, chest pain, tachycardia, and
hypoxia. Her events during this hospitalization are summarized
as below:
.
# SOB/Chest pain: Patient with long history of hypoxemia and is
on home O2 and CPAP, although her compliance with the CPAP is
questionable. Her initial O2 sats improved drastically in the ED
on the non-rebreather, and she remained stable on 4L by NC on
the floor. It was felt that most likely she had some event at
home (O2 not on) that led to her presentation. Cardiac events
were felt unlikely given normal enzymes, unchanged EKG, symptom
resolution. She has a history of pulmonary HTN, with echo during
last admission demonstrating significantly worsening pressures
and RV dilation. She had a CXR in the ED without PNA although
with pleural effusion that has been relatively stable; however
she had no cough or clear fevers at home so this was not thought
to be a contributing factor. PE was felt to be less likely given
a negative CTA during the last admission. On the floor, she was
continued on O2 by NC. She had no desaturation events overnight.
On HD#2, an ABG was drawn. This demonstrated severe hypercapnea
with a pCO2 of 106. Patient was asymptomatic. Because BiPAP
could not be done on the floor, the patient was then transferred
to the MICU.
.
Patient was placed on BiPAP in the ICU and pCO2 levels only
mildly improved. Patient was counseled extensively regarding the
importance of compliance with BiPAP. Her anxiety was a major
obstacle in wearing the BiPAP mask. Patient's ability to
tolerate BiPAP improved with the introduction of ativan 0.25 mg
qhs. She was encouraged to wear her supplemental oxygen at all
times and to use BiPAP whenever sleeping or feeling tired. The
etiology of patient's significant hypercarbia and hypoxia was
unclear. [**Name2 (NI) **] has presumed pHTN in the setting of left
pneumonectomy. Her recent CT chest also showed some evidence of
pulmonary edema/effusions. Patient reports her symptoms are
largely unchanged over the last few months, however, she is
requiring frequent hospital admissions. An echo was performed
that showed no evidence of shunt. Ultimately the decision was
made to undergo right heart catheterization to evaluate
pulmonary pressures. The catheterization showed decreased
pressures with increased oxygen delivery. As a result of the
right heart catheterization she was started on sildenafil 20 mg
po tid. Patient had an episode of increased somnolence and
hypercarbia (pCO2 132) after starting the sildenafil. It was
unclear whether the increased oxygenation decreased respiratory
drive or whether use of ativan contributed to this presentation.
He ativan dose was decreased, she was placed on BiPAP and her
pCO2 returned to her baseline of 115 and her symptoms resolved.
After discussion with Ms. [**Known lastname **], her pulmonologist Dr. [**Last Name (STitle) 2168**],
and her family the decision was made to transfer her to a
pulmonary rehabilitation center that could work with her
increase her BiPAP tolerance and increase her mobilty. Patient
was counseled extensively regarding the importance of compliance
with BiPAP. Her anxiety was a major obstacle in wearing the
BiPAP mask. Patient's ability to tolerate BiPAP improved with
the introduction of ativan 0.25 mg qhs. She was encouraged to
wear her supplemental oxygen at all times and to use BiPAP
whenever sleeping or feeling tired.
.
# Sinus Tachycardia/Palpitations: This was felt to be most
likely from hypoxia. Initially dehydration from recent diarrhea
was also considered. She was given a 500 cc NS bolus on HD#1.
Her HR continued to be elevated. Her TSH was normal. Per
medical records the patient's tachycardia is chronic and
asymptomatic. Heart rate ranged from 90-110 during majority of
hospitalization.
# AVNRT: Patient had a brief episode of AVNRT in the evening
following right heart catheterization. She was symptomatic with
lightheadedness, hypotension (SBP 80s), and neck palpitations.
The arrhythmia resolved abruptly with vagal maneuver. Patient's
outpatient cardiologist Dr. [**Last Name (STitle) 73**] was notified. The
decision was made not to start a low dose beta blocker as
patient has problems in the past with orthostasis and this may
exacerbate those symptoms. She was monitored on telemetry for
the duration of the hospitalization without further episodes.
.
# DISCHARGE: [**Hospital1 **] PULMONARY REHAB
# CODE: FULL
Medications on Admission:
- Levothyroxine 25 mcg PO DAILY
- Ranitidine HCl 150 mg PO BID
- Alendronate 70 mg PO once a week: every saturday.
- Loratadine 10 mg Tablet PO once a day prn allergy symptoms.
- Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet PO twice a
day.
- Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs QID prn shortness of breath or wheezing.
- Multivitamin PO once a day.
- Zolpidem 5 mg Tablet PO at bedtime for 5 days.
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for anxiety.
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/wheezing.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing. neb
9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every [**3-7**]
hours as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Pulmonary Hypertension
Pulmonary edema
Sinus tachycardia
Discharge Condition:
Patient has persistent sinus tachycardia (her baseline) and
stable blood pressures. She requires 4L supplemental oxygen via
nasal cannula and BiPAP during sleep.
Discharge Instructions:
You were admitted to the hospital after presenting to the
emergency department for shortness of breath and chest pain.
When you arrived in the emergency room, your blood oxygen level
was low. This returned to a better level once we gave placed you
on BiPAP. Because of your high oxygen requirements and your need
for BiPAP you were transferred to the ICU where you were closely
monitored. You underwent several studies to evaluate your heart
and lung function.
.
The following changes were made to your home medications:
1) START Sildenafil 20 mg by mouth three times a day to help
your oxygen levels
2) START Lorazepam 0.25 mg by mouth at night to help with
anxiety while on BiPAP machine
It is very important the you use your supplemental oxygen at ALL
TIMES and that you use your BiPAP EVERY NIGHT.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 2168**] within two weeks of
discharge.
ICD9 Codes: 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3144
} | Medical Text: Admission Date: [**2159-5-7**] Discharge Date: [**2159-5-16**]
Date of Birth: [**2082-5-29**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26543**] was a 76-year-old
gentleman with a significant past medical history. He
presented to an outside hospital prior to this
hospitalization complaining of one month of chest pain and
fatigue with exertion. The patient was admitted to that
hospital and evaluated for coronary artery disease. He
underwent a stress thallium test which was positive.
He was transferred to the [**Hospital1 188**] for cardiac catheterization, and this study revealed
severe 3-vessel disease. A Cardiology Surgery consultation
was performed, and the patient was found to be a suitable
candidate to undergo a coronary artery bypass graft.
HOSPITAL COURSE: On [**2159-5-10**], Mr. [**Known lastname 26543**] was taken to
the operating room at the [**Hospital1 188**] by Dr. [**Last Name (STitle) 1537**] of the Cardiothoracic Surgery Service, and
he underwent an on-pump coronary artery bypass graft times
two with left internal mammary artery to the left anterior
descending artery and a right lesser saphenous to the obtuse
marginal. The patient tolerated the procedure well, and he
was transferred in a stable condition to the Cardiothoracic
Surgery Recovery Unit.
Overnight, he was weaned off his pressors and was
successfully and uneventfully extubated by the next morning.
He required 2 units of packed red blood cells for a low
hematocrit.
His postoperative course was prolonged and complicated by
cardiac arrhythmias requiring amiodarone and diltiazem to
control his atrial fibrillation and rapid heart rate. By
postoperative day two, his cardiac arrhythmia was not totally
controlled, and his creatinine started to rise. He was noted
to have labored breathing, and by postoperative day three,
the nursing noticed that the patient was more confused than
usual and was having problems trying to find words as well as
moving his right side.
An emergent head CT was obtained, and it revealed an image
most consistent with a left posterior cerebral artery
infarction. He was evaluated by the Stroke Service and
Neurology who recommended to keep his systolic blood
pressures at about 140 and to obtain a magnetic resonance
imaging with a stroke protocol.
By postoperative day five, Mr. [**Known lastname 26543**] continued to be in
rapid atrial fibrillation and on intravenous amiodarone drip
as well as a maximum diltiazem drip. His neurologic status
did not improve, and later that day he became progressively
acidotic, and his white blood cell count became elevated.
At that point, there was a concern for this patient to be
having an ischemic bowel since he developed peritoneal signs.
An emergent Surgery consultation was obtained, and the
patient was taken to the operating room for an exploratory
laparotomy. He was found to have an ischemic bowel, and a
small bowel resection times two with an ileocolectomy as well
as an aorta to superior mesenteric artery bypass with a
Dacron graft was performed since the patient was found to
have a thrombosed superior mesenteric artery.
The patient received 6 liters of crystalloid and 3 units of
packed red blood cells, and after the surgery he was
transferred in a critical condition back to the
Cardiothoracic Surgery Recovery Unit.
These findings were discussed in detail with the family, and
there were explained about the seriousness of this patient's
condition. Overnight, he was kept on maximum Intensive Care
Unit support including amiodarone drip, diltiazem, as well as
pressors without significant improvement. His white blood
cell count remained elevated, and his acidosis worsened. He
was started on continuous venovenous hemofiltration since his
creatinine was 2.2.
By 6 o'clock in the afternoon, despite the continuous
venovenous hemofiltration and the full Intensive Care Unit
support, his condition worsened, and General Surgery decided
to take him back to the operating room for a second
exploratory laparotomy. Once in the operating room, and upon
entering the abdominal cavity, the entire bowel was noted to
be ischemic. There were no free perforations, and the bypass
graft was still patent. The patient's abdomen was closed,
and he was transferred back to the Cardiothoracic Surgery
Recovery Unit to discuss the prognosis with the family.
The operating room findings were discussed with the wife, and
after she spoke with Dr. [**Last Name (STitle) **] from the General Surgery
Service, she wished to make the patient comfort measures only
in light of the global ischemic bowel disease. Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1537**] was informed, and all of the pressor support was
discontinued. Shortly after the pressor support was stopped,
the patient expired in the Cardiothoracic Surgery Recovery
Unit.
The house officer was called to evaluate the patient and he
was found to have no pupil reflex, no corneal, no spontaneous
breathing, no gag reflex pulling the ET-tube, no palpable
pulse or audible heart sounds. The patient was pronounced
dead at 10:06 p.m. on [**2159-5-16**]. His family was notified
as well as Dr. [**Last Name (STitle) 1537**]. The Medical Examiner was also notified,
and he declined the case. The family did not want a
postmortem examination, and the patient will shortly be
transferred to the morgue to await further arrangements by
the family.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 26544**]
MEDQUIST36
D: [**2159-5-17**] 00:35
T: [**2159-5-17**] 10:40
JOB#: [**Job Number **]
ICD9 Codes: 9971, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3145
} | Medical Text: Admission Date: [**2199-10-9**] Discharge Date: [**2199-10-15**]
Service: MEDICINE
Allergies:
morphine
Attending:[**Doctor First Name 3298**]
Chief Complaint:
transfer from OSH for ERCP for bile leak
Major Surgical or Invasive Procedure:
ERCP with stent placement
History of Present Illness:
This is an 86 yo F with CAD s/p CABG, HTN, dyslipidemia, GERD,
history of CVA, and tracheobronchomalacia and eosinophilic
bronchitis who presented on transfer from [**Hospital3 60338**] for ERCP for a biliary leak. Patient initially presented
to OSH on [**10-5**] with RUQ abdominal pain and nausea without
vomiting. Her labs were significant for WBC 11.6, Tbili 0.5,
Dbili 0.2, amylase 97, lipase 26, ALT 22, AST 22, alk phos 121,
UA positive. Patient had a RUQ ultrasound which showed interval
development of mild to moderate biliary dilatation (CBD 9mm at
level of ampulla). Also with 9 mm gallstone in the fundus of
the gallbladder. She underwent a laparoscopic cholecystectomy
[**10-6**] which was a difficult procedure and JP drain was left in
place. Due to persistently high output and suspicion of bile
leak ERCP was attempted [**2199-10-8**] to assess for cystic duct leak
however unable to cannulate common bile duct. Decision made to
transfer patient to [**Hospital1 18**] for ERCP with biliary stent if there
is a cystic duct leak.
On presentation here patient reported [**7-24**] RUQ pain, described
as sharp. Pain steadily worsening. She denied nausea,
vomiting, diarrhea, cp, sob or lightheadedness/dizziness. No
fever or chills. No po intake since ERCP. Patient did have a
significant amount of epigastric abdominal pain after ERCP on
day prior to arrival but that resolved after procedure. She
denied hematochezia or melena. Last BM prior to admission.
ROS as per HPI otherwise 10 pt ROS negative
Past Medical History:
CAD s/p CABG in [**2190**]
S/p PPM
Aortic regurg
HTN
Dyslipidemia
Nephrolithiasis
Chronic back pain
GERD
Hx of CVA with left eye blindness
Tracheomalacia
Eosinophilic bronchitis
Social History:
Lives with husband in [**Name (NI) 6691**]; 2 children and 2
grandchildren. Retired from paper company. No history of
tobacco, no etoh or illicits.
Family History:
Mother deceased from CHF
Father deceased from unclear causes
Physical Exam:
ON ADMISSION:
VS: 98.1 136/67 76 20 99% 2L NC
Appearance: alert, NAD, thin
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: +s1, s2 [**2-17**] diastolic murmur at LUSB, no peripheral edema,
2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, + RUQ ttp, slight distension, +bs, incisions with
small amount of serosanginuous drainage; no rebound/guarding, JP
drain with dark bile output
Msk: 5/5 strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
ON DISCHARGE:
VS: T 98 (afebrile >24 hrs), BP 126/68, P 83, RR 20, O2 Sat 99%
on RA
Gen: Thin elderly female in NAD
HEENT: anicteric, MMM
CV: regular rate and rhythm, no periperhal edema, JVP not
elevated (at clavicle with patient at 20 degrees)
Pulm: Mild crackles at bases resolved with cough and taking deep
breaths, good air movement bilaterally, no wheezing or rhonchi
Abd: Soft, mildly hypoactive BS, slight tenderness to palpation
in right upper quadrant w/o guarding or rebound, JP drain in
place with small amount of bilious fluid, no organomegaly or
masses appreciated
Extrem: W and WP with no clubbing, cyanosis, or edema
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-12.0* RBC-3.43* Hgb-10.8* Hct-30.8* MCV-90 RDW-13.5 Plt
Ct-332
--Neuts-78.8* Lymphs-12.1* Monos-4.3 Eos-4.5* Baso-0.4
PT-15.8* PTT-30.5 INR(PT)-1.4*
Glucose-67* UreaN-14 Creat-0.7 Na-141 K-4.1 Cl-108 HCO3-24
ALT-52* AST-30 LD(LDH)-170 AlkPhos-86 Amylase-90 TotBili-0.9
Lipase-34
Calcium-8.8 Phos-2.6* Mg-1.6
On Discharge:
WBC-10.1 RBC-3.47* Hgb-10.6* Hct-30.8* MCV-89 RDW-14.4 Plt
Ct-431
Glucose-95 UreaN-9 Creat-0.7 Na-140 K-4.2 Cl-105 HCO3-29
AnGap-10
ALT-29 AST-27 AlkPhos-76 TotBili-0.6
Other Important Labs
[**2199-10-10**] 07:25AM BLOOD CK-MB-5 cTropnT-0.05*
[**2199-10-10**] 04:53PM BLOOD CK-MB-9 cTropnT-0.06*
[**2199-10-11**] 04:29AM BLOOD CK-MB-6 cTropnT-0.07*
==============
MICROBIOLOGY
==============
Blood Cultures *2 [**2199-10-9**]: No growth- FINAL
Bile Culture [**2199-10-9**]:
GRAM STAIN (Final [**2199-10-9**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2199-10-12**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2199-10-15**]): NO GROWTH.
C diff toxin assay [**2199-10-12**]: Negative
==============
OTHER RESULTS
==============
ECG Study Date of [**2199-10-10**] Atrial fibrillation with ventricular
premature beats. Left axis deviation. Diffuse ST-T wave
abnormalities. No previous tracing available for comparison.
PORTABLE ABDOMEN Study Date of [**2199-10-10**] IMPRESSION: No evidence
of obstruction. The evaluation of free air is limited on this
supine radiograph. Suggest upright films to better assess for
free air.
CHEST (PORTABLE AP) Study Date of [**2199-10-10**]
IMPRESSION: Free intraperitoneal air. Please see comments above
regarding
documentation of communication of this finding.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2199-10-10**]
IMPRESSION:
1. Inflammatory changes and free air but no drainable
collection. Free air
of uncertain significance in the setting of recent surgery
although bowel
perforation cannot be excluded.
2. Small focal fluid collection adjacent to the pancreas.
4. Distended fluid-filled loops of bowel suggest an ileus.
5. Bibasilar atelectasis and effusions.
6. Biliary stent and pneumobilia consistent with recent ERCP.
Abdominal
drain with tip in the surgical bed.
ERCP [**2199-10-10**]:
Impression:
-The major papilla was gaping, but did have the appearance of a
fish mouth papilla.
-Extravasation was noted at the right intrahepatic duct c/w with
a duct of Luschka leak.
-Otherwise normal biliary tree.
-A sphincterotomy was performed.
-A biliary stent was placed.
-Otherwise normal ercp to third part of the duodenum
Portable TTE (Complete) Done [**2199-10-11**] Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. There are three aortic valve leaflets. The aortic
valve leaflets are moderately thickened. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Brief Hospital Course:
86 yo F with CAD, s/p PM, HTN, dyslipidemia, GERD, hx of CVA,
tacheomalacia and eosinophilic bronchitis who initially
presented to OSH on [**2199-10-5**] with cholecystitis now s/p lap
chole with complicated surgery requiring JP drain presented in
transfer with concern for bile leak.
1) Cholecystitis s/p lap chole: On admission, patient with
abdominal pain and increased JP drain output concerning for bile
leak. Pt was initially admitted to Medicine, and the ERCP team
was consulted. She underwent successful ERCP with placement of
a plastic stent, which relieved the biliary leak. Following the
procedure, pt developed acute respiratory distress and hypoxia.
CXR was concerning for acute pulmonary edema. She was treated
with lasix for diuresis and she was transferred to the ICU for
further care. In the ICU, patient was noted to have free air
under the diaphragm and was evaluated by surgery for urgent OR.
However, given stable abdominal exam with no evidence of acute
abdomen, and temporal relationship to lap chole, air was
attributed to recent surgery and no intervention was necessary.
Her breathing rapidly stabilized (see below). Abdominal exam
improved with tenderness around JP drain resolving steadily
after ERCP and at discharge had only slight tenderness around
drain with movement. Surgery consult recommended JP drain
removal be performed as an outpatient by her primary surgeon.
She was initially treated with vanc/zosyn, though this was
changed to cipro/flagyl as exam remained stable. Her diet was
gradually advanced, which she tolerated well. She was
discharged with plan to complete two more day of
ciprofloxacin/metronidazole for a total course of 7 days after
biliary stent placement.
2) Acute on chronic diastolic congestive heart failure: Patient
was transferred to ICU on [**10-10**] after developing sudden
respiratory distress on the floor in the setting of elevated BP
(presumed catecholamine surge). Pt was diuresed with lasix IV
boluses with significant improvement in her respiratory status.
She was weaned off the facemask and maintained her saturation on
nasal canula. Home blood pressure medications were restarted and
she was euvolemic on transfer out of the ICU. Echocardiogram
showed normal EF, mild AS. Furosemide was stopped and she was
weaned off supplemental oxygen with no further respiratory
distress.
3) Atrial fibrillation: Pt has history of previous AF and was on
coumadin but stopped some time prior to admission in the context
of severe GI bleed. After discussion with PCP and cardiologist
pt is usually in sinus and during hospitalization had a brief
episode of well rate controlled AF that converted back to sinus.
Given history of severe bleeding coumadin will be discussed
further as an outpatient but held for now. This was decided in
discussion with PCP and stroke risk was discussed with patient
and husband. Aspirin and diltiazem were continued.
4) Diarrhea: Patient had diarrhea after being transferred out of
the MICU but this was low volume and not associated with fever,
leukocytosis or other symptoms. C diff was negative and this
began to improve after solid food was restarted. Likely due to
functional hypermotility and liquid diet.
5) GERD: She was continued on her her home PPI
6) Eosinophilic bronchitis: She was continued on her home
fluticasone-salmeterol inhaler and albuterol PRN
7) CAD s/p CABG: She never had signs or symptoms of ACS. She
was continued on her home ASA and diltiazem. Simvastatin was
held at admission then restarted at discharge.
8) HTN, benign: She was hypertensive post procedure but then
blood pressures were well controlled on home regimen of
diltiazem and amlodipine.
9) History of cerebrovascular disease: Blood pressure control
was continued with dilt and amlodipine. Her aspirin was
similarly continued.
10) Glaucoma: She was continued on her home cyclosporin drops.
The patient tolerated a full diet prior to discharge. She
received heparin SC for DVT prophylaxis. She was full code.
Transitional Issues:
- She will be discharged to acute rehab given deconditioning and
poor exercise tolerance for PT
- She will follow up with Dr. [**Last Name (STitle) 73823**], her surgeon, regarding
removal of her JP drain
- She should have an MRCP as an outpatient to evaluate a
possible pancreatic cyst seen on in house CT scan
- She will follow up with Dr. [**Last Name (STitle) 64453**], her cardiologist, for
further management of her diastolic heart failure and CAD
- She will follow up with Dr. [**Last Name (STitle) **] in 6 wks for repeat ERCP
and evaluation of need for more stents vs stent removal
- Doctors [**Name5 (PTitle) 73824**] and [**Name5 (PTitle) 64453**] [**Name5 (PTitle) **] continue to manage patient's
atrial fibrillation and discuss/ weigh risks and benefits of
anticoagulation with the family
Medications on Admission:
Outpatient Medications:
Diltiazem ER 360mg daily
Protonix 20mg [**Hospital1 **]
Advair 250/50 [**Hospital1 **]
Norvasc 2.5mg daily
ASA 81
Vit D3 [**2187**] IU daily
MVI
Vit C 500mg daily
Simvastatin 40mg daily
Gelnique Sachets 10% gel q evening
Restasis 1 gtt ea eye [**Hospital1 **]
Tylenol prn
.
Transfer Meds: per discharge summary, no doses listed
Norvasc
Vitamin C
ASA
Cyclosporin
Cardizem
Fluticasone
Hydrocodone with acetaminophen
MVI
Protonix
Kcl
Zocor
Genteal to eyes
Vit D3
Discharge Medications:
1. diltiazem HCl 360 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
2. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO twice a
day.
7. multivitamin Capsule Sig: One (1) Capsule PO once a day.
8. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Gelnique 10 % (100 mg /gram) Gel in Packet Sig: One (1)
packet Transdermal at bedtime.
11. cyclosporine 0.05 % Dropperette Sig: One (1) drop each eye
Ophthalmic [**Hospital1 **] (2 times a day).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: last day [**10-17**]. Tablet(s)
16. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 2 days: last day [**10-17**].
Discharge Disposition:
Extended Care
Facility:
Mt. Greylock ECF
Discharge Diagnosis:
# Bile leak s/p cholecystectomy
# Cholecystitis
# Hypoxic respiratory distress/acute diastolic heart failure
# Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted in transfer from [**Hospital6 6689**] for
complicated cholecystitis and cholecystectomy complicated by
bile leakage. You underwent ERCP with stent placement, and the
leak stopped. Your hospitalization was complicated by a period
of heart failure, but this improved with treatment. Due to
weakness you are being discharged to a rehabilitation facility
who will help manage your medications.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73823**]
[**Hospital1 **] Surgical Associates
Friday, [**10-25**] at 1:30 PM
[**Apartment Address(1) 73825**]
[**Location (un) 6691**], MA
Phone: [**Telephone/Fax (1) 73826**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 64453**]- Cardiology
Monday, [**11-4**] 9:15 am
[**Street Address(2) 73827**], [**Apartment Address(1) 36475**]
[**Location (un) 6691**], MA
Phone [**Telephone/Fax (1) 73828**]
Dr. [**First Name (STitle) **] [**Name (STitle) **]
Thursday, [**11-21**]
Arrive at 7 am for 8 am repeat ERCP
[**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
ENDOSCOPY SUITES
Phone [**Telephone/Fax (1) 13246**]
(you should not eat on the morning of the procedure)
ICD9 Codes: 4280, 4241, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3146
} | Medical Text: Admission Date: [**2112-8-17**] Discharge Date: [**2112-8-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
bradycardia and hypotension, transferred from [**Hospital1 **]
Major Surgical or Invasive Procedure:
R internal jugular central line placement
History of Present Illness:
89 yo woman with past medical history signficant for
hypertension, atrial fibrillation, hyperlipidemia,
hypothyroidism, presents from [**Hospital 100**] Rehab, where she found to
have decreased mentation, with associated bradycardia to the
40s, and SBP in the 50s. Her daughter reports that four days ago
she was well w/o complaints. Today, however, when she visited
the patient, the patient was difficult to arouse and couldn't
sit up on her own. The patient was able to recongize her
daughter, but was confused and more somulent than usual. At that
time she was found to have a SBP of 60 and a pulse in the 40s.
.
No f/c, n/v, diarrhea, chest pain, or other complaints. The
[**Hospital6 459**] reports she has had a 10 pound weight gain
over the last several weeks. She was also started on a fentanyl
patch in the last week for chronic lower back pain, and
neurontin for pain over the last month or two as well.
.
In the ED, her VS 96.6 HR 45 53/22 18 99RA were, was given
atropine 1mg, 2L NS she was started on dopamine with good
response, BP increased to 130s.
.
In addition, she was otherwise afebrile, but had a leukocytosis,
with 35% bandemia, CXR with a possible LL infiltrate and was
started on vancomycin and ceftazidime.
.
Pt with recent admission to OSH with falls in [**Month (only) 116**], and decision
was made for relocation to Nursing homes. She is wheelchair
bound at baseline, although her daughter reports her strength is
"pretty good."
.
Per her daughter and the rehab center, on review of symptoms,
she denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative. She has had some lower extremity edema
noted by her daughter last week. The [**Hospital 100**] Rehab reports she
has had no antibiotics in the last four months.
Past Medical History:
Arthritis
left knee arthroscopy
Atrial Fibrillatin
HTN
T12 compression fracture with scoliosis
Spinal Stenosis
GERD
Hypothyroidism
Hypercholesterolemia
Anxiety
Cataract Surgery
Hysterectomy
Social History:
lives at Senior Home,
no tob/etoh; no regular exercise
Family History:
Son who died with CAD
Physical Exam:
VS: T 93.2 , BP 96/69 , HR 67 , RR 18 , 98 O2 % on 3L
Gen: Sedated, but arousable elderly, NAD
HEENT: NCAT. Sclera anicteric. PERRL, Conjunctiva were pink, dry
MMM, JVD flat, no LAD, supple, no thyromegaly
Neck: Supple with JVP of 8cm
CV: S1 S2 rrr, SEM III/VI greatest LLSB, apex, also RUSB
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. diffuse rhonchi at
bases.
Abd: Normoactive BS, soft, TTP lower quadrants, no RT, no
[**Doctor Last Name **] sign, no hepatosplenomegaly
Skin: b/l escharred heel ulcers, decubitus no obvious ulcers,
EXT: 2+ pitting edema, up to mid calves, DP pulses 1+ b/l
Pertinent Results:
[**2112-8-17**] 04:30PM BLOOD WBC-17.3*# RBC-3.45*# Hgb-9.5*#
Hct-29.4*# MCV-85 MCH-27.4 MCHC-32.2 RDW-16.7* Plt Ct-208
[**2112-8-17**] 04:30PM BLOOD Neuts-58 Bands-35* Lymphs-2* Monos-3
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2112-8-17**] 04:30PM BLOOD Glucose-141* UreaN-25* Creat-1.7* Na-132*
K-5.5* Cl-92* HCO3-26 AnGap-20
[**2112-8-17**] 04:30PM BLOOD CK(CPK)-198*
[**2112-8-17**] 11:40PM BLOOD CK-MB-22* MB Indx-13.7* cTropnT-0.08*
[**2112-8-17**] 11:40PM BLOOD TSH-3.1
[**2112-8-18**] 12:19AM BLOOD Type-ART Temp-36.0 O2 Flow-4 pO2-61*
pCO2-70* pH-7.28* calTCO2-34* Base XS-3 Intubat-NOT INTUBA
[**2112-8-18**] 08:06AM BLOOD Lactate-4.6* Na-131* K-4.3
.
Micro data
[**2112-8-17**] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY {GRAM
POSITIVE COCCUS(COCCI)}; ANAEROBIC BOTTLE-PRELIMINARY {GRAM
POSITIVE COCCUS(COCCI)} INPATIENT
[**2112-8-17**] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY {GRAM
POSITIVE COCCUS(COCCI)}; ANAEROBIC BOTTLE-PRELIMINARY {GRAM
POSITIVE COCCUS(COCCI)} INPATIENT
[**2112-8-17**] URINE URINE CULTURE-PRELIMINARY {ESCHERICHIA COLI}
Brief Hospital Course:
89-year-old woman with PMH HTN, Afib, decubitus ulcers,
presenting with bradycardia, shortness of breath, hypotension,
and septic shock likely from a) gram positive cocci [**2-19**]
decubitus ulcers b) urosepsis c) pneumonia.
.
The patient initially was resuscitated with IVF's and started on
broad antibiotic coverage with vancomycin, ceftazadime, and
flagyl. Central venous access was initiated to monitor CVP per
sepsis goal directed therapy guidelines. The patient presented
with do not resuscitate / do not intubate advanced directives.
Patient was supported with oxygen by nasal cannulae.
Bradycardia was resolved with atropine and hypotension was
treated with dopamine iv infusion.
.
Family, including son and daughter, were notified and came to
the hospital. Discussions were engaged regarding ulimate goals
of care. The decision was made to provide comfort measures only
and to withdraw active treatment of ultimate pathology.
Pressors and antibiotics were discontinued, and within 45
minutes the patient passed secondary to cardiac arrest.
.
The patient was pronounced dead at 12:51pm and arrangements were
made for burial proceedings with the family.
Medications on Admission:
Caltrate 600+D 2 tabs daily
Amiodarone 300mg Daily
Cozaar 100mg Daily
Levothyroxine 50 mcg daily (50mcg on Sunday)
Coumadin 2mg Daily
Zocor 40mg daily
Trazadone 100mg qhs
Lasix 40mg daily
Potassium
Vitamin B12
Neurontin 100mg TID
Celexa 10mg QD
Oxycodone 5mg Q4 PRN
Fentanyl 50mcg Q3D
Xanax 0.125mg [**Hospital1 **]
Xanax 0.125 q8PRN
Lasix 40mg QD
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 0389, 5849, 486, 2724, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3147
} | Medical Text: Admission Date: [**2169-10-13**] Discharge Date: [**2169-11-16**]
Date of Birth: [**2119-3-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
unsucessful suicide attempt via method of hanging
Major Surgical or Invasive Procedure:
[**2169-10-23**] - tracheostomy and percutaneous G tube
History of Present Illness:
Patient is a 50 year old male who was brought to the trauma bay
after an unsucessful suicide attempt via the method of hanging.
Patient hung himself in the attic and rope reportedly broke and
he was found walking down the stairs. The ambulance was called.
He was intubated on the scene and transferred to [**Hospital1 18**] - GCS 3T.
Past Medical History:
hypertension
Social History:
Patient has a 16 year old daughter. [**Name (NI) **] recently lost a job and
was to be evicted from his apartment on the day he attmpted
suicide.
Has relationships with ex-spouses x2
Family History:
non-contributory
Physical Exam:
Upon presentation:
HR:74 BP:173/90 Resp:15 O(2)Sat:100% normal
Constitutional: Comfortable
HEENT: Pupils equal, round and reactive to light
Large amount of neck edema and subcutaneous air,
circumferential ligature mark on neck, no expanding hematoma
or bruit, intubated, dried blood in nares
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Nondistended, Soft
GU/Flank: No costovertebral angle tenderness
Extr/Back: No edema
Skin: No rash, Warm and dry
Neuro: sedated
Psych: Sedated
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
INR(PT)
[**2169-11-15**] 1.5*
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2169-10-29**] 05:10 10.2 3.30* 9.7* 29.4* 89 29.3 32.9 13.9 531*
Imaging:
[**2169-10-13**] CT head without contrast
No acute intracranial process. Significant soft tissue emphysema
in the
anterior tissues of the neck and face.
[**2169-10-13**] CT c-spine w/o contrast
1. Fracture of the posterior pedicles of C2 vertebral body
bilaterally.
2. Question fracture of hyoid bone .
3. Likely fracture of the left lamina of the thyroid cartilage
posteriorly.
[**2169-10-13**] CT torso
1. Multiple fractures of the left transverse processes of the
lumbar spine
and left seventh rib as detailed above.
2. Anterior chest wall subcutaneous air.
3. No mediastinal hematoma or evidence of extravasation.
4. Endobronchial debris causes atelectasis of the right upper
lobe.
[**2169-10-13**] CTA neck
1. Occlusion of the left common carotid and the left internal
carotid artery extending up to the level of the cavernous
carotid on the left with good flow from collaterals from the
circle of [**Location (un) 431**] seen in the supraclinoid carotid and left MCA
is felt to be secondary to a dissection given mechanism of
injury.
2. Thrombosis left external carotid artery.
3. Irregularity in the wall of the right common carotid artery
just inferior to the carotid bulb is likely secondary to a small
dissection.
4. C-spine fractures as detailed on the cervical spine CT.
5. Left hyoid bone inferiorly displaced fracture of the greater
cornu.
6. Left thyroid cartilage mildly displaced fracture.
7. Significant subcutaneous emphysema in the anterior neck is
felt to be
secondary to a tracheal injury at the level of the thyroid
cartilage.
[**2169-10-13**] MR cervical spine
Known fracture at C2, better seen on the previous CT scan.
Injury to the posterior interspinous ligament at C1-C2 as well
as possibly to the ALL and PLL. Increased signal within the
C2-C3 disc space, concerning for acute injury to the disc. Small
CSF density collection anteriorly in the epidural space
extending from C2-C3 to C5-C6 which could represent a hygroma or
epidural hematoma without significant compromise of the cord.
There is no evidence for cord contusion.
[**2169-10-16**] CT torso
Compressive atelectasis/comsolidation at both lung bases with no
evidence for intra-abdominal abscess identified.
[**2169-10-16**] CTA neck
1. Persistent occlusion of the left common carotid near its
takeoff from the aortic arch, at the level of the clavicular
head with distal reconstitution of the external carotid branch
via muscular collaterals, as well as the petrous portion of the
internal carotid artery, likely via filling from an ophthalmic
artery collateral as well as via the circle of [**Location (un) 431**], which is
intact.
2. Interval improvement in irregularity previously seen in the
region of the right carotid bulb.
3. Though MRI is more sensitive for this, there is no evidence
of territorial cerebral infarct.
4. Previously described soft tissue and bony traumatic changes
of the neck
and oropharynx including fracture of the bilateral C2 pedicles,
subcutaneous emphysema, soft tissue stranding, and mottled
density filling the nares and oropharynx. Left hyoid and thyroid
fractures are again noted, though subcutaneous emphysema has
improved.
[**2169-10-18**] CT neck w/o contrast
1. Diffuse edema such that infection cannot be excluded;
however, no
drainable fluid collection or abscess formation is seen at this
time.
2. Small area of enhancement with central hypodensity, which
could represent a developing fluid collection in the right
oropharynx. This area may be amenable to direct visualization.
3. Similar additional findings including fractures of the
pedicles at C2 and left transverse foramen. Fracture of the left
hyoid.
4. Stable appearance of occlusion of the left carotid artery
with distal
reconstitution of the external carotid.
5. Diffuse edema and subcutaneous emphysema, overall slightly
decreased from initial examination and similar to the immediate
prior examination of [**2169-10-16**].
[**2169-10-20**] neck US
Multiple hematomas extending throughout the neck soft tissues,
right greater than left. Given the heterogeneous contents, these
are not
amenable to aspiration.
MICROBIOLOGY:
[**10-13**] MRSA screen positive
[**10-13**] BCx x2: pending
[**10-13**] UCx: F-no growth
[**10-15**] UCx: F- no growth
[**10-15**] sputum cx: GS- >25 PMNs, 3+ GPCs; Cx- moderate growth MRSA
[**10-15**] BCx x2: F- no growth
[**10-17**] Packing x3: 1. MRSA 2. Strep anginosus sensitive to gent,
rifamp, tetra, bactrim, and vanco
11/7 L fem TLC tip cx: No significant growth.
Brief Hospital Course:
The patient was admitted to the Trauma Surgical Service for
evaluation and treatment after unsuccessful suicide attempt.
Neuro: A MRI head and C-spine were obtained at neurosurgery's
request. His head CT showed no acute intracranial processes. CT
cervical spine showed fracture of the posterior pedicles of C2
vertebral body bilaterally; their final recommendation was for a
hard cervical collar to be worn for six weeks. He will follow up
with Neurosurgery at that time.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: Patient was brought in intubated. The tracheostomy
was done by the thoracic service on [**10-23**]. He was transitioned
to a trach mask and was stable. His tracheostomy was eventually
removed and he is on room air with stable oxygen saturations in
the high 90% range.
GI/GU/FEN: A PEG was placed on HD11 and tube feedings were
started and advanced to goal. He underwent video swallow x 2 for
which he failed requiring that he remain on tube feedings. The
plan is for him to follow up as an outpatient with ENT and
Speech for video swallow and electrical stimulation. In the
meantime he is NPO except for no more than 8 oz water in 24 hour
period for swishing and spitting. He is receiving blous tube
feedings; he was provided with teaching by nursing on how to
administer the bolus feedings.
ID: No active issues. Fever curve and WBC were monitored, his
last WBC on [**10-29**] was 10.2 which is within normal range; his T
max was 98.4 on [**11-15**] at time of this dictation.
Endocrine: Blood sugars were monitored and treated.
Hematology: He was treated with a heparin drip for his carotid
dissection and transitioned to Coumadin. His goal INR is [**1-18**], on
[**11-15**] his INR was 1.5; he received Coumadin 10 mg on [**11-14**] and
will need to receive 10 mg on [**11-15**] with an INR check for [**11-16**] to
adjust dose if necessary. He will require at least daily INR's
until he is therapeutic and then the INR can be checked
1-2x/week. He will remain on the Coumadin for ~6 months, a
carotid ultrasound will need to be done prior to stopping the
Coumadin.
Prophylaxis: He received compression boots and Pepcid.
Psychiatry: Psychiatry was consulted who followed patient; he
was maintained on a one-to-one sitter and suicide precautions.
He has been recommended for inpatient psychiatric stay.
He was evaluted by Physical therapy and is independent with
transfers, ambulation, feeding himself and personal hygiene.
Medications on Admission:
None
Discharge Medications:
1. Outpatient [**Name (NI) **] Work
PT/INR 2-3x/week and prn based on goal INR 2-3 range
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): via feeding tube.
Disp:*30 Tablet(s)* Refills:*2*
3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day) as needed for constipation: via feeding tube.
4. sodium chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal TID (3 times a day).
Disp:*1 * Refills:*2*
5. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) Grams PO Q12H (every 12 hours) as needed for constipation.
6. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*350 ML(s)* Refills:*0*
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
via feeding tube.
8. warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Goal INR [**1-18**]; adjust dose based on INR please.
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
10. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN line
maintenance
Peripheral IV - Inspect site every shift
11. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasms.
12. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30)
Ml's PO twice a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
s/p Self hanging attempt
Injuries:
C2 posterior lamina fracture
Right 7th rib fracture
Bilateral carotid dissection
Thrombosis of the left common carotid, w/ ext into left internal
& external carotid arteries
Hyoid bone fracture
L1-L5 mildly displaced transverse process fractures
Respiratory failure
Dysphagia
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 after a self hanging attempt.
Your trauma caused significant bodily injuries. You were
required to have an operation which provided you with a
protective airway for breathing and a special feeding tube was
placed to provide you with nutrition. You underwent swallowing
tests in the hospital and it has been determined at this time
that your swallowing muscles are still weak. In 4 weeks you will
see the Ear, Nose & Throat doctors followed by [**Name5 (PTitle) **] appointment
with the Speech Specialist, a repeat video swallow test will be
done then. Until that time you will need to continue with your
tube feedings as instructed. DO NO eat anything by mouth.
The cervical collar will needto remain in palce until told to
remove it by the Neurosurgeon, Dr. [**Last Name (STitle) 548**].
It is OK for you to shower. Avoid tub baths for now until your
feeding tube is removed.
Avoid lifting heavy objects greater than 10 lbs.
You will need to continue on the blood thinning medication
called Coumadin for at least 6 months because of the injury to
the artery in your neck (carotid artery). Blood tests will need
to be drawn at least 1-2x/week called an INR to measure how thin
your blood is
Followup Instructions:
Follow up in 4 weeks in [**Hospital **] clinic, call [**Telephone/Fax (1) 41**] for an
appointment.
After you follow up with ENT you will need to have a repeat
Swallow study done in 4 weeks to determine if you can be
upgraded to a diet. Please call [**Telephone/Fax (1) 3731**] to request to have
a Vital Stim test done. You will also need to have the video
swallow test repeated at that time.
Follow-up with Dr. [**Last Name (STitle) 548**], Neurosurgery in 4 weeks with a
Non-contrast CT scan of the cervical spine. Call [**Telephone/Fax (1) 1669**]
for an appointment. The clinic Our is located in the [**Hospital **]
Medical Building, [**Hospital Unit Name 12193**], [**Street Address(2) 87879**], [**Location (un) 86**], [**Numeric Identifier 718**].
Follow up in [**Hospital 2536**] clinic in 4 weeks, call [**Telephone/Fax (1) 600**] for an
appointment.
It was notedthat you do not have a PCP; there are 2 options for
obtaing one:
1. Contact the MD referral line at [**Telephone/Fax (1) 5867**] - patients or
their families must call
2. Dr. [**First Name (STitle) 9054**] [**Name (STitle) 6481**] at [**Hospital1 18**] [**Location (un) **] which is closer to the
[**Location (un) 15005**]/[**Hospital1 189**] area that you have indicated you will be going to
after discharge, is taking new patients, the office number is
[**Telephone/Fax (1) 4775**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
ICD9 Codes: 5185, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3148
} | Medical Text: Admission Date: [**2103-1-14**] Discharge Date: [**2103-1-17**]
Date of Birth: [**2055-7-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Chest pain and alcohol withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 yo M with ETOH abuse c/b dilated cardiomyopathy (EF 49%
9/07), HCV, h/o lung aspergillosis c/b cavitary lesion who p/w
etoh withdrawal and chronic reproducible chest pain. He
currently drinks [**1-3**] gallon of vodka daily, his last drink was
evening of [**2102-1-13**]. He reports that after his recent d/c from
the hospital on [**1-6**], he attempted to make multiple follow up
appointments with MDs and detox, but "did not hear back"; he
became frustrated and again began drinking [**1-3**] gallon of
vodka/day. He reports he has also been having chest pain which
is chronic in nature which he reports gets worse when he's
drinking significant amounts. He reports it "hurts every time
my heart pumps". He denies CP with deep inspiration and denies
SOB. He has had no cough or hemoptysis. He reports since being
in the ED, he feels increasingly tremulous and anxious and is
hypertensive "because he's withdrawing." He denies
hallucinations.
In the ED, initial vitals were 97.3 98 [**Telephone/Fax (2) 23538**]% on 2L
NC. Urine tox was positive for benzos and cocaine; serum EtOH
level was 249. ECG reportedly with "NSST depressions and J pt
elevations". CEs were negative x2 sets. CXR was performed
which showed stable radiographic appearance of known cavitary
lesions in both lung apices with no new process identified.
Plan was initially for d/c from ED given negative CEs, however
patient began to withdraw in ED with sx of tremulousness,
anxiety, hypertension. He received thiamine, folic acid, MVI.
He received a total of 40mg diazepam (30mg IV, 10mg PO). He was
hypertensive to the 170s-230s systolic and received his home
dose lisinopril and IV hydralazine x2. His home dose beta
blocker was held given urine tox positive for cocaine.
Of note, he has had multiple past admissions for CP and EtOH
withdrawal, most recently from [**Date range (1) 23539**] at which time he
required large amounts of benzos for safe detox. He was
discharged home with plans to be admitted to inpatient substance
abuse program at [**Hospital1 882**], however he did not do this.
He is now being admitted to the ICU for EtOH withdrawal for
q30min-1h CIWA.
ROS: No fevers/chills. No cough/sob, no palpitations. No
N/V/diarrhea. No melena/hematochezia. No dysuria/hematuria.
No rashes. Wound on back from recent fall is healing well.
Past Medical History:
Past Medical History:
- EtOH abuse
- h/o withdrawl seizures
- Alcoholic Dilated Cardiomyopathy (EF 25%)
- cocaine abuse (last use ~ 3 weeks ago)
- hypothyroidism
- h/o head and neck cancer s/p resection and radiation in [**2093**]
- bilateral cavitary lung lesions; bx demonstrated Aspergillous
fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**]
- h/o C. diff colitis
- h/o IVDA per OSH records (pt denies)
Social History:
Smokes < [**1-3**] ppd recently; prior to that he smoked 1 ppd x30
years. Heavy EtOH use (usually >1 gallon vodka per day). Sober
x10 years up until ~2 years ago; more recently, reports several
months of sobriety. +Cocaine abuse; last use several wks ago. He
denies IVDA. Sexually active with his girlfriend.
Family History:
Mother with CAD. Sister with h/o CVA.
Physical Exam:
VS: Temp: 97.5 BP: 185/119 HR:102 RR:19 O2sat 97%RA
GEN: Appears mildly tremulous, moderate distress
[**Month/Day (2) 4459**]: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules, left anterior
neck with soft tissue defect s/p surgery for head and neck
cancer
RESP: CTA b/l
CV: rrr, soft II/VI systolic murmur at RUSB
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice, wound mid low back healing without
erythema, induration, warmth, fluctuance
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. 2+DTRs-patellar and
biceps.
Pertinent Results:
[**2103-1-14**] 01:24AM ASA-NEG ETHANOL-249* ACETMNPHN-NEG*
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2103-1-14**] 08:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
Brief Hospital Course:
# Alcohol withdrawal: His last drink was on [**2103-1-13**] and on
admission he was tremulous and required increasing CIWA scale.
On hospital day #2, he was transferred to the ICU for q30min-1h
CIWA. In the ICU on [**1-14**], he received 200 mg total of valium,
on CIWA scales for anxiety and tremor. On [**1-15**] he received 140
mg valium in the ICU. He was transferred to the medicine floor
on [**1-15**] and was continued on a CIWA scale. Psychatry was
consulted due to high [**Month/Year (2) **] requirement. He was started on a
standing valium regimen and was tapered, in addition to the CIWA
scale. He was also continued on MVI, thiamine and folate. On
transfer to [**Hospital1 882**] Level 4 detox program on [**2103-1-17**], his
standing valium dose was tapered to 15 mg [**Hospital1 **]. In addition, he
was continued on his CIWA scale.
.
# Polysubstance abuse: In the ED, his toxicology screen was
positive for ETOH, benzos, and cocaine. In the setting of
cocaine use, his beta blocker was discontinued on admission.
.
# Chest pain: He reported intermittent chest pain that has been
chronic in nature. Per his history, his pain worsens in the
setting of withdrawl and bodyaches. Of note, his exercise MIBI
is without evidence of ischemia from [**9-9**]. In addition,, his
pain is reproducible on exam and thus appears most consistent
with musculoskeletal pain.
.
# Hypertension: He was hypertensive on admission in the setting
of withdrawl. His beta blocker was discontinued and he was
continued on his home regimen of lisinopril.
.
# Dilated Cardiomyopathy (EF 25%): He remained euvolemic
throughout hospitalization. He was continued on ASA and ACE-I.
.
Medications on Admission:
Aspirin 81 mg PO DAILY
Levothyroxine 75 mcg PO DAILY
Buspirone 10 mg PO BID
Toprol XL 150 mg Tablet PO once a day
Lisinopril 30 mg PO DAILY
Trazodone 50 mg PO HS
Olanzapine 5 mg PO HS
B-complex with vitamin C
Hexavitamin
Folic acid 1mg PO daily
Thiamine 100mg PO daily
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO every
twenty-four(24) hours.
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed.
11. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary
Alcohol abuse
Secondary
Polysubstance abuse
Congestive heart failure
Hypertension
Hypothyrodism
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital for alcohol withdrawal. You
should continue to abstain from alcohol use. Please take all of
your medications as prescribed.
If you develop chest pain, shortness of breath, persistent fever
> 101, or any other serious concerns, please return to the
nearest emergency room.
Followup Instructions:
Please follow up with your primary care provider at [**Name9 (PRE) **]
Community Health Center at [**Telephone/Fax (1) 23520**] in [**3-6**] weeks. You will
need further evaluation of your difficulty swallowing.
Completed by:[**2103-1-31**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3149
} | Medical Text: Admission Date: [**2118-8-14**] Discharge Date: [**2118-8-19**]
Date of Birth: [**2063-5-16**] Sex: M
Service: MEDICINE
Allergies:
Prochlorperazine / Iodine
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 79353**] is a 55 yo man w/ metastatic melanoma and known mets
to brain (incl cerebellum), who presents with one day of
headache and altered mental status. History is obtained by the
patient's wife due to the patient being sedated from the ED.
Over the past few days prior to admission, the pt's wife notes
that he had not been sleeping well at night due to increased
urinary frequency. However, other than feeling more tired
during the day he had been overall doing well. On the morning
prior to admission, the patient developed a severe headache,
associated with nausea and several episodes of bilious vomiting.
He was unable to keep down any POs. Additionally, he had
increasing confusion and agitation and so was taken to [**Hospital3 12748**]. In the ED there, head CT revealed hemorrhage
of some of his brain mets with 2mm midline shift and mild
hydrocephalus. He received 8mg IV dexamethasone, 4mg IV
morphine x 2, and zofran. [**Hospital1 18**] oncology fellow was contact[**Name (NI) **]
and transfer was arranged.
Of note, pt has had 2 recent admissions to [**Hospital1 18**] with nausea,
vomiting, dizziness and dehydration. This was felt to be due to
combination of Taxol and progression of CNS disease. During
admission Mr. [**Known lastname 79353**] was made aware that surgical resection of
the cerebellar metastasis may relieve these symptoms, however,
he has refused any kind of surgery on more than one occasion on
review of the medial record. He was placed on 4 mg every 8 hours
of dexamethasone and was discharged with home IV fluids and PICC
line on [**2118-7-19**].
In the ED, initial vs were: T 97.5, P 60, BP 166/90, R 15, O2
sat 98% RA. Patient was agitated, but not talking or answering
questions. He was given 3mg of ativan for sedation to obtain a
repeat CT head. He brady'd to the 30s after receiving sedation,
but HR improved up to low 100s spontaneously. Repeat CT head
was reviewed by neurosurgery and showed no change from OSH
imaging, without hydrocephalus or risk for herniation.
Additionally, it was felt there was no significant change since
his last imaging 2 months ago. Family declined surgical
intervention, per his prior wishes. He was given decadron 10mg
IV and transferred to the [**Hospital Unit Name 153**] for close monitoring.
On arrival to the [**Hospital Unit Name 153**], the patient is somnolent and unarousable
but appears comfortable. His wife is at the bedside.
Past Medical History:
PMH:
1. Metastatic melanoma: Onc hx adapted from recent onc clinic
note by [**Doctor First Name **] [**Location (un) **]:
Mr. [**Known lastname 79353**] [**Last Name (Titles) 1834**] wide local excision and left parotid neck
node dissection for a 6 mm thick melanoma of his left parietal
scalp in [**2116-7-3**], with 3 of 27 nodes being positive. He
received adjuvant interferon, but had a soft tissue recurrence
in the left neck a few months into therapy. This was resected
and interferon therapy was resumed post surgery until [**Month (only) 404**] of
[**2117**], when he developed contralateral neck soft tissue
recurrence treated with surgical resection and parotidectomy in
[**2117-4-3**]. Pathology revealed 4 of 8 nodes positive, and a
large lymph node measuring 1.7 cm in the parotid. His interferon
therapy was discontinued at this time. A PET CT scan in [**Month (only) 216**]
of [**2117**] revealed lung nodules and a 3.3 cm left inguinal mass.
Head MRI revealed a single brain metastasis in the right corona
radiata. He [**Year (4 digits) 1834**] CyberKnife radiosurgery to this lesion in
[**2117-11-3**]. He began high dose IL2 in [**2117-12-4**],
without response. He developed deep vein thrombosis in [**Month (only) 404**]
of [**2118**], requiring Lovenox. Followup head MRI revealed disease
progression in the CNS. He was begun on CTLA4 antibody protocol
on [**2118-3-1**], with 6 week scan showing disease
progression, particularly in the CNS, and he [**Year (4 digits) 1834**] whole
brain radiation therapy started on [**2118-4-12**]. He completed
a 4-week course of radiation on [**2118-4-22**]. Repeat CT scan
showed evidence of disease progression, particularly in the left
inguinal area. Mr. [**Known lastname 79353**] [**Last Name (Titles) 1834**] surgical resection of a mass
in his left groin area in [**2118-5-4**]. Surgery was able to
remove the mass. Ventriculostomy [**2118-6-23**] for occlusive
hydrocephalus. Had first dose of taxol [**2118-6-28**].
2. s/p appendectomy as a child
3. Degenerative joint disease in the L5 area
4. Cervical neck surgery [**2112**]
5. DVT as above
.
Social History:
Married, 2 children. Lives with wife and has pet dog. Formerly
worked as a commercial fisherman, a construction worker, and
other odd jobs. Quit smoking 15 years ago after 20 pack-year
history. Very occasional EtOH.
Family History:
Mother passed away with metastatic uterine CA.
Physical Exam:
Vitals: T: 99.8, BP: 149/69, P: 87, R: 15, O2: 97% RA
General: Somnolent, moving all extremities spontaneously but is
not responsive to painful stimuli, no acute distress
HEENT: Well-healed surgical scar on the superior aspect of the
head, sclera anicteric, pupils 2mm and minimally responsive,
MMM, oropharynx clear
Neck: surgical scar in the left neck, supple, JVP not elevated,
no LAD
Lungs: coarse upper airway sounds, 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, 2+ pulses, no clubbing, cyanosis or
edema; 10cm subcutaneous mass in the left axilla, 6-8cm
subcutaneous mass in the left groin near his surgical excision
site, and 5cm subcutaneous mass at the internal aspect of the
right calf
Skin: pinpoint echymoses on his abdomen [**3-7**] lovenox injections
Pertinent Results:
LABS ON ADMISSION:
[**2118-8-13**] 07:00PM BLOOD WBC-9.6 RBC-3.97* Hgb-11.8* Hct-34.4*
MCV-87 MCH-29.7 MCHC-34.2 RDW-15.8* Plt Ct-326
[**2118-8-13**] 07:00PM BLOOD Plt Ct-326
[**2118-8-13**] 07:00PM BLOOD Glucose-112* UreaN-23* Creat-0.7 Na-137
K-4.2 Cl-101 HCO3-23 AnGap-17
[**2118-8-13**] 07:00PM BLOOD TSH-2.0
LABS ON DISCHARGE:
[**2118-8-17**] 12:00AM BLOOD WBC-6.3 RBC-3.41* Hgb-9.9* Hct-29.8*
MCV-87 MCH-29.1 MCHC-33.3 RDW-15.9* Plt Ct-232
[**2118-8-17**] 12:00AM BLOOD Plt Ct-232
[**2118-8-17**] 12:00AM BLOOD Glucose-119* UreaN-32* Creat-0.7 Na-144
K-4.0 Cl-111* HCO3-23 AnGap-14
[**2118-8-17**] 12:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.3
CXR [**2118-8-13**]: New opacification at the right lung base
accompanied by a greater elevation of
the right hemidiaphragm could be atelectasis alone or
combination of
atelectasis and pneumonia, particularly aspiration. Large nodule
in the right
mid lung unchanged since [**Month (only) 547**]. Heart size normal. No
appreciable pleural
effusion. No pneumothorax.
EKG [**2118-8-14**]: Sinus tachycardia, rate 140. Vertical axis. Cannot
exclude inferior
myocardial infarction of indeterminate age. S1-Q3-T3 pattern.
Consider
acute pulmonary embolism. Compared to the previous tracing of
[**2118-8-14**]
sinus bradycardia has given way to sinus tachycardia and axis is
now vertical.
Also, non-specific inferolateral repolarization changes have
appeared.
HEAD CT [**2118-8-14**]: No new focus of hemorrhage. Overall unchanged
picture of hemorrhagic metastases.
Brief Hospital Course:
1. ALTERED MENTAL STATUS: Most likely multifactorial but
primarily from leptomeningeal involvement and hemorrhagic brain
metastases with contributions from over-sedation from home
benzodiazepines, PNA and UTI. On admission to the ICU patient
was quite sedated and only minimally responsive. Across his stay
he became more responsive and was able to follow commands, move
all extremities, and at times speak quite coherently, although
his mental status continued to wax and wane. During his
hospitalization he also developed a left sided facial droop
thought likely due to evolving brain metastases and
leptomeningeal involvement.
2. GOALS OF CARE/CODE STATUS: The patient code status was made
DNR/DNI during this admission and this was confirmed with the
patient's wife. A family meeting was held to discuss goals of
care, and it was decided to move towards hospice care after
discharge. The patient's wife, however, appeared to hold out
ongoing hope for the patient's recovery, and the patient himself
expressed the desire to attempt one more round of Taxol.
Discharged with home VNA and bridge to hospice.
3. METASTATIC MELANOMA WITH HEMORRHAGIC BRAIN METS: Known mets
to scalp, neck, groin, brain s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16859**], [**First Name3 (LF) **] mass resection and
ventriculostomy for obstructive hydrocephalus. On Taxol at
admission, first dose 5/26. In previous discussions, patient
has been clear that he did not desire further surgical
intervention for control of his brain mets. He repeatedly stated
his desire for one more attempt at treatment with Taxol, which
was decided against given the patient's disease progression
despite taxol therapy. Dexamethasone was continued for cerebral
edema and all anticoagulation was held.
4. FEVERS/PNA/UTI: Fever and CXR on admission with consolidation
at right base concerning for aspiration pneumonia, as well as
WBCs in U/A. No elevation of WBC. Started on Vanc/Zosyn later
changed to Vanc/Cefapime after blood cultures remained negative.
Urine Cx grew out enterococcus which was sensitive to
ampicillin, nitrofurantoin and vancomycin.
5. NAUSEA/VOMITING: Likely related to leptomeningeal involvement
and metastatic impingement on fourth ventricle versus recent
chemo. No evidence of increased intracranial pressure on head CT
but during stay patient did develop left sided facial droop.
Could be related to vertigo in setting of additional brain edema
as in recent admission. He also has had dizziness and
lighthededness with standing and sitting up, and on previous
admission patient had orthostatic hypotension. Patient was
treated with Ondansetron and Decadron.
6. h/o DVT: Dx in [**2-11**]. Lovenox stopped on admission given
hemorrhagic brain mets.
Medications on Admission:
Dexamethasone 4mg PO q8
Lovenox 80mg SQ [**Hospital1 **] (held since [**8-12**])
Ativan 0.5mg PO TID
Vicodin 1-2 tabs q6-8 prn
Olanzapine 2.5mg PO BID prn
Zofran 8mg PO TID prn
Colace 100-200mg PO daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q4H (every 4
hours) as needed for pain.
Disp:*500 ml* Refills:*4*
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*40 Tablet(s)* Refills:*3*
4. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*40 Tablet(s)* Refills:*2*
5. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2
times a day).
Disp:*300 ml* Refills:*2*
6. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for agitation, hallucinations: Please take 1
tablet up to 3 times per day as needed for agitation or
hallucinations.
Disp:*90 Tablet(s)* Refills:*2*
7. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-4**] Tablet,
Rapid Dissolves PO every four (4) hours: please take 1-2 tablets
up to every 4 hours, as needed, to control nausea and vomiting.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2*
8. IVF
Resumption of hydration and line per critical care systems.
Normal saline as needed for hydration.
9. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Dexamethasone Intensol 1 mg/mL Drops Sig: Six (6) ml PO
every eight (8) hours.
Disp:*qs 2 weeks* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PRIMARY:
1. Melanoma, metestatic
2. Leptomeningeal invovlement
3. Mental status changes
4. UTI
5. PNA
Discharge Condition:
clinicall stable, moderately alert, pain controlled, patient and
family aware of diagnosis, on comfort measures and IVF only
Discharge Instructions:
You were admitted for change in mental status thought to be
secondary to progression of your cancer. Your symptoms are
consistent with tumor involvement of the fluid in your spinal
cord (called leptomeningeal invovlement). We had a family
meeting with palliative care and Dr. [**Last Name (STitle) 79354**] team and discussed
goals of care. You will be discharged home with VNA services
with bridge to hospice. You will have a PICC line with IV
fluids.
.
We have made changes to your medication. Please follow the
discharge instruction.
.
Call your doctor if you have worsening pain or agitation or any
other questions.
Followup Instructions:
Call your doctor if you have worsening pain or agitation or any
other questions.
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
ICD9 Codes: 431, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3150
} | Medical Text: Admission Date: [**2102-1-8**] [**Month/Day/Year **] Date: [**2102-1-20**]
Date of Birth: [**2033-8-28**] Sex: F
Service: SURGERY
Allergies:
Codeine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
febrile, bacteremic due to PICC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 yo woman w/Hx ventral hernia repair c/b enterocut fistula,
abdom wall abscess, more recently w/PICC-associated enterococcus
and coag neg staph bacteremia, now admitted on [**2102-1-8**] with GPC
bacteremia and Klebs UTI.
Past Medical History:
SBO s/p surgery complicated by ventral heria repair and wound
infection requiring vancomycin and pigtail placement in [**Month (only) **]
[**2100**]; s/p hysterectomy, s/p lap chole, s/p LOA, epilepsy,
anxiety, tremors, depression, hypothyroid, sz d/o
Social History:
currently living at NE Siani since [**Year (4 digits) **]. no tobacco or EtOH
Family History:
Noncontributory
Physical Exam:
T: 98.2 P: 86 R: 20 BP: 136/84, O2Sat 99% RA
General: Alert, oriented, follows commands, watching TV
HEENT: NCAT, PERRL, OP clear without exudates/lesions
Neck: no LAD/JVD
Lungs: CTA B
Heart: RRR, 2/6 systolic murmur
Abdom: midline 10 x 10cm wound with ostomy bag over top, and
J-tube entering the middle of such wound. LLQ mildly tender
Extrem: *LUE AC w/3x3cm tender nodule over former site of PICC
line
*RUE new PICC c/d/i, no erythema
GU: Foley intact
Neuro: MAE, PERRL
Skin: no rash
Pertinent Results:
[**2102-1-8**] 02:55PM PLT COUNT-222
[**2102-1-8**] 02:55PM NEUTS-68.8 LYMPHS-13.5* MONOS-8.6 EOS-9.0*
BASOS-0.1
[**2102-1-8**] 02:55PM WBC-9.3 RBC-3.26* HGB-8.6* HCT-26.7* MCV-82#
MCH-26.4* MCHC-32.2 RDW-13.2
[**2102-1-8**] 02:55PM estGFR-Using this
[**2102-1-8**] 02:55PM GLUCOSE-103 UREA N-68* CREAT-2.1*# SODIUM-138
POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
[**2102-1-8**] 04:23PM LACTATE-1.5
[**2102-1-8**] 03:50PM URINE HOURS-RANDOM
[**2102-1-8**] 03:50PM URINE UHOLD-HOLD
[**2102-1-8**] 03:50PM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2102-1-8**] 03:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2102-1-8**] 03:50PM URINE RBC->50 WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-0
[**2102-1-17**] 06:31AM BLOOD WBC-13.5* RBC-3.25* Hgb-8.7* Hct-26.1*
MCV-80* MCH-26.7* MCHC-33.3 RDW-14.2 Plt Ct-358
[**2102-1-16**] 05:44AM BLOOD WBC-11.1* RBC-3.13* Hgb-8.2* Hct-25.3*
MCV-81* MCH-26.3* MCHC-32.6 RDW-13.6 Plt Ct-324
[**2102-1-15**] 04:10AM BLOOD WBC-10.6 RBC-3.05* Hgb-8.2* Hct-24.7*
MCV-81* MCH-26.8* MCHC-33.1 RDW-13.4 Plt Ct-308
[**2102-1-9**] 09:10PM BLOOD Neuts-80.1* Lymphs-9.8* Monos-5.5
Eos-4.5* Baso-0.1
[**2102-1-17**] 06:31AM BLOOD Plt Ct-358
[**2102-1-17**] 06:31AM BLOOD PT-40.9* INR(PT)-4.5*
[**2102-1-16**] 05:44AM BLOOD Plt Ct-324
[**2102-1-16**] 05:44AM BLOOD PT-30.1* PTT-36.5* INR(PT)-3.1*
[**2102-1-15**] 04:10AM BLOOD Plt Ct-308
[**2102-1-15**] 04:10AM BLOOD PT-22.6* PTT-38.8* INR(PT)-2.2*
[**2102-1-17**] 06:31AM BLOOD Glucose-93 UreaN-48* Creat-3.4* Na-139
K-4.4 Cl-104 HCO3-25 AnGap-14
[**2102-1-16**] 05:44AM BLOOD Glucose-89 UreaN-48* Creat-3.4* Na-140
K-4.1 Cl-106 HCO3-23 AnGap-15
[**2102-1-15**] 04:10AM BLOOD Glucose-96 UreaN-50* Creat-3.4* Na-140
K-3.4 Cl-109* HCO3-21* AnGap-13
[**2102-1-14**] 04:44AM BLOOD Glucose-101 UreaN-59* Creat-3.5* Na-142
K-3.2* Cl-111* HCO3-22 AnGap-12
[**2102-1-10**] 06:19PM BLOOD CK(CPK)-12*
[**2102-1-10**] 01:07PM BLOOD CK(CPK)-15*
[**2102-1-9**] 09:10PM BLOOD ALT-27 AST-26 CK(CPK)-18* AlkPhos-272*
TotBili-0.4
[**2102-1-10**] 06:19PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2102-1-10**] 01:07PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2102-1-9**] 09:10PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2102-1-17**] 06:31AM BLOOD Calcium-8.7 Phos-6.7* Mg-2.2
[**2102-1-16**] 05:44AM BLOOD Calcium-8.5 Phos-6.1* Mg-2.4
[**2102-1-15**] 04:10AM BLOOD Calcium-8.7 Phos-5.5* Mg-1.8
[**2102-1-14**] 04:44AM BLOOD Calcium-9.0 Phos-4.8*# Mg-1.9
[**2102-1-13**] 01:54AM BLOOD Calcium-9.1 Phos-6.5* Mg-2.2
[**2102-1-12**] 06:52PM BLOOD calTIBC-194* Ferritn-1898* TRF-149*
[**2102-1-9**] 10:50AM BLOOD calTIBC-209* Ferritn-GREATER TH TRF-161*
[**2102-1-12**] 06:52PM BLOOD Triglyc-90 HDL-26 CHOL/HD-3.3 LDLcalc-41
[**2102-1-16**] 05:44AM BLOOD Vanco-19.0
[**2102-1-13**] 07:56PM BLOOD Vanco-14.9
[**2102-1-12**] 06:52PM BLOOD Vanco-29.3*
[**2102-1-8**] 02:55PM BLOOD HoldBLu-HOLD
[**2102-1-11**] 02:14AM BLOOD Type-ART pO2-170* pCO2-39 pH-7.41
calTCO2-26 Base XS-0
[**2102-1-10**] 03:04PM BLOOD Type-ART pO2-171* pCO2-31* pH-7.44
calTCO2-22 Base XS--1
[**2102-1-9**] 09:25PM BLOOD Type-ART pO2-160* pCO2-40 pH-7.38
calTCO2-25 Base XS-0
[**2102-1-9**] 06:53PM BLOOD Type-ART pO2-448* pCO2-41 pH-7.38
calTCO2-25 Base XS-0 Intubat-INTUBATED
[**2102-1-9**] 06:53PM BLOOD Lactate-1.8
[**2102-1-8**] 04:23PM BLOOD Lactate-1.5
[**2102-1-12**] 06:52PM BLOOD PREALBUMIN-Test
[**2102-1-9**] 10:50AM BLOOD PREALBUMIN-Test
Brief Hospital Course:
Mrs [**Known lastname 107389**] was admitted to the Surgery service with a
Klebsiella UTI and coagulase negative staph positive blood
cultures at her rehab. She was started on Cefriaxone and
Vancomycin and her PICC line was pulled and the tip cultured and
blood and urine cultures were also sent. All cultures were
negative. On [**1-9**], she became anxious and then developed
respiratory distress, hyopoxia, and acidosis that required
emergent intubation. She was transfered to the ICU where her
respiratory distress was attributed to CHF as a TTE showed a EF
of 40% whereas she had previously had a normal EF. She was
diuresed and extubated. Renal was consulted for worsening renal
funciton that they believed was secondary to ATN. A renul
ultrasound showed only mild left pelvocaliectasis and no signs
of obstruction or hydronephrosis. Upper extremity ultrasound
revealed left IJ occluding thrombus and and left upper extremety
non-occlusive thrombus. The patient was started on Heparin drip
and bridged to coumadin. A repeat ECHO on [**1-12**] showed improved
EF of >55% and no vegetations. Mrs [**Known lastname 107389**] was transferred back
to the regular floor and did well. Infectious disease was
consulted and recommended continuing the vancomycin and stopping
the ceftriaxone as a 10 day course of treatment had been
completed. Repeat blood and urine cultures were negative. A new
PICC line was placed on [**1-13**] for antibiotics and TPN, but given
her recent bacteremia and her tolerating tube feeds well, TPN
was not restarted. She remained afebrile and was tolerating her
tube feeds well, and was advanced slowly to a regular diet in
addition to her tube feeds. A left upper extremity ultrasound of
the old PICC site showed findings suggestive of left antecubital
thrombosed pseudoaneurysm. Due to the presence of multiple
thrombi, infectious disease recommended continuing the IV
Vancomycin for 4 weeks and will continue to follow her
laboratory and micro data at rehab. Her abdominal
wound/ostomy/fistula continued to require daily care by
wound/ostomy nurses. Recommendations for wound care and
nutrition were included in the page one.
.
Heme: Pt was found to have left IJ and left upper extremety
thrombi. Given her respiratory distress early in her admission a
chest ct-angiogram was considered but not performed secondary to
her worsening renal function. She was started on therapeutic
dosing of heparin and bridged to coumdin. Her INR was
therapeutic on [**Month/Year (2) **], but her daily coumdain dose was not
stable and will need to be monitored closely at rehab.
.
Renal: Mrs [**Known lastname 107389**] presented in acute renal failure, which
worsened somewhat during her hospital course, despite adequate
hydration and consistently good urine output. Renal was
consulted and felt was ATN and recommended renal ultrasound and
monitoring urine output. The renal ultrasound showed no
obstruction or hydronephrosis. Her creatinine and urine output
should be followed at rehab.
.
Cardiac/Respiratory: Pt had episode of respiratory
distress/hypoxia as described above, that appeared to be a
combination of anxiety and new CHF with reduced EF on ECHO. EKG
was unchanged and troponin 0.03, 0.03, 0.04, which was
considered to be negative in the context of her worsening renal
failure. She was stabilized in the ICU, diuresed and easily
extubated. Repeat ECHO was normal and her respiratory status
remained stable after returning to the floor. She has had no
chest/respiratory complaints and is satting 97-100% on room air.
.
Infectious disease: Pt presented with Klebsiella UTI and Co-Ag
neg staph bacteremia likely secondary to a line infection. For
her UTI she completed a 10 day course of Ceftriaxone. For her
bacteremia, her PICC was pulled, she was started on IV
Vancomycin, and will have a 4 week course given her thrombi.
Micro
[**2008-1-5**] blood cxr at OSH: GPC ([**1-24**])
[**1-6**] urine cxr at OSH: klebsiella [**Last Name (un) 36**] to bactrim, aztreo,
cefaz, ceftaz, ceftriaxone, resistant to cipro amp levo
nitrofurantoin
[**1-8**] urine cxr: contam final
[**1-8**]: blood cxr: ng final
[**1-8**]: PICC tip cxr: ng final
[**1-10**] urine: ng final
[**1-11**]/: MRSA SCREEN NEG
Medications on Admission:
. nystatin 5ml PO q6
2. ferrous sulfate 300mg PO BID
3. metoprolol 100mg PO TID
4. mirtazapine 15mg PO qhs
5. citalopram 40mg [**Hospital1 **]
6. heparin sodium 50units IV q8
7. primidone 50mg qHS
8. olanzapine 5mg daily
9. lipids 250ml IV Mon/We/Fri
10. esomeprazole 40mg IV BID
11. ascorbic acid 500mg [**Hospital1 **]
12. levetiracetam 500mg IV BID
13. ergocalciferol [**Numeric Identifier 1871**] units PO Mon, Thurs
14. TPN
15. fentanyl patch 75mcg TD q72 hours
16. ceftazidine 1gm IV q8h
17. vancomycin 1gm IV q8h
18. tylenol 650mg PO q4 prn
19. albuterol 2.5mg neb prn
20. zofran 4mg IV prn - last dose 2/14
21. hydromorphone 6mg IV q4h prn - last dose 2/15
22. nutren with replete at 20cc/hr
23. quetiapine 200mg PO BID
[**Numeric Identifier **] Medications:
1. Acetaminophen 325 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Insulin Regular Human 100 unit/mL Solution [**Numeric Identifier **]: SSI
Injection ASDIR (AS DIRECTED).
3. Olanzapine 5 mg Tablet, Rapid Dissolve [**Numeric Identifier **]: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Numeric Identifier **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Fentanyl 100 mcg/hr Patch 72 hr [**Numeric Identifier **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
6. Citalopram 20 mg Tablet [**Numeric Identifier **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Quetiapine 200 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Primidone 50 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO HS (at
bedtime).
9. Mirtazapine 15 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
10. Levothyroxine 100 mcg Tablet [**Numeric Identifier **]: Two (2) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 50 mg Tablet [**Numeric Identifier **]: Two (2) Tablet PO TID
(3 times a day).
12. Hydralazine 25 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO Q6H (every 6
hours) as needed for SBP > 150.
13. Sevelamer HCl 400 mg Tablet [**Numeric Identifier **]: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Warfarin 2 mg Tablet [**Numeric Identifier **]: 1.5 Tablets PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
[**Doctor First Name **] Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
[**Location (un) **] Diagnosis:
s/p component release and mesh repair of ventral hernia,
enterocutaneous fistula, klebsiella UTI, Acute Renal Failure,
bacteremia.
[**Location (un) **] Condition:
good
[**Location (un) **] Instructions:
Mrs. [**Known lastname 107389**] will require 4 weeks of vancomycin IV (end date
[**2102-2-5**]). She will need weekly labs: CBC/diff, BUN/Cr, LFT,
Vanco trough faxed to Infectious Disease R.Ns. at ([**Telephone/Fax (1) 18871**].
Her VANCOMYCIN SHOULD BE HELD UNTIL A VANC LEVEL IS BELOW 20,
then restarted at 750mg Q48 hours. VANC TROUGHS SHOULD BE
CHECKED AND REVIEWED BEFORE EACH DOSE UNTIL STABLE. IF QUESTIONS
PLEASE CALL INFECTIOUS DISEASE. DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 17490**].
Continue tube feeds per nutrition recommendations and
wound/ostomy care.
Please return to [**Hospital1 18**] if you have increasing pain, drainage, or
fever, shaking chills, shortness of breath.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3243**]
MD Phone: [**Telephone/Fax (1) 2359**]
Date/Time:[**2102-2-7**] 1:30
ICD9 Codes: 5845, 7907, 5990, 2762, 4280, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3151
} | Medical Text: Admission Date: [**2142-9-27**] Discharge Date: [**2142-10-2**]
Date of Birth: [**2104-10-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Lower GI bleed in setting of ulcerative colitis flare
Major Surgical or Invasive Procedure:
Colonoscopy ([**2142-9-29**])
10 units PRBC's
History of Present Illness:
The pt is a 37-yo man with ulcerative colitis who presents with
3-4 days of bloody bowel movements. He had been experiencing a
flare of his ulcerative colitis, that begain back in [**2141-7-14**].
He was treated with oral steroids for 6 weeks, uptitrated to
40mg Prednisone daily, and is also using cortisone retention
enemas. He has also noted swelling in his knees. He is being
followed by his gastroenterologist Dr. [**Last Name (STitle) 79460**] at [**Hospital1 2025**]. He had
noted improvement in his abdominal symptoms until about 3-4 days
PTA, when he noted bloody bowel movements. Since then he has
been having [**5-20**] bloody bowel movements daily. On [**Month/Day (3) 766**], he had
his Hct checked at [**Hospital 1191**] Hospital, where he works, and noted
that it was about 29 (down from baseline ~38). One day PTA, he
had profuse bleeding and passed out. His BP at the time was
80/60. He was brought in to the ED for further evaluation.
Upon arrival to the ED: VS- afeb, HR 85, SBP 120s-130s, O2-sats
100% RA. Hct on arrival was 20.8. He was given 2L NS and
transfused 2units PRBCs. He was started on IV Flagyl given
concern for C.diff after it was noted that his WBC was 19.
Serial Hcts during transfusion showed little change (final Hct
in ED 21.1), although he remained HD stable. He was admitted to
the MICU for further care.
Past Medical History:
-Ulcerative Colitis - dx age 19, had severe lower GI bleeding at
age 21, a flare in [**2133**], then no problems until the last couple
years when he has had an escalation of his symptoms and most
recently required escalating doses of prednisone
-Allergic Rhinitis
-OSA - uses CPAP of 9
-(+) ppd - after initial steroids in [**2125**], s/p 9 months INH
-H/o dysplastic nevi on back s/p resection
Social History:
Patient is a physchiatrist. Wife is an Oncologist at [**Hospital1 18**].
Denies prior tobacco use. Drinks approximately 1 drink per month
with slight increase in alcohol use leading up to UC flair.
Family History:
Father is Ashkenazi [**Name (NI) **] who had history of IBS and GIST (passed
at age 66). Mother is Korean and has h/o HTN and glaucoma.
Physical Exam:
VS: Tmax: 99.3 (during transfusion), Tcurr: 98.7, HR: 75, BP
112/62, RR: 18, 100% on RA
GENERAL: NAD, comfortable, appropriate, somewhat pale
HEENT: EOMI, conjunctival pallor, oropharynx benign, mucus
membranes are dry
LUNGS: CTA bilaterally, no rhonchi or wheezes
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: BS+, soft, mildy tender during palpation of LLQ, no
guarding, no rebound
EXTREMITIES: No peripheral edema, No obvious effusions of knees
bilaterally
NEURO:AxOx3
Pertinent Results:
CBC:
[**2142-9-26**] WBC-19.3* RBC-2.32* HGB-6.9* HCT-20.8* MCV-90 MCH-29.9
MCHC-33.3 RDW-14.1
[**2142-9-26**] NEUTS-79.2* LYMPHS-17.6* MONOS-2.7 EOS-0.3 BASOS-0.2
[**2142-9-27**] HGB-7.3* HCT-21.1*
[**2142-9-27**] WBC-15.0* RBC-2.76* HGB-8.2* HCT-24.1* MCV-87 MCH-29.7
MCHC-34.0 RDW-15.3
[**2142-9-27**] HCT-24.4*
[**2142-9-27**] HCT-26.4*
[**2142-10-2**] Hct-37.8
[**2142-9-26**] 09:40PM PT-13.8* PTT-19.6* INR(PT)-1.2*
Electrolyes:
[**2142-9-26**] 09:40PM GLUCOSE-175* UREA N-24* CREAT-1.0 SODIUM-136
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12
[**2142-9-27**] 09:57AM ALBUMIN-2.9* CALCIUM-8.0* PHOSPHATE-3.0
MAGNESIUM-2.0
[**2142-9-27**] 09:57AM ALT(SGPT)-20 AST(SGOT)-14 LD(LDH)-128 ALK
PHOS-43 TOT BILI-0.4
[**2142-9-27**] 10:24AM LACTATE-1.1
Iron Studies:
[**2142-10-1**] 05:20AM BLOOD calTIBC-217* Ferritn-56 TRF-167*
LE U/S:IMPRESSION: No DVT on the right leg
CT AB: IMPRESSION: Colitis extending from the mid ascending
colon to the distal one-third of the transverse colon. The
terminal ileum, rectum, and sigmoid colon are spared. The
differential for the etiologies include infectious and
inflammatory. Please correlate with laboratory values, for
example, for history of C. diff colitis.
Brief Hospital Course:
# Lower GI bleed: Pt presented with 3-4 days of multiple bloody
bowel movements, and hematocrit nadir of 19%. He was initially
cared for in the ICU. GI was consulted, and recommended therapy
with Solumedrol 20 mg IV every 8 hours, intravenous Cipro and
flagyl, and oral mesalamine 2400 mg PO BID and mesalamine
enemas. A CT scan of the abd/pelvis on [**2142-9-27**] showed colitis.
Colonoscopy on [**9-28**] showed a single lesion in the transverse
colon without continuous lesions more consistent with CD than
UC. Biopsies are still pending at the time of discharge. He was
transfused a total of 10 units of PRBCs during his hospital
stay, with subsequent stabilization of his hematocrit. His last
transfusion was on [**2142-9-30**]. Of note, C. difficile was sent and
returned negative.
He was transitioned to oral antibiotics on [**10-1**] and Prednisone
on [**2142-10-2**]. He additionally tolerated a regular diet at the
time of discharge. He was discharged with out-patient follow-up
with GI at [**Hospital1 2025**].
Med changes: Ciprofloxacin and Flagyl for 7 day course (will end
on [**2142-10-7**]). Prednisone [**Date Range 15123**] starting at 60mg PO will defer to
Primary GI doctor [**First Name (Titles) **] [**Last Name (Titles) 15123**]. Bacrim DS and protonix while on
high dose steroids. Mesalamine will be continued at home. An
appointment was made with his primary GI doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] [**10-8**]
at 1:45.
#. Swollen right knee - While in the hospital, the patient
additionally reported arthralgia involving his R>L knee, without
overlying skin changes. The possibility of extra-intestinal
manifestations of IBD was raised. LENI was negative for DVT.
Medications on Admission:
Hydrocortisone retention enema QHS
Asacol 2400 mg [**Hospital1 **]
Prednisone 40 mg daily
Claritin 10 mg daily
Multivitamin
Calcium
Vitamin C
Discharge Medications:
1. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Six (6)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR ([**Hospital1 766**] -Wednesday-Friday) as needed for pcp
[**Name9 (PRE) 6187**] for 3 weeks.
Disp:*9 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
3 weeks.
Disp:*21 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute flare of inflammatory bowel disease.
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with acute ulcerative colitis flare
and 3-4 days bloody bowel movements and low hematocrit. An
abdominal CT scan showed colitis, and you were treated with
antibiotics (Flagyl and Cipro) for suspected GI infection.
After a few days, the cultures did not grow anything. A
colonoscopy was also performed and biopsies were taken, the
results were pending at the time of discharge. Once you were
hemodynamically stabilized, you were transferred from the MICU
to the floor. During your time on the floor, your Hct
stabilized and there were no signs of acute bleeding. After
slowly advancing your diet and following up with the GI
recommendations, it was decided to discharge you with
antibiotics, and have you follow-up with your GI and primary
care doctors.
Please take all medications as directed and attend all follow-up
appointments. Since you were admitted, we have made some changes
to your medication regimen:
- Prednisone 60mg [**Hospital1 15123**] as directed by your GI doctor.
- Ciprofloxacin and Flagyl 7 day course to be completed on
[**2142-10-7**].
- Bactrim DS while on high dose steroids.
- Protonix while on steroids.
If you have worsening abdominal or back pain, fevers, chills,
loss of control of your bowels, numbness/weakness, please seek
medical attention or come to the emergency department
immediately.
Followup Instructions:
Please follow-up with your GI specialist at [**Hospital1 2025**], Dr. [**Last Name (STitle) 79460**].
An appointment has been made for 1:45 on [**Last Name (STitle) 766**] ([**2142-10-8**]).
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
ICD9 Codes: 5789, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3152
} | Medical Text: Admission Date: [**2101-1-13**] Discharge Date: [**2101-2-11**]
Date of Birth: [**2030-1-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Right hydrothorax, fluid overload, fever
Major Surgical or Invasive Procedure:
[**2101-1-13**]: right ultrasound-guided thoracentesis
[**2101-1-14**]: flexible bronchoscopy
[**2101-1-18**]: bronchoscopy, thorascoscopy video-assisted right
drainage of effusion, decortication, removal of gortex mesh
History of Present Illness:
Mr. [**Known lastname 75713**] is a 71 year-old male with history of right upper
lobe lung cancer s/p right thoracotomy with right upper
lobectomy and en-block chest wall resection with decortication
of the middle and lower lobes. The procedure was difficult
procedure and complicated by prolonged hospital stay due to
bronchopleural fistula. He returned for followup on [**2101-1-13**] with
improving
postoperative chest discomfort, yet reported shortness of
breath, nonproductive cough, and bilateral lower extremity
edema, despite being recently placed on lasix by his PCP. [**Name10 (NameIs) **] had
a low-grade fever to 100.1 the evening prior to his followup
appointment. CXR ([**2101-1-13**]) revealed right hydropneumothorax. He
was subsequently admitted to the Thoracic Surgery service for
further workup and management.
Past Medical History:
PMH:
Traumatic blindness (left eye)
Hypertension
Alcohol-induced gastric ulcers (alcohol-free x20yr)
Lung CA, R chest wall ([**4-11**]), s/p carboplatin, taxol with
avastin
h/o serratia marascens VAP
PSH:
s/p appendectomy, date unknown
[**2100-12-22**]: Bronchoscopy, Reoperative right thoracotomy with right
upper lobectomy and en bloc right chest wall resection (ribs 3,4
and 5) with [**Doctor Last Name 4726**]-Tex chest wall reconstruction and decortication
of right middle and right lower lobes.
.
[**2100-12-25**]: Flexible bronchoscopy with therapeutic aspiration and
bronchoalveolar lavage.
.
[**2100-12-26**], [**2100-12-27**], [**2100-12-28**], [**2101-1-19**]:
Flexible bronchoscopy with therapeutic aspiration.
.
[**2101-1-13**]: Right sided thoracentesis under ultrasound guidance.
Social History:
Lives with wife
EtOH: {x}N { }Y Quit
Tobacco: {x}N { }Y Quit 20 years ago
Drugs: {x}N { }Y Amount:
Married: { } N {x}Y
Occupations: Construction worker
Exposures: Asbestos, chemical / construction materials
Diabetes: N
Immunodeficiency: N
Cancer: Y
Family History:
Notable for cerebral hemorrhage. Father with lung cancer.
Brother with gastric cancer and another brother with emphysema.
Sister with cystic fibrosis.
Physical Exam:
General: NAD, thin-appearing male, awake, alert
HEENT: NC/AT, mucous membranes moist, OP clear, no lesions
Neck: Supple, no lymphadenopathy
Cardiovascular: RRR no murmurs
Respiratory: Significantly decreased right base, slightly
decreased on left base. Empyema tubes x3.
Back: Well-healed thoracotomy scar
Gastrointestinal: soft, nontender, nondistended, normoactive
bowel sounds
Musculoskeletal: [**2-6**]+ pitting edema LE bilaterally
Skin: Right port without erythema, bilateral splinter
hemorrhages
Pertinent Results:
[**2101-1-13**]: CXR (on admit)
No evidence of remaining aerated pulmonary tissue in right-sided
hemithorax and central right-sided airways only followed 2-3 cm
distal to the bifurcation. A hydropneumothorax is present on the
right side with an air-fluid level above thoracic arch. Multiple
right-sided upper rib defects consistent with chest wall
reconstruction. Mild-to-moderate mediastinal shift towards right
side indicative of volume loss. The left-sided hemithorax shows
grossly normal appearance of the lung without evidence of acute
infiltrates or congestive pattern.
.
[**2101-1-13**]: Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS
.
[**2101-1-25**]: ECHO:
Left atrium is mildly dilated. Mild symmetric left ventricular
hypertrophy. Left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. There is a small
pericardial effusion.
.
[**2101-1-27**]: CT Chest
IMPRESSION:
1. New, large hematoma in the right upper chest, predominantly
pleural, despite two apical pleural tubes; new submuscular, R
chest wall hematoma.
2. Persistent right pleural thickening and worsening
atelectasis.
3. New small left pleural effusion.
.
[**2101-2-3**]: CT Chest
IMPRESSION:
1. Resolving large hematoma in the right upper chest with
reexpansion of the right upper lobe volume.
2. Persistent right extrathoracic hematoma with less gas.
3. Resolving left pleural effusion.
.
[**2101-2-9**]: Renal U/S: No evidence of hydronephrosis
.
[**2101-2-10**]: CXR (prior to discharge)
IMPRESSION: No relevant changes in right hemithorax. Minimal
increase in a subtle perihilar, but diffuse opacity in the left
lung.
Brief Hospital Course:
Neuro: On admit, the patient was given oral pain medication, on
which he reported adequate pain relief. Following right VATS and
post-operative intubation, he was placed on propofol gtt and
given dilaudid IV until extubated. When able to tolerate po, he
was placed on oral pain medication. Prior to discharge, his pain
was adequately controlled on tylenol.
.
Cardiopulmonary: Following admission, the patient underwent a
bronchoscopy on [**2101-1-14**] which revealed a small amount of
granulation tissue at the base of cords c/w prior intubation
trauma, healthy appearing surgical stump, mucous in RLL, and
edematous RML/RLL bronchi. Based on the right hydropneumothorax
revealed on CXR, a right apical chest tube was inserted (drained
~1000cc serosanginous) at the bedside and pleural fluid cultures
were obtained. tPA was placed through the tube prior to
obtaining CT Chest on [**2101-1-17**]. On [**2101-1-18**], due to the persistent
right effusion, the patient underwent a flexible bronchoscopy,
right video-assisted thoracoscopy with drainage, and
decortication. Two additional right chest tubes were placed
while in the operating room. The patient tolerated the procedure
well, yet post-operatively, was electively intubated following
right hemithorax whiteout demonstrated on CXR. He was
subsequently transferred to the ICU and underwent bronchoscopy
which revealed moderate inflammation and edema in the distal
trachea and mainstem bronchi with a mucous plug in the bronchus
intermedius and right middle lobe takeoff. Repeat bronchoscopy
on [**2101-1-19**] revealed a small amount thick mucoid secretions in
the LLL, with an intact RUL stump. Following bronchoscopy, he
was weaned to extubate without incident. On [**2101-1-20**], he was
transferred to [**Hospital Ward Name 121**] 7. He had multiple CT scans during the
remainder of the hospitalization, results aforementioned. On
[**2101-1-26**] he was transferred to the TICU for hypotension and
decreased hemocrit. After stabilization of hemocrit (received 6
units pRBCs) and blood pressure stabilization, he was
transferred to [**Hospital Ward Name 121**] 7 on [**2101-1-28**]. Once on the floor, tPA was
placed through the chest tubes. He became hypertensive (SBP
180s) intermittently, and was administered hydralazine IV prn in
addition to atenolol and lisinopril (home medications). On
[**2101-2-7**], all three chest tubes were placed to waterseal. The
anterior CT was subsequently converted to an empyema tube. Prior
to discharge, the posterior and basilar tubes were converted to
empyema tubes. CXR on [**2101-2-11**] revealed no relevant changes in the
right hemithorax.
.
FEN/GI: Following admit, the patient tolerated a regular diet.
He was given Ensure supplements and calorie counts were
initiated per nutritional recommendations. Over 3 days, calorie
were 1403 and protein 47 grams. Lasix 40mg daily was continued
for diuresis and electrolytes were repleted as appropriate. On
discharge, he was tolerating a regular diet; denied nausea or
vomiting.
.
ID: On admit, patient had temperature of 101.2, WBC=8.5. He was
initially placed on vancomycin and levofloxacin IV while
awaiting culture results. Diflucan was started on [**2101-1-15**] due to
[**Female First Name (un) **] albicans growth in pleural fluid from [**2101-1-13**] and
subsequently [**2101-1-18**]. Levofloxacin was discontinued on [**2101-1-24**].
Infectious disease was consulted for antibiotic management.
Recommendations included: checking TEE to r/o endocarditis,
continuing diflucan from [**Date range (1) 75840**], checking LFTs every
2weeks while on diflucan, and obtaining f/u CT scan at end of
treatment course to determine resolution of effusion. On
discharge, the patient was afebrile, WBC=9.9. He was discharged
on vancomycin, to continue until all empyema tubes removed, and
fluconazole, to continue until [**2101-2-28**].
.
Renal: On [**2101-2-9**], the patient's creatinine increased to 1.7
(from 1.3 on admit). Fractional excretion of sodium was 0.9.
Renal ultrasound revealed right kidney 11.6 cm, left kidney 10.7
cm, with no evidence of hydronephrosis, nephrolithiasis, or
renal mass. Urinalysis was negative; no eosinophils. Renal team
was consulted and thought acute renal failure was likely
drug-related. Renal recommmendations included holding lisinopril
and renally dosing antibiotics. Creatinine was closely followed;
on discharge, creatinine was 1.9.
.
Endo: Blood sugars were closely monitored. The patient was
placed on an insulin sliding scale. On [**2101-2-4**], the patient was
triggered for a blood sugar of 26. He was confused and
disoriented, yet improved with 1/2 amp D50 x2 and [**Location (un) 2452**] juice.
He subsequently received D10W, insulin was held, and
fingersticks were closely monitoring. He did not have any
further low blood sugars during the remainder of his
hospitalization.
.
Heme: He was given heparin SQ 5000U TID for DVT prophylaxis. He
received 2 units pRBC on [**2101-1-26**] for Hct drop (28.6 to 23.8).
Post-tranfusion Hct was 25.9, and he subsequently received 4
more units pRBC, with resulting Hct of 33.0. On discharge, Hct
was 26.6.
Medications on Admission:
Atenolol 100 mg daily
Oxycodone-Acetaminophen 5-325 mg, 1-2 tabs po q4-6hr prn pain
Docusate Sodium 100 mg [**Hospital1 **]
Lisinopril 20 mg [**Hospital1 **]
Hydrochlorothiazide 25 mg daily
Doxazosin 6mg qhs
Lasix 40mg daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
2. Doxazosin 4 mg Tablet [**Hospital1 **]: 1.5 Tablets PO HS (at bedtime).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every
24 hours): Dr. [**Doctor Last Name 75841**] disease will stop this medication.
Disp:*30 Tablet(s)* Refills:*1*
7. Atenolol 100 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO once a day:
Hold for
SBP<100, HR<60.
8. Diazepam 5 mg Tablet [**Doctor Last Name **]: [**1-5**] to 1 [**1-5**] Tablet PO Q12H (every
12 hours) as needed.
9. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day (2) **]: One (1)
gm Intravenous Q 24H (Every 24 Hours).
Disp:*30 gm* Refills:*1*
10. Atenolol 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO q pm.
11. Outpatient Lab Work
check vanco level, liver function tests, and bun/creat on monday
[**2101-2-14**] and call to Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**]
12. Heparin Lock Flush (Porcine) 10 unit/mL Solution [**Telephone/Fax (1) **]: One
(1) ML Intravenous DAILY (Daily) as needed.
Disp:*qs unit/ml* Refills:*0*
13. Tylenol 325 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO every four (4)
hours.
14. Saline Flush 0.9 % Syringe [**Telephone/Fax (1) **]: One (1) Injection prn.
Disp:*qs syringe* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Lung CA, right chest wall s/p carboplatin, taxol with avastin,
s/p right thoracotomy with right upper lobectomy and enblock
right chest wall resection with [**Doctor Last Name 4726**]-Tex chest wall
reconstruction
Secondary:
Hypertension
Gastric Ulcers
COPD
CRI (baseline Cr 1.5)
Traumatic blindness L eye
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops discharge
Cover chest tube site with a clean dry dressing daily. The gauze
at the end of the chest tubes can changed as often as needed. If
the chest tube falls out- cover the site with a gauze and call
Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] immediately.
Complete Diflucan through [**2101-2-28**]
LFT's every 2 weeks while on Diflucan: Fax results to Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 432**]
You may only [**Last Name (un) 41829**] bathe until the chest tubes are removed.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on thursday [**2101-2-17**] at 3pm in the
[**Hospital Ward Name **] clinical center [**Location (un) **]. Please arrive 45 minutes
prior to your follow up appointment and report to the [**Location (un) **]
radiology for a chest xray.
Follow-up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2101-2-28**] 11:00 in the [**Last Name (un) 2577**] Building basement [**Last Name (NamePattern1) 10357**]
ICD9 Codes: 5849, 5859, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3153
} | Medical Text: Admission Date: [**2136-1-12**] Discharge Date: [**2136-1-23**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 yo male s/p recent hospitalization for colectomy and
splenectomy complicated by anastomotic leak and treated with a
diverting ileostomy with g-j tube placement and appendectomy. He
was discharged to rehab and returned less than 1 week later with
fever and acute renal failure.
Past Medical History:
HTN
Hiatal hernia
TIA (on Plavix)
Asthma
Spinal stenosis
AR and MR (requires SBE prophylaxis)
Social History:
Married and lives with wife
[**Name (NI) **] in [**Name (NI) 108**] during winter months
Family History:
Noncontributory
Physical Exam:
Gen: NAD, AAOx3
CV: RRR
Pulm: some coarse BS bilat
Abd: soft, NT, wound open and packed, ostomy intact
Ext: no c/c/e
Pertinent Results:
[**2136-1-12**] 06:10PM GLUCOSE-98 UREA N-49* CREAT-1.5* SODIUM-134
POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-20* ANION GAP-14
[**2136-1-12**] 06:10PM CALCIUM-9.4 PHOSPHATE-4.1 MAGNESIUM-2.2
[**2136-1-12**] 06:10PM WBC-13.9* RBC-3.75* HGB-11.9* HCT-35.0*
MCV-94 MCH-31.7 MCHC-33.9 RDW-17.1*
[**2136-1-12**] 06:10PM PLT COUNT-418
Cardiology Report ECHO Study Date of [**2136-1-13**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Pulmonary embolus. Right
ventricular function.
Height: (in) 67
Weight (lb): 185
BSA (m2): 1.96 m2
BP (mm Hg): 129/54
HR (bpm): 56
Status: Inpatient
Date/Time: [**2136-1-13**] at 10:41
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007W006-0:13
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.2 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.1 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.5 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.5 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.3 cm
Left Ventricle - Fractional Shortening: 0.44 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%)
Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.7 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A Ratio: 0.89
Mitral Valve - E Wave Deceleration Time: 368 msec
TR Gradient (+ RA = PASP): 19 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the report of the prior study (images
not
available) of [**2134-6-29**].
LEFT ATRIUM: Mild LA enlargement. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. The IVC is
normal in
diameter with >50% decrease collapse during respiration
(estimated RAP [**4-12**]
mmHg).
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional
LV systolic function. Overall normal LVEF (>55%). Transmitral
Doppler and TVI
c/w Grade I (mild) LV diastolic dysfunction. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Mildly dilated ascending
aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets. No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral
annular calcification. Mild thickening of mitral valve chordae.
Trivial MR. LV
inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
The patient
appears to be in sinus rhythm.
Conclusions:
The left atrium is mildly dilated. The left atrium is elongated.
The estimated
right atrial pressure is 5-10 mmHg. There is moderate 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%). 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 root is
mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic
valve leaflets are moderately thickened with focal calcification
of the
noncoronary cusp. There is no aortic valve stenosis.Trace aortic
regurgitation
is seen. Trivial mitral regurgitation is seen. There is a
trivial/physiologic
pericardial effusion.
IMPRESSION: Moderate symmetric LVH. Normal left ventricular
systolic function.
Compared with the report of the prior study (images unavailable
for review) of
[**2134-6-29**], there is no significant change.
CTA CHEST W&W/O C&RECONS, NON-
Reason: r/o PE
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with concern for PE.
REASON FOR THIS EXAMINATION:
r/o PE
CONTRAINDICATIONS for IV CONTRAST: None.
EXAMINATION: CT of the chest with and without contrast dated
[**2136-1-13**].
COMPARISON: CT of the abdomen dated [**2136-1-12**].
INDICATION: Question pulmonary embolism.
TECHNIQUE: Axial imaging was obtained through the chest before
and after the administration of IV contrast.
FINDINGS FOR CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There
is heavy atherosclerotic calcification of the thoracic aorta and
great vessels. There is cardiomegaly and coronary artery
calcification. There is no pericardial effusion.
After administration of IV contrast there is evidence of
thrombus in the right main pulmonary artery as well as segmental
and subsegmental branches of the right upper lobe pulmonary
arteries. No thrombus is seen within the left pulmonary
arteries. Small mediastinal lymph nodes are demonstrated which
are numerous but not enlarged by CT criteria. Scattered air
space disease is seen within the right middle lobe and right
lower lobe which may represent atelectasis, infection, or
infarction given evidence of pulmonary embolism. There is
bibasilar atelectasis. There is no evidence of pneumothorax or
pleural effusion.
Limited imaging of the upper abdomen demonstrates evidence of
splenectomy with small fluid collection in the left upper
quadrant measuring 3 cm which contains gas consistent with
post-surgical changes. Small amount of fluid measuring 2.4 cm x
1.6 cm is seen adjacent to the pancreatic tail.
IMPRESSION:
1. Evidence of pulmonary embolism on the right as described with
air space consolidation within the right middle and right lower
lobes which may represent atelectasis, infection, or pulmonary
infarction given evidence of pulmonary embolism.
2. Limited evaluation of post-surgical changes in the left upper
quadrant as seen on prior CT abdomen and pelvis. Findings were
discussed with the resident taking care of the patient at
completion of the examination.
Reason: S/P RECENT SURGERY NOW TACHYPNEIC EVAL FOR PE
RADIOPHARMECEUTICAL DATA:
7.1 mCi Tc-[**Age over 90 **]m MAA ([**2136-1-12**]);
44.0 mCi Tc-99m DTPA Aerosol ([**2136-1-12**]);
HISTORY: S/P RECENT SURGERY NOW TACHYPNEIC EVAL FOR PE
INTERPRETATION:
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views
demonstrate marked
central clumping consistent with airways disease. There is
diffuse irregularity
of tracer uptake within the lung parenchyma.
Perfusion images in the same 8 views show multiple large
peripheral wedge-shaped
defects in the right lung. Perfusion irregularity of the left
lung is much less
pronounced than the right.
Chest x-ray shows a left lower lobe opacity.
While the above findings may in part be attributed to airways
disease, they are
concerning for pulmonary embolism and consistent with a
moderately high
probability for pulmonary embolism.
IMPRESSION: Moderate-High Likelihood for pulmonary embolism.
Brief Hospital Course:
He was admitted to the Surgery Service under the care of Dr.
[**Last Name (STitle) **]. He underwent a lung scan which revealed moderate to high
probability of pulmonary embolus. CTA of the chest was done
following the lung scan which revealed a thrombus in the right
pulmonary artery. He was started on a Heparin drip and later
started on Coumadin and Lovenox as a bridge until his INR
becomes therapeutic.
On HD #5 he experienced episode of increased shortness of breath
and chest pressure after performing morning ADL's; EKG and CXR
were all normal; his CK and troponin were flat. He again
experienced a similar episode on HD #7, EKG without change
compared to previous one; chest radiograph performed and pending
at time of this dictation. This episode was proceeded by a
session of chest physiotherapy and resolved shortly after that.
His supplemental oxygen was discontinued at that time as his
room air saturations were 95%.
On HD #8 he was noted to have guaiac positive stool via his
ileostomy. His Coumadin was stopped; the Lovenox was changed to
Heparin and he remained on the Plavix. His hematocrits were as
follows:
[**2136-1-20**] 01:20AM 32.6*
[**2136-1-19**] 09:00PM 34.6*
[**2136-1-19**] 07:14PM 32.6*
[**2136-1-19**] 09:30AM 33.5*
A GI consult was obtained and recommendations for scoping were
made. The scope showed: The first stoma was examined. We reached
50 cm and found no blood and normal ileal mucosa with bile.
The second the stoma was examined and initially normal ileal
mucosa was seen aprox 15 cm. Following 15 cm, colonic mucosa was
observed. Multiple polyps were seen.
Polyp in the 25 cm
Polyp in the 30 cm
Otherwise normal colonoscopy to anastomosis
Recommendations: Pt will need a repeat colonscopy once he is off
his coumadin
Monitor hct
Physical therapy was consulted and have recommended rehab stay
following his acute hospitalization.
The patient has continued to progrss well, tolerating a normal
diet and having O2 sats in the high 90's on room air. His HCt
has remained stable and he is discharged in stable condition to
rehab to followup with Dr. [**Last Name (STitle) **] and with Dr. [**First Name (STitle) 679**] of
gastroenterology. He will remain on lovenox until his INR is at
a therapeutic range of [**1-7**] at which point the lovenox will be
stopped and he will be continued on coumadin only for
anticoagulation.
Medications on Admission:
Plavix 75'
Flomax 0.4'
Cozaar 50'
Lipitor 10'
Lopressor 25"
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol [**Date Range **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Date Range **]: Two (2)
Puff Inhalation QID (4 times a day).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR [**Date Range **]: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
4. Atorvastatin 10 mg Tablet [**Date Range **]: One (1) Tablet PO at bedtime.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Date Range **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Acetaminophen 325 mg Tablet [**Date Range **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
7. Warfarin 2 mg Tablet [**Date Range **]: One (1) Tablet PO HS (at bedtime):
Adjust daily dose based on INR.
8. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: Two (2) Tablet PO TID
(3 times a day): hold for HR <60; SBP <110.
9. Losartan 50 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Date Range **]: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
11. Clopidogrel 75 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
12. Colace 100 mg Capsule [**Date Range **]: One (1) Capsule PO twice a day as
needed for constipation.
13. Milk of Magnesia 800 mg/5 mL Suspension [**Date Range **]: Ten (10) ML's
PO twice a day as needed for constipation.
14. Enoxaparin 100 mg/mL Syringe [**Date Range **]: Seventy (70) mg
Subcutaneous Q12H (every 12 hours): discontinue after
therapeutic INR ([**1-7**]) reached on warfarin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab [**Location (un) 3915**]
Discharge Diagnosis:
Pulmonary embolus
Discharge Condition:
Stable
Discharge Instructions:
Please call or return if you have a fever >101.5, severe pain,
inability to pass gas or stool, nausea/vomiting, chest pain,
shortness of breath, drainage from the wound, or any other
concerns.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks, call [**Telephone/Fax (1) 6439**] for an
appointment.
Please call for a followup with GI, Dr. [**First Name (STitle) 679**], ([**Telephone/Fax (1) 16940**] for
a repeat ileoscopy.
Completed by:[**2136-1-23**]
ICD9 Codes: 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3154
} | Medical Text: Admission Date: [**2165-1-6**] Discharge Date: [**2165-2-22**]
Date of Birth: [**2116-4-16**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Unresponsive, right hemiparesis
Major Surgical or Invasive Procedure:
Left Hemicraniectomy
Arterial line
central venous access
Chest tube
Intubation
Tracheostomy
PEG
History of Present Illness:
The patient is a 48 year old man with a history of atrial
fibrillation (not on anti-coagulation), hypertension, right
basal ganglia bleed in [**1-4**] now presenting as a transfer from
an OSH for unresponsiveness and right-sided weakness. The
history as per the wife (through translator) is that she woke up
at 6 am and was unable to wake up her husband. [**Name (NI) **] appeared to
be moving his the right side less as well (no facial droop
appreciated). His last known well state was at 12 am. She
activated EMS and he was taken to an OSH. There he was noted to
have eyes open but was not following commands. They performed a
head CT and discovered that he had hypodensities in the left-
MCA distribution with
surrounding parenchymal edema. He was transferred here for
further management including intensive care services. He
arrived in our ER at about 9:30 am.
Past Medical History:
-atrial fibrillation not on anti-coag
-IDDM
-HTN
-right basal ganglia bleed [**1-4**] that left him with some
residual
left sided weakness
Social History:
-lives with wife and daughter
-works as a cook
-current smoker (since teenage years)
-EtOH use
-Cantonese speaking
Family History:
-unknown at this time
Physical Exam:
Vitals: 98.8 178/90 78 (irreg) 98% room air
General: middle-aged man lying still on stretcher
Neck: supple
Lungs: Clear to auscultation
CV: Irregular rate and rhythm
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema
Neurologic Examination:
Patient with minimal response (eye opening to sternal rub);
non-verbal; not following commands; weak corneal reflex; weak
gag reflex; left eye deviation; no dolls eye response; withdraws
to pain on left arm and leg, no response on right; some
spontaneousmovement on left arm; absent reflexes on right; brisk
on left
Pertinent Results:
CT (head)[**2165-1-6**]:
1. Large left MCA infarct with loss of the [**Doctor Last Name 352**]/white matter
differentiation.
2. There is hyperdensity of the left MCA, suggesting acute
thrombosis of this vessel.
NCHCT ([**2165-2-7**] - most recent): Status post large left MCA stroke
and left craniectomy with interval decreased brain swelling, but
persistent herniation of the left hemisphere through the
craniectomy defect. Small hemorrhages are present within the
infarcted left cerebrum.
CBC: 9.2/42/391
Normal LFTs on [**2165-2-17**]
Usually needs K and Mg replacement.
Brief Hospital Course:
Pt was found to have a large left MCA infarction with swelling
and impending herniation. After discussion with the family, the
decision was made given the patient's young age of 48 to proceed
with craniectomy to avoid impendeding brain stem herniation. On
[**2165-1-6**] he had left frontal, parietal, temporal, occipital
craniectomy with duraplasty and placement of subgaleal drain.
He was admitted to the neuro-ICU for continued management. He
was transferred to the step-down unit on [**2165-1-24**].
The left MCA stroke was likely due to cardioembolic source (afib
not on coumadin). Pt was initially started mannitol, then taken
to OR for craniectomy. Initially, he was started on dilantin for
seizure ppx. This was later switched to depakote due to concern
for drug fever. Head CT remained stable. Started on aspirin
325.
He should be continued on depakote for seizure prophylaxis as he
will need to go to the OR eventually for skull replacement.
Check VPA level q week. ** He will need a repeat Noncontrast
head CT in [**4-5**] weeks with scan sent to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] for review
to determine when he should have his skull replaced. ** In the
meantime, he has a helmet to wear to protect his brain.
Exam upon discharge: awake, alert, looks at examiner when she
enters the room, nonverbal, does not follow commands or mimic,
tracks money to the right, will turn his head to the right but
has a left gaze preference. Left arm/leg is strong. Right face
droop. Right pareisis. Will move arm and leg proximally just a
little to noxious stimuli.
Pt has a hx of Afib. Rate is controlled with diltiazem,
metoprolol. He will occasionally go into rapid afib with HR
150's but most of the time he is asymptomatic.
HTN was controlled with dilt, betablocker, and captopril.
Respiratory wise, he was initially intubated in the ER for
airway protection. On [**1-7**], early am noted to have RUL PTX,
chest tube was placed. PTX resolved. He developed PNA during
his course with pseudomonas in sputum (pan-[**Last Name (un) 36**]). He was
treated for PNA. Trach was placed [**1-11**]. He has been stable
from a respiratory standpoint.
ID:
He was initially started on levoflox for presumed aspiration
pneumonia and cefazolin post craniectomy. On [**1-7**], sputum Cx was
positive for Klebsiella (pan [**Last Name (un) 36**]) and pseudomonas (pan [**Last Name (un) 36**]).
On [**1-10**] he was started empiric vancomycin for empiric coverage
of CSF vs line infection. On [**1-11**], ID was consulted. He was
started on Gent and Zosyn. Vanco was continued. On [**1-15**],
Flagyl was started for c.diff infection. Zosyn was changed to
Ceftaz on [**1-15**]. On [**1-28**], Gent and Cef d/c'd. WBC decreasing
and pt remains afebrile. Last set of cultures ([**2087-1-25**]) shows
pansensitive pseudomonas in sputum, blood and urine cx negative.
Finished a 14 day course of Flagyl for positive c.diff on [**1-30**].
He then became tachycardic, tachypnic, diaphoretic on [**2165-2-13**]
and was sent to the ICU as he met criteria for sepsis. He was
called out the next day and he was never hemodyamically
unstable. Found to have a pseudomonas UTI. He will complete a
10 day course of cipro for the pseudomonas on [**2165-2-22**].
Diabetes: Pt placed on NPH and RISS for coverage. Please
adjust NPH and insulin as needed per finger sticks QID.
GI/FEN: Pt had PEG placed. Continued on PPI and tube feeds.
PPX: pneumoboots, SC heparin, PPI
Medications on Admission:
-prazosin 1 [**Hospital1 **]
-lipitor 10 qd
-verapamil 180 [**Hospital1 **]
-toprol xl 50 qd
-NPH
-clonidine 0.3 [**Hospital1 **]
-protonix
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
units Injection TID (3 times a day): for DVT prophylaxis.
4. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
5. Valproate Sodium 250 mg/5 mL Syrup Sig: 500 mg PO Q6H (every
6 hours): Please check a level each week, goal 50-100. This is
for seizure prophylaxis.
6. Docusate Sodium 150 mg/15 mL Liquid Sig: [**2-3**] PO BID (2 times
a day).
7. Acetaminophen 160 mg/5 mL Elixir Sig: 325 - 650 mg PO Q4-6H
(every 4 to 6 hours) as needed.
8. Albuterol Sulfate 0.083 % Solution Sig: 1 neb IH Inhalation
Q6H (every 6 hours) as needed.
9. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): via peg tube.
10. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): via peg tube.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed): to reddened skin.
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush: swish and suction.
13. Insulin
NPH 45 units AM, 10 units PM
Regular insulin sliding scale with finger sticks QID.
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): to complete a 10 day course, started on
[**2165-2-13**], last day will be [**2165-2-22**].
15. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day): hold for SBP<110.
16. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day): hold for SBP<110, HR<55.
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for congestion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Left MCA stroke
Atrial fibrillation
DM
HTN
Discharge Condition:
Stable - awake, alert, nonverbal, does not follow commands, left
gaze preference, right hemiparesis.
Discharge Instructions:
Please keep follow up appointments. Please call your doctor or
return to the emergency room if you experience worsening or new
weakness, respiratory distress or other concerning symptoms.
Followup Instructions:
1. Follow up with neurosurgery (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**]) to have skull
replaced in approximately one month. ([**Telephone/Fax (1) 88**]. You will
need a repeat Noncontrast head CT to evaluate your readiness for
surgery in [**4-5**] weeks. **PLEASE HAVE THIS CT SENT TO Dr.
[**Last Name (STitle) 1132**].**
2. Please call your primary care doctor to arrange an
appointment after discharge from rehab. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
[**Telephone/Fax (1) 56439**]
3. Please call [**Telephone/Fax (1) 1694**] to arrange follow up in stroke
clinic after your discharge from rehab.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 5185, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3155
} | Medical Text: Admission Date: [**2145-9-7**] Discharge Date: [**2145-9-12**]
Date of Birth: [**2090-7-16**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Cipro
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Hypotension, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 47367**] is a 55 yo male s/p allogeneic stem cell transplant
for AML [**6-/2143**] with chronic GVHD on long-term steroids, DM, hx
of PE on coumadin.
.
He presents to his [**Hospital 3242**] clinic with fatigue for several days, and
anorexia, with about 12-16 hours of worsening shortness of
breath.
.
Endorses increased cough with yellow sputum production and
chills, but no fever. This morning, he reported an acute episode
of dyspnea that did not rapidly improved, and occured with
little amounts of activity and somewhat improved with rest. No
PND/orthopnea. No hemoptysis.
.
He has had no new rashes, and has not had documented fevers. He
has no diarrhea, but has been nauseated without vomiting. He
reports mild epigastric pain. He has a mild headache made
somewhat worse with light, but he feels that this is very
consistent with flares of GVH and not different (has occured he
estimates about 8 times).
.
In clinic SBP 70's, and he was given saline with improvement,
but then the BP decreased down to the 80's. Labs from clinic
showed that Cr increased to 2.9 (baseline 1.1). WBC increased
somewhat. He was transferred to the ED for further evaluation.
.
In the ED, initial vs were: 4 97.6 72 105/73 18 99% He was
given total of 3L of saline, and recent vital signs were 98.8
129/85 80 16 96% on 2L at time of transfer. A bedside "shock"
ultrasound US in ED showed no cardiac effusion, no evidence of
gross RV overload. EKG was not significantly changed. Her INR
was 3.0. Of note, he was also complaining of left sided
shoulder/neck pain associated with shortness of breath and
diaphoresis.
.
For interventions, he received 1 gm vanc and 1gm aztreonam, 40
mg medrol, and 2 L IVF in clinic, and another liter in the ED.
Past Medical History:
- AML-M7: s/p matched unrelated allogenic transplant on
[**2143-6-24**]
- Chronic extensive GVHD of skin and liver, liver biopsy [**4-23**]
consistent with GVHD, managed with cyclosporine, steroids,
periodic CellCept, and has received 1 cycle of Rituxan.
- Type 2 DM
- Hyperlipidemia
- H/o AVN bilateral hips
- HTN
- H/o nephrolithiasis, lithotripsy and previous nephrostomy tube
and emergent surgery to repair ureteral damage
- h/o left interpolar renal lesion, followed with MRs
- h/o BCC s/p excision
- h/o SCC left cheek, s/p Mohs' [**5-/2144**]
- h/o multiple back surgeries: Lumbar L5-S1 surgery x 3, and
cervical spine fusion (bone graft, no hardware)
- h/o anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**]
- Chronic numbness, neuropathic pain in left upper extremity.
- Multilevel compression fractures T11, T12, L1 and mild
compression L3 and L4.
- h/o pulmonary embolism [**11/2144**] on anticoagulated from
[**11/2144**]-present
- h/o RSV [**11/2144**] requiring ICU admission
- h/o OSA, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**]
Social History:
Lives with his wife, and one of children, worked as a [**Company 22957**]
technician until [**Month (only) 547**] when he took early retirement and he is
no longer working. Tob: previously smoked 1ppd for many years
but quit 2.5 years ago
EtOH: h/o social use; none recently
Family History:
Mother died suddenly in her 70s. Father died of unknown cancer
with tumors visible across body. One sister has thyroid cancer.
One brother has diabetes and kidney stones. One sister has
[**Name (NI) 5895**].
Physical Exam:
Tmax: 36.7 ??????C (98.1 ??????F)
Tcurrent: 36.7 ??????C (98.1 ??????F)
HR: 85 (85 - 85) bpm
BP: 101/66(75) {101/66(75) - 101/66(75)} mmHg
RR: 11 (11 - 11) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
.
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: mild RUQ->mid epigastrium tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema . No calf or thigh tenderness.
Skin: depigmentation on hands, redness of neck, but no notable
skin changes otherwise. No rashes.
Pertinent Results:
[**9-9**] CT chest without contrast
IMPRESSION:
1. Mostly resolved parenchymal opacities, leaving several
parenchymal bands which are felt most likely to represent
residua of a prior infectious or inflammatory process.
2. Subacute to chronic rib fractures, including along the right
posterior
seventh rib, where there is faint but suspicious sclerosis
extending further laterally than would usually be expected in
the setting of an uncomplicated rib fracture. In the setting of
prior treated hematological malignancy, the finding of vague
sclerosis raises concern for a bone marrow abnormality such as
myelofibrosis or potentially a form of disease recurrence.
Mostly, however, the bones appear within normal limits.
.
[**9-9**] PFT's
SPIROMETRY
Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 3.86 5.05 76 3.83 76 -1
FEV1 2.83 3.60 79 2.69 75 -5
FEV1/FVC 73 71 103 70 98 -4
.
[**9-8**] RUQ US
IMPRESSION:
1. Polyp at neck of gallbladder (1.2cm), which was also seen on
prior
ultrasound scan [**2145-2-9**]. This has not changed significantly
since prior
ultrasound scan, but followup imaging is advised.
.
[**9-8**] Echo
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. 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 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
borderline pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a fat pad.
.
Micro:
[**9-8**] CMV VL negative
[**9-8**] sputum: oropharyngeal flora
[**9-8**] urine cx negative
[**9-8**] viral screen and cx negative
[**9-7**] blood cx negative
.
ON ADMISSION:
[**2145-9-7**] 01:05PM BLOOD WBC-11.1* RBC-4.39* Hgb-16.0 Hct-49.0
MCV-112* MCH-36.5* MCHC-32.7 RDW-14.9 Plt Ct-264
[**2145-9-7**] 01:05PM BLOOD Neuts-85.1* Lymphs-7.0* Monos-5.2 Eos-2.5
Baso-0.3
[**2145-9-7**] 01:05PM BLOOD PT-30.5* INR(PT)-3.0*
[**2145-9-7**] 01:05PM BLOOD UreaN-28* Creat-2.9*# Na-140 K-4.4 Cl-101
HCO3-29 AnGap-14
[**2145-9-7**] 01:05PM BLOOD ALT-24 AST-20 LD(LDH)-201 CK(CPK)-37*
AlkPhos-155* TotBili-0.3
[**2145-9-7**] 01:05PM BLOOD cTropnT-0.05*
[**2145-9-7**] 01:05PM BLOOD Albumin-4.2 Calcium-9.3 Phos-2.6* Mg-2.4
[**2145-9-7**] 08:13PM BLOOD Lactate-1.9
.
ON DISCHARGE:
[**2145-9-12**] 05:40AM BLOOD WBC-7.2 RBC-3.45* Hgb-12.5* Hct-38.3*
MCV-111* MCH-36.2* MCHC-32.7 RDW-15.0 Plt Ct-211
[**2145-9-12**] 05:40AM BLOOD Neuts-68.8 Lymphs-17.2* Monos-7.9
Eos-5.7* Baso-0.4
[**2145-9-12**] 05:40AM BLOOD Plt Ct-211
[**2145-9-12**] 05:40AM BLOOD Glucose-80 UreaN-18 Creat-0.9 Na-143
K-3.7 Cl-104 HCO3-30 AnGap-13
[**2145-9-12**] 05:40AM BLOOD ALT-25 AST-18 LD(LDH)-181 AlkPhos-112
TotBili-0.2
[**2145-9-12**] 05:40AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.1 UricAcd-4.6
Brief Hospital Course:
55 y/o male with ?viral syndrome vs. other atypical infection
with hypotension that is suspected to be hypovolemia or adrenal
insufficiency, with acute renal failure.
.
# Lethargy: concern for viral syndrome, including activation of
CMV, or a respiratory virus. He has been known EBV+ in the past.
This could also be related to sensation of dyspnea that he has
been having, and warranted further cardiovascular and pulmonary
work-up in parallel with the infectious work-up. In the ICU,
continued broad spectrum antibiotics of vancomycin and aztreonam
(given allergy). Infectious workup largely negative including
CMV VL, respiratory panel, EBV VL, fungal markers, blood
cultures, urine cultures, CT chest. Pt's lethargy improved with
IVFs, antibiotics, and stress dose steroids. Did not ever need
pressors.
.
# Dyspnea/Cough: Concern for infectious process. Regarding VTE,
his risk should be reduced with therapeutic INR, though the
concern for coumadin failure merits consideration, though would
be unlikely and he has no other signs and symptoms of DVT. PFTs
completed [**9-9**], with official report pending at time of this
summary. CT chest showing resolving parenchymal processes,
resolving infectious/inflammatory process. Continued broad
spectrum antibiotics initially. When no infiltrate noted on CXR,
decreased ABX to 5 days of azithromycin for treatment of
bronchitis.
.
# Hypotension: A bedside "shock" ultrasound US in ED showed no
cardiac effusion, no evidence of gross RV overload. EKG
unchanged. Patient's hypotension was fluid/stress dose steroids
responsive. Initially given stress dose steroids with plans to
resume home dose. Also given IVF repletion. BPs normalized.
Likely etiology was slight adrenal insufficiency in setting of
viral syndrome despite negative infectious workup. Patient
discharged with prednisone 7.5 mg daily.
.
# Acute Renal Failure: Likely pre-renal azotemia. Improved with
IVFs. Cr 0.9 on discharge.
.
# Mild epigastric/RUQ tenderness: No laboratory e/o hepatitis.
RUQ US showing polyp at neck of gallbladder (1.2cm), which was
also seen on prior ultrasound scan [**2145-2-9**]. No other findings
to explain epigastric pain. This pain has resolved on discharge.
.
# Pulmonary Embolism [**11-23**]: continued coumadin with INR goal
[**1-19**].
# Diabetes: Continued NPH 12 units [**Hospital1 **], with close sugar
monitoring and diabetic diet.
Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a
day
BUDESONIDE [ENTOCORT EC] - (Dose adjustment - no new Rx) - 3 mg
Capsule, Sust. Release 24 hr - 1 (One) Capsule(s) by mouth twice
a day
FOLIC ACID - (Dose adjustment - no new Rx) - 1 mg Tablet - 1
(One) Tablet(s) by mouth once a day
HYDROMORPHONE - 2 mg Tablet - [**12-18**] Tablet(s) by mouth every [**3-22**]
hours as needed for pain
INSULIN LISPRO [HUMALOG] - SS
LISINOPRIL - (Dose adjustment - no new Rx) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
METOPROLOL TARTRATE - 25 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day
OXYCODONE - 20 mg Tablet Sustained Release 12 hr - 3 (Three)
Tablet(s) by mouth every morning (60 mg), 1 tablet every 2pm (20
mg) and 3 tablets every evening (60 mg)
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once day
PREDNISONE - 2.5 mg Tablet - 2 (Two) Tablet(s) by mouth once a
day
RISEDRONATE [ACTONEL] - 35 mg Tablet q Saturday
TESTOSTERONE [ANDROGEL] - 50 mg/5 gram (1 %) Gel in Packet -
Apply to upper torso once daily
WARFARIN [COUMADIN] - (Dose adjustment - no new Rx) - 2.5 mg
Tablet - 2 (Two) Tablet(s) by mouth once a day or as directed
CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] - (Dose adjustment - no
new Rx) - 400 unit Tablet - 1 Tablet(s) by mouth DAILY (Daily)
INSULIN NPH HUMAN RECOMB - (Prescribed by Other Provider) - 100
unit/mL Suspension - 12 units twice a day Please take first dose
in the morning and the second dose at bedtime
Discharge Medications:
1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
5. OxyContin 60 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day: QAM and QPM.
6. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO once a day: at 1400 every day.
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO twice a day.
9. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): For total 7.5 mg daily.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week: On
Saturdays.
13. AndroGel 1 %(50 mg/5 gram) Gel in Packet Sig: One (1) packet
Transdermal once a day: Apply to upper torso once daily as
directed.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) units Subcutaneous twice a day.
15. Insulin Lispro 100 unit/mL Solution Sig: Varied units
Subcutaneous four times a day: As per home sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Hypotension/adrenal insufficiency
Bronchitis
Acute renal failure
.
Secondary diagnosis:
AML s/p MUD allogeneic SCT [**6-/2143**]
Chronic GVHD of skin/liver
h/o PE
Diabetes mellitus
Discharge Condition:
Stable, afebrile, BP 113/76, RR 16, sats 96% on RA, INR 1.8.
Discharge Instructions:
You were admitted with fatigue, shortness of breath, cough, low
blood pressure and acute renal failure. We were concerned for
early sepsis and you were in the ICU initially. You received
broad spectrum antibiotics and stress dose steroids, but a full
workup (including viral swabs, cultures, ECHO, and CT chest)
were unrevealing. CT chest showed resolving infiltrates and your
symptoms improved so the antibiotics were switched to
azithromycin for presumed bronchitis. Your prednisone was
increased due to presumed mild adrenal insufficiency.
.
The following medication changes were made:
1) Prednisone increased to 7.5mg daily
2) Azithromycin (antibiotic) started, to be completed as
outpatient
3) Your lisinopril (blood pressure medication) and metoprolol
were discontinued. Do NOT resume these medications until
speaking to Dr. [**Last Name (STitle) **].
.
You need to have your INR checked on Tuesday, [**2145-9-14**]. You also
need to follow up with Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 3236**] within the
next week. Please call their office tomorrow to make this
appointment.
.
of the following symptoms: fever, chills, shortness of breath,
difficulty breathing, abdominal pain, cough, flu symptoms, or
any other worrisome symptoms.
Followup Instructions:
You need to have your INR checked on Tuesday, [**2145-9-14**].
.
Please call Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 72254**] office to make an
appointment to be seen later this week. They can be reached at
[**Telephone/Fax (1) 3241**].
Completed by:[**2145-9-17**]
ICD9 Codes: 0389, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3156
} | Medical Text: Admission Date: [**2183-12-15**] Discharge Date: [**2183-12-22**]
Date of Birth: [**2116-4-4**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Soma / Fentanyl
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Low back and more bothersome buttock and radiating
right leg pain found to be related to retrolisthesis at L3-
L4, lumbar spinal stenosis, adjacent segment disease. He
underwent a prolonged and multimodal course of conservative
care including injections, physical therapy, medications, and
activity modifications. His syndrome was refractory this. Due
to the refractory nature of his syndrome, as well as the
severity of the symptoms, which did limit his ability to
walk, he elected to undergo surgical treatment.
Major Surgical or Invasive Procedure:
1. Anterior interbody fusion with correction of spinal
deformity L3-L4.
2. Interbody reconstruction with biomechanical device L3-L4
by direct lateral approach.
3. Removal of hardware L4, L5, S1.
4. Inspection of posterolateral fusion.
5. Bilateral L2 laminotomy.
6. Revision laminotomy, bilateral, L3, L4, L5.
7. Laminectomy S1.
8. Posterolateral fusion L3-L4.
9. Posterolateral instrumentation L3-L4.
10.Application of local autograft for fusion augmentation.
11.Application of allograft for fusion augmentation.
History of Present Illness:
back and more bothersome buttock and radiating
right leg pain found to be related to retrolisthesis at L3-
L4, lumbar spinal stenosis, adjacent segment disease. He
underwent a prolonged and multimodal course of conservative
care including injections, physical therapy, medications, and
activity modifications. His syndrome was refractory this. Due
to the refractory nature of his syndrome, as well as the
severity of the symptoms, which did limit his ability to
walk, he elected to undergo surgical treatment.weakness in his
right leg. He has had right knee
buckling on several occasions, particularly with prolonged
walking over two minutes
Past Medical History:
Significant for interstitial lung disease,
spine surgeries [**2172**], [**2174**], [**2176**] as described above.
Hypertension, bilateral total knee replacement, gallbladder
surgery in [**2146**], knee replacement in [**2153**], lung biopsy [**2179**].
Physical Exam:
[**2-23**] right iliopsoas and quadriceps.
Rest of BLE - hip abductors, left quad and iliopsoas [**3-24**]
SILT
Reflexes 2 + in knees and ankles.
Plantars downgoing.
Pertinent Results:
[**2183-12-15**] 08:49PM TYPE-ART PO2-452* PCO2-43 PH-7.28* TOTAL
CO2-21 BASE XS--6
[**2183-12-15**] 08:44PM GLUCOSE-129* UREA N-21* CREAT-1.0 SODIUM-139
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-20* ANION GAP-13
[**2183-12-15**] 08:44PM CALCIUM-7.9* PHOSPHATE-4.0 MAGNESIUM-2.0
[**2183-12-15**] 08:44PM WBC-6.6 RBC-4.67 HGB-13.9* HCT-40.0 MCV-86
MCH-29.8 MCHC-34.8 RDW-14.3
[**2183-12-15**] 08:44PM PLT COUNT-227
[**2183-12-15**] 08:44PM WBC-6.6 RBC-4.67 HGB-13.9* HCT-40.0 MCV-86
MCH-29.8 MCHC-34.8 RDW-14.3
[**2183-12-15**] 08:44PM PT-12.7 PTT-29.0 INR(PT)-1.1
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2. Physical
therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet
Medications on Admission:
Current medications include Tramadol 50 2 tabs twice a day,
Darvocet-N 100 2 tablets q.4 hours, nabumetone 500 mg 1-1/2
tablets twice a dayisosorbide mononitrate, nitroglycerin,
verapamil, aspirin 81, L-thyroxine, Senna, Advil p.r.n., Lyrica
Discharge Medications:
1. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (TU,TH,SA).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Nabumetone 750 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB/Wheezing.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Actimmune 2,000,000 unit/0.5 mL Solution Sig: One (1) ML
Subcutaneous Monday, Wednesday and Friday HS ().
9. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 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. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
16. Cefepime 2 gram Recon Soln Sig: One (1) Intravenous every
twelve (12) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
.1. Adjacent segment degeneration, adjacent segment disease
L3-L4.
2. Spondylolisthesis L3-L4.
3. Spinal stenosis L3-L4, L4-L5, L5-S1.
4. Prior lumbosacral fusion L4-S1.
5. Healed posterolateral fusion L4-S1.
Discharge Condition:
Stable,
Patient alert orientd and tolerating oral diet.
Discharge Instructions:
You have undergone the following operation: Lumbar anterior and
posterior fusion with instrumentation.
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You may have been given a brace. This brace is to be
worn when you are walking. You may take it off when sitting in a
chair or while lying in bed.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
o We will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Ambulation with assitance,
Gait training.
Stair climbing.
Treatments Frequency:
Physical therapy every day to make the patient self ambulatory.
Steri strips to fall off on their own.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2183-12-31**] 2:15
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2183-12-31**] 1:55
Completed by:[**2183-12-22**]
ICD9 Codes: 486, 2930, 2749, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3157
} | Medical Text: Admission Date: [**2196-7-10**] Discharge Date: [**2196-7-13**]
Service: MEDICINE
Allergies:
Namenda
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Syncope/Bradycardia
Major Surgical or Invasive Procedure:
Permanent Pacemaker
History of Present Illness:
Ms. [**Known lastname 14495**] is an 89 y/oF with hyperlipidemia and mild memory
impairment/early alzheimer's being transferred from [**Hospital1 **]
with bradycardia/pauses leading to syncope.
.
Her daughter relates her relevant story today. She was out with
her family doing normal daily activities including walking
around, having lunch. Then at 130pm her she was buckled into the
back seat of the car and her daughter reports she not response,
head rolled against the window, eyes rolled back, for about
15-20 seconds. Did not hit her head (she was sitting in the back
seat, buckled in), no falls. Daughter denies [**Name2 (NI) **]/clonic
movement suggestive of sz activity. She denies dehydration or
decreased PO intake ("she eats like a horse"). When she awoke,
she was "white as a ghost" and "didn't feel well" but doesn't
sound like she was post-ictal. She didn't remember any events of
the day which apparently is unusual for her (h/o dementia
though).
.
She was taken to [**Hospital1 18**]-[**Location (un) 620**] where she was 96.9 145/60 18
100% WBC 7.0 (N51, L 37, M8), Hct 38.4, Plts 163. Chem fairly
unremarkable including renal fxn 22/0.9, BS 112. CK 166/MB
3.8/MBI 2.3/Trop <0.01. UA with small LE and [**3-25**] WBC's. CXR was
clear. She was originally going to be admitted for 24hr
telemetry with concern for dysrhythmia. EKG per report NSR @
65bpm without ST changes. She apparently became agitated and
wanted to leave, and received Haldol at 1930pm.
.
Per OSH records "At 1:46am pt had 36 seconds of no heart beat
(asystole), but easily woken up. At 3:09 heart stopped for 20
seconds, was unresponsive and received 1mg Atropine, when awake,
has no c/o any discomfort. Stat Trop at 2am is 0.01, CK 125, EKG
no changes, gait unsteady." Transfer to [**Hospital1 18**] for further
management.
.
Her ROS is as above, including some memory deficits, but
otherwise she appears very functional, gait is steady, able to
do her ADL's. No other focal symptoms in any other major
systems, including cardiac review of systems.
Past Medical History:
1. ? TIA per report, vs total global amnesia in [**2177**], lasted few
days, nl EEG
2. Dementia
3. Hyperlipidemia
4. Osteoporosis
5. Vitamin D deficiency
6. Reactive depression [**2186**] after loss of husband
7. S/p cataract extraction [**2188**]
8. Nail avulsion/paronychia
Social History:
The patient denies tobacco, alcohol, or drug
use. She lives in [**Hospital3 **] and has a family nearby with
support and has a daughter who presents with her today.
Widowed two children, three grandchildren, six
great-grandchildren. Does not smoke. Walks daily
Family History:
No family history of sudden cardiac death
Physical Exam:
97.6 110/60 p69 19 100% NC
Thin elderly frail female in no distress, pleasant but unable to
report history. Conversational.
PERRLA, EOMI. Mouth dry appearing.
No carotid bruits. JVD not elevated. Carotid pulsations normal.
Marked kyphosis, CTAB no w/c/r/r, some decreased BS's at the
bases
RRR, heart sounds soft, no murmurs appreciated. PMI not
palpable. Bilateral radial and DP's are easily palpable.
Abd soft, NT ND, Hyperactive BS's.
No BLE edema noted
AO to person only. CN 2-12 intact, no facial droop, no
dysarthria. Spontaneously moving all four extremities with good
[**6-22**] age appropriate strength no focal neuro deficits noted.
Sensation intact through bod. Cerebellar exam intact. Reflexes
hyporeflexic in UE's and not able to comply with exam in lower
extrems.
Pertinent Results:
[**2196-7-10**] CXR
FINDINGS: There are no old films available for comparison. No
rib fractures are identified and there is no pneumothorax. The
cardiac silhouette is normal. The aorta is mildly tortuous.
There is no focal infiltrate or effusion.
CBC
[**2196-7-13**] 05:02AM BLOOD WBC-8.1 RBC-4.76 Hgb-13.2 Hct-40.3 MCV-85
MCH-27.7 MCHC-32.7 RDW-13.3 Plt Ct-151
[**2196-7-12**] 04:30AM BLOOD WBC-7.1 RBC-4.93 Hgb-13.8 Hct-42.1 MCV-85
MCH-28.1 MCHC-32.9 RDW-13.6 Plt Ct-164
[**2196-7-10**] 05:24AM BLOOD WBC-7.3 RBC-4.70 Hgb-13.0 Hct-40.3 MCV-86
MCH-27.6 MCHC-32.2 RDW-13.2 Plt Ct-164
Chemistry
[**2196-7-13**] 05:02AM BLOOD Glucose-94 UreaN-28* Creat-1.0 Na-142
K-4.2 Cl-109* HCO3-22 AnGap-15
[**2196-7-12**] 04:30AM BLOOD Glucose-95 UreaN-19 Creat-0.9 Na-142
K-3.8 Cl-110* HCO3-20* AnGap-16
[**2196-7-11**] 04:18AM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-144
K-3.8 Cl-110* HCO3-24 AnGap-14
[**2196-7-10**] 05:24AM BLOOD Glucose-110* UreaN-24* Creat-0.9 Na-142
K-4.4 Cl-109* HCO3-26 AnGap-11
[**2196-7-13**] 05:02AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1
[**2196-7-12**] 04:30AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
[**2196-7-11**] 04:18AM BLOOD Albumin-4.4 Calcium-9.3 Phos-2.7 Mg-2.2
Cholest-189
[**2196-7-10**] 05:24AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.2
HbA1c
[**2196-7-11**] 08:14AM BLOOD %HbA1c-5.7 eAG-117
Lipid Panel
[**2196-7-11**] 04:18AM BLOOD Triglyc-89 HDL-95 CHOL/HD-2.0 LDLcalc-76
TFT
[**2196-7-10**] 05:24AM BLOOD TSH-5.1*
[**2196-7-10**] 05:24AM BLOOD T4-6.0
Brief Hospital Course:
Patient is an 89 yo F with h/o dementia, hyperlipidemia who is
transferred from [**Hospital1 18**]-[**Location (un) 620**] for further evaluation of syncope
and found to have sinus pauses of over thirty seconds;
transferred to [**Hospital1 18**] for further evaluation.
.
#SINUS NODAL DISEASE: Patient was transferred to the CCU from
[**Location (un) 620**] for further monitoring. Besides hyperlipidemia there
was no other clear explanation for sinus exit block that she
exhibited as there was no evidence of ischemia, medications,
hypothyroidism. The syncopal episodes were likely due to the
sinus node dysfunction.
She was evaluated by the electrophysiology service and underwent
placement of a permanent pacemaker on [**2196-7-11**]. She will follow
up closely in device clinic for further management of pacemaker
.
#DELIRIUM: The pt was noted to be agitated and delirious on
admission. Following pacemaker placement, she was very
agitated. Patient has baseline dementia, however family noted
that this was not her norm. She did poorly with conservative
anti-delirium measures. Was very difficult to redirect her even
with the assistance from family. In order to protect the newly
placed pacemaker, patient had to be placed in soft restraints.
Patient continued to fight against the restraints and move her
left arm, and so small doses of IV haldol was utilized. A total
of 3 mg of IV haldol was administered, following which she fell
asleep. The morning following, she was back to her baseline.
.
#DEMENTIA: patient was continued on home regimen of aricept
.
#HYPERLIPIDEMIA: patient was continued on home regimen of
simvastatin
.
#HISTORY OF TIA: patient was continued on home regimen of
aspirin 81 mg
Medications on Admission:
1. Aricept 5mg daily
2. Simvastatin 40 mg daily
3. ASA 81 daily
4. Calcium carbonate Vitamin D
Discharge Medications:
1. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet
PO once a day.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aricept 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours for 2 days.
Disp:*2 Capsule(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
Disp:*180 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**] & Hospice
Discharge Diagnosis:
Primary Diagnosis:
- Sinus arrest, now s/p pacemaker
Secondary Diagnosis:
- Dementia
- Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because of you had a pause in
your heart rhythm. You had a pacemaker placed to help in
controlling your heart rhythm. During this hospitalization, you
were cared for in the cardiac intensive care unit. You will
need to follow up with your primary care doctor and the device
clinic as an outpatient.
You medications have changed. Please make note of the following
changes:
1. Start taking cephalexin 500 mg, every 8 hours, for one day
2. Start taking tylenol 650 mg, every 8 hours, as needed for
pain
The rest of your medications have not changed. Please continue
to take them as originally prescribed.
Followup Instructions:
Please be sure to follow up at the DEVICE CLINIC for follow up
on your new pacemaker on [**2196-7-20**] at 3:00 PM. The office number
is [**Telephone/Fax (1) 62**]. The office is located on the [**Location (un) 436**] of the
[**Hospital Ward Name 23**] Clinical Center ([**Location (un) 830**], [**Location (un) 86**], [**Numeric Identifier 718**])
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4390**],
within 3-4 weeks after discharge from the hospital. The office
number is [**Telephone/Fax (1) 3070**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3158
} | Medical Text: Admission Date: [**2146-8-14**] Discharge Date: [**2146-8-17**]
Date of Birth: [**2064-12-9**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
percutaneous nephrostomy tube placement, [**2146-8-13**]
History of Present Illness:
81 yo male with presumed COPD and recently diagnosed metastatic
bladder CA with known left hydronephrosis presents from OSH ED
after complaining of abd pain. The pt reports that he was in his
usual state of health until mid-day on the day PTA. At that
point, he noted the onset of RLQ abd pain that was non-radiating
and intermittently sharp and dull. He presented to the ED at
[**Hospital1 **]-[**Location (un) 620**] where he was afebrile but noted to appear unwell and
have an SBP in the 90s with associcated sinus tachycardia. A CT
scan there demonstrated left hydronephrosis and a question of
gallbladder distention.
In the [**Hospital1 18**] ED, initial vitals were 97.2, 103, 24, 98/68 and
90% RA. An abd ultrasound was obtained in the ED. This study did
not show gall bladder abdnormalities but did demonstrate
extensive hepatic mets. He was given emperic doses of Zosyn and
vancomycin as well as 5L NS. A urology consultation was obtained
given the pt's hydronephrosis and a positive UA. There was a
concern for left sided upper urinary tract infection and urgent
percutaneous nephrostomy tube placement was advised; this was
performed by IR immediately after the pt's arrival to the MICU.
A VQ scan was also obtained given the pt's tachycardia and
relative hypoxia; the results of this study are pending.
ROS was otherwise essentially negative. The pt endorsed
intermittent hemature but denied recent unintended weight loss,
fevers, night sweats, chills, headaches, dizziness or vertigo.
No changes in hearing or vision, neck stiffness,
lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia,
odynophagia, heartburn, nausea, vomiting, diarrhea,
constipation, steatorrhea, melena, hematochezia, cough,
hemoptysis, wheezing, shortness of breath, chest pain,
palpitations, dyspnea on exertion, increasing lower extremity
swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while
walking, joint pain.
Past Medical History:
multiple papillary bladder tumors
--first dx in [**4-18**]
--s/p BCG therapy
--concern for mets to mid left femur, known extensive liver mets
renal stones many years ago
s/p left inguinal hernia repair
lung nodule concerning for possible malignancy noted on CT scan
Social History:
Retired clerical worker. Smoked multiple PPD from age 14 to 61.
Denies EtOH.
Family History:
No FH of malignancy or other heritable disease. Both parents
lived to advanced age.
Physical Exam:
General: Awake and alert though mildly sleepy. NAD, pleasant,
appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP.
Neck: Supple, no significant JVD or carotid bruits appreciated.
Pulmonary: Few crackles at bases bilaterally, no wheezes or
rhochi.
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: Soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: Trace edema, 2+ radial and DP pulses b/l
Skin: No rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor. 2+ biceps, triceps, brachioradialis, patellar
reflexes and 2+ ankle jerks bilaterally. Plantar response was
flexor bilaterally.
Pertinent Results:
[**2146-8-14**] 01:05AM WBC-16.3* RBC-4.49* HGB-14.2 HCT-41.5 MCV-92
MCH-31.6 MCHC-34.2 RDW-14.0
[**2146-8-14**] 01:05AM NEUTS-91.8* LYMPHS-4.4* MONOS-3.3 EOS-0.3
BASOS-0.1
[**2146-8-14**] 01:05AM GLUCOSE-100 UREA N-68* CREAT-2.4* SODIUM-140
POTASSIUM-5.6* CHLORIDE-103 TOTAL CO2-18* ANION GAP-25*
.
CXR:
The cardiomediastinal contour is normal. The heart is not
enlarged. There is linear platelike atelectasis at the left lung
base. The lungs are otherwise clear. Osseous structures are
unremarkable.
IMPRESSION: No evidence of focal consolidation on this single
view.
.
Abd US
1. Innumerable hepatic metastases from bladder cancer.
2. Cholelithiasis without evidence of cholecystitis.
3. No evidence of intrahepatic biliary ductal dilatation; normal
size of CBD.
Brief Hospital Course:
81 yo male presenting with bladder cancer, found to have abd
pain, tachycardia and borderline blood pressure, s/p perc
nephrostomy tube drainage of left hydronephrosis, became
persistently hypotensive and subjectively dyspneic with a
refractory metabolic acidosis. It was decided to place the
patient via care measures and he was placed on a morphine drip
-- the patient subsequently expired.
#UTI: Treating with Cipro. Await culture results. WBC slightly
decreased. Does not meet SIRS criteria. Pt was agressively
volume repleted.
.
#ARF: Pt's baseline somewhat unclear, however SCr was 1.7 at OSH
approximately one week ago, further elevated on admission, still
further increasing today. Some baseline renal dysfunction
expected given pt's obstruction; suspect that acuity of further
obstruction resulting in additional failure. Pt s/p perc
drainage placement and volume repletion. Developed a refractory
metabolic acidosis with resultant tachypnea.
.
#SOB/question COPD: Pt with extensive smoking history and a
question of COPD based on prior imaging. No has crackles on exam
after 5L volume resuscitation in MICU. Patient became
subjectively dyspneic and tachypneic during exams which was
summarily relieved by morphine after CMO status.
.
#Abnormal LFTs/coagulopathy: Likely secondary to extensive
hepatic mets.
.
#Abd pain: Has resolved. Likely secondary to worsening
hydronephrosis/UTI, although numerous other etiologies were
certainly possible.
Medications on Admission:
oxycontin PRN
colace
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2146-8-21**]
ICD9 Codes: 0389, 5845, 5990, 3051, 496, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3159
} | Medical Text: Admission Date: [**2167-10-28**] Discharge Date: [**2167-11-5**]
Date of Birth: [**2096-5-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / Tricor
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2167-10-30**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
Diag, SVG to OM, SVG to LPDA), Right Carotid Endarterectomy
[**2167-10-28**] Cardiac Cath
History of Present Illness:
Mr. [**Known lastname 1458**] is a 71 y/o male transferred from [**Hospital3 **] after
+ETT (had chest pain with EKG changes). Underwent cardiac cath
which revealed severe three vessel disease.
Past Medical History:
Carotid Stenosis s/p Left Carotid Endarterectomy,
Hyperlipidemia, Hypertension, Peripheral Vascular Disease,
Peptic Ulcer Disease with GI bleed 12 yrs ago, Borderline
Diabetes Mellitus, s/p Left Carotid Endarterectomy, s/p
Hemorrhoidectomy
Social History:
Quit smoking less than 1 yr ago. Smoked x 30-40 years. Denies
ETOH use.
Family History:
Mother with MI at age 68.
Physical Exam:
At Discharge:
VS:T98 BP150/80 P69 RR20 I&O925/700+ Wt88.5kg 96% 2LNC
Gen:NAD
Chest:lungs CTA bilaterally
Heart:RRR, no M/C/R
Abd: S, NT, ND
Ext:1+ edema, well perfused
Incision: C/D/I, sternum stable
Pertinent Results:
[**2167-10-30**] Echo: PRE CPB The left atrium is moderately dilated. The
left atrium is elongated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. 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 ascending aorta. There are
simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are mildly to
moderately 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 a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **]
was notified in person of the results in the operating room at
the time of the study. POST CPB Normal biventricular systolic
function. Thoracic aorta appears intact. No significant change
from the pre bypass study.
[**2167-10-29**] Carotid U/S: 70-79% stenosis of the bilateral internal
carotid arteries.
[**2167-11-5**] 05:55AM BLOOD WBC-12.0* RBC-3.30* Hgb-10.0* Hct-28.6*
MCV-87 MCH-30.4 MCHC-35.0 RDW-13.8 Plt Ct-149*
[**2167-11-5**] 05:55AM BLOOD Plt Ct-149* LPlt-3+
[**2167-11-5**] 05:55AM BLOOD Glucose-89 UreaN-26* Creat-1.1 Na-137
K-4.2 Cl-98 HCO3-30 AnGap-13
[**2167-11-5**] 05:55AM BLOOD WBC-12.0* RBC-3.30* Hgb-10.0* Hct-28.6*
MCV-87 MCH-30.4 MCHC-35.0 RDW-13.8 Plt Ct-149*
[**2167-10-28**] 04:30PM BLOOD WBC-8.1 RBC-3.94* Hgb-12.5* Hct-33.8*
MCV-86 MCH-31.7 MCHC-37.0* RDW-12.8 Plt Ct-109*
[**2167-11-5**] 05:55AM BLOOD PT-14.5* INR(PT)-1.3*
[**2167-10-28**] 04:30PM BLOOD PT-13.7* PTT-29.4 INR(PT)-1.2*
[**2167-11-5**] 05:55AM BLOOD Glucose-89 UreaN-26* Creat-1.1 Na-137
K-4.2 Cl-98 HCO3-30 AnGap-13
[**2167-10-28**] 04:30PM BLOOD Glucose-120* UreaN-18 Creat-0.9 Na-139
K-3.5 Cl-102 HCO3-29 AnGap-12
[**2167-11-3**] 04:35AM BLOOD Mg-2.4
[**2167-10-29**] 06:45AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.3 Cholest-129
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 1458**] was transferred from OSH after
+ETT. Underwent Cardiac Cath on [**10-28**] which revealed severe three
vessel coronary artery disease. Patient underwent pre-operative
work-up which included echo and carotid u/s. On [**10-30**] he was
brought to the operating room where he underwent a coronary
artery bypass graft x 4 and left carotid endarterectomy. 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. Chest tubes were removed on
post-op day one. Beta blockers and diuretics were initiated and
he was gently diuresed towards his pre-op weight. On post-op day
two he was transferred to the telemetry floor for further care.
HIT panel was drawn as platelets trended down post-operatively
and found to be negative. He was also anemic with a HCT at 23.2
on post-op day three, but patient refused transfusion. His HCT
rose on its own. He was placed on amiodarone for atrial
fibrillation and converted. He remained in normal sinus rhythm
for greater than 24 hours so coumadin was discontinued. By
post-operative day 6 he was ready for discharge.
Medications on Admission:
Home: Crestor 40mg qd, Gemfibrozil, Atenolol 50mg qd
At Transfer: Aspirin 325mg qd, Lopressor 12.5mg [**Hospital1 **], Nitro gtt,
Norvasc 5mg qd, Imdur 30mg qd, Omeprazole 20mg qd, Crestor 40mg
qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*qs ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Lifecare Center of [**Location **]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Carotid Stenosis s/p Right Carotid Endarterectomy
PMH: Hyperlipidemia, Hypertension, Peripheral Vascular Disease,
Peptic Ulcer Disease with GI bleed 12 yrs ago, Borderline
Diabetes Mellitus, s/p Left Carotid Endarterectomy, s/p
Hemorrhoidectomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 11763**]
Dr. [**Last Name (STitle) **] (vascular) in 4 weeks.([**Telephone/Fax (1) 8343**]
Dr. [**Last Name (STitle) 10165**] [**Name (STitle) 31187**] in [**1-25**] weeks ([**Telephone/Fax (1) 40026**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] in [**12-24**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2167-11-5**]
ICD9 Codes: 4111, 2762, 4439, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3160
} | Medical Text: Admission Date: [**2165-8-9**] Discharge Date: [**2165-9-3**]
Date of Birth: [**2095-10-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cipro Cystitis / Aspirin / Nsaids / Dicloxacillin
/ Aldomet / Motrin / Lisinopril / Vioxx
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
hallucinations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC:[**CC Contact Info 102866**]
HPI: (per patient, who is a poor historian given her altered
mental status) Pt is a 69 yo F with PMH schizoaffective
disorder, DM2, CAD, dCHF, HTN, restrictive lung disease, discoid
lupus, and vascular dementia who presented to [**Hospital1 18**] from her
[**Hospital3 **] facility for altered mental status and
hallucinations of 3 day duration. Pt states the hallucinations
began around the same time that developed sores in her mouth
that made it painful/hard for her to eat. Visual hallucinations
consist of animals and people. The animals are "sometimes
scary." Also admits to auditory hallucinations in which she
hears voices. She cannot recall the specific things the voices
tell her, but says they are sometimes bad and sometimes good.
She knows the hallucinations are not real. She denies suicidal
or homicidal ideation. She also c/o fatigue and weakness for
past three days, and reports insomnia and racing thoughts over
that time as well. She c/o pain in her left leg and has a
history of falls, but denies recent fall (confirmed by [**Hospital 4382**] facility).
ROS per HPI plus:
(+) headache "like my head is going to bust open," feeling cold,
shortness of breath, cough productive of yellow sputum,
rhinorrhea, urinary incontinence (at baseline), abdominal pain,
constipation, left shoulder pain, and left knee pain.
(-) She denies chest pain, nausea, vomiting, dysuria.
In ED VS were T 98.6 F, HR 110, BP 148/100, RR 20, O2 sat 98% on
room air.
ED course: Chest x-ray, and head CT without contrast were
obtained. No neurologic symptoms were noted. UA was negative.
Lactate and CPK were found to be elevated. Final ED Diagnosis:
Hallucinations
Past Medical History:
#. DM2 - oral meds.
#. CAD s/p MI '[**46**]
- does not tolerate aspirin or ACE -> on Plavix
#. diastolic CHF, EF > 55% 7/08
#. HTN
#. Restrictive lung disease - not on home O2. FEV/FVC 108%, FVC
45%, FEV1 48% 6/07.
#. h/o R LE DVT, many years ago per pt
#. discoid lupus erythematosus
#. h/o CVA - MRI in [**2156**] w/ moderate microvascular changes in
the cerebral white matter
#. h/o of SVT
#. schizo-affective disorder
#. dementia
#. GERD c/b short segment [**Last Name (un) 865**] and hiatal hernia
#. h/o cellulitis
#. h/o seizures, per pt many years ago, not on medications
#. s/p total abdominal hysterectomy
#. small bowel obstruction s/p ex lap w/ lysis of adhesions and
partial small bowel resection ([**2162-7-30**])
#. OSA, does not use CPAP
#. OA
#. osteopenia
Social History:
Resides in [**Last Name (un) 4367**] [**Hospital3 400**] Facility where she has meals
prepared. She dresses and bathes herself. She is able to see her
family members frequently. She smoked 2ppd for 20 yrs, but quit
in [**2162-6-29**]. Denies current alcohol. She uses a walker for
ambulation.
Family History:
Father: Died of MI at less than 50 years of age.
Mother: History of breast CA.
Physical Exam:
ADMISSION EXAM:
Physical Exam:
VS: 99.4 F, BP 155/98, HR 106, RR 18, 96% on 2L
GA: AOx3, NAD
HEENT: head normocephalic, atraumatic. moist mucous membranes.
EOM intact. visual field exam limited by pt's limited attention.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: crackles heard at lung bases bilaterally, diminished lung
sounds.
Abd: soft, obese, NT, +BS. no g/rt. HSM difficult to assess due
to body habitus. neg [**Doctor Last Name 515**] sign.
Extremities: no edema. DPs, PTs 2+.
Skin: hyperpigmented macule present on forehead, hypopigmented
patch of skin on left shin, erythema on left foot, midfoot,
medial maleolus, 1st MTP joint.
Neuro/Psych: CNs III-XII intact. visual acuity not assessed. [**5-2**]
strength in U/L extremities, however, pt. is slow to lift her
left arm, and strength testing is also limited by pain in knees.
DTRs 2+ BL (biceps, brachioradialis). sensation intact to LT.
cerebellar fxn (FTN, HTS) and gait not assessed.
MSE findings: flat affect. tangential thought process and
content, with perseveration on the topic of her marriage at the
age of 17. poor attention (cannot state days of the week in
reverse order; gets only from Sat. to Wed.)
.
Discharge PE:
Physical Exam:
VS: 98.6 130/72 87 22 98 on RA
GEN: AAO x2 (not oriented to date), pleasant and conversational,
NAD, breating comfortably
CVS: RRR, no m/r/g, normal S1, S2
PULM: lungs clear to auscultation b/l
ABD: soft, obese, NT, ND, +BS
EXT: slight LE edema b/l. No TTP, 2+ DP pulses
neuro: AAOx2, CN 2-12 grossly intact, [**5-2**] UE/LE strength
Pertinent Results:
[**2165-8-9**] 12:21PM BLOOD WBC-12.8* RBC-5.07 Hgb-13.3 Hct-41.5
MCV-82 MCH-26.3* MCHC-32.1 RDW-16.7* Plt Ct-350
[**2165-8-9**] 12:21PM BLOOD Neuts-74.1* Lymphs-19.9 Monos-3.1 Eos-1.8
Baso-1.0
[**2165-8-9**] 12:21PM BLOOD PT-12.8 PTT-26.0 INR(PT)-1.1
[**2165-8-10**] 07:30AM BLOOD ESR-52*
[**2165-8-11**] 07:35AM BLOOD ACA IgG-2.2 ACA IgM-3.2
[**2165-8-11**] 07:35AM BLOOD Lupus-NEG
[**2165-8-9**] 12:21PM BLOOD Glucose-373* UreaN-28* Creat-1.3* Na-133
K-4.7 Cl-95* HCO3-25 AnGap-18
[**2165-8-9**] 12:21PM BLOOD ALT-31 AST-46* AlkPhos-119* TotBili-0.6
[**2165-8-9**] 04:50PM BLOOD proBNP-248
[**2165-8-10**] 07:30AM BLOOD CK-MB-3 cTropnT-<0.01
[**2165-8-9**] 12:21PM BLOOD Calcium-10.2 Phos-4.7*# Mg-2.0
[**2165-8-12**] 11:40AM BLOOD TotProt-7.1 Albumin-3.7 Globuln-3.4
[**2165-8-11**] 07:35AM BLOOD %HbA1c-9.7* eAG-232*
[**2165-8-13**] 09:05AM BLOOD VitB12-621 Folate-13.9
[**2165-8-11**] 07:35AM BLOOD TSH-2.6
[**2165-8-19**] 08:00AM BLOOD Ammonia-18
[**2165-8-10**] 07:30AM BLOOD CRP-119.2*
[**2165-8-10**] 07:30AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2165-8-11**] 07:35AM BLOOD b2micro-3.4*
[**2165-8-12**] 11:40AM BLOOD PEP-NO SPECIFI
[**2165-8-9**] 12:29PM BLOOD Lactate-2.7*
[**2165-8-20**] 03:28PM BLOOD freeCa-1.23
Images:
[**2165-8-9**] CXR: Mild interstitial edema and cardiomegaly.
[**2165-8-9**] CT HEAD: No acute intracranial process.
[**2165-8-10**] LLE DOPPLER:No left lower extremity deep vein
thrombosis.
[**2165-8-12**] CALF MRI:1. No signs of muscle edema or myonecrosis in
the left calf.2. Subcutaneous soft tissue edema of the left calf
may reflect third spacing of fluid and edematous changes or
cellulitis in the proper clinical setting. 3. Probable small
bone infarcts involving the posterolateral distal tibia and
lateral aspect of the talus correlated with [**2165-8-9**] left
ankle radiographs 4. Mild thickening of the Achilles tendon at
attachment site with associated enthesopathy at the posterior
calcaneus.
[**2165-8-15**] CTA CHEST: No evidence of PE. Moderate cardiomegaly with
moderate coronary calcifications. Small hiatal hernia. No
evidence of aortic pathology.
[**2165-8-16**] MRI HEAD NON CON:1. No evidence of acute infarct,
intracranial hemorrhage, or mass lesion. 2. Changes of chronic
small vessel ischemic disease. 3. Generalized cerebral atrophy.
4. Focus of old hemorrhage in right frontal lobe which is
unchanged.
Brief Hospital Course:
69 yo F with PMH schizoaffective disorder, CAD, HTN, DM,
restrictive lung disease, discoid lupus, and h/o CVA, who p/w 3d
h/o audio and visual hallucinations, leg pain, and SOB with
altered mental status.
ACTIVE ISSUES:
#Alered Mental Status/Hallucinations: Given pt's history of
schizoaffective disorder and vascular dementia, initial
presentation was thought to be related to delirium vs.
progressive dementia or primary psychiatric condition. Initial
work-up for infectious and neurologic causes of delirium were
unrevealing. Urine analysis was unremarkable, chest xray showed
no infiltrate, blood cultures showed no growth. A head CT was
negative for an acute intracranial process. A head MRI was also
obtained to further evaluate for neurologic causes,and showed
only chronic changes and no new areas of ischemia. An EEG was
obtained and was negative for epileptiform activity. Over the
course of the work up described above, the pt slowly became more
withdrawn, which was different from her initial presentation in
which she was talkative and quite labile with religious ideosity
and frequent outburts of "hallelujah" and "praise [**Doctor Last Name **]." She
began to answer fewer questions, and began to appear somewhat
paranoid. Psychiatry saw pt and recommended increasing
antipsychotic dosage from short acting seroquel 250mg po qhs, to
long-acting seroquel 300mg po qHS and adding on haldol 1mg po
BID. This was done, and the next morning ([**2165-8-16**]) the patient
seemed withdrawn and stuporous. She was awake but not
responsive to questions verbally, answering only with mild head
nodding. At this time, she was found to have a urinary tract
infection (see below), seroquel and haldol were discontinued and
the urinary tract infection was treated and her mental status
improved the following day, returning to a level similar to at
the time of admission.
On [**2165-8-20**], she appeared ill and was again withdrawn. She was
febrile and diaphoretic. Antibiotic coverage was broadened to
vanc/cefepime/flagyl. Pt then developed recurrent SVT to the
220s, relieved with carotid massage. She appeared rigid and
diaphoretic. She was transferred to the ICU for further
management. In the unit psychiatry was consulted and atypical
presentation for neuroleptic malignant syndrome was considered.
She was treated with 2mg cogentin and ativan with mild
improvement in her mental status. She was transferred back to
the general medicine floor, where her mental status continued to
wax and wane but never returned to her initial level of
interactiveness on admission. She was responsive to some
questions, but refusing to answer others. She did not
participate in physical exam commands. She remained stable at
this point for several days. Given the extensive negative work
up for delirium, this was considered to be her new baseline and
placement was found for skilled nursing facility for discharge
with permission from her health care proxy. At time of
discharge, the patient remains AAO x2 (unchanged from before);
she is alert and talkative; still having delusions that her
family is outside waiting for her; gets agitated about wanting
to leave hospital and often refuses to sit or stay in bed.
Throughout hospitalization the patient was convinced that her
hallucinations and delusions were real.
.
# Urinary tract infection: [**2165-8-18**] patient was febrile and urine
analysis suggested urinary tract infection. She was treated with
ceftriaxone. Urine culture revealed
grew out presumptive Strep Bovis and E.coli grow out in her
urine.
.
# Supraventricular Tachycardia: Patient has a remote hx SVT, on
metoprolol for rate control. On [**2165-8-19**] she developed SVT to the
220s, which resolved spontaneously. Over the course of the
following day, she had 4 more episodes of SVT which responded to
carotid massage, she was never hypotensive. SHe was transferred
to the MICU for closer monitoring. Cardiology was consulted who
identified the rhythm as atrial tachycardia vs. AVNRT. The
patient has been stable on Metoprolol 200 mg [**Hospital1 **].
# Hypoxia: On admission, patient was hypoxic with 2LNC O2
requirement. There was no evidence of pulmomary edema or
consolidation. She was quickly weaned to room air. As part of a
work up, an ABG was performed which showed pO2 of 58, this
corrected to 92 with 2LNC. Patient was maintained on
supplemental oxygen without improvement in mental status. Given
significant a-A gradient, and persistent tachycardia, CTA was
performed and showed no evidence of pulmonary embolism. Patient
has a 20 pack year history and likely has baseline hypoxia with
sufficient compensation to maintain peripheral O2 saturation
>92%. At time of discharge, the patient no longer has an oxygen
requirement, and is satting mid to high 90s on RA.
# Ankle pain: Initial laboratory analysis was remarkable for CK
in the 800s and an elevated ESR and CRP. Given her complaints of
left leg and ankle pain, orthopedic and rheumatologic causes
were considered, as well as PE. Plain films of the left ankle
and hip were negative for fracture, but did show an area of
possible bone infarct in the distal tibia of unclear
significance. Rheumatology was consulted who did not believe
the presentation was consistent with SLE, or gout. Amyloidosis
was also considered however SPEP and UPEP, total protein and
globulin levels were unremarkable. Statin-induced myopathy was
considered, and statin was held however CK had already begun to
trend down when the statin was stopped, making statin induced
myopathy unlikely. A LE doppler was negative for DVT. MRI of
the leg MRI was done to evaluate for myositis, skeletal
vasculitis or other inflammatory myopathy, and diabetic
myonecrosis. It was negative for any muscle inflammation or
necrosis, and showed only edema in the subcutaneous tissues,
which had been noted on physical exam. Within the first few days
of her admission, ankle pain and erythemia resolved, etiology
remains unclear.
.
#Cog-wheel rigidity/masked facies/resting tremor - On admission
to the MICU, the patient developed acute presentation of
symptoms concerning for extrapyrimidal symptoms related to
antipsychotics. Patient had received PRN doses of haldol, home
seroquel 250 mg. However, all antipsychotics had been D/C'd 2
days prior to symptom onset. Antipsychotics were held. The
patient was given 1 mg cogentin x 2. Psych was consulted, who
felt that her symptoms were consistent with EPS. The patient
was started on Ativan 1mg q6 hrs PRN agitation. Upon transfer
back to the general medicine floor, her rigidity had improved
and she continued to be treated with prn ativan for agitation,
though this made pt quite somnolent. On [**2165-8-25**] she was
restarted on seroquel 50mg po BID prn agitation in an effort to
avoid sedation associated with benzos. Then as per Psych
recommendation, the patient was restarted on low dose, 25 mg,
seroquel [**Hospital1 **]. All other PRN doses of seroquel and Ativan were
held. The patient seems to be responding well to this regimen.
.
# Hypertension - pt had very difficult BP management while in
house. She was still measuring in SBP 170s on several occasions
despite being on max dose of numerous BP meds, including
metoprolol, losartan, furosemide, and clonidine patch. While in
house, hydralazine 10mg po TID was added to pt's regimen, and
metoprolol was further increased to 200mg po BID for management
of SVT. On this regimen, her pressures ranged from SBP 140s -
150s, occassionally in the 170s.
# hypercholesterol: Because of elevated CKs (peaked at 819),
the patient's Simvastatin was discontinued. CK normalized to 92
by time of discharge. She should have her CK rechecked as
outpatient and consider restarting simvastatin as outpatient.
INACTIVE ISSUES:
# CAD - Chronic. Clopidogrel was continued on admission but
simvastatin was discontinued shortly after admission secondary
to elevated CK levels.
# restrictive lung disease: Chronic. Patient was continued on
albuterol, ipratropium, tiotropium. Symbicort was replaced with
advair during admission due to formulary. Pt is likely
compensated at a lower pO2 secondary to her lung disease. She
was repeatedly hypoxic during admission without complaints of
shortness of breath. Of note, pulse oximetry measured O2 sats
in mid-90s on several occasions in which ABG drawn at same time
showed hypoxia, so pulse ox is not reliable measure of oxygen
status in this patient.
# DM - held glyburide, gave SSI while in house
# h/o candidal rash: miconazole powder
TRANSITIONAL ISSUES:
# schizoaffective disorder: The patient was admitted on Seroquel
250 qhs and because of the possibility of NMS, the patient is
being discharged on Seroquel 50 mg [**Hospital1 **]. Her lorazepam was held
throughout hospital admission.
# please check the patient's CK as an outpatient, as she had
elevated CK levels as outpatient.
Medications on Admission:
- AMLODIPINE 10mg daily
- CLOPIDOGREL [PLAVIX] - 75 mg daily
- FUROSEMIDE - 40 mg daily
- GLYBURIDE - 5 mg daily
- IPRATROPIUM-ALBUTEROL [COMBIVENT] - 2.5-0.5/3mL one vial neb
q6H prn
- LORAZEPAM - 0.5mg qHS
- LOSARTAN [COZAAR] - 100 mg daily
- METOPROLOL ER - 200 mg daily
- PANTOPRAZOLE - 40 mg [**Hospital1 **]
- QUETIAPINE [SEROQUEL] - 250 mg qHS
- SIMVASTATIN - 20 mg daily
- CALCIUM CARBONATE - 500 mg (1,250 mg) TID with meals
- ERGOCALCIFEROL (VITAMIN D2) - 1000 unit daily
- FERROUS SULFATE - 325 mg (65 mg Iron) daily
- MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth daily
- SENNA - 8.6 mg two tabs daily prn constipation
- CLONIDINE patch 0.3mg apply every wednesday
- saline nasal spray 1 spray each nostril [**Hospital1 **]
- spiriva 18mcg cap 1 puff daily
- symbicort 160/4.5 mcg HFA two puffs [**Hospital1 **]
- ibuprofen 400mg po TID prn
- nystatin 100,000U powder apply to affected area TID prn
- proair HFA inh 90mcg 1-2 puffs q4-6h prn
- acetaminophen 650mg po TID
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) INH
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
5. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed for constipation.
9. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
10. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal
twice a day.
11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
13. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
14. nystatin 100,000 unit/g Powder Sig: One (1) APPL Topical
three times a day as needed: to affected area.
15. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-30**]
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
16. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for fever or pain.
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO TID with meals.
19. ergocalciferol (vitamin D2) 400 unit Tablet Sig: 2.5 Tablets
PO once a day.
20. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
21. metoprolol tartrate 100 mg Tablet Sig: Two (2) Tablet PO
twice a day.
22. hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
23. Outpatient Lab Work
Please check CK on [**2165-9-9**] and fax results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**]
at [**Telephone/Fax (1) 23926**]
24. Seroquel 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
altered mental status, NOS
extra-pyramidal adverse effect, anti-pyschotics
hypertension
supraventricular tachycardia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Thank you for letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you
were having hallucinations, altered mental status, and shortness
of breath. You were given a diuretic that removed fluid from
your lungs and your breathing improved. You had an extensive
work up to identify the cause of your altered mental status and
no cause could be found.
While you were in the hospital, you developed muscular side
effects from your anti-psychotic medications. These were
stopped temporarily and your symptoms improved. We restarted
you at low doses of your anti-psychotic medications now that
your symptoms have been improving.
Your blood pressure and heart rate were elevated during your
admission. You were started on two new medications to manage
this.
The following changes were made to your medications:
STARTED:
hydralazine 10mg by mouth three times a day
CHANGED:
metoprolol 200mg by mouth twice a day
seroquel 50 mg by mouth twice a day
STOPPED:
lorazepam
simvastatin
Thank you for letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you
were having hallucinations, altered mental status, and shortness
of breath. You were given a diuretic that removed fluid from
your lungs and your breathing improved. You had an extensive
work up to identify the cause of your altered mental status and
no cause could be found.
While you were in the hospital, you developed muscular side
effects from your anti-psychotic medications. These were
stopped temporarily and your symptoms improved. We restarted
you at low doses of your anti-psychotic medications now that
your symptoms have been improving.
Your blood pressure and heart rate were elevated during your
admission. You were started on two new medications to manage
this.
The following changes were made to your medications:
STARTED:
hydralazine 10mg by mouth three times a day
CHANGED:
metoprolol 200mg by mouth twice a day
seroquel 25 mg by mouth twice a day
STOPPED:
lorazepam
simvastatin: please discuss with your primary care doctor when
you can restart simvastatin
Thank you for letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you
were having hallucinations, altered mental status, and shortness
of breath. You were given a diuretic that removed fluid from
your lungs and your breathing improved. You had an extensive
work up to identify the cause of your altered mental status and
no cause could be found.
While you were in the hospital, you developed muscular side
effects from your anti-psychotic medications. These were
stopped temporarily and your symptoms improved. We restarted
you at low doses of your anti-psychotic medications now that
your symptoms have been improving.
Your blood pressure and heart rate were elevated during your
admission. You were started on two new medications to manage
this.
The following changes were made to your medications:
STARTED:
hydralazine 10mg by mouth three times a day
CHANGED:
metoprolol tartrate 200mg by mouth twice a day
seroquel 50 mg by mouth twice a day
STOPPED:
lorazepam
simvastatin: please discuss with your primary care doctor when
you can restart simvastatin
Followup Instructions:
Your doctor, Dr. [**Last Name (STitle) 1266**], [**First Name3 (LF) **] see you at [**Location (un) 583**] House.
Below is his contact information.
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **]
Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 608**]
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2165-9-24**] at 10:15 AM
With: [**Location (un) 394**]/[**Name8 (MD) **] MD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2165-9-4**]
ICD9 Codes: 5990, 5849, 2760, 4280, 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3161
} | Medical Text: Admission Date: [**2102-10-10**] Discharge Date: [**2102-10-18**]
Date of Birth: [**2041-11-27**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: This is a 60-year-old male with
no medical care for the last ten years, who had sudden onset
of dyspnea while riding his bike. He had positive
palpitations, no chest pain, no nausea or vomiting or
diaphoresis. He stopped and rested, with no relief.
He entered the [**Hospital1 69**] Emergency
Department and was found to have an oxygen saturation of 70%.
Electrocardiogram showed no complex tachycardia, with an
elevated blood pressure. Adenosine was given with no effect.
It was given again, and he was broken to normal sinus rhythm
with a rate of 80s. Chest x-ray showed congestive heart
failure at that time, and he was started on a nitro drip,
given aspirin and lasix, and the patient improved.
PAST MEDICAL HISTORY: Questionable hypertension, which was
untreated, arthritis, essential tremor.
MEDICATIONS: Ibuprofen as needed.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs on admission: Afebrile,
heart rate in the 80s, blood pressure normal, oxygen
saturation 98% on 3 liters. He was alert and oriented, no
jugular venous distention was noted. Pupils equal, round and
reactive to light. He had crackles halfway up the lung
fields. His cardiovascular examination showed distant heart
sounds, regular rate and rhythm, with no murmurs, gallops or
rubs. His abdomen was soft, nontender, nondistended, bowel
sounds present. The extremities were warm and well perfused,
with no cyanosis, clubbing or edema.
LABORATORY DATA: White count 16.5, hematocrit 46.0, platelet
count 362. Sodium 141, potassium 3.2, chloride 101,
bicarbonate 20, BUN 12, creatinine 0.9, glucose 101.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**]
service and begun workup of congestive heart failure. The
patient was taken to the cardiac catheterization laboratory,
which showed three vessel disease and was planned for
coronary artery bypass graft at that time. EP studies were
also done at that time due to his narrow complex
supraventricular tachycardia requiring adenosine.
During the catheterization, it was found that the patient had
moderate aortic insufficiency and it was planned that he
would have an AVR at the same time.
On [**2102-10-12**], the patient was taken to the operating room,
where a coronary artery bypass graft x 3 and AVR was
performed. The patient was transferred to the CSRU
postoperatively. He did well. The patient was weaned from
his ventilator and was extubated and continued to improve.
His Foley was removed. His chest tube was removed.
The patient was noted to have supraventricular tachycardia
postoperatively, which was broken with adenosine. Lopressor
was started in order to control his supraventricular
tachycardia, however, the patient continued to have repeat
episodes of supraventricular tachycardia. He was kept in the
Intensive Care Unit for monitoring and for administration of
adenosine. EP was following at this time, and it was planned
for a workup. His Lopressor was increased, but again had no
effect.
The patient was taken to the EP laboratory on [**2102-10-17**], where
he was studied and found to have a pathway which was
successfully ablated. Physical Therapy was consulted for
ambulation, and the patient did well, and it was felt that
the patient would be safe to be discharged home.
After his ablation, the patient was transferred to the floor,
where he did well. On postoperative day number six, the
patient had no further episodes of supraventricular
tachycardia, and his heart rate was stable. The patient was
able to clear stairs with physical therapy, and the patient
was discharged home in stable condition.
The patient is instructed to follow up with Dr. [**Last Name (STitle) 70**] in
four weeks, and with Dr. [**Last Name (STitle) 284**] of Cardiology in two to
four weeks, and his primary care physician in one to two
weeks.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg by mouth twice a day
2. Lasix 20 mg by mouth twice a day
3. Potassium chloride 20 mEq by mouth twice a day
4. Colace 100 mg by mouth twice a day
5. Zantac 150 mg by mouth twice a day
6. Aspirin 325 mg by mouth once daily
7 Percocet one to two tablets by mouth every four hours as
needed
The patient is discharged in stable condition.
DISCHARGE DIAGNOSIS:
1. Supraventricular tachycardia status post ablation
2. Coronary artery disease status post coronary artery
bypass graft x 3
The patient is discharged in stable condition to home, and is
instructed to follow up with Dr. [**Last Name (STitle) 70**] in four weeks, Dr.
[**Last Name (STitle) 284**] in two to four weeks, and his primary care
physician in one to two weeks.
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 10459**]
MEDQUIST36
D: [**2102-10-17**] 23:26
T: [**2102-10-18**] 00:41
JOB#: [**Job Number **]
ICD9 Codes: 4241, 4271, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3162
} | Medical Text: Admission Date: [**2132-8-11**] Discharge Date: [**2132-8-12**]
Date of Birth: [**2066-11-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
inability to replace trach at home
Major Surgical or Invasive Procedure:
Tracheostomy replacement
History of Present Illness:
Pt is a 65 y.o male with h.o severe OSA (central and
peripheral), who is usually trached with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] cannula
who presents after trach had not been in place for a few days.
Pt ordinarily changes his trach by himself q3months. However, on
this occasion, it was too difficult to replace and now the trach
has been off for a few days. Pt did go to local ER yesterday
([**Location (un) 8117**]), but he was unable to have the trach replaced and was
noted to have significant granulation tissue at the stoma site.
.
In the ED, initial vs were: T P BP R O2 sat.
+ 17:15 0 98.4 68 146/94 20 96
IP was consulted and observed that ordinarily pt needs to close
the stoma to talk and now can talk without closing the stoma. IP
suggests bipap overnight. If pt required intubation, the cuff
would have to be placed below the stoma. IP is planning to do a
rigid bronch tomorrow to either revise the stoma vs. place a
T-tube.
.
Pt states that over the last few months, he has noticed
increased difficulty when changing his trach every 4-6months.
This week, pt noticed increased difficulty when changing his
trach, a few days ago, he also noticed that something did not
feel right after he coughed and eventually the tube feel out and
pt was unable to replace it. In addition, pt states he has had a
multiple revisions and was told there is a great deal of scar
tissue at the site. He has not tolerated bypap in the past and
states he uses 4L at tM at night at baseline.
.
On the floor, pt feels well. He denies SOB/PND, fever/chills,
CP/palp, URI/cough, abd
pain/n/v/d/c/melena/brbpr/dysuria/hematuria, skin rash, +chronic
b/l ankle pain. However, pt reports that he has been unable to
sleep for the last 3 days [**2-11**] trach malfunction, he has been
sleeping upright and did awake with an am headache yesterday. In
addition, he reports palp ~1months ago, with a reportedly
negative w/u.
Past Medical History:
-obstructive and central sleep apnea-dx
20 years ago s/p uvulopalatopharyngoplasty, multiple
attempts with CPAP,tracheostomy eight years ago.
-hypothyroid
-OA
-asthma
Social History:
works in sales, selling sheet metal. He lives with his wife,
drinks 1 ETOH drink daily, denies any w/d symptoms or seizures,
denies drug use.
Family History:
sister with DM
Physical Exam:
PE on admission:
Vitals: T 97.3, BP 145/77, HR 76, RR 18 sat 87-93% on RA
General: Alert, oriented, no acute distress, occasional sounds
of air from trach.
HEENT: nc/at, perrla, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, +trach site with
granulation tissue, pink mucosa, no drainage/C/D/I.
Lungs: b/l ae +crackles at bases, no w/r
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2132-8-11**] 08:34PM BLOOD WBC-7.1 RBC-5.27 Hgb-15.8 Hct-48.3 MCV-92
MCH-30.0 MCHC-32.8 RDW-13.5 Plt Ct-219
[**2132-8-11**] 08:34PM BLOOD Neuts-52.9 Lymphs-34.9 Monos-7.2 Eos-4.1*
Baso-0.9
[**2132-8-11**] 08:34PM BLOOD PT-12.1 PTT-26.5 INR(PT)-1.0
[**2132-8-11**] 08:34PM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-140
K-4.1 Cl-105 HCO3-27 AnGap-12
[**2132-8-12**] 04:12AM BLOOD ALT-34 AST-32 LD(LDH)-184 AlkPhos-58
TotBili-0.9
[**2132-8-12**] 04:12AM BLOOD Albumin-4.4 Calcium-9.3 Phos-3.6 Mg-2.1
.
CXR:
Lateral aspect of the left lower chest is excluded from the
examination.
Other pleural surfaces and the imaged portions of the lungs are
clear. Heart size is normal. Trachea is grossly intact, but not
fully imaged by this type of examination. Pending upon clinical
circumstances, chest CT should be considered.
Brief Hospital Course:
Pt is a 65 y.o male with h.o severe OSA (central/peripheral) s/p
trach who now presents s/p trach dislodgement.
.
# Airway management - Pt with h.o severe OSA who failed trials
of cpap in the past. Pt with trach x15+ yrs per history. Now,
has been a few days w/o trach in place and with evidence of
granulation tissue and healing stoma. IP consulted and
recommended MICU observation o/n. Rigid bronch was performed
and they were able to balloon dilate the stoma and replace the
trach. They used the same type as before. See OMR for
procedure note. He tolerated the procedure well and came back
to the MICU with his new trach in place and capped. He was
talking and without pain. His oxygenation was normal. IP saw
patient on the floor and cleared him for home with follow up in
two weeks to have the stitch in his trach removed. He will now
have it exchanged in office visits rather than at home.
.
#OSA-with management as above. Pt with h.o central and
peripheral sleep apnea. Did fine overnight with humidified air
over stoma. Trach now back in place.
.
#asthma-home advair, albuterol, ipratropium were continued.
.
#hypothyroidism-continued home levoxyl.
Discharged home in good condition post-op. Patient was advised
not to drive for 24 hrs after getting sedation.
Medications on Admission:
Glucosamine-Chondroitin 250 mg-200 mg Cap
Advair Diskus 500 mcg-50 mcg/Dose for Inhalation
1 puff Twice a day
Salmon Oil-1000 1,000 mg-200 mg Cap
Multivitamins Chewable Tab
Ventolin 5 mg/mL (0.5 %) Neb Solution
1 Puff As neded
Levothyroxine 125 mcg Tab
1 Tablet(s) by mouth
Rhinocort Aqua 32 mcg/Actuation Nasal Spray
1 Puff Twice a day
Ipratropium Bromide 0.03 % Nasal Spray Aerosol
1 As needed
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) puff Inhalation Q6H (every 6 hours) as
needed for sob/wheeze.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Rhinocort Aqua 32 mcg/Actuation Spray, Non-Aerosol Sig: One
(1) puff Nasal twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Obstructive sleep apnea
.
Secondary:
Asthma
Hypothyroidism
Osteoarthritis
Discharge Condition:
Good.
Discharge Instructions:
You were admitted because your trach fell out and you were
unable to replace it. The interventional pulmonary physicians
replaced your trach site and sutured it. You will need to have
the sutures removed in 2 weeks.
.
Please resume taking all medications as you were previously
taking prior to admission.
.
Please call Dr. [**Last Name (STitle) **] if you develop significant pain at the
trach site, increased redness or drainage from from the site,
difficult breathing, or any other concerns.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 2 weeks for removal of
the sutures. They will call you to schedule this appointment.
His phone number is [**Telephone/Fax (1) 3020**].
Completed by:[**2132-8-13**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3163
} | Medical Text: Admission Date: [**2173-3-20**] Discharge Date: [**2173-3-24**]
Date of Birth: [**2139-3-28**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Right leg pain, transfer from OSH r/o necrotizing fascitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
33M with no significant PMH who punctured his leg two days
ago with barbed wire after tripping and falling, later burning
his legs and arms bilaterally on a space heater. The patient
reports pain in his right leg that is [**11-10**] with little relief
from narcotics (patient took 15 tablets of oxycodone 30mg at
home). The pain is pulsatile and extends from his upper right
shin to his foot. Patient is unable to bear weight on right
leg.
He was initially seen at [**Hospital1 **] [**Location (un) 620**], where he received
vancomycin and clindamycin overnight and was given a tetanus
shot. He was transferred to [**Hospital1 18**] after threatening to sign out
AMA. In the [**Location (un) 620**] ED, the patient received vancomycin and
clinda, he then received Zosyn at [**Hospital1 18**]. He has received
Dilaudid for pain control with little effect.
Past Medical History:
Past Medical History:
- Attention deficit disorder
- Substance abuse
Past Surgical History:
- None
Social History:
Current smoker. Social alcohol use. History of snorting
heroin, but no IVDU.
Family History:
Paternal grandmother with DM
Physical Exam:
On admission:
Vitals: Tm/Tc 97.8, HR 81, BP 148/65, RR 18, O2 100% on RA
GEN: A&O (per nurse was difficult to arouse earlier), wincing in
pain
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: LLE with 2 cm healing, non-draining second-degree burn on
anterior shin. RLE with circumferential edema of crus, 1+
pitting edema of foot. Poorly-demarcated erythema now extending
beyond border marked earlier, extending from just below knee to
ankle. Multiple 1cm x 1cm scabs and 4cm x 3cm healing,
non-draining second-degree burn on upper shin. Dorsalis pedis
pulses intact bilaterally. Full ROM and strength in both LE and
feet.
On discharge:
VS: 98.1 52 (ranging 50's to low 60's) 127/62 18 98%A
GEN: A&O, NAD
CHEST: Lung sounds CTAB, bradycardic normal S1S2, no
murmurs/rubs/gallops
ABD: Soft, nontender, nondistended, +BS
EXTR: LLE with multiple healing scabs 1cm x 1cm, 4cm x 3cm
healing, nondraining. Very minimal errythema, inside previously
outlined area. Minimal edema LLLE, +DP and TP pulses, full ROM
and strength in bilateral LE.
Pertinent Results:
[**2173-3-20**] RLE CT:
Extensive soft tissue thickening and edema consistent with
cellulitis. No evidence of necrotizing fasciitis. No abscess
formation.
[**2173-3-22**] RLE US:
No evidence of deep vein thrombosis in the right leg.
Superficial thrombophlebitis is seen in the greater saphenous
vein in the
right calf.
[**2173-3-22**] LUE US:
No evidence of deep vein thrombosis in the left arm.
[**2173-3-20**] 08:01AM WBC-6.6 RBC-4.02* HGB-12.1*# HCT-34.8*#
MCV-87 MCH-30.1 MCHC-34.8 RDW-12.7
[**2173-3-20**] 08:01AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2173-3-20**] 08:01AM PLT SMR-NORMAL PLT COUNT-223
[**2173-3-20**] 08:01AM SED RATE-20*
[**2173-3-20**] 08:01AM CRP-20.7*
[**2173-3-20**] 08:01AM GLUCOSE-102* UREA N-10 CREAT-0.6 SODIUM-137
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13
[**2173-3-20**] 08:05AM LACTATE-1.3
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2173-3-20**] under the acute care service
for monitoring and management of his RLE cellulitis. A CT scan
was obtained in the ED (see pertinent results for details) which
showed no evidence of necrotizing fascitis. He was
hemodynamically stable and was admitted to the surgical floor
for monitoring and IV antibiotics.
He was started on IV antibiotics empirically. The wound was
monitored closely and showed significant evidence of improvement
in errythema. He remained afebrile. Given his history of
substance abuse, his pain level was routinely assessed and he
was administered appropriate amounts of pain medications as
needed. He was started on a clonidine patch as well. However, on
HD#3 he ingested his clonidine patch because he reports he was
in severe pain and his heart was racing. He became bradycardic
to the 20's and 30's without hypotension and was given activated
charcoal with NG tube lavage and transferred to the trauma ICU
for monitoring.
While observed in the trauma ICU, Mr [**Known lastname 105674**] bradycardia slowly
resolved. By the afternoon his heartrate was in the low 50's and
it had been 24 hours since the clonidine ingestion so he was
deemed appropriate for floor transfer. During his stay there, a
palpable cord in his RLE was identified, as well as an
indurated/cord-like area of his LUE, so doppler exams were
performed on each which showed no evidence of DVT. Chronic pain
and psychiatry consults were both obtained. At that time,
Chronic Pain recommended oxycodone 15mg TID based on his
reported outpatient usage of 45-60mg TID. He was given one dose
of methadone 20mg on [**2173-3-23**] with the understanding it would not
be continued. After it was determined his cardiovascular
measures were stable and he was tolerating PO intake, he was
transferred back to the floor.
On the floor he remained afebrile and hemodynamically stable
with a HR in the 50's. He remained alert and oriented. His RLE
cellulitis continued to improve.
On [**2173-3-24**] he is afebrile, hemodynamically stable without
leukocytosis. He is out of bed ambulating independently as
tolerated. He is being discharged with a 2 week course of
Bactrim for MRSA coverage for his cellulutis and a limited
prescription for oxycodone until he follows up with his primary
care provided on [**2173-3-30**].
Medications on Admission:
Adderall 30 mg PO BID
Discharge Medications:
1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): do not exceed > 4 gm of aceaminophen in 24 hours.
3. oxycodone 15 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*19 Tablet(s)* Refills:*0*
4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
6. Adderall 30 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Cellulitis of the right lower extremity
2. Clonidine ingestion
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 an infection in your skin
of your right leg. You have been treated with antibiotics and
the infection is stable. You are being discharged home with a
presciption for two more weeks of antibiotics. Please take the
entire course of antibiotics as prescribed.
You are being discharged on narcotic pain medication to control
your pain. It is important to take this medicine as directed.
Do not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. If you are experiencing no
pain, it is okay to skip a dose of pain medicine.
Constipation is a common side effect of narcotics. If needed,
you may take a stool softener (such as Colace, one capsule) or
gentle laxative (such as milk of magnesia, 1 tbs) twice a day.
You can get both of these medicines without a prescription.
Do not drink alcohol or drive/operate heavy machinery while
taking narcotics.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Followup Instructions:
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: TUESDAY [**2173-3-30**] at 12:00 PM
With: [**First Name8 (NamePattern2) 247**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2173-3-26**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3164
} | Medical Text: Admission Date: [**2192-9-23**] Discharge Date: [**2192-9-28**]
Date of Birth: [**2140-7-8**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Diarrhea for 6 weeks, anuric x3 days.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt's history and hospital course reviewed. Briefly, this is a
52M w/ h/o HIV who p/w 3 days of anuria and general malaise. He
had been having diarrhea for the past 6 weeks and on
presentation to the ED for his anuria, he was found to be
hypotensive to 84/60 and in ARF with Cr 5.7 (baseline 1.0). He
also complained of left-sided chest discomfort, a substernal
pressure radiating across his chest that had been ongoing for
2-3 weeks. Sepsis protocol was initiated and RSC CVL was placed.
BP improved to SBP of 100 with 4L IVF and IV heparin was started
for troponin leak of 0.11. He was transferred to the MICU.
.
While in the MICU, the patient's ARF responded well to IVF, with
his Cr decreasing to 1.8 on transfer to the floor. TnT decreased
from 0.11 to 0.02. However, TTE showed a markedly dilated RV
cavity and moderate global RV free wall hypokinesis consistent
with RV pressure/volume overload. The patient's pretest
probability for PE was considered high given his HIV status,
chest pain, and TTE results, but a V/Q scan showed low
probability. Given his post-test estimated probability of PE was
20%, he was continued on anticoagulation. Hct drop from 33.8 on
admission to 26.1 after fluid resuscitation with guaiac positive
stool, hypovolemia, likely demand ischemia, and h/o abnormal EGD
raised strong suspicion for GIB, but his Hct returned to 33.3 by
time of transfer to floor. His platelets dropped from 160 on
admission to 97, and HIT antibody test was positive [**9-25**], so he
was switched to argatroban. On the day of transfer, the pt
spiked a low-grade temperature to 100.7. He was pan-cultured but
no antibiotics were started as there was no clear infectious
source.
Past Medical History:
HIV - dx [**2179**], CD4 <100 on [**2192-9-11**], on HAART
HIV neuropathy
Vacuolar Myelopathy - impaired sensation from neck down
Spastic Bladder
Muscle Spasticity of Leg
CAD s/p cypher times 3 (mid-RCA, prox-RCA, and mid-LAD)
+PPD but negative CXR and sputum
s/p Appy
Social History:
Lives with wife, son, and father, smokes 1.5 ppd x 35 years, occ
etoh, no drugs, previously worked as manager, now on disability
Family History:
Father alive at 86 and healthy, mother deceased at age 85 from
breast cancer, one sister and one brother both healthy
Physical Exam:
VS: 100.6, 139/95, 85, 20, 100% RA, 83.3kg
Gen - sitting comfortably in bed, NAD
HEENT - PERRL, EOMI, sl thrush, MMM
NECK - supple, LAD (old), no JVD
Lungs: CTAB
CV - RRR, nl S1S2, no m/r/g
Abd - soft, ND, NT, no reb/gaurd, NABS
Ext - no c/c/e, dry skin over lower extremities
Neuro - CN II-XII intact, spastic lower extremities with 3/5
weakness, nl strength in upper ext. AAO X3, no focal deficits
Pertinent Results:
[**2192-9-23**] 12:35PM GLUCOSE-98 UREA N-41* CREAT-5.7*# SODIUM-135
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-19* ANION GAP-20
[**2192-9-23**] 12:35PM WBC-8.1# RBC-3.91* HGB-11.9* HCT-33.8* MCV-87
MCH-30.3 MCHC-35.1* RDW-17.9*
[**2192-9-23**] 12:35PM ALT(SGPT)-16 AST(SGOT)-37 CK(CPK)-264* ALK
PHOS-115 TOT BILI-0.5
[**2192-9-23**] 12:35PM LIPASE-180*
[**2192-9-23**] 08:13PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2192-9-23**] 08:13PM URINE RBC-[**5-12**]* WBC-[**2-5**] BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2192-9-23**] 10:58PM CORTISOL-3.6
[**2192-9-23**] 10:58PM CORTISOL-24.5*
[**2192-9-23**] 10:58PM CALCIUM-6.4* PHOSPHATE-3.7 MAGNESIUM-1.9 URIC
ACID-7.4*
.
[**9-23**] CXR: PORTABLE AP CHEST RADIOGRAPH: The right subclavian
venous line is terminating in mid SVC. There is no evidence of
pneumothorax. Cardiac and mediastinal contours are within normal
limits, and there is no consolidation or effusion.
.
[**9-23**] CT OF THE ABDOMEN WITHOUT IV CONTRAST. Dependent changes
are seen at the lung bases. Allowing for limitations of a
non-contrast study, the liver, gallbladder, pancreas, spleen,
and kidneys appear unremarkable. Again seen is a rounded
hypodensity in the right adrenal likely representing adrenal
adenoma, not significantly changed in appearance from prior
study. Visualized portions of bowel appear unremarkable. There
is no evidence of free air or free fluid within the abdomen.
Scattered lymph nodes are seenthroughout the mesentery and
retroperitoneum, however, none appear to meet CT criteria for
pathological enlargement.
.
-CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid
appear
unremarkable. Air is seen within the bladder, likely secondary
to Foley catheterization. No evidence of free air or free fluid
within the pelvis.
.
-ECHO ([**5-8**]): EF 55% , no regional wall abnormaliites, mild
pulmonary HTN.
.
-ECHO [**2192-9-24**]: The left atrium is normal in size. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. The right ventricular cavity is markedly dilated with
moderate global free wall hypokinesis. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is minimal mitral regurgitation. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
.
[**2192-9-24**] LENIs: no DVT
.
[**2192-9-24**] V/Q scan: low probability for PE
Brief Hospital Course:
This is a 52 y.o. HIV positive male ([**2192-9-11**]: CD4 72,
VL>100,000) with a 6 week history of diarrhea and low-grade temp
who was initially admitted to the MICU for hypotension and ARF,
improved after volume resuscitation.
.
# Diarrhea. Likely the patient was hypotensive and in renal
failure secondary to hypovolemia precipitating ARF. The patient
had a small amount of outpatient work-up for this, negative to
date, including: Stool C. Diff, culture and CMV viral load
undetectable. The patient was given symptomatic treatment,
including imodium and his diarrhea improved dramatically. He was
unable to provide a stool sample while on the floor. The patient
was given a prescription for an outpatient stool sample for
repeat stool culture (including viral and bacterial), DFA for
crytosporidium and giardia, ova & parasites, microsporidium. The
GI team was consulted on the patient. It was their
recommendation that the patient have an infectious work-up. If
negative and diarrhea persists, the patient should have a
colonoscopy at a later date when aspirin and plavix can be held
(at least 9 months from the time of drug eluting stent
placement. At the time of discharge, the patient's diarrhea was
well-controlled with loperamide and the patient was tolerating
fluids PO. He was encouraged to have aggressive PO fluid intake
whenever diarrhea occurs.
.
# Fevers. The patient had a low-grade (100) fever after coming
to the floor from the MICU. This may be secondary to the same
process as the diarrhea. However, the patient has poorly
controlled HIV and therefore is at risk for numerous sources.
Empiric antibiotics were deferred as no source of infection was
found.
.
# Hypotension. Likely secondary to persistent diarrhea. The
patient was aggressively hydrated with IV NS in the MICU. He
came to the floor normotensive and maintained this volume status
for the remainder of his time in the hospital.
.
# Acute renal failure. Likely pre-renal secondary to persistent
diarrhea and volume depletion. The patient's Cr improved to
normal range after volume resuscitation.
.
# Chest pain. The patient had a CTA that was negative for PE. He
had a slight troponin elevation thought consistent with demand
ischemia in the setting of hypotension and poor troponin
excretion in the setting of renal failure. The patient's
troponin trended downward throughout his admission and he never
showed CK elevations.
.
# CAD. No signs of acute ischemia. Troponin leak with normal CK
likely secondary to demand ischemia and ARF. The patient was
continued on ASA, plavix, beta blocker, statin. His ACEi was
held for renal failure and then restarted prior to discharge. On
echo, the patient had new mechanical dysfunction. The patient
should have outpatient p-MIBI to assess for perfusion deficits.
.
# HIV. On [**2192-9-11**], CD4 72, VL>100,000. The patient's HAART has
been held while in the MICU for renal failure. These medications
were restarted prior to discharge. The patient's PCP will
consider initiating prophylactic antibiotics as an outpatient.
.
# Anemia. Patient's baseline appears 29-30. Patient with drop in
Hct likely in part secondary to dilution. The patient had guaiac
positive stool with known abnormal colonoscopy and EGD in past
is concerning for GI bleed. The patient had multiple units of
blood transfusion while in the MICU. His Hct normalized prior to
discharge.
.
# Thrombocytopenia. The patient's platelets declined to 90 while
in the MICU and he was found to be HIT antibody positive.
Heparin products were held and the patient's platelet count
stabilized.
Medications on Admission:
Ritonavir 100 qd
3TC 300 mg qd
DDI 400 mg qd
Atazanavir 300 mg qd
Lisinopril 5 mg qd
ASA 325 qd
Plavix 75 qd
Atenolol 25 mg qd
Lipitor 20 qd
Famotidine 20 mg [**Hospital1 **]
Gabapentin 300 mg qhs
Sucralfate 1 g qid
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
5. Didanosine 400 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Atazanavir 100 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Disp:*90 Capsule(s)* Refills:*2*
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Capsule(s)* Refills:*1*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
13. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Stool sample: Please send for C. Diff toxin assay, DFA for
Cryptosporidium/Giardia, routine stool cx, Microsporidium,
Yersinia, Vibrio, Ova and Parasites.
Give this sample at Dr. [**Last Name (STitle) 12103**] office.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diarrhea
.
Secondary: HIV
Discharge Condition:
Good
Discharge Instructions:
Take all medications as prescribed.
.
Attend all follow-up appointment.
.
You must give a stool sample for analysis at your primary care
physician's office.
.
It is recommmended that you have an outpatient colonoscopy.
Please have your primary care physician help you schedule this
study.
.
If you have recurrent diarrhea you must drink a large amount of
water to replace what is lost in your stool.
.
If you develop nausea, vomiting, fevers, chest pain, shortness
of breath or decreased urine output please call your doctor or
return to the hospital.
Followup Instructions:
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 3308**]), Monday [**2192-10-8**] 10:30AM. Give a
stool sample at this office visit to look for possible causes of
your diarrhea. Please make Dr. [**Last Name (STitle) **] aware that it is recommended
for you to have a colonoscopy when it is safe to hold your
aspirin plavix (9 months after your coronary stent was placed).
ICD9 Codes: 5849, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3165
} | Medical Text: Admission Date: [**2174-9-15**] Discharge Date: [**2174-9-29**]
Date of Birth: [**2099-1-29**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Allopurinol / Levaquin /
Keflex / Zosyn / tamsulosin / Tipranavir / Probenecid / Ambien
Attending:[**First Name3 (LF) 4854**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75yo F PMHx ESRD s/p LR Renal tx, w multiple recent admissions
[**Date range (1) 105532**] E. coli UTI and bacteremia, AMS [**Date range (1) 16006**], AMS
discharged [**9-1**] for UTI w AMS re-presents w persistent fatigue
since previous discharge and AMS x 2d. Per patient's family, pt
has been disoriented and displaying erratic behavior; no
associated fever/chills/dysuria, N/V/D, chest pain, cough, HA.
Family brought her to ED for further evaluation. She completed
a course of cefpodoxime on [**9-7**]
Of note patient has a hsitory of resistant hypertension with
blood pressures at baseline in the 180s despite
multi-antihypertensives. On recent admission her BP was elevated
at 200s during her admission, and was 150-190s at the time of
discharge.
In ED, initial vital signs were 98.3 64 187/72 16 97%RA. Labs
notable for WBC 15.1 (N83), Hct 31 (baseline), Cr 4.3 (baseline
high 2s, low 3s), lactate 1.0, Trop .04, UA <1wbc, few bacteria.
Patient had unremarkable CXR, transplant kidney u/s grossly
unchanged. Her blood pressure went up to 230s and was staying
in the 200s despite getting her home medications. She received
.2mg clonidine, 20 furosedmide,100mg hydralazine and 100mg of
labetalol at 10pm. She made urine but the volume was not
recorded. Given that her blood pressures were still elevated in
the 200s she was started on a labetalol drip and transferred to
the MICU. At the time of transfer her sBP was 186.
On arrival to the MICU she was on the labetalol drip at 2mg/min
with a BP of 170/110 and she was A+ox3 and aware of why she was
in the hospital. She had no complaints specifically no headache,
blurred vision, abd pain n/v.
Review of systems:
She denies any dysuira, fevers, chills, changes in urine output
or abdominal pain. She denies headache, changes in vision,
dizziness. She denies any recent falls or unsteadyness on her
feet. Denies any changes in bowel mvoements or hematochezia.
Past Medical History:
s/p LR Renal Tx [**2160**] secondary to Chronic recurrent UTIs,
analgesic nephropathy and nephrocalcinosis
HTN - uncontrolled
Isolated Seizure episode - thought to be secondary to Zosyn
administration
Anemia of Chronic Disease
Thrombocytopenia
Diverticulosis and Dieulafoy Lesions
Osteoporosis
Squamous Cell Cancer s/p Mohs
Lower back pain due to lumar spinal stenosis
Herpes Encephalitis
Hyperlipidemia
Hypothyroidism
h/o TIA
Peptic ulcer disease
Chronic Tophaceous Gout
h/o right rectus sheath hematoma
s/p cataract surgery
h/o colonic polyps
Social History:
She is married and lives with her husband. Retired [**Name2 (NI) **]. They
winter in [**State 108**], and she enjoys golfing. Remote history of
smoking tobacco- quit 40 yrs ago, smoked x20yrs. Old outside
hospital records indicate prior ETOH use, though she denies any
current use.
Family History:
Mother died from melanoma. No h/o colon cancer in family.
Physical Exam:
ADMISSION EXAM
Vitals: 98.7, 170/110, 68, 13 98RA
General: Alert, somulent nodding off, ill and cachectic but in
NAD.
HEENT: Sclera cloudy yellow. Ptosis bilaterally, MMM, oropharynx
clear with own dentition in place, unable to cooperate with EOM
exam
Neck: supple, JVP elevated to earlobe while at 15deg recumbency
no LAD
CV: Regular rate and rhythm, normal S1 + S2,systolic murmur,
rubs, gallops
Lungs: Faint crackles bilaterally throughout
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, dusky and echomotic on circumfrential lower
extremities and lower arms bilaterally. One sore on mid back.
2+DP/PT pulses bilaterally. No peripheral edema.
Neuro: CNII-XII intact, movign all extremities without problems,
following commands. Tremulous with astreixis when attempting
sustained grip
Discharge Exam:
Vitals; T-97.6 BP-155/85 HR-70 RR-20 O2-97%RA
PE: Gen: No acute distress. Laying in bed with covers pulled
around her.
HEENT: MMM. EOMI. NCAT
Neck: Supple. No JVD
CV: RRR. NS1&S2. 3/6 SEM heard best at LUSB.
Resp: Poor inspiratory effort. b/l crackles consistent with
atelectasisGI: BS+4. Soft. Non-tender. Non-distended. no
organomegaly
Ext: 2+ pitting edema. Dark, dusky skin on all extremities.
Pertinent Results:
ADMISSION LABS
[**2174-9-15**] 03:10PM PT-11.0 PTT-41.7* INR(PT)-1.0
[**2174-9-15**] 03:10PM PLT COUNT-194
[**2174-9-15**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2174-9-15**] 03:10PM NEUTS-83* BANDS-1 LYMPHS-7* MONOS-9 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2174-9-15**] 03:10PM WBC-15.1*# RBC-3.26* HGB-9.8* HCT-31.0*
MCV-95 MCH-30.2 MCHC-31.7 RDW-13.9
[**2174-9-15**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2174-9-15**] 03:10PM ALBUMIN-3.8
[**2174-9-15**] 03:10PM CK-MB-2 cTropnT-0.04*
[**2174-9-15**] 03:10PM ALT(SGPT)-39 AST(SGOT)-41* CK(CPK)-20* ALK
PHOS-125* TOT BILI-0.8
[**2174-9-15**] 03:10PM estGFR-Using this
[**2174-9-15**] 03:10PM GLUCOSE-112* UREA N-97* CREAT-4.3*#
SODIUM-137 POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-18* ANION GAP-17
[**2174-9-15**] 03:20PM LACTATE-1.0
[**2174-9-15**] 03:20PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2174-9-15**] 05:00PM URINE MUCOUS-RARE
[**2174-9-15**] 05:00PM URINE HYALINE-1*
[**2174-9-15**] 05:00PM URINE RBC-2 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2174-9-15**] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2174-9-15**] 05:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.009
[**2174-9-15**] 05:00PM URINE bnzodzpn-NEG barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2174-9-15**] 05:00PM URINE HOURS-RANDOM UREA N-467 CREAT-45
SODIUM-33 POTASSIUM-31 CHLORIDE-31
Urine lytes [**2174-9-15**]: UreaN:467 Creat:45 Na:33 K:31 Cl:31
FeUrea calculated at 46%
.
U/A [**9-15**]: Yellow Hazy 1.009 pH 5.5 UrobilNeg BiliNeg LeukNeg
BldNeg NitrNeg Prot100 GluNeg KetNeg RBC2 WBC<1 BactFew
YeastNone Epi<1
.
Discharge Labs:
[**2174-9-28**] 05:58AM BLOOD WBC-10.9 RBC-2.17* Hgb-6.5* Hct-20.6*
MCV-95 MCH-30.1 MCHC-31.8 RDW-14.6 Plt Ct-181
[**2174-9-28**] 05:58AM BLOOD Neuts-72.4* Lymphs-19.7 Monos-4.4 Eos-3.2
Baso-0.3
[**2174-9-28**] 05:58AM BLOOD PT-11.5 PTT-33.3 INR(PT)-1.1
[**2174-9-28**] 05:58AM BLOOD Glucose-99 UreaN-42* Creat-2.8* Na-141
K-4.1 Cl-106 HCO3-27 AnGap-12
[**2174-9-28**] 05:58AM BLOOD ALT-26 AST-17 AlkPhos-92 TotBili-0.7
[**2174-9-28**] 05:58AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.3
[**2174-9-23**] 02:46PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2174-9-22**] 11:56AM BLOOD Type-ART pO2-74* pCO2-37 pH-7.37
calTCO2-22 Base XS--3
.
Pertinent Labs:
[**2174-9-22**] 02:27AM BLOOD CK-MB-1 cTropnT-0.04*
[**2174-9-21**] 05:45PM BLOOD CK-MB-1 cTropnT-0.04*
[**2174-9-16**] 01:32AM BLOOD cTropnT-0.04*
[**2174-9-15**] 03:10PM BLOOD CK-MB-2 cTropnT-0.04*
[**2174-9-22**] 11:56AM BLOOD Type-ART pO2-74* pCO2-37 pH-7.37
calTCO2-22 Base XS--3
[**2174-9-23**] 02:46PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2174-9-23**] 02:46PM BLOOD HCV Ab-NEGATIVE
.
PPD: Negative
.
Micro:
[**2174-9-27**] Blood Culture, Routine-PENDING INPATIENT
[**2174-9-27**] Blood Culture, Routine-PENDING INPATIENT
[**2174-9-26**] URINE CULTURE-Neg
[**2174-9-22**] URINE CULTURE-Neg
[**2174-9-22**] Blood Culture, Routine-Neg
[**2174-9-22**] Blood Culture, Routine-Neg
[**2174-9-21**] Blood Culture, Routine-Neg
[**2174-9-16**] URINE CULTURE-Neg
[**2174-9-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2174-9-15**] URINE CULTURE-FINAL ESBL {ESCHERICHIA COLI}
[**2174-9-15**] Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **]
[**2174-9-15**] Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **]
.
Images:
Head CT [**2174-9-15**] - no infarct nor intracranial hemorrhage
RUQ U/S [**2174-9-16**]- Unremarkable appearance of the liver and
gallbladder. No biliary dilatation. No hydronephrosis seen in
the transplanted kidney. Elevated resistive indices again noted
as were reported on the prior transplant kidney ultrasound.
R shoulder XR [**2174-9-17**]: There is some AC joint arthropathy. This
is stable since the [**2171-6-6**] study. The glenohumeral
joint is within normal limits. There are some cystic changes at
the humeral head. There is also degenerative change of the
glenohumeral joint with spurring anteriorly, new since [**2171**]
study. The visualized right lung apex is clear. No acute bony
injury is noted
KUB Portable [**2174-9-18**]: Nonspecific bowel gas pattern. No findings
to suggest ileus or obstruction. Limited assessment for free
air.
Status post laminectomy and fusion at L4-5, with findings
suggestive of
hardware loosening. Clinical correlation is requested.
CXR portable [**2174-9-22**]: In comparison with the study of [**9-21**],
cardiac silhouette is within normal limits and there is no
definite pulmonary vascular congestion. Hazy opacification at
the bases, more prominent on the right, suggests small pleural
effusions with compressive atelectasis. No discrete pneumonia
is appreciated. Central catheter tip again extends to the
mid-to-lower portion of the SVC.
EKG [**2174-9-23**]: Sinus rhythm. Within normal limits. Compared to the
previous tracing of [**2174-9-22**]
no interval change.
U/S RUE [**2174-9-27**]:
Brief Hospital Course:
75 year old female with a past medical history of end stage
renal disease and transplant with chronic kidney disease and
resistant hypertension with baseline blood pressure in the 180s
who presented for altered mental status to the ED and developed
hypertensive urgency with blood pressures in the 200s requiring
labetalol drip for control. Admitted to the ICU for management
of her blood pressure. Diagnosed with ESBL E.coli UTI in ED and
started on IV meropenem. Transferred to floor after BP
stabilized. Pt became very lethargic and hypotensive on floor,
and transferred back to MICU. Started HD and improved. Some AMS
after transfer back to the floor, but clear on discharge.
.
Active Issues:
#Hypertensive urgency - Patient has baseline resistant
hypertension with SBPs often in the 180s. Per patient, she
manages all of her medications herself, however, was missing her
clonidine patch per ED. Her hypertension could have been due to
missing medications. There was concern that her altered mental
status was related, however no evidence on CT head of
hemorrhage. Her renal function was also worsening, concerning
for decreased perfusion to the kidneys leading to acute on
chronic renal failure however a renal ultrasound of her
transplanted kidney was normal. Given her worsening renal
function, losartan was held in the MICU. She responded well to
the labetalol, and her systolic blood pressure remained stable
in the 150s-180s, which seems to be her baseline. She was
transferred to the general medicine service once her blood
pressure stabilized. Unfortunately, as her home meds were
restarted by the general medicine team, she developed relative
hypotension to the 130s and altered mental status. She was
transferred back to the MICU, where her home verapamil and
clonidine were withheld and she was bolused with IVF. Low-dose
verapamil and clonidine patch were slowly reintroduced, and SBP
was again stabilized. Transferred back to the floor. SBP ranged
between 120's-170's on floor.
.
#Altered mental status - There was concern that the patient was
not acting like herself at home. She has a history of AMS in the
setting of UTI and with her recent hospitalization for UTI.
Initial concern for underlying infection. Her urine was found to
have a resistant strain of E.Coli. Meropenem was started and AMS
began to clear. After transfer to the floor she was oriented x3.
AMS developed again on the floor and pt became relatively
hypotensive. See above. Antibiotics were then broadened include
vancomycin in the MICU due to concern that her AMS represented a
worsening or new infection. She was pancultured, which found no
infection. Both meropenem and vancomycin were d/c'ed as they
were thought to be contributing to confusion. After being
transferred back to the floor, she was again pan-cultured and
fever/WBC were trended. She had no signs/symptoms of active
infection, so PICC line was pulled. Thought that AMS likely
secondary to uremia. After hemodialysis, patient lethargy and
disorientation improved dramatically. AMS may have also had a
component of ICU delirium. At time of discharge she was alert,
responsive, and oriented x3.
.
#ESBL E. coli UTI: See above. History of multiple UTIs in the
past requiring hospital admission. Found to have ESBL E. coli
UTI on this admission. Started on 14 day course of IV meropenem,
but only received 8 days total. Thought that abx may be
contributing to AMS. She was recultured multiple times with no
growth. Her PICC line was discontinued on day of discharge. ID
was consulted for prophylactic therapy and recommended that she
not have prophylaxis at this time, and recommend urology
follow-up. She had no fever or leukocytosis.
.
#Diarrhea: Pt developed watery diarrhea on day of discharge. C.
diff pending.
.
Chronic Issues:
#Acute on chronic renal failure s/p transplant - She has chronic
kidney disease with a baseline creatinine of ~3.1 over the past
few months. Repeat renal ultra sound in the ED was
unremarkable. This acute worsening of renal function could be
due to hypertension. Urine lytes with FeUrea of 46% which is not
clearly prerenal or ATN. During her MICU stay a foley was placed
monitored urine output, we renally dosed medications, creatinine
was trended daily, renal transplant was consulted, her
immunosuppresive agents prednisone and cyclosporine were
continued. The renal transplant team felt that her [**Last Name (un) **] may be a
result of [**Last Name (un) **] failure. The hope was to prolong time to
hemodialysis, and undergo AV [**Last Name (un) **]. However, her delirious state
on the floor, compunded with hyperkalemia prompted initiation of
HD via tunneled HD catheter. Her AMS improved quite dramatically
and Cr trended down to ~2. Her HD schedule is MWF. Transplant
surgery has completed the work-up for AV [**Last Name (un) **]. They will
contact the rehab facility with time and date for surgery
.
#Hx Gout/foot pain: Currently pain free. Extensive h/o gouty
flares and allergic to allopurinol. After discussion with
pharmacy, decided to restart low dose uloric at 20mg daily.
.
# Hypothyroidism - This is a chronic issue. Her thyroid function
tests were checked and she was continued on her home
levothyroxine.
.
#Anemia of chronic disease- Her hematocrit was higher on
admission than her previous discharge hematocrit at 31.0, given
that all of her hematologic cell lines are elevated she was
likely hemoconcentrated at admission. She remained stbale during
this admission with hct ~27-30%
.
#H/o seizure disorder: On Keppra. In setting of zosyn use
previous seizure ,and then again at OSH earlier in [**Month (only) 205**] when
received another dose of zosyn. Was followed by neurology on
previous admission who recommended continuing keppra and will
follow-up with them.
.
#H/o GI bleed: No GIB during this admission. On protonix 40mg
qday
.
TRANSITIONAL ISSUES:
- Was very obstinate to care (refused any blood draws or
medications multiple times), per transplant this is her pattern
when infected.
- outpatient ID for consideration of suppressive therapy for
recurrent UTIs
- Hemodialysis MWF
- Will be called Re: Surgery appt for AV [**Month (only) **]
- F/u C. diff
- Please continue uloric in this pt with extensive h/o gout
- downtrending HCT, check CBC tomorrow, may continue to monitor
twice weekly until ensure stability
- h/ multiple UTI's. No ppx recommended
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. CloniDINE 0.2 mg PO BID
hold for sbp<100 or hr<60
5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
hold for sbp<100 or hr<60
6. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
7. Febuxostat 40 mg PO DAILY
8. HydrALAzine 100 mg PO TID
hold for sbp<100 or hr<60
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Losartan Potassium 100 mg PO DAILY
hold for sbp<100 or hr<60
11. PredniSONE 5 mg PO EVERY OTHER DAY
12. Propranolol 120 mg PO BID
hold for sbp<100 or hr<60
13. Sodium Bicarbonate 1300 mg PO TID
14. Verapamil 120 mg PO Q8H
hold for sbp<100 or hr<60
15. LeVETiracetam 500 mg PO BID
16. Acetaminophen-Caff-Butalbital Dose is Unknown PO BID:PRN
headache
17. Mirtazapine 15 mg PO HS
18. Furosemide 20 mg PO PRN edema
19. Proparacaine HCl 0.5% Opth. 1 DROP BOTH EYES Q 8H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. CloniDINE 0.2 mg PO TID
Hold for SBP <120 mmHg
3. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
4. Febuxostat 20 mg PO DAILY
5. HydrALAzine 100 mg PO TID
hold for sbp<100 or hr<60
6. LeVETiracetam 500 mg PO BID
7. Levothyroxine Sodium 88 mcg PO DAILY
8. PredniSONE 5 mg PO EVERY OTHER DAY
9. Proparacaine HCl 0.5% Opth. 1 DROP BOTH EYES Q 8H
10. Verapamil 20 mg PO Q8H
hold for sbp<140 or hr<60
11. Propranolol 120 mg PO BID
hold for sbp<100 or hr<60
12. Bengay 1 Appl TP [**Hospital1 **]:PRN back muscle pain
13. Lidocaine 5% Patch 1 PTCH TD DAILY back pain
apply to back
14. Nephrocaps 1 CAP PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. Calcitriol 0.25 mcg PO EVERY OTHER DAY
17. Atorvastatin 20 mg PO DAILY
18. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
hold for sbp<100 or hr<60
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary diagnosis:
End stage renal disease
E.coli urinary tract infection
Altered mental status
Resistant hypertension
hypertensive urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at [**Hospital1 18**]. You were admitted
because you were confused and had very high blood pressure. You
were admitted to the intensive care unit and started on
medication through your veins to bring your blood pressure down.
Once it was down you were transferred to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**]
service and your home blood pressure medications were slowly
added back. Your blood pressure dropped too low on this service
and you were transferred back to the intensive care unit. Your
blood pressure medications were added back slowly, and you came
back to [**Doctor Last Name 3271**] [**Doctor Last Name 679**]. Here your blood pressure remained stable
and you were discharged. On most of your home BP medications.
Because your kidney function is not as good as it should be,
your furosemide and losartan were stopped. Please stop taking
these medications for now. They may need to be added back on at
a later date depending on your BP.
You had another infection of your urinary tract on this
admission. You were started on antibiotics through your veins,
but was stopped because the antbiotics might have been making
you confused. You do not currently have an infection, but let
your doctor know if you have any burning, difficulty urinating,
or worsening confusion.
Your kidney function was decreased at time of admission. We
thought this might be causing some confusion for you. You were
started on hemodialysis, and your confusion got better. You will
need hemodialysis on Monday, Wednesday, and Friday. You will be
scheduled with surgery to implant a [**Last Name (LF) **], [**First Name3 (LF) **] that you won't
need a HD catheter. They will call you with this appointment.
Medications to CHANGE:
Clonidine 0.2mg twice a day to 0.2mg three times a day
Verapamil 120mg three times a day to 20mg three times a day
Uloric 40mg daily to 20mg daily
Cyclosporine 100mg twice a day to 75mg twice a day
Medications to START:
Pantoprazole 40mg daily
Nephrocaps daily
Bengay apply to back daily
lidocaine patch apply to back daily
Medications to STOP:
STOP losartan
STOP furosemide
STOP sodium bicarbonate
STOP butalbital
STOP mirtazipine
Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2174-12-19**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD [**Telephone/Fax (1) 2928**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
****We realize you have dialysis on this day but the appt is
earlier in the morning in hopes that you could go before your
dialysis. If this appt still does not work for you, please feel
free to call the office to reschedule.
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2174-10-12**] at 4:00 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2174-11-8**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: Transplant
Name: Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **]
When: Dr. [**Last Name (STitle) 105535**] office is working on a follow up appointment
for you in [**5-22**] days after your hospital discharge. You will be
called with the appointment date and time. If you have not heard
from the office in 2 business days please call the number listed
below.
Location: [**Hospital1 **]
Address: [**Doctor First Name **], 7TH FL, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 673**]
[**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**] MD, [**MD Number(3) 4858**]
ICD9 Codes: 5856, 5990, 5849, 2449, 2749, 2724, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3166
} | Medical Text: Admission Date: [**2127-9-25**] Discharge Date: [**2127-10-8**]
Date of Birth: [**2057-7-6**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Codeine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Found Unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 70 yoF w/ a h/o CHF EF 20%, DMII, CAD , PVD, HTN,
COPD, and CKD w/ a baseline Cr of 2.0 who presents with not
being "quite her self" x 1 days and found unresponsive at home
by husband. FS was 20 given glucose and FS normal in ER.
Initially upon presentation to ER was obtunded and since has
been improving. Non cooperative to questioning.
.
In the ED, rectal temp 104. BP and HR had been normal as well
as O2 sats normal. Lactate 7. CVP was initially 13. Given Vanc
and Ceftriaxone (at meningitis doses) and flagyl. CT of abd /
pelvis was s/p 3 liters IVF in ED. INR was 5.6. EKG J point
elevation in V3, ST depressions in V5-V6 which are not new.
Most recent set of vitals 36.7, 67, 107/68, 17, 100% on nasal
cannula but now on non rebreather because SvO2 is low.
Past Medical History:
PMH:
1. Diabetes Mellitus type II on orals
2. CAD 3vd
3. Chronic systolic heart failure , EF 20%
4. Multinodular goiter
5. Hypertension
5. Spinal stenosis
6. PVD s/p aortobifemoral bypass, left toe amputations
7. Peripheral neuropathy
8. Hyperlipidemia
9. Depression
10. Anemia
11. CKD Stage III with neuropathy, nephropathy
12. Frequent falls/gait instability
13. Cervical spondylosis s/p C4-7 laminectomy and fusion in [**2-4**]
14. s/p choly
15. h/o SBOs
16. COPD
Social History:
Level of function prior to [**5-8**] admission was ambulate household
distances, wheelchair for community. Lives in senior
housing/elevator building with husband. Used bedside commode in
home. Pack per day smoker for >40 yrs, denies EtOH, denies
illicit drug use.
Worked as salesclerk and for the turnpike. Has five children,
two living.
Family History:
Five children, three living. One from HIV, one shot, one drugs.
Husband reports both her parents died from "cancer I think,
trouble breathing." One son has seizures.
Physical Exam:
Vitals: T: 104.8 in ER (axillary 95 in ICU) BP: 125/70 HR: 64
RR: 15 w/ periods of apnea O2Sat: 99-100% RA
GEN: patient is responsive to verbal stimuli, she is able to
follow with her eyes the interviewer but unable to follow any
other commands, she is unable to answer any questions.
HEENT: PEERL (3-4mm bilat), EOMI, sclera anicteric, no epistaxis
or rhinorrhea
NECK: JVP 14cm, no thyromegaly or cervical lymphadenopathy,
trachea midline
COR: RRR, [**2-5**] HSM at LLSB and at apex
PULM: Lungs CTAB, no W/R/R, however patient not following
commands so poor inspiratory effort
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: Pitting 1+ edema to knees, darkening of skin on lower
extremities.
NEURO: 1+ reflexes biceps, triceps, achilles, patellar reflexes
all bilaterally symmetric, muscle tone is increased in the upper
and lower extremities
Pertinent Results:
[**2127-9-25**] 07:19PM POTASSIUM-5.1
[**2127-9-25**] 07:19PM CK(CPK)-85
[**2127-9-25**] 07:19PM CK-MB-4 cTropnT-0.18*
[**2127-9-25**] 04:36PM URINE HOURS-RANDOM UREA N-251 CREAT-87
SODIUM-56
[**2127-9-25**] 04:36PM URINE bnzodzpn-NEGATIVE barbitrt-NEGATIVE
opiates-NEGATIVE cocaine-NEGATIVE amphetmn-NEGATIVE
mthdone-NEGATIVE
[**2127-9-25**] 01:49PM LACTATE-3.3*
[**2127-9-25**] 01:49PM HGB-11.1* calcHCT-33 O2 SAT-83
[**2127-9-25**] 12:33PM LACTATE-3.2*
[**2127-9-25**] 11:32AM LACTATE-3.8*
[**2127-9-25**] 11:25AM CK(CPK)-75
[**2127-9-25**] 11:25AM CK-MB-3 cTropnT-0.16*
[**2127-9-25**] 11:25AM VIT B12-GREATER TH FOLATE-GREATER TH
[**2127-9-25**] 11:25AM FREE T4-0.79*
[**2127-9-25**] 11:25AM ASA-NEG ACETMNPHN-6.0 bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2127-9-25**] 10:37AM TYPE-MIX INTUBATED-NOT INTUBA COMMENTS-GREEN
TOP
[**2127-9-25**] 10:37AM LACTATE-4.5* K+-5.5*
[**2127-9-25**] 10:37AM O2 SAT-84
[**2127-9-25**] 08:44AM COMMENTS-GREEN TOP
[**2127-9-25**] 08:44AM GLUCOSE-122* LACTATE-7.6* NA+-142 K+-6.3*
CL--102
[**2127-9-25**] 08:30AM GLUCOSE-126* UREA N-59* CREAT-3.9*#
SODIUM-140 POTASSIUM-6.3* CHLORIDE-101 TOTAL CO2-23 ANION
GAP-22*
[**2127-9-25**] 08:30AM ALT(SGPT)-412* AST(SGOT)-1161* CK(CPK)-65 ALK
PHOS-103 TOT BILI-1.5
[**2127-9-25**] 08:30AM LIPASE-28
[**2127-9-25**] 08:30AM CK-MB-NotDone cTropnT-0.21*
[**2127-9-25**] 08:30AM ALBUMIN-2.6* CALCIUM-8.3* PHOSPHATE-6.9*#
MAGNESIUM-2.0
[**2127-9-25**] 08:30AM TSH-36*
[**2127-9-25**] 08:30AM T4-4.4* T3-41*
[**2127-9-25**] 08:30AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV
Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2127-9-25**] 08:30AM WBC-11.5*# RBC-3.29* HGB-11.1* HCT-35.5*
MCV-108* MCH-33.9* MCHC-31.4 RDW-19.5*
[**2127-9-25**] 08:30AM NEUTS-86.7* LYMPHS-9.0* MONOS-4.2 EOS-0.1
BASOS-0
[**2127-9-25**] 08:30AM PLT COUNT-197
[**2127-9-25**] 08:30AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2127-9-25**] 08:30AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
[**2127-9-25**] 08:30AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2127-9-25**] 08:30AM PT-49.2* PTT-33.9 INR(PT)-5.6*
[**2127-9-25**] 08:30AM PLT COUNT-197
[**2127-9-25**] 08:30AM NEUTS-86.7* LYMPHS-9.0* MONOS-4.2 EOS-0.1
BASOS-0
[**2127-9-25**] 08:30AM WBC-11.5*# RBC-3.29* HGB-11.1* HCT-35.5*
MCV-108* MCH-33.9* MCHC-31.4 RDW-19.5*
[**2127-9-25**] 08:30AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV
Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2127-9-25**] 08:30AM T4-4.4* T3-41*
[**2127-9-25**] 08:30AM TSH-36*
[**2127-9-25**] 08:30AM ALBUMIN-2.6* CALCIUM-8.3* PHOSPHATE-6.9*#
MAGNESIUM-2.0
[**2127-9-25**] 08:30AM CK-MB-NotDone cTropnT-0.21*
[**2127-9-25**] 08:30AM LIPASE-28
[**2127-9-25**] 08:30AM ALT(SGPT)-412* AST(SGOT)-1161* CK(CPK)-65 ALK
PHOS-103 TOT BILI-1.5
,
CT abdomen/pelvis:IMPRESSION:
1. Limited study without oral or intravenous contrast.
Sensitivity for
detecting abscess or bowel ischemia is markedly diminished.
2. Umbilical hernia is seen containing non-obstructed bowel
loops.
3. Multiple bilateral non-obstructing renal stones without
evidence of
hydronephrosis.
4. Cardiomegaly and bilateral pleural effusions.
5. Ascites.
6. Diffuse atherosclerotic disease.
,
TTE:The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
The estimated right atrial pressure is 10-20mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is top normal/borderline dilated. There is severe
global left ventricular hypokinesis (LVEF = 15-20 %). No masses
or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. The right
ventricular cavity is dilated with severe global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. The tricuspid
regurgitation jet is eccentric and may be underestimated. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
CXR [**9-29**]:IMPRESSION:
Likely slight increase in right pleural effusion compared to
[**2127-9-26**] with
difficult comparison to [**2127-9-27**] because of differences in
position. Persistent
CHF and left lower lobe atelectasis.
.
RUQ US:
IMPRESSION: Very limited examination secondary to patient
cooperation.
Patent hepatic veins and IVC. To-and-fro flow within the main
portal vein may
indicate underlying hepatic congestion or an underlying primary
hepatic
process.
,
CT head;FINDINGS: There is no evidence of hemorrhage, recent
infarction,
hydrocephalus or edema. There is an old lacune in the extreme
capsule on the
left. There is cerebral atrophy and small vessel ischemic
change. The
included paranasal sinuses and mastoid air cells are clear.
There are no
fractures.
IMPRESSION: No acute intracranial processes. Old lacune.
.
CXR [**10-1**]:
IMPRESSION:
1. Low lung volumes and interval increase in bilateral pleural
effusions and
pulmonary vascular congestion.
2. Paucity of abdominal gas suggesting ascites.
Brief Hospital Course:
This is a 70 yoF w/ a h/o CHF EF 20%, DMII, CAD , PVD, HTN,
COPD, and CKD w/ a baseline Cr of 2.0 found unresponsive by her
husband. [**Name (NI) **] initial presentation was felt to be due to acute
liver failure. Her course was complicated by acute renal failue,
liver failure, coagulopathy, and DIC. Below is her course by
system. She was in the ICU from [**Date range (1) 23681**], and then on the
general medical floor.
.
# Delerium/Altered mental status/Dementia: The patients acute
change in mental status was ultimately thought to be due to The
patient initially was found to be unresponsive by husband- seems
as though she had been lethargic for at least 10 days. She
also has been profoundly hypothyroid in the past and also has a
? of underlying alzheimers dementia with fluctuating mental
status in the past as well. In the presence of fever, it was
thought that patient was infected. Given mental status was
altered and no other localizing source,there was initial concern
for meningitis. LP was not attempted because of elevated INR
and thrombocytopenia. The patient was covered for several days
with Vanc/CTX/Amp for empiric meningitis coverage (2 days) and
then just CTX/flagyl for 3 days to cover for SBP. She ruled out
for pneumonia with a negative CXR, head CT was negative, CT
abd/pelvis negative, there was no clot in IVC on RUQ US, and
minimal ascites on ultrasound. The pt did have elevated TSH
levels, but thyroid function is unreliable in this setting of
acute illness. Her TSH prior to admission was similar, and her
levothyroxine had recently been increased to 88 mcg daily as an
outpatient. The patient was started on lactulose as per below,
and her mental status gradually improved. Of note, recent MRI
showed changes most consistent with Alzheimer's dementia. She
had been seen by behavioral neurology by Dr. [**Last Name (STitle) 724**], and it is
felt she suffers from a mixed etiology disorder involving
microvascular and probable Alzheimer's disease encephalopathy.
She was noted to have some rigidity and cogwheeling on exam, [**First Name8 (NamePattern2) **]
[**Last Name (un) 309**] body dementia and Parkinsons' need to be evaluated as an
outpatient. She will follow up with neurology (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **])
.
# Lactic Acidosis: Initial lactate of 7.6 on admission resolved
with fluid resuscitation.
.
# Renal failure: Her creatinine was 3.9 on admission, with
baseline of 2.0. Thought to be prerenal, trended down with IVF.
No hydronephrosis on ct scan. Her HCTZ, lisinopril, and lasix
were all held. After her renal failure was resolving with Cr
down to 2.3 and pt was in acute CHF, lisinopril and lasix were
restarted.
.
# Acute Hepatitis: The patient presented with picture c/w acute
hepatitis, of unclear etiology. Her ALT was 412 and AST 1161 on
admission. Tox screen was negative. The patient was seen by
hepatology and it was felt that perhaps her hepatitis was drug
induced. She has known hepatitis C, but this was felt unlikely
to cause her acute liver failure. Liver US was negative for
portal vein thrombosis. She was started on rifaximin and
lactulose with improvement in her encephalopathy. Hep B
serologies, Hep A serologies were negative. Hep C viral load was
greater than 1,000,000. She will need outpatient hepatology
follow up (has follow up at the end of [**Month (only) 359**]).
-Hepatitis E Ab ordered and pending
.
# Coagulopathy: Felt to be due to DIC and worsening liver
failure. Schisotcytes were seen on initial smear, which
improved. Hematology/oncology was consulted and felt pt likely
had DIC. Her platelets dropped to the 30s and then began to
recover. Her INR rose to 11.3 and then improved. She did receive
some vitamin K. Heparin dependent Ab was negative. Antithrombin
(AT), protein C, and protein S, Factor V and VIII levels were
all low. Hematology felt....
.
# Acute on Chronic systolic heart failure: EF 15-20%. Appeared
stable on repeat echo this admission. Pt also has mod-severe
TR/MR. [**Name13 (STitle) **] last stress test had shown no defect, but this was on
rest imaging. Per her cardiologist, Dr. [**First Name (STitle) 437**], the patient's
heart failure is not likely ischemic in nature. This
cardiomyopathy has been new since [**2122**]. The etiology of her
chronic systolic heart failure is unclear. [**Name2 (NI) **] lasix,
lisinopril, and hctz were held on admission for acute renal
failure, hypernatremia, and dehydration. She was treated with
several days of IV D5W. She was noted to have increasing pleural
effusions, O2 requirement, and BNP of >70,000. Her lisinopril
was restarted once her creatinine was 2.3 and she was given IV
Lasix. Her metoprolol was changed to carvedilol per Dr. [**First Name (STitle) 437**] to
give better afterload reduction. Dr. [**First Name (STitle) 437**] advised against
aladactone given her CRF and predisposition to hyperkalemia.
.
# Macrocytic Anemia: B12 and folate were normal, Her hct
remained stable around 34 despite DIC.
.
# Fever: The patient had a fever of 104 on presentation.
Ultimately this was felt to be due to hepatitis. Her initial
work up was negative for any other acute infectious source. As
per above, she was covered with antibiotics initially for
concern of meningitis or SBP. Her fever had resolved by HD #3.
Urine cultures grew yeast. Her foley was removed.
.
# HTN: The pt is on metoprolol, lisinopril and hctz at home. Her
hctz and lisinopril were held given her acute renal failure. Her
metoprolol was increased and she was started on norvasc.
Lisinopril was restarted after her acute renal failure resolved.
,
# ? CAD: No history of recent stents in our system but on
aspirin and plavix on admission. In fact, there is no evidence
the patient has CAD, but this keeps being written in her notes.
She was cotinued on metoprolol and aspirin, but her plavix was
held in the setting of DIC/thrombocytopenia. Per Dr. [**First Name (STitle) 437**], her
cardiologist, the plavix does not need to be restarted as we
have no evidence the pt has CAD.
.
.
# Elevated D-dimer/FDP: The patient had a D dimer trending up to
7000, but no further evidence of DVT. LENI of the BL LE were
negative for DVT. It is possible the pt has a PE which has been
brought up before, but she could not have a CTA due to her renal
failure, no VQ scan due to pulmonary edema, and no heparin given
her thrombocytopenia and elevated INR. She had no DVT in either
the L or R lower extremity and no portal vein clot on US.
.
Thrombocytopenia: Due to DIC, the pts plts decreased to the 30s
but gradually trended back up to ____ at the time of discharge.
.
#. LLE DVT: Diagnosed [**5-8**]. Was on coumadin as an outpatient.
Her coumadin was stopped given her DIC and coagulopathy. Repeat
LE US showed no DVT. In discussion with hematology oncology, it
was felt further anticoagulation is not necessary.
.
.#. Hypernatremia: Thought to be due to poor po intake. The
patient had a sodium up to 149, improved with D5W.
.
#. Hypoglycemia/Diabetes Mellitus Type II, controlled, no
complications: Hypoglycemia on admission was thought to be in
setting of liver failure. This was treated with several days of
D5W infusion. She was maintained on sliding scale insulin.
,
# Pleural Effusions: [**Month (only) 116**] be related to 3rd spacing in setting
of acute illness, chronic CHF. Her CHF was treated as per above.
.
#. Hypothyroidism: Labs unreliable in setting of acute illness.
Most recently pts levothyroxine had been increased to 88 mcg as
outpatient due to elevated TSH. She was continued on this dose.
.
#. COPD: No evidence of flare. She was continued on
albuterol/ipratropium nebs prn
.
# Depression: holding wellbutrin in setting of hepatic failure
.
#. FEN. Thin liquids, Ground consistency solids; w
Medications on Admission:
colace
coumadin 2 mg daily
omeprzole 20 mg daily
Lasix 20 mg in AM and 80 mg in PM
Vit D 400
Plavix 75 mg daily
metoprolol 25 mg daily
lisinopril 40 mg daily
HCTZ 25 mg daily
Buproprion 150 mg daily
ASA 81 mg daily
Neurontin 100 mg at night
Levothyroxine 75 mcg daily
Imdur 30 mg daily
Ultram
MS [**First Name (Titles) **] [**Last Name (Titles) 8910**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Last Name (Titles) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
2. Lactulose 10 gram/15 mL Syrup [**Last Name (Titles) **]: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
3. Furosemide 20 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Levothyroxine 88 mcg Tablet [**Last Name (Titles) **]: One (1) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 20 mg Tablet [**Last Name (Titles) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Carvedilol 25 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Norvasc 5 mg Tablet [**Last Name (Titles) **]: One (1) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 1* Refills:*2*
10. Tramadol 50 mg Tablet [**Last Name (STitle) **]: [**1-1**] pill Tablet PO Q12H (every 12
hours) as needed for PRN PAIN.
Disp:*30 Tablet(s)* Refills:*0*
11. Rifaximin 200 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
12. Bupropion 150 mg Tablet Sustained Release [**Month/Day (2) **]: One (1)
Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
13. Vitamin D 1,000 unit Tablet [**Month/Day (2) **]: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
14. Plavix 75 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Month/Day (2) **]:
Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute liver failure
Acute renal failure
Diffuse intravascular coagulation
Hypoglycemia
Acute on chronic systolic heart failure
Delirium
Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with acute liver failure, acute renal failure,
hypoglycemia, and delerium. You were treated supportively. You
also developed acute heart failure, which was treated with
diuretics.
Followup Instructions:
1. Neurology: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]; appointment on [**11-12**] at 1
PM; [**Location (un) **] [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**], [**Hospital1 18**],
Phone:[**Telephone/Fax (1) 657**]
.
2. Hepatology (Liver doctor): Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2127-10-27**] 12:00 PM, at [**Hospital1 18**] [**Hospital Unit Name 3269**], [**Hospital Ward Name 517**], [**Location (un) **], Liver Center
.
3. Needs appt with Dr. [**Last Name (STitle) 23537**] (a resident at [**Company 191**]) [**Telephone/Fax (1) 250**]
4. Needs appt with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in [**3-4**] weeks
ICD9 Codes: 0389, 5849, 4254, 2762, 2760, 4280, 496, 3572, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3167
} | Medical Text: Admission Date: [**2200-8-1**] Discharge Date: [**2200-8-3**]
Date of Birth: [**2132-6-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
cardiac arrest at home this AM
Major Surgical or Invasive Procedure:
s/p cabg x3/MV repair [**2200-7-21**]
History of Present Illness:
68 yo male who was discharged home on [**7-29**] after cabg x3/MV
repair with Dr. [**Last Name (STitle) **]. Had cardiac arrest at home this AM and
was resuscitated from apparent asystole to a junctional rhythm.
Had decreased level of responsiveness since his arrest this
morning and hyperkalemia with worsening renal function.He was
transferred into [**Hospital1 18**] for further management.
Past Medical History:
Ischemic Cardiomyopathy, Systolic Congestive Heart Failure,
Coronary Artery Disease, Mitral Regurgitation, Prior MI [**2198**]
complicated by cardiac arrest, Chronic Renal Insufficiency,
COPD, History of Upper GI Bleed secondary to esophogeal varices
- s/p cauterization, History of ETOH abuse
[**2200-7-21**] cabg x3/MV repair
Social History:
Former smoker, 50 pack year history of tobacco. Former heavy
alcohol abuse, none since [**2198**]. He is a former carpenter and
Marine Corp Veteran. Lives in [**State 4565**] and is here visiting
for the summer. Currently living with his daughter.
Family History:
Denies premature coronary artery disease.
Physical Exam:
eyes open with decorticate posturing when being suctioned
occasional twitching of eyes and mouth
no spontaneous movement of extremities noted
lungs coarse bilat.
RRR with holosystolic murmur
abd softly distended, no BS noted
extrems cool,no edema;knees mottled
Pertinent Results:
[**2200-8-3**] 07:55AM BLOOD WBC-24.5* RBC-3.10* Hgb-9.8* Hct-29.0*
MCV-94 MCH-31.6 MCHC-33.8 RDW-18.1* Plt Ct-284
[**2200-8-3**] 07:55AM BLOOD PT-24.6* PTT-83.1* INR(PT)-2.5*
[**2200-8-3**] 07:55AM BLOOD Plt Ct-284
[**2200-8-3**] 07:55AM BLOOD UreaN-41* Creat-2.2* Na-132* Cl-105
HCO3-15*
[**2200-8-3**] 02:11AM BLOOD Glucose-77 UreaN-54* Creat-3.2* Na-131*
K-5.1 Cl-97 HCO3-20* AnGap-19
[**2200-8-3**] 02:11AM BLOOD ALT-491* AST-694* LD(LDH)-1216*
AlkPhos-111 Amylase-286* TotBili-1.8*
[**2200-8-3**] 02:11AM BLOOD Lipase-14
[**2200-8-3**] 02:11AM BLOOD CK-MB-20* cTropnT-1.06*
[**2200-8-3**] 07:55AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.9
Cardiology Report ECG Study Date of [**2200-8-2**] 1:08:56 AM
Sinus tachycardia. Poor R wave progression with loss of R waves
in
lead V4. Possible prior anterior myocardial infarction. Compared
to tracing
of [**2200-7-17**] no significant change is seen except heart rate is
now faster.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] F.
RADIOLOGY Final Report
MR HEAD W/O CONTRAST [**2200-8-3**] 11:59
MR HEAD W/O CONTRAST
Reason: Anoxic injury of brain?
[**Hospital 93**] MEDICAL CONDITION:
68 year old man with post CPR stroke
REASON FOR THIS EXAMINATION:
Anoxic injury of brain?
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Status post CPR stroke. Evaluate for anoxic injury to
the brain.
Routine MRI of the brain without gadolinium was performed.
There are no comparison studies.
FINDINGS:
There is abnormal signal throughout the supra- and
infratentorial brain specifically, in the frontal and parietal
cortex, bilateral thalami and caudate nucleus and in the
cerebellum. The deep [**Doctor Last Name 352**] and cortical abnormalities likely
represent sequela of hypoxic ischemic injury. The cerebellar
diffusion abnormalities could represent watershed or embolic
ischemia. Abnormal signal is also seen in the right putamen.
There are also probable scattered small vessel ischemic sequela
in the subcortical white matter.
Intracranial flow voids appear to be maintained.
Bilateral mastoid opacification is seen. There is fluid pooling
in the nasopharynx and the nasal cavities, which may be related
to intubation.
IMPRESSION:
Findings likely relating to hypoxic ischemic injury and
watershed ischemia.
DR. [**First Name (STitle) **] [**Name (STitle) 12563**]
Approved: SUN [**2200-8-3**] 6:01 PM
Brief Hospital Course:
Admitted [**2200-8-1**] to CSRU intubated and unresponsive with a poor
neurological status. Renal and neuro consults done as prognosis
was poor on triple pressor support. Dr. [**Last Name (STitle) **] discussed the
prognosis with the family and CVVHD was started initially for
continued support. On [**8-2**], he showed signs of anoxic brain
injury with possible ischemia. Cardioverted on the morning of
[**8-3**] for rapid AFib. MRI of the head on [**8-3**] showed diffuse
areas of infarct. He remained hypotensive despite pressor
therapy, and a family discussion was held with neurology and Dr.
[**Last Name (STitle) **]. Family decided to make the pt. DNR and he expired at
14:17 on [**8-3**].
Medications on Admission:
at home:
lasix 20 mg daily
KCl 20 mEq daily
colace 100 mg [**Hospital1 **]
ASA 81 mg daily
lipitor 40 mg daily
paroxetine 20 mg daily
toprol XL 12.5 mg [**Hospital1 **]
at transfer:
dopamine drip
heparin drip ( for ? PE)
combivent MDIs
protonix 40 mg IV daily
rocephin one gram IV daily
ASA 325 mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p cardiac arrest [**8-1**]
s/p cabg x3/MVrepair [**7-21**]
multi-organ system failure
Discharge Condition:
expired
Completed by:[**2200-10-20**]
ICD9 Codes: 5845, 2767, 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3168
} | Medical Text: Admission Date: [**2186-3-20**] Discharge Date: [**2186-3-25**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
altered mental status.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
37 y/o male patient with Type I DM, HTN, gastroparesis, ESRD on
HD who presents to ED with hypertensive urgency. The patient
came to the ED with his usual nausea, vomiting, abdominal pain
and was found to be hypertensive to 267/171, HR 102. History is
difficult to obtain from patient d/t somnolence and lack of
desire to participate in interview. He was given ativan a total
of 2 mg of Ativan, 4 mg of dilaudid, labetolol 20 mg IV x 3 and
hydralazine 20 mg IV x 1 with good response (BP at one point
down to 83/58). He recieved 2L NS, Clonidine 0.2mg, Metoprolol
25mg, and Nifedipine XL 30mg. He also received Anzamet. His BP
stabalized and his nausea and abd pain improved.
.
Of note, the patient is admitted to hospital ~3 times every
month
for similar complaints with last admission [**Date range (1) 92782**]. In the
past, he has eloped prior to formal discharge
Past Medical History:
1. DM type I
2. ESRD on hemodialysis started [**2-/2184**] on Tu, Th, Sat
3. Severe autonomic dysfunction with multiple hospitalizations
for hypertensive emergency, gastroparesis, and orthostatic
hypotension.
4. History of esophageal erosion, MW tear
5. CAD with 1-vessel disease (50% stenosis D1 in [**7-/2181**]), normal
stress
[**11/2182**]
6. hx of Foot Ulcer
7. h/o clot in AV graft x2 ([**Month (only) 958**] and [**2185-8-13**])
Social History:
Denies alcohol or tobacco use. Endorses occassional marijuana
use. Lives with his [**Hospital1 **] mother and their three children.
Family History:
His father recently died of ESRD and diabetes. His mother is in
her 50s and has hypertension. He has two sisters, one with
diabetes, and six brothers, one with diabetes.
Physical Exam:
per Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 916**]
Vitals: 97.5, 157/82, 83, 16, 96% 2L
General: sleepy, arouses to voice but limited participation with
physical exam
HEENT: PERRL, left pupil smaller than right, pt will not
participate in EOMI, sclera anicteric, MM dry, No OP lesions
Neck: Supple, no JVD
CV: RRR, nl S1, S2, 2/6 systolic murmur at LUSB
Lungs: CTAB post
Chest: HD line in place without erythema
Abd: Soft, ND, nontender, + BS, no guarding, no rebound,
multiple well healed scars
Ext: no c/c/e, left arm with fistula with good thrill
Skin: no rashes
Pertinent Results:
admit EKG: Sinus rhythm. Early repolarization, no other change
from prev
Admission labs:
137 97 47
--------------< 287
4.2 23 8.3
Ca: 9.2 Mg: 2.0 P: 2.3 D
.
13.1
11.3 >----< 166
40.2
N:90.9 Band:0 L:5.3 M:3.4 E:0.2 Bas:0.2
PT: 21.4 PTT: 32.8 INR: 2.1
.
Trends:
WBC: 11.3 - 7.6
INR: 2.1 - 2.3 - 2.4 - 3.0 - 3.7 - 1.3
CK: [**Telephone/Fax (3) 92783**]
CKMB: 4 - 7 - 8
Trop: 0.21 - 0.33 - 0.36
Urine tox neg
Serum tox neg
.
Micro:
NGTD
.
Rads:
[**3-21**]: Head CT: No definite intracranial hemorrhage or mass
effect.
[**3-22**]: Head MRI: FINDINGS: No intracranial mass lesion,
hydrocephalus, shift of normally midline structures, minor or
major vascular territorial infarct is apparent. The signal
intensities of the brain parenchyma are normal. Specifically, no
increased T2 signal is seen in the parietal or occipital regions
to suggest posterior reversible encephalopathy. The surrounding
osseous and soft tissue structures are unremarkable. Major
vascular flow patterns are normal.
IMPRESSION: Unremarkable MRI of the brain.
Brief Hospital Course:
37 yo M with Type I DM, HTN, gastroparesis, ESRD on HD who
presented to ED with hypertensive urgency. Upon presentation it
was unclear when last time was that patient took meds, but
hypertension likely d/t inability to take meds in setting of
N/V. Also contribution of autonomic dysfunction. No evidence of
active end organ damage. His outpt meds were restarted and his
BP improved. Remainder of hospital course by problem:
.
# Mental Status Change - On day following admission, the patient
was found to be diaphoretic, confused, and had repetition of
speach saying only "dilaudid." A trigger was called and given
the acuteness of this change, he was transferred to the ICU.
DDx included possible toxic metabolic vs. HTN/hypotension.
Electrolytes and CBC were unchanged. There were no signs of
infection. CE were cycled and there was no acute EKG changes.
CT of head without bleed or mass. MRI brain was negative. His
mental status improved over the following three days and he was
at his reported baseline for at least 24h prior to discharge.
.
# AV fistula/Access - patient with h/o clotted fistula and with
very difficult peripheral access. His [**Month/Day (4) **] was held for two
nights in anticipation of possible portacath placement. He also
received vit k 1mg IV x1 on [**3-23**]. However, the procedure was
delayed and it was determined to be done as an outpatient. His
[**Month/Day (4) **] was held at discharge until after his port placement
scheduled for the following week. During his stay he had a
right femoral line placed, which was removed prior to discharge.
.
# Hypertension - patient with wild swings in BP. As above, was
hypertensive initially. We treated with his home meds.
.
# DM - We continued his home regimen of NPH 5u [**Hospital1 **] and HISS. He
had wild swings in his blood glucose with the lowest recorded in
the 20s. He was aware, and he improved with an amp of D50.
.
# Cards Vasc: After altered ms, EKG with unchanged ant ST elev
(likely J point elevation). Trop were mildly elevated. No
chest pain at this time. CK/MB stable.
- cont asa, bblocker
.
# ESRD - on HD and followed by renal. We continued calcium
acetate and HD as scheduled.
.
# Access - As above. He had a femoral line which was removed
prior to dispo. He is in need of a portacath given his frequent
admissions and difficult access.
.
FEN - DM/Renal diet
.
PPx - [**Hospital1 **], PPI, ambulating
.
Full Code
Medications on Admission:
1. Metoclopramide 10 mg q6hrs
2. Metoprolol 75tid
3. Calcium Acetate 667 mg Capsule PO TID
4. Ativan 1 mg Tablet Sig: One (1) Tablet PO q6h prn.
5. Dilaudid 4 mg PO q3-4hr prn.
6. Clonidine 0.3 mg/24 hr Patch Weekly
7. Clonidine 0.2 mg Tablet PO TID
8. Warfarin 1.5 mg PO DAILY
9. Nifedipine 30 mg Tablet Sustained Release PO daily
10. Pantoprazole 40 mg Tablet, Delayed Release
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. Humalog SS
13. Insulin NPH 2 UNITS Subcutaneous twice a day.
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed for agitation.
5. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every
3 to 4 Hours) as needed.
6. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
9. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Humalog 100 unit/mL Solution Sig: variable units
Subcutaneous four times a day: use sliding scale as directed.
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Two (2)
units Subcutaneous twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- hypertensive urgency
- altered mental status
- DMI
- ESRD on HD
Secondary:
- autonomic dysfunction
- s/p esophageal erosion
- hx of CAD
- hx of foot ulcerations
- h/o clot in AV graft x2
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital with hypertensive urgency.
You developed altered mental status and were monitored in the
ICU. You had a head CT and MRI which were negative. You
remained on hemodialysis.
.
Please take your medications as instructed. Please contact your
PCP if you experience shortness of breath, chest pain, worsening
abdominal pain, fevers, or chills.
.
We are holding your [**Hospital1 **] for your surgery. Do not take your
[**Hospital1 **] until you discuss when to restart it with your primary
care physician or nephrologist.
.
Please return on Tuesday [**2186-3-28**] at 12:30 to have your portacath
placed by surgery. It is very important for you to keep this
appointment.
Followup Instructions:
please return on Tuesday [**2186-3-28**] at 12:30pm for your portacath
placement. Please have nothing to eat since midnight the night
prior.
.
Please contact your PCP for an appointment within the next two
weeks. Please followup with your nephrologist as scheduled.
Completed by:[**2186-3-25**]
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3169
} | Medical Text: Admission Date: [**2137-6-6**] Discharge Date: [**2137-6-19**]
Date of Birth: [**2071-5-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Oxacillin / Ciprofloxacin
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest Pain/Dyspnea on Exertion
Major Surgical or Invasive Procedure:
[**2137-6-6**] Cardiac Cath
[**2137-6-10**] Aortic Valve Replacement with 23mm St. [**Male First Name (un) 923**] Regent
Mechanical Valve
History of Present Illness:
66-year-old male with aortic stenosis, atrial fibrillation,
coronary artery disease and type II diabetes who was admitted
for cardiac catheterization following an abnormal stress test.
He had been doing well until [**2137-5-1**] at which time he developed
chest burning and dypnea on exertion. He was admitted and
underwent nuclear stress test on [**2137-5-2**] where he was able to
exercise 6 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol and stopped due to
fatigue. Nuclear images revealed a new partially reversible
inferolateral wall perfusion defect and a fixed inferior wall
defect. He was referred for cardiac catheterization. In the cath
lab he was found to have single vessel coronary disease as
previously but his aortic valve area was 0.68 cm2. He is being
admitted for aortic valve replacement.
Past Medical History:
Aortic Stenosis, Diabetes Mellitus, Atrial Fibrillation, Chronic
Diastolic Heart Failure, Chronic Kidney Disease, Chronic back
pain, Gout, s/p Tonsillectomy
Social History:
He is married and works as a French and Spanish teacher in a
high school. He does not smoke or drink. He has two daughters.
Family History:
His mother had CABG @ age 80. Father died of Lung ca (smoker).
HTN and DM in family.
Physical Exam:
T: 97.9 BP: 117/73 HR: 83 RR: 18 O2: 97% on RA
General: Well appearing male, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: RRR, s1 + s2, II/VI SEM radiating throughout
Resp: clear to ausculation bilaterally, no wheezes, rales,
ronchi
GI: obese, soft, non-tender, non-distended, +BS
GU: no foley
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Skin: No rashes
Pulses: DP and PT pulses palpable bilaterally
Pertinent Results:
ECG ([**6-6**]): Atrial fibrillation at a rate of 82. ST-T wave
abnormalities.
Cardiac Catheterization ([**6-6**]): 1. Selective coronary
angiography of this right dominant system demonstrated single
vessel coronary artery disease. The left main demonstrated no
angiographically apparent flow limiting disease. The left
anterior descending artery demonstrated mild diffuse disease
throughout without any significant stenosis. The left
circumflex demonstrated a totally occluded obtuse marginal
filling via right to left collaterals. The right coronary
artery demonstrated no angiographically apparent disease. 2. LV
ventriculography was deferred. 3. Limited resting hemodynamics
demonstrated normal right (RVEDP 7 mm hg) and left (LVEDP 7 mm
Hg) heart filling pressures. The cardiac index calculated via
the Fick method was preserved at 2.0 L/min/m2. 4. The mean
pressure gradient across the aortic valve was 47 mm Hg and a
peak of 60 mm Hg. The calculated aortic valve area of 0.68 cm2.
The aortic valve was heavily calcified.
Echo ([**6-10**]): PRE-BYPASS: 1. The left atrium is dilated. Mild
spontaneous echo contrast is seen in the body of the left
atrium. The left atrial appendage emptying velocity is depressed
(<0.2m/s). 2. The right atrium is dilated. No atrial septal
defect is seen by 2D or color Doppler. 3. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is lateral wall hypokinesis of the
mid to the apical segments ). Overall left ventricular systolic
function is mildly depressed (LVEF= 45 %). 4. Right ventricular
chamber size and free wall motion are normal. 5. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. 6. The aortic valve leaflets are
moderately thickened. There is severe aortic valve stenosis
(area <0.8cm2). Mild (1+) aortic regurgitation is seen. 7. The
mitral valve leaflets are moderately thickened. Mild (1+) mitral
regurgitation is seen. Due to co-existing aortic regurgitation,
the pressure half-time estimate of mitral valve area may be an
OVERestimation of true mitral valve area. 8. There is no
pericardial effusion. POST-BYPASS: For the post-bypass study,
the patient was receiving vasoactive infusions including
phenylephrine and is being AV paced. 1. A well-seated bileaflet
valve is seen in the aortic position with normal leaflet motion
and gradients (mean gradient = 15 mmHg). No aortic regurgitation
is seen. 2. Left ventricular systolic function is low normal
(LVEF 45%). 3. Right ventricular systolic function is normal. 4.
Aortic contours are intact post decannulation.
Brief Hospital Course:
As mentioned in the HPI Mr. [**Known lastname **] was admitted following his
cardiac cath which revealed Aortic Stenosis and single vessel
coronary artery disease. He received medical management for
several days and underwent pre-operative work-up while awaiting
for surgery. On [**6-10**] he was brought to the operating where he
underwent a aortic valve replacement. 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-operative day one
his chest tubes were removed. He was started on beta blockers
and diuretics and gently diuresed towards his pre-op weight.
Also on this day he was started on Coumadin with Heparin bridge
for mechanical valve. Coumadin was titrated. On post-op day two
his epicardial pacing wires were removed and his was transferred
to the telemetry floor for further care. Cleared for discharge
to rehab on POD #11 Target INR is 2.5-3.0 for mechanical valve.
INR in uptrend on DC 2.1.
Medications on Admission:
Medications at Home: Niacin 1000 mg daily, KCL 10 mEq [**Hospital1 **], Lasix
80 mg 1-2 tabs daily prn, Zocor 20 mg 1 tab daily, Coumadin 2.5
mg 1 tab for 6 days and 3.75 every Saturday LD [**2137-6-2**], Ativan 1
mg qhs prn, Xanax 0.25 mg [**Hospital1 **] prn, Aldactone 25 mg daily, ASA 81
mg, 2 tablets daily, Lisinopril 10 mg daily, Metoprolol tartrate
100 mg [**Hospital1 **], Nitroglycerin 0.4 mg 1 tab sl q 5 min prn chest
pain, Novolog 70/30 40 Units [**Hospital1 **], Magnesium Oxide 400 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Niacin 500 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days: 7 days.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
10. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once):
goal is 2.5 - 3.
11. INSULIN
Insulin SC Fixed Dose Orders
Breakfast Dinner
70 / 30 40 Units 70 / 30 40 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL 4 oz. Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-140 mg/dL 2 Units 2 Units 2 Units 0 Units
141-200 mg/dL 4 Units 4 Units 4 Units 2 Units
201-240 mg/dL 6 Units 6 Units 6 Units 4 Units
241-280 mg/dL 8 Units 8 Units 8 Units 6 Units
12. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): until gouty flare up resolves then DC.
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Diabetes Mellitus, Atrial Fibrillation, Chronic Diastolic
Heart Failure, Chronic Kidney Disease, Chronic back pain, Gout,
s/p Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower daily, no baths, no lotions, creams or powders to
incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Dr. [**First Name (STitle) **] will be following your INR and adjusting your
Coumadin for a goal INR of 2.5-3 when you are discharged from
rehab.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 73**] in [**2-24**] weeks
Dr. [**First Name (STitle) **] in [**1-23**] weeks
Dr. [**First Name (STitle) **] will be following your INR and adjusting your
Coumadin for a goal INR of 2.5-3. Rehab: please contact Dr.
[**First Name (STitle) **] prior to his discharge from rehab. Daily INRs while at
rehab.
Completed by:[**2137-6-16**]
ICD9 Codes: 4241, 4280, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3170
} | Medical Text: Admission Date: [**2154-10-25**] Discharge Date: [**2154-10-28**]
Date of Birth: [**2084-6-29**] Sex: M
Service: MEDICINE
Allergies:
lisinopril / amlodipine
Attending:[**Last Name (NamePattern1) 15287**]
Chief Complaint:
dizziness with standing
Major Surgical or Invasive Procedure:
EGD (upper endoscopy)
History of Present Illness:
70 y/o M with h/o diverticulosis of the entire colon c/b LGIB in
the past, PAF on Coumadin c/b CVA when off Coumadin (no residual
deficits), CKD (baseline Cr 1.5) and HTN presenting from
[**Hospital 197**] clinic hypotensive with SBP 80s. Previously, he
required transfusion with 9U pRBCs and colectomy was
recommended; pt refused colectomy and his Couamdin was held. He
subsequently had an ischemic posterior CVA and his Coumadin was
restarted. In [**Hospital 197**] clinic he endorsed lightheadedness and
orthostasis and was sent to the ED. Denies BRBPR, hematemesis or
melena. He states that he is orthostatic most mornings, which
improves throughout the day, usually after eating breakfast.
.
In the ED, HCT was 25 (baseline 27-35) INR 3.8. Rectal exam was
negative for BRBPR, though stool was faintly guiac positive. He
was given 2L NS and GI was consulted; felt EGD could wait until
Monday. NG tube/lavage were not performed. 18G and 16G PIV were
placed at the PT was admitted to the MICU. VS at time of MICU
transfer: T 98 BP 130/60 HR 77 RR 18 Sat 99% RA.
.
MICU VS: T 98 BP 121/66 HR 68 RR 18 O2 Sat 100% RA
States he feels back at baseline, no complaints.
Past Medical History:
Diverticulosis, entire colon, c/b recurrent GIB, last [**2152**]
HTN
PAF on Coumadin
BPH
CKD, stage II
Renal cysts
CVA
Social History:
Works as cook at [**Last Name (un) **] College. Single, lives alone.
Has three grown children. Quit smoking >40 years ago. Prior
history of alcohol abuse, but has been sober x13 years.
Family History:
No significant CV disease including strokes in family.
+HTN and HLD in several members. No notable DM2 history.
Physical Exam:
Admission Exam:
T 98 BP 121/66 HR 68 RR 18 O2 Sat 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 7cm above the RA at 45 degrees, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Discharge Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 7cm above the RA at 45 degrees, no LAD
CV: Iregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
Pertinent Results:
ADMISSION LABS
[**2154-10-25**] 03:00PM BLOOD WBC-6.9 RBC-3.20* Hgb-7.9* Hct-25.7*
MCV-80* MCH-24.7* MCHC-30.7* RDW-17.9* Plt Ct-261
[**2154-10-25**] 03:00PM BLOOD Neuts-47.9* Lymphs-38.5 Monos-7.9 Eos-1.0
Baso-0.6
[**2154-10-25**] 02:26PM BLOOD PT-39.1* PTT-50.2* INR(PT)-3.8*
[**2154-10-25**] 02:26PM BLOOD Glucose-87 UreaN-24* Creat-1.5* Na-140
K-3.8 Cl-105 HCO3-24 AnGap-15
[**2154-10-25**] 02:26PM BLOOD ALT-24 AST-20 AlkPhos-84 TotBili-0.4
[**2154-10-25**] 02:26PM BLOOD Albumin-4.2
[**2154-10-26**] 02:13AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.7
[**2154-10-25**] 02:26PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2154-10-25**] 02:34PM BLOOD Lactate-1.0
.
Discharge Labs:
[**2154-10-28**] 07:05AM BLOOD WBC-8.3 RBC-3.59* Hgb-8.8* Hct-28.8*
MCV-80* MCH-24.6* MCHC-30.7* RDW-18.2* Plt Ct-248
[**2154-10-28**] 07:05AM BLOOD PT-23.9* PTT-42.0* INR(PT)-2.3*
[**2154-10-28**] 07:05AM BLOOD Glucose-105* UreaN-18 Creat-1.3* Na-139
K-3.9 Cl-104 HCO3-28 AnGap-11
[**2154-10-28**] 07:05AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.7
.
Micro:
[**2154-10-25**] 02:26PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2154-10-25**] URINE CULTURE-Neg
.
Studies:
[**2154-10-28**] EGD: Small hiatal hernia. Schatzki's ring. Normal mucosa
in the third part of the duodenum (biopsy). Otherwise normal EGD
to third part of the duodenum
.
Path:
[**2154-10-28**] Duodenal BIpsy: Pending
Brief Hospital Course:
70 y/o M with h/o diverticulosis of the entire colon c/b LGIB in
the past, PAF on Coumadin c/b CVA when off Coumadin (no residual
deficits), CKD (Cr 1.5) and HTN admitted to the MICU for GIB and
hypotension. Transfused 1U PRBC and remained HD stable, so
transferred to the floor. On the floor denied dizziness,
lightheadedness, fatigue, or other pre-syncopal symptoms. Had
EGD with normal appearing mucosa and no sign of stigmata of
bleed. Discharged with plan for capsule endoscopy.
.
Active Issues
# GIB: INR was supratherapeutic at 3.8 on admission. Coumadin
intially held. HD stable and Hct stable following 1U PRBC in ED.
Guiac positive, so thought this may represent slow GIB.
Initially treated in MICU, but quickly transferred to medicine
floor. Warfarin restarted at lower dose. Denied any melena/BRBPR
during stay. Has full colonic diverticula, but presentation not
consistent with diverticular bleed. Pt with iron deficiency
anemia and no EGD since [**2152**], so EGD performed to work up
anemia. No signs of active bleed or stigmata of prior bleed. Was
discharged with plans for capsule endoscopy as an outpatient.
Continued on PO omeprazole 20mg [**Hospital1 **].
.
#Paroxysmal A. fib: Pt was in and out of a. fib during this
admission. Coumadin initially held with supratherapeutic INR,
but was restarted when INR <3. The last time his INR was
subtherapeutic, he had a CVA. Was rate controlled without
medical intervention.
.
# Hypotension: Slightly hypotensive on presentation. Resolved
s/p 2L NS in the ED. Normotensive during stay on floor. Likely
related to hypovolemia; possibilities include GIB vs hypovolemia
from diuretic use. No fevers or localizing s/sx to suggest
sepsis. Patient reports chronic problem with orthostasis. Could
be possible med side effect from anti-hypertensive medications
vs. terazosin.
.
Chronic Issues:
# Hyperlipidemia: Continued aspirin and statin
.
# CKD: Cr 1.5 on admission, which is baseline. Discharged with
Cr of 1.3
.
# BPH: Continued Finasteride and Terazosin
.
Transitional Issues:
#Will need INR check on [**2154-10-30**] to determine if further
adjustment is necessary
#Will need to follow-up duodenal biopsy results
#Will get capsule endoscopy with GI for further work-up of ?GIB
.
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Atenolol 100 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
6. Terazosin 10 mg PO HS
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Ferrous Sulfate 325 mg PO TID
10. Cyclobenzaprine 5 mg PO TID:PRN msucle spasm
.
Discharge Medications:
1. Atenolol 100 mg PO DAILY
hold for sbp < 100, HR < 55
2. Finasteride 5 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
hold for SBP < 90, HR < 55
4. Omeprazole 20 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Terazosin 10 mg PO HS
7. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
8. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
gastrointestinal bleed
Hypotension
iron deficiency anemia
SECONDARY:
Diverticulosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 805**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for several days of weakness
and fatigue, low blood pressure, and blood in your stool. Your
blood count (hematocrit) was very low and you were transfused 1
unit of red blood cells. Because your blood pressure was low,
you spent the night in the intensive care unit. You were then
transferred to the medicine floor.
We wanted to make sure there was no slow bleed in your stomach
you we looked at it with a camera (endoscopy). This was normal
and did not show any signs of bleeding. You had biopsies taken
and will be contact[**Name (NI) **] with the results of the biopsy. You should
follow up with the GI doctors as [**Name5 (PTitle) **] outpatient for further
workup to determine what if you are bleeding. They will want you
to swallow a capsule that can take pictures of the portion of
your GI tract not seen with EGD.
Medications to CHANGE:
DECREASE warfarin from 6.25mg daily to 5mg daily (have INR
checked on [**2154-10-31**])
Followup Instructions:
Name: PA [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Appointment: Monday [**2154-11-4**] 11:30am
*This is a follow up appointment of your hospitalization. You
will be reconnected with your primary care provider after this
visit. Please have your hematocrit (blood count) checked at this
appointment.
We are working on a follow up appointment for your
hospitalization in [**Location (un) 2274**] Gastroenterology with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 85321**]. It is recommended you be seen within 1 month of
discharge. The office will contact you at home with the
appointment. If you have not heard within a few business days
please contact the office at [**Telephone/Fax (1) 2296**].
Department: NEUROLOGY
When: TUESDAY [**2154-12-10**] at 8:00 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
ICD9 Codes: 4589, 2768, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3171
} | Medical Text: Admission Date: [**2160-6-17**] Discharge Date: [**2160-6-30**]
Date of Birth: [**2160-6-17**] Sex: M
Service: NB
HISTORY: A 39-2/7 week's gestational age infant admitted to
the Neonatal Intensive Care Unit with respiratory distress.
MATERNAL HISTORY: A 29-year-old, gravida 2, para 0, now 1,
woman with the following antenatal screens: O positive,
antibody negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, GBS negative.
PREGNANCY HISTORY: EDC [**2160-6-22**]. Antepartum course
benign. Spontaneous onset of labor progressing to vacuum-
assisted vaginal delivery under epidural anesthesia.
Maternal interpartum fever to 99.3. No other clinical
evidence of chorioamnionitis. Rupture of membranes 10 hours
prior to delivery, initially yielding clear amniotic fluid,
but with terminal meconium noted at delivery. Triple nuchal
cord noted at delivery.
NEONATAL COURSE: Infant initially hypotonic, with meconium
noted on trunk only. Bulb suctioned, dried, brief CPAP
provided, but no bag mask ventilation. Infant developed
grunting respirations and retractions. Apgar scores were 6
at 1 minute and 7 at 5 minutes. [**Hospital **] transferred to the
Neonatal Intensive Care Unit in 100 percent oxygen.
PHYSICAL EXAM ON ADMISSION: Birthweight 3,240 gm, length 52
cm, head circumference 32.5 cm. Term-appearing infant in
mild respiratory distress. Anterior fontanelle soft and flat,
moderate caput, nondysmorphic, palate intact, moderate nasal
flaring. Mild retractions, fair breath sounds bilaterally, a
few scattered, coarse crackles. Well-perfused, regular rate
and rhythm, femoral pulses normal, normal S1, S2, no murmur.
Abdomen soft, nondistended, no organomegaly, no masses, bowel
sounds active, anus patent, three-vessel cord. Normal male
genitalia, testes descended bilaterally. Active, tone normal
and symmetric, moving all extremities, normal
grasp/suck/gag/Moro. Skin intact. Normal spine, limbs,
hips, clavicles.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: [**Hospital **] transferred to
the Neonatal Intensive Care Unit for respiratory distress and
was initially placed on nasal CPAP. Initial chest x-ray
showed [**8-29**] ribs expanded, left lower lobe opacification,
possible atelectasis, otherwise normal parenchyma. Small
right pneumothorax without mediastinal shift. Infant changed
from CPAP to an Oxyhood at 100 percent for nitrogen washout.
Initial arterial blood gas on admission showed a pH of 7.32,
CO2 37, PAO2 115, bicarb 20, base excess minus 6. Infant
weaned on the oxygen [**Doctor Last Name **], and respiratory symptoms subsided
spontaneously. A repeat chest x-ray on day of life 1 showed
improvement of the right pneumothorax, and the infant weaned
to room air by day of life 2. The infant did not require
needle aspiration or chest tube placement. The pneumothorax
resolved spontaneously. Respiratory rates have been in the
30's-50's. Infant noted to have desaturations to as low as
60 percent, requiring blow-by oxygen at times which improved
over time. The last desaturation requiring mild stimulation
was on [**6-25**].
CARDIOVASCULAR: The infant required 2 normal saline boluses
of 10 cc/kg each on admission for poor perfusion. Perfusion
improved, and the infant has remained hemodynamically stable
this hospitalization. Heart rate 130's-150's, no murmur.
FLUID, ELECTROLYTES AND NUTRITION: The infant was initially
receiving nothing by mouth but 60 cc/kg/D of D10W. Enteral
feedings were started on day of life 2 of Enfamil 20 cal/oz
or breast milk 20 cal/oz. Infant has been feeding ad lib
breast milk 20 cal/oz or breastfeeding po, and taking 120-160
cc/kg/D. Voiding and stooling qs. Infant has tolerated
feedings without difficulty. The most recent weight was
3,270 gm.
GI: The most recent bilirubin level drawn on day of life 2
showed a total bili of 1.7 with a direct of 0.5. The infant
has not received phototherapy this hospitalization.
HEMATOLOGY: CBC on admission a white blood cell count of
41.2, hematocrit 51.2 percent, platelets 269,000, 52
neutrophils, 4 bands, 37 lymphocytes. A repeat CBC on day of
life 2 showed a white blood cell count of 21.3, hematocrit
53.3 percent, platelets 283,000, 59 neutrophils, 0 bands.
The infant has not received any blood transfusions this
hospitalization.
INFECTIOUS DISEASE: The infant received 48 hours of
ampicillin and gentamicin for respiratory distress. Blood
cultures remain negative.
NEUROLOGY: Due to frequent desaturations and vacuum-assisted
delivery, a head ultrasound was done on day of life 10 which
was within normal limits. No intraventricular or
intracranial hemorrhages noted. Infant has had a normal
neurological exam, no seizure activity.
SENSORY: Hearing screening was performed with automated
auditory brain stem responses. Infant passed both ears.
PSYCHOSOCIAL: Parents very involved.
CONDITION AT DISCHARGE: Full-term infant, stable on room
air.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 36246**], phone
number [**Telephone/Fax (1) 36247**], fax number [**Telephone/Fax (1) 58423**].
CARE RECOMMENDATIONS:
1. Feedings at discharge: Breastfeeding or breast milk 20
cal/oz, po ad lib.
2. Discharge medications: Vi-Daylin 1 ml po qd.
3. Car seat position screen: Infant passed car seat test
prior to discharge.
4. State newborn screens: Sent on day of life 2 and day of
life 13, results are pending.
5. Immunizations: Infant received hepatitis B vaccine on
[**2160-6-23**].
6. Follow-up appointment: Primary pediatrician and VNA to
visit on Wednesday, [**7-2**].
DISCHARGE DIAGNOSES: Status post respiratory distress
secondary to pneumothorax.
Status post rule out sepsis, ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2160-6-30**] 14:10:16
T: [**2160-6-30**] 14:56:01
Job#: [**Job Number **]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3172
} | Medical Text: Admission Date: [**2151-1-25**] Discharge Date: [**2151-1-27**]
Date of Birth: [**2077-10-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain, hypotension
Major Surgical or Invasive Procedure:
Stress MIBI test
History of Present Illness:
73 year old patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] with a history of
rheumatic heart disease with moderate MR [**First Name (Titles) **] [**Last Name (Titles) **], PAF (on
coumadin), hypertension who has a history of vague chest pain.
She was admitted to [**Location (un) **] back in [**Month (only) 359**] and ruled out.
Stress on [**2150-11-9**] exercised for 4 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol
to a heart rate of 98. She experienced no chest pain and had no
significant ST-T wave changes. Nuclear images did show a
posterolateral reversible defect in addition to a small anterior
apical defect. She was seen last week by Dr. [**Last Name (STitle) 11493**] in the office
for evaluation of near syncope and given an event monitor. Today
she went to the [**Location (un) **] ER due to increasing chest pain over the
past week with associated weakness. No significant findings on
event monitor per [**Doctor Last Name 11493**]. Per patient, she has had symptoms of
left shoulder pain radiating down her left arm and up left jaw
for many years and all previous work-up has been negative.
However, in past month, she has developed a new type of chest
discomfort over entire chest and associated with nausea and
feeling fatigued and lightheaded. No palps, no SOB, no LOC, no
association with any activity. She has 4 episodes a day lasting
about 5 minutes. Nothing make it better or worse and they occur
irregardless of activity.
.
Upon arrival to [**Location (un) **] ER, INR 3.3. EKG without acute findings
of ischemia. She received SLNTG X3 with no effect. Nitro gtt
started and CP free after 30 min. Then, 45 min later developed
hypotension to 84/36, pt asymptomatic -> nitro gtt stopped, 500
of NS, then 1L NS bolus. SBP in mid80's and she was transferred
to [**Hospital1 18**].
.
On route to [**Hospital1 18**], SBP dropped again->500 cc NS given. SBP
dropped to 47/26 -> started dopamine 20 mcg in ambulance. BP
rose to 110-130s within 5 minutes. NO chest pain, palps, SOB
during this, but did feel more fatigued.
.
In CCU, afebrile, 111/64, 62, 100%2LNC. She reports feeling
fatigued, but no other symptoms of CP, palp, SOB, LHD,
dizzyness. At baseline, she can climb 2 flights of stairs and
now feels slightly more fatigued than usual.
.
ROS remarkable for intermittent right eye loss of vision "like
blind pulled down" for past month, occasional tingling and
numbess of right face for at least 6 years (prior to stroke).
+PND, sleeps with 2 pillows, no LE swelling, no pleuritic CP,
recent illnesses, bladder/bowel changes.
Past Medical History:
- HTN
- hyperlipidemia
- PAF: on coumadin, started propafenone 2 years ago which has
kept her in sinus
- Hx of rheumatic fever: MR/MS [**Name13 (STitle) **] per Dr. [**Last Name (STitle) 11493**] note, no
significant valvular disease
- GERD
- Stroke: 6 years ago with recovery of right hand function
- thyroidectomy due to goiter
- colon cancer s/p surgery and chemotherapy
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is family history of premature coronary artery disease or
sudden death in brother who died of MI age 51.
Father: stroke, lung ca, HTN, MI
Physical Exam:
VS 96.0 104/56 62 17 99% 2LNC
Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 8 cm; no carotid bruits
CV: RR, normal S1, S2. I/VI systolic murmur at apex. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: trace pitting edema; faint DP pulses bilaterally
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
EKG demonstrated sinus rhythm, 60bpm, nl axis, PR 200 msec, no
ST or TW changes compared to earlier in day. PR from OSH EKG
TELEMETRY demonstrated: normal rhythm,
2D-ECHOCARDIOGRAM: Per patient, she had an echo 1 week prior
which was reportedly normal
ETT: Per Dr. [**Last Name (STitle) 11493**] notes: [**2150-11-9**]. 4 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
protocol to a heart rate of 98. She experienced no chest pain
and had no significant ST-T wave changes. Nuclear images did
show a posterolateral reversible defect in addition to a small
anterior apical defect.
CXR: In comparison with the study of [**1-25**], the patient has
taken a
better inspiration. The cardiac silhouette is within normal
limits with mild prominence of the ascending aorta that would
reflect aortic stenosis or hypertension.
Pertinent labs on discharge:
[**2151-1-27**] WBC-3.9* RBC-3.93* Hgb-12.1 Hct-36.0 MCV-92 MCH-30.8
MCHC-33.6 RDW-13.7 Plt Ct-149*
[**2151-1-27**] PT-16.9* PTT-31.5 INR(PT)-1.5*
[**2151-1-26**] PT-32.5* PTT-38.3* INR(PT)-3.4*
[**2151-1-25**] PT-31.8* PTT-37.7* INR(PT)-3.3* ->given 5mg PO vit K
[**2151-1-26**] TSH-2.9 Free T4-1.3
[**2151-1-26**] %HbA1c-6.1*
[**2151-1-26**] Triglyc-107 HDL-40 CHOL/HD-3.3 LDLcalc-70
Brief Hospital Course:
Patient is a 73 y/o F hx PAF on coumadin, HTN, bradycardia and
first degree AVB now presents with chest pressure and
lightheadedness
CAD: Patient has no known diagnosis of CAD, and cardiac cath
from [**2148**] from [**Hospital3 2568**] had clean coronary arteries. She ruled
out for an MI here and had a stress stress P - MIBI which
revealed no perfusion defects and an LVEF of 65%. Recent stress
test per OSH cardiologist notes echo done last week per Dr.
[**Last Name (STitle) 11493**] no valve abnormalites. Prior report of MS/MR incorrect.
She has been having these symptoms for the past month and her
cardiologist felt that there may be a component of near syncope
[**3-13**] bradycardia as opposed to CAD. However, her symptoms were
relieved with nitro. NO EKG changes. [**Hospital3 **] cath report from
[**2148**] show clean coronary arteries. Given negative stress,
recent cath that was negative, reportedly normal echo a decision
was made not to cath the patient. Beta blocker, aspirin, statin
were continued. Her coumadin was held as an inpatient as she
was supratherapeutic, this drifted down to INR 1.5 upon
discharge, she was discharged with a lovenox bridge. A1C 6.1%.
LDL 70, HDL 40, Total 131, Trig 107.
Chest Pain: 2 weeks at most 30 min at a time, no assoc w/
exerction, not reproduced w/ palpation dull in nature, several
times per day. Supratherapeutic on couadmin and not pleurtic
making PE less likely, no tenderness on exam so costochondritis
is less likely, cannot rule out coronary vasospasm. Patient
should also have a workup for GERD as an outpatient.
Rhythm: Hx of paroxsysmal afib, continue anticoagulation and
propafenone. INR 1.4 on discharge, discharged with lovenox
bridge with close follow up with her primary cardiologist.
Hypotension: patient was hypotensive in the setting of nitro
gtt, transiently on a dopamine drip for a SBP in the 40s
although the patient was mentating at the time and there is a
question as to whether the pressure was actually as low as
recorded. Hypotension did not return and the patient was
normotensive with the addition of her home antihypertensive
regimen.
Loss of vision/curtain like loss of vision in R eye on waking
for the past month. temporal arteritis given ESR of 7 and
normal physical exam. Normal carotids on exam, possibly TIA,
the patient should have carotid ultrasounds as an outpatient at
an early date if she has not already had them. She is on
aspirin and anticoagulated.
Medications on Admission:
propafenone 150 mg b.i.d.
aspirin 325 mg
Cozaar 50 mg
Levoxyl 112 mcg daily
Prilosec 20 mg
Zocor 20 mg
metoprolol 50 mg b.i.d.
Coumadin 3 mg daily
Discharge Medications:
1. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Propafenone 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once
Daily at 16).
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day): Continue taking lovenox
injections until INR is between [**3-14**] on coumadin as directed by
your primary care physician.
[**Name Initial (NameIs) **]:*14 syringes* Refills:*1*
10. Outpatient Lab Work
Please check PT/INR on [**2151-1-29**] at Dr.[**Name (NI) 62094**] Office and
every week thereafter. Please follow up results with him to
decide on coumadin dosing and how long to continue with the
lovenox injections
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Atypical chest pain
Secondary diagnoses:
Paroxysmal atrial fibrillation on coumadin
Hypertension
Hyperlipidemia
History of rheumatic fever
Discharge Condition:
Good, chest pain free, ambulating
Discharge Instructions:
You were admitted for workup of chest pain, lightheadness. You
had a full workup of your heart which was negative for any
problems with your heart as the reason for your symptoms. This
was including a stress test that was negative for any
significant cardiac abnormalities.
While you were here, your coumadin level (INR) was found to be
low. We have started you on a medication, Lovenox, to be
injected twice daily. This should be continued until your INR
becomes therapeutic at a level of [**3-14**]. You should follow up with
your primary care doctor this week for regular checks of your
INR to determine when you can stop this medication. Your first
lab check for this will be in 2 days from discharge on [**2151-1-29**]
where you should get your INR checked before your annual
physical exam with Dr. [**Last Name (STitle) 27542**].
Please take all your medications as prescribed and keep all
follow up appointments. We made no changes to your medications
except the addition of the lovenox injections twice a day until
your INR is within the 2-3 range on your coumadin and Dr.
[**Last Name (STitle) 27542**] gives the okay for you to stop the lovenox
injections.
If you develop chest pain, increased shortness of breath, severe
weakness or any other symptom that concerns you, please call
your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room as soon as
possible.
Followup Instructions:
Please keep the following appointment:
Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2151-2-15**] 9:40
It is very important that you follow up with your primary care
doctor, Dr. [**Last Name (STitle) 27542**], this week to check your coumadin level
(INR). Please keep your follow up appointment on [**2151-1-29**] with
Dr. [**Last Name (STitle) 27542**]. At this visit, and weekly afterwards, he will
need to follow up on your INR level to decide how long you
should continue on the lovenox injections.
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3173
} | Medical Text: Admission Date: [**2133-6-18**] Discharge Date: [**2133-6-22**]
Date of Birth: [**2099-9-28**] Sex: F
Service: MEDICINE
Allergies:
Unasyn / Vancomycin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
periorbital swelling and erythema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
33F without significant PMHx admitted with one day h/o
progressively worsening pain and swelling around her right eye.
She reports that her symptoms started on the evening prior to
admission with a raised painful bump in the corner of her right
eye. She reports touching it freqently but denies trying to open
in up or drain it. The swelling progressed and by the next
morning it was significantly more swollen. She presented to her
PCP who immediately referred her to the ED.
In the, she was noted to have temp 102, HR in the 100s, BP was
stable. She was given 3L IVF and a dose of vanc and unasyn. She
was admitted to the medical floor. Soon after arrival to medical
floor she was noted to have BP 80s and lactate 3.3. She was
given an additional 3L of IVF on the floor though remained
hypotensive for roughly 1 1/2 hours while awaiting an ICU bed,
however on arrival to ICU bp was 108/62.
Past Medical History:
none
Social History:
lives with roomates, denies tobacco use, drinks [**5-2**] alcoholic
beverages per week, denies any past or present drug use, no
sexual contacts in past 6 months.
Family History:
denied any significant family history
Physical Exam:
VS: Tm 102 HR 106 108/62 32 97RA
General: awake, alert, in no distress, pleasant and conversant
HEENT: R eye periorbital swelling and erythema involving lids as
well as conjunctiva itself. She is able to move eyes with full
ROM and no pain. PERRL
Chest: CTAB
CV: RRR, no m/r/g
Abd: soft, NT/ND
Ext: warm, dry no edema
Pertinent Results:
[**2133-6-18**] CT Orbits:
1. Significant soft tissue swelling, centered on the eyelid,
involving the right side of the face from the level of the
mandible to the right frontal region.
2. Extensive right preseptal swelling about the orbit, without a
discrete abscess. No evidence of post-septal involvement.
3. Slight hyperenhancement of the superficial aspect of the
right lacrimal gland, may reflect secondary inflammation from
the overlying facial cellulitis rather than true lacrimal
cellulitis.
[**2133-6-19**] CXR: There are low lung volumes that accentuate the
cardiac silhouette. The lungs are clear. There is no
pneumothorax or pleural effusion
Notable Admission Labs:
[**2133-6-18**] 01:45PM WBC-32.5*# RBC-4.25 HGB-11.9* HCT-35.3*
MCV-83 MCH-28.1# MCHC-33.8 RDW-14.8
[**2133-6-18**] 01:52PM LACTATE-3.3*
[**2133-6-18**] 02:00PM GLUCOSE-131* UREA N-9 CREAT-0.9 SODIUM-133
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-26 ANION GAP-12
Discharge Labs:
[**2133-6-22**] 04:45AM BLOOD WBC-8.8 RBC-3.60* Hgb-10.2* Hct-29.9*
MCV-83 MCH-28.4 MCHC-34.2 RDW-14.8 Plt Ct-291
[**2133-6-22**] 04:45AM BLOOD Glucose-111* UreaN-5* Creat-0.6 Na-139
K-4.0 Cl-105 HCO3-27 AnGap-11
[**2133-6-19**] 11:45AM BLOOD Lactate-1.9
Brief Hospital Course:
In the ED, she was noted to have temp 102, HR in the 100s, BP
was stable. She was given 3L IVF and a dose of vanc and unasyn.
CT orbits showed significant soft tissue swelling involving the
right side of the face from the level of the mandible to the
right frontal region, extensive right preseptal swelling without
a discrete abscess, slight hyperenhancement of the right
lacrimal gland, may reflect secondary inflammation from the
facial cellulitis rather than a dacryocystitis. She was
evaluated by ENT and opthomalogy.
She was admitted to the medical floor for management of
orbital/periorbital cellulitis and presumed sepsis. Soon after
arrival to medical floor she was noted to have BP 80s and
lactate 3.3. She was given an additional 3L of IVF on the floor
though remained hypotensive for roughly 1 1/2 hours while
awaiting an ICU bed, however on arrival to ICU bp was 108/62.
In the ICU her BP was stable, she was continued on her IV
antibiotics. The pain in her face improved and her swelling
objectively improved over night. She was considered stable for
discharge to the medical floor. A two week course of abx are
planned with a PICC line after blood cultures remain negative.
Ms. [**Known lastname 30533**] is a 33 yo generally healthy female admitted with
one day h/o progressively worsening pain and swelling c/w early
pre-septal orbital cellulitis and SIRS/Sepsis.
1)Early orbital cellulitis - She presents with rapidly
progressing right periorbital soft tissue swelling and erythema
c/w periorbital cellulitis (pre-septal), likely originating from
cutaneous source. Also with findings on exam concerning for
early orbital cellulitis including conjunctival erythema and
edema as well as lacrimal gland swelling. She was followed by
opthamology throughout her admission. She improved on IV
antibiotics initially vancomycin and unasyn. There was no
evidence of deeper post septal spread of infection on CT scan.
Wound cultures were positive for Group A strep and she was
changed to Augmentin on discharge to complete a two week course.
Blood cultures were all negative.
2)SIRS/Sepsis - On admission she had high fevers, hypotension
with SBP in the 80's, tachycardia, and markedly elevated WBC
count c/w SIRS/early sepsis. She was [**Hospital 30534**] transferred to
the ICU for overnight monitoring given the severity of her
infection. She responded to 3L IVF and did not require
pressors. She was treated with vancomycin and unasyn while in
the ICU and blood pressure stabilized by the following day and
she was called out to the floor. She remained hemodynamically
stable throughout the remainder of her admission.
Medications on Admission:
MTV
ferrous sulfate
B vitamin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 12 days: Last day of
antibiotics [**2133-7-3**].
Disp:*36 Tablet(s)* Refills:*0*
3. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. Ferrous Sulfate Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Orbital Cellulitis
SIRS
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital because you had a serious
infection around your eye. You were treated with IV antibiotics
and monitored initially in the ICU. You improved on antibiotic
and you were changed to oral antibiotics prior to discharge.
Medications:
1) You were discharged on Augmentin to complete a 2 week course
of antibiotics.
No other medications were added.
Please follow up as below.
Please call your doctor or return to the hospital if you
experience any concerning symptoms including worsening of the
swelling, redness or pain around your eye, fevers, change in
your vision or any other worrisome symptoms.
Followup Instructions:
Please call Dr. [**First Name (STitle) 1395**] at [**Telephone/Fax (1) 2205**] and schedule an
appointment to follow up within 2 weeks of discharge.
You will need to follow up with opthamology in the next week.
Please call the clinic tomorrow at [**Telephone/Fax (1) 253**] to schedule an
appointment.
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3174
} | Medical Text: Admission Date: [**2194-11-26**] Discharge Date: [**2194-12-2**]
Date of Birth: [**2117-7-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Pravachol / Lipitor / Zocor / Vytorin / Crestor / Boniva /
Fosamax / Niaspan / Latex
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2194-11-28**] Coronary Artery Bypass Graft x 3 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
obtuse marginal, Saphenous vein graft to posterior descending
artery)
History of Present Illness:
77 year old female with history of hypertension, hyperlipidemia,
and carotid artery stenosis with complaints of exertional chest
pain and episodes of shortness of breath at rest. She had an
abnormal stress test yesterday and was referred for cardiac
catheterization. Now asked to evaluate for surgical
revascularization given 3VD.
Past Medical History:
Hypertension
Hyperlipidemia
Carotid artery stenosis
Osteoporosis
Degenerative joint disease-Right knee
Right hip trochanter bursistis
Basal Cell CA Left cheeck
Irritable bowel syndrome
?Right nostril hemangioma- (in chart, pt unsure)
s/p Mohs surgery x2 Left cheek
s/p Tonsillectomy
s/p cholecystectomy
Social History:
Race:Caucasian
Lives with:husband
Occupation:Retired
Tobacco:denies
ETOH:occasional
Family History:
Father died of CAD in 50s; mother died of CAD in her 70s; son
with MI, CAD, and stents
Physical Exam:
Pulse:57 Resp: 18 O2 sat: 100%RA
B/P Right:162/61 Left: 173/59
Height:5'5" Weight:125 lbs
General: comfortable
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur negative
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact. moves 4 ext
Pulses:
Femoral Right: drsg c/I/D Left:palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: Left:
Radial Right: palp Left: palp
Carotid Bruit Right: (-) Left: (-)
Pertinent Results:
[**2194-11-28**] 01:39PM BLOOD WBC-9.8 RBC-3.71* Hgb-10.9*# Hct-31.5*
MCV-85 MCH-29.5 MCHC-34.7 RDW-13.7 Plt Ct-203
[**2194-11-27**] 04:59PM BLOOD PT-13.0 PTT-58.6* INR(PT)-1.1
[**2194-11-26**] 09:10PM BLOOD PT-13.0 PTT-22.2 INR(PT)-1.1
[**2194-11-26**] 09:10PM BLOOD Glucose-113* UreaN-37* Creat-1.3* Na-141
K-3.7 Cl-101 HCO3-28 AnGap-16
[**2194-11-26**] 09:10PM BLOOD ALT-14 AST-21 LD(LDH)-222 CK(CPK)-36
AlkPhos-50 TotBili-0.4
[**2194-11-26**] 09:10PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2194-11-26**] 09:10PM BLOOD Albumin-4.6
[**2194-11-26**] 09:10PM BLOOD %HbA1c-5.8
========================================================
[**2194-12-1**] 05:55AM BLOOD WBC-9.8 RBC-4.02*# Hgb-11.5*# Hct-33.1*
MCV-82 MCH-28.6 MCHC-34.8 RDW-15.7* Plt Ct-158
[**2194-12-1**] 05:55AM BLOOD Plt Ct-158
[**2194-12-1**] 05:55AM BLOOD Glucose-93 UreaN-16 Creat-0.9 Na-141
K-4.2 Cl-103 HCO3-29 AnGap-13
=========================================================
Radiology Report CHEST (PA & LAT) Study Date of [**2194-12-2**] 9:38
AM
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman s/p CABG
FINDINGS: In comparison with the study of [**12-1**], there is
persistence of a
small right apical pneumothorax. Continued bilateral pleural
effusions with relatively mild engorgement of pulmonary vessels.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: TUE [**2194-12-2**] 10:21 AM
=
=
=
=
=
================================================================
Brief Hospital Course:
Mrs [**Known lastname 24224**] was admitted to [**Hospital1 18**] preoperatively after having
several episodes of chest pain at home while awaiting coronary
bypass surgery. On day of admission she was ruled out for
myocardial infarction and started on heparin infusion. She had
no further episodes of chest pain. On [**11-28**] she was brought to
the operating room where she underwent a coronary artery bypass
graft x3. Please see operative report for surgical details. I
summary she had Left internal mamary to left anterior descending
artery, reverse saphenous vein graft to obtuse marginal artery
and reverse saphenous vein graft to posterior diagonal artery.
her bypass time was 63 minutes with a crossclamp of 56 minutes.
She tolerated the operation well and following surgery she was
transferred to the CVICU for continued monitoring. She did well
in the immediate post-op period was weaned from sedation, awoke
neurologically intact and extubated. She was hemodynamically
stable and weaned off of all vasoactive medications on the
operative night. Her chest tubes and pacing wires were removed
per cardiac surgery protocol. She was started on Bblockers and
these were titrated up. She was transferred to the floor on
POD#2. She did experience some nausea and indigestion on
transfer to the floor and this was treated with zofran and
reglan with good effect. She was very anxious and had to have
several family members present at times to help calm her down.
Her activity level was advanced with the assistance of physical
therapy. The remainder of her hospital course was uneventful and
on POD 4
it was decided she was ready for transfer to rehabilitation at
Lifecare in [**Location (un) 5165**].
Medications on Admission:
ASA 81mg po daily
Atenolol 50mg po daily
HCTZ 25mg po daily
Vitamin D 1000 units po BID
Fluocinonide topical 0.025% PRN:rash
Discharge Medications:
1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once 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. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
7. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for throat discomfort.
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for
HR<60
SBP<100.
11. Fluocinonide 0.1 % Cream Sig: as directed Topical once a
day as needed for rash.
12. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x3 with
LIMA-LAD, SVG-OM, SVG-PDA
PMH: Hypertension
Hyperlipidemia
Carotid artery stenosis
Osteoporosis
Degenerative joint disease-Right knee
Right hip trochanter bursistis
Basal Cell CA Left cheeck
Irritable bowel syndrome
? Right nostril hemangioma- (in chart, pt unsure)
s/p Mohs surgery x2 Left cheek
s/p Tonsillectomy
s/p cholecystectomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact you [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with all wound issues.
2) Report any fever of greater then 100.5
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) Please shower daily. Wash wound with soap and water. No
lotions, creams or pwoders to incision until it has healed.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month from date of surgery.
7) Please call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] in [**2-25**] weeks
Dr. [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) **] in [**1-24**] weeks
Completed by:[**2194-12-2**]
ICD9 Codes: 4111, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3175
} | Medical Text: Admission Date: [**2114-2-14**] Discharge Date: [**2114-2-23**]
Date of Birth: [**2067-3-6**] Sex: F
Service: MEDICINE
Allergies:
Latex / Penicillins
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation
Central venous catheterization
History of Present Illness:
Ms. [**Known lastname 60258**] is a 46 year-old woman with history of advanced
interstitial lung disease, likely NSIP, chronic diastolic CHF,
DM, and chronic pain s/p MVA who presents with respiratory
failure. Patient unable to provide history, so HPI gathered from
OMR and sign-out. Patient was presumably in USOH on home O2 and
began to feel unwell over the past 7 days, with increased home
O2 requirement, fever, cough and sputum production. She saw her
PCP who treated her for presumed asthma exacerbation and started
the patient on a steroid taper (unclear dose). The patient did
not improve with this treatment regimen. At home, patient's
respiratory distress worsened and she called EMS who took her to
OSH ED. At OSH she was found to be hypoxic to 60-70's on RA, she
was treated with 750 mg levaquin, 125 mg solumedrol, 4 mg
morphine, duonebs and 12.5 mg benadryl, and transfered to [**Hospital1 18**]
for further care.
.
In the ED, initial vs were: T AFeb P 116 BP 118/69 R 30 O2 sat.
85% 7L. Patient was given etomidate, succinylcholine and
vecuronium for intubation and sedated with propofol. She was [**Last Name (un) **]
given 1g IV ceftriaxone, 100 ucg fentanyl, and albuterol nebs.
Even on the ventilator, her O2 Sats were still in the 80's with
ABG 7.07/91/78 on 100% FiO2. After optimization of her
ventilator settings with low RR and high Vt, the patient's O2
sats improved to 90's. On the floor, the patient was intbuated
and sedated. IV access was challenging to obtain and a central
line was placed. Her vitals were HR 121 BP 128/59 RR 20 O2 Sat
98% on 100% FiO2.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Non-specific interstitial pneumonitis (possibly idiopathic
pulmonary hemosiderosis?)
- s/p lung biopsy by VATS [**2109**] at [**Hospital1 **], lost to follow-up until
[**2112**]
- followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], perhaps started prednisone course
[**2114-1-30**]
- Home O2 requirement of ~4L
- [**2114-1-2**] PFTs: DLCO 40% predicted, TLC 58% predicted, FEV1 54%
- Overall consistent with restrictive lung disease
CHF with recent hospitalization (per OMR)
Diabetes
Depression
Chronic pain status post MVA
?Cardiomegaly
TTE with ?rheumatic MV disease
CAD s/p MI (normal MIBI in [**2109**])
Cervical dysplasia
Colonic polyps s/p multiple polypectomies
Hiatal hernia
Migraines
PSH:
TAH-BSO
Cervical cone bx
Mediastinoscopy & L VATS [**2109**]
Social History:
She lives in [**Location **]. She is currently widowed. She has been
disabled after a motor vehicle accident which happened several
years ago.
- Tobacco: ~25 pack year history
- Alcohol: denies
- Illicits: h/o illicit drug use in youth
Family History:
She has two children. She has several relatives who have had
lung problems and has died from complications related lung
disease. Her mother had COPD, died of respiratory failure,
father with cardiovascular disease. She had a sister
who died after a lung biopsy was performed. She states that
several of her family members may have had asbestos exposure
including the patient.
Physical Exam:
ON ADMISSION:
Vitals: AFeb HR 121 BP 128/59 RR 20 O2 Sat 98% on 100% FiO2
General: Intubated, mildly sedated, in mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, difficult to assess JVP due to short, thick neck
Lungs: Tubular, coarse breath sounds anteriorly with occasional
expiratory squeaks
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
ON DISCHARGE:
Vitals: 97.5 HR 58 BP 100/66 RR 20 O2 Sat 98% on 6L NC
General: NAD, comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no JVP
Lungs: Symmetric chest rise, no increased resp effort, dew
scattered crackles. 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.
Pertinent Results:
ADMISSION LABS:
[**2114-2-13**] 11:40PM WBC-10.6 RBC-4.06* HGB-11.3* HCT-32.9*
MCV-81* MCH-27.9 MCHC-34.5 RDW-15.1
[**2114-2-13**] 11:40PM NEUTS-89.4* LYMPHS-7.4* MONOS-2.3 EOS-0.5
BASOS-0.3
[**2114-2-13**] 11:40PM PLT COUNT-198
[**2114-2-13**] 11:40PM GLUCOSE-227* UREA N-10 CREAT-0.9 SODIUM-133
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-21* ANION GAP-18
[**2114-2-13**] 11:54PM LACTATE-2.3* K+-4.0
[**2114-2-13**] 11:40PM PT-14.8* PTT-35.6* INR(PT)-1.3*
[**2114-2-13**] 11:40PM proBNP-1023*
[**2114-2-13**] 11:40PM cTropnT-<0.01
MICRO:
[**2114-2-13**] BLOOD CULTURE X2 - NGTD (PENDING)
[**2114-2-14**] 10:30 am Influenza A/B by DFA
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2114-2-14**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2114-2-14**]):
Negative for Influenza B.
[**2114-2-14**] 11:07 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2114-2-14**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2114-2-16**]):
Commensal Respiratory Flora Absent.
YEAST. RARE GROWTH.
[**2114-2-15**] 10:37 am URINE Source: Catheter.
URINE CULTURE (Final [**2114-2-16**]): NO GROWTH.
[**2114-2-15**] 12:05 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2114-2-15**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
[**2114-2-15**] BLOOD CULTURE - NGTD (PENDING)
STUDIES:
[**2114-2-13**] CXR: Interval recurrence or progression of diffuse
alveolar
opacification in setting of known chronic interstitial lung
disease (NSIP/ILD leading diagnostic considerations per OMR).
This could be pulmonary edema or widespread pneumonia or
hemorrhage. Given the course consideration should also be given
to drug or toxin exposure exacerbating a preexisting reaction.
[**2114-2-14**] TTE: Suboptimal image quality. Right ventricular cavity
enlargement with free wall hypokinesis. Normal left ventricular
cavity size and regional/global systolic function. Mild mitral
stenosis.
Compared with the prior study (images reviewed) of [**2110-4-9**],
the right ventricular findings are new and suggestive of
myocardial contusion. The severity of mitral stenosis has
increased. The severity of mitral regurgitation has declined
(may be due to tachycardia and suboptimal image quality).
[**2114-2-15**] EKG: Sinus rhythm and increase in rate as compared to
the previous tracing of [**2110-4-9**]. There is right axis deviation
and low limb lead voltage. There is now ST segment elevation in
leads V1-V3 with biphasic to inverted T waves in leads V1-V5,
more prominent as compared to the previous tracing of [**2110-4-9**].
The rate is increased. These findings are consistent with active
anterolateral ischemic process. Followup and clinical
correlation are suggested.
CTA Wet read [**2114-2-23**]:
No PE. Some consolidations/septal thickening suggestive of fluid
vs infection. Enlarged pulm artery suggestive of pulmonary HTN.
Brief Hospital Course:
Ms. [**Known lastname 60258**] is a 46 year-old woman with history of advanced
interstitial lung disease, likely NSIP, CHF, DM, and chronic
pain s/p MVA who presents with respiratory failure.
ICU Course:
Patient was intubated in the ED secondary to respiratory
distress and oxygen saturations in the 80s. She was admitted to
the MICU were a CVL was placed. She was treated initially
empirically with levofloxacin and broadened to
vancomycin/cefepime/azithromycin for empiric coverage of HCAP.
She was also given IV steroids, then transitioned to prednisone
40 mg daily, for an ILD flare per her outpatient pulmonologist,
Dr. [**Last Name (STitle) **]. Influenza swab was sent and returned negative. Sputum
cultures grew commensal respiratory flora and yeast. She was
also diuresed with IV lasix given an elevated BNP of 1023 over
her baseline of 363 from [**10-1**] and overload on CXR. IV Lasix
40mg IV was effective and diuresis. Echocardiogram showed
findings of RV free wall hypokinesis c/w contusion related to
MVA as well as mild MS and MR. [**Name14 (STitle) 2287**] cardiology recommended
further evaluation with TEE as this valvular disease may be
contributing to her heart failure. She was extubated on [**2-16**]
with return to her baseline home oxygen requirement. Just prior
to transfer to the floor patient was started on morphine
60mg/30mg/60mg PO TID for her chronic fibromyalgia neck and
shoulder pain.
*ACTIVE ISSUES*
# Acute on chronic diastolic heart failure: The patient is on
daily lasix 60 mg at home and has a history of chronic diastolic
heart failure secondary to rheumatic heart disease (echo in [**2109**]
showed EF>55%, mild-mod MV regurg). Her dyspnea was thought to
be due to volume retention in the setting of starting steroids
for baseline lung disease. In the MICU she was started on IV
lasix 40 mg with good response. On the floor her lung exam was
notable for bibasilar crackles and high-pitched inspiratory
squeaks, as well as bipedal pitting edema. She was therefore
continued on IV lasix with resolution of dyspnea and improved
lung exam. Her oxgen requirement was lowered to her baseline of
6L NC. A repeat CXR on [**2-21**] showed substantial improvement in
pulmonary edema compared to the prior study of [**2-17**]. To
evaluate the role of mitral valve dysfunction on CHF
exacerbation, she also underwent a repeat echo given poor window
of bedside TTE in the MICU. The echo was largely unchanged from
her prior in [**2109**], with preserved EF 70% and mild resting left
ventricular outflow tract obstruction. Rheumatic mitral valve
deformity was noted along with mild MV stenosis. Cardiology
recommended starting the patient on low-dose metoprolol due to
concern for CHF exacerbation from tachycardia/decreased filling
time in the setting of the patient's MR/MS. [**First Name (Titles) **] [**Last Name (Titles) 8337**]
metoprolol succinate 12.5mg daily well. The patient was
transitioned to po lasix 40 mg, and on this low dose continued
to produce output 3-4L daily. She appeared consistently
euvolemic on this dose. Her Cr remained stable throughout this
period. On discharge her weight was 100.2 kg, compared to her
baseline weight of 101.2 kg ([**2114-1-2**]). The CTA on day of
discharge revealed signs of some fluid overload and decision was
made to send her home on 60mg daily (her usual home dose) and to
likely taper down to 40mg daily if appropriate when she sees her
primary care physician. [**Name10 (NameIs) **] was discharged on lasix 60mg daily
and metoprolol 12.5 mg daily. Pt was satting in the mid-high 90s
on 6L at time of discharge.
# ILD: The patient has advanced interstitial lung disease with
tissue diagnosis of fibrotic NSIP in [**2109**]. She is on baseline 6L
O2 at home and is followed closely by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. While
inhouse it was thought that her lung disease was contributing to
her dyspnea and acute presentation. She was therefore continued
on prednisone 40 mg po daily. The patient was seen by Dr. [**Last Name (STitle) **]
who recommended a slow steroid taper over 1-2 months with
possible outpatient transition to azathioprine. Given her
continuation of steroids, she was started on a PPI. She was also
started on PCP prophylaxis with bactrim and discharged on
Cal/VitD.
# Diabetes mellitus: The patient had poor glycemic control
during her stay, with post-meal FSBG levels consistently >400.
A HgA1c was 9.2. Her lantus was increased to 24 from baseline
20 with good effect. She was started on a novolog sliding scale
with frequent adjustment. [**Last Name (un) **] saw the patient while inhouse
for elevated sugars. The decision was made to STOP metformin
given her CHF, and the patient was instructed not to resume this
outpatient. She was discharged on lantus 24 U qhs and novolog
sliding scale (Starting breakfast and lunch at 12 for BG
100-150, increase by 2; dinner at 8 Units for BG 100-150,
increase by 2; bedtime at 4 for BG 151-200, increase by 2).
# Chronic pain s/p MVA: Baseline chronic back pain was
controlled with her home morphine dose 60mg/30mg/60mg PO TID
which was started in the MICU. She had adequate pain control
during her hospitalization.
*INACTIVE ISSUES:*
# Anemia: The patient is chronically anemic and remained so
with Hcts ranging from 27.9-31.9. This is consistent with her
baseline.
# Hypertension: Patient's aldactone was held given diuresis and
relatively low BPs on the floor. Because she was started on
metoprolol, her aldactone was discontinued.
# Depression/anxiety: The patient was continued on her home
doses of sertraline 200 mg daily and diazepam 5 mg q6 prn.
Labs/Studies Pending at Discharge:
- CTA final read ([**2114-2-23**])
Transitional Care Issues:
- Patient will need electrolytes checked on Friday [**3-2**].
VNA has been arranged and PCP [**Name Initial (PRE) 13109**].
-Aldactone was held during admission. [**Month (only) 116**] be resumed outpatient
if patient tolerates metoprolol.
-Started metoprolol 12.5mg succinate daily. Reccomend continued
monitoring outpatient as she might benefit from higher dose.
Medications on Admission:
Diazepam 5mg q6-8h PRN anxiety
Lasix 60mg daily
Lantus 20u daily
Metformin 1000mg [**Hospital1 **]
Morphine 60/30/60 mg PO qAM/afternoon/PM
Oxycodone 5mg PO BID (between morphine doses)
Sertraline 200mg daily
Diovan 80mg daily
Various vitamins: D2, B6, B12, fish oil
(per [**Location (un) 2274**] records, additionally)
Fioricet 2 tablets q4h PRN severe HA
Spironolactone 25mg daily
Hydroxyzine 50mg qAM/PM
Discharge Medications:
1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Continue until you see Dr. [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*1*
3. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. 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*
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation every 4-6 hours as needed for wheeze.
Disp:*1 inh* Refills:*0*
6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
Disp:*40 ML(s)* Refills:*0*
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q12H (every 12 hours) as needed for
neck/shoulder pain.
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for pain.
11. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO NOON (At Noon).
12. diazepam 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for anxiety.
13. Outpatient Lab Work
Please draw chem 7 on [**2114-2-27**] and fax to:[**Telephone/Fax (1) 6808**] attn: Dr
[**First Name8 (NamePattern2) 4320**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
14. insulin glargine 100 unit/mL Solution Sig: Twenty Four (24)
Subcutaneous at bedtime.
Disp:*1 month's supply* Refills:*2*
15. insulin Novolog Sig: One (1) four times a day: Follow
Sliding Scale.
Disp:*1 month's supply* Refills:*2*
16. Insulin Syringe MicroFine 0.3 mL 28 x [**12-24**] Syringe Sig: One
(1) Miscellaneous four times a day.
Disp:*1 month's supply* Refills:*2*
17. Lasix 40 mg Tablet Sig: 1 and [**12-24**] Tablet PO once a day: take
total of 60mg (1.5 tablets) a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company **] [**Location (un) **]
Discharge Diagnosis:
Primary diagnoses:
Acute on Chronic Diastolic Congestive Heart Failure
Interstitial Lung Disease
Congestive Heart Failure
Secondary diagnoses:
Diabetes Mellitus
Coronary Artery Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 60258**],
You were admitted to the hospital for shortness of breath. We
believe this was most likely due to extra fluid in your lungs.
When you first arrived to our Emergency Department, a tube was
placed in your throat to help you breathe (intubation). You
were admitted to the intensive care unit, where you were given a
medication (Lasix) to help decrease the fluid in your lungs.
You were treated with steroids to decrease possible inflammation
in your lungs. You also received antibiotics to cover the
bacteria that cause lung infections. You responded well to these
treatments and your breathing tube was eventually removed.
In the ICU, you had an ultrasound of your heart (Echo) which
showed slightly worsened disease of one of your heart valves
(from rheumatic heart disease). Your heart function is
otherwise unchanged from your last echo in [**2109**].
You were then transferred to the medicine floor, where you
completed the course of antibiotics. You were continued on
steroids. Your IV Lasix was transitioned to Lasix by mouth, and
you continued to put out a considerable amount of extra fluid
which helped your oxygenation. Your oxygen requirements
decreased to your home oxygen of 6 Liters. You were able to
ambulate on your own without issue. You will go home on lasix
60mg daily. This dose might be lowered to 40mg daily after you
see your primary care doctor next week if she feels it is
appropriate.
Your sugars were found to be elevated, especially after starting
prednisone. We had diabetes specialists see you who helped to
titrate your insulin. You will go home on Insulin Sliding Scale
regimen that was reviewed with you in the hospital. Please
follow the attached Sliding Scale regimen.
On the day of discharge you had some chest pain with breathing.
We obtained a CT scan of your lungs and it showed there is no
clot in your lungs, this is good news.
Remember to check daily weights. If your weight goes up by 3
pounds, please call Dr [**Last Name (STitle) **], you might need a higher dose of
your lasix. This is VERY important. If you can not get through
to Dr [**Last Name (STitle) **], please call your primary care doctor.
The following changes were made to your medications:
STOP Metformin. Do not take this medication any more. It should
not be taken by patients with heart failure.
STOP Aldactone. You may resume this if your PCP agrees and if
your blood pressure tolerates. We started you on metoprolol and
decided to stop the aldactone for now.
START insulin sliding scale with Novolog, see the attached form
for an explanation.
CHANGED lantus from 20->24 U every evening
START: Bactrim, take 1 tab daily to prevent pneumonia while on
steroids.
START: Pantoprazole 40mg daily, take this while on steroids
START Prednisone 40 mg daily. You will be on this medication
until further discussion with your pulmonologist Dr. [**Last Name (STitle) **].
START Metoprolol 12.5mg daily. Please take [**12-24**] pill of the 25mg
daily. This will protect your heart from future heart failure
episodes.
CONTINUE: Lasix 60mg daily to help remove fluid from your lungs
No other medication changes were made. Please continue to take
them as you have been doing.
Follow-up appointments have been made for you. Please see the
details below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 105541**]
Appointment: Friday [**3-2**] at 1:45PM
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2114-3-12**] at 8:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: MONDAY [**2114-3-12**] at 8:30 AM
Department: MEDICAL SPECIALTIES
When: MONDAY [**2114-3-12**] at 8:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2114-3-22**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4280, 4019, 4240, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3176
} | Medical Text: Admission Date: [**2148-8-11**] Discharge Date: [**2148-9-5**]
Date of Birth: [**2100-8-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
i was in a car accident
Major Surgical or Invasive Procedure:
Lumbar fusion L 345 on [**2148-8-14**]
.
Blood transfusion
.
Multiple intubations
History of Present Illness:
This is a 48 /o white male with non significant pmhx who was
involved in a MVA. Pt states he was belted driver who was
leaving friends house and then remembers seeing a car that he
thought was parked and next thing he recalls his friend was
banging on his window. Pt was transferred to [**Hospital1 18**] from a new
[**Hospital **] hospital after w/u revealed L4 burst fracture. Pt
currently admits to low back pain and tingling in LLE when he
everts his L foot. Denies nausea, vomiting, headache, double or
blurred vision, loss of control of bowel or bladder.
Past Medical History:
testicular cancer s/p orchiectomy and radical lymph node
dissection
Social History:
He drinks at least one bottle of wine a day, and on the weekends
drinks more hard liquor (whiskey), occasional cocaine use, most
recently on the day of his accident. He has had 2 [**Last Name (un) 20934**] prior to
this one. Prior to that he hadn't used any cocaine for "years."
He denies tobacco use, has girlfriend of 12 years who he lives
with at home. He works as a [**Doctor Last Name **] musician.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: 162/82, 88, 18, 100% 99.6
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT, no hemotympanum, no battles or raccoons, no CSF
rhinorrhea or otorrhea.
Neck: without point tenderness from occiput to C7
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor: exam full throughout, slight breaking of strength to LLE
KE and HF to pain.
.
Sensation: Intact to light touch. No sensory levels noted
sensation intact distal to proximal as well
reflexes: upper extremity brisk, B/l knee jerks 2+, ankle jerks
absent/pt unable to participate.
Toes downgoing bilaterally
Rectal exam slightly increased rectal tone, normal sphincter
control, no priapism at present.no clonus, no spasticity.
Pertinent Results:
[**2148-8-11**] 03:54PM HCT-24.0*
[**2148-8-11**] 09:10AM HCT-25.4*
[**2148-8-11**] 04:31AM GLUCOSE-111* UREA N-7 CREAT-0.5 SODIUM-138
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
[**2148-8-11**] 04:31AM ALT(SGPT)-28 AST(SGOT)-67* ALK PHOS-96
AMYLASE-30 TOT BILI-1.8*
[**2148-8-11**] 04:31AM LIPASE-19
[**2148-8-11**] 04:31AM ALBUMIN-3.9 CALCIUM-8.3* PHOSPHATE-3.4
MAGNESIUM-2.3
[**2148-8-11**] 04:31AM WBC-8.1 RBC-3.51* HGB-7.9* HCT-25.9* MCV-74*
MCH-22.6* MCHC-30.6* RDW-18.5*
[**2148-8-11**] 04:31AM PLT COUNT-121*
[**2148-8-11**] 04:31AM PT-18.4* PTT-31.4 INR(PT)-1.7*
[**2148-8-11**] 12:04AM COMMENTS-GREEN TOP
[**2148-8-11**] 12:04AM GLUCOSE-122* LACTATE-2.8* NA+-138 K+-4.6
CL--101 TCO2-25
.
[**8-11**]: MRI of Lumbar spine
FINDINGS: There is minimal increased T2 signal within the L4
vertebral body in the location of the burst fracture. There is
mild retropulsion of few of the fracture fragments. There is a
large degree of loss of the vertebral body height.
There is no evidence of neural foraminal narrowing at any level.
Just
posterior to the burst fracture, the retropulsed fragments cause
mild-to-
moderate spinal canal stenosis. They may impinge upon the
traversing L4 nerve roots in the lateral recesses. Again the
study is moderately limited due to patient motion artifact.
There is no high-degree compression of the cauda equina. The
remaining vertebral bodies are normal in alignment and marrow
signal.
IMPRESSION: Burst fracture of L4 with mild edema. There is
moderate
retropulsion of few of the fracture fragments. While these do
not cause high- grade spinal canal stenosis, they may impinge
upon the L4 nerve roots in the lateral recesses. Please
correlate with patient's physical examination.
.
CT of the chest, abdomen, and pelvis after contrast. ([**2148-8-16**])
1. Bilateral pleural effusions with associated atelectasis.
2. Ascites.
3. No evidence of metastatic disease.
.
CT Chest without contrast ([**2148-8-23**])
IMPRESSION:
1. No significant interval change compared to [**2148-8-16**].
Redemonstrated are bilateral dependent atelectatic changes with
small pleural
effusions, stable.
2. No evidence of pulmonary consolidations to suggest a
presence of
pneumonia. Fine detail in the lungs is obscured by motion
artifact.
3. Abdominal ascites.
.
CT HEAD +/- CONTRAST:Negative CT of the brain without evidence
of enhancing mass, particularly within the cerebellopontine
angle. However, MRI is more sensitive for the detection of a
mass and MRI with gadolinium should be considered if there
remains clinical concern.
.
RUQ ultrasound [**2148-8-27**]
LIVER ULTRASOUND STUDY WITH DOPPLER: Both grayscale and color
Doppler
ultrasound examination of the liver was performed. No focal
liver lesions are seen. Coarsened echotexture of the liver
consistent with cirrhosis.
There is no intrahepatic or extrahepatic biliary ductal
dilatation. There is no ascites. The common bile duct measures
5 mm in diameter. The gallbladder is relatively contracted.
The right kidney measures 11.7 cm in length, and there are no
renal stones or hydronephrosis seen.
The main portal vein, anterior, and posterior branches of the
right portal vein, and left portal vein are patent with
appropriate directionality. The hepatic vein and its branches
are patent.
IMPRESSION: No focal liver lesions or ascites. Patent vessels
as described above. Coarsened echotexture of the liver
consistent with cirrhosis.
.
[**2148-8-21**] EEG
IMPRESSION: Largely normal portable EEG. Plentiful movement
artifact
and the faster beta rhythm (possibly due to benzodiazepine
medication)
obscured much of the background, but no focal abnormalities or
epileptiform features were evident.
Brief Hospital Course:
Impression/Plan: 47 y/o man with pmhx s/f testicular cancer,
etoh and cocaine abuse, admitted after MVC with L4 burst
fracture s/p L3-5 fusion on [**2148-8-14**]. He had a prolonged ICU
course complicated by respiratory failure with multiple
intubations, altered mental status and likely alcohol
withdrawl/dt's.
.
MICU course: Pt was admitted through the emergency department
after an MVA. He was admitted to the ICU and placed on log roll
precautions for his spine. He was intubated on hospital day
number 2 for his safety as he was experiencing the DT's and was
being non compliant with his bedrest status. He was taken to
the OR later that day for a lumbar fusion L 345. The operation
was without complication. He did receive blood transfuion and
transfusion of platelets for a HCT <25 and an INR of 1.5. He
later than trended up again on his INR to 1.4 however we did not
continue to treat as he was now post-op. He had a drain placed
in the lumbar region in the OR which was removed on [**Doctor Last Name **] #2. A
TLSO was ordered pre-operatively and is in use while pt is OOB.
He also had a head CT and a CT of the Torso with and without
contrast for two reasons. One, on his original head CT he had
what appeared to be a right sided CPA possible meningioma. This
was unfounded on the contrasted image. The CT of the torso was
performed because the outside tramua images were "wet read" as
having spots on the liver. The Torso CT here is negative
however there is a hypodensity noted in one of the lobes of the
liver that is too small to characterize that should be follwed
by the PCP. [**Name10 (NameIs) **] was placed in the D/C instructions. On POD#4
(hosp day 6)he had altered mental status and possible aspiration
and required reintubation. He was started on broad coverage
antibiotics (ceftaz and flagyl) for pneumonia. Although the
patient transiently improved on [**8-18**] and was weaned to [**4-12**], he
was noted to have fluctuations in MS [**First Name (Titles) **] [**Last Name (Titles) 17577**] copious
secretions on [**8-19**]. Extubated [**8-20**], but continued to have
copious secretions which he could not clear. Approximately 12h
later the patient became extremely anxious due to inability to
clear secretions and req'd re-intubation.
.
On [**8-21**] the patient was transferred to the MICU service for
[**Month/Year (2) 17577**] management of his requirement for mechanical
ventilation. On transfer the patient was started on lactulose
for presumed hepatic encephalopathy. His antibiotic coverage was
expanded to include vancomycin for a presumed VAP. A repeat CT
of the chest did not show any evidence of pneumonia and his
antibiotics were held. Since the patient was out of the window
for [**Month/Year (2) 17577**] etoh w/d, his agitation was managed w/ haldol
standing and prn. On [**8-25**] the patient was extubated (following
commands, good cough, minimal secretions).
.
Course on the floor: transferred on [**8-27**]
.
1. Respiratory failure: Patient had multiple failed extubations
likely secondary to untreated liver failure causing
encephalopathy. He responded to lactulose and now has been
extubated since [**8-25**], satting well on room air. Although patient
was febrile during his MICU course he didnt have pneumonia on
CXR or on CT scan. d/c all antibiotics. He had an incentive
spirometer at bedside for use.
.
2. Altered mental status: Probably secondary to liver disease
with encephalopathy, in combination with alcohol withdrawl. No
evidence of head trauma, and his EEG was non-focal. Patient
likely out of alcohol withdrawl at this point, more than two
weeks into hospital stay. His mental status has improved
slightly, but because of continued slowing, an MRI/MRA of the
brain was obtained to assess for diffuse axonal injury.
Neurology followed throughout hospital course. His standing
haldol was discontinued to prevent confusion, and he did not
require any during his stay on the floor. MRI/MRA of brain
showed no evidence of diffuse axonal injury as was suspected due
to his generalized slowed cognitive function. At discharge, he
had some residual deficits, thought to be secondary to resolving
encephalopathy, likely with some underlying retardation due to
chronic alcohol abuse. He was scheduled for follow-up
Behavioral Neurology evaluation as an outpatient.
.
3. Liver disease: Likely secondary to alcoholic cirrhosis.
Hepatitis serologies are negative, except for prior
infection/vaccination for Hepatitis B. Iron not significantly
elevated, indicating that hemochromatosis is not a likley cause
of his liver dysfunction. He does have evidence of impaired
liver function with increased INR. MELD score is 4, indicating
low 90 day mortality. RUQ ultrasound shows evidence of
cirrhosis, no ascites. Outpatient follow up with hepatology in
[**Month (only) 1096**], to assess his ESLD. He should continue lactulose and
metoprolol for variceal prophylaxis. Addictions consult
provided patient with places to go for alcohol rehabilitation.
Patient states intent to first return home to assess his
capacity to be in his native environment. He has a follow up
appointment with Hepatology in [**Month (only) 1096**].
.
4. L4 burst fracture s/p fusion on [**8-14**]: He should continue TLSO
brace when out of bed, should continue using it until he sees
neurosurgery 6 weeks after fusion.
He will need standing thoracic and lumbar spine films with his
TLSO brace on that neurosurgery will follow up with at their
appointment. At the time of discharge, he was unable to stand
on his own, and we were not able to do these in house. They
will need to be done by the rehab facility or by his PCP. [**Name10 (NameIs) **]
well on oxycodone for pain control
.
5. Fever: This was never an issue while on the medical floor.
SBP r/o with paracentesis. [**Month (only) 116**] have been related to alcohol
withdrawl. He was been afebrile on admission to the floor and
did not continue to spike fevers.
.
6. Anemia: Likely secondary to combo of malnutrition, anemia
chronic disease, given low MCV and low iron with normal TIBC.
Transfuse for Hct < 25. Continue MVI, folate, thiamine, and
iron supplementation.
.
7. FEN: S/S done on [**8-27**]. Advance diet to soft solids and thin
liquids with supervised feedings. Alternate bites and sips.
Pills crushed in puree. Monitor for aspiration. Added ensure to
lunch and dinner per nutrition recs.
.
8. Prophylaxis: Heparin SQ, pneumoboots, ppi as an inpatient.
DVT prophylaxis was discontinued at discharge, as patient was
ambulating with his walker.
.
9. Code: Full
.
10. Dispo: Given patient's deconditioned state as a consequence
of the protracted hospital course, and previously fully
functional status, he was discharged to [**Hospital **] Rehabilitation.
Prior to discharge, he was provided with a self help face sheet
with resources for AA and other addiction services.
Medications on Admission:
none
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*3 L* Refills:*2*
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*2*
9. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) teaspoon PO
DAILY (Daily).
Disp:*150 mL* Refills:*2*
10. Ranitidine HCl 15 mg/mL Syrup Sig: Two (2) teaspoons PO BID
(2 times a day).
Disp:*1 L* Refills:*2*
11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*1 L* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
s/p lumbar fusion L345
Discharge Condition:
neurologically stable
Discharge Instructions:
1) Please call the neurosurgery office at [**Telephone/Fax (1) **] if you
have any questions or concerns, Please call immediately if you
have any fever 101.5 or greater, any redness swelling or
drainage from or around your incision. Please call if your pain
is not controlled by your pain meds or if you have any new
numbness tingling or weakness.
.
2) Call your primary care doctor at [**Telephone/Fax (1) 250**] if you have
worsening swelling of your abdomen, legs, shortness of breath,
vomiting up blood, dark, tarry stools, or mental status changes.
.
3) You have been provided with information about addiction
rehabilitation options. You should give serious consideration
to the resources that are available. Please make every effort
to abstain from alcohol and drug use after you are discharged.
Followup Instructions:
You are scheduled to follow-up with Neurologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**]
on next Monday, [**9-9**] at 10:30 a.m. Her office is in [**Apartment Address(1) **] of the [**Hospital Ward Name 860**] Building at [**Hospital1 18**] located at [**Location (un) 3387**]. Her office number is [**Telephone/Fax (1) 1690**] should you need to
reschedule or cancel.
.
Please follow up with your Neurosurgeon Dr. [**Last Name (STitle) 548**] on [**Last Name (STitle) 20212**],
[**10-2**] at 10:45. Around 9:30 on that same morning, you
should go to [**Hospital Ward Name 517**] [**Hospital **] Care Center, Department of
Radiology on the [**Location (un) **] to have x-rays of your spine. His
office number is [**Telephone/Fax (1) 2992**]. After your x-rays, you will go
to Dr.[**Name (NI) 2845**] office in The [**Hospital Unit Name **] located at [**Hospital Unit Name 69616**].
.
You have an appointment to see your new primary care doctor,
[**Doctor First Name 714**] [**Doctor Last Name **], MD [**First Name (Titles) **] [**Last Name (Titles) 20212**], [**10-2**] at 3 p.m. Her
office is in the [**Hospital Ward Name 23**] building on the [**Location (un) **], Central
Suite. ([**Telephone/Fax (1) 1300**]. Please call to confirm your address,
information.
.
You have been scheduled to follow up with a hepatologist
regarding your liver cirrhosis. You have an appointment
scheduled for [**Telephone/Fax (1) 20212**], [**11-13**] @ 1:50, with Dr. [**First Name (STitle) **]
[**Name (STitle) 69617**], [**Hospital Unit Name **], [**Location (un) **], ([**Telephone/Fax (1) 1582**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 5180, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3177
} | Medical Text: Admission Date: [**2158-10-11**] Discharge Date: [**2158-10-15**]
Date of Birth: [**2135-4-9**] Sex: M
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
polyuria, diabetic ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 2152**] is a 23 year-old man with diabetes mellitus type 2,
depression, and alcohol abuse, who presented to the ED yesterday
with generalized weakness, fatigue, polyuria, and polydipsia in
the last two weeks, as well as nausea and vomiting. He had URI
symptoms two weeks ago. He had been diagnosed with DM about 5
years ago; he had been treated with insulin for some time, and
then transitioned to metformin when his glucose control
improved. He stopped metformin about two years ago, due to
depression.
.
In the ED he was tachycardic, with blood sugar in 600s, and
found to have anion gap metabolic acidosis and ketonuria,
consistent with DKA. He was treated with insulin drip and IVF,
and admitted to the ICU.
.
In the ICU, his sugars improved, and his anion gap closed. He
was transitioned to Lantus. [**Last Name (un) **] was consulted. He reported
chest pain in the ICU which has since resolved (and cardiac
biomarkers negative x3).
.
Currently, he feels much better. His only complaint is of
frequent urination.
.
Review of systems:
(+) Per HPI
(-) Denies fever or chills. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath, or
wheezing. Denies chest pain. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria. Denies arthralgias or myalgias.
Past Medical History:
Diabetes mellitus type 2
Depression
Alcohol abuse
Social History:
Lives in group home in [**Hospital1 8**]. Born in [**Location (un) 7349**], has lived in
[**State 350**] for many years. Smokes [**1-26**] cigarettes per day.
Drinks alcohol about 3-4 times per week, 6-7 bottles of beer
each time. No history of IVDU. Has used marijuana. He has
"disowned" his family. Unemployed.
Family History:
Mother: heart disease, breast cancer
Physical Exam:
Vitals 96.6 82 152/94 18 99% RA
Gen - comfortable, pleasant, obese
HEENT - sclerae anicteric, moist mucous membranes
Neck - supple, no LAD
Pulm - CTAB, good air movement
CV - RRR, no murmur
Abd - soft, nontender, nondistended
Ext - warm, no edema
Neuro - alert, interactive, 5/5 strength in bilateral UEs and
LEs, normal sensation to light touch (including in feet)
Pertinent Results:
[**2158-10-12**] 02:49AM BLOOD WBC-12.2* RBC-3.82* Hgb-12.1* Hct-32.6*
MCV-85 MCH-31.6 MCHC-37.1* RDW-13.1 Plt Ct-203
[**2158-10-12**] 08:55AM BLOOD Glucose-247* UreaN-6 Creat-0.7 Na-134
K-4.0 Cl-106 HCO3-22 AnGap-10
[**2158-10-11**] 05:30PM BLOOD ALT-75* AST-29 AlkPhos-169* TotBili-1.1
[**2158-10-12**] 08:55AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.9
[**2158-10-11**] 05:52PM BLOOD %HbA1c-10.9* eAG-266*
CXR - FINDINGS: AP upright and lateral views of the chest were
obtained
demonstrating clear well-expanded lungs without focal
consolidation, effusion, pneumothorax. Cardiomediastinal
silhouette is normal. Bony structures are intact. No free air
below the right hemidiaphragm.
IMPRESSION: No signs of pneumonia or other acute intrathoracic
process.
Brief Hospital Course:
## Diabetic ketoacidosis: Mr. [**Known lastname 2152**] was admitted to the ICU for
management of mild diabetic ketoacidosis. His presentation was
likely precipitated by medication nonadherence and recent URI.
He was treated with an Insulin drip, IV fluids, and electrolyte
repletion. He was transferred to the floor the following day.
Insulin drip was transitioned to Lantus, which was titrated to
30U daily in addition to an aggressive meal-time sliding scale,
which was printed out for the patient on discharge. He was on
Metformin, but this was stopped due to transaminitis. He was
sent home with VNA services to assist with glycemic control.
.
## Transaminitis: Patient developed acute worsening
transaminitis during this admission. RUQ ultrasound showed
evidence of fatty infiltration. Liver service was curbsided and
recommended sending off [**Doctor First Name **], anti-mitochondrial Ab, anti-smooth
muscle Ab, ferritin, and ceruloplasmin, which are pending at the
time of discharge.
.
## Alcohol abuse: He was counseled on the risks of excessive
alcohol abuse and the risk of liver damage. Social Work met with
him. He was not interested in cutting back at this point,
stating that alcohol enabled him to be more creative. He
displayed no signs or symptoms of alcohol withdrawal.
.
## Smoking: Also counseled on smoking cessation. Offered a
nicotine patch.
.
## Depression: Home Psych meds were continued.
Medications on Admission:
Topamax
Wellbutrin
Prozac
Vistaril
Patient does not know doses. Meds prescibed by his psychiatrist,
whose number/contact info he does not recall. Meds are provided
by his group home in [**Hospital1 8**] [**Telephone/Fax (1) 91310**]. I called the home -
they said patient takes Depakote 1000mg qhs and Risperdal 5 mg
qhs. Patient said he will clarify.
Discharge Medications:
1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
2. topiramate 25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
3. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
4. Vistaril 50 mg Capsule Sig: One (1) Capsule PO once a day.
5. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
6. Depakote 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO at bedtime.
7. Risperdal 1 mg Tablet Sig: Five (5) Tablet PO at bedtime.
8. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day.
Disp:*2 vials* Refills:*1*
9. syringe (disposable) 3 mL Syringe Sig: One (1) syringe
Miscellaneous once a day.
Disp:*100 syringes* Refills:*1*
10. glucometer Sig: One (1) glucometer use as directed.
Disp:*1 glucometer* Refills:*0*
11. Alcohol Prep Swabs Pads, Medicated Sig: One (1) box
Topical use as directed.
Disp:*1 box* Refills:*0*
12. glucometer test strips Sig: One (1) strip four times a
day.
Disp:*100 0* Refills:*1*
13. Lancets,Ultra Thin Misc Sig: One (1) lancet
Miscellaneous use as directed for checking fingersticks.
Disp:*100 lancets* Refills:*1*
14. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
once a day: use sliding scale as directed.
Disp:*2 vials* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Diabetes mellitus type 2, uncontrolled, w/ complications
Diabetic ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 2152**], you were admitted for diabetic ketoacidosis (very high
blood sugars). It is important to keep your blood sugars under
control through medications, regular follow-ups with your
primary care doctor, and being mindful of your diet.
We strongly recommend that you stop smoking to avoid
complications such as heart and lung disease.
We also strongly recommend that you stop drinking alcohol. It
appears that alcohol is damaging your liver.
You should take Lantus 30 units every morning and use the
sliding scale that you have been given. Call your doctor if your
blood sugars are above 300.
Your liver function tests were abnormal. More labs tests were
ordered to evaluate this, but the results are not available yet.
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2158-10-23**] at 3:25 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
Completed by:[**2158-10-16**]
ICD9 Codes: 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3178
} | Medical Text: Admission Date: [**2138-6-5**] Discharge Date: [**2138-6-8**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
bilateral chest tube placement
Endotracheal tube placement
History of Present Illness:
88 yo male s/p mvc, partially ejected, [**Last Name (un) 60537**] car, initially
disoriented with agonal respirations, no BP through transfer.
Unresponsive in trauma bay.
Past Medical History:
unknown
Social History:
unknown
Family History:
NC
Physical Exam:
98.4 100% ETT
General GCS 3
HENT: occipital lac. PERRL 2 mm, reactive
TM clear
Chest: CTAb, RRR; no e/o injury
Neck: trachea midline
Abd: soft, ?tender, ND, fast neg
Pelvis: stable
Rectal: decreased tone, guaiac neg
Ext: w/wp no obvious fracture
Back: no deformity; ?tenderness
Pertinent Results:
[**2138-6-5**] 11:58PM TYPE-ART TEMP-37.1 RATES-18/ TIDAL VOL-550
PEEP-10 O2-80 PO2-125* PCO2-44 PH-7.28* TOTAL CO2-22 BASE XS--5
AADO2-411 REQ O2-70 INTUBATED-INTUBATED VENT-CONTROLLED
[**2138-6-5**] 10:30PM TYPE-ART PO2-103 PCO2-40 PH-7.30* TOTAL
CO2-20* BASE XS--5
[**2138-6-5**] 10:30PM LACTATE-1.4
[**2138-6-5**] 10:00PM CK(CPK)-255*
[**2138-6-5**] 10:00PM CK-MB-12* MB INDX-4.7 cTropnT-0.06*
[**2138-6-5**] 02:59PM GLUCOSE-149* UREA N-27* CREAT-1.2 SODIUM-144
POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-22 ANION GAP-14
[**2138-6-5**] 02:59PM CK(CPK)-241*
[**2138-6-5**] 02:59PM CK-MB-10 MB INDX-4.1 cTropnT-0.06*
[**2138-6-5**] 02:59PM WBC-8.4 HCT-29.5*
[**2138-6-5**] 02:59PM PLT COUNT-155
[**2138-6-5**] 02:59PM PT-13.7* PTT-29.9 INR(PT)-1.2
[**2138-6-5**] 02:43PM LACTATE-1.7
[**2138-6-5**] 12:50PM CK(CPK)-213* AMYLASE-46
[**2138-6-5**] 12:50PM CK-MB-9 cTropnT-0.09*
[**2138-6-5**] 12:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2138-6-5**] 12:50PM WBC-7.8 RBC-2.93* HGB-9.1* HCT-27.7* MCV-94
MCH-30.9 MCHC-32.7 RDW-14.7
[**2138-6-5**] 12:50PM PLT COUNT-170
CXR: bilateral chest tube deep
Pelvis: neg
CT head: right depressed temporal fracture; right temporal [**Doctor Last Name 534**]
bleed; Right orbital fracture
CT neck: C1, C2 fracture
CT torso: left complete PTX; trace free fluid in abd and pelvis;
no HS injury
Brief Hospital Course:
Was admitted to Trauma SICU where pt was further evaluated by
neurosurgery, ophthamology and orthopedic services. Pt was
thought to have serious brain injry and likely was thought to
have residual, permanent deficits if patient were to regain
consciousness, and was given a very poor prognosis. TSICU stay
was complicated by acidosis and hemodynamic instability
requiring multiple pressors. Family was made aware of any
progress or lack thereof, on a daily basis, and on HD#4, pt was
made comfort care only.
Pt never regained mental status function and passed at 1656 on
[**2138-6-9**]. Pupils were dilated and fixed. No signs of spontaneous
respirations or cardiac activity was noted. Admitting and ME
were notified. Family made aware.
Medications on Admission:
?
Discharge Medications:
Expired
Discharge Disposition:
Expired
Facility:
[**Hospital1 **] Hospital
Discharge Diagnosis:
Pt expired on [**2138-6-9**] of cardiac arrest after being made CMO.
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 2762, 4275, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3179
} | Medical Text: Admission Date: [**2147-11-11**] Discharge Date: [**2147-11-24**]
Date of Birth: [**2091-5-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Intracranial Hemorrhage
Major Surgical or Invasive Procedure:
[**11-11**]: Left Hemicraniotomy for Temporal resection for bleed
[**11-18**]: Left Craniotomy for Lt Temporal Mass resection
History of Present Illness:
Pt is a 56 y.o. male who had a fall to the ground while making
his bed this afternoon. The fall was not witnessed, but was
heard from the next room. He was found by his mother and was
reportedly "thrashing around" on the floor and non-responsive.
Pt was brought to [**Hospital 11694**] Hospital in [**Location (un) 2251**], MA and found to
have an acute LEFT temporal mass and ICH on CT. Pt was
transferred to the ED at [**Hospital1 18**] for further evaluation and
treatment. Per his mother, wife, and sister, he has been more
irritable over the past few weeks and has also had some recent
memory loss.
Past Medical History:
OSAS
Social History:
Works at the [**Hospital **] hospital in JP as a programming clerk. Lives in
[**Location **], MA with his wife and son. Is retired Army. Quit smoking
5 years ago. Does not use ETOH or illicit drugs.
Family History:
Father died of MI. No known family h/o of intracranial
hemorrhages or cancers.
Physical Exam:
T: afebrile BP:154/88 HR:96 RR: 18 O2Sats: 100% 3LNC
Gen: non-verbal. eyes are closed. Appears uncomfortable.
Groaning.
HEENT: Pupils: 1-2mm, minimally reactive. EOMs: Pt not moving
eyes.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: non-verbal.
Orientation: unable to assess.
Recall: unable to assess.
Language: Making incomprehensible groans.
Cranial Nerves:
I: Not tested
II: Pupils are 1-2 mm and minimally reactive to light.
III, IV, VI: Unable to respond to commands. Eyes are midline and
conjugate.
V, VII: Facial droop on right side
VIII: Hearing intact to voice.
IX, X: unable to assess.
[**Doctor First Name 81**]: unable to assess.
XII: unable to assess.
Motor: RUE: not moving, RLE: +clonus. LUE: Grip-[**5-20**], LLE:
Gastroc - [**5-20**]. No tremors.
Sensation: intact on left.
Toes downgoing on right, upgoing on left.
Coordination: could not assess.
On Discharge:
XXXXXXXXXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2147-11-11**] 05:55PM BLOOD WBC-20.4* RBC-4.59* Hgb-13.6* Hct-40.2
MCV-88 MCH-29.7 MCHC-33.9 RDW-13.1 Plt Ct-195
[**2147-11-11**] 05:55PM BLOOD Neuts-90.6* Lymphs-6.4* Monos-2.6 Eos-0.2
Baso-0.1
[**2147-11-11**] 05:55PM BLOOD PT-13.8* PTT-22.7 INR(PT)-1.2*
[**2147-11-11**] 05:55PM BLOOD Glucose-148* UreaN-12 Creat-1.1 Na-138
K-3.7 Cl-103 HCO3-22 AnGap-17
[**2147-11-11**] 05:55PM BLOOD Albumin-4.3 Calcium-8.8 Phos-3.0 Mg-1.9
[**2147-11-11**] 05:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Labs on Discharge:
XXXXXXXXXXXXXXX
Imaging:
Head CT([**11-11**]):
MPRESSION: Extensive left hemispheric hemorrhage with
surrounding vasogenic
edema and mass effect, including rightward uncal and subfalcine
herniation, as described. The differential includes hypertensive
and amyloid related
intraparenchymal hemorrhage, though other underlying pathologies
(i.e. mass)
cannot be excluded.
CTA Head([**11-12**]):
IMPRESSION:
1. Large left-sided temporal lobe hematoma with surrounding
edema and mass
effect with subfalcine and uncal herniation with midline shift.
2. Displacement of the vascular structures secondary to hematoma
without
intrinsic vascular abnormality such as an aneurysm, stenosis or
occlusion. No abnormal vascular structure seen to suggest
arteriovenous malformation.
MRI Head([**11-12**]):
IMPRESSION: Left temporal hematoma partially evacuated following
craniotomy. Mass effect and midline shift is identified. No
distinct enhancement seen within the hematoma or in the other
parts of the brain to indicate an underlying lesion. Patchy
enhancement at the margin posteriorly appear to be due to
vascular enhancement.
Pathology Results([**11-11**]):
I. Left temporal dura (A, B): Dura and mildly hypercellular
cortex with scattered atypical cells.
II. Left temporal lobe tissue (C-E): Oligodendroglioma, WHO
grade II. See note.
III. Blood clot (F): Blood and fibrin.
MRI Head([**11-16**]):
IMPRESSION:
1. New areas of enhancement in the periphery of the hematoma
with irregular
and nodular appearance as well as a few vague areas of
enhancement in the
right basal ganglia, in the right thalamus, in the left
parasagittal brain
parenchyma adjacent to the thalamus. The cause of enhancement is
unclear and this may relate to postsurgical changes at the site
of the surgery. However, given the vague areas of enhancement in
the right thalamus and superior to the left thalamus, associated
inflammatory or infective etiology cannot be excluded. Correlate
clinically.
2. Mild increase in the size of the left subdural fluid
collection as well as the subcutaneous fluid collection in the
left frontotemporal region.
3. No significant change in the significant mass effect on the
left lateral
ventricle, subfalcine and uncal herniation with mass effect on
the left
posterior cerebral artery and the posterior communicating
artery. In the left posterior cerebral artery in the left side
of the midbrain. Close followup can be considered, to assess the
stability or progression of the enhancing areas.
MRI Head ([**11-18**]):
IMPRESSION: Left-sided temporal and subinsular rim-enhancing
mass with mass
effect on the left lateral ventricle, midline shift, and uncal
herniation with deformity of the brainstem. The appearances are
unchanged compared with [**2147-11-16**]. Left-sided frontoparietal
craniotomy with subgaleal fluid
collection.
MRI Head ([**11-19**]):
IMPRESSION:
1. Increased T2 signal, slow diffusion and increased fractional
anisotropy
within the left posterior temporal lobe is suggestive of new
infarct in the
left posterior cerebral artery distribution.
2. Persistent shift of midline structures and left uncal
herniation with
compression of midbrain and pons.
3. Post-operative changes as described above.
Head CT([**11-22**]):
No evidence of new hemorrhage or mass effect. Persistent,
significant
rightward shift of midline structures and left uncal herniation.
Further
evolution of left posterior cerebral artery distribution
infarct.
Head CT ([**11-23**]):
Unchanged mass effect, postsurgical changes and evolving left
posterior
cerebral artery distribution infarct.
Brief Hospital Course:
The patient arrived at the [**Hospital1 18**] ED on [**2147-11-11**] with EMS and was
found to be hemi-paretic on the right side. He was clinically
assessed and immediately taken for non-contrast head CT and head
CTA. He was found to have an intracranial hemorrhage vs mass,
which was determined to be a surgical emergency. He was taken to
the OR for left craniotomy and exploration. The patient
tolerated the procedure, and was taken to the TSICU, where he
remained intubated and sedated. The patient underwent serial
physical exams and radiographic imaging for progressive
assessment. As his clniical status improved, he was transferred
to the step-down neurosurgical unit on POD 4.
Pathology taken from the intracerebral mass was consistent with
Oligodendroglioma, WHO grade II and the patient was taken back
to the OR on [**2147-11-18**] for resection of this mass and temporal
lobectomy. He tolerated this procedure well and recovered in the
PACU for a period of 24 hrs. He was transferred back to the
neurosurgical floor on [**2147-11-20**].
Secondary to new onset of headaches, the patient had repeat head
CTs on [**11-22**] and [**11-23**], which were considered normal and stable.
Throughout his post-surgical hospitalization, Mr. [**Known lastname **] has
had several incidents of low grade temperature elevations(101.3)
which are atelactic in nature as his CBC has been stable, and
not evidence of infection was noted at the incision site. On his
day of discharge, he had complained of mild "numbness" in the
right hand. Upon examination, he was full in strength, and it
was secondary to ulnar nerve compression based on how he was
sitting, or likely residual from perioperative positioning. He
was then discharge to rehab on [**2147-11-24**]
Medications on Admission:
Occasional NSAID use
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
6. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 99 doses.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Docusate Sodium 50 mg/5 mL Liquid Sig: [**2-15**] PO BID (2 times
a day).
11. Regular Insulin
Regular Insulin per Sliding scale on nursing handout
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Grade II Oligodendroglioma
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 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.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing in one
week. Please have results faxed to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**11-28**] days for removal of your
staples or sutures. Please call ([**Telephone/Fax (1) 88**] to schedule this
appointment.
You also have an appointment scheduled in the Brain [**Hospital 341**] Clinic
for Provider:[**Name10 (NameIs) **] [**Name11 (NameIs) 4253**] MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2147-12-4**] 4:00. You can also call to schedule your
appointment to be seen by Dr. [**Last Name (STitle) **] on this same day.
Completed by:[**2147-11-24**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3180
} | Medical Text: Admission Date: [**2162-4-27**] Discharge Date: [**2162-5-7**]
Service: NEUROLOGY
Allergies:
Codeine / Erythromycin Base
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Change in mental status
Major Surgical or Invasive Procedure:
Placement of PEG-J tube
History of Present Illness:
This is a [**Age over 90 **] yo F with h/o afib off coumadin x 1 week for
cystoscopy today to evaluate hematuria, who returned from
cystoscopy with her family today at about 5:30-6pm. At
approximately 6:30pm patient became unresponsive all of a
sudden.
She was brought back to [**Hospital3 2568**] where she was found to be
aphasic with right face droop. She had emesis en route to [**Hospital3 26611**] and was intubated with lido/etom/succ/vec. Given ativan
2mg IV x 1 as well. [**Hospital3 2568**] discussed case with Dr. [**First Name (STitle) **] and
it was decided she was not a t-PA candidate as she was out of
the
3 hr window. She was transferred to [**Hospital1 18**] for evaluation of
intra- arterial tPA (after discussion with stroke fellow Dr.
[**First Name (STitle) **], but this was not given as she already had evidence of
infarct on her head CT. CTA at OSH showed a left MCA cut off
(films not available for review). BP at OSH 151/58.
Past Medical History:
right eye cataract surgery
HTN
afib and valve repair, on coumadin
hypothyroidism
hematuria
hemicolectomy for diverticulitis
"vein occlusion of the left eye" - ?
Social History:
: never married, no kids, lives with sister, fully functional
and independent in all ADLs. No tob/etoh/drugs. Retired
executive secretary. FULL CODE.
Family History:
: not obtained
Physical Exam:
Vitals: 96 88 afib 168/107 16 100% on vent
GEN: elderly woman, pale, intubated, laying on stretcher,
pulling
at sheets with left hand, appears uncomfortable
HEENT: NC/AT, anicteric sclera, dry mm
NECK: supple, no carotid bruits
CHEST: CTA bilat
CV: irreg irreg without murmurs
ABD: soft, NT/ND, +BS
EXTREM: no edema, radial and DP pulses 2+
NEURO:
MENTAL STATUS: (ativan given approximately 3 hours before exam),
does not open eyes to voice, does not follow commands
CRANIAL NERVES:
Pupil exam: irreg pupil on right, minimally reactive. Left
pupil 2mm and reactive. FUNDUS on right appears normal, no
papilledema, no hemorrhage.
EOM exam: + dolls. Upon repeat exam, eyes deviated to the
left,
but not fixed. Follows fingers to right but not past midline.
Corneal reflex: present bilaterally
Facial symmetry: limited by ETT, upper face appears symmetric
with grimace to pain
Gag reflex: + present
MOTOR: spontaneous movements of left arm and leg, picking at
sheet and antigravity arm, bending of the left knee. Right arm
is flacid and falls when you pick it up. Left foot has some
spontaneous movement, minimal and distal.
SENSORY: withdrawls vigorously on the left arm/leg and right
foot, sluggish withdrawl right arm.
REFLEXES: 2+ and symmetric with upgoing toe on the right, down
on
the left.
Pertinent Results:
[**2162-4-27**] 12:37AM BLOOD WBC-13.0* RBC-3.48* Hgb-10.3* Hct-31.0*
MCV-89 MCH-29.7 MCHC-33.4 RDW-13.6 Plt Ct-266
[**2162-4-28**] 08:33PM BLOOD Hct-29.3*
[**2162-5-3**] 09:55AM BLOOD WBC-4.9 RBC-3.36* Hgb-10.0* Hct-30.4*
MCV-90 MCH-29.8 MCHC-32.9 RDW-13.9 Plt Ct-277
[**2162-5-4**] 08:05AM BLOOD WBC-7.5# RBC-3.84* Hgb-11.4* Hct-34.5*
MCV-90 MCH-29.7 MCHC-33.0 RDW-13.8 Plt Ct-368
[**2162-5-5**] 04:40PM BLOOD WBC-12.8* RBC-3.93* Hgb-11.8* Hct-35.5*
MCV-90 MCH-29.9 MCHC-33.2 RDW-13.6 Plt Ct-419#
[**2162-5-5**] 08:15PM BLOOD WBC-14.8* RBC-3.89* Hgb-11.8* Hct-36.0
MCV-92 MCH-30.2 MCHC-32.7 RDW-13.8 Plt Ct-381
[**2162-5-6**] 07:25AM BLOOD WBC-15.1* RBC-3.50* Hgb-10.4* Hct-31.0*
MCV-89 MCH-29.8 MCHC-33.7 RDW-13.6 Plt Ct-410
[**2162-5-5**] 08:15PM BLOOD Neuts-86* Bands-11* Lymphs-3* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2162-4-27**] 12:37AM BLOOD PT-13.2 PTT-23.2 INR(PT)-1.2
[**2162-4-27**] 12:37AM BLOOD Plt Ct-266
[**2162-4-27**] 06:59AM BLOOD PT-12.6 PTT-25.3 INR(PT)-1.1
[**2162-4-27**] 06:59AM BLOOD Plt Ct-262
[**2162-5-5**] 10:20AM BLOOD PT-12.9 PTT-22.8 INR(PT)-1.1
[**2162-5-6**] 07:25AM BLOOD PT-13.7* PTT-25.6 INR(PT)-1.3
[**2162-5-6**] 07:25AM BLOOD Plt Ct-410
[**2162-5-5**] 08:15PM BLOOD Plt Ct-381
[**2162-5-6**] 07:25AM BLOOD Glucose-94 UreaN-20 Creat-0.7 Na-140
K-3.5 Cl-107 HCO3-22 AnGap-15
[**2162-4-27**] 12:37AM BLOOD Glucose-165* UreaN-14 Creat-1.0 Na-139
K-3.1* Cl-102 HCO3-22 AnGap-18
[**2162-4-30**] 09:10AM BLOOD Glucose-161* UreaN-27* Creat-1.0 Na-136
K-3.3 Cl-103 HCO3-22 AnGap-14
[**2162-5-6**] 07:25AM BLOOD Amylase-104*
[**2162-5-6**] 07:25AM BLOOD Lipase-22
[**2162-5-6**] 07:25AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.6
[**2162-4-27**] 12:37AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2162-4-27**] 06:59AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2162-4-27**] 06:59AM BLOOD %HbA1c-6.2* [Hgb]-DONE [A1c]-DONE
[**2162-4-27**] 06:59AM BLOOD Triglyc-78 HDL-35 CHOL/HD-4.1 LDLcalc-92
[**2162-4-27**] 06:59AM BLOOD TSH-3.1
[**4-27**] CT head-Left middle cerebral artery territory acute
infarction, which is quite extensive, with suggestion of a left
middle cerebral artery occlusion. The results were immediately
relayed to the ED dashboard at the time of the interpretation
and discussed with the attending physician in the emergency
room.
[**5-5**] Head CT Evolving left MCA territory infarction producing
slight mass
effect on the left lateral ventricle and slight left to right
shift more
prominent compared to the prior study.
[**5-5**] CT Abd-) Nonspecific 4-mm nodular opacity at the right
lung base.
2) Multiple foci of intra-abdominal free air located anterior
to the liver
and other multiple foci of extraluminal air near the distal
duodenum/proximal
jejunum with stranding and free fluid present in the anterior
pararenal space
and left paracolic gutter. Although no extravasated oral
contrast is
identified, this constellation of findings in this patient
status post recent
GJ- tube placement is worrisome for perforated viscus. The
presence of
stranding in the left anterior pararenal space near the pancreas
also raises
the possibility of pancreatitis. Correlation with laboratory
values is
recommended. The findings worrisome for perforated viscus were
relayed by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at approximately 7:30 on
[**2162-5-5**] and
later discussed with the covering surgical house staff.
3) Dilated pancreatic duct in the tail region of the pancreas
with several
smaller adjacent cystic lesions that may represent separate
small cysts or
dilated side branches.
4) Large exophytic left renal cyst with multiple small
low-attenuation
lesions in the kidneys bilaterally that may represent cysts.
5) 4.1 x 4.6 cm right adnexal cyst.
6) Slight nodular enlargement of the right adrenal gland,
incompletely
characterized on this single-phase study.
Brief Hospital Course:
A/P: [**Age over 90 **] yo F with afib, off coumadin x 1 week for cystoscopy to
eval hematuria, who presented 6 hrs after sudden onset of
unresponsiveness. On exam has right arm hemiplegia and
flacidity, and right leg appeared weaker than left. Eyes
deviated
to the left although do follow fingers to the midline. She was
intubated on admission thus exam was limited. CT showed
evidence
of left MCA infarction.
1. Neuro -She was initially admitted to neuro ICU for q 1 hr
neuro checks. Heparin and tPA were held for fear of hemorhagic
transformation. Antihypertensives were held with only metoprolol
being used for rate control with afib. She continued to have rt
sided flacid paralysis with both expressive and receptive
aphasia. It was unclear if the pt would protect her airway so
NGT was placed in the ICU for enteral nutrition. Due to no
improvement in exam, we discussed with the family the need for
percutaneous feeding tube if her mental status did not improve.
The Health Care Proxy who is the patient's daughter decided that
she would have wanted a feeding tube, although per heresay of
the rest of the family the patient had documented not wanted a
feeding tube should she be unable to eat. Ethics service was
consulted and recommended that we should obey the HCP who we
hope is acting in the patients best interest and a PEG tube was
placed on [**5-4**]. After PEG tube placement the patient deveolped
an acute abdomen so Levofloxacin and Flagyl were started and
surgery was consulted. Abdominal CT revealed free air and mild
hematoma to be the likely cause of the patient's pain, but the
family refused surgical exploration. Her NGT was placed to low
wall suction and PEG left to gravity for 2 days at which point
tube feeds were started per nutrition recs. Prior to discharge
she was also started on baby aspirin. [**Name2 (NI) **] abdominal pain
resolved and all medications were changed over to PO. Blood
cultures remained negative but plan was made for an empiric 10
day course post discharge of the above antibiotics. She will
also need the T fasteners on the PEG tube to be removed by
cutting them below the tube on [**5-11**] or 7-10 days after J tube
placement.
2. GU-Pt had undergone cystoscopic BCG therapy with bx for
bladder CIS at outside hospital. She developed uliguria with
continued hematuria so urology was consulted on [**4-28**] and
recommended CBI. Her urine slowly cleared over the next 2 days
but the foley was left in since we wanted to control for
recurrent hematuria while coumadin is restarted.
3. Afib - She was rate controlled with with standing IV
metoprolol with prn and also required intermitted IV hydralazine
for blood pressure control. The restart of coumadin was
initially held for placement of PEG but plan was made to restart
coumadin with therapeutic INR range of [**12-24**]. She was changed over
to PO metoprolol on [**5-7**] but will need to be monitored on
telemetry until she is better rate controlled.
4. Hyperthyroidism-Synthroid was held on admission and TSH was
WNL. It was unclear what her outpatient dose of synthroid dose
so this was held initially but restarted at low dose with plan
to recheck a TSH in one month.
5. Pulm-The patient had large amounts of secretions post
extubation but chest xr was clear. She cont to have episodes of
apnea without hypoxia thought to be due to cerebral edema as
seen on follow-up CT.
6. Px-Patient was continued on a PPI and SC heparin
Medications on Admission:
coumadin
PPI
Toprol
synthroid
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*qs qs* Refills:*2*
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed for fever/pain.
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q
8H (Every 8 Hours).
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
7. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
10. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please titrat to INR [**12-24**].
11. Promote with Fiber Liquid Sig: One (1) PO once a day:
Continuous as per page 1.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Large left MCA stroke
Discharge Condition:
Stable
Discharge Instructions:
If the patient develops any increasing abdominal pain, inability
to move her bowels, vomiting, loss of spontaneous movement on
avaialable she should return to the emergency room.
Followup Instructions:
ICD9 Codes: 2859, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3181
} | Medical Text: Admission Date: [**2175-1-11**] Discharge Date: [**2175-1-20**]
Date of Birth: [**2132-1-28**] Sex: F
Service: SURGERY
Allergies:
Amoxicillin / Erythromycin Base / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient presented with abdominal pain at [**Hospital6 1597**], CT
scan revealed free air. Patient was transferred to [**Hospital1 18**].
Major Surgical or Invasive Procedure:
Status Post Marginal ulcer repair
History of Present Illness:
This patient is a 42 year old female who complains
of ABD PAIN. Went to [**Hospital3 **] ED this am for abd pain ,has free
air to abd per CT at bypass site.rec,d Fentanyl 50 per amb
enroute. Had Flagyl IV Appears uncomfortable MY HPI: transfer
from [**Hospital3 2568**]. Presnted there w/ diffuse abdominal pain that
started this AM. At OSH, CT demonstrated free air. Pt is s/p
gastric bypass in [**2171**] here by Dr. [**Last Name (STitle) **]. Per OSH CT, increased
air at anastamosis, suggestive of perforation. Received abx,
IVF,
analgesia at OSH. En route & at OSH had decreased SBP to 60, now
improved w/ IVF.
Past Medical History:
Hypertension, dyslipidemia, asthma, and obstructive sleep apnea
on CPAP.
Social History:
She denies any alcohol, drug or tobacco abuse. She states she
quit smoking
three weeks ago.
Family History:
Non-contributory
Physical Exam:
Temp:97.5 HR:88 BP:98/65 Resp:20 O(2)Sat:98 normal
Constitutional: uncomfortable
Head / Eyes: Normocephalic, atraumatic, Pupils
equal, round
and reactive to light,
Extraocular
muscles intact
ENT / Neck: Oropharynx within normal limits
Chest/Resp: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal
first and
second heart sounds
GI / Abdominal: Soft, Nondistended, diffusely
tender, +
rebound, + guarding
GU/Flank: No costovertebral angle
tenderness
Musc/Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
[**2175-1-11**] 12:25PM BLOOD WBC-19.7*# RBC-5.07 Hgb-9.7*# Hct-33.7*
MCV-67*# MCH-19.1*# MCHC-28.6*# RDW-17.3* Plt Ct-452*#
[**2175-1-13**] 12:23PM BLOOD WBC-12.3* RBC-3.82* Hgb-7.4* Hct-25.2*
MCV-66* MCH-19.4* MCHC-29.5* RDW-17.5* Plt Ct-381
[**2175-1-18**] 06:10AM BLOOD WBC-5.1 RBC-4.24 Hgb-8.2* Hct-27.7*
MCV-65* MCH-19.2* MCHC-29.4* RDW-18.4* Plt Ct-355
[**2175-1-11**] 12:25PM BLOOD Plt Smr-HIGH Plt Ct-452*#
[**2175-1-13**] 02:07AM BLOOD PT-13.5* PTT-26.1 INR(PT)-1.2*
[**2175-1-18**] 06:10AM BLOOD Plt Ct-355
[**2175-1-11**] 12:25PM BLOOD Glucose-76 UreaN-18 Creat-0.8 Na-141
K-4.6 Cl-108 HCO3-21* AnGap-17
[**2175-1-13**] 02:07AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-140
K-4.1 Cl-107 HCO3-26 AnGap-11
[**2175-1-16**] 06:20AM BLOOD Glucose-99 UreaN-4* Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-29 AnGap-10
[**2175-1-11**] 12:25PM BLOOD Lipase-35
[**2175-1-14**] 03:34AM BLOOD Lipase-12
[**2175-1-11**] 12:39PM BLOOD Lactate-3.0*
[**2175-1-11**] 05:01PM BLOOD Calcium-8.0* Phos-3.6 Mg-1.5*
[**2175-1-14**] 01:43PM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8
[**2175-1-18**] 06:10AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.1
Brief Hospital Course:
Patient transferred from [**Hospital3 **] with abdominal pain and free
air noted on CT scan. Patient went to the operating room where a
Closure of marginal ulcer,Omental patch, Gastrostomy and
Takedown of gastroenteric fistula was performed.
Initially postop patient was monitored very closely in the
intensive care unit. Pain control was difficult to achieve with
use of ketamine.
On postoperative day 3 patient was transferred to the floor. PPI
and antibiotics were continued intravenously and patient's labs
were closely monitored.
On postoperative day 5 patient was started on a bariatric diet.
R arm cellulitis was noted and patient started on warm packs and
vancomycin.
On postoperative day 6 R arm celluilitis improved and patient
progressed to a bariatric stage 3 diet.
We will discharge her to home today with oral protonix, keflex
for cellulitis and follow up with Dr. [**Last Name (STitle) **] in one week.
Medications on Admission:
lisinopril 10 QD, symbicort
Discharge Medications:
1. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day: Please take for one week.
Disp:*28 Capsule(s)* Refills:*0*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*300 ML(s)* Refills:*0*
4. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day.
Disp:*500 ml* Refills:*0*
5. Multivitamin Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Perforated marginal ulcer
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**9-22**] 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 incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 49**] in one week at [**Hospital Ward Name **]
[**Hospital Ward Name 23**] building [**Location (un) 470**]. Please call [**Telephone/Fax (1) 2723**] to make an
appointment.
Completed by:[**2175-1-20**]
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3182
} | Medical Text: Admission Date: [**2183-11-20**] Discharge Date: [**2183-12-3**]
Date of Birth: [**2129-9-14**] Sex: F
Service: SURGERY
Allergies:
Ivp Dye, Iodine Containing / Thimerosal / Carboplatin / Taxol
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal Distention
Vomiting
Anorexia
Major Surgical or Invasive Procedure:
Exploratory laparotomy, abdominal colectomy,
sigmoid mucous fistula and end ileostomy, transgastric
gastrojejunostomy tube placement and splenic flexure
takedown
History of Present Illness:
54F with h/o recurrent metastatic ovarian cancer s/p TAH/BSO
[**4-/2180**], on Taxol (last RX [**11-12**]), who presents to oncology
clinic with a 2 day history of progressive abdominal distention,
anorexia, vomiting and decreased bowel function.
Past Medical History:
Recurrent Ovarian cancer
Asthma
Obesity
Social History:
She has one son who is 28 years old. She works as a financier
and is self employed. She lives in the [**Location (un) 5583**] area. She
does not drink or smoke.
Family History:
She had a grandmother who at the age of 83 developed colon
cancer. There is no other cancer in her family. She is not of
Ashkenazi [**Hospital1 **] descent.
Physical Exam:
Admission Physical Exam - [**2183-11-20**]
97.6 100 159/89 18 100%RA
AOx3, nontoxic
RRR, CTAB
Obese, markedly distended/tympanitic
+BS, mild right sided abdominal tenderness
Rectal- normal brown guaic (-) stool, no strictures
1+ edema
Pertinent Results:
Admission Labs
-------------------
[**2183-11-20**] 01:34PM BLOOD WBC-8.3# RBC-4.32 Hgb-11.5* Hct-35.3*
MCV-82 MCH-26.6* MCHC-32.6 RDW-20.6* Plt Ct-429
[**2183-11-20**] 02:20PM BLOOD Neuts-72.2* Lymphs-21.5 Monos-5.5 Eos-0.4
Baso-0.3
[**2183-11-20**] 02:20PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Microcy-2+
[**2183-11-20**] 01:34PM BLOOD Plt Ct-429
[**2183-11-20**] 01:34PM BLOOD Gran Ct-6080
[**2183-11-20**] 02:20PM BLOOD Glucose-159* UreaN-16 Creat-0.7 Na-134
K-3.2* Cl-96 HCO3-27 AnGap-14
[**2183-11-20**] 02:20PM BLOOD estGFR-Using this
[**2183-11-20**] 02:20PM BLOOD ALT-67* AST-39 AlkPhos-99 TotBili-0.5
DirBili-0.2 IndBili-0.3
[**2183-11-20**] 02:20PM BLOOD Albumin-4.2 Phos-2.9 Mg-1.9
Discharge Labs
-------------------
[**2183-11-27**] 09:55AM BLOOD WBC-10.5 RBC-3.47* Hgb-9.8* Hct-29.4*
MCV-85 MCH-28.2 MCHC-33.3 RDW-18.2* Plt Ct-356
[**2183-11-27**] 09:55AM BLOOD Plt Ct-356
[**2183-12-1**] 05:10AM BLOOD Glucose-98 UreaN-5* Creat-0.4 Na-139
K-3.8 Cl-108 HCO3-23 AnGap-12
[**2183-11-23**] 03:05AM BLOOD ALT-19 AST-21 AlkPhos-47 Amylase-28
TotBili-0.6
[**2183-12-1**] 05:10AM BLOOD Calcium-7.6* Phos-2.6* Mg-1.9
[**2183-11-26**] 06:32AM BLOOD Triglyc-218*
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: CT with RECTAL contrast to rule out distal obstructive
proce
Field of view: 46 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
54F with large bowel obstruction
REASON FOR THIS EXAMINATION:
CT with RECTAL contrast to rule out distal obstructive process
CONTRAINDICATIONS for IV CONTRAST: IV dye allergy
INDICATION: Plain film concerning for large bowel obstruction.
COMPARISON: CT scan dated [**2183-10-30**] and plain films dated
[**2183-11-20**].
TECHNIQUE: MDCT acquired images of the abdomen and pelvis were
obtained after the administration of IV, oral, and rectal
contrast. Multiplanar reformatted images were also obtained.
CT OF THE ABDOMEN WITH IV CONTRAST
The imaged portions of the lung bases are clear. There is
diffuse fatty infiltration of the liver. There is a gallstone
within the gallbladder. The pancreas and spleen are
unremarkable. The adrenal glands are normal. There are multiple
left renal cysts and a right renal lesion that is too small to
characterize, that probably represents a cyst.
There is dilatation of the cecum with diameter measuring up to
12.3 cm. Oral contrast is present within the cecum. No dilated
loops of small bowel are seen. Note is made of subtle
pneumatosis of the cecum with no wall edema. The transverse
colon measures up to 7.8 cm, only mildly dilated by size
criteria with no wall edema or pneumatosis. There is a focal
narrowing of the lumen of the sigmoid flexure with adjacent
peritoneal metastasis producing a low-grade obstruction at this
location. The descending colon is of normal size. There is an
inflammatory mass located at the mid-upper pelvis (series 5,
image 69). Rectal contrast material passes freely through the
rectum and sigmoid colon to the level of this inflammatory mass
(series 7, image 24). Approximately 1 liter of contrast was
given. There is no intra-abdominal free air. There is no
mesenteric or portal venous gas. The superior mesenteric artery,
celiac artery, and inferior mesenteric arteries all appear
patent.
CT OF THE PELVIS WITH IV CONTRAST: The bladder is unremarkable.
The patient is status post TAHBSO. There is no pelvic free
fluid. Rectum is unremarkable with rectal tube in place.
Bone windows reveal no suspicious lytic or sclerotic lesions.
There are degenerative changes.
IMPRESSION:
1) Dilatation of the cecum with measurement up to 12.3 cm, and
only mild dilatation of the transverse colon, with the
descending colon being of normal diameter. There is a focal area
of mild luminal narrowing at the splenic flexure with adjacent
mesenteric/serosal metastasis. More inferiorly, in the mid
pelvis there is an ill-defined mesenteric metastatic lesion,
with rectal contrast noted to clearly pass from the rectum
through the sigmoid colon up to the level of this mass. No
rectal contrast could be passed through this level. Notably,
there is residual stool present within the rectum and sigmoid
colon. Taken together, findings are suggestive of at least a
partial large bowel obstruction. Complete or high-grade
obstruction cannot be excluded as rectal contrast material was
not noted to pass through the level of this inflammatory mass.
Further evaluation could be performed with a barium enema to
assess for passage of contrast through this level.
2) Pneumatosis is noted of the cecum, without associated wall
edema. The significance of this finding is not certain. It is
not felt to be likely due to ischemia. Correlate clinically.
KUB
-------
Compared to CT torso of [**2183-10-30**]. There is diffuse distention of
the large bowel to the level of the distal sigmoid colon, at
which point there appears to be an abrupt cut off which
corresponds to an area of serosal implant seen on the prior CT
of [**2183-10-30**]. Overall, the findings are highly concerning for
distal large bowel obstruction. The large bowel measures up to
10 cm in maximum diameter involving the transverse and hepatic
flexure. No evidence of free intraperitoneal air.
IMPRESSION: Findings highly suspicious for distal large bowel
obstruction. Findings discussed with Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] after the
study.
Portable TTE
---------------
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W057-1:08
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.5 cm
Left Ventricle - Fractional Shortening: 0.46 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 65% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 0.90
Mitral Valve - E Wave Deceleration Time: 210 msec
TR Gradient (+ RA = PASP): 25 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Suboptimal technical quality, a focal LV wall motion
abnormality
cannot be fully excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Borderline
PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat
pad, though a loculated anterior pericardial effusion cannot be
excluded.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Suboptimal
image quality - bandages, defibrillator pads or electrodes.
Suboptimal image
quality - body habitus.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Due to
suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets appear structurally normal with good leaflet excursion.
No aortic
regurgitation is seen. The mitral valve appears structurally
normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is
borderline pulmonary artery systolic hypertension. There is a
prominent
anterior fat pad.
IMPRESSION: Preserved global and regional biventricular systolic
function.
CLINICAL IMPLICATIONS:
Based on [**2173**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a low risk (prophylaxis not recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
Chest Xray
--------------
Admission [**2183-11-21**]
Portable AP chest radiograph compared to [**2183-3-2**]. The
heart size is mildly enlarged but stable. The mediastinal
contours are unchanged. The lungs are clear. There is no
sizeable pleural effusion. The left subclavian line tip is in
mid SVC.
IMPRESSION: No evidence of acute cardiopulmonary process.
[**2183-11-30**] Chest Xray
FINDINGS: Compared with [**2183-11-22**], there has been partial interval
clearing of the left lower lobe atelectasis/infiltrate/effusion.
No infiltrates are seen in the left mid/upper and right lung
fields.
Brief Hospital Course:
[**Known firstname 636**] [**Known lastname **] was admitted to the surgery service under the care
of Dr. [**First Name (STitle) 2819**] on [**2183-11-20**]. CT scan and KUB showed evidence of
large bowel obstruction. She was taken to the operating room on
HD 1 where she underwent an exploratory laparotomy, abdominal
colectomy, sigmoid mucous fistula and ileostomy, transgastric
gastrojejunostomy, tube placement and splenic flexure takedown.
She was transferred to the ICU intubated postoperatively. At
POD 1 she was tachycardic and with low urine output. She was
treated with fluid resuscitation and 1 unit PRBCs. She was on
day 2 of Kefzol/Flagyl.
At POD 2 she was extubated. Urine output was improved and she
was afebrile. Her antibiotics were discontinued. Hct was stable
at 29.6. Tube feeds were started at jejunostomy. Lasix was
started for diuresis. Blood glucose was evaluated and treated
with RSSI.
At POD 3 an ECHO was performed which was WNL with LVEF>55%. She
was transferred to the floor. Blood pressure was elevated and
continued to be controlled with IV metoprolol.
At POD 4 tube feedings continued with reports of high residuals.
A KUB was completed without evidence of obstruction. NGT
remained in place. Blood pressure was elevated. Diuresis
continued. Physical therapy was consulted.
At POD 5 there was return of bowel function. NGT was removed.
Diet was advanced to sips. She was febrile to 101.4 Urinalysis
was negative. Urine and blood cultures were sent. RIJ was
removed and tip sent for culture. CXR was negative.
At POD 6 she complained of nausea. Reglan was started and her
diet was advanced as tolerated. She was started on PO
medications.
At POD 7 she had high ostomy output. C. difficile was sent and
was negative. Fluid placement was provided to accommodate
output. Tube feeds were held to decrease output. She was
afebrile.
At POD 8 the ostomy output continued to be high at >4000cc.
Imodium and Metamucil were started. IV fluids were provided to
accommodate output. Blood, urine and line tip cultures from
POD5 were negative. Tube feeds were restarted.
At POD 11 she was doing well. Ostomy output remained high at
1575cc but was certainly improved from initial post operative
bowel function recovery. Metamucil and Imodium dosing was
increased. The tube feeds were at goal at 60cc/hr. She was
discharged in good condition to an acute rehabilitation center.
She was to follow up with Dr. [**First Name (STitle) 2819**] in clinic in [**12-23**] weeks.
Medications on Admission:
Taxol
Effexor XR 37.5
Discharge Medications:
1. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
2. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for slow ostomy output.
3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for pain.
4. Erythromycin 5 mg/g Ointment Sig: One (1) 1cm ribbon
Ophthalmic TID (3 times a day) for 5 days: Left eye.
5. Psyllium 1.7 g Wafer Sig: [**12-23**] Wafer PO TID (3 times a day).
6. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): 40mg SC daily.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for htn: Please hold for SBP <110 and
HR <65.
8. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Ovarian Cancer
Large Bowel Obstruction
Postoperative Fever
Discharge Condition:
Good
Discharge Instructions:
Please return or contact for:
* Fever (>101 F) or chills
* Persistent or worsening abdominal pain
* Increased or decreased output from ostomy
* Inability to urinate or dark urine
* Nausea or vomiting
* Redness or drainage at incision
* Any other concerns
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in clinic on [**2183-12-11**] 1:00pm.
The clinic is located on the [**Location (un) 470**] of the [**Hospital Unit Name **]
near the [**Hospital Ward Name 517**]. You may call ([**Telephone/Fax (1) 6347**] for any
questions for concerns.
Completed by:[**2183-12-3**]
ICD9 Codes: 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3183
} | Medical Text: Admission Date: [**2126-1-21**] Discharge Date: [**2126-1-28**]
Date of Birth: [**2052-8-6**] Sex:
Service:
CHIEF COMPLAINT: This man came in with a chief complaint of
chest and neck pain and shortness of breath.
HISTORY OF PRESENT ILLNESS: A 73-year-old man with past
medical history significant for CAD, status post three-vessel
CABG, AVR, and pacer, who presented with chest pain which
started approximately 1 week prior to admission. Described
it as soreness which comes at rest and activity. The patient
also complained of shortness of breath, beginning in [**Month (only) **] or
[**Month (only) 205**] which previously is his main complaint. The patient
also has neck pain with exertion, which abates at rest. Last
week prior to admission, the patient had increasing shortness
of breath and "neck pain" which escalated and prompted his
visit to his PCP. [**Name10 (NameIs) **] patient did lie flat and denies PND.
Chest pain started over the prior week but increased
shortness of breath prompted an ETT, which showed a large
mild reversible defect. Because of this result, the patient
escalating systems the primary care doctor referred the
patient to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for possible intervention.
REVIEW OF SYSTEMS: Negative for cough and fever. Negative
for overindulgence in food and alcohol over the holidays.
Positive rash. Fair appetite, which is approximately stable.
No abdominal pain, nausea, vomiting or diarrhea. Positive
occasional monocular loss of vision in the left eye, maybe
the right eye too. Carotid ultrasound "okay" per the
patient.
PAST MEDICAL HISTORY: CAD (CABG three-vessel and AVR [**2124-7-17**], reason positive ETT).
Status post pacer placement in the context of unclear
disorder ? heart block for AAA repair, [**2123-6-18**].
Status post cardioversion [**Month (only) 116**] or [**2125-6-17**] but felt return of
neck pain in [**2125-9-17**].
Hypothyroidism.
AAA repair 4 to 5 years prior to admission.
Borderline hypertension.
Chronic renal insufficiency.
Kyphosis.
ALLERGIES: NKDA.
MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Synthroid 75 mg p.o. q.d.
3. Lotrel 510 mg q.d.
SOCIAL HISTORY: The patient was an electric technician,
retired, and lives with his wife and son who is 39 years old.
The patient has 1 to 2 drinks a day. Former smoker, quit in
[**2090**].
FAMILY HISTORY: Mother died at 97 of unclear causes. Father
died at 65 with ? CAD but the father is a World War I veteran
with many exposures. He has three children who are alive and
well and he is the only child himself.
PHYSICAL EXAMINATION: VITAL SIGNS: The patient had a heart
rate of 107, blood pressure 138/74, saturating 96 percent on
room air, and respiratory rate is 21. GENERAL: He is an
elderly man, alert, and mildly tachypneic in no apparent
distress. HEENT: Bilateral ear lobe creases, mottled nose,
and anicteric sclerae. NECK: JVP approximately 6 cm.
HEART: A 2/6 systolic murmur at the left sternal border and
apex. Regular rhythm and tachycardic. No gallops or rubs
appreciated. LUNGS: Clear bilaterally. CHEST: Soft 3 to 4
cm mass above the left nipple. ABDOMEN: Soft, nontender,
and nondistended. No hepatosplenomegaly. Multiple surgical
scars. EXTREMITIES: Same with no CCE and 2 plus DP pulses
bilaterally. NEUROLOGIC: Cranial nerves II through XII
intact. Moves all extremities well.
LABORATORY DATA: Admission labs are notable for eosinophil
percentage of 10.9 percent and creatinine of 2.9. CK on
admission was 77 with a troponin of less than 0.01. The
patient's recent stress SPECT showed a large valvular
reversible defect in the inferior lateral apex, EF of 67
percent (positive for large inferolateral and inferoapical
ischemia with normal EF.) Echo on [**2126-1-11**] outside
hospital showed mild LVH, EF 55 percent, mild thickened MV
with trace MR, dilated ascending aorta, normal aortic valve,
normal right ventricular size and function but with mild-to-
moderate tricuspid regurgitation, and no pericardial
effusion. Chest x-ray on admission also showed no acute
cardiopulmonary process or change from [**2124-8-10**].
BRIEF SUMMARY OF HOSPITAL COURSE: A 73-year-old man with
history significant for coronary artery disease status post
three-vessel CABG, AVR, and pacer, who had 6 months' history
of increasing shortness of breath and neck pain. It is
angina equivalent. The patient presented in the context of
positive stress and escalating pain over the last 1-1/2
weeks. The patient was catheterized and found to have
diffuse disease. Given chronic renal insufficiency on
dialysis, the patient was reassessed on the second
catheterization to avoid giving him too much contrast with
one procedure per his attending, Dr. [**Last Name (STitle) **]. However, the
patient had a vagal episode and vague UTI at the outside of
the second catheterization with anginal chest pain. The
patient had a short stay in the CCU as a result. The patient
no longer considered to be a catheterization candidate and
remaining options include medical management and ? of repeat
CABG. The plan therefore changed to send the patient home
for outpatient evaluation after carotid ultrasound read.
Given that the carotid ultrasound showed complete occlusion
of the right ICA and 40 percent of the left ICA, the patient
was sent home. This will be detailed below.
PROBLEM LIST: Cardiovascular rhythm, no changed tachycardiac
event as before. Continue beta-blocker. The patient will
also have a pacemaker interrogated by EP which showed normal
pacemaker function. It should be slowed only with beta
blockade to control the underlying cause of sinus
tachycardia, which was performed during the course of his
admission. CAD, the patient underwent cardiac
catheterization as discussed above. He was continued on beta
blockade, statin, and aspirin and thus consideration given to
Isordil treatment as an outpatient will be decided on
followup. The patient has decreased EF to 40 percent. The
patient was continued on beta blockade but never had symptoms
of clinical CHF on exam.
Renal failure. The patient had improved creatinine over the
course of the admission. The patient only had a small bump
in his creatinine to 3.0 from baseline in mid to high 2s with
his cardiac catheterization. However given that his chronic
renal insufficiency had never been adequately explained,
renal ultrasound was performed. These results were as
follows:
Normal appearance of the left kidney and urinary bladder.
Right kidney which appeared atrophic and 1 to 2 cm cystic
stricture present in the right renal bed. Functionally, the
patient has unilateral kidney and ACE inhibitor was therefore
held.
Hypercholesterolemia. There is no significant increase in
LDL but the patient had reduced HDL, so statin was continued
given his known coronary artery disease.
Hypothyroidism, outpatient Synthroid regimen was continued.
Rash, the patient developed a maculopapular rash over the
face and torso, which improved with steroid cream. Is to
question as to whether this rash is related to metoprolol,
there is a question of discontinuing this drug but Cardiology
input was to continue this protective drug given his coronary
artery disease unless the symptoms became terribly
bothersome.
Question TIA during cardiac catheterization. The patient
developed right hand numbness and weakness, speech slurring,
and hypotension during cardiac catheterization. The symptoms
resolved with the administration of atropine. The patient
had positive amaurosis in the left eye in the past. He also
has nausea and vomiting with these episodes. Vascular and
Neurology consults were called in regards to this and as a
result the patient had a CT head which showed no acute
hemorrhage or infarct, chronic small vessel disease.
Ultrasound of the carotids were also performed, which showed
complete occlusion of the right ICA and 40 percent of the
left ICA. The Vascular consults recommended MRA but given
that the patient has the pacemaker, he cannot have an MRI.
The other alternative would be CT angiograms with the
carotids but given his high creatinine, this was also
rejected as an option. Given the patient's comorbidities and
asymptomatic state, the Vascular Service recommended starting
Plavix and follow up with Dr. [**Last Name (STitle) **]. In light of this
result, the patient was discharged to home in stable
condition.
DISCHARGE INSTRUCTIONS: To return to the ER. Call his
cardiologist for any chest or neck pain, increasing shortness
of breath, dizziness or unusual sweating.
DIAGNOSES: Coronary artery disease.
Renal insufficiency.
Heart failure.
Hypothyroidism.
Carotid stenosis.
FOLLOW UP: Follow up with primary care physician [**Name Initial (PRE) 176**] 1 to
2 weeks.
Follow up with Dr. [**Last Name (STitle) **] within 1 to 2 weeks.
Follow up with Dr. [**Last Name (STitle) **], Vascular Surgery, within next 4
weeks.
CONDITION ON DISCHARGE: The patient was discharged home in
stable condition.
DISCHARGE MEDICATIONS:
1. Synthroid 75 mcg p.o. q.d.
2. Aspirin 325 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Metoprolol 12.5 mg p.o. b.i.d.
5.
Fluocinolone cream b.i.d. p.r.n. rash.
6. Plavix 75 mg p.o. q.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8158**], [**MD Number(1) 8159**]
Dictated By:[**Last Name (NamePattern1) 25972**]
MEDQUIST36
D: [**2126-6-20**] 13:22:30
T: [**2126-6-21**] 09:23:09
Job#: [**Job Number **]
ICD9 Codes: 4111, 5849, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3184
} | Medical Text: Admission Date: [**2109-10-28**] Discharge Date: [**2109-11-7**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
woman admitted to [**Hospital1 69**] from
[**Hospital6 **] where she presented with lethargy and
decreased p.o. intake. Husband states she fell out of bed
because of weakness. CT of the head showed subarachnoid
hemorrhage. Of note, she was admitted to [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **]
Hospital a week ago with headache, refused magnetic resonance
scan at that time.
PAST MEDICAL HISTORY: Significant for hypertension,
increased cholesterol, carotid stenosis, question Alzheimer's
disease with short term memory loss. Hypothyroidism, status
post stroke in the past.
MEDICATIONS: Plavix, Accupril, Synthroid,
Hydrochlorothiazide, Lipitor and Toprol.
The patient was admitted to the Surgical Intensive Care Unit
for close monitoring and blood pressure control. She had a
cerebral arteriogram which showed no aneurysm or
arteriovascular malformation as a cause of the subarachnoid
hemorrhage. She was monitored closely in the surgical
Intensive Care Unit with tight blood pressure control and
followed by Cardiology service. The patient had CTA which
was grossly negative for any aneurysm, also had magnetic
resonance scan and MRA which also was negative.
The patient had severe hypertension and was treated with
Lopressor 100 mg p.o. b.i.d., Procardia XL 30 mg p.o. q day
and Accupril 40 mg q day with intermittent intravenous
Hydralazine and Lopressor for systolics greater than 160.
The patient was transferred to the regular floor on [**2109-10-31**]
in stable condition.
On [**2109-11-1**] in the late evening the patient had hypertensive
crisis with blood pressure into the 224/90 range and
complained of increased headache and confusion. She was
started on Nipride and was subsequently switched to p.o.
medications as mentioned previously. She currently is on the
regular floor in stable condition neurologically oriented
times one to two, moving all extremities with no weakness.
She has been followed by the physical therapy, occupational
therapy, found to require rehabilitation prior to discharge
home. She is currently without fever.
She is on Lipitor 10 mg p.o. q day, Synthroid 100 mg p.o. q
day, Accupril 40 mg q day, Procardia XL 30 mg p.o. q day,
Lopressor 100 mg p.o. b.i.d., Zantac 150 mg p.o. b.i.d.,
Procardia XL has been increased to 60 mg p.o. q day, hold for
systolic pressure less than 110. Levaquin 500 mg p.o. q day
for five days which will be discontinued today for urinary
tract infection. Hydrochlorothiazide 25 mg p.o. q day and
Hydralazine 40 mg p.o. q 6 hours hold for systolic blood
pressure less than 160.
The patient's vital signs stable, she is afebrile, she will
be discharged to rehabilitation with follow-up with Dr. [**Last Name (STitle) 1132**]
in one months time.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2109-11-7**] 11:35
T: [**2109-11-7**] 12:45
JOB#: [**Job Number 35840**]
ICD9 Codes: 431, 5990, 2761, 2720, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3185
} | Medical Text: Admission Date: [**2116-3-2**] Discharge Date: [**2116-3-4**]
Service: CARDIOLOGY
CHIEF COMPLAINT: Atrial flutter.
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
male with coronary artery disease, status post porcine mitral
valve replacement and aortic valve replacement, now with
atrial flutter. He presented to an outpatient urology
appointment for bladder stones and was noted to have a rapid
heart rate in the 150's. An electrocardiogram showed
borderline wide complex tachycardia at 150.
The patient was sent to his cardiologist, Dr. [**Last Name (STitle) 696**], who
was not available. He was sent to Dr. [**Last Name (STitle) 73**], who
performed carotid sinus massage and found that the patient
was in atrial flutter with 2:1 block. The patient denied
palpitations. He had no chest pain, shortness of breath,
lightheadedness, headache, visual changes, numbness, tingling
or weakness.
PAST MEDICAL HISTORY:
1. Coronary artery disease with a left internal mammary
artery graft to the left anterior descending artery in [**2106**]:
A cardiac catheterization on [**2116-1-6**] showed significant
restenosis of the left anterior descending artery that was
status post percutaneous transluminal coronary angioplasty,
moderate in-stent restenosis of the circumflex coronary
artery. Re-intervention of the left anterior descending
artery was deferred due to gross hematuria. More
specifically, the proximal left anterior descending artery
had a discreet 70% stenosis. The right coronary artery was
large with discreet moderate 40-50% proximal stenosis. The
posterior descending artery was diffusely diseased with a 30%
maximal stenosis. The left main coronary artery was at most
20%. The second diagonal artery had been dilated in [**2115-8-10**] and showed mild stenosis, at most 30-40%. There was
moderate diffuse in-stent restenosis of the proximal
circumflex coronary artery up to 50%.
Initially, it appeared that an left anterior descending
artery intervention was planned. However, on heparin and
Integrelin, the patient had gross hematuria and this was
deferred. In discussion with his primary care physician, [**Name10 (NameIs) **]
was decided, given that no stenoses were greater than 70%,
that plans be for medical management. An echocardiogram in
[**2115-9-10**] showed the left atrium to be moderately dilated.
The left ventricular cavity size was normal. There was
severe regional left ventricular systolic dysfunction, right
ventricular chamber size and systolic function were normal.
A bioprosthetic aortic valve as well as a bioprosthetic
mitral valve were seen without evidence of aortic
regurgitation. The motion of the mitral valve appeared
normal with mild mitral regurgitation and an ejection
fraction of 25%.
The patient had a history of paroxysmal atrial fibrillation
following valve surgery in [**2106**]. He also had a recurrence in
[**2115-2-9**]. He had symptomatic treatment in the past with
beta blockers, which caused sinus pauses and severe
bradycardia. The patient was status post aortic valve
replacement with porcine on [**2106-5-31**] for aortic stenosis,
questionably rheumatic. He developed congestive heart
failure at that time. He was status post mitral valve
replacement with porcine in [**2106-5-10**].
2. Chronic obstructive pulmonary disease.
3. Prostate nodule, status post biopsy in [**2111**] which was
negative.
4. Adult onset diabetes.
5. Hematuria in [**2115-12-11**] with heparin and Integrelin.
This was found to be secondary to bladder stones.
MEDICATIONS ON ADMISSION:
Aspirin 325 mg p.o. q.d.
Digoxin 0.125 mg p.o. q.o.d.
Glyburide 2.5 mg p.o. q.d.
Isordil 10 mg p.o. t.i.d.
Lipitor 5 mg p.o. q.d.
Norvasc 5 mg p.o. q.d.
Zantac 150 mg p.o. q.d.
ALLERGIES: The patient had an allergy to shellfish.
PHYSICAL EXAMINATION: The patient had a temperature of
96.9??????F, a heart rate of 120, a blood pressure of 120/70 and a
respiratory rate of 18. In general, the patient was in no
acute distress. On head, eyes, ears, nose and throat
examination, the pupils were 2 cm and symmetric. The the
extraocular movements were intact with sustained nystagmus on
the right and lateral gaze. There was left facial droop.
The neck was supple with no lymphadenopathy. The carotids
were without bruits.
There were respiratory crackles one third of the way
posteriorly bilaterally. The cardiovascular examination was
a slightly irregular with a I/VI systolic murmur at the apex.
The abdomen was soft, nontender and nondistended with
positive bowel sounds. The extremities had no edema. There
were 1+ dorsalis pedis pulses bilaterally. On neurologic
examination, the patient was alert and conversant. Strength
was [**6-13**] with 2+ biceps symmetrically. Touch was intact.
LABORATORY: The patient had a white blood cell count of
8,700, hematocrit of 42.3 and platelet count of 229,000.
Prothrombin time was 13.8, partial thromboplastin time was
25.7 and INR was 1.3. There was a sodium of 141, potassium
of 3.8, chloride of 103, bicarbonate of 25, BUN of 20,
creatinine of 0.9. Digoxin level was 0.3. Glucose was 149.
Calcium was 9.3. Phosphate was 3.4. Magnesium was 2.1.
RADIOLOGY: A chest x-ray showed possible mild upper zone
redistribution consistent with, if at all, mild congestive
heart failure.
ELECTROCARDIOGRAM: The electrocardiogram had a wide complex
tachycardia at 150 with a left axis and a left bundle branch
block.
HOSPITAL COURSE: The patient is an 81-year-old male with
coronary artery disease, status post porcine mitral valve
replacement and aortic valve replacement, who presented in
atrial flutter. Initially, his rate was about the 150's with
2:1 conduction. The patient had a history of severe
bradycardia with beta blockers, however cautiously he was
given 5 mg of intravenous Lopressor upon presentation and his
heart rate slowed to the 80's and 90's. He was started on
12.5 mg p.o. t.i.d. of Lopressor, which he tolerated well.
The patient had heart rates well controlled in the 70's to
80's and remained in atrial flutter. The patient had a
Digoxin level checked, which was 0.3. He was on a very low
dose of Digoxin, 0.125 mg p.o. q.o.d., which was continued.
Apparently, he had digitalis toxicity in the past, hence his
very low dose. The patient was also started on heparin and,
once he was therapeutic, he was loaded on Coumadin.
It was anticipated that in one month he would need to undergo
cardioversion, probably with amiodarone, given his low
ejection fraction. Liver function tests and thyroid
functions were pending at the time of this dictation and his
chest x-ray did not show evidence of interstitial disease.
The patient's INR was 1.3 at the time of this dictation. The
patient ruled out for a myocardial infarction on this
admission.
2. ISCHEMIA: The patient was status post cardiac
catheterization on [**2116-1-6**] with restenosis of the left
anterior descending artery and circumflex coronary artery,
not intervened upon secondary to hematuria with his
anticoagulants. Again, the greatest stenosis was 70% of the
left anterior descending artery and this had been medically
managed. There were no plans for intervention on this
admission. He was continued on his aspirin and Lipitor and
ruled out for a myocardial infarction.
3. PUMP: The patient had an ejection fraction of 25%. His
blood pressure upon presentation was 120/70 however, given
his low ejection fraction, his Norvasc was discontinued and
he was started on a low dose ACE inhibitor. He tolerated the
Captopril at 6.25 mg and then 12.5 mg. He was continued on
his Isordil and switched over to Lisinopril on the day of
discharge. Please note that prior to starting
anticoagulation, Dr. [**Last Name (STitle) **], his urologist, was contact[**Name (NI) **]
and said that it was okay to heparinize the patient and he
did not exhibit any evidence of hematuria.
The hospital course was also remarkable for a symptomatic
multifocal ventricular tachycardia of five beats on two
consecutive nights. The plans were for an electrophysiologic
study, which was to be done in-house.
NOTE: The remainder of this dictation will be done in the
addendum.
DISCHARGE DIAGNOSES:
Atrial flutter.
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Last Name (NamePattern1) 104014**]
MEDQUIST36
D: [**2116-3-4**] 11:10
T: [**2116-3-5**] 06:37
JOB#: [**Job Number **]
ICD9 Codes: 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3186
} | Medical Text: Admission Date: [**2176-5-9**] Discharge Date: [**2176-5-19**]
Date of Birth: [**2112-12-30**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63F h/o Mantle cell lymphoma s/p Part B hyper CVAD [**2176-4-29**] to
[**2176-5-3**] presents with fever and neutropenia and only localizing
infectious symptoms to the right labia. She noted excoriation of
this area secondary to frequent urination post chemotherapy and
mild swelling and erythema that developed on the day of
admission. On presentation to the emergency department her vital
signs were HR to the 150s, BP dropped from 157/63 to 90/50, Hco3
19, lactate 3.7. Due to rapid extension of the right labial
erythema and edema, consults to Surgery and Gynecology were
obtained. CT scan of the abdomen and pelvis were significant for
no air in the soft tissues and both consult services agreed with
medical management and close observation. The patient was
aggressively hydrated with 2L NS with improvement in her BP and
Vancomycin 1 gram, Cefepime 2grams and Clindamycin 600mg were
administered intravenously in the ED. The patient was admitted
to the MICU for close monitoring and her sepsis.
Past Medical History:
Mantle Cell Lymphoma diagnosed in [**10-29**] s/p 2 cycles of
hyper-CVAD
s/p cholecystectomy [**1-31**]
Tonsillectomy (age 8) via XRT
Recurrent ENT Infections as child
TAH/BSO - [**Hospital1 112**] [**2170**]
SCC Lower Lip s/p Resection [**2172**]
Social History:
Patient lives with her husband and has one son. She is [**Name8 (MD) **] RN
and currently works as a NH administrator. Tob: quit smoking 39
years ago; used to smoke 5cig/day x 5 years. EtOH: used to drink
less than 3x/week, currently no alcohol intake. No recreational
drug use
Family History:
No known leukemias or lymphomas. Father died at 42 from rectal
cancer. Paternal aunt died at 68 from BRCA. Paternal uncle and
brother have DM. Maternal aunt died at 97 from MI. No FHx of
early MI's.
Physical Exam:
T=103.9, HR 118, BP 92/43, RR 18, O2 sat 100% on RA
Gen- non-toxic appearing
HEENT-PERRLA, EOMI, sclera anicteric, OP clear
Neck- no LAD, JVP est < 5 cm H2O
Chest- slight decreased breath sounds at the left base. L port
C/D/I
CV- tachycardic, regular, normal s1 and s2, no s3 or s4. no
murmur or rub. No rv heave
Ab- soft/nontender/nondistended, normoactive bowel sounds. No
masses or hepatosplenomegaly
Ext- no clubbing, cyanosis, or edmea. 2+DP/PT pulses. warm/dry.
Genital- right labial swolling with erythema and induration over
the inferior aspect. No extension to perianal area. No
flocculence.
Pertinent Results:
Admission labs:
LACTATE-3.7* (the following day: [**2176-5-10**] 04:45AM BLOOD
Lactate-1.9)
GLUCOSE-173* UREA N-19 CREAT-1.3* SODIUM-135 POTASSIUM-3.6
CHLORIDE-103 TOTAL CO2-19* ANION GAP-17
ALT(SGPT)-94* AST(SGOT)-49* ALK PHOS-106 AMYLASE-30 TOT BILI-1.3
WBC-0.1*# RBC-2.89* HGB-9.1* HCT-25.3* MCV-88 MCH-31.4
MCHC-35.9* RDW-15.4
PLT COUNT-36*#
PT-13.3 PTT-24.3 INR(PT)-1.1
Discharge labs:
WBC-3.3* RBC-3.49* Hgb-10.8* Hct-30.7* MCV-88 MCH-30.9
MCHC-35.2* RDW-15.2 Plt Ct-120*
BLOOD ALT-14 AST-11 LD(LDH)-152 AlkPhos-81 TotBili-0.5
BLOOD Calcium-8.1* Phos-2.7 Mg-2.0
Micro:
[**5-9**]: blood cultures 1/2 bottles positive with E coli
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
subsequent negative blood cultures: [**5-11**] x2, [**5-12**] x2, [**5-13**] x2
UCx negative [**5-10**], [**5-12**]
Imaging:
CT abdomen/pelvis [**5-10**]:
IMPRESSION: Vulvitis of the right labia majora, with involvement
of the clitoris. No focal gas collections to suggest the
presence of necrotizing fasciitis. The right adductor fascia is
preserved. No radiographic evidence of osteomyelitis within the
pubic symphysis.
MRI pelvis [**5-13**]:
1. Asymmetric enlargement of the right labia majora, with edema
and asymmetric thickening of the medial aspect of the right
labia. This may be secondary to an infectious or inflammatory
process, but direct involvement by lymphoma should be
considered.
2. No evidence of abscess or fasciitis.
3. Superficial subcutaneous edema involving the anterior aspect
of both thighs.
4. Bilateral iliac lymphadenopathy, left greater than the right.
5. Heterogeneous bone marrow signal within the proximal portions
of both proximal femurs, likely related to the patient's history
of lymphoma.
6. Small free fluid in the pelvis.
Brief Hospital Course:
1. vulvitis - Pt was initially admitted to the intensive care
unit, and the sepsis protocol was activated. She was volume
resucitated with 5LNS with improvement in tachycardia and blood
pressure. Two out of four blood cultures (both from the P-AC)
were positive for E. coli, and pt was placed on broad
antibiotics. She continued to appear clinically well despite
continued fevers to 102. Despite broad antibiotic coverage the
infection spread to the perianal area and more superiorly. The
infectious disease service was consulted and recommended
continuing clindamycin despite increasing hyperbilirubinemia to
provide optimal coverage for toxin producing bacteria. The
Surgery and Gynecology Consult services continued to follow the
patient, beginning while in the MICU, and medical therapy was
recommended, particularly given concern for introducing
infection in the setting of her neutropenia. Pt continued to do
well and was transferred to the floor. CT scan showed no
evidence of fasciitis or abscess. As there was further concern
per surgery team to rule out abscess or fasciitis, an MRI was
also performed, which showed neither of these processes. Pt was
maintained on meropenem IV, and the erythema of her R thigh and
mons continued to improve daily, as did her pain. The wound
care nurse showed the pt how to apply duoderm to the area of
tissue necrosis/ulceration. Swabs of the area sent for VZV
cultures are thus far negative. Pt was concerned about having
an IV infusion pump at home due to the multiple animals living
in her home; she was therefore switched to ceftriaxone/flagyl to
finish out a 2-week total antibiotics course. After the switch,
pt was afebrile for the next 48 hours and showed continued signs
of improvement. She will return to clinic for daily ceftriaxone
until [**5-23**], which is her last dose. On discharge, there was
complete resolution of erythema on her thigh and mons;
persistent induration along the R labia, with a round, ~1cm area
of ulceration on the posterior R labia with an intact eschar
overlying the ulceration. Of note, pt's pain was controlled
with Tylenol. She attempted oxycodone but did not like the
effects on her mental status. She reported that her pain was
tolerable with Tylenol.
2. mantle cell lymphoma - pt was status post her second cycle
of hyperCVAD. She was neutropenic initially, but her counts
recovered, and her G-CSF was stopped. She continued to do well.
She was transfused for anemia and thrombocytopenia as needed.
It was thought unlikely that the area of necrosis/ulceration was
due to lymphoma, given the results of the imaging studies, as
above.
3. supraventricular tachycardia - While in the MICU, pt's
course was complicated by runs of SVT consistent with AVNRT,
requiring adenosine to terminate the rhythm and initiation of
metoprolol.
4. hypertension - Pt's BP was in the 130s-140s, even with
metoprolol. This was uptitrated, and pt was discharged on
Toprol XL 25mg po daily. This should be followed for further
blood pressure control.
5. FEN/GI - Pt was ultimately able to take po and was no longer
neutropenic on discharge, making her diet unrestricted.
Electrolytes were repleted as needed, notably potassium. This
should be checked as an outpatient to ensure that she does not
require potassium supplementation at home.
6. Code - full
Medications on Admission:
fluconazole 100mg po daily
estradiol 1mg po daily
tylenol prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
3. Estradiol 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1)
gram Intravenous Q24H (every 24 hours) for 4 days: return to
clinic for infusion daily, end date [**3-25**].
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. vulvar cellulitis
2. mantle cell lyphoma
3. Eschericia coli sepsis, resolved
4. hypertension
Discharge Condition:
stable, tolerating po, ambulating
Discharge Instructions:
Please return daily for ceftriaxone intravenous infusion for the
next few days; your last day of treatment will be [**5-23**], to
complete a 14-day course.
If you notice fevers, chills, worsening pain, or increased
redness of your vulva or leg, please go to the emergency room.
Followup Instructions:
Please return to 7Feldberg for infusion of intravenous
ceftriaxone daily until [**5-23**].
ICD9 Codes: 5849, 2875, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3187
} | Medical Text: Admission Date: [**2168-8-11**] Discharge Date: [**2168-8-11**]
Date of Birth: [**2093-1-7**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
cardiac arrest
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75yoW with salivary cancer metastatic to lungs, bone, liver,
kidneys brought to [**Hospital1 18**] ED after cardiac arrest. Patient
reportedly found down for 30minutes and intubated in the field
for airway protection. On arrival to [**Hospital1 18**] no BP or HR, K 6.8,
lactate 17.9. She was treated with epinephrine/atropine x2,
pronounced dead, but then regained HR and pulse. BP 58/31,
right femoral line placed, and she was started on dopamine. She
received calcium gluconate and insulin/D50 for hyperkalemia.
Currently HR 128, BP 113/99. ABG 7.08/45/432. She is not
responsive to pain or verbal stimuli.
Past Medical History:
previous care at [**Hospital3 **]
- metastatic cancer, thought to be salivary gland primary
Social History:
patient lives with her daughter. two daughters involved in her
care.
Family History:
non-contibutory
Physical Exam:
T 92.4 HR 128 BP 113/99 RR 16
A/C TV 400 RR 16 FiO2 100% PEEP 5 ABG 7.08/45/432
Gen: comatose
HEENT: pupils fixed 5mm, anicteric, ETT, OG tube with bloody
output
CV: tachycardic, regular, no mrg
Resp: coarse bilaterally
Abd: thin, no bowel sounds, soft, large palpable masses
RLQ/RUQ/LLQ
Ext: muscle wasting, 1+ radial pulses B, decreased DP pulses
Neuro: nonresponsive to pain, pupils nonreactive, doll's eyes
Pertinent Results:
[**2168-8-11**] 12:56PM TYPE-ART PO2-432* PCO2-45 PH-7.08* TOTAL
CO2-14* BASE XS--16
[**2168-8-11**] 12:56PM K+-3.8
[**2168-8-11**] 12:25PM GLUCOSE-571* LACTATE-17.9* NA+-139 K+-3.9
CL--100 TCO2-15*
[**2168-8-11**] 12:05PM UREA N-23* CREAT-0.9
[**2168-8-11**] 12:05PM CK(CPK)-36
[**2168-8-11**] 12:05PM AMYLASE-125*
[**2168-8-11**] 12:05PM CK-MB-NotDone cTropnT-0.02*
[**2168-8-11**] 12:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-8-11**] 12:05PM URINE HOURS-RANDOM
[**2168-8-11**] 12:05PM URINE HOURS-RANDOM
[**2168-8-11**] 12:05PM URINE GR HOLD-HOLD
[**2168-8-11**] 12:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2168-8-11**] 12:05PM WBC-21.0* RBC-4.02* HGB-8.7* HCT-30.3*
MCV-75* MCH-21.6* MCHC-28.7* RDW-16.3*
[**2168-8-11**] 12:05PM PLT COUNT-404
[**2168-8-11**] 12:05PM PT-15.6* PTT-58.4* INR(PT)-1.6
[**2168-8-11**] 12:05PM FIBRINOGE-432*
[**2168-8-11**] 12:05PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2168-8-11**] 12:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2168-8-11**] 12:05PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2168-8-11**] 12:05PM URINE AMORPH-FEW
[**2168-8-11**] 11:44AM TYPE-[**Last Name (un) **] PO2-32* PCO2-69* PH-7.15* TOTAL
CO2-25 BASE XS--7
[**2168-8-11**] 11:44AM K+-6.8*
Brief Hospital Course:
75yo woman with history of metastatic cancer, primary thought to
be salivary, presented after cardiac arrest, intubated in the
field, rescuscitated in the ED by PEA ACLS protocol. CT head
revealed a large posterior fossa intracranial hemorrhage.
Neurologic exam demonstrated brain death. Neurosurgery and
Neurology consults were called for confirmation. Initial exam
was done with the patient hypothermic. She was warmed with a
warming blanket, and repeat exam again demonstrated brain death.
The family was notified that patient was brain dead. The organ
donation team was notified. The family declined organ donation.
The ventilator was withdrawn. The medical examiner was called
and declined evaluation.
Medications on Admission:
percocet prn
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
ICD9 Codes: 431, 2767, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3188
} | Medical Text: Admission Date: [**2107-11-12**] Discharge Date: [**2107-12-21**]
Date of Birth: [**2045-12-2**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
renal failure s/p CRT
Major Surgical or Invasive Procedure:
HD line placement
History of Present Illness:
61M with history of ESRD s/p CRT [**2101**], hypertension, diabetes,
diastolic CHF, admitted on [**2107-11-12**] with acute on chronic
dyspnea, now s/p PEA arrest. He presented on [**11-12**] with 2 days of
worsening dyspnea, cough, and fever/chills. Also with
orthopnea, PND, and worsening edema in all 4 extremities.
.
Labs showed ARF with creatinine of 5.8 (up from 2.9). During
hospital course on the floor, renal function continued to worsen
and urine output was low even with furosemide (unclear etiology
of ARF). Also noted to have intermittent somnolence but
arousable and fully oriented. ABGs repeatedly with partially
compensated respiratory acidosis (has also had this in the
recent past), team unsure how reliable ABGs were given bilateral
UE fistulas.
.
Patient was in angio having hemodialysis line placed when his
arrest event occurred. He was placed in a lateral decubitus
position due to difficulty lying flat due to shortness of
breath. Towards the end of his line placement, he became more
agitated and was pushing his facemask away. O2 sats were unable
to be obtained. He was then placed in supine position for line
suturing. He was then noted to be nonresponsive, code blue
call. Then noted to be pulseless. CPR initiated and initial
rhythm asystole/very slow PEA, subsequently faster PEA. Total
pulseless time 13 minutes. Received total 2 mg epinephrine, 2
amps bicarb, 1 mg atropine, insulin/D50, IVFs via new HD line.
Regained pulses with first SBP >180. Intubated.
.
In the MICU, patient seemed to be waking up some but with also
evidence of extensor posturing in upper and lower extremities.
Neuro consulted. Aline and CVL placed.
.
Review of systems: unable to obtain
Past Medical History:
- Renal cell carcinoma s/p resection [**2093**]
- Severe obstructive sleep apnea,(not wearing CPAP at home)
- ESRD s/p CRT [**2101**], complicated by transplant renal artery
stenosis necessitating stent placement in [**2103**]
- Resistant HTN
- Diastolic congestive heart failure, TTE [**2107-8-18**]: Moderate
diastolic LV dysfunction with elevated LVEDP. Mild pulmonary
hypertension
- Diabetes, type 2, on insulin
- GERD
- Barrett's Esophagus
- s/p patella avulsion repair
- history of hypercalcemia
- hyperparathyroidism
Social History:
Married with seven children
Employment: Employed as a chef at [**Hospital1 18**]
Tobacco: No h/o
Alcohol: No h/o
Family History:
Mother with kidney disease.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Intubated; initially not sedated. Not opening eyes but
moving all extremities to pain and initally spontaneously.
?myoclonic and posturing as below.
HEENT: Sclera anicteric, pupils equal at 2 mm though minimal
reactive. ETT in place.
Neck: HD line in place. Obese neck, difficult to appreciate JVD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, loud systolic
murmur best at RUSB and LUSB.
Abdomen: soft, distended, appears non-tender, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
[**2-8**]+ bilateral LE edema, also +bilateral UE edema, ?right
slightly greater than left
Neuro: Moving some spontaneously and responsive to pain in the
UEs, not much pain response in the LEs. Seems to be
intermittently with extensor posturing (lasts 2-3 seconds at a
time), sometimes associated with ?myoclonic movements of ankles.
+ significant bilateral ankle clonus.
Pertinent Results:
[**2107-11-12**] 8:10p
.
Other Urine Chemistry:
UreaN:549
Creat:199
Na:<10
TotProt:53
Prot/Cr:0.3
Osmolal:347
.
Color
Yellow Appear Clear SpecGr 1.013 pH 5.0 Urobil Neg Bili Neg
Leuk Tr Bld Neg Nitr Neg Prot 75 Glu Neg Ket Neg RBC 0-2
WBC [**6-15**] Bact None Yeast None Epi 0-2
Other Urine Counts
RenalEp: 0-2
CastHy: 0-2
.
[**2107-11-12**] 4:10p
138 103 72
------------- 178
5.0 27 5.8 ∆
.
Ca: 9.6 Mg: 2.6 P: 4.3 ∆
CK: 315 MB: 5 Trop-T: 0.08
.
Alb: 2.9
proBNP: 1817
.
.....8.4
5.5 ----- 212
.....26.8
N:68.5 L:21.8 M:6.9 E:2.4 Bas:0.5
.
CXR [**2107-11-14**]: In comparison with the study of [**11-12**], there are
lower lung volumes. Enlargement of the cardiac silhouette
persists with mild vascular congestion suggested.
.
EKG: NSR at 94, NANI, low limb lead voltage, poor RWP (old); no
significant change from prior.
.
TTE [**2107-11-14**]: The left atrium is moderately dilated. mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic arch is mildly dilated. There is
mild pulmonary artery systolic hypertension. There is a very
small circumferenital pericardial effusion.
.
Renal ultrasound [**11-13**]: No new findings.
.
CT Chest [**11-15**]: On CT, there is no evidence of air embolism.
Cardiomegaly, mild axillary and mediastinal lymphadenopathy.
Bilateral pleural effusions with areas of subsequent
atelectasis, patchy lower lobe predominant parenchymal opacity
is potentially suggestive of a combination of pneumonia and
atelectasis. No pathologic air collection in the mediastinum and
the lung interstitium.
.
CT Head [**11-15**]: 1. No acute intracranial hemorrhage or acute
vascular territorial infarction. There is no hydrocephalus.
2. Opacification of sphenoid sinus, maxillary, ethmoid air cells
and
nasopharynx, most likely related to recent intubation.
.
CT Head [**11-17**]: 1. No acute intracranial hemorrhage or obvious
major territorial acute infarct, mass effect, or hydrocephalus.
If there is continued concern, MR of the head with
diffusion-weighted imaging sequence is more sensitive in the
detection of acute stroke.
2. Diffuse opacification of the sphenoid sinus, nasopharynx, the
maxillary
and the ethmoid air cells partly related to mucosal thickening,
secretions
from intubation. However, patient also had a left antrochoanal
polyp in the past, which is incompletely assessed on the present
study.
3. Discontinuous foci in the left parietal bone may relate to
thinning of the bone, from arachnoid granulations or other
etiology, to correlate with any history of surgery. However,
this appearance is unchanged compared to the prior CT sinus
study done on [**2102-10-19**].
.
RUE US [**11-20**]: Although subclavian vein not evaluated, remainder
of right upper extremity venous system appears normal with no
evidence of DVT, and DVT would be likely in the subclavian vein
given respiratory variation and normal appearance of remainder
of the study.
.
MR [**Name13 (STitle) 430**] [**11-21**]: 1. Severely limited examination demonstrates
changes of chronic microvascular white matter ischemic disease
with old left frontal encephalomalacia without evidence for
acute infarct.
2. Extensive paranasal sinus and mastoid air cell disease.
.
KUB [**11-25**]: 1. Severely limited examination demonstrates changes
of chronic microvascular white matter ischemic disease with old
left frontal encephalomalacia without evidence for acute
infarct.
2. Extensive paranasal sinus and mastoid air cell disease.
.
KUB [**11-26**]: There is no evidence of free air. NG tube tip is in
the stomach. Right femoral catheter remains in place. There is
no evidence of bowel obstruction. There is nonspecific bowel gas
pattern.
.
Portable Abdomen XR [**11-29**]: There is no evidence of ileus, small
or large bowel obstruction.
.
Abdominal US [**12-6**]: Normal right upper quadrant ultrasound with
no findings to suggest the cause of the patient's pain.
.
CT Abd/Pelvis [**12-6**]: 1. Small thrombus within the IVC and at the
junction of the right common iliac vein and transplanted renal
vein.
2. Diffuse mesenteric stranding with no small or large bowel
pathology
identified.
.
CT Head [**12-11**]: 1. . No acute intracranial abnormality.
2. Partial opacification of mastoid air cells bilaterally,
maxillary, ethmoid and sphenoid sinuses, partly polypoidal.
.
CT Abd/Pelvis [**12-11**]: 1. Very large spontaneous hematoma
involving a majority of the left hepatic lobe. A small amount of
perihepatic hematoma and scattered areas of blood within the
mesentery and along the left pericolic gutters tracking into the
pelvis. No definite site of active extravasation identified.
2. Branches of left portal vein are attenuated and not well
visualized in
the midst of the hematoma but are patent.
3. No change in small 1.5 cm thrombus within the infrarenal IVC.
Second
separate smaller thrombus in the right common iliac vein near
the transplant renal vein anastomosis on the prior study not
definitely visualized and may have cleared with anticoagulation.
4. Atelectasis of both dependent lower lobes.
5. More confluent consolidative opacity of the superior right
lower lobe
could be explained with atelectasis but is concerning for
possible area of
aspiration or pneumonia.
.
CT Abdomen [**12-16**]: Limited study but no gross evidence of
obstruction.
.
CXR [**12-19**]: There is interval development of vascular
engorgement, perihilar opacities, and bibasilar opacities, left
more than right, findings which might be consistent with
interval progression of pulmonary edema. Evaluation after
diuresis is recommended to exclude the possibility of underlying
infectious process.
Brief Hospital Course:
61M with ESRD s/p CRT, HTN, DM, admitted with dyspnea and ARF.
During IR placement of an HD catheter he suffered a PEA arrest x
2. He was cooled using artic sun protocol. He slowly recovered,
but his hospitalization was complicated by prolonged intubation
leading to tacheostomy placement, Psuedomonas UTI, HAP,
Stenotrophomonas PNA, aspiration PNA, acute on chronic kidney
injury leading to loss of fuction of his transplanted kidney,
IVC thombosis, spontaneous intrahepatic hemorrage during
heparinization for his thrombus, gout flair, and altered mental
status which has slowly improved. After more than a month in the
hospital he has stabilized, is ambulating with assistance,
speaking through a Passe Muir valve, and tolerating tube feeds.
.
# Aspiration: Patient had emesis [**2107-12-13**] and aspirated tube
feeds. Developed aspiration pneumonitis vs. aspiration PNA. CXR
showed no clear evidence of PNA but CT showed confluent
consolidative opacity of superior RLL. Pt was febrile following
aspiration event and ended up re-intubated. Now s/p 7-day course
of vanc/zosyn for aspiration that ended on [**2107-12-18**]. Respiratory
status has dramatically improved and he is now on trach mask
only. He had a video swallow evaluation on [**2107-12-20**] which showed
silent aspiration. It was suggested that he have a diet of
nectar thick liquids and soft consistency solids. meds must be
crushed in purees with Q6 hour oral care. He should have follow
up with speech therapy at rehab with repeat video swallow if
diet is to be advanced.
.
# Stenotrophomonas PNA: Diagnosed from repeated sputum cultures.
On Bactrim x14 day course, day 1=[**12-16**] to d/c [**12-30**]. Note that
Bactrim must be give FOLLOWING HD as it is dialyzed off.
Intially diagnosed [**12-2**], but was inadquately treated as Bactrim
was given prior to HD rather than after.
.
# Pseudomonas UTI: Had a long course of Cefepime for UCx
positive for Pseudomonas x 2.
.
# Line infection: S/p Cefepime initially for UTI. Then Linezolid
was added for purulent appearing CVL. His lines were exchanged
and complicated by PEA arrest during procedure. His CVL grew out
Micrococcus. According to ID, the Cefepime should have covered
it. He received a 14d course of Cefepime and 9d course of
Linezolid. A PICC line and new HD line were placed and have had
no further complications.
.
# Labile blood pressures: Pt had been intermittently hypotensive
(infectious source vs hypovolemia vs adrenal insufficiency). His
infections were treated. He was given stress dose steroids. He
was on pressors for hypotension. Ultimately this resolved and he
became persistently hypertensive to the 190s to 220s. He was
started on a labetalol drip as well as PRN hydralazine. He has
been transitioned from Labetalol drip to PO Labetalol on [**12-9**],
then switched to Labetalol PRN. On [**12-14**], Labetalol was d/c??????ed.
Continue atenolol at 50mg daily. Continue lisinopril 10mg daily.
.
# Foot Pain: Likely gout, particularly given resolving hematoma
and renal failure. Receiveing pulse steroids with Prednisone
40mg daily x5 days starting on [**2107-12-20**]. Will resume chronic
Prednisone 5mg PO daily for maintenance of transplanted kidney
thereafter. [**Month (only) 116**] need suppressive allopurinol in the future for
his gout.
.
# DVT: Patient found to have venous thrombi in several vessels
including his IVC. He was on a heparin drip, being bridged with
coumadin. However, all anticoagulation stopped when liver
hematoma developed (see helow). Hematology was consulted
regarding whether it is appropriate to resume anticoagulation
given the risk of bleed, and recommended SC Heparin tid until he
follows up with Hematology and possibly vascular surgery
regarding possible benefits vs. risks of an IVC filter
placement. The patient should not be anti-coagulated with agents
other than SC Heparin given his high risk of bleed.
.
# Abdominal Distension: Patient??????s abdomen became distended and
tympanitic during this hospitalization. CT abdomen [**12-11**] showed
large liver hematoma with scattered areas of perihepatic
hematoma and scattered blood within the mesentery but without
definite sites of active extravasation. Distension likely [**2-7**]
chemical peritonitis which is resolving following reversal of
anticoagulation vs. functional ileus/[**Last Name (un) **]??????s syndrome from
infection/sepsis, intra-abdominal bleed, narcotic use, or
respiratory failure. This is consistent with the patient??????s
continued +bowel sounds and leukocytosis, but CT abdomen did not
show dilated R side of colon and loops of bowel were read as
WNL. Currently improved abdominal pain and minimally improved
distension. Abd is much less tense than prior. Continue Reglan
2.5mg TID standing for treatment of presumed diabetic
gastroparesis. Advancing diet as tolerated with tube feeds.
.
# Liver Hematoma: As above, CT showed hematoma of liver while
on heparin drip for IVC thombus. IR consulted re: possible
embolization, did not feel the bleed was acute (felt >48 hours
old) and wished to preserve hepatic artery and liver function if
possible, so recommended monitoring Hct. General surgery
consulted re: possible relation to PEG placement, but did not
believe this was [**2-7**] procedure based on the location of the
hematoma. Recommended montoring q6h Hct and coags, transfusing
as needed and keeping Hct >20. Received total of 3 unit pRBC
after reversal of PTT with FFP. Awaiting hematology
recommendation for long term anticoagulation given presence of
IVC thombus but complication of hemorrhage. (Ultimately decided
to hold all anticoagulation given severity of liver bleed.)
.
# Respiratory failure. Originally intubated in setting of arrest
with hypoxia beforehand. Was very difficult to wean from vent
due to persistent hypoxia, recurrent PNA, and altered mental
status. Trach and PEG placed on [**12-2**]. Now stable on trach. Had
aspiration even as above leading to short tern re-intubation.
Now tolerating trach mask. Speaking with Passe Muir valve.
.
# Altered mental status s/p PEA arrest: S/p PEA arrest x 2.
Underwent Artic Sun cooling protocol. Suring weaning of sedation
was severely agitated. Ultimately was transitioned from fentanyl
to methadone and then weaned on seroquel. He had a significant
set back from his liver hematoma and aspiration PNA. Neuro was
consulted and noted a staring spell that was concerning for
seizures. He was monitored with continuous EEG, which showed
epileptiform spikes but not outright seizure activity. Neuro
recommended startingKeppra, with Keppra 500mg qday and an extra
250mg after HD. The patient has slowly improved and is not
conversant, [**Location (un) 1131**], walking with assistance, and no longer
agitated. He is alert and oriented.
.
# Acute on chronic renal failure. He is s/p CRT in [**2101**].
Etiology of ARF likely multifactorial due to hypotension from
PEA, sepsis, contrast loads, and nephrotoxic drugs. Her the
Renal Service, he will not recover renal function of his kidney.
He will require HD henceforth. Continue prednisone 5mg PO daily
for rejection as well as Renagel 800 tid, Sevelemer 800 tid.
.
# FEN: Speech and Swallow Recs - video swallow: silent
aspiration seen on s/s for thin liquids. Recs: 1. Suggest a PO
diet of nectar thick liquids and soft consistency solids. 2. PMV
on for all POs. 3. Meds crushed with purees. 4. Monitor for
nutritional intake. 5. Q6 oral care. 6. Follow up speech therapy
in rehab s/p d/c
Medications on Admission:
-Amlodipine 10 mg [**Hospital1 **]
-Calcitriol 0.25mcg QD
-Cinacalcet 90 mg QD
-Clonidine 0.1 mg [**Hospital1 **]
-Lasix 120mg PO BID
-Labetalol 600mg [**Hospital1 **]
Lisinopril 10mg QHS
-Minoxidil 10mg [**Hospital1 **]
-Mycophenolate Mofetil 500mg [**Hospital1 **]
-Prednisone 5mg QD
Vardenafil 10mg PRN
-Aspirin 81mg QD
Insulin NPH & Regular Human Ten (10) units Subcutaneous qPM.
Insulin NPH & Regular Human Twenty (20) Units Subcutaneous qAM.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**]
units Injection PRN (as needed) as needed for line flush.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q6H
(every 6 hours) as needed for fever, pain.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
6. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-7**]
Drops Ophthalmic PRN (as needed) as needed for irritation.
8. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day).
9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
for renal transplant.
11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Four
(4) Tablet PO QHD (each hemodialysis): DC on [**12-29**].09. Give
AFTER HD.
12. Metoclopramide 10 mg Tablet Sig: 2.5 mg PO BID (2 times a
day).
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Increase as needed for persistent HTN.
14. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
dyspnea, wheeze.
17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours) as needed for shortness of
breath, dyspnea.
18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 5 days: DC on [**2107-12-24**]. Please give IN ADDITION to standing
prednisone 5mg PO daily for rejection.
19. 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.
20. Keppra 250 mg Tablet Sig: One (1) Tablet PO after HD: in
addition to daily dose of Keppra 500mg PO BID.
21. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): For IVC thrombi until further
evaluated by vascular surgery as outpatient.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
Primary:
- Renal failure
- Volume overload / acute on chronic CHF
- PEA arrest
- Altered mental status
- Bacterial pneumonia
- Ventilator associated pneumonia
- Aspiration pneumonia
- Urinary tract infection
- Hypertensive urgency
- Repiratory failure
.
Seconary:
- Renal cell carcinoma s/p resection [**2093**]
- Severe obstructive sleep apnea,(not wearing CPAP at home)
- ESRD s/p CRT [**2101**], complicated by transplant renal artery
stenosis necessitating stent placement in [**2103**]
- Resistant HTN
- Diastolic congestive heart failure, TTE [**2107-8-18**]: Moderate
diastolic LV dysfunction with elevated LVEDP. Mild pulmonary
hypertension
- Diabetes, type 2, on insulin
- GERD
- Barrett's Esophagus
- s/p patella avulsion repair
- history of hypercalcemia
- hyperparathyroidism
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted initially for volume overload and shortness of
breath. You had a long and complicated hospitalization for
treatment of this and various complications. You suffered a
severe type of heart attack called a PEA arrest. You required
life support from this event and were dependent on a breathing
machine for several weeks. Due to this a tracheostomy (breathing
tube in your neck) and feeding tube were placed. You had several
infections including a urinary tract infection, blood infection,
and pneumonias. You developed a clot in your veins and was
placed on blood thinners. Unfortunately, you bled while on the
blood thinners and these were stopped. Your kidney function
worsened and your transplanted kidney stopped functioning. You
were restarted on dialysis.
.
Please continue to take your medications as ordered.
.
Please attend your follow up appointments.
.
Followup Instructions:
Appointment #1
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Neurology
Date/ Time: Wednesday, [**1-4**] at 1pm
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 44**]
Appointment #2
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Transplant
Date/ Time: [**Last Name (LF) 766**], [**1-9**] at 3:20pm
Location: [**Hospital Ward Name 517**], [**Hospital Ward Name **] Bldg, [**Last Name (NamePattern1) 439**], [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 673**]
Appointment #3
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6944**]
Specialty: Hematology
Date/ Time: Wednesday, [**1-25**] at 1:40pm
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 6946**]
During your appointment with Dr. [**Last Name (STitle) 6944**] (Hematology), please
discuss whether you will need to be evaluated by vascular
surgery regarding possible placement of an Inferior Vena Cava
filter, and whether the benefits outweigh the risks, given your
blood clots.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2107-12-21**]
ICD9 Codes: 5849, 4275, 5070, 9971, 5990, 4280, 5856, 4168, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3189
} | Medical Text: Admission Date: [**2178-11-10**] Discharge Date: [**2178-11-12**]
Date of Birth: [**2111-9-14**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
brain hemorrhage
Major Surgical or Invasive Procedure:
intubated
History of Present Illness:
Patient with 1 week of severe headaches, fell down stairs at her
house and found unresponsive and hypertensive at the scene.
Transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
? hypertension
Social History:
lived with husband, no smoking, no alcohol, no drug use
Family History:
noncontributory
Physical Exam:
T 98.4 P85 BP 209/104 RR10 sat 100%bagged mask
head:pupils fixed and dilated bilaterally, R parietal hematoma
Pulm: poor respiratory effort - intubated with good breath
sounds bilaterally
CV: RRR, -MRG
GI: no trauma visible, plevis stable, rectal lax tone with no
blood
GU: WNL
Neuro: GCS 3, upgoing toes
Pertinent Results:
[**11-10**]
CT head: Large intraparenchymal hemorrhage centered within the
right basal ganglia , pons and midbrain, with blood dissecting
into the lateral, third and fourth ventricles. Given location of
hemorrhage most likely etiology include hypertensive hemorrhage.
There is extensive edema surrounding the hemorrhage site with
subfalcine and uncal herniation.
CT c-spine: No fracture or subluxation is identified involving
the cervical spine. Multilevel degenerative changes are seen,
notably disc space narrowing at C5-C6 and vertebral height loss
and sclerosis of C6. ET tube is present. Dystrophic
calcification noted within the right lobe of the thyroid. Mild
emphysematous change within the lung apices. The prevertebral
soft tissues are normal.
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lungs show mild
dependent atelectasis without focal consolidation. 7.2 x 5.8 mm
ground-glass nodule is seen within the superior segment of the
right lower lobe which is likely inflammatory. No pleural or
pericardial effusion identified. The heart and great vessels are
within normal limits. The aorta maintains a normal contour
without evidence of dissection. ET tube is present with the tip
just above the carina. No axillary or mediastinal
lymphadenopathy is identified. Note is made of a dilated fluid-
filled esophagus.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Liver demonstrates
a 7 mm low- density lesion within the right lobe, incompletely
characterized. The gallbladder, adrenal glands, spleen, and
pancreas are within normal limits. The kidneys enhance and
excrete contrast symmetrically. Note is made of a fluid- filled
stomach and proximal small bowel, although no evidence of
obstruction. No intra- abdominal free air, free fluid or
lymphadenopathy is identified. The abdominal aorta maintains a
normal contour. The celiac, SMA and [**Female First Name (un) 899**] are normally opacified.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, uterus,
and intrapelvic small bowel are within normal limits. No free
fluid or lymphadenopathy is identified. The bladder contains a
Foley catheter
Brief Hospital Course:
Patient with herniation and large intraparenchymal bleed on CT,
intubated and transferred to ICU. Pupils fixed and dilated,
neurosurgery evaluated patient and reported no available
intervention. Family was contact[**Name (NI) **] and the decision was made to
withdraw care on [**2178-11-12**]. Patient taken off of the ventilator
at 21:00, and the patient was pronounced dead at 21:17.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
intraparenchymal hemorrahage/death
Discharge Condition:
death
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3190
} | Medical Text: Admission Date: [**2158-7-2**] Discharge Date: [**2158-8-2**]
Date of Birth: [**2074-6-4**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Ceftazidime
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Ileus and altered mental status
Major Surgical or Invasive Procedure:
PICC line insertion
History of Present Illness:
Mr. [**Known lastname 656**] is an 84 year old gentleman recently readmitted after
a prolonged hospital course for ileus. He initally presented to
an outside Emergency Room on [**6-5**] after a fall, found to have
hemothorax with an INR of 11. His hospital course was
complicated by continued intractable pain, nerve blocks and
transfers to and from the surgical floor. He developed atrial
fib with RVR and increased work of breathing and was found to
have a loculated R pleural effusion. He underwent VATS converted
to thoracotomy for decortication. He grew out MRSA and MSSA with
ID recommending Vancomycin until [**7-31**]. He had difficulty weaning
form the vent and was put in for a trach/PEG. He was discharged
to rehab with a PICC in place to treat the infection above,
still with what may have been hypoactive delirium.
.
The patient was readmitted on [**7-2**] with AMS, ileus and concern
for a bowel obstruction. He was found to have + blood cultures
from his PICC (with associated clot, PICC changed), and found to
have Klebsiella & Pseudomonas VAP for which he is on a 21 day
course of Ceftaz/Cipro to end [**7-24**]; TEE negative. He has also
developed Afib with RVR for which he has been started on
Amiodarone; hypertension intermittently controlled with Nitro
gtt; worsening renal function and agitated delirium for which
geriatics is following.
.
At the time of transfer, the patient is not easily arousable and
cannot answer questions. A discussion with his primary TSICU
team and Geriatrics consultant yields the concerns above.
.
Review of systems: Unable to obtain, patient not easily
arousable/oriented
Past Medical History:
Past Medical History:
1. s/p fall with hemothorax ([**2158-6-8**])
2. DVT, right leg in 11/[**2156**].
3. Hypertension
4. COPD
5. elevated cholesterol
6. Osteoarthritis of the hip
7. BPH
Past Surgical History:
[**2158-6-18**] Right video-assisted thoracoscopy converted to right
thoracotomy, decortication of lung and evacuation of retained
hemothorax/empyema.
[**2158-6-22**] Percutaneous tracheostomy placement and
gastroesophagoscopy with percutaneous gastrostomy tube
placement.
Social History:
No drug abuse
Married, former smoker
Family History:
Positive for cancer in brother, heart disease,
mother, father, kidney disease, aunt.
Physical Exam:
On Admission:
101.6 F 71 133/61 25 100% CMV 1 350x23 +5
GEN: sedated, NAD
HEENT: trach in place, No scleral icterus, mucus membranes moist
Skin: no rash, wounds. PICC in LUE- no edema, erythema,
drainage
CV: irreg, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: obese, firm, distended, appears tender-max RUQ, no rebound
or guarding, no palpable masses
Ext: No LE edema, LE warm and well perfused
On discharge:
Afebrile, VSS
GEN: awake, alert, appropriate, NAD
HEENT: trach in place, moist mucous membranes
Pulm: Clear to auscultation bilaterally anteriorly
CV: irregular, no m/r/g noted
Abd: soft, NT, ND, +BS
Ext: 1+ pitting edema in the LE bilaterally to the knees
Rash: Diffuse erythematous morbilliform eruption worse from the
waist down
Pertinent Results:
Imaging:
[**7-2**] pCXR - Moderate right pleural effusion with bibasilar
opacity. Overall, this may represent cardiac congestion with
associated volume loss. Other less likely considerations include
aspiration or bilateral infectious consolidation.
[**7-2**] CT torso - new dilated loops of small bowel concerning for
early SBO, possible closed loop obstruction. transition point
somewhere in LLQ with distortion of mesentery ?rotation of
bowel. new free fluid within abdomen. scattered areas of bowel
wall thickening. +gallstones, unchanged. b/l basilar
consolidations. (preliminary)
[**7-3**]- UE US- Grayscale and Doppler son[**Name (NI) 1417**] of the left
internal jugular, subclavian, axillary, brachial, and basilic
veins demonstrate normal flow,
compressibility, augmentation, and waveforms. At the site of the
bandage and prior PICC at the left cephalic vein there is
intraluminal distention and thrombus with no flow present.
[**7-4**]- ECHO No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). with normal free wall contractility. There are
simple atheroma and focal nonmobile (>4mm) plaque in the
descending thoracic aorta and aortic arch. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
[**7-13**]- ct HEAD: No acute intracranial hemorrhage, large mass or
mass effect is identified.
There is no large hypodense area to suggest an acute infarct.
There is a
small hypodense focus in the right posteroinferior frontal lobe
which is more
conspicuous than a recent head CT performed [**2158-6-17**]. This
may represent
volume averaging or a small area of intraparenchymal change
(2:15).
Note is made of bilateral tortuous ophthalmic veins, which are
unchanged from
prior study. There is no increased density in the cavernous
sinuses to
suggest thrombus. There is diffuse opacification at the
bilateral mastoid air
cells, which is new since prior study. There are air-fluid
levels in the left
sphenoid sinus. There is diffuse osteopenia. No other bony
abnormalities are
identified.
[**7-17**]- MRI:
IMPRESSION:
1. No evidence of acute cerebral infarction.
2. Minimal if any small vessel ischemic disease.
3. Symmetric prominent bilateral superior ophthalmic veins raise
question of
carotid-cavenous fistla. This is similar as compared to [**2158-6-17**].
Clinical correlation to symptoms is recommended.
4. Paranasal sinus disease.
[**7-19**] - RUQ US: Sludge-filled gallbladder, as seen previously,
not suggestive of cholecystitis
[**7-28**] - Upper extremity dopplers: No new DVT (old dvt in left
cephalic vein remains)
ADMISSION LABS:
[**2158-7-2**] 12:45AM BLOOD WBC-14.8* RBC-3.00* Hgb-8.9* Hct-27.2*
MCV-91 MCH-29.8 MCHC-32.9 RDW-16.3* Plt Ct-557*
[**2158-7-2**] 12:45AM BLOOD Neuts-84.8* Lymphs-12.5* Monos-2.2
Eos-0.2 Baso-0.3
[**2158-7-19**] 02:59AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+
[**2158-7-2**] 12:45AM BLOOD Plt Ct-557*
[**2158-7-2**] 12:45AM BLOOD PT-14.4* PTT-24.2 INR(PT)-1.2*
[**2158-7-2**] 12:45AM BLOOD Glucose-150* UreaN-45* Creat-2.0* Na-146*
K-3.9 Cl-103 HCO3-30 AnGap-17
[**2158-7-2**] 12:45AM BLOOD ALT-28 AST-33 LD(LDH)-301* AlkPhos-322*
Amylase-38 TotBili-1.9* DirBili-1.1* IndBili-0.8
[**2158-7-2**] 12:45AM BLOOD Albumin-2.9* Iron-80
[**2158-7-3**] 12:21AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.9*
[**2158-7-2**] 12:45AM BLOOD calTIBC-203* Ferritn-1196* TRF-156*
[**2158-7-2**] 02:35AM BLOOD Type-ART Rates-14/15 Tidal V-450 FiO2-40
pO2-318* pCO2-43 pH-7.47* calTCO2-32* Base XS-7
Intubat-INTUBATED
DISCHARGE LABS:
[**2158-8-2**] 03:25AM BLOOD WBC-10.6 RBC-3.16* Hgb-9.6* Hct-28.3*
MCV-90 MCH-30.4 MCHC-33.9 RDW-17.7* Plt Ct-292
[**2158-8-2**] 03:25AM BLOOD Neuts-82.5* Lymphs-10.9* Monos-4.1
Eos-2.3 Baso-0.1
[**2158-8-2**] 03:25AM BLOOD Glucose-112* UreaN-58* Creat-1.3* Na-140
K-3.8 Cl-97 HCO3-36* AnGap-11
[**2158-8-2**] 03:25AM BLOOD ALT-33 AST-34 LD(LDH)-265* AlkPhos-239*
TotBili-0.6
[**2158-8-2**] 03:25AM BLOOD Albumin-3.0* Calcium-8.1* Phos-3.0 Mg-2.1
Brief Hospital Course:
#) Agitated Delirium: While the patient was originally admitted
to [**Hospital1 18**] to the surgical service for management of his SBO vs.
ileus, the reason for his extended stay was his agitated
delirium. While in the surgical ICU, he was started on
precedex, and as per geriatrics consult, he was started on
standing seroquel and his sleep wake cycle was re-established.
However, his precedex was stopped as this isn't a long term
solution, and his delirium worsened. Organic causes of the
agitated delirium were ruled out. He was transferred to the
medical ICU for continued care of his agitated delirium. While
in the medical ICU, we tried a multitude of medications,
including a change in his antipsychotics, as well as a variety
of benzodiazepines. Geriatrics and psychiatry continued to
consult, however all prn and standing medications tried were
unsuccessful. Ultimately, we restarted precedex drip in an
effort to wash out all other psychoactive medications. Over the
course of 5 days, we were able to wean off the precedex while
starting clonidine. While the clonidine is for his blood
pressure, it was thought that since it works on the same
receptor as the precedex, it would also assist in the control of
his agitated delirium. After weaning off the precedex, he
remains on 0.1 mg of clonidine POBID and has been clear in terms
of his sensorium for over 3 days now. He has also been started
on depakote as per our geriatrics team.
.
#) DRESS (drug rash with eosinophilia and systemic symptoms):
The patient developed a morbilliform rash that was through
secondary to the ceftazidime that was started for his
pseudomonas and klebsiella from the sputum. His eosinophils
increased to a peak of 15%, and associated with this was an
increase in his LFTs as well as progression of his renal
failure. A derm consult agreed and they suggested three days of
IV solumedrol. Afterward, he was started on a prednisone taper
(120 mg x 3 days, 80 mg x 3 days, and 40 mg x 3 days). For
symptomatic control, we used barrier creams. On the day of
discharge, his rash seems to be a little worse, so rather than
continuing with the taper, we have decided to continue him on 40
mg of prednisone and to slow the taper. Now, he should receive
three more days of the 40 mg dose (until the [**7-5**]),
and then transitioned to 20 mg daily. He should also NOT
receive ceftazidime, nor should he receive any lasix (the sulfa
groups thought to be contributing to the DRESS).
.
#) Renal failure: The patient's creatinine continued to rise
throughout his hospitalizations. Urine electrolytes and
eosinophils were sent which were consistent with ATN rather than
AIN. Given the DRESS (see above), we felt that this was the
likely reason for the renal failure. His Cr has returned to
baseline prior to transfer to rehabilitation. While he had ATN,
we kept him even in terms of ins and outs. He was refractory to
lasix when he was acutely in renal failure. Also, given the
thought that the sulfa group in lasix may worsen DRESS, he
instead was placed on 100 mg of ethacrynic acid POBID which has
worked well for him.
.
#) Respiratory distress: The patient required being placed on
the ventilator via his trach in what was thought to be volume
overload and ventilator associated pneumonia. His sputum grew
pseudomonas, and as above, ceftazidime was not helpful as it
caused the DRESS syndrome. He was ultimately treated for his
VAP with 8 days of cipro and meropenem, as well as an earlier
course of cefepime. For gram positive coverage, the patient was
continued on his vancomycin (see below). Also, during his
hospitalization, his trach was changed x 1 as he had a cuff leak
upon arriving to the MICU. In terms of the volume overload, he
was started on 100 mg of ethacrynic acid POBID to help him
slowly diurese some of the fluid off. His volume status is much
improved from when his Cr peaked at 3.0. He was ultimately
weaned from the ventilator approximately 1.5 weeks prior to
discharge.
.
#) Staph bacteremia: The patient had GPCs in the blood early in
his hospitalization. The patient's vancomycin (originally
started for MRSA in the pleural cavity) was continued and an ID
consult was done. They felt the course should continue until
[**7-31**], and vancomycin was stopped on that date. Future blood
cultures have been negative. A TEE was done and was negative
for endocarditis.
#) Ileus vs SBO: Pt was initially admitted to the surgical team
for management of this issue. After multiple scans, it was
thought that this was an ileus secondary to narcotic usage.
Also, with the renal failure, the level of bowel edema likely
contributed to the inability to take tube feeds. After his
creatinine normalized, he was able to take tube feeds more
consistently and has been at goal. This has largely resolved,
and we are continuing to diurese him for his bowel edema.
.
#) Atrial fibrillation: Anticoagulation was not initiated for
him as his risk of stroke while in house was considered to be
low, and given the recent surgical procedure, we held off in the
setting of his other medical issues. He is maintained on
metoprolol tartrate 25 mg POTID for his rate control and this
has not been an issue in the few days leading up to discharge.
.
#) Hypertension: The patient's blood pressure would acutely
increase with his agitated delirium, however he was also found
to be hypertensive at baseline. His blood pressure medications
were titrated, and a nitro gtt was used intermittently while
titration was attempted. Ultimately, his pressures and regimen
stabilized and clonidine was started in an effort to also help
with his mental status. Please see his medication list for his
current regimen.
.
#) Anemia: The patient has worsening anemia with no new
suggested bleeding sites, could represent underproduction, bone
marrow suppression from infection, abx, renal disease or
nutritional deficiency. His Hct stabilized and was checked
daily.
.
#) Elevated blood glucose: No history of diabetes. SSI for
glucose control, goal <200
We continued him on 12 units of lantus QHS. He has been doing
well on this regimen, however, it will likely need to be
titrated in the future once his prednisone taper continues.
#) h/o DVT: not currently candidate for anticoag. LENIs
negative, UENI?????? no new DVT
Will consider anticoagulation at a later date
#) Code Status: The patient was originally full code, however
during his hospitalization, his family decided to change him to
DNR. This will have to be an ongoing discussion with the
patient and his family.
Medications on Admission:
Vancomycin 1 gram q24 (last trough [**7-1**]- 32)
Finasteride 5 mg Tab Oral 1 Tablet(s) Once Daily
Combivent 1 Aerosol(s) Four times daily nebulizer
Docusate Sodium 50 mg/5 mL Oral 2 Liquid(s) Twice Daily
Esomeprazole Magnesium 40 mg Once Daily
Heparin (Porcine) 5,000 unit/mL TID
Losartan 100 mg Tab Oral 1 Tablet(s) Once Daily
Methadone 10 mg/5 mL Oral Soln Oral 1 Solution(s) every 8 hours
Metoprolol Tartrate 25 mg Tab Oral 1 Tablet Twice Daily 8AM &
2PM
Quetiapine 50 mg Tab Oral [**12-12**] Tablet(s) Twice Daily 8AM & 2PM
Senna 187 mg Tab Oral 2 Tablet(s) Once Daily, at bedtime
Simvastatin 10 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
Tamsulosin SR 0.4 mg 24 hr Cap Oral 1 Capsule, Sust. Release 24
hr(s) Once Daily
Tramadol 50 mg Tab Oral [**12-10**] Tablet(s) every 6 hours
Insulin Regular Human 100 unit/mL Cartridge Injection
sliding scale Cartridge(s) Four times daily
Erythromycin Ethylsuccinate 250mg/6.25ml Suspension(s) every 6
hours
Miconazole Powder Misc.(Non-Drug; Combo Route) to sacral wound
Powder(s) every 8 hours
Metoclopramide 10 mg Tab Oral 1 Tablet(s) every 6 hours
Bumetanide 0.25 mg/mL Injection Injection 0.5mg Solution(s) Once
Daily at 8PM
Acetaminophen 650 mg/20.3 mL Oral Soln Oral
1 Solution(s) every 4 hours, as needed
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Tablet,Rapid
Dissolve, DR(s)
2. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
3. Divalproex 125 mg Capsule, Sprinkle [**Last Name (STitle) **]: One (1) Capsule,
Sprinkle PO QID (4 times a day).
4. Ammonium Lactate 12 % Lotion [**Last Name (STitle) **]: One (1) application Topical
twice a day as needed for rash.
5. Clonidine 0.1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
6. Prednisone 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily):
Continue with 2 tabs daily for 3 days, then taper to 1 tab daily
for 3 days.
7. Ethacrynic Acid 25 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO BID (2
times a day).
8. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6
hours).
9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
10. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed for scrotum erythema.
11. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
12. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
13. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mls PO BID
(2 times a day).
14. Senna 8.6 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
15. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Delirium, ventilator associated pneumonia, bacteremia and renal
failure, ileus now resolved
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:
Please follow your rash closely. You are currently on prednisone
which will be decreased over the next few days. Currently you
are on 40 mg of prednisone daily for 3 more days followed by 20
mg for 3 more days.
Please contact your PCP for any concerning changes in mental
status or if your urine output drops off.
Followup Instructions:
You will be following up with the physician at the rehab center.
Completed by:[**2158-8-2**]
ICD9 Codes: 5845, 2930, 2760, 7907, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3191
} | Medical Text: Admission Date: [**2169-6-2**] [**Month/Day/Year **] Date: [**2169-6-10**]
Date of Birth: [**2088-3-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Malaise
Major Surgical or Invasive Procedure:
Placement of Left SC central catheter
Placement of PICC line, removed by patient
Replacement of PICC line
Transesophageal Echocardiogram
History of Present Illness:
HPI: 81 year old female with medical history significant for HTN
and LE edema p/w lethargy, malaise. Her grandson forced her to
go to the [**Name (NI) **]. She states that for days she states that she has
had decreased appetite and feeling not "her normal self" over
the past few days. She states that she has also noted diarrhea
over the past few days but not watery. Grandson called EMS. Pt
was found to be hypotensive in the ED with vitals in ED T 97.2 p
72 bp 62/31. Later had fever to 100.8 in ED, with a lactate,
3.5. She was treated per sepsis protocol. L subclavian was
placed, she received 4L NS, vanc, levo, flagyl. She has only
made 10 cc of UOP in the past hour and transferred ot the ICU on
neosynephrine. Cr also noted to increase from baseline 1.1 to
3.1. Her UA was positive. Transferred to MICU for further
evaluation and code sepsis protocol.
Past Medical History:
1. HTN
2. LE edema
3. Atrophic dermatitis
Social History:
SOCIAL HISTORY: Patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3064**] survivor who lives by
herself. She lives near her grandson who is involved in her
care. The patient is noted to have poor compliance with hygiene,
she has not bathed within weeks. The patient likely needs
assistance at home with either home VNA or home health aides.
Family History:
FAMILY HISTORY: No history of DVT, does note a family history
of
breast cancer.
Physical Exam:
Vitals: 100.1 107/65, 82, 17, 100% on 2L NC, CVP 7
.
General - elderly appearing female lying flat in bed in NAD
HEENT- PERRL, EOMI
CHEST- CTAB, breast ulcerations
CV - RR, no M
Abd - midline abdominal scar with ulcerations, soft, NT/ND, +BS
Ext - trace le edema
Skin - no cellulitis
Pertinent Results:
Admission Labs:
.
[**2169-6-1**] 07:30PM PLT COUNT-317
[**2169-6-1**] 07:30PM HYPOCHROM-1+
[**2169-6-1**] 07:30PM NEUTS-74.7* LYMPHS-19.6 MONOS-3.5 EOS-2.0
BASOS-0.3
[**2169-6-1**] 07:30PM WBC-15.9* RBC-4.52# HGB-13.1# HCT-39.4 MCV-87
MCH-29.0 MCHC-33.3 RDW-14.5
[**2169-6-1**] 07:30PM LIPASE-22
[**2169-6-1**] 07:30PM ALT(SGPT)-24 AST(SGOT)-41* ALK PHOS-146*
AMYLASE-22 TOT BILI-0.5
[**2169-6-1**] 07:30PM GLUCOSE-171* UREA N-38* CREAT-3.1*#
SODIUM-144 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-24 ANION GAP-20
[**2169-6-1**] 08:46PM LACTATE-3.5*
[**2169-6-1**] 08:46PM TYPE-ART PO2-137* PCO2-33* PH-7.51* TOTAL
CO2-27 BASE XS-4
[**2169-6-1**] 09:15PM URINE TRICH-OCC
[**2169-6-1**] 09:15PM URINE HYALINE-[**6-17**]*
[**2169-6-1**] 09:15PM URINE RBC-0-2 WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2169-6-1**] 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2169-6-1**] 09:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2169-6-1**] 09:15PM PT-13.9* PTT-24.4 INR(PT)-1.2*
[**2169-6-1**] 09:15PM URINE UHOLD-HOLD
[**2169-6-1**] 09:15PM URINE HOURS-RANDOM
[**2169-6-1**] 09:15PM TOT PROT-5.9* ALBUMIN-2.0* GLOBULIN-3.9
[**2169-6-1**] 09:15PM TOT BILI-0.5
[**2169-6-1**] 09:15PM GLUCOSE-133* UREA N-37* CREAT-2.8*
SODIUM-149* POTASSIUM-3.0* CHLORIDE-109* TOTAL CO2-26 ANION
GAP-17
[**2169-6-2**] 03:11AM HCT-30.7*
[**2169-6-2**] 03:11AM CORTISOL-13.4
[**2169-6-2**] 03:11AM CORTISOL-22.1*
[**2169-6-2**] 03:11AM CORTISOL-25.5*
[**2169-6-2**] 03:11AM CALCIUM-6.3* PHOSPHATE-2.8 MAGNESIUM-1.6
[**2169-6-2**] 03:11AM LD(LDH)-292*
[**2169-6-2**] 03:11AM GLUCOSE-75 UREA N-30* CREAT-2.2* SODIUM-147*
POTASSIUM-2.8* CHLORIDE-116* TOTAL CO2-22 ANION GAP-12
[**2169-6-2**] 03:40AM LACTATE-2.0
[**2169-6-2**] 03:40AM TYPE-MIX TEMP-36.6 O2 FLOW-2 PO2-129* PCO2-42
PH-7.35 TOTAL CO2-24 BASE XS--2 INTUBATED-NOT INTUBA
[**2169-6-2**] 07:52AM PLT COUNT-258
[**2169-6-2**] 07:52AM WBC-16.7* RBC-3.70* HGB-10.6* HCT-32.7*
MCV-89 MCH-28.8 MCHC-32.6 RDW-14.5
[**2169-6-2**] 07:52AM CALCIUM-6.6* MAGNESIUM-1.6
[**2169-6-2**] 07:52AM POTASSIUM-4.4
[**2169-6-2**] 08:13AM freeCa-1.05*
[**2169-6-2**] 08:13AM LACTATE-1.3
[**2169-6-2**] 08:13AM TYPE-[**Last Name (un) **] TEMP-35.6 PO2-44* PCO2-39 PH-7.35
TOTAL CO2-22 BASE XS--3
[**2169-6-2**] 03:38PM URINE RBC-[**11-27**]* WBC-[**6-17**]* BACTERIA-FEW
YEAST-NONE EPI-[**3-12**]
[**2169-6-2**] 03:38PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2169-6-2**] 03:38PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2169-6-2**] 03:38PM URINE HOURS-RANDOM CREAT-117 SODIUM-77
[**2169-6-2**] 03:39PM CALCIUM-7.3* PHOSPHATE-2.7 MAGNESIUM-2.4
[**2169-6-2**] 03:39PM GLUCOSE-220* UREA N-25* CREAT-1.8* SODIUM-143
POTASSIUM-4.2 CHLORIDE-118* TOTAL CO2-18* ANION GAP-11
Pertinent Labs/Studies:
.
ECG: Sinus tach at 110 bpm. nl axis, borderline QT prolongation.
QT 360. No ST/T changes.
.
Imaging:
[**2169-6-2**] - Portable Chest
The left subclavian line tip is in the level of the junction of
brachiocephalic vein and superior vena cava. There is no
pneumothorax or apical hematoma. The heart size is normal.
Mediastinal widening seen on the current chest x-ray is most
probably due to supine position and relatively low
lung volumes. To exclude hematoma, an erect chest PA and Lat
films should be obtained. The lungs are clear. There is no
pleural effusion.
.
[**2169-6-2**]: Portable Chest - IMPRESSION: No acute cardiopulmonary
process.
.
[**2169-6-6**]: Transesophageal Echocardiogram:
Intravenous sedation was administered as described above. The
patient developed asymptomatic hypotension with a systolic blood
pressure of 70 mm Hg. The patient remained alert and interactive
and did not appear to be sedated. Blood pressure normalized
quickly with intravenous fluids. The patient requested that we
try to complete the test. One attempt was made at passing the
TEE probe, however, the patient was unable to swallow it. The
test was terminated. If a TEE is still clinically necessary, an
anesthesiologist will be needed to provide deeper sedation and
blood pressure support.
.
[**2169-6-6**] - Echocardiogram (TTE)
Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%).
3. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
5. There is mild pulmonary artery systolic hypertension.
6. No evidence of endocarditis seen.
7. Compared with the prior study (images reviewed) of [**2169-5-3**],
there is no significant change.
.
[**2169-6-7**]: IMPRESSION: Successful placement of a 40cm single lumen
left brachial vein PICC line. The tip is in the SVC. The line is
ready for use.
.
[**2169-6-7**]: Chest Pa/Lat - IMPRESSION: Small right pleural
effusion. Prominent mediastinum likely due to mediastinal fat.
.
[**2169-6-8**]: IMPRESSION: Successful placement of a 46 cm
single-lumen PICC through the left brachial vein with the tip in
the superior vena cava. The line is ready for use.
.
.
Microbiology:
Blood cultures:
[**2169-6-1**]: 4/4 Bottles growing MRSA
[**2169-6-3**]: NGTD
[**2169-6-4**]: NGTD
[**2169-6-5**]: NGTD
[**2169-6-6**]: NGTD
[**2169-6-6**]: (central line tip) - Coag Pos Staph
.
Urine:
[**2169-6-1**]: 10K-100K STREPTOCOCCUS MILLERI
[**2169-6-2**]: No growth
[**2169-6-3**]: No growth
[**2169-6-6**]: No growth
.
Relevant Labs:
[**2169-6-1**] 08:46PM BLOOD Lactate-3.5*
[**2169-6-2**] 03:40AM BLOOD Lactate-2.0
[**2169-6-2**] 08:13AM BLOOD Lactate-1.3
.
[**2169-6-2**] 03:11AM BLOOD Cortsol-25.5*
[**2169-6-2**] 03:11AM BLOOD Cortsol-22.1*
[**2169-6-2**] 03:11AM BLOOD Cortsol-13.4
.
[**2169-6-6**] 06:42AM BLOOD TSH-5.8*
[**2169-6-7**] 02:06PM BLOOD Free T4-0.8*
.
[**2169-6-6**] 06:42AM BLOOD calTIBC-83* Ferritn-425* TRF-64*
[**2169-6-6**] 06:42AM BLOOD Triglyc-77 HDL-40 CHOL/HD-2.1 LDLcalc-28
[**Month/Day/Year **] Labs:
.
[**2169-6-9**] 09:45AM BLOOD WBC-15.2* RBC-3.14* Hgb-8.9* Hct-27.5*
MCV-88 MCH-28.4 MCHC-32.4 RDW-17.1* Plt Ct-398
[**2169-6-9**] 05:46AM BLOOD WBC-13.7* RBC-2.79* Hgb-8.2* Hct-24.7*
MCV-88 MCH-29.3 MCHC-33.1 RDW-16.6* Plt Ct-371
[**2169-6-9**] 05:46AM BLOOD Glucose-104 UreaN-6 Creat-0.9 Na-142
K-4.6 Cl-113* HCO3-21* AnGap-13
[**2169-6-9**] 05:46AM BLOOD Mg-1.8
[**2169-6-10**] 06:00AM BLOOD WBC-13.3* RBC-2.91* Hgb-8.4* Hct-25.7*
MCV-88 MCH-29.1 MCHC-32.9 RDW-17.1* Plt Ct-441*
[**2169-6-10**] 06:00AM BLOOD Glucose-82 UreaN-6 Creat-0.8 Na-142 K-4.5
Cl-114* HCO3-22 AnGap-11
Brief Hospital Course:
The patient is an 81 year old female with medical history
significant for LE edema and HTN who was admitted to the MICU
with lethargy and hypotension, eventually discovered to have
MRSA sepsis from unknown source.
.
# Sepsis/MRSA bacteremia - As per H+P, the patient presented
with lethargy and hypotension found to be febrile with elevated
lactate. A central line was placed, the patient was started on
broad-spectrum antibiotics with vancomycin, levofloxacin, and
Flagyl and volume resuscitation was initiated. The patient was
transferred to the ICU on Neosynephrine and was rapidly weaned
off pressors within 24 hours. The patient's MICU course was
complicated by ARF likely secondary to ATN in the setting of
hypotension with eventual complete recovery of renal function
with adequate treatment of infection and volume resuscitation.
The patient was Blood cultures revealed 4/4 bottles from
admission growing MRSA. Initally it was thought that the source
of infection may have been from the urine as the patient had a
positive UA on admission, however, subsequent cultures revealed
Streptococci Milleri rather than MRSA. The patient's antibiotics
regimen was tailored to IV Vancomycin, dosed per renal function,
as monotherapy. Given that urine did not grow MRSA, it was not
clear what the patient's source of infection was. Of note, the
patient is noted to have many cutaneous wounds and excoriations.
Although no area of frank cellulitis or fluctuance was
idenitified, it is suspected this to be the most likely source
currently. However, given high grade bacteremia on admission
with MRSA, there was clinical concern that the patient may have
seeded her cardiac valves. The patient underwent attempted TEE
but was unable to tolerate the procedure. The patient developed
hypotension in the setting of sedation with rapid resolution
with fluid bolus and trendelenberg. Subsequent attempt with less
sedation was not tolerated by the patient secondary to
discomfort. It was recommended that if TEE were necessary the
patient would require anesthesia to be involved. Given that the
patient rapidly cleared her cultures with therapy, it was
thought that a TTE should first be attempted. TTE demonstrated a
hyperdynamic LV with EF > 75% but no vegetations or evidence for
endocarditis. The patient remained afebrile for the remainder of
her hospital course with decrease in leukocytosis since
admission from 16 to 12. On [**Month/Day/Year **] the patient continues to
have a mild leukocytosis, ranging between [**12-21**] generally but
clinically appears quite well. Despite negative blood cultures,
tip culture from the patient's central line has since grown
MRSA. Blood surveillance cultures drawn the same day are
negative however, signifying the patient was not experiencing
significant bactermia from the central line. Subsequent
surveillance cultures continue to be culture negative and
additional surveillance culture was drawn on morning of
[**Month/Year (2) **] given positive CL tip. This will continue to be
monitored and facility would be made aware if any cultures turn
positive. Given documented bacteremia the patient will require
IV antibiotics with Vancomycin, with plans for total duration of
4 weeks given no definite source was identified. The patient
started antibiotic therapy with Vancomycin on [**2169-6-4**]. Because
of hypotension, the patient's home medications of Valsartan and
Lasix were held. The patient is currently normotensive but not
hypertensive. The patient therefore is being discharged without
these medications, with instructions to follow up with her PCP
upon [**Date Range **] from extended care facility to determine when or
if she should restart these medications.
.
# ARF: As above, the patient developed acute renal failure
during the ICU course, likely secondary to hypotension with
subsequent ATN. The patient's creatinine returned to [**Location 213**] with
normalization of blood pressure with volume support,
antibiotics, and treatment as above. The patient continues to
produce good urine and is currently at her baseline creatinine
on [**Location **].
.
#. Wounds/ Skin ulcerations - The patient on presentation was
wound to have a number of cutansous wounds over her extremities
and trunk, mostly healed and scabbing, with some more recent
excoriations. The patient had been prescribed protopic cream and
petroleum jelly as an outpatient but was not using these
regularly per family report. The patient overall was admitted
with generally poor hygiene and suspicion that the patient's
MRSA may have been introduced via cutaneous injury. The patient
continued to receive wound care throughout her hosptialzation
with daily cleansing and Aloe Vesta. The patient should continue
to receive wound care at the extended care facility as detailed
in page 1.
.
#. LE Edema - The patient on admission was reported to have a
history of CHF. However, review of OMR notes reveals
echocardiogram was ordered to rule out CHF with plan for ongoing
work-up of LE edema given lack of evidence for CHF by recent
echocardiogram. Prior to admission, the most recent
echocardiogram reveale an EF > 55% without comment on evidence
of diastolic dysfunction. Repeat echocardiogram this admission
revealed a hyperdynamic LV with EF 75%. The patient was treated
with volume as above initially given evidence of sepsis. With
normalization of pressures fluid balance was allowed to
equilibrate. Physical exam was remarkable for mild LE edema as
has been previously documented, but the patient otherwise
appears relatively euvolemic. The patient maintained good oxygen
saturation on room air. As an outpatient the patient was on a
medical regimen including Diovan 160 mg po qd as well as lasix
40mg po qd. These medications have been held throughout the
[**Hospital 228**] hospital course as her pressures have generally ranged
from 100-120. On further exam the patient was noted to have mild
diffuse edema. The patient's Albumin was noted to have fallen
from 3.0 one month prior to 1.6. This was thought likely to be
secondary to geenrally poor po intake and previous sepsis. The
patient was written for boosts and nutritional support was
continued. Urine dip revealed no proteinurea and the patient had
a normal cholesterol. TSH was mildy elevated and free T4 was
just below the lower limit of normal. Given the patient's recent
illness however decision was made not to initiate thryroid
replacement at this time as this more likely represents sick
euthyroid than true hypothyroidism.
.
#. Anemia - the patient was noted to have an anemia on
admission. Iron binding studies were consistent with anemia of
chronic disease. The patient had a single OB positive stool on
transfer with all subsequent negative. The patient's Hct
remained stable throughout the course with some expected
fluctuation within lab error and volume status.
.
#. Tachycardia - On [**Hospital **] the patient is known to have mild
persistent sinus tachycardia with HR ranging from 70 to 120. THe
etiology is not clear but the patient is doing clinically well,
afebrile, not in pain, and hemodynamically stable. As above, the
patient's labs trend towards hypo rather than hyperthyroidism.
The patient is with excellent O2 sats. The patient was taking
[**Doctor First Name **] daily previously. This was discontinued recently given
thought that anti-cholinergic effect may be contributing to
tachycardia. If the patient's tachycardia persists after
[**Doctor First Name **] from extended care facility she should have ongoing
evaluation with PCP.
.
# CODE status - As per discussion with ICU team, the patient was
maintained as DNR/DNI
Medications on Admission:
Diovan 160 mg a day,
Aspirin 81 mg a day,
[**Doctor First Name **] 180 mg a day
Lasix 40 mg a day
[**Doctor First Name **] 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection every eight (8) hours: please continue while
patient is generally bed bound.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical TID (3 times a day) as needed.
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 24H (Every 24 Hours): First dose [**2169-6-4**]. Patient
should complete a 4 week course until [**2169-7-5**]. Patient will
require monitoring of Vanc trough q week as per instructions.
9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily): 2ml IV daily:PRN
10ml NS followed by 2ml of 100U/ml Heparin each lumen daily and
PRN.
[**Month/Day/Year **] Disposition:
Extended Care
Facility:
[**Location (un) 11729**] Home - [**Location (un) 686**]
[**Location (un) **] Diagnosis:
MRSA Bacteremia/Sepsis
[**Location (un) **] Condition:
Stable. Patient hemodynamically stable, afebrile. Upon
[**Location (un) **], patient has known sinus tachycardia, with rates
100-125 without obvious cause with basic workup. Patient should
receive ongoing outpatient evaluation upon [**Location (un) **]. Patient
has known persistent mild leukocytosis with white count [**12-21**].
Patient is receiving antibiotics x 4 weeks for her infection.
[**Month/Year (2) **] Instructions:
1. Please take all medications as prescribed from this
[**Month/Year (2) **]. You were previously taking Diovan and Lasix. These
medications were stopped during this admission because of low
blood pressure. Your blood pressure is currently normal, but not
elevated. Because of this, you should not take these medications
again until you see your primary care doctor. [**First Name (Titles) 616**] [**Last Name (Titles) **]
from rehab, please see your PCP to discuss when or if you should
restart these medications.
.
2. Please keep all outpatient appointments
.
3. Please return to the hospital or seek medical attention for
any symptoms of chest pain, shortness of breath, fever/chills,
nausea/vomiting, or any other concerning symptoms.
Followup Instructions:
You should continue to receive care at your extended care
facility.
.
After [**Last Name (Titles) **], it is very important you have follow up with
your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. After [**Last Name (NamePattern1) **]
from the extended care facility you should make an appointment
to be seen within one to two weeks with Dr. [**Last Name (STitle) **]. If he is
not available please ask to be seen by any available physician
at [**Name9 (PRE) 191**]. PLease call [**Telephone/Fax (1) 250**] to make this appointment
.
The following medications have been held this admission: Diovan
and Lasix. You should discuss with your primary care doctor
during your visit whether or not you should restart these
medications. Until then, do not take these medications
ICD9 Codes: 5849, 5990, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3192
} | Medical Text: Admission Date: [**2178-6-29**] Discharge Date: [**2178-6-30**]
Date of Birth: [**2133-6-10**] Sex: M
Service: MEDICINE
Allergies:
Fish Product Derivatives / Shellfish Derived / Peanut / Grass
Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
45yo M with PMHx of refractory asthma with > 100 hospitalization
and 17 past intubations now presenting with wheezing, SOB,
worsening over the past 2 days.
Patient developed cough and shortness of breath for the past
week that he attributes to the hot weather. Over the past 2
days, patient has had worsening SOB and wheezing, not managed
with home nebulizers. Prior to presentation in the ED, the
patient used his nebulizers 6 times on the AM of presentation
with no changes in symptoms. He reports that he increased his
prednisone dose from 30mg daily to 80mg daily 3 days ago. His
cough is productive of sputum, described as clear, thick and
yellow. He reports that he had fever of 99.2 1 week ago. He has
also noticed DOE, which the patient does not experience at
baseline.
Of note, he reports that his wife has been ill with coughing and
runny nose.
Initial vitals upon arrival to the ED: 98.0 103 153/98 22 97%
RA. In the [**Last Name (LF) **], [**First Name3 (LF) **] verbal report, the patient is speaking in
full sentences though having difficulty completing full
sentences, but with no accessory muscle use and no tachypnea.
The patient had a CXR which showed no effusions or
consolidations concerning for PNA. The patient was given 2
Duo-Neb treatments, IV magnesium, and IV solumedrol 125mg ONCE.
On arrival to the MICU, the patient is feeling tired, but denies
chest pain, chest tightness, shortness of breath, abdominal
pain, nausea, or vomiting.
Past Medical History:
- Severe asthma with greater than 100 hospitalizations, multiple
intubations (17), followed by Dr. [**Last Name (STitle) **] in pulm, plan to refer
to Dr. [**First Name (STitle) **] at [**Hospital1 112**]
- OSA on CPAP at night
- Avascular necrosis of the hip and shoulder from prolonged
steroid use, status post hip replacement ([**2173**])
- GERD
- H/o L Achilles tendon rupture s/p repair
Social History:
Works as school bus driver. Lives with wife and one of his three
children. Still smoking 1ppd. Has on average a bottle of
wine/week when he can afford it. Denies ilicits.
Family History:
Two children with asthma as well as mother with asthma.
Physical Exam:
Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: bilateral wheezes, no rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge: same as above except:
VS: 97% RA with ambulation
Lungs: CTAB
Pertinent Results:
[**2178-6-29**] 12:00PM BLOOD WBC-12.9*# RBC-5.20 Hgb-15.6 Hct-47.5
MCV-91 MCH-30.1 MCHC-32.9 RDW-13.5 Plt Ct-310
[**2178-6-29**] 12:00PM BLOOD Neuts-66.4 Lymphs-23.8 Monos-7.9 Eos-1.4
Baso-0.6
[**2178-6-29**] 12:00PM BLOOD Glucose-91 UreaN-15 Creat-1.0 Na-140
K-5.1 Cl-109* HCO3-21* AnGap-15
[**2178-6-29**] 01:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.027
[**2178-6-29**] 01:40PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2178-6-29**] 01:40PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
TransE-<1
[**2178-6-29**] 01:40PM URINE CastHy-5*
[**2178-6-29**] 01:40PM URINE Mucous-MANY07/02/12 1:40 pm URINE
**FINAL REPORT [**2178-6-30**]**
URINE CULTURE (Final [**2178-6-30**]): NO GROWTH.
CXR: FINDINGS: Frontal and lateral views of the chest were
obtained. The heart is of normal size with normal
cardiomediastinal contours. Bilateral streaky linear perihilar
opacities are compatible with reactive airway disease,
progressed since [**2175**] and similar to [**2178-5-16**]. The lungs
are otherwise clear. No lobar consolidation, pleural effusion,
or pneumothorax. The osseous structures are unremarkable. No
radiopaque foreign bodies.
IMPRESSION: Bilateral streaky perihilar opacities, compatible
with reactive airway disease, similar to [**2178-5-16**] though
progressed since [**2176-9-13**].
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] with an exacerbation of his
reactive airway disease, asthma vs COPD vs bronchiectasis. He
was started on standing bronchodilator nebs and prednisone 60mg
daily and admitted to the ICU. His CXR showed no PNA. His
respiratory status improved dramatically in the next 24h and his
oxygen sat was 97% RA with ambulation. He was encouraged to quit
smoking again and provided script for nicotine lozenges. He was
discharged with a plan to taper prednisone in the following
manner: take 60mg x 4 days, 50mg x 4 days, 40mg x 4 days, then
return to usual dose of 30mg daily. He should likely have a high
res CT chest as an outpatient to eval for bronchiectasis. He may
also have an element of COPD contributing to this picture. He
will follow up with PCP in next few days, pulmonary next month.
Medications on Admission:
1. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
Inhalation Q4H:PRN shortness of breath or wheezing
2. fluticasone 220 mcg/actuation Inhalation [**Hospital1 **] 6 puffs twice a
day
3. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
4. Montelukast Sodium 10 mg PO DAILY
5. Loratadine 10 mg Oral Daily
6. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
7. Omeprazole 20 mg PO BID
8. Tiotropium Bromide 1 CAP IH DAILY RX *Spiriva with HandiHaler
18 mcg 1 cap IH daily
9. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4H:PRN shortness of breath or wheezing
10. Nicotine Lozenge 4 mg PO Q1H:PRN craving
11. PredniSONE 30mg PO daily
Discharge Medications:
1. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation Q4H:PRN shortness of breath or wheezing
RX *DuoNeb 0.5 mg-3 mg (2.5 mg base)/3 mL 1 nebulizer IH every
four (4) hours Disp #*60 Vial Refills:*0
2. fluticasone *NF* 220 mcg/actuation Inhalation [**Hospital1 **]
6 puffs twice a day
RX *Flovent HFA 220 mcg 6 puffs IH twice a day Disp #*1 Inhaler
Refills:*0
3. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
4. Montelukast Sodium 10 mg PO DAILY
RX *Singulair 10 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Loratadine *NF* 10 mg Oral Daily Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
6. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
RX *Serevent Diskus 50 mcg 1 discus IH every twelve (12) hours
Disp #*1 Inhaler Refills:*0
7. Omeprazole 20 mg PO BID
8. Tiotropium Bromide 1 CAP IH DAILY
RX *Spiriva with HandiHaler 18 mcg 1 cap IH daily Disp #*1
Inhaler Refills:*0
9. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q4H:PRN shortness of breath or wheezing
RX *albuterol sulfate 90 mcg 2 puffs IH every four (4) hours
Disp #*1 Inhaler Refills:*0
10. Nicotine Lozenge 4 mg PO Q1H:PRN craving
RX *nicotine (polacrilex) 4 mg 1 lozenge by mouth every hour
Disp #*120 Lozenge Refills:*0
11. PredniSONE 60 mg PO DAILY
RX *prednisone 10 mg 1 Tablet(s) by mouth as directed Disp #*91
Tablet Refills:*0
RX *prednisone 10 mg 1 Tablet(s) by mouth as directed Disp #*100
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Asthma/COPD exacerbation
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 difficulty breathing.
This was likely due to an exacerbation of your asthma. You may
also have COPD, another chronic lung disease. It is important
you take all of your breathing medications every day. You should
stop smoking to avoid having more of these episodes.
.
Some of your medications were changed during this admission:
START prednisone taper, take 60mg daily for one week, then 40mg
daily for one week, then 20mg daily for one week, then 10mg
daily for one week.
.
You should continue to take all of your other medications as
prescribed.
Followup Instructions:
You should have a follow up appointment with Dr. [**Last Name (STitle) **] within
the next 3 days. Please call [**Telephone/Fax (1) 2010**] to schedule this
appointment when you get home today.
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2178-8-5**] at 10:20 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2178-8-5**] at 10:40 AM
With: [**Known firstname **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: WEDNESDAY [**2178-8-5**] at 10:40 AM
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3193
} | Medical Text: Admission Date: [**2112-3-26**] Discharge Date: [**2112-3-29**]
Date of Birth: [**2058-9-15**] Sex: F
Service: MEDICINE
Allergies:
Optiray 350
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
weakness, hyponatremia
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
53F with panhypopituitary, HTN, HL who presented today from the
ED with 3 days of nausea, vomiting, weakness and dizziness. This
began while she was at work on Thursday, with multiple episodes
of non-bloody emesis as well as dizziness. She reports she may
have had some abdominal pain that preceded these symptoms by a
couple days. She continued to take all of her home medications
including prednisone throughout these symptoms.
.
In the ED, her initial vitals were 98 70 92/57 18 100%. She was
found to have a sodium of 110 and was given 2L of normal saline.
Transferred to the [**Hospital Unit Name 153**] for sodium correction.
.
On arrival to the ICU, she continues to feel dizzy with some
abdominal pain, but overall feels improved.
Past Medical History:
hypertension
hyperlipidemia
panhypopituitarism due to [**Doctor Last Name 30762**] syndrome
gastritis
positive PPD (finished INH, [**2103**])
Social History:
Lives with husband and 3 children. Works on an electronics
assembly line
- Tobacco: none
- Alcohol: none
- Drugs: none
Family History:
Mother: hypertension
Physical Exam:
ADMISSION EXAM:
.
Vitals: 98.2 75 95/50 13 96%
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, mildly tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
.
[**2112-3-26**] 12:30PM BLOOD WBC-6.4 RBC-4.13* Hgb-12.2 Hct-32.9*
MCV-80*# MCH-29.5 MCHC-37.0*# RDW-11.8 Plt Ct-344
[**2112-3-26**] 12:30PM BLOOD Neuts-78.5* Lymphs-13.1* Monos-4.4
Eos-1.4 Baso-2.7*
[**2112-3-26**] 12:30PM BLOOD Glucose-81 UreaN-8 Creat-0.6 Na-110*
K-4.8 Cl-75* HCO3-21* AnGap-19
[**2112-3-26**] 05:04PM BLOOD Calcium-7.3* Phos-3.1 Mg-1.4*
[**2112-3-26**] 12:30PM BLOOD Osmolal-238*
[**2112-3-26**] 05:04PM BLOOD TSH-<0.02*
[**2112-3-26**] 08:59PM BLOOD T4-11.4 T3-95 calcTBG-0.87 TUptake-1.15
T4Index-13.1* Free T4-2.1*
[**2112-3-26**] 05:04PM BLOOD Cortsol-4.0
[**2112-3-27**] 05:00PM BLOOD freeCa-1.06*
[**2112-3-28**] 01:05AM BLOOD freeCa-1.11*
[**2112-3-26**] 02:11PM BLOOD Lactate-1.4
.
.
IMAGING STUDIES:
[**2112-3-26**] CT HEAD W/O CONTRAST - There is no acute intra-axial or
extra-axial hemorrhage, mass, midline shift, or territorial
infarct. Ventricles, sulci, and basilar cisterns are
unremarkable and stable in configuration compared to prior. Note
is made of a lipoma within the quadrigeminal plate cistern on
the right. Orbits are symmetric and unremarkable. Paranasal
sinuses included on this exam are clear. Skull and extracranial
soft tissues are unremarkable.
.
[**2112-3-26**] CHEST (PA & LAT) - Right basilar opacity is probably
atelectasis, but could represent early or developing pneumonia
in the appropriate clinical setting.
.
Cardiovascular Report ECG Study Date of [**2112-3-26**] 12:38:32 PM
Normal sinus rhythm with Q-T interval prolongation. Compared to
the previous
tracing of [**2107-11-25**] the Q-T interval is significantly longer.
Clinical
correlation is suggested.
.
MICROBIOLOGIC DATA:
[**2112-3-26**] Blood culture - ngtd
[**2112-3-26**] MRSA screen - no MRSA
DISCHARGE LABS:
[**2112-3-28**] 11:30AM BLOOD WBC-5.5# RBC-4.24 Hgb-12.5 Hct-34.8*
MCV-82 MCH-29.4 MCHC-35.9* RDW-12.7 Plt Ct-402
[**2112-3-29**] 06:15AM BLOOD Glucose-70 UreaN-16 Creat-0.6 Na-144
K-4.6 Cl-108 HCO3-28 AnGap-13
[**2112-3-28**] 11:30AM BLOOD Calcium-8.9 Phos-1.5*# Mg-2.2
[**2112-3-26**] 08:59PM BLOOD T4-11.4 T3-95 calcTBG-0.87 TUptake-1.15
T4Index-13.1* Free T4-2.1*
Studies pending at discharge:
None
Brief Hospital Course:
53 yo female with PMH significant for panhypopituitarism in the
setting of postpartum hemorrhage ([**Doctor Last Name 1349**] syndrome),
hypertension, hyperlipidemia admitted with viral gastroenteritis
and adrenal crisis associated with hyponatremia to 110 and
hypotension.
#Adrenal crisis/Hyponatremia:
Patient presented with hyponatremia and hyponatremia to 110 in
the setting of an acute illness. It was felt that the patient
was relatively [**Name2 (NI) 34512**] insufficent given his acute illness and
was treated with IVF and stress dose hydrocortisone. Sodium
rapidly improved and GI symptoms resolved quickly as well.
Endocrine was consulted and recommended D5W in addition to DDAVP
0.1mcg IV x1 to promote free water reabsorption and prevent too
rapid of correction of sodium. HOwever, they did note that rapid
correction of sodium in the setting of steroid repletion was
okay and expected. Patient was transitioned from stress dose
steroids to a rapid prednisone taper and was discharged on a
rapid taper to return to his previous maintenance prednisone
regimen of 5mg po daily as his acute illness had resolved.
Patient will follow with endocrine as an outpatient.
#HYPOTHYROIDISM - Patient has known diagnosis of postpartum
hemorrhage leading to panhypopituitarism. Admission TSH < 0.02
with TFTs demonstrating T4 11.4, T3 95, free T4 2.1. Initially
IV Levothyroxine was used for replacement but was switched to PO
Levothyroxine dosing when GI issues resolved. Patient will
follow with endocrine as an outpatient.
.
CHRONIC CARE
#GASTRITIS - Patient was continued on omeprazole 20 mg PO daily
#HYPERLIPIDEMIA - Pastient was continued on Simvastatin 5 mg PO
daily
.
#Contact: [**Name (NI) **] (daughter) - [**Telephone/Fax (1) 34513**]
#Code: FULL
#Disposition:
Patient was discharged to follow up with Endocrinology in one
week and PCP [**Last Name (NamePattern4) **] 3 weeks. She will have labs prior to her
Endocrine follow up appointment. Patient was counseled on
symptoms of adrenal insufficiency and told to call her doctor if
she experiences any neurologic symptoms.
Medications on Admission:
HCTZ 12.5mg daily
Levothyroxine 125 mcg daily
Losartan 50mg daily
Omeprazole 20mg daily
Prednisone 5mg daily
Simvastatin 5mg daily
Calcium carbonate 500mg / Vitamin D 200 unit [**Hospital1 **]
Discharge Medications:
1. prednisone 5 mg Tablet Sig: as directed Tablet PO as
directed: Please take:
4 tablets on Wed [**3-/2029**]
2 tablets on [**Doctor First Name **] [**3-31**]
1 tablet/daily thereafter.
Disp:*35 Tablet(s)* Refills:*2*
2. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day: Please do not restart until [**2112-3-31**].
7. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day:
Please do not start until [**2112-3-30**].
8. Outpatient Lab Work
Please draw
1) CBC
2) Chem 7
and send labs STAT. Thanks
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Adrenal insufficiency
Viral gastroenteritis
Panhypopituitarism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a viral gastroenteritis and adrenal
insufficiency causing very low sodium levels. Your viral
gastroenteritis improved and your symptoms improved with
appropriate steroid replacement. You are being discharged on a
prednisone taper.
You should take 20mg of prednisone on Wed [**3-/2029**], 10mg of
prednisone on Thursday [**2112-3-31**] and resume your usual 5mg daily of
prednisone on Friday [**2112-4-1**].
You should also follow up with both your PCP and Endocrinology
in the next few weeks as detailed below.
You are being given a prescription to have your labs drawn on
the morning Monday [**2112-4-4**]. Please arrive a few hours
before your appointment to have your labs drawn in the [**Hospital Ward Name 23**]
or [**Hospital3 **] laboratory.
Please call your doctor if you experience any fevers, chills,
low energy, malaise, abdominal pain, feel as if you are going to
pass out, or notice any focal weakness, difficulties moving, or
changes in sensation.
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: MONDAY [**2112-4-4**] at 2:30 PM
With: DR. [**Last Name (STitle) **] & ZHIHENG [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2112-4-18**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2761, 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3194
} | Medical Text: Admission Date: [**2189-12-8**] Discharge Date: [**2189-12-13**]
Date of Birth: [**2118-10-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Atenolol / Fish Oil
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Patient complains of worsening chest pain.
Major Surgical or Invasive Procedure:
CABG x3 LIMA to LAD, SVG to OM, SVG to PDA
History of Present Illness:
[**Known lastname 7474**] is a 71-year-old male
with worsening anginal symptoms who underwent cardiac
catheterization that showed a proximal LAD stenosis involving
and diagonal, not thought to be a good candidate for
percutaneous intervention, presenting for surgical
revascularization.
Past Medical History:
Hypertension
Elevated triglycerides
Several inguinal hernia repairs
[**2187**] TURP
Mohs surgery of left ear for skin cancer
Squamous cell cancer removed from arm
Intermittent back pain (treated with chiropractic therapy)
Removal of colon polyps
Social History:
Patient is married with three children. He
previously worked as a specifications writer for an engineering
firm.
Family History:
Mother died of CAD in her 80's. Father died of
pneumonia at age 37.
Physical Exam:
HEENT:PERRLA, FROM, no LAD
CV: RRR, no M/R/G
Pulm: CTA-B
ABD:soft NT, ND, no HSP
Ext: trace edema, 2+femoral, DP and PT pulses
Neuro: AAOx3, CN II-XII grossly intact
Pertinent Results:
[**2189-12-8**] 12:20PM freeCa-1.19
[**2189-12-8**] 12:20PM HGB-15.3 calcHCT-46
[**2189-12-8**] 12:20PM TYPE-ART PO2-426* PCO2-41 PH-7.44 TOTAL
CO2-29 BASE XS-4 INTUBATED-INTUBATED VENT-CONTROLLED
[**2189-12-8**] 11:14PM TYPE-ART PH-7.41
[**2189-12-8**] 11:14PM GLUCOSE-154* K+-3.4*
Brief Hospital Course:
On [**2189-12-8**] the patient was taken to the OR for a 3
vessel CABG (LIMA to LAD, SVG to OM, SVG
to PDA). The patient tolerated surgery well, was extubated the
night of surgery and was transferred from the CSRU on postop day
one to the regular cardiac hospital floor. On post op day two
the patient's foley was removed as were his chest tubes. On
post op day three the patient's pacing wires were removed. The
patient tolerated a cardiac heart healthy diet, diuresed well
after surgery while his pain was controlled throughout his
hospital stay. The patient was discharged on post op day five.
He will follow up with his PCP [**Name Initial (PRE) 176**] 10 days for medication
adjustment if needed and routine blood work. Additionally, the
patient was cleared by physical therapy and he will be going
home with visiting nursing services to monitor his wounds,
assure medication compliance and check vital signs.
Medications on Admission:
ASPIRIN 81MG--One by mouth every day
DYAZIDE 37.5-25MG--One by mouth every day
LISINOPRIL 40MG--2 by mouth every day
NITROSTAT 0.4MG--One under the tongue as needed for cp; may
repeat q5 minutes x 2, then as directed.
TOPROL XL 200MG--One by mouth every day
VITAMIN B COMPLEX --One by mouth twice a day
VITAMIN C 500MG--One by mouth every day
VITAMIN E 400U--One by mouth every day
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
Disp:*20 Packet(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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
HTN
CAD
dyslipidemia
Discharge Condition:
Stable
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Particularly your left
upper extremity. Please call with any concerns or questions. You
must follow up with a primary care physician [**Name Initial (PRE) 176**] 10 days for
medication adjustment and rountine laboratories.
Followup Instructions:
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2190-1-25**] 10:20
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5004**] [**Telephone/Fax (1) 250**] Follow-up
appointment should be in 2 weeks
Provider: [**Name10 (NameIs) 2052**],[**Name11 (NameIs) 2053**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5003**] Follow-up
appointment should be in 3 weeks
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3195
} | Medical Text: Admission Date: [**2195-4-6**] Discharge Date: [**2195-4-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F h/o CVA p/w SOB, tachypnea. Patient was recently
hospitalized [**2-7**] - [**2-10**] for SOB, tachypnea which was ultimately
diagnosed as URI and treated with azithromycin x 5 days. Since
that time patient has been at baseline, living in [**Hospital 7137**]. However, this AM she developed fever to 101.5,
respiratory congestion, diaphoresis, hypoxia (82% RA, 93% 2L)
and tachypnea, and was referred to [**Hospital1 18**] ED. Although she has a
reported history of aspiration and is on a pureed diet at
baseline, there was no witnessed aspiration event.
.
In the ED, patient was found to be afebrile with T 97.9, HR 119
BP 134/89, RR 35, O2 sat 98% NRB. ABG 7.30 / 57 / 285 / 29.
Patient looked to be in visible respiratory distress at this
time and was transitioned to BiPap. After several hours, the
patient looked more comfortable and was admitted to the ICU on
nasal cannula for further workup and management. Repeat ABG
before transfer was 7.34 / 54 / 108 / 30.
.
On arrival to the unit, the patient had VS T 98.7, HR 109, BP
134/89, RR 52, Sats 100% 4L NC. She was breathing shallowly but
comfortably and did not appear to be in any visible distress.
Patient is nonverbal at baseline but did not endorse any
specific complaints other than feeling uncomfortable.
Review of sytems:
Limited assessment given poor cooperation second to non-verbal
patient. Patient actively denied chest pain, SOB, but endorsed
"discomfort" with breathing.
Past Medical History:
1. Head trauma in [**2184**].
2. History of subarachnoid hemorrhage.
3. History of dementia.
4. Anemia of chronic disease
5. Depression.
6. History of urinary tract infections.
7. Contracture of Left upper extremity.
8. mostly non-verbal. can state her name and say a few other
things and shake her head yes and no.
Social History:
lives at [**Hospital3 2558**]. HCP is daughter [**Name (NI) **] [**Name (NI) 46**] in
[**Location (un) 686**], phone # [**Telephone/Fax (1) 38634**]. [**Doctor First Name 38635**] daughter is [**Name (NI) **]
1-[**Telephone/Fax (1) 38636**].
Family History:
NC
Physical Exam:
Vitals: T 98.7, HR 109, BP 134/89, RR 52, Sats 100% 4L NC\
GEN: alert, no acute distress
HEENT: Patient refused to open mouth for exam. R eye ptosis.
No visible facial droop.
Neck: Supple.
CV: tachycardic, reg rhythm, no mrg
RESP: Transmitted upper airway sounds on shallow breathing
throughout in all lung fields.
ABD: S, NT/ND, +BS
EXT: Contractures of upper and lower extremities. WWP.
DISCHARGE EXAM:
Vitals: T97.7, BP 144/91, HR 81, RR 20, Sat 100%RA
Lungs: Occasional rhonchi, but otherwise normal breath sounds
Heart: RRR, no m/r/g
Abd: + bowel sounds
Ext: diffuse muscle atrophy, no edema
Pertinent Results:
[**2195-4-6**] 02:47PM BLOOD WBC-7.6# RBC-3.23* Hgb-10.8* Hct-32.4*
MCV-100* MCH-33.5* MCHC-33.4 RDW-13.8 Plt Ct-208
[**2195-4-7**] 04:39AM BLOOD WBC-9.7 RBC-3.30* Hgb-10.8* Hct-32.7*
MCV-99* MCH-32.8* MCHC-33.1 RDW-13.6 Plt Ct-162
[**2195-4-6**] 02:47PM BLOOD Neuts-86.0* Lymphs-10.5* Monos-2.3
Eos-1.0 Baso-0.2
[**2195-4-7**] 04:39AM BLOOD Neuts-83.3* Lymphs-11.9* Monos-2.7
Eos-2.0 Baso-0.1
[**2195-4-6**] 02:47PM BLOOD PT-12.3 PTT-24.7 INR(PT)-1.0
[**2195-4-7**] 04:39AM BLOOD PT-12.8 PTT-27.7 INR(PT)-1.1
[**2195-4-6**] 02:47PM BLOOD Glucose-230* UreaN-16 Creat-0.6 Na-144
K-4.2 Cl-109* HCO3-28 AnGap-11
[**2195-4-7**] 04:39AM BLOOD Glucose-90 UreaN-10 Creat-0.5 Na-140
K-3.9 Cl-108 HCO3-25 AnGap-11
[**2195-4-7**] 04:39AM BLOOD ALT-9 AST-19 LD(LDH)-188 AlkPhos-70
TotBili-1.4
[**2195-4-7**] 04:39AM BLOOD Albumin-3.6 Calcium-8.7 Phos-2.7 Mg-2.2
[**2195-4-6**] 02:52PM BLOOD Rates-/37 FiO2-100 pO2-285* pCO2-57*
pH-7.30* calTCO2-29 Base XS-0 AADO2-385 REQ O2-67 Intubat-NOT
INTUBA Comment-GREEN TOP
[**2195-4-6**] 06:16PM BLOOD pO2-108* pCO2-54* pH-7.34* calTCO2-30
Base XS-2 Intubat-NOT INTUBA
[**2195-4-6**] CXR: IMPRESSION:
Patient rotation and respiratory motion make the exam
suboptimal. Given this, no definite acute cardiopulmonary
process is seen. If clinical concern persists, suggest repeat
chest radiograph.
[**2195-4-7**] CXR: FINDINGS: In comparison with the study of [**4-6**],
there is little overall change. Scoliosis of the thoracic spine
convex to the right is again seen. Cardiac silhouette remains
at the upper limits of normal or slightly enlarged. Some
indistinctness of pulmonary vessels again could reflect
respiratory motion, though the possibility of mild elevation of
pulmonary venous pressure should be considered. Some tortuosity
of the aorta persists.
URINE CULTURE (Final [**2195-4-8**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
Ms. [**Known lastname 38637**] is a [**Age over 90 **] year old woman with history of dementia and
recent aspiration who presented with tachypnea, hypoxia, and
fever, likely secondary to aspiration pneumonitis.
# tachypnea, hypoxia - Initially, thought to be due to HAP vs.
mucous plugging vs. aspiration vs. bronchitis vs. URI. History
and physical exam limited by patient cooperativity and
communicability. No appreciable infiltrate seen on CXR, but
imaging suboptimal secondary to contractures and patient
respiratory motion. Given patient's fevers, initial hypoxia,
and recent cough, she was initially treated empirically for
healthcare-associated PNA (with vancomycin and Zosyn). The first
night of admission, her oxygenation improved dramatically, and
the following morning, she was satting 97% on room air.
Antibiotics were discontinued; the etiology of her hypoxia was
felt to be aspiration, and her tachypnea/fevers aspiration
pneumonitis. She was seen by speech and swallow, who recommended
a trial of pureed solids and nectar-thick liquids.
# UTI, bacterial - growing E. coli sensitive to cefazolin.
Initially treated with Bactrim, but when sensitivities
demonstrated that it is resistant to Bactrim, switched to
Keflex. Should be treated for total of 7 days with Keflex.
# [**1-12**] positive blood cultures. One out of 4 bottles grew GPC's
in pairs/chains. Given stable hemodynamics and lack of fever,
felt to be contaminant.
# dementia - Patient minimally verbal and with limited
interactivity at baseline. Per daughter, patient's mental
status at baseline throughout the admission.
# nutrition - Pureed solids and nectar-thick liquids as above. I
addressed the idea of tube feeding with Ms. [**Known lastname 38638**] daughter,
including the data that shows that such tubes do not improve
mortality or prolong life, and that I did not recommend it. Her
daughter believes that her mother eats enough orally to maintain
nutrition, and she wants her mother to continue to eat; she is
not interested in tube feeds at this time. Conversations
regarding her poor nutritional status should continue.
# code status - A long discussion was held with the patient's
daughter with regard to the irreversibility of her dementia and
the likelihood of future aspiration. She understands that her
mother may continue to aspirate. I emphasized that she may
aspirate to the extent that intubation would be required, and
that once intubated, Ms. [**Known lastname 38638**] nutritional status is so poor
that she would not likely be able to be extubated. However, her
daughter did not wish to change her mother's code status at this
time. Further conversations should be had with Ms. [**Known lastname 38638**]
daughter regarding her code status and the low likelihood that
resuscitation would be successful.
Medications on Admission:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two Hundred (200) mg
PO BID (2 times a day): Hold loose stools.
2. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily): Hold loose stools.
3. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: last dose should be on [**2195-2-13**]. Tablet(s)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 7 days.
3. Miralax 17 gram/dose Powder Sig: One (1) packet PO once a
day.
4. Colace 50 mg/5 mL Liquid Sig: Fifteen (15) mL PO twice a day.
5. Multivitamin Liquid Sig: One (1) dose PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aspiration pneumonitis
Bacterial UTI
Dementia
Poor nutritional status
Discharge Condition:
Per daughter, patient is at baseline. A&O x 0, answers are one
word. Denies pain. Not ambulatory.
Discharge Instructions:
You were admitted with fever, low oxygen levels, and problems
breathing; this was caused by an aspiration event. You were seen
by our swallowing experts, and they have recommended that you
take only pureed solids and nectar-thickened liquids. Your
oxygen levels improved with minimal intervention, and you
returned to baseline. You were also found to have a urinary
tract infection, which is being treated with antibiotics.
Followup Instructions:
Please follow up with your primary care doctor at the nursing
home within 1 week.
ICD9 Codes: 5070, 5990, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3196
} | Medical Text: Admission Date: [**2115-6-18**] Discharge Date: [**2115-6-23**]
Date of Birth: [**2115-6-18**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 4886**] is a former 36 [**4-15**] week infant
admitted to the Neonatal Intensive Care Unit with neonatal
depression. He was born at 7:36 a.m. at 36-3/7 weeks, 2570
grams, to a 35 year old G7 P3-4 mother with expected date of
confinement of [**2115-7-12**]. Expected date of confinement was
determined by third trimester ultrasound, as LMP dating was
uncertain. Prenatal labs include blood type O negative,
antibody negative, hepatitis B surface antigen negative, HIV
negative, RPR nonreactive, rubella immune, GBS positive.
Pregnancy complicated by late prenatal care, concerns for
mild hypertension, and concerns for fetal growth restriction
and oligohydramnios. Mother was admitted [**6-17**] for induction
of labor and for worsening blood pressures and
oligohydramnios.
Perinatal course was complicated by spontaneous rupture of
membranes on the morning of delivery at 7:22, with acute
fetal deceleration and cord prolapse noted. The mother was
brought for an emergency cesarean section. Until rupture of
membranes, fetal heart rate had been reassuring. Following
rupture of membranes, fetal heart rate was difficult to
determine. Mother received perioperative antibiotics, but did
not receive GBS prophylaxis.
At delivery the infant emerged limp and dusky, without
respiratory effort or spontaneous movements. He was dried,
warmed, and vigorously stimulated without effect. Positive
pressure ventilation was begun, with improvement in color.
Initial heart rate was greater than 100, and heart rate
remained greater than 100 throughout. By 4-5 minutes of life,
intermittent gasps and grimaces were noted. At 9-10 minutes
of life, the infant began having regular respiratory effort,
with a weak cry, and positive pressure ventilation was
discontinued. He was brought to the newborn intensive care
unit in oxygen. Apgar scores were 2 (+2 for heart rate), 4
(+2 heart rate, +1 color, +1 grimace), and 7 (-1 for color, -
1 tone, -1 grimace).
In the NICU, he was continued in supplemental oxygen and an
IV was placed. He was given 20 cc/kg of normal saline bolus.
PHYSICAL EXAMINATION: Birth weight - 2570 grams, 25-50th
percentile. Discharge weight 2575 grams, 25-50th percentile.
Admission length 48 cm, 50-75th percentile. Discharge length
48 cm, 50-75th percentile. Admission head circumference 32
cm, 25-50th percentile. Discharge head circumference 32 cm,
25-50th percentile.
Vital signs on admission: Temperature 97, heart rate 140-170,
respiratory rate 40-60's, admission blood pressure 61/35 with a
mean of 48. Oxygen saturation 90-92 percent in room air.
General- A well developed infant in no acute distress, responsive
to painful stimuli, but overall decreased activity, decreased
tone and decreased responsiveness. Approximately 35 weeks.
HEENT - Normocephalic, atraumatic. Fontanel soft and flat.
Pupils equal, round, reactive to light. Closes eyes in
response to light. Nares and ears normal. Palate intact. Neck
is supple, no lesions. Chest is moderately aerated, clear. No
grunting, flaring or retracting. Cardiac - Regular rate and
rhythm. No murmur. Normal S1 and S2. Femoral pulses are 2+.
Abdomen - There is a 3-vessel cord. No masses, no
hepatosplenomegaly. Quiet bowel sounds. Genitourinary -
Normal male. Testes palpable high in scrotum bilaterally.
Patent anus. Extremities are warm. Capillary refill is
approximately 1 second. Extra postaxial digits of hands
bilaterally, with rudimentary stalk. Small bruising and
swelling over proximal left forearm. No obvious deformity.
Skin has no rash, no petechiae. Warm. Neurologic at rest -
Diminished tone and activity. Lies with arms and legs flexed
and extended. Responsive to exam. Intact grasp. Weak suck and
Moro. Deep tendon reflexes 1+. No clonus.
Admission D stick 114. ABG approximately 30 minutes of life
was 7.24, 41, 66, 18 on blow-by O2. Cord venous pH 7.32.
HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY. The baby transitioned to room air by day of
life 1. He remained in room air. He has had no apnea,
bradycardia or desaturations.
2. CARDIOVASCULAR. The baby initially had 1 normal saline IV
bolus, 20 cc/kg, for perfusion, but did not require any
pressor support. Blood pressures have been with systolics
in the 50's to 80's, diastolics in the 35-40's, with means
in the 50's. The baby has had no murmur, no cardiovascular
instability.
3. FLUID, ELECTROLYTES AND NUTRITION. The baby initially was
NPO. Had a peripheral IV inserted and received maintenance
IV D10W. Subsequent D sticks were greater than 60. Enteral
feedings were introduced on day of life 2. He is currently
feeding Similac 20 cal/oz ad lib, taking in greater than
60 cc/kg/day, voiding and stooling. Electrolytes at 12
hours were sodium 138, potassium 5 (hemolyzed), chloride
105, CO2 25. BUN 5, creatinine 0.6, calcium 7.9, ionized
calcium 1.18. AST 10, ALT 57. Phosphorus was 218. At 24
hours, electrolytes were 140, potassium 4, chloride 104,
CO2 25. See weight, length and head circumference above.
4. GASTROINTESTINAL. The baby had a peak bilirubin on [**6-21**]
of 14.5/0.4. He was treated with phototherapy for
approximately 24 hours. Lights were discontinued on [**6-22**],
and the bilirubin was 11.5/0.5. Rebound bilirubin was
10.2/0.3.
5. HEMATOLOGY. The blood type was O negative, Coombs
negative. The baby did not require any blood products
during this admission. He had an admission hematocrit of
49.7.
6. INFECTIOUS DISEASE. The baby initially had a blood culture
and a CBC sent. He had a white count of 19.1 with 21 polys,
1 band, platelet count 219, hematocrit 49.7. He was started
on prophylactic ampicillin and gentamicin for 48 hours.
Antibiotics were then discontinued, as the baby was
clinically well and cultures remained negative. He has had no
further issues with infection.
7. NEUROLOGY. The baby was noted to have a few episodes of
back arching with mild tonic posturing of upper and
possibly lower extremities. No overt seizure activity was
observed. He was breathing efficiently at the time, with
no apnea. A neurology consultation was obtained. At the
time of their exam, he had slightly decreased muscle tone,
but responded to tactile and painful stimuli with good
recoil. No clonus. Deep tendon reflexes zero to one plus.
He had an EEG performed, and a head ultrasound.
The EEG was essentially normal, as was the head
ultrasound, which was performed on [**6-20**]. Dr. [**First Name (STitle) 57006**] was
the neurologist from [**Hospital3 1810**] who consulted on
this case and felt that at this point in time, no further
follow up by Neurology was indicated.
8. Plastic surgery removed the bilateral extra-axial digits
on [**6-20**] using absorbable sutures. The area is healing
nicely, with a plan to follow up with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**] one
month after discharge at [**Hospital3 1810**] ([**0-0-**]).
9. SENSORY. Audiology - Hearing screen was performed with
automated auditory brain stem response. Baby passed this
screening. Ophthalmology - Eye exam not indicated based on
gestational age greater than 32 weeks.
10.PSYCHOSOCIAL. The parents look forward to [**Known lastname 449**]
[**Last Name (NamePattern1) **] transitioning home and are pleased with his
progress.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: [**Location (un) 669**] Comprehensive Care, [**Telephone/Fax (1) 61888**], FAX [**Telephone/Fax (1) 38261**].
CARE RECOMMENDATIONS:
1. Continue ad lib feedings, Similac 20 with iron.
2. Medications - None at time of discharge.
3. Car seat position screening - Passed.
4. State newborn screen - Sent on [**6-21**], day of life 3, results
pending.
5. Immunizations received - Hepatitis B vaccine on [**2115-6-22**].
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: 1)
Born at less than 32 weeks. 2) Born between 32-35 weeks
with two of the following: day care during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities or school age siblings. 3) 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 appointments scheduled with [**Location (un) 669**] Comprehensive
Care within 1 week. Mother will make appointment with Dr.
[**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 5385**], plastic surgery, at [**Hospital3 1810**] in 1
month.
DISCHARGE DIAGNOSES: Former 36 [**4-15**] week male status post
perinatal depression, status post rule out sepsis with
antibiotics, status post rule out seizure activity,
polydactyly bilaterally.
[**Known lastname 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2115-6-22**] 22:20:13
T: [**2115-6-22**] 23:47:16
Job#: [**Job Number 61889**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3197
} | Medical Text: Admission Date: [**2171-8-1**] Discharge Date: [**2171-8-9**]
Date of Birth: [**2107-3-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
64yo man with advanced colon cancer on chemo/radiation (dx 1.5
yrs ago), s/p repeat surgery 6 months ago, presented to the ED
with one week of progressive N/V/D, weakness, coffee ground
emesis and black stools. He has been unable to tolerate POs for
1 week and has been getting IV fluids at home. Also with
weakness, exertional dyspnea, intermittent chest pain
approximately 2 days ago, which has since resolved. The patient
states that he has a tumor pushing on his stomach and another on
his abdominal wall. His most recent EGD in [**Month (only) 116**] showed
esophagitis, semi-solid food material, and extrinsic compression
of antrum. His previous colonoscopy in [**Month (only) 958**] showed noduar
mucosa at anastamosis, and a biopsy showed adenoCa. He underwent
a laporotomy in [**Month (only) 116**] with diffuse metastatic disease, Bx of
abdominal wall mass showed metastatic adenoCa.
In the ED, he was tachycardic with HR 100 to 110s, hypotensive
BP 90s/70s, which responded to SBP 120 with IV fluids. Exam was
notable for a frail patient with dry MM, abdominal tenderness at
scar on abdomen, bilateral edema. Labs were significant for Hct
27.9 (baseline mid-20 to mid 30s), WBC 20.0 (91% PMNs), BUN 34,
Cr 1.0, HCO3 42, K 2.3, lactate 2.9, normal LFTs, positive UA.
He was admitted to the OMED medicine service, where he had a
drop in hematocrit from 27.9 to 23.8. Plt 365. He threw up 400cc
of maroon colored / coffee ground emesis. GI assessed, and
recommended transfer to the [**Hospital Unit Name 153**] for EGD in the AM. The patient
received 2 units pRBCs before transfer to the [**Hospital Unit Name 153**].
Upon transfer to the [**Hospital Unit Name 153**], his vitals were T 97.3, BP 119/86, HR
07, RR 18, O2 95% /RA
Past Medical History:
PAST ONCOLOGIC HISTORY:
- [**6-/2169**] developed nausea, vomiting diarrhea - saw GI and
decided on watchful waiting
- [**8-/2169**] developed worsening abdominal pain, N/V intermittently
- [**9-/2169**] KUB consistent with SBO, CT scan showing poa[**Name (NI) 28210**] large
bowel obstruction with concern for mass
- [**2169-10-2**] exploratory laparotomy with right hemicolectomy and
ileocolic anastomosis. Tumor in proximal transverse colon with
no intra-abdominal findings to suggest metastatic disease;
pathology showed that tumor invaded through muscularis propria
Specifically, the tumor was invading through into the subserosa
or the non-peritonealized pericolic or perirectal soft tissues
and so it
was pathologically stage T3. 21 lymph nodes were examined and 2
out of the 21 were positive for malignancy and so he had a
pathologic N1B disease.
- Received 3 cycles of FOLFOX that was changed to 5FU/LEUCOVORIN
due to allergic reaction to the oxaliplatin. Complete 6 cycles
of chemotherapy on [**4-24**]. Last cycle was incomplete.
- [**3-/2171**]: CT: disease recurrence at prior surgical site
- [**2171-5-20**]: operation:unresectable tumor, peritoneal spread
and carcinomatosis
- [**2171-6-19**]: start on irinotecan 125mg/m2 3 wks on/1 wk off
PAST MEDICAL HISTORY:
HTN
Rosacea
erectile dysfunction
Social History:
Retired school teacher. Former smoker, quit in [**2169**]. Also quit
EtOH in [**2170**]. Denies illicits. Two grown children in the area.
Wife is his HCP.
Family History:
Denies history of malignancy or bleeding diathesis
Physical Exam:
Vitals: T 97.3, BP 119/86, HR 07, RR 18, O2 95% /RA
General: Alert, oriented, pleasant man, appears chronically ill
but in in NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, 3/6 systolic murmur heard best
over RUSB
Lungs: Appears nonlabored on RA. Good air movement with coarse
expiratory rhonci which clear with cough.
Abdomen: soft, non-distended, tender irregular mass palapated
just right of midline in epigastrum. bowel sounds present, no
organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, left leg markedly more swollen than
right.
Neuro: AAOx3. CNII-XII intact, moving all extremities with equal
strength against gravity, grossly normal sensation.
Pertinent Results:
[**2171-8-9**] 08:20AM BLOOD WBC-9.4 RBC-2.90* Hgb-8.2* Hct-25.4*
MCV-88 MCH-28.4 MCHC-32.4 RDW-18.2* Plt Ct-318
[**2171-8-6**] 06:38AM BLOOD WBC-14.6* RBC-3.01* Hgb-8.4* Hct-26.2*
MCV-87 MCH-27.8 MCHC-32.0 RDW-18.4* Plt Ct-254
[**2171-8-2**] 09:50PM BLOOD WBC-13.8* RBC-3.33* Hgb-9.3* Hct-28.6*
MCV-86 MCH-27.9 MCHC-32.5 RDW-17.8* Plt Ct-279
[**2171-8-2**] 12:09PM BLOOD WBC-12.1* RBC-3.12* Hgb-8.9* Hct-26.9*
MCV-86 MCH-28.4 MCHC-33.0 RDW-17.8* Plt Ct-270
[**2171-8-2**] 07:39AM BLOOD WBC-15.0* RBC-3.29* Hgb-9.2* Hct-28.3*
MCV-86 MCH-27.9 MCHC-32.5 RDW-17.8* Plt Ct-295
[**2171-8-2**] 01:20AM BLOOD WBC-17.6* RBC-2.71* Hgb-7.4* Hct-23.8*
MCV-88 MCH-27.1 MCHC-30.9* RDW-19.2* Plt Ct-365
[**2171-8-1**] 04:20PM BLOOD WBC-20.0*# RBC-3.19* Hgb-8.7* Hct-27.9*
MCV-87 MCH-27.2 MCHC-31.2 RDW-18.8* Plt Ct-487*
[**2171-8-1**] 04:20PM BLOOD Neuts-90.6* Lymphs-6.6* Monos-2.6 Eos-0.1
Baso-0.1
[**2171-8-9**] 08:20AM BLOOD PT-12.2 PTT-40.4* INR(PT)-1.1
[**2171-8-6**] 06:38AM BLOOD PT-12.0 PTT-28.8 INR(PT)-1.1
[**2171-8-2**] 12:09PM BLOOD PT-15.7* INR(PT)-1.5*
[**2171-8-2**] 07:39AM BLOOD PT-15.8* PTT-26.5 INR(PT)-1.5*
[**2171-8-9**] 08:20AM BLOOD Glucose-85 UreaN-23* Creat-0.7 Na-141
K-3.3 Cl-108 HCO3-26 AnGap-10
[**2171-8-8**] 05:56AM BLOOD Glucose-103* UreaN-24* Creat-0.8 Na-138
K-3.4 Cl-103 HCO3-26 AnGap-12
[**2171-8-6**] 06:38AM BLOOD Glucose-106* UreaN-18 Creat-1.0 Na-137
K-3.1* Cl-100 HCO3-33* AnGap-7*
[**2171-8-3**] 04:26AM BLOOD Glucose-125* UreaN-19 Creat-0.8 Na-143
K-3.6 Cl-104 HCO3-36* AnGap-7*
[**2171-8-2**] 12:09PM BLOOD Glucose-127* UreaN-27* Creat-0.7 Na-146*
K-3.2* Cl-104 HCO3-38* AnGap-7*
[**2171-8-2**] 07:39AM BLOOD Glucose-126* UreaN-30* Creat-0.7 Na-149*
K-3.1* Cl-102 HCO3-42* AnGap-8
[**2171-8-2**] 01:20AM BLOOD Glucose-105* UreaN-34* Creat-0.9 Na-150*
K-2.3* Cl-102 HCO3-40* AnGap-10
[**2171-8-1**] 04:20PM BLOOD Glucose-109* UreaN-34* Creat-1.0 Na-146*
K-2.3* Cl-92* HCO3-42* AnGap-14
[**2171-8-1**] 04:20PM BLOOD ALT-11 AST-24 AlkPhos-95 TotBili-0.7
[**2171-8-6**] 06:38AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.9
[**2171-8-3**] 04:26AM BLOOD Calcium-7.2* Phos-2.7 Mg-1.8
[**2171-8-1**] 04:20PM BLOOD Albumin-3.3* Calcium-9.1 Phos-3.0 Mg-1.9
[**2171-8-1**] 04:29PM BLOOD Lactate-2.9*
[**2171-8-1**] 05:10PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.023
[**2171-8-1**] 05:10PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-SM Urobiln-8* pH-6.0 Leuks-NEG
[**2171-8-1**] 05:10PM URINE RBC-1 WBC-11* Bacteri-FEW Yeast-NONE
Epi-<1
[**2171-8-1**] 05:10PM URINE CastGr-2* CastHy-98*
[**2171-8-9**] 09:10AM PLEURAL WBC-50* RBC-77* Polys-65* Lymphs-19*
Monos-9* Plasma-1* Meso-2* Macro-3* Other-1*
[**2171-8-9**] 09:10AM PLEURAL TotProt-2.1 Glucose-96 LD(LDH)-67
Cholest-36 Triglyc-22
[**2171-8-1**] 4:20 pm BLOOD CULTURE
**FINAL REPORT [**2171-8-7**]**
Blood Culture, Routine (Final [**2171-8-7**]):
PSEUDOMONAS PUTIDA . FINAL SENSITIVITIES.
sensitivity testing performed by Microscan.
MEROPENEM <= 1 MCG/ML. SULFA X TRIMETH > 2/38 MCG/ML.
AMIKACIN <= 4 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS PUTIDA
|
AMIKACIN-------------- S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 2 S
CEFTRIAXONE----------- <=4 S
CIPROFLOXACIN--------- <=0.5 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 2 S
MEROPENEM------------- S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- R
[**2171-8-1**] 4:20 pm BLOOD CULTURE
**FINAL REPORT [**2171-8-7**]**
Blood Culture, Routine (Final [**2171-8-7**]):
PSEUDOMONAS PUTIDA .
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
351 0199M
[**2171-8-1**].
Aerobic Bottle Gram Stain (Final [**2171-8-2**]): GRAM NEGATIVE
ROD(S).
[**2171-8-1**] 5:21 pm URINE Site: NOT SPECIFIED
**FINAL REPORT [**2171-8-3**]**
URINE CULTURE (Final [**2171-8-3**]): NO GROWTH.
[**2171-8-3**] 1:08 am URINE Source: CVS.
**FINAL REPORT [**2171-8-3**]**
Legionella Urinary Antigen (Final [**2171-8-3**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**2171-8-9**] 6:40 am BLOOD CULTURE PORT #1.
Blood Culture, Routine (Pending):
[**2171-8-9**] 9:10 am PLEURAL FLUID
GRAM STAIN (Final [**2171-8-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
Brief Hospital Course:
1. Pseudomonal Bacteremia
- The most likely source was his probiotics shakes, which do
contain this bacteria, although not on the bottle.
- ID was consulted, and the patient was changed from zosyn to
ceftazidime to complete a 14 day course
- Given the indwelling port, surveillance cultures of the port
were obtained, and will followed up in [**Hospital **] clinic
2. Acute blood loss anemia due to esophagitis with GI Bleeding
- He present with maroon emesis and decreasing hematocrit.
Likely due to recent XRT to abdomen (gastritis) although also
likely a major component of regurgitation from the gastric
obstruction from the cancer
- EGD in [**Month (only) 116**] showed only extrinsic compression of the antrum of
the stomach and some mild reflux changes with no vacies or
ulcers. He was transferred to MICU and received 2 units of PRBC
with appropriate response in his hematocrit. He was started on
protonix gtt. GI was consulted and performed an EGD on [**8-2**]
showed esophagitis, but unable to fully visualize stomach as
there was some food in it. After EGD, he was placed on
sucralfate QID and pantoprazole 40mg [**Hospital1 **]. His hct was stable
and was transferred out of MICU.
- The gastric obstruction was treated with reglan with moderate
effect, and he was able to eat a fair amount of pureed diet
3. Pleural Effusion
- The precense of the effusion is concerning given the
bacteremia, so he underwent thoracentesis with 700cc removed.
Cytology was sent given concern for malignant effusion
4. Bacterial UTI:
He has positive UA with 11 WBC and few bacteria with an elevated
WBC of 20, which most likely is due to the pseudomonas. The
antibiotics for pseudomonas bacteremia should cover the bacteria
for UTI even if it is a different organism.
5. Bilateral Leg edema:
- LE edemas has been present for the past two months since his
ex lap for colon resection. B/L LENIs showed no evidence of
thrombosis.
6. Chest pain:
transient bilateral chest pain on [**7-30**] evening in the setting of
XRT/UGIB. His pain lasted 1/2 hour and has since resolved.
Tropnin was negative and EKG showed no ST elevations.
7. Colon cancer:
he has completed a 10-day course of XRT, as well as [**2-15**] doses of
chemotherapy which is likely how he got immunosuppressed causing
the bacteremia from the probiotic.
8. Benign Hypertension:
Transitional Issues
============================
Follow up with ID on the surveillanc cultures
Follow up with PCP about ability to eat (as reglan takes effect)
Follow up with IP regarding his pleural effusion
Full Code
Medications on Admission:
- AZELAIC ACID [FINACEA] 15% Gel apply to face twice a day.
- CITALOPRAM 10 mg
- DOXYCYCLINE 100 mg twice a day
- ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit capsule - weekly
- LORAZEPAM - 0.5 mg tablet - [**1-14**] Tablet(s) Q4H PRN
- OMEPRAZOLE - 20 mg capsule daily
- ONDANSETRON HCL - 4 mg tablet daily
- POTASSIUM CHLORIDE - 20 mEq tablet daily
- PROCHLORPERAZINE MALEATE - 10 mg tablet Q6H PRN nausea
- TADALAFIL [CIALIS] - 20 mg tablet Q36H hours prn
- TRETINOIN [ATRALIN] - 0.05 % Gel - Pea sized amount at bedtime
Discharge Medications:
1. CefTAZidime 1 g IV Q8H
RX *Fortaz in D5W 2 gram/50 mL 2 grams IV every eight (8) hours
Disp #*22 Each Refills:*0
2. Citalopram 10 mg PO DAILY
3. Doxycycline Hyclate 100 mg PO Q12H
4. Loperamide 2 mg PO QID:PRN diarhea
5. Tretinoin 0.05% Cream 1 Appl TP QHS
6. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
7. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
8. Sucralfate 1 gm PO QID
cannot be given with any other medications or two hours
following.
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*28 Tablet Refills:*0
9. Lorazepam 0.5 mg PO Q4H:PRN anxiety
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. tadalafil *NF* 20 mg Oral Q8H:PRN Sexual Intercourse
Discharge Disposition:
Home With Service
Facility:
Steward Home Care
Discharge Diagnosis:
Pseudomonal Bacteremia
Acute Blood Loss Anemia
GI Bleeding
Esophagitis
Moderate Malnutrition
Colon Cancer metastatic to bowel/retroperitoneum
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 have been started on Reglan which should make your stomach
move food more easily. This takes some time to fully work, so do
not be suprised that you may have some intermittant nausea
You had a thoracentesis to remove fluid from your chest. If you
epxerience sudden difficulty breathing, please go directly to
the ED.
You should not take your probiotic supplement anymore as this
may have been the source of the infection
Followup Instructions:
Department: [**State **]When: MONDAY [**2171-8-19**] at 2:40 PM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: INFECTIOUS DISEASE
When: TUESDAY [**2171-8-20**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
We are working on a follow up appointment for your
hospitalization in Interventional Pulmonary with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **]. You need to be seen in 1 month of discharge. The office
will contact you at home with an appointment. If you have not
heard within a few business days please call the office at
[**Telephone/Fax (1) 3020**].
ICD9 Codes: 7907, 2851, 5990, 5119, 2760, 2768, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3198
} | Medical Text: Admission Date: [**2193-3-28**] Discharge Date: [**2193-4-4**]
Service: NEUROLOGY
Allergies:
Darvon
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
right putaminal hemorrhage
Major Surgical or Invasive Procedure:
MRI
History of Present Illness:
Mr. [**Known lastname **] is an 88year old right handed male with h/o
hypertension,
hyperlipidemia, CAD s/p CABG now presenting with sudden onset
headache, left arm weakness found to have a right putaminal
hemorrhage. Pt was well until this afternoon around 2pm when at
lunch with his son developed the above symptoms. Taken to
[**Hospital1 **] where his exam was notable for "right sided weakness."
Patient was apparently fully alert and conversant. He vomited in
the CT scan at the OSH and was intubated. Head CT revealed right
putaminal hemorrhage. Following intubation his blood pressures
dropped requiring two pressors. He was transferred to [**Hospital1 18**] via
[**Location (un) **] for further care.
Pt was unable to offer a ROS. According to his son he was seen
at
[**Hospital1 **] ~2 weeks ago for nephrolithiasis. He is somewhat
sedentary at baseline, but independent of all ADL's.
Past Medical History:
CAD- s/p CABG in [**2174**]
Pulmonary HTN
systolic HF- EF 35%
Hypertension
hyperlipidemia
nephrolithiasis
Social History:
pt is a car enthusiast, on the board of the [**First Name8 (NamePattern2) 4304**] [**Location (un) 4223**] Auto
museum in [**Location (un) **]. never smoker, no ETOH, no illicits.
Family History:
NC
Physical Exam:
Vitals: T 98, BP 125/54 (on levophed), HR 59, R 14, 100% CMV
Gen- ill appearing, intubated and sedation (recently rec'd
fentanyl from [**Location (un) **])
HEENT- NCAT, anicteric sclera, MMM
Neck- no carotid bruits
CV- RRR
Pulm- CTA B
Abd- soft, nt, nd, BS+
Extrem- no CCE
Neurologic exam:
MS- opens eyes to voice, does not follow commands. localizes
sternal rub with right hand.
CN- PERRL 4-->3mm, blinks to visual threat bilat, intact
corneals
bilat, intact gag.
Motor/sensory- moving right arm and leg spontaneously,
purposefully withdraws right arm, leg and left leg to noxious.
no
withdrawal or left arm to noxoious stim.
Reflexes: left patellar 3+, [**Hospital1 **], brachiorad 3+ on left, right
with
2+ patell, [**Hospital1 **], tri. absent ankles.
Plantar response was upgoing bilaterally.
Pertinent Results:
[**2193-4-4**] 05:48AM BLOOD WBC-10.9 RBC-4.22* Hgb-13.7* Hct-38.4*
MCV-91 MCH-32.3* MCHC-35.6* RDW-13.4 Plt Ct-244
[**2193-4-3**] 06:28AM BLOOD WBC-8.9 RBC-4.53* Hgb-13.9* Hct-41.1
MCV-91 MCH-30.7 MCHC-33.8 RDW-13.9 Plt Ct-230
[**2193-4-2**] 05:55AM BLOOD WBC-8.0 RBC-4.41* Hgb-13.9* Hct-39.7*
MCV-90 MCH-31.6 MCHC-35.1* RDW-13.8 Plt Ct-212
[**2193-3-30**] 12:53AM BLOOD WBC-12.6* RBC-4.30* Hgb-13.7* Hct-38.9*
MCV-91 MCH-31.9 MCHC-35.2* RDW-14.1 Plt Ct-183
[**2193-3-29**] 03:55AM BLOOD WBC-11.0 RBC-4.16* Hgb-13.4* Hct-38.8*
MCV-93 MCH-32.3* MCHC-34.6 RDW-13.5 Plt Ct-177
[**2193-3-28**] 06:15PM BLOOD WBC-11.8* RBC-4.68 Hgb-14.7 Hct-43.4
MCV-93 MCH-31.4 MCHC-33.9 RDW-13.7 Plt Ct-228
[**2193-4-1**] 06:20AM BLOOD PT-14.1* PTT-24.2 INR(PT)-1.2*
[**2193-3-30**] 12:53AM BLOOD PT-14.1* PTT-25.3 INR(PT)-1.2*
[**2193-4-4**] 05:48AM BLOOD Glucose-149* UreaN-17 Creat-0.9 Na-147*
K-3.2* Cl-115* HCO3-25 AnGap-10
[**2193-4-3**] 06:28AM BLOOD Glucose-122* UreaN-16 Creat-0.9 Na-148*
K-3.4 Cl-113* HCO3-23 AnGap-15
[**2193-4-2**] 05:55AM BLOOD Glucose-120* UreaN-17 Creat-0.9 Na-143
K-3.4 Cl-110* HCO3-23 AnGap-13
[**2193-4-1**] 06:20AM BLOOD Glucose-100 UreaN-17 Creat-0.9 Na-144
K-3.8 Cl-107 HCO3-25 AnGap-16
[**2193-3-31**] 08:26AM BLOOD Glucose-147* UreaN-19 Creat-0.9 Na-141
K-3.7 Cl-108 HCO3-25 AnGap-12
[**2193-3-30**] 12:53AM BLOOD Glucose-98 UreaN-16 Creat-1.1 Na-142
K-3.7 Cl-109* HCO3-25 AnGap-12
[**2193-3-29**] 03:55AM BLOOD Glucose-112* UreaN-21* Creat-1.1 Na-140
K-4.4 Cl-109* HCO3-22 AnGap-13
[**2193-4-4**] 05:48AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.1
[**2193-3-29**] 03:55AM BLOOD %HbA1c-6.0*
[**2193-3-29**] 03:55AM BLOOD Triglyc-48 HDL-44 CHOL/HD-2.9 LDLcalc-75
CT Head [**3-29**]:Right basal ganglia hemorrhage with mild
surrounding edema. No herniation or hydrocephalus.
CT ABD: 1. Three nonobstructing left renal calculi ranging in
size between 4 mm and 2 cm. Multiple bladder diverticula. 2.
Cholelithiasis.
3. Findings consistent with prior myocardial infarction at the
aex of the
left ventricle. 4. Small hiatal hernia.
CT HEAD [**4-4**]: Unchanged size and appearance of right basal
ganglia intraparenchymal hemorrhage. No new blood or
intraventricular extension. No subfalcine herniation.
Brief Hospital Course:
Pt was admitted to the ICU initially for close monitoring. His
hemorrahge is thought to be due to hypertension. He had serial
imaging with no change in size of hemorrage. He was monitored
with frequnet neuro-checks and cardiac telemtery. He was stable
and sent to the neurology floor. He developed hematuria and an
CT-abd revieled non-occlusive renal stones. He failed multiple
speech evaluations and a PEG was placed in IR without
difficulty. PT/OT were consulted. He was noted to have an UA
suspicious for UTI despite 3 days of IV cipro and was thus
changed to IV ceftriazone for 5 day course. Repeat urine cx is
pending at discharge. He will follow-up with Dr. [**Last Name (STitle) **] as an
outpt.
Medications on Admission:
Proscar daily
Folic acid 1mg daily
Folguard ? strength
Atorvastatin 20mg daily
Metoprolol 75mg QAM, 50mg qnoon, 50mg QHS
Persantine 150mg daily
Imdur 60mg daily QHS
Lisinopril 10m gdaily
Aspirin 325mg daily
Amlodipine 5mg daily
Discharge Medications:
1. Letter
To whom it may concern,
[**Known firstname 2174**] [**Known lastname **] is under my medical care at [**Hospital1 827**]. Due to his current condition, he is unable to
sign his name or write, or otherwise communicate.
Sincerely,
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10927**], MD
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Docusate Sodium Oral
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
11. CeftriaXONE 1 g IV Q24H Duration: 5 Days
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Cerebral Hemorrhage R Putamen
Discharge Condition:
Left upper extremity paresis, left neglect
Discharge Instructions:
You were admitted because of a bleed in your brain. It was
likely due to high blood pressure. If you have any new weakness
or numbness you should return to the ER.
Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2193-6-5**] 1:30
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 431, 4019, 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3199
} | Medical Text: Admission Date: [**2147-6-5**] Discharge Date: [**2147-6-9**]
Date of Birth: [**2090-4-1**] 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:
Emergent CABG X 3 ([**2147-6-5**])
History of Present Illness:
57 y/o male w/no previous cardiac history, presented to [**Hospital 1474**]
Hospital with sudden onset chest pain, ruled in for acute MI,
placed on heparin/Plavix/Aggrastat, transferred emergently to
[**Hospital1 18**] Cath lab. This revealed 90% LM with extensive thrombus,
as well as 80% prox. LAD disease. An IABP was placed, and he
was takebn to the OR emergently for CABG.
Past Medical History:
DM-2
HTN
s/p bilat hip replacements
s/p gunshot injury to abdomen
s/p spinal fusion
GERD
hx. [**Doctor Last Name 360**] [**Location (un) 2452**] exposure
Social History:
works as substance abuse counsellor
denies ETOH
denies tobacco
married
Family History:
non-contributory
Physical Exam:
Pre-op: unremarkable
Today:
Neuro: grossly intact
Lungs CTAB
Cor: RRR
Abd: benign
Ext: 1+ bilat edema
Sternal incison clean, dry, no erythema
Left leg EVH sites C/D/I
Pertinent Results:
[**2147-6-8**] 06:45AM BLOOD WBC-7.5 RBC-3.46* Hgb-10.2* Hct-29.6*
MCV-86 MCH-29.4 MCHC-34.4 RDW-13.3 Plt Ct-124*
[**2147-6-7**] 03:42AM BLOOD PT-12.5 PTT-28.0 INR(PT)-1.0
[**2147-6-8**] 06:45AM BLOOD Glucose-44* UreaN-20 Creat-0.9 Na-138
K-3.7 Cl-97 HCO3-33* AnGap-12
[**2147-6-7**] 03:42AM BLOOD Glucose-70 UreaN-14 Creat-0.8 Na-134
K-4.1 Cl-100 HCO3-28 AnGap-10
[**2147-6-5**] 03:00PM BLOOD ALT-22 AST-23 AlkPhos-122* Amylase-19
TotBili-0.4
Brief Hospital Course:
Taken to OR emergently from the Cath Lab due to significant LM
disease w/extensive thrombus. Underwent CABG X 3 (LIMA > LAD,
SVG > distal LAD, SVG > Ramus). Intra-op TEE revealed normal RV
function (mild global & apical hypokinesis), trace MR, trace AI,
EF 50%.
Post-op to CSRU, extubated day of surgery, hemodynamically
stable, IABP d/c'd on POD #1, transferred to telemetry floor on
POD # 2, chest tubes removed on POD # 3, he was cleared by
physical therapy and discharged to home on POD#4
Medications on Admission:
Glyburide 2.5 mg [**Hospital1 **]
MS Contin 60mg po BID (am & HS) and 30mg QD (midday)
Lisinopril 5mg QD
Tenormin 25mg [**Hospital1 **]
Zantac 300 mg HS
Trazadone 100 mg HS
ASA 81 mg
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO twice a day for 7 days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
7. Morphine 15 mg Tablet Sustained Release Sig: Four (4) Tablet
Sustained Release PO every twelve (12) hours: 4 tablets Q AM & Q
HS, 2 tablets midday.
Disp:*70 Tablet Sustained Release(s)* Refills:*1*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
South [**State 1727**] VNA
Discharge Diagnosis:
CAD
MI
DM
HTN
Discharge Condition:
good
Discharge Instructions:
no lifting > 10# or driving for 1 month
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
Followup Instructions:
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11907**] (cardiologist) [**7-6**] at 3:20 pm
([**Telephone/Fax (1) 63797**]
with Dr. [**Last Name (STitle) 10273**] (PCP) in [**1-19**] weeks
with Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2147-6-13**]
ICD9 Codes: 4019 |
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