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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3200
} | Medical Text: Admission Date: [**2165-3-30**] Discharge Date: [**2165-4-9**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 84 year-old
gentleman with a history of stroke and normal pressure
hydrocephalus status post VP shunt who fell on [**2165-3-19**]
after slipping on some ice. He is unsure if he hit his head
and had no loss of consciousness. Family reports that over
the last 24 hours he has had difficulty with his speech and
walking. He denies any headache currently. He has a
productive cough. No diplopia. No fever. No nausea or
vomiting.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Pernicious anemia.
3. Normal pressure hydrocephalus status post VP shunt.
4. History of right hemispheric stroke with residual
aphagia.
5. Benign prostatic hypertrophy.
6. Gastroesophageal reflux disease.
7. Hypercholesterolemia.
8. Hypertension.
9. Chronic obstructive pulmonary disease.
PHYSICAL EXAMINATION: On physical examination vital signs
are stable. The patient was awake, alert and oriented times
two. His shunt was visible in his right temporal area. His
pupils are equal, round and reactive to light. Extraocular
movements intact. Lungs clear to auscultation.
Cardiovascular regular rate and rhythm. Abdomen soft,
nontender, nondistended. Positive bowel sounds. Extremities
no edema. Neurological awake, alert and oriented to person
and place, unsure of the city. His motor strength was 4 out
of 5 on the right side and 5 out of 5 on the left. He had a
right facial droop and right pronator drift. CT showed 2 cm
left frontal parietal subdural hematoma with significant
midline shift.
HOSPITAL COURSE: The patient was therefore taken immediately
to the Operating Room where he underwent a left craniotomy
for evacuation of subdural hematoma without intraoperative
complications. Postoperatively, the patient was monitored in
the Surgical Intensive Care Unit where he had a drain in
place and remained on flat bed rest. The patient had a
repeat head CT on postoperative day number one, which showed
a large amount of air as well as some residual subdural
hematomas. Neurologically the patient was sleepy, but
arousable, moving all extremities with continued right sided
weakness. The patient was kept in the Intensive Care Unit on
flat bed rest with drain in place. On postoperative day
number two the patient's mental status somewhat improved. He
was oriented to name only, following commands. He still had
right facial weakness and right upper extremity weakness. A
second repeat head CT showed continued air and a small amount
of residual subdural hematoma. The patient was therefore
considered for a repeat craniotomy for ligation of his VP
shunt although it was felt that this could be done at the
bedside. The patient had his subdural drain discontinued on
[**2165-4-4**] and was transferred to the regular floor. On [**4-5**]
he underwent bedside ligation of his VP shunt in order to
assist in reexpanding his brain and decreasing the air in his
head. The patient tolerated the procedure well. His vital
signs have remained stable. He is awake, alert and oriented
times three. He has a slight right pronator drift. He was
seen by physical therapy and occupational therapy and found
to require a short rehab stay prior to discharge to home.
His vital signs and medications on discharge include Zantac
150 mg po b.i.d., Diltiazem 180 mg po q day, ________________
5 mg po q day, Albuterol inhaler one to two puffs q 6 hours
prn, Lipitor 10 mg po q day, Colace 100 mg po b.i.d.,
Percocet one to two tabs po q 4 hours for pain.
The patient's condition is stable at the time of discharge
and he will follow up with Dr. [**Last Name (STitle) 1327**] in two to three weeks
time with a repeat CT scan at that time.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2165-4-5**] 01:21
T: [**2165-4-5**] 14:17
JOB#: [**Job Number 111526**]
ICD9 Codes: 496, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3201
} | Medical Text: Admission Date: [**2114-1-24**] Discharge Date: [**2114-2-13**]
Date of Birth: [**2070-12-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Abdominal discomfort, nausea.
Major Surgical or Invasive Procedure:
Cardiac catheterization, [**2114-1-31**].
Hemodialysis, initiated on [**2114-2-9**].
PA cathether placement, AV-fistula repair.
History of Present Illness:
A 43yoM with h/o ESRD [**3-1**] GN, s/p kidney transplant x 2 ([**2089**],
[**2097**]), CAD s/p MI, VF arrest, cath/stent to proximal LAD, s/p
ICD placement, stroke in [**2105**], recent history of left olecranon
bursitis, admitted for AV fistula repair. Transferred from the
PACU for w/u of persistent nausea/abd. pain and diarrhea.
Abdominal pain thought to be [**3-1**] to poor outflow from heart
leading to bowel edema or abdominal angina.
.
Pt's ICD was triggered twice while Pt. was in shower on day of
admission to CCU. Pt. underwent right-sided cardiac
catheterization and Swan-Ganz catheter placement, which revealed
elevated wedge pressures and preserved RA/RV pressures,
consistent with left heart failure. Pt. and was transferred to
CCU for management of elevated PCWP and severe low-output heart
failure.
Past Medical History:
1. ESRD: [**3-1**] GN s/p kidney transplant x2 in [**2089**] and [**2097**];
followed by [**First Name8 (NamePattern2) 3122**] [**Doctor Last Name 1860**].
2. CAD: s/p MI and PCI & stent in [**2105**]; s/p right sided
placement of ICD d/t AVF in the left arm; cardiologist is [**First Name4 (NamePattern1) 919**]
[**Last Name (NamePattern1) 911**].
3. CHF: ([**1-1**]) LVEF=20%, 3+ MR.
4. CVA in [**2105**]: no residual complications/defiicits
5. AFib
6. HTN
7. multiple basal cell and squamous cell ca s/p multiple
resections and XRT to lower face.
8. Gout
9. Erectile dysfunction
10. Right lung pneumonia with pleurisy
Social History:
He is married, lives in [**Location 13011**] with wife of 11 years, son (6yo)
and daughter (2yo). He owns and runs a landscaping/contracting
business and works for the city sanding the streets during the
winter. He denies tobacco or recreational drug use. He drinks
EtOH socially.
Family History:
Alcoholism in Mother, maternal uncle and grandfather,
Parkinsons??????s Disease in paternal grandmother, Lymphoma in
paternal grandfather, peripheral vascular disease in maternal
grandmother, no h/o kidney disease, other CA, heart disease,
CVA, or psychiatric diseases.
Physical Exam:
PE: VS: 96.8 | 125/83 | 123(AFib) | 16 | 96% on 2L NC
gen: NAD, pleasant and cooperative.
HEENT: PERRL and EOM intact, OP clear, MMM.
neck: no masses, no LAD, no JVD, no carotid bruit.
CV: irreg irreg, nl s1s2, no murmurs.
chest: cta b/l, no crackles or wheezes.
abd: soft, nt/nd, +bs, no organomegaly.
extr: no cyanosis, no clubbing; [**3-2**]+ LE edema up to knees; 1+ dp
pulses b/l.
neuro: awake, alert, a&ox3, cn ii-xii intact; motor, sensory,
coordination, and language grossly intact.
Pertinent Results:
[**2114-1-7**] Liver U/S - Gallbladder wall thickening without other
signs to suggest cholecystitis. Clinical correlation is
recommended to exclude other etiologies for gallbladder wall
thickening such as hypoalbuminemia, CHF or hepatitis.
.
[**2114-1-8**] Echo - LVEF<20%. Severe LV dilation. Severe global left
ventricular hypokinesis with septal and apical akinesis. Overall
left ventricular systolic function is severely depressed. An LV
mass/thrombus cannot be excluded. RV cavity is dilated. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. 1+AR, 2+MR, mod. PA HTN.
The end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
.
[**2114-1-9**] GB Scan - 1. No evidence of acute cholecystitis.2
Delayed uptake of tracer into the hepatic parenchyma consistent
with hepatocellular dysfunction. 3. Delayed tracer emptying into
the small bowel.
.
[**2114-1-12**] EGD - Erythema and congestion in the antrum compatible
with gastritis Erythema and congestion in the first part of the
duodenum compatible with duodenitis Otherwise normal EGD to
second part of the duodenum.
.
[**2114-1-25**] CT Abd - Ascites within the abdomen. Cardiomegaly.
Cholelithiasis without cholecystitis. Degenerative changes with
cystic changes seen in the right femoral head. Superior
displacement of the femoral head. These findings may be
post-traumatic or post- infectious in etiology. Dedicated hip
films are recommended.
.
[**2114-1-27**] Renal transplant u/s - 1. Stable appearance of the
right kidney without evidence of hydronephrosis or perirenal
collection. Patent renal vessels as described above. 2. Moderate
ascites.
.
[**2114-1-31**] Cath - 1. Resting hemodynamics demonstrated markedly
elevated left and right sided filling pressures. The mRA
pressure was 20 mmHg and the mean PCWP was 35-42 mmHg. The
cardiac output and cardiac index were significantly reduced at
3.5 l/min and 1.5 L/min/m2, respectively. There was reactive
pulmonary hypertension (pulmonary vascular resistance was 160
dynes.sec/cm2). FINAL DIAGNOSIS: 1. Severe low output heart
failure.
.
[**2114-1-31**] CXR - Severe cardiomegaly is chronic. There is no
longer any pulmonary edema. Transvenous pacer defibrillator lead
is unchanged in position with the tip projecting over the floor
of the right ventricle and the proximal electrode spanning the
superior vena cava and upper right atrium. A right internal
jugular line passes to the region of the pulmonary outflow
tract, but the tip is indistinct. There is no pneumothorax or
mediastinal widening. The left lateral aspect of the lower chest
is excluded from the examination. Lungs are grossly clear.
.
[**2114-2-5**]: CXR - Persistent Cardiomegaly. Cardiac pacer leads are
in good position. The lung fields are clear. There are no
pleural effusions. Note that the left CP sulcus is not included
in the film. IMPRESSION: Persistent cardiomegaly.
.
[**2114-2-13**] 12:30PM BLOOD WBC-8.9 RBC-3.92* Hgb-11.2* Hct-35.1*
MCV-90 MCH-28.6 MCHC-32.0 RDW-15.4 Plt Ct-184
[**2114-1-25**] 03:35PM BLOOD WBC-5.1 RBC-4.78 Hgb-14.6 Hct-43.9 MCV-92
MCH-30.5 MCHC-33.2 RDW-15.0 Plt Ct-161
[**2114-1-25**] 03:35PM BLOOD PT-39.4* PTT-42.9* INR(PT)-12.1
[**2114-1-25**] 03:35PM BLOOD Plt Ct-161
[**2114-2-13**] 12:30PM BLOOD UreaN-62* Creat-4.2* Na-140 K-4.4 Cl-101
HCO3-27 AnGap-16
[**2114-1-24**] 05:36PM BLOOD Glucose-83 UreaN-76* Creat-5.6*# Na-137
K-4.1 Cl-104 HCO3-17* AnGap-20
[**2114-1-24**] 05:36PM BLOOD ALT-32 AST-27 LD(LDH)-305* AlkPhos-122*
Amylase-67 TotBili-2.0*
[**2114-1-24**] 05:36PM BLOOD Lipase-70*
[**2114-2-13**] 12:30PM BLOOD Albumin-3.6 Calcium-9.2 Phos-2.7
[**2114-1-24**] 05:36PM BLOOD Albumin-3.6 Calcium-9.3 Phos-5.5* Mg-2.3
[**2114-2-1**] 04:20AM BLOOD TSH-1.0
[**2114-2-11**] 05:50AM BLOOD PTH-189*
[**2114-1-30**] 12:45PM BLOOD PTH-283*
[**2114-2-11**] 05:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-NEGATIVE
[**2114-1-30**] 12:45PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2114-2-7**] 07:45AM BLOOD Cyclspr-76*
[**2114-1-25**] 03:35PM BLOOD Cyclspr-253
[**2114-1-24**] 05:36PM BLOOD tTG-IgA-5
[**2114-2-11**] 05:50AM BLOOD HCV Ab-POSITIVE
[**2114-2-8**] 07:30AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Pending.
Brief Hospital Course:
A 47yoM with ESRD secondary to glomerulonephritis, s/p kidney
transplant x 2 ([**2089**], [**2097**]) s/p MI, VF-arrest, cath/stent and
stroke in [**2105**], recent history of left olecranon bursitis,
admitted for AV-fistula repair, and also for w/[**Location 14755**]
nausea/abd pain and diarrhea.
.
The patient reported a 4 month history of chronic abdominal
pain. He had an extensive workup including HIDA/EGD/GB u/s all
of which have been unrevealing. The GI team followed the Pt.
and wanted to get a CTA to look for mesenteric ischemia. He was
given n-acetylcysteine and bicarbonate to preserve his renal
function. During administration of the contrast, it infiltrated
into his arm and the study could not be completed. A plastics
consult was called to r/o compartment syndrome. The recommended
elevation and ice to the arm. The swelling and erythema slowly
resolved. The patients kidney funtion continued to deteriorate
and further contrast studies could not be performed. When the
cardiology team was consulted they felt that any mesenteric
ischemia was likely [**3-1**] to poor forward flow rather than
mesenteric stenosis/ischemia so the CTA would not be as helpful
if this were the case. The patient also has an extended history
of diarrhea also worked up extensively by GI as an outpatient.
On admission, stool studies, SSYC, microsporidium, cyclospora,
cryptosporidium, C-Diff (given recent antibiotic use), and ova
and parasites were sent, all of which came back negative. GI
felt it was important at some point to get a colonoscopy but
given his tenuous cardiac status/poor renal function, it was
thought that a prep would dehydrate the patient and cause
further renal damage. The colonoscopy was put on hold to be
rescheduled by PCP at [**Name Initial (PRE) **] later date.
.
It was decided to admit the patient to the CCU for a PA catheter
(which was placed in cath lab) and tailored CHF therapy to
improve his cardiac function in the hopes that this would
improve his abdominal symptoms. The Pt. is known to have a
severely depressed left ventricular ejection fraction and mitral
regurgitation, and was volume overloaded, oliguric, and found to
have an elevated wedge pressure. Treatment was initiated with
milrinone (to maximize cardiac contractility and stroke volume),
and lasix (to decrease preload and achieve optimal filling
pressures). The Pt. responded favorably to this regimen with
improved cardiac function. With compression stockings, his
lower extremity edema began to resolve as well. With improved
forward flow to the kidneys, the Pt. began diuresing quite
briskly to IV lasix, and his creatinine trended down to
approximately 4.0. When the Pt. was nearing euvolemia, the
milrinone was weaned off, and the Pt. was switched to PO lasix
and transferred to a medical floor.
.
At this time, his abdominal symptoms had resolved, supporting
the hypothesis that his symptoms were secondary to elevated
preload leading to 3rd-spaced fluids in the bowel wall (bowel
edema). Unfortunately, the Pt. did not diurese to PO lasix (or
bumetamide) and experienced a rapid reaccumulation of lower
extremity edema, worsening of abdominal symptoms (including
abdominal cramping, nausea, and emesis), and rising creatinine.
The Pt. was seen by the renal team, who felt that if the pt.
could not be managed on PO diuretics, then with a rising
creatinine hemodialysis would be necessary. The Pt. underwent
dialysis for the first time on [**2114-2-9**], and had several
dialysis sessions while in the hospital, which were all well
tolerated, and yielded an improvement and ultimately a
resolution of all abdominal symptoms.
.
The Pt. was also seen by electrophysiology, as he was not
tolerating beta-blockers for rate control of atrial
fibrillation. The Pt. was started on amiodarone for rhythm
control (also because the Pt. had a history of a V-fib cardiac
arrest). When the tailored CHF therapy was completed, the Pt.
was started on low-dose digoxin for further rhythm control. The
Pt. has an ICD in place, and remained in A-Fib with rapid
ventricular response (avg. heart rate 90s-110s). The Pt. was
anticoagulated with coumadin with goal INR of 2.0-2.5.
.
For history of CAD, the Pt. was treated with aspirin and [**First Name8 (NamePattern2) **] [**Last Name (un) **]
(avapro, which he had been on in the past). Beta-blockers
(coreg, metoprolol) were tried but not tolerated, and statin
therapy was deferred because the Pt. was known to have a very
low LDL, and also because statins can alter the effectiveness of
Pt's immunosuppressive meds.
.
Patient had an episode of gout flare on his ankle 24 hours prior
to discharge. No evidence of fever or leukocytosis. Prednisone
dose was increased and patient felt better. After discussing
this issue with Dr [**Last Name (STitle) 1860**], it was decided to d/c azathioprine and
continue allopurinol. Patient will have a follow up appointment
with Dr [**Last Name (STitle) 1860**] in about a week, and in the mean time, prednisone
will be tapered back to immunosuppression dose.
.
Pt. has hyperparathyroidism (PTH [**2113-1-30**]: 283; PTH [**2114-2-12**]:
189). Pt. has been treated with calcium. Will continue to
periodically monitor calcium and phosphate levels.
.
Pt. met with nutritionist while in the hospital and was educated
re: low-sodium cardiac-healthy diet options.
Medications on Admission:
Azathioprine 50 mg PO QD
Prednisone 10 mg PO QOD
Metoprolol Tartrate XL 50 mg po QD
Calcitriol 0.25 mcg po qd
Isosorbide Mononitrate 30 mg SR po qd PRN HTN
Pantoprazole 40 mg po qd
Cyclosporine Modified 50mg PO bid
Warfarin 2/4 mg po qod
Discharge Medications:
1. 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*
2. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*270 Tablet(s)* Refills:*2*
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Warfarin 2 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily):
please check your INR frequently, goal is 2.0-2.5.
Disp:*60 Tablet(s)* Refills:*2*
5. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO QD ().
Disp:*15 Tablet(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Cyclosporine 25 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*2*
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day:
Take 30 mg (3 tab) for 1 day, then 20mg (2tab) for 3 days, then
10mg (1 tab) for 3 days and finally 1 tab every other day until
you see Dr [**Last Name (STitle) 1860**].
Disp:*40 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
1. severe low-output congestive heart failure.
2. acute on chronic renal insufficiency (ESRD s/p renal
transplant).
Discharge Condition:
Good, stable.
Discharge Instructions:
Please continue to take all of your medications exactly as
prescribed.
.
- take your prednisone [**Doctor Last Name 2949**] as prescribed- this is the
schedule: 30mg x 1 day, 20mg x 3 days, 10mg x 3 days and then 10
mg every other day until you see Dr [**Last Name (STitle) 1860**].
.
Please weigh yourself without clothes on today when you get
home, and record your weight. Then weigh yourself every day
without clothes, and if your weight increases by more than 3
pounds, call your PCP or Dr. [**Last Name (STitle) 911**] for instructions about
changing the dose of your diuretic.
.
If you experience abdominal symptoms, chest pain, shortness of
breath, leg swelling, or palpitations, please return to the
hospital.
Followup Instructions:
Please call Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] (cardiology) at [**Telephone/Fax (1) 920**] to
schedule an appointment within the next week.
.
Please call Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] (renal) at ([**Telephone/Fax (1) 773**] to
schedule an appointment within the next week. Dr.[**Name (NI) 14756**] office
will call you with an appointment time. If you do not hear from
them by tomorrow, you should call them at the above number.
Completed by:[**2114-2-14**]
ICD9 Codes: 5849, 5856, 4280, 2749, 4240, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3202
} | Medical Text: Admission Date: [**2145-2-9**] Discharge Date: [**2145-2-12**]
Date of Birth: [**2104-8-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
intoxication
Major Surgical or Invasive Procedure:
intubation [**2145-2-9**], extubated [**2145-2-9**]
History of Present Illness:
This is a 40 year-old female BIBA after being found down at
court house. According to her family, she drank a pint of vodka
last night and came home around 1am, visibly intoxicated. Became
more lucid during the early morning, and then told her of their
plans to take her to court for a section 35/court ordered rehab.
She then drank a second pint of vodka prior to going to court.
Shortly after arriving at court, she slumped over and became
unresponsive. EMS was called, and found her unresponsive to
sternal rub but with normal vital signs. An oral airway was
placed and she was bag-valve ventilated on the way to [**Hospital1 18**].
To the best of the family's knowledge, she did not consume any
other drugs or medicines. They say she has been on a "binge" for
the last 24 hours or so, with no clear trigger; drinking binges
in the past have been associated with breakups or other social
stressors. Between drinking binges, she is stable and holds down
a job.
In the ED, she was intubated for airway protection. She was
briefly hypotensive to 90s systolic, fluid responsive. Tox
screens showed alcohol level of 638 but were otherwise negative.
First CXR showed R mainstem intubation; ETT was withdrawn and is
now in good position above the carina. Vital signs prior to
transfer to ICU: 97.4, 119/93, 16, 76, 100% on vent.
Past Medical History:
Thyroidectomy for (malignant) nodule
Insomnia
Bipolar Disorder
Social History:
Works as a 5th grade teacher in JP, has son and [**Name2 (NI) **]. Has
been hospitalized at least 5 times for alcoholism, most recently
in 10/[**2144**]. Family thinks she may have had a withdrawal seizure
in [**Month (only) 359**], no history of DTs. Does smoke tobacco, no known IV
or other drug use.
Family History:
Non contributory.
Physical Exam:
Vitals: Tm 99.7 Tc 97.2 115/80 p75 R18 96%RA
GEN: Well-appearing, well-nourished, appears sad/anxious
HEENT: EOMI, PERRL,
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
Neuro: CN2-12 intact. No asterixis
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
ADMISSION LABS:
[**2145-2-9**] 12:58PM WBC-11.9* RBC-4.89 HGB-15.0 HCT-42.4 MCV-87
MCH-30.6 MCHC-35.3* RDW-15.1
[**2145-2-9**] 12:58PM PT-14.6* PTT-22.6 INR(PT)-1.3*
[**2145-2-9**] 12:58PM PLT COUNT-343
[**2145-2-9**] 12:58PM FIBRINOGE-204
.
[**2145-2-9**] 12:58PM ASA-NEG ETHANOL-638* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2145-2-9**] 12:58PM OSMOLAL-467*
[**2145-2-9**] 12:58PM CALCIUM-7.8* PHOSPHATE-3.9 MAGNESIUM-2.2
[**2145-2-9**] 12:58PM LIPASE-39
[**2145-2-9**] 12:58PM ALT(SGPT)-15 AST(SGOT)-22 ALK PHOS-51 TOT
BILI-0.2
[**2145-2-9**] 01:00PM GLUCOSE-106* LACTATE-2.1* NA+-150* K+-4.3
CL--108 TCO2-25
[**2145-2-9**] 12:58PM UREA N-13 CREAT-0.7
[**2145-2-9**] CXR: FINDINGS: Endotracheal tube has been repositioned
with tip approximately 3.5 cm from the carina. NG tube courses
through the mediastinum with tip and side port within the
expected region of the stomach. Superior mediastinal widening is
minimal and likely due to positioning. The heart size is within
normal limits. Low inspiratory volumes are present. Opacities
within the left upper and lower lobes are less conspicuous on
current study and may reflect aspiration or atelectasis. No
effusion or pneumothorax detected.
IMPRESSION:
1. Standard position of endotracheal tube after repositioning.
2. Left upper and lower lobe opacities may reflect atelectasis
or
aspiration.
[**2145-2-9**] NONCONTRAST HEAD CT: No edema, mass effect, acute
hemorrhage, or major
vascular territorial infarction is detected. The ventricles and
sulci are
normal in size and configuration.
There is a mucus retention cyst in the right maxillary sinus.
There are
aerosolized secretions in the sphenoid sinus, which is not
divided into right and left compartments. There is mild mucosal
thickening in the ethmoid sinuses. There is fluid in the nasal
cavity and nasopharynx, which may be related to the presence of
the endotracheal tube. The bones are unremarkable.
IMPRESSION:
No evidence of acute intracranial abnormalities.
[**2145-2-9**] CT of Cervical Spine: There is no fracture or
malalignment. Disc space height is preserved. No paravertebral
soft tissue swelling is noted. Small enplate osteophytes are
noted at C6-C7 without evidence of high-grade spinal canal
stenosis. Evidence of thyroidectomy is seen. Endotracheal and
nasogastric tubes are present.
IMPRESSION: No fracture or malalignment.
.
[**2145-2-11**] 08:45AM BLOOD WBC-7.3# RBC-4.05* Hgb-12.6 Hct-36.1
MCV-89 MCH-31.0 MCHC-34.8 RDW-14.9 Plt Ct-202
[**2145-2-11**] 08:45AM BLOOD Glucose-100 UreaN-9 Creat-0.6 Na-138
K-3.4 Cl-103 HCO3-27 AnGap-11
[**2145-2-10**] 04:20AM BLOOD ALT-14 AST-19 AlkPhos-51 TotBili-0.5
[**2145-2-11**] 08:45AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0
[**2145-2-9**] 12:58PM BLOOD TSH-1.0
Brief Hospital Course:
Ms. [**Known lastname 19987**] is a 40 year-old female with reported bipolar
disorder, hypothyroidism, and ongoing alcohol abuse who was
admitted with alcohol intoxication and intubation for airway
protection.
.
# Decreased level of consciousness: History of heavy alcohol
consumption immediately prior to event and lab studies
consistent with alcohol intoxication. Admission bicarb was
normal, so low suspicion for methanol or other concomitant
intoxication. Intubated for airway protection in ED. The osm gap
of 17 even after correcting for ethanol on admission suggested
there may have been some element of alcoholic ketoacidosis. Head
and C Spine CTs were negative for evidence of trauma. During ICU
stay [**2-9**] she became more and more awake needing higher and
higher levels of sedation leading to a self-extubation. She did
well after this, protected her own airway with good O2 Sat.
.
# alcohol abuse: According to EMS report, patient had just been
committed for rehab, and by history is actively using alcohol
until admission. Therefore, low threshold for withdrawal until
48-72 hours out from last use, which was [**2-9**] around noontime.
We gave pt IVF with folate, thiamine, multivitamin empirically
x3 days. On [**2-9**], we gave the family a letter of medical
necessity to petition joudge to extend Section 35 for 48 more
hours. She was placed on a CIWA scale with PO Valium on [**2-10**].
SW was consulted for transition to rehab.
.
After transfer out of the ICU, patient was continued on CIWA
scale, but symptoms of anxiety predominated. Patient was started
on Diazepam 2 mg po q8hr scheduled beneath the CIWA scale to
help reduce baseline anxiety level. On [**2144-2-11**] (early am),
patient did feel what may have been tactile hallucinations, with
sense of someone tugging on her sheets. These symptoms did not
recur. On [**2144-2-12**], pt appeared much more comfortable, with less
anxiety, and no signif tremor.
.
# Chest pains:
pain on sternal palpation, likely d/t sternal rub in field. Not
suggestive of rib fracture on exam. Breathing comfortably.
- NSAIDS and Tylenol
.
# Hypothyroidism:
- synthroid 175 mcg
.
# Bipolar do:
- Seroquel q hs for sleep and reported history of Bipolar d/o
.
# Comm: with [**Name2 (NI) **] and sister, who is a lawyer and has been
very active w/ dealing with problems related to alcoholism
.
CODE: presumed full
DISPO: to alcohol rehab, today under Section 35 via family.
Medications on Admission:
Unable to obtain accurate meds on admission due to
unresponsiveness.
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO q8 HR prn.
4. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for CIWA >10 for 2 days: for alcohol withdrawl
symptoms.
5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
# Acute alcohol intoxication requiring intubation
# Chronic alcohol abuse
# Musculoskeletal chest pains (from sternal rubs in field)
# Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
Discharge to [**Hospital **] rehab program under Section 35.
Completely abstain from alcohol, and complete alcohol rehab
program.
Please seek medical attention if you develop fevers, chills,
cough, difficulty breathing, worsening tremor, hallucinations,
seizures, or any other concerns.
Followup Instructions:
Please follow up with your primary care provider [**Name Initial (PRE) 176**] [**2-12**]
weeks, or sooner if you develop any problems such as fevers,
cough, difficulty breathing.
.
Continue to use incentive spirometer 4-5 times per hour for the
next 2-3 days.
ICD9 Codes: 2762, 2760, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3203
} | Medical Text: Admission Date: [**2185-12-23**] Discharge Date: [**2185-12-25**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
MICU admission for malignant hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 37 y/o male with type I DM with known
gastroparesis, ESRD on dialysis, and multiple prior admissions
for nausea/vomiting and difficult to control hypertension who
presented to the ED last PM with 1 day of N/V, and SBP in 250's.
Pt had dialysis yesterday afternoon, and then experienced
symptoms later that evening. Pt denies CP, SOB, F/C. Of note,
pt has had multiple [**Hospital1 18**] admissions in the past for similar
symptoms and was recently discharged on [**2185-12-10**].
.
ED COURSE: He had N/V, and was found to have an elevated BP of
250's/140's. He was initially placed on Nipride gtt, but this
was then d/c'd and he was given Labetolol 20mg IV x1 and hydral
10mg IV x 3. He also received dilaudid 2mg IV x 5, Ativan 2mg
IV x 5, droperidol 2.5mg IM x 1, and Anzemet 12.5mg IV x 1.
.
Pt currently feels well, and denies N/V, CP, SOB.
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), normal stress
[**11/2182**]
6. Foot Ulcer - 2 months, healing slowly
7. h/o clot in AV fistula clot on [**Year (4 digits) **]
Social History:
Denies any alcohol, tobacco, or drug use. He has his own room
but lives with his son's mother. His son is 12 years old.
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:
VS- T 96 BP 197/96 --> 145/94, HR 86, RR 13, O2 97% 2L NC
Gen: Pleasant male lying on bed in no acute distress
HEENT: Sclerae muddy. MMM. OP clear.
NECK: Supple, No LAD, No JVD. No thyromegaly.
CV: RRR. nl S1, S2. Has 2/6 systolic murmur at LUSB as well as
[**4-18**] sysotlic murmur radiating to apex. L sided port in place.
LUNGS: CTAB
ABD: Soft, nt, nd, +BS. No rebound/guarding.
EXT: WWP, NO CCE. 2+ DP pulses BL. Has a healing ulcer on the
inferior R foot. No surrounding erythema or drainage.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2185-12-23**] 12:48AM BLOOD PT-34.3* PTT-40.7* INR(PT)-3.7*
[**2185-12-24**] 04:20AM BLOOD PT-52.1* PTT-44.3* INR(PT)-6.2*
[**2185-12-24**] 01:42PM BLOOD PT-48.7* PTT-39.5* INR(PT)-5.7*
Brief Hospital Course:
Mr. [**Known lastname **] is a 37 year old male with hypertension, ESRD on
dialysis, and multiple prior admissions for hypertension with
nausea & vomiting who presented with HTN and nausea/vomiting.
.
# Nausea/vomiting: The presentation appears to be consistent
with his prior admissions for severe autonomic dysfunction with
hypertensive emergency, and gastroparesis.
- He was continued on his usual medications including ativan,
dilaudid, and anzemet, as well as antihypertensive regimen with
resolution of his nausea and vomiting.
.
# Hypertension: Upon admission, his SBP were up to 250's
initially. His regular antihypertensive regimen was resumed
including clonidine patch, PO clonidine, metoprolol, ativan,
dilaudid and his BP improved. He was 132/87 upon discharge
.
# ESRD on dialysis: Mr. [**Known lastname **] usual dialysis schedule was
T/Th/Saturday. He received Saturday dialysis during this
admission and will resume his usual schedule upon discharge. He
was followed by the renal team during this admission.
.
# Type I DM: Glucose upon admission was 300. He was continued
on his home dose of NPH 6 units [**Hospital1 **] and an insulin sliding scale
and glucose control was adequate.
.
# Elevated INR: Patient with INR elevated to 5.7 during this
admission. The patient's [**Hospital1 197**] was held and he was
instructed to stop his [**Hospital1 197**] upon discharge and to be seen in
coagulation clinic on [**Hospital1 766**] to recheck his INR. The patient
was not reversed as he had no signs of bleeding.
.
# Ulcer on right foot: Stable during this admission. There were
no signs of infection.
.
# FEN: Patient was maintained on a renal, gastroparesis diet.
.
# PPx: ? HIT per renal, but HIT Ab negative during last
admission. Will use pneumoboots for now. Platelets were stable
at 184 upon discharge.
.
# CODE: Full
.
Medications on Admission:
Metoprolol Tartrate 37.5 mg [**Hospital1 **]
B Complex-Vitamin C-Folic Acid 1 mg qd
Warfarin 3mg PO qhs
Clonidine 0.4 mg PO tid
Clonidine 0.3 mg/24 hr Patch QTHUR
Calcium Acetate 1334 tid w/meals
Metoclopramide 5 mg qid
Insulin NPH 6U [**Hospital1 **]
Ativan 2 mg q4-6hrs prn
Ondansetron HCl 4 mg/5 mL PO q8h prn
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Metoclopramide 5 mg/5 mL Solution Sig: One (1) PO every six
(6) hours as needed for nausea.
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO three
times a day: take with meals.
5. Ondansetron HCl 4 mg/5 mL Solution Sig: Five (5) mL PO every
eight (8) hours as needed for nausea.
6. Ativan 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for nausea.
7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: 6 units
Subcutaneous twice a day.
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
9. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
10. Outpatient [**Hospital1 **] Work
Please check INR at dialysis on Tuesday [**2185-12-27**] given
supratherapeutic INR at discharge (INR 5.7).
Discharge Disposition:
Home
Discharge Diagnosis:
.
Primary: Malignant hypertension, Gastroparesis
.
Secondary:
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), normal stress
[**2183**]
6. Foot Ulcer - 2 months, healing slowly
7. h/o clot in AV fistula (on [**Year (4 digits) **])
.
Discharge Condition:
Good: Taking POs well. No nausea/vomiting. BP well controlled.
Discharge Instructions:
.
1- Please take all medications as prescribed. Do not take your
[**Year (4 digits) 197**] until you are seen at dialysis on Tuesday [**12-27**]
for a check of your INR (your INR is currently elevated (5.7)).
.
2- Please followup with your PCP [**Last Name (NamePattern4) **] 1 week. You will need an
outpatient echo to evaluate your heart function given complaints
of paroxysmal nocturnal dyspnea.
.
3- Please seek medical attention for severe nausea/vomiting or
for elevated blood pressure (sbp> 200) that does not resolve
after taking your usual outpatient BP medication regimen.
.
Followup Instructions:
.
1- Please hold your [**Last Name (NamePattern4) 197**] until you are seen at dialysis on
Tuesday for a repeat INR. Your [**Last Name (NamePattern4) 197**] is currently
supratherapeutic.
.
2- Please followup with your outpatient doctor to have an echo
of your heart scheduled to evaluate your symptom of paroxysmal
noctural dyspnea.
.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2185-12-24**]
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3204
} | Medical Text: Admission Date: [**2179-4-22**] Discharge Date: [**2179-4-26**]
Date of Birth: [**2100-7-27**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Weakness, falls, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness:
78 year old female with metastatic invasive lobular breast
cancer on gemcitabine with peripheral neuropathy who presents
with fever and multiple falls. Patient was admitted to OMED
from [**4-16**] - [**4-17**] for bilateral LE cellulitis. She was given
Vancomycin and showed improvement and was discharged on Keflex
for 8 days. She reports comliance with this medication and some
reduction in swelling of her legs but claims that they are still
"hard" (swollen) and red (L > R). She also reports having
multiple falls, [**3-11**] the day of admission, where she had to crawl
on the ground to get to her phone. He complains of left ankle
pain; she says she fell on her rear but never hit her head or
lost consciousness.
.
In the ER, initial vitals T 103 102 147/62 18 94% RA., She
received Tylenol, Vancomycin, and Cefepime, and admitted for
further evaluation. She was not aware she had a fever but
reports she has felt "cold" but no rigors.
.
Review of Systems:
(+) Per HPI, nausea, poor appetite, fatigue
(-) Denies night sweats. Denies blurry vision, diplopia, loss of
vision, photophobia. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies chest pain or tightness,
palpitations. Denies cough, shortness of breath. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, melena,
hematemesis, hematochezia. Denies dysuria, stool or urine
incontinence. Denies arthralgias or myalgias. Denies rashes or
skin breakdown. No numbness/tingling in extremities. All other
systems negative.
.
Past Medical History:
PAST ONCOLOGIC HISTORY:
[**2156**] carcinoma of the right breast treated with excision,
axillary sampling and radiation to breast and axilla. In [**Month (only) 205**]
[**2169**] she was diagnosed with an invasive lobular carcinoma of the
same breast. The tumor was ER,PR + and HER2 negative. On [**8-5**] [**2169**] she underwent a right mastectomy for a greater than 5 cm
tumor. She was therefore staged as T3N?M0. The nodes were not
evaluable because of prior excision and radiation. She elected
not to have chemotherapy and took Arimidex as adjuvant therapy
beginning in [**2170-8-6**]. Because of a rising CA [**93**]-29 a PET
scan was done on [**2174-5-16**] which revealed: There is focal
abnormal uptake of FDG throughout the spine, bilateral ribs,
bilateral clavicles, left scapula, left humerus, sternum,
bilateral iliac bones. There is also uptake within subcentimeter
left hilar lymph nodes (SUV 4.8), and asymmetrically within the
right lingual tonsil (SUV 4.8). There are bilateral maxillary
retention cysts/polyps, colon diverticulosis, a 5mm right lower
lobe nodule (not FDG avid but may be due to small size), and a
nodular component to a left lower lobe scar. The Arimidex was
discontinued in the hope of seeing a withdrawal response. It did
not occur so on [**2174-7-15**] she was begun on Aromasin with
monthly Faslodex injections. A PET scan done on [**2176-5-21**]
showed dramatic improvement in osseous metastatic disease and
resolution of FDG avidity and increased sclerosis of the
previously FDG avid skeletal metastases. There was no new
skeletal lesion. She was hospitalized at [**Hospital1 18**] from [**11-30**]-30, [**2176**] because of severe diarrhea. On [**2177-9-2**] she had a PET
scan which showed: 1. Widespread new osseous metastatic disease
throughout ribs, vertebral bodies, scapulae, and several new
lesions in pelvis, all FDG-avid. 2. Stable non-FDG-avid right
lower lobe 7 mm pulmonary nodule. She was treated initially with
Capecitabine to which she was intolerant. She was started on
weekly Taxol in [**2177-12-6**]. On [**2178-10-1**] she had a PET
scan which shows: 1. Mixed response, with overall improvement
in the multi-focal osseous metastasis. A majority of the FDG
avid lesions seen in the prior study, are now non FDG avid.
However a few new FDG avid lesions are present. 2. Stable non
FDG avid right lower lobe pulmonary nodule.
Per Neuro-Onc Note:
[**2156**] Carcinoma of the right breast treated with excision,
axillary sampling and radiation to breast and axilla
[**2158-1-6**] Re-excision of right breast mass and right axillary LAD
by Dr. [**Last Name (STitle) **]
[**6-/2170**] Right breast mass found
[**2170-7-4**] Biopsy of right breast Pathology: invasive lobular
carcinoma, ER/PR positive and HER2 negative
[**2170-7-30**] Right total mastectomy by Dr. [**Last Name (STitle) **], Pathology:
greater than 5.0 cm tumor ( T3), ER/PR+,HER2-
[**8-9**] - [**7-13**]: Anastrozole, stopped due to rising CA [**93**]-29,
[**2174-5-16**] PET-CT showed progression
[**7-13**] - [**2177-8-12**] Exemestane-fulvestrant
[**2177-9-2**] PET-CT showed progression
[**9-15**] Started capecitabine, had a response, but stopped for
diarrhea
[**2177-12-13**] - [**2179-2-9**] Paclitaxel x15
[**2178-10-1**] PET-CT showed progression
[**2-14**] -[**12-17**] Monthly zoledronate and vinorelbine,
3-weeks-on/1-week-off
[**2179-2-16**] PET-CT showed progression
[**2179-3-2**] Vinorelbine restarted
PAST MEDICAL HISTORY:
Breast cancer as above
Post-auricular revision mastoidectomy with tympanoplasty, right
ear, with split thickness skin grafting [**2164-1-24**]
Dilatation and curettage, polypectomy [**2166-6-19**] and [**2169-5-11**]
Chronic constipation
Hypertension
DM2, diet controlled
Poor hearing, has bilateral hearing aids
Cholecystectomy
GERD
asthma
hyperlipidemia
D&C for endometrial polyp, [**2165**] and [**2168**].
Her previous colonoscopy on [**2174-8-31**] only showed Diverticulosis
of the sigmoid colon and descending colon. But in [**2170**], she had
two adenomas
.
Social History:
She lives alone, and has been using Meals on Wheels since her
husband died. She has two children, a daughter in [**Name (NI) 4310**]
([**Doctor First Name 1785**]) and a son in [**Name (NI) 1459**]. She has six grandchildren and
two great grandchildren. She quit smoking 3ppd 25yrs ago and
does not drink alcohol. She says she has family who live
upstairs from her and she has VNA 2-3x/week.
Family History:
Mother died of colon cancer. Father died of complications of
lead poisoning.
Physical Exam:
Vitals: T 102.9 bp 111/42 HR 95 RR 16 SaO2 99RA
GENERAL: NAD, animated and conversant
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva,
patent nares, MMM, wears dentures, dry mucous membranes
CARDIAC: RRR with III/VI systolic murmur
LUNG: CTAB, normal effort
ABDOMEN: Nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well
NEURO: proprioception in lower extremities and pinprick
sensation is intact. Able to move all extrmities. Gait not
tested nor full strength in LE not tested secondary to pain and
instability. CN grossly intact
SKIN/EXT: Warm and erythema of LLE with some mild underlying
edema,
also mild erythma and warmth of RLE as well which is improved
from the faint line drawn of margin previously. Erythema on LLE
does not have distinct borders and is difficult to trace.
Substantial
onychomycosis of nails on RLE.
PSYCH: Cooperative
Pertinent Results:
Admission labs:
[**2179-4-22**] 06:02PM PT-14.6* PTT-29.9 INR(PT)-1.4*
[**2179-4-22**] 06:02PM PLT COUNT-148*
[**2179-4-22**] 06:02PM NEUTS-86.6* LYMPHS-8.6* MONOS-4.3 EOS-0.4
BASOS-0.1
[**2179-4-22**] 06:02PM WBC-8.4# RBC-2.92* HGB-8.6* HCT-27.2* MCV-93
MCH-29.5 MCHC-31.7 RDW-15.7*
[**2179-4-22**] 06:02PM GLUCOSE-147* UREA N-24* CREAT-1.2* SODIUM-134
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-20* ANION GAP-17
[**2179-4-22**] 07:03PM LACTATE-0.8
[**2179-4-22**] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2179-4-22**] 08:45PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.008
Micro:
-BCx (x5) - NGTD
-C. diff ([**2179-4-24**]) - PCR positive for C. diff
Imaging:
-LENIs ([**2179-4-22**]):
1. No evidence of deep venous thrombosis in the left common
femoral,
superficial femoral or popliteal veins.
2. Limited evaluation of the calf veins due to subcutaneous
edema.
-CXR ([**2179-4-22**]): No acute cardiopulmonary process.
-Renal US ([**2179-4-24**]): No stones or hydronephrosis.
-KUB ([**2179-4-25**]): Supine and left decubitus views of the abdomen
show considerable
increase in distention and wall thickening of the large bowel
consistent with
pancolitis. There is no free intraperitoneal gas. Presence of
intraperitoneal fluid is can only be assessed by abdominal CT
scanning,
performed subsequently and reported separately.
-CT abd/pelvis ([**2179-4-25**]):
1. Diffuse thickening and wall edema with stranding of the
colon consistent
with severe pancolitis, most likely infectious in etiology;
however,
inflammatory or ischemic causes cannot be excluded. Borderline
dilated
transverse colon, which in the right clinical setting is a sign
of toxic
megacolon. There is no evidence for perforation.
Small-to-moderate ascites.
2. Small bilateral pleural effusions with atelectasis, worse on
the right.
3. Multiple sclerotic bony lesions consistent with patient's
known bony
metastatic disease. No acute fractures.
4. Small hiatal hernia.
Brief Hospital Course:
78F with met breast CA on gemcitabine, initially admitted for
fevers, abdominal pain and leukocytosis, subsequently found to
have C. diff colitis, [**Last Name (un) **] and and concern for toxic megacolon
#C. diff colitis with toxic megacolon and sepsis: While on the
medicine floor, she was found to have worsening abdominal pain
and distention in the setting of C. diff, which was likely
related to her recent antibiotics during prior admission for
cellulitis. She was treated with PO vancomycin and IV Flagyl.
She was transferred to the [**Hospital Unit Name 153**] for hypotension and hypoxia, the
latter of which is discussed below. KUB was suggestive of
pancolitis. She had a CT abd/pelvis which confirmed pancolitis
and suggested borderline toxic megacolon. An NG tube was placed
for decompression which the patient removed. Her blood pressure
improved with multiple fluid boluses and she did not require
pressors. Surgery was consulted and felt that there was no
surgical intervention indicated given that her surgical
mortality would be extremely high. On HD5, she became
increasingly lethargic and confused. The worsening of her
clinical condition raised concern for worsening of her sepsis
and progression of her toxic megacolon. A meeting between the
family, [**Hospital Unit Name 153**] team and surgical team was held during which it was
decided to make the patient comfort-measures only. She expired
on [**4-26**] at [**2096**].
#[**Last Name (un) **]: Initially presumed to be pre-renal given her diarrhea and
poor PO intake. However, it is likely she progressed to ATN
given her poor urine output despite fluid challenge. Lisinopril
was held and renal was consulted. Cr continued to rise during
her ICU stay and she remained oliguric. Bladder pressure was
also elevated to 16 in the setting of her C. diff pancolitis and
toxic megacolon, indicating potential for early abdominal
compartment syndrome.
#Hypoxia: She was initially transferred to the [**Hospital Unit Name 153**] for the
above findings as well as hypoxia with O2 sat of 70s on RA.
There was concern for aspiration and she was empirically treated
with Vanc/Zosyn for aspiration PNA as well as HCAP given her
recent admission. In the [**Hospital Unit Name 153**], her hypoxia had resolved and she
was satting well on RA. It is unclear whether the hypoxia prior
to transfer was due to poor O2 sat [**Location (un) 1131**].
#Thrombocytosis: Plt elevated to over 1,000,000 during her [**Hospital Unit Name 153**]
stay, thought to be reactive thrombocytosis in the setting of
her sepsis and toxic megacolon. She was continued on ASA 81mg.
#Pseudohyperkalemia: [**1-7**] her thrombocytosis as above, potassium
was wnl when checked as whole blood sample in green top tube.
#Metabolic acidosis: Both anion gap (from her lactic acidosis)
and non-anion gap (likely from GI losses as well as fluid
resuscitation with NS). She was given bicarbonate in her fluids
in an attempt to improve her acidosis. Renal was also consulted
prior to her transition to CMO.
#Death: After transition to CMO care, as discussed above, the
patient died on [**4-26**] at [**2096**].
--Inactive issues--
#Metastatic breast cancer: Followed by oncology as an
outpatient, recently received gemcitabine.
#Hypertension: Home BP meds held in the setting of sepsis and
hypotension.
#Hyperlipidemia: Cont home simvastatin
Medications on Admission:
1. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. smooth move tea Sig: One (1) once a day.
8. calcium Oral
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for constipation.
11. vitamin d3-K-berberine-hops Sig: One (1) once a day.
12. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 8 days (start date [**4-17**])
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnoses:
Clostridium difficule colitis
Sepsis
Toxic megacolon
Acute kidney injury
Secondary diagnoses:
Metastatic breast cancer
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 0389, 5070, 5845, 5119, 2762, 2767, 4019, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3205
} | Medical Text: Admission Date: [**2166-7-28**] Discharge Date: [**2166-7-30**]
Date of Birth: [**2118-9-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Pancreaticoduodenal pseudoaneurysms
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47M with bleeding pancreaticoduodenal pseudoaneurysms s/p mult
coil embolizations with active blush following procedure at OSH
tx'd for further management. Hcts downtrending on transfer 40 on
admission to OSH to 28 on tx to [**Hospital1 18**].
Past Medical History:
Recent tooth abscess I&D with abx
Social History:
drinks "2-3 beers a day", smokes 2 packs per day, has used
percocet recreationally, works as a cab driver.
Family History:
history of perforated gastric ulcers
Physical Exam:
VS: 98.7 114 175/120 16 97RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended, +tympany. Minimal tenderness on exam,
mostly focused periumbilical. No pulsatile masses.
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**2166-7-27**] 11:44PM HCT-29.5*
[**2166-7-28**] 03:35AM HCT-28.9*
[**2166-7-28**] 07:05AM HCT-30.7*
[**2166-7-28**] 11:43AM HCT-31.9*
[**2166-7-28**] 08:00PM HCT-28.2*
[**2166-7-28**] 12:45AM PT-12.9 PTT-26.2 INR(PT)-1.1
[**2166-7-30**] 06:50AM BLOOD WBC-7.4 RBC-3.47* Hgb-10.2* Hct-29.6*
MCV-85 MCH-29.3 MCHC-34.3 RDW-13.4 Plt Ct-394
[**2166-7-27**] EKG:
Sinus tachycardia with respiratory swing in axis. Prominent
voltage in
leads I and aVL for left ventricular hypertrophy. Left atrial
abnormality.
QS deflection in lead V1 and Q wave in lead V2 may represent
prior anteroseptal myocardial infarction. There are diffuse
non-specific ST-T wave changes. No previous tracing available
for comparison. Followup and clinical correlation are suggested.
Brief Hospital Course:
Patient was transferred from OSH s/p embolization of multiple
bleeding pancreaticoduodenal pseudoaneurysms, though had one
aneurysm which was not able to be effectively embolized by IR.
Patient was transferred in [**Hospital1 18**] for further management. Pt
admitted to SICU for monitoring. Pt kept NPO/IVF. Hct
stabilized without transfusion requirement at 28-31 with patient
remaining hemodynamically stable. Abdominal exam remained
unchanged. Elevated blood pressures managed with hydralazine
and IV labetalol, transitioned to metoprolol. Patient
transferred to floor on HD#2 in good condition. Diet was
advanced as tolerated and currently patient on regular diet.
Patient's BP continue to be elevated, his Metoprolol was
increased to 50 mg [**Hospital1 **] prior discharge. Patient will follow up
with his PCP regarding BP management. Patient also instructed
continue to take abx prescribed by his dentist for tooth
abscess.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. 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*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pancreaticoduodenal pseudoaneurysms
2. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-26**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Please call [**Telephone/Fax (1) 2998**] to arrange a follow up appointment with
Dr. [**First Name (STitle) **] in [**3-20**] weeks after discharge.
.
Please follow up with Dr. [**Last Name (STitle) 85185**] (PCP) on [**2166-8-4**] at 8:45 am.
Completed by:[**2166-7-30**]
ICD9 Codes: 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3206
} | Medical Text: Admission Date: [**2155-7-9**] Discharge Date: [**2155-7-14**]
Date of Birth: Sex: F
Service: Medicine
DISPOSITION: [**Hospital3 **] Center
CHIEF COMPLAINT: The patient was admitted to the Medical
Intensive Care Unit Service on [**7-9**] and then was admitted
onto the General Medicine Service on [**7-12**]. She was
admitted with a chief complaint of gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: The patient is an 88 year old
woman with a history of chronic lymphocytic leukemia,
prolymphocytic leukemia type, pulmonary hypertension who
presents with epistaxis to the Emergency Department. She was
noted to be hypoxic with oxygen saturations in the 70s. A
chest x-ray was done that showed bilateral pleural effusions
and some concern for aspiration versus congestive heart
failure. The epistaxis was controlled with Gelfoam. At this
point the patient complained of laying on something wet in
the Emergency Department. She was noted to be sitting in a
pool of bright red blood. Her hematocrit decreased from 33
at 1 PM to
[**Name8 (MD) 34268**], M.D.
Dictated By:[**Last Name (NamePattern1) 8228**]
MEDQUIST36
D: [**2155-7-13**] 14:29
T: [**2155-7-13**] 16:26
JOB#: [**Job Number 34269**]
cc:[**Hospital3 34270**]
ICD9 Codes: 5789, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3207
} | Medical Text: Admission Date: [**2119-8-22**] Discharge Date: [**2119-8-31**]
Date of Birth: [**2053-4-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
66 year old hx of DM, ?compliance on oral meds, hx of
depression/schizoaffective d/o presented w/ pancreatitis and
DKA.
.
Patient reported starting to have epigastric pain on [**Name (NI) 1017**] PTA.
He described the pain as constant sharp [**5-23**] epigastric pain
with no radiation. He has not experienced such pain before. THis
was associated with nausea and decreased appetite. He went to
[**Hospital1 **] on Monday and was subsequently transferred to [**Hospital1 18**]
for further management of pancreatitis.
.
His initial lipase was 1330. In the ED, he was afebrile and with
stable vital sign. He was found to have a slightly widened anion
gap w/ ketones in association with gluocose in 400s and was then
transferred to [**Hospital Unit Name 153**] for insulin drip.
Past Medical History:
DM2
Depression-admit in [**2116**] dx prob schizoaffective dx. h/o major
depression.
Hyperlipidemia
GERD
s/p CCY
last EGD 5 years ago
esophageal ring w/ gastritis
fatty liver on u/s
Social History:
occasional alcohol, denies tobacco/IVDU
Family History:
non-contributory
Physical Exam:
99.4 98 143/76 17 100% 2L
NAD
M dry, poor oral dentition, NC/AC, PERRL
neck supple, no LAD
RRR
CTAB
abd soft, mildly tender to palpation over epigastrum, obese
extr WWP, no edema, resolving sores over shins
A+O X 3, CN II-XII intact, motor + sensory intact over lower
extremities; flat affect
Pertinent Results:
[**2119-8-22**] 02:55AM PLT COUNT-252
[**2119-8-22**] 02:55AM PLT COUNT-252
[**2119-8-22**] 02:55AM WBC-18.3* RBC-4.24* HGB-13.0* HCT-37.3*
MCV-88 MCH-30.7 MCHC-34.9 RDW-12.9
[**2119-8-22**] 02:55AM ALBUMIN-4.1 CALCIUM-8.5 PHOSPHATE-1.1*
MAGNESIUM-2.0
[**2119-8-22**] 02:55AM LIPASE-1336*
[**2119-8-22**] 02:55AM ALT(SGPT)-25 AST(SGOT)-21 ALK PHOS-60
AMYLASE-786* TOT BILI-0.5
[**2119-8-22**] 02:55AM GLUCOSE-437* UREA N-38* CREAT-1.2 SODIUM-134
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-16* ANION GAP-17
[**2119-8-22**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2119-8-22**] 03:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2119-8-22**] 03:00AM PT-13.5* PTT-23.3 INR(PT)-1.2
[**2119-8-22**] 03:15AM GLUCOSE-424* LACTATE-4.0* K+-4.3
[**2119-8-22**] 04:45AM CALCIUM-7.0* PHOSPHATE-1.2* MAGNESIUM-1.7
[**2119-8-22**] 04:45AM GLUCOSE-267* UREA N-32* CREAT-0.9 SODIUM-138
POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-15* ANION GAP-15
[**2119-8-22**] 06:35AM CALCIUM-7.1* PHOSPHATE-1.2* MAGNESIUM-1.8
[**2119-8-22**] 06:35AM GLUCOSE-186* UREA N-30* CREAT-0.9 SODIUM-138
POTASSIUM-3.3 CHLORIDE-112* TOTAL CO2-17* ANION GAP-12
[**2119-8-22**] 06:51AM K+-3.0*
[**2119-8-22**] 02:54PM PLT COUNT-225
[**2119-8-22**] 02:54PM WBC-20.1* RBC-3.75* HGB-11.6* HCT-31.6*
MCV-84 MCH-31.0 MCHC-36.8* RDW-12.6
[**2119-8-22**] 02:54PM CALCIUM-7.4* PHOSPHATE-1.7* MAGNESIUM-2.3
[**2119-8-22**] 02:54PM GLUCOSE-124* UREA N-21* CREAT-0.7 SODIUM-137
POTASSIUM-3.1* CHLORIDE-107 TOTAL CO2-18* ANION GAP-15
[**2119-8-22**] 06:02PM CK-MB-5 cTropnT-<0.01
[**2119-8-22**] 06:02PM CK(CPK)-329*
[**2119-8-22**] 06:02PM GLUCOSE-57* UREA N-15 CREAT-0.7 SODIUM-137
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-20* ANION GAP-18
[**2119-8-22**] 06:02PM ALBUMIN-3.9 CALCIUM-7.9* PHOSPHATE-1.3*
MAGNESIUM-2.3
[**2119-8-22**] 06:02PM WBC-22.9* RBC-3.84* HGB-11.7* HCT-32.4*
MCV-84 MCH-30.5 MCHC-36.2* RDW-12.6
[**2119-8-22**] 06:02PM PLT COUNT-259
[**2119-8-25**] 06:55AM BLOOD WBC-8.7 RBC-3.28* Hgb-10.0* Hct-29.3*
MCV-89 MCH-30.4 MCHC-34.1 RDW-13.1 Plt Ct-171
[**2119-8-25**] 06:55AM BLOOD Plt Ct-171
[**2119-8-25**] 06:55AM BLOOD Glucose-223* UreaN-10 Creat-0.8 Na-134
K-4.3 Cl-102 HCO3-22 AnGap-14
[**2119-8-25**] 06:55AM BLOOD ALT-25 AST-27 AlkPhos-116 Amylase-56
TotBili-0.7
[**2119-8-25**] 06:55AM BLOOD Calcium-8.0* Phos-2.1* Mg-1.9
.
[**8-22**] CT abd/pelvis:
1. Pancreatitis, with non-enhancement of the pancreatic neck.
This finding is concerning for necrosis of the pancreatic neck.
The pancreatic body and tail enhance with contrast, however.
Less than one-third of the gland is affected.
2. Distention of the stomach and prominence of the duodenum
bowel wall,
especially in the second portion near the pancreatic head. There
is
surrounding mesenteric stranding, which may be related to the
pancreatitis. However, duodenitis is another diagnostic
consideration.
3. Small bilateral pleural effusions with associated
atelectasis.
4. Rounded lesion within the L4 vertebral body, of relative
lucency. This
probably represents a hemangioma, but if there is any clinical
concern,
further evaluation with bone scan could be performed.
5. Air in the bladder, likely related to instrumentation. Please
correlate with urinalysis.
[**8-22**] CXR: Right lower lobe atelectasis with elevated right
hemidiaphragm.
[**8-24**] CXR: Comparison is made to [**2119-8-23**]. The left
subclavian central venous line tip is not definitely visualized
due to technique. Lung volumes are further reduced. There is
unchanged pulmonary edema, allowing for the differences in
volume. There is worsening right lower lobe atelectasis. Patchy
left lower lobe opacity could be additional atelectasis or
possible aspiration.
.
[**2119-8-28**] ECHO: IMPRESSION: Normal biventricular cavity size and
systolic function. No structural heart disease or pathologic
flow identified. Mildly dilated thoracic aorta.
Brief Hospital Course:
# DKA: The pt has a history of DM2 with poor medicine compliance
related to difficulty with proper education, and financial
troubles with buying insulin. He presented to the ED at
[**Hospital **] hospital with a blood sugar of 976, and anion gap of
30. His blood gas was 7.31/26/121 at that time. His urine had
glucose of 1000 and 50 ketones. He was started on an insulin
drip and transferred to [**Hospital1 18**] for an ICU bed. On arrival at
[**Hospital1 18**] his blood sugar was 437 and his anion gap was 15. He was
admitted to the ICU on and insulin drip, and his blood sugars
normalized, and the anion gap closed. He was taken off the
insulin gtt, and transferred to the floor on the second hospital
day. [**Last Name (un) **] Diabetes Center was consulted, and provided
recommendations for an insulin regimen for him while in the
hospital, and initiated teaching for home insulin use. Once he
began eating, his metformin 1000 [**Hospital1 **] was restarted.
.
# Pancreatitis: Mr. [**Known lastname **]' pancreatitis is thought to be
idiopathic, with a lipase of 1330 on admission. Gallstones were
an unlikely cause as he had normal LFTS, CT and U/S. He has no
significant ETOH history and triglycerides within normal limits.
CT showed <[**1-16**] of the pancreas involved with a question of
possible neck region necrosis, and a prominent duodenum wall. It
was felt that there were no indications for antibiotic
treatment. His WBC count and amylase & lipase steadily returned
to normal and his hematocrit was stable. He was given percocet
for pain control. After he came to the floor from the MICU,
where he had been NPO, we advanced his diet as tolerated, and he
was tolerating a full po diabetic diet on discharge with no
problems.
.
# anemia:Mr. [**Known lastname **] was likely hemoconcentrated when admitted,
and his hematocrit was stable throughout his hospitalization.
.
# trouble swallowing: Mr. [**Known lastname **] reported occasional difficulty
with swallowing, and has a known history of an esophageal ring.
.
# hypoxemia: A CXR showed RLL atelectasis w/ pleural effusion.
Mr. [**Known lastname **] was diuresed (his fluid status had been very positive
since admission due to his pancreatitis), and encouraged to use
an incentive spirometer. His respiratory function steadily
improved, and he was stable on room air for several days prior
to discharge.
.
# sinus tachycardia: Mr. [**Known lastname **] was tachycardic throughotu his
hospitalization. In discussion with him and his PCP we found
that he is tachycardic at baseline. We had extremely low
suspicion for PE, and he was clinically asymptomatic and [**Last Name (un) 2677**]
throughotu his stay.
.
# ID: Mr. [**Known lastname **] had bacteria in his UA and was treated with
Cipro until his urine culture returned as no growth. He had no
clinical evidence of pancreatic necrosis, and was therefore not
treated for that. His blood cultures showed no growth.
.
# Psychiatric: Mr [**Known lastname **] has a history of depression, anxiety,
and schizoaffective d/o. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33474**] is his outside
psychiatrist. We continued his quetiapine, chlorpromazine and
doxepine per his home regimen.
.
# Prophylaxis: Mr. [**Known lastname **] was on subcutaneous heparin and a PPI.
.
# FULL CODE
.
# Contacts: Sister: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 63333**]
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] [**Telephone/Fax (1) 63334**]
Psych MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33474**] ([**Telephone/Fax (1) 63335**]
.
DISPO: We considered that Mr. [**Known lastname **] might need a SNIF given his
psychiatric history and issues with insulin teaching and
compliance in the apst. He was not willing to consider this, and
his PCP felt it would be reasonable for him to be at home. His
sister felt she would be available for some assistance, and he
was set up with the VNA. Additionally, his PCP will get him into
the diabetes program at [**Hospital3 1280**] Hospital for closer follow up
on his diabetic control and treatment plan.
Medications on Admission:
Prilosec OTC qhs
Glyburide 20mg [**Hospital1 **]
Metformin 1000mg [**Hospital1 **]
seroquel 100 qhs
thorazine 100 qhs
doxepine 100 qhs
lipitor 20mg daily
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
3. Doxepin 50 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. Chlorpromazine 50 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Insulin NPH/Reg 70-30 InnoLet 70-30 unit/mL Insulin Pen Sig:
Fifty Five (55) units Subcutaneous QAM: with breakfast.
Disp:*1 month supply* Refills:*2*
7. Insulin NPH/Reg 70-30 InnoLet 70-30 unit/mL Insulin Pen Sig:
Thirty (30) units Subcutaneous QPM: With dinner.
Disp:*1 month supply* Refills:*2*
8. BD Pen Needle Ultrafine II 30G [**5-29**]"
use a fresh needle for each dose of insulin
please dispense 1 month supply
2 refills
9. One Touch Ultra Test Strips
use a new strip for each fingerstick
dispense 1 month supply
2 refills
10. One Touch Ultra Lancets
Please use a new lancet for each fingerstick
dispense 1 month supply
2 refills
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Principal:
1. Acute Pancreatitis.
2. Diabetic Ketoacidosis.
3. Congestive Heart Failure.
Secondary:
1. Diabetes Mellitus Type II.
2. Schizoaffective Disorder.
3. Abnormal ECG.
4. Hyperlipidemia.
5. GERD.
6. Esophageal Ring.
7. Hepatic Steatosis.
8. S/P Cholecystectomy.
Discharge Condition:
Patient is fully recovered from his pancreatitis and DKA, with
stable blood sugars on a twice-a-day insulin regimen.
Discharge Instructions:
1. Please take your insulin as prescribed every day.
2. Please check your blood sugars by fingerstick with glucometer
twice a day - in the morning and at bedtime - and record the
results.
3. If you are vomiting or not eating for some reason, decrease
your insulin to 37 units in the morning and 20 units at night.
4. If you ever experience symptoms of shakiness, sweating, and
dizziness, check your blood sugar and if it is < 90 drink juice.
5. Don't hesitate to call your doctor with any questions
regarding your medications. He is there to help you stay
healthy.
6. Please follow the diet recommendations provided to you.
Carbohydrates increase your blood sugar and need to be
minimized.
Please return to the hospital or call your doctor if you have
abdominal pain, nausea/vomiting, chest pain, shortness of breath
or if there are any concerns at all.
Followup Instructions:
Please follow up with [**Location (un) **],SHUN-HOW Tuesday [**2119-9-5**] at 10:30 AM.
[**Telephone/Fax (1) 63334**].
*Dr. [**First Name (STitle) **] will get you an appointment to follow up in the
diabetes clinic at [**Hospital3 1280**] hospital*
Completed by:[**2119-11-15**]
ICD9 Codes: 4280, 2767, 2762, 5849, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3208
} | Medical Text: Admission Date: [**2155-5-20**] Discharge Date: [**2155-6-7**]
Date of Birth: [**2094-4-14**] Sex: M
Service: SURGERY
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESLD with HCV cirrhosis and HCC called in for liver transplant
Major Surgical or Invasive Procedure:
[**2155-5-20**]: liver transplantation with Roux-en-Y
hepaticojejunostomy, portal vein thrombectomy, splenic artery
jump graft, arterial conduit.
[**2155-5-26**]: Roux tube cholangiogram
History of Present Illness:
61 y.o. M with chronic HCV cirrhosis, genotype 3, portal
HTN, HCC s/p RFA hepatocellular carcinoma. Called in for
potential liver transplant tonight. RFA done [**11-2**] with CT
[**2155-3-12**] suggesting recurrence of superior aspect of former site
in segment II. RFA repeated [**2155-4-2**].
ROS: Negative for weight loss, fevers, chills, nausea, vomiting,
diarrhea, and recent illness
Past Medical History:
HCV cirrhosis, genotype 3, Varices grade 3in GE
junction/lower [**1-27**] of esopagus, portal HTN, HCC s/p RFA x2
([**11-2**], [**4-4**]), c scope [**7-4**] grade 1 int hemorrhoids/1 cord
rectal
varices/angioectasia in rectum, HTN, back pain, osteopenia, PPD
+, h/o substance abuse, epistaxis
PSH: CCY [**2130**]
Social History:
Married with two children, imiigrated from [**Country **] ~ [**2150**]. Denies
any history of alcohol, tobacco, or drug use.
Family History:
Father and brother both with CAD.
Physical Exam:
VS: T 98.7, HR 65, BP 119/72, RR 18, PO2 98% on RA
Gen: Alert and oriented, no apparent distress
HEENT: No scleral icterus, mucous membranes moist
CV: Regular rate and rhythm, no murmurs, rubs, or gallops
Resp: Clear to auscultation
Abd: Well healed, right subcostal incision well healed, soft,
non-tender, non-distended
Ext: 1+ edema bilateral, palpable pedal pulses
Pertinent Results:
[**2155-6-3**] 06:10AM BLOOD WBC-5.5 RBC-3.10* Hgb-10.1* Hct-28.6*
MCV-92 MCH-32.7* MCHC-35.4* RDW-20.6* Plt Ct-77*
[**2155-6-2**] 06:45AM BLOOD PT-13.9* PTT-23.9 INR(PT)-1.2*
[**2155-6-2**] 06:45AM BLOOD Glucose-132* UreaN-26* Creat-1.0 Na-130*
K-4.8 Cl-104 HCO3-22 AnGap-9
[**2155-6-3**] 06:10AM BLOOD Glucose-130* UreaN-33* Creat-1.2 Na-134
K-5.1 Cl-102 HCO3-23 AnGap-14
[**2155-6-2**] 06:45AM BLOOD ALT-93* AST-54* AlkPhos-280* TotBili-1.1
[**2155-6-3**] 06:10AM BLOOD ALT-103* AST-55* AlkPhos-285* TotBili-1.0
[**2155-6-3**] 06:10AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0
[**2155-6-2**] 06:45AM BLOOD tacroFK-7.5
Brief Hospital Course:
61 y/o male with Hep C cirrhosis and HCC s/p RFA who presented
for liver transplant. He was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**].
He received routine immunosuppression induction in the OR to
include Cellcept, Solumedrol with post op taper and prograf to
be started on the evening of POD 0.
In the OR, Dr [**Last Name (STitle) 816**] noted the his native liver was quite large
with a tremendous amount of adhesions in the right upper
quadrant based on the prior cholecystectomy. Of note, the
omentum was plastered up into the liver and the duodenum was
plastered
into the gallbladder fossa. The dissection was bloody, tedious
and quite difficult given the significant amount of portal
hypertension that the patient had. The hilum was foreshortened
and very stuck, and the portal vein was quite thin. There was a
large clot burden in the portal vein. The artery anastomosis was
done twice, and still unfavorable results so then an iliac jump
graft was fashioned from the splenic artery to the common
hepatic artery with excellent results. Because of the large size
of the bile duct, they elected to do a Roux-en-Y jejunostomy. A
Roux tube was placed, two JP drains were placed in usual
fashion. He received 6 L crystalloid, 19 units PRBCs, 19 units
FFP and 6 units platelets. There were no apparent complications,
the patient was transferred to the SICU intubated and
hemodynamically stable.
The patient was extubated on the afternoon of POD 1. Because of
the Roux, he kept the NGT for 2 days, and then once this was
d/c'd his diet was advanced very slowly. On POD 5 the Roux tube
was interrogated, there was no evidence of leak and the tube was
capped.
LFTs increased postop then trended down. However, aroung post op
day 5, alk phos and alt trended up daily. Liver duplex was done
on [**5-31**] to evaluate. Vessels were patent and there was no ductal
dilatation. On [**6-2**], a liver biopsy was done demonstrating
biliary features raising the possibility of obstruction,
ischemia, or ascending cholangitis/sepsis. The scattered
apoptotic hepatocytes are suggestive of concomitant involvement
by early recurrent viral hepatitis C.
Routine immunosuppression pathway was followed, solumedrol taper
the PO prednisone. Prograf levels were monitored daily after
starting dosing on the afternoon of POD 1. Cellcept was 1 gm [**Hospital1 **]
with no evidence of GI upset.
The patient reports a poor appetite, and prefers family ethnic
foods. He had return of bowel function by POD 5. He was followed
by [**Last Name (un) **] post op, he received intermittent insulin, however,
they felt that long term insulin management were not going to
necessary.
Incision has been clean/dry/intact. The medial JP was removed on
POD 6 and the lateral JP was removed on [**6-1**].
The patient was ambulating with supervision. PT recommended
rehab.
Medications on Admission:
Xanax 0.25mg prn [**Hospital1 **], nadolol 20mg qd, spironolactone/HCTZ 50/50
qd, Caltrate-D 600-400 [**Hospital1 **], clotrimazole 10mg troche 5xd,
trazodone 50mg prn HS, lactulose 15ml qd, oxycodone 5mg prn
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
6. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
7. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
10. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-26**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
11. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
13. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
14. insulin glargine 100 unit/mL Solution Sig: Four (4) units
Subcutaneous at bedtime.
15. insulin lispro 100 unit/mL Solution Sig: follow sliding
scale units Subcutaneous four times a day.
16. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours): the tranplant center will call you if dose
adjustments are needed.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
18. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
HCV/ HCC with cirrhosis now s/p liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fevers >
101, chills, increased abdominal pain, nausea, vomiting,
diarrhea, inability to tolerate medications, increased yellowing
of skin or eyes, redness, drainage or bleeding around the
incision site, or any other concerning symptoms.
No heavy lifting
Please have labs drawn every Monday and Thursday, CBC, Chem 10,
AST, ALT, ALk Phos, T bili, Albumin and trough Prograf levels,
fax results to the transplant clinic. (Fax [**Telephone/Fax (1) 697**])
Please do not change medication dosing without prior
discussion/approval of the transplant clinic.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2155-6-12**]
9:30
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2155-6-19**]
9:30
Completed by:[**2155-6-7**]
ICD9 Codes: 5845, 5715, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3209
} | Medical Text: Admission Date: [**2139-12-10**] Discharge Date: [**2139-12-15**]
Date of Birth: [**2139-12-10**] Sex: M
Service: Neonatology
ID: Baby [**Name (NI) **] [**Known lastname 10010**] is a 5 day old former 33 [**4-16**] wk infant being
transferred from [**Hospital1 18**] NICU to [**Hospital 1474**] Hospital Special Care
Nursery.
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 10010**] is the former 1.650
kilogram product of a 33-4/7 week gestation pregnancy both to
a 19-year-old G1, P0 woman. Prenatal screens: Blood type A-
positive, antibody negative, rubella immune, RPR nonreactive,
hepatitis B surface antigen negative, group B Strep unknown.
The pregnancy was complicated by pregnancy-induced
hypertension and proteinuria. The mother was transferred to
the [**Hospital1 69**] on [**2139-12-9**]
from [**Hospital 1474**] Hospital. The mother was treated with magnesium
and required intermittent doses of labetalol. She received a
course of betamethasone.
Ultrasound on [**12-8**] and [**2139-12-9**] showed normal
amniotic fluid with biophysical profile [**8-17**], estimated fetal
weight of 1.796 kilograms. Due to persistent elevated blood
pressure and rising creatinine, labor was induced. The fetal
heart rate tracing was nonreassuring with baseline rate of
approximately 120 beats per minute with decreased
variability. Biophysical profile was [**4-17**], and the mother was
taken to cesarean section. There was intact membranes at
delivery. No antepartum antibiotics were given.
At delivery, the infant emerged with moderate tone and weak
respiratory effort which improved with vigorous stimulation.
Blow-by oxygen was needed for intermittent apnea. Apgars were
6 at 1 minute and 8 at 5 minutes. The infant was admitted to
the neonatal intensive care unit for further treatment of
prematurity.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 1.65 kilograms, head circumference 30 cm,
length 42.5, all 25th percentile for gestational age.
General: Well-developed premature infant responsive to exam,
but overall with decreased activity and vigor at rest, on
continuous positive airway pressure with mild intercostal
retractions. Skin: Warm, pink, mildly pale, no bruises or
rashes. Head, eyes, ears, nose, and throat: Nondysmorphic.
Fontanel: Soft and flat, mild molding. Palate: Intact. Ears
and nares: Patent. Positive red reflexes bilaterally. Neck:
Supple without lesions. Chest: Moderately aerated, mildly
coarse breath sounds, shallow respirations, minimal grunting.
Cardiac: Regular rate and rhythm, no murmur. Pulses: +2.
Abdomen: Soft, no hepatosplenomegaly, no masses, quiet bowel
sounds, 3-vessel cord. GU: Normal male, testes descended
bilaterally. Anus: Patent. Extremities: Back normal. Hips
stable. Neuro: Tone and activity mildly decreased. Intact
morrow and grasp reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: [**Known lastname **] was placed on continuous positive
airway pressure shortly after admission to the neonatal
intensive care unit for his respiratory distress. His
initial oxygen requirement was 35%. By day of life #2, he
had weaned to room air, and on day of life #3, he was
taken off the continuous positive airway pressure. He has
remained in room air without any respiratory distress
since that time. He has not had any spontaneous episodes
of apnea or bradycardia. Clinical presentation was
consistent with retained fetal lung fluid.
2. Cardiovascular: [**Known lastname **] has maintained normal heart rates
and blood pressures. No murmurs have been noted. Recent
blood pressure is 64/47 with a mean of 54.
3. Fluid, electrolytes, and nutrition: [**Known lastname **] was initially
NPO and maintained on intravenous fluids. Enteral feeds
were started on day of life #2 and gradually advanced. At
the time of discharge, he is taking 105 cc per kilogram
per day of breast milk or Preemie Enfamil formula. He
has thus far taken all feedings PO. IVF were
discontinued the night prior to transfer after IV
infiltrated; dstik off IVF was 63. Initial dstik at
admission was 37, which normalized with IVF. Serum
electrolytes were obtained on day of life 2 and 3 and were
within normal limits. Weight on the day of discharge is 1.57
kilograms.
4. Infectious disease: Due to his prematurity and the
unknown etiology of the respiratory distress, [**Known lastname **] was
evaluated for sepsis at the time of admission to the
neonatal intensive care unit. A complete blood count with
white count and differential were within normal limits. A
blood culture was obtained prior to initiating
intravenous ampicillin and gentamicin. Blood culture was
no growth at 48 hours and the antibiotics were
discontinued.
5. Hematological: Hematocrit at birth was 56.3%. [**Known lastname **] did
not receive any transfusions of blood products.
6. Gastrointestinal: [**Known lastname **] required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin was on day of life #3, a total of
10.3/0.3 mg per deciliter direct. Phototherapy was
administered for 48 hours, and bilirubin on day of life #4
was 6.3/0.3. Phototherapy was discontinued on the day of
transfer, with recommendation for rebound on [**12-16**].
7. Neurological: [**Known lastname **] has maintained a normal neurological
exam during admission, and there are no neurological
concerns at the time of discharge.
8. Sensory: Hearing screening has not yet been performed.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to [**Hospital 1474**] Hospital for
continuing level II care. Primary pediatrician is Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 58721**] [**Street Address(2) 14531**], [**Hospital1 1474**], [**Numeric Identifier **], phone #[**Telephone/Fax (1) 65038**]
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. 105 cc per kilogram per day of breast milk or Preemie
Enfamil 20 calorie per ounce p.o. or per gavage, advance
to 140-150 cc/kg/day as able.
2. No medications. Consider iron supplementation.
3. Car seat position screening is recommended prior to
discharge.
4. State newborn screen was sent on [**2139-12-14**] with no
notification of abnormal results to date. A repeat screen
is recommended on [**2139-12-24**].
5. No immunizations have been administered.
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 and 35 weeks with 2 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 6
months of age. Before this age and for the first 24 months
of the child's life, immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity at 33-4/7 weeks gestation.
2. Transitional respiratory distress.
3. Suspicion for sepsis ruled out.
4. Unconjugated hyperbilirubinemia, resolving.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2139-12-15**] 00:00:53
T: [**2139-12-15**] 04:40:14
Job#: [**Job Number 65039**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3210
} | Medical Text: Admission Date: [**2136-12-7**] Discharge Date: [**2136-12-13**]
Date of Birth: [**2060-10-27**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient had a CVA in [**2136-4-4**]
status post subdural hematoma, drainage with craniotomy in
[**2136-5-5**]. A MRA was done shown to have an AVM of the left
parieto-occipital area, referred to [**Hospital1 190**] for workup and treatment of the AVM.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Cerebrovascular accident with decreased peripheral visual
field loss in both the right upper and lower fields and right
sided weakness.
3. Gastroesophageal reflux disease.
4. Hypothyroid.
5. Increased triglycerides.
6. Osteoarthritis with severe back pain.
7. Esophageal strictures with dilation.
8. Intracerebral left occipital hemorrhage.
9. Chronic left subdural hematoma.
PAST SURGICAL HISTORY: Right total knee replacement in [**2128**],
rectocele and cystocele repair in [**2128**], bilateral cataracts,
total abdominal hysterectomy in [**2095**], craniotomy in [**5-6**].
ALLERGIES: Penicillin and sulfa.
MEDICATIONS AT HOME:
1. Levoxyl 125 mcg q day.
2. Lisinopril 40 mg q day.
3. Atenolol 50 mg q day.
4. Meclozine 25 mg prn.
5. Lorazepam 0.5 mg tid.
6. Tylenol #3 four tablets a day.
7. Requip 0.05 mg po bid.
8. Multivitamins.
9. Colace 100 mg po q day.
PHYSICAL EXAMINATION: The patient is alert and oriented.
Speech fluent. Pupils reactive, but surgical. EOM full.
Decreased peripheral vision through right in both superior
and inferior fields. Face symmetric, no drift noted, 5/5
strength bilateral upper and lower extremities. Patient uses
cane to walk. Does have a stable gait.
LABORATORIES: Within normal limits.
HOSPITAL COURSE: On [**12-7**], was admitted. Cerebral angiogram
with embolization of the left PCA AVM was done, observed in
Intensive Care Unit for close neurological monitoring of
blood pressure control. Remained in the Intensive Care Unit
for three days secondary to blood pressure control. Was
transferred to floor on postprocedure day #3.
On [**12-11**] went back to the operating room for craniotomy and
resection of the left PCA AVM. Went to the Neurological
Intensive Care Unit, intubated postprocedure. The patient
was extubated on postoperative day #1 and transferred to
floor on postoperative day #2.
A follow-up angiogram was done showing no residual AVM.
Patient is doing well. No pronator drift. EOMs full. Face
symmetric, 5/5 strength bilateral upper and lower
extremities. Right visual field loss inferior greater than
superior, no change from preoperative. Patient was seen by
physical therapy.
DISCHARGE MEDICATIONS:
1. Levoxyl 125 mcg q day.
2. Lisinopril 40 mg q day.
3. Atenolol 50 mg q day.
4. Meclozine 25 mg prn.
5. Lorazepam 0.5 mg tid.
6. Tylenol #3 four tablets a day.
7. Requip 0.05 mg po bid.
8. Multivitamins.
9. Colace 100 mg po q day.
10. Percocet 1-2 tablets po q4-6 prn.
DISPOSITION: Neurologically stable.
DISCHARGE: Discharged to Rehab. Follow up with Dr. [**Last Name (STitle) 1132**] in
one month.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2136-12-13**] 10:39
T: [**2136-12-13**] 10:44
JOB#: [**Job Number 88174**]
ICD9 Codes: 5990, 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3211
} | Medical Text: Admission Date: [**2152-9-11**] Discharge Date: [**2152-9-29**]
Service: Medicine, [**Hospital1 **] Firm
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES: (Discharge diagnoses included)
1. Myocardial infarction.
2. Aspiration pneumonia.
3. Small-bowel obstruction.
4. Dysphagia.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
woman who was admitted with complaints of nausea and vomiting
who presented to the Emergency Department on [**9-11**] and
was found to have a small-bowel obstruction upon KUB.
The patient was initially on the Medicine Service and was
transferred to the Surgery Service for possible surgical
intervention for this small-bowel obstruction.
On [**9-14**], the patient was found to be in respiratory
distress and was intubated and transferred to the Coronary
Care Unit. The patient underwent a cardiac catheterization
after the finding of a ST elevation myocardial infarction on
electrocardiogram with elevation of her cardiac enzymes.
The cardiac catheterization was positive for diffuse disease
of the right coronary artery as well as right posterior
descending artery disease, as well as 99% mid and left
anterior descending artery stenosis which was crossed with
two stents, and the patient was on a dopamine drip status
post procedure.
Her course was further complicated by septic shock and
aspiration pneumonia. The patient was later weaned off
pressors, extubated, and transferred to the floor for further
care.
PAST MEDICAL HISTORY: (Past medical history is notable for)
1. Colon cancer; status post a right colectomy in [**2136**],
status post radiation therapy.
2. The patient has a history of multiple small-bowel
obstructions; notably in [**2148-12-25**] and in [**2151-12-26**] which was at an outside hospital.
3. The patient is status post appendectomy.
4. Status post bilateral breast cancer.
5. Status post modified radical mastectomy.
6. History of osteoarthritis.
7. History of osteoporosis.
8. History of squamous cell carcinoma.
9. History of hypertension.
10. History of cataracts.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON TRANSFER: (Current medications upon transfer
to the floor included)
1. Atenolol 50 mg by mouth once per day.
2. Zantac 150 mg by mouth twice per day.
3. Tylenol by mouth as needed.
4. Multivitamin one tablet by mouth once per day.
5. Glucosamine chondroitin.
SOCIAL HISTORY: The patient lives alone. She has a house
keeper that comes twice per week. The patient does not drink
and does not smoke. The patient does not use illicit drugs.
FAMILY HISTORY: Family history is notable for mother,
father, and brother who all died of colon cancer.
PHYSICAL EXAMINATION ON PRESENTATION: On initial
presentation, the patient had vital signs with a temperature
of 97.2 degrees Fahrenheit, her heart rate was 80, her blood
pressure was 240/99, and her oxygen saturation was 100% on 3
liters, and her respiratory rate was 20. In general, she was
an elderly and thin woman in moderate discomfort. She was
alert and oriented times three. Head, eyes, ears, nose, and
throat examination was notable for a moist oropharynx. The
neck was supple. No lymphadenopathy. No thyromegaly.
Pupils were equal, round, and reactive to light. Extraocular
movements were intact. There was no jugular venous
distention. There were no carotid bruits. Cardiovascular
examination was notable for a 1/6 systolic ejection murmur at
the apex. The lungs were clear to auscultation bilaterally.
The abdomen was notable for decreased bowel sounds, was
moderately distended, and had a mild epigastric tenderness on
palpation. There were no palpable masses. There was a
midline scar with a hernia. Extremity examination was
notable for no clubbing, cyanosis, or edema. The dorsalis
pedis pulses were 2+ bilaterally. On neurologic examination,
the patient had a right facial droop which the patient said
was chronic. Otherwise, cranial nerves II through XII were
intact. Strength was [**4-29**] but symmetric bilaterally. On the
lower extremity examination, it was a limited examination
secondary to the patient's discomfort. Deep tendon reflexes
were 2+ and symmetric.
PERTINENT LABORATORY VALUES ON PRESENTATION: Initial
laboratories revealed the patient's white blood cell count
was 12.2, her hematocrit was 37.2, and her platelets were
262. Her Chemistry-7 was unremarkable. Creatine kinase and
troponin levels were notable for a creatine kinase of 93 and
a troponin of less than 0.01.
PERTINENT RADIOLOGY/IMAGING: In the Emergency Department a
head computed tomography was performed without contrast which
showed only chronic edema, no acute changes, and no acute
bleed.
A chest x-ray showed no evidence of congestive heart failure
or pneumonia.
KUB was again positive for a small-bowel obstruction.
CONCISE SUMMARY OF HOSPITAL COURSE: Upon transfer to the
floor, the patient's plan was for continuation of her
antibiotics for her aspiration pneumonia as well as a workup
of her possible dysphagia.
The patient had been transferred to the floor with a
nasogastric tube with tube feeds running. A Speech and
Swallow consultation was called. The patient was evaluated
at the bedside and found to be able to tolerate swallows of
pureed foods with appropriate shin tuck technique. However,
she was markedly weak after these efforts, and so the
nasogastric tube was continued. The patient underwent a
video swallow.
With the results of the video swallow, the recommendation
from Speech and Swallow was to continue with by mouth feeds
of pureed solids but to maintain the tube feeds for an extra
day.
The patient completed her course of levofloxacin and Flagyl
for two weeks each. Her digoxin was continued for her
tachycardia. She had been started on this medication in the
Unit. Her blood pressure was controlled with captopril and
atenolol. She was also continued on Plavix 75 mg by mouth
once per day status post stent placement. She was also
continued on a daily dose of 325 mg of aspirin.
For prophylaxis, she was given subcutaneous heparin at 5000
units subcutaneously twice per day.
Also, during her hospitalization, it was noted that her mouth
was notable for a bloody scab on her hard palate.
Ear/Nose/Throat was consulted, who removed the scab and
diagnosed mouth crusting. The patient was offered a
humidified [**Doctor Last Name **], and the dry scab was pealed off revealing
normal oral mucosa behind it. The patient was also given
topical Vaseline for her lips.
The patient was also evaluated by Physical Therapy who
thought her appropriate for rehabilitation placement at this
point.
DISCHARGE DISPOSITION: Pending a final evaluation by Speech
and Swallow, and discontinuation of her nasogastric tube, and
initiation of full oral intake, the patient was to be
discharged to rehabilitation.
MEDICATIONS ON DISCHARGE: Her final discharge medications
will be added as an Addendum to this Discharge Summary, but
may also be found on the page 1 discharge papers.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Last Name (NamePattern1) 8442**]
MEDQUIST36
D: [**2152-9-28**] 12:38
T: [**2152-9-28**] 13:33
JOB#: [**Job Number 101091**]
ICD9 Codes: 2765, 0389, 4280, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3212
} | Medical Text: Admission Date: [**2154-12-5**] Discharge Date: [**2154-12-14**]
Date of Birth: [**2081-3-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Crestor / Zocor / Cozaar / Vicodin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2154-12-6**] Cardiac catheterization
[**2154-12-10**] Coronary Artery Bypass Grafting x 5 - left internal
mammary artery to left anterior descending, with saphenous vein
grafts to first diagonal, second diagonal, obtuse marginal, and
posterior descending artery
History of Present Illness:
Ms. [**Name13 (STitle) 4680**] is a 73 year old female with pmhx of atrial
fibrillation, dysplipidemia and hypertension transferred from
[**Hospital3 934**] for elective cardiac catheterization after
NSTEMI. She was admitted to [**Location (un) **] on [**2154-12-4**] after an episode
of [**10-18**] tightness in her throat that woke her up from sleep.
Her BP at that time was 190/110 which is elevated from her
baseline of 120-130's. Pain associated with radiation to the
left arm. Denies SOB, palpitations or diaphoresis but reports
mild nausea. Patient reports prior episodes of exertional chest
tightness that started in [**Month (only) 205**] and have been increasing in
frequency since that time. She also reports symptoms with less
exertion. Denies chest pain at rest. At [**Location (un) **] she had elevated
cardiac biomarkers with peak troponin I of 0.84, now trending
down with most recent value of 0.74. Her peak CK-MB was 9.6. She
was started on ASA 325mg daily, plavix, lopressor, zocor and
heparin gtt. She is currently chest pain free and has had no
further episodes since her initial episode. Her coumadin was
held on [**2154-12-5**] in preparation for procedure
Past Medical History:
1. Paroxysmal Atrial fibrillation
2. Hypertension
3. Dyslipidemia
4. History of TB s/p L thoracostomy and upper left lower lobe
resection in [**2096**]'s
5. History of facial SCC's and basal cell CA's s/p Moh's
Social History:
Social history is significant for the absence of current or
previous tobacco use. There is no history of alcohol abuse.
Patient lives with her husband in [**Name (NI) 26671**] and has 4 children.
Her grandson is a ER nurse [**First Name (Titles) **] [**Last Name (Titles) 18**].
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had MI at age 80 and father died of
unknown causes.
Physical Exam:
Admission: VS - 98.9 103/59 71 18 98% on RA
Gen: Pleasant appearing elderly female in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 6 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits.
Ext: Trace edma to mid-shin bilaterally. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
discharge:
VS: 99, 136/77, 80SR, 20, 93%RA
Gen: NAD, WG, WN WF
CV: RRR, no murmur or rub
lungs: CTAB
Abd: NABS, soft, non-tender, non-distended
Ext: trace edema
Incisions: [**Doctor Last Name **]- c/d/i without erythema or drainage, sternum
stable
LLE- evh: c/d/i without erythema or drainage
Pertinent Results:
[**2154-12-6**] 06:50AM BLOOD WBC-7.6 RBC-4.27 Hgb-13.4 Hct-39.0 MCV-91
MCH-31.4 MCHC-34.4 RDW-13.3 Plt Ct-357
[**2154-12-6**] 06:50AM BLOOD PT-21.2* PTT-51.5* INR(PT)-2.0*
[**2154-12-6**] 06:50AM BLOOD Glucose-96 UreaN-28* Creat-0.9 Na-141
K-4.9 Cl-104 HCO3-26 AnGap-16
[**2154-12-6**] 05:10PM BLOOD ALT-12 AST-20 AlkPhos-43 Amylase-36
TotBili-0.5
[**2154-12-5**] 06:22PM BLOOD CK(CPK)-75
[**2154-12-6**] 06:50AM BLOOD CK(CPK)-84
[**2154-12-5**] 06:22PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2154-12-6**] 06:50AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2154-12-6**] 06:50AM BLOOD Calcium-9.9 Phos-2.7 Mg-2.4
[**2154-12-6**] 05:10PM BLOOD %HbA1c-6.2*
[**2154-12-6**] ECHO: The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
[**2154-12-6**] Cardiac Cath: 1. Selective coronary angiography of this
right dominant system demonstrated two vessel coronary artery
disease. The LMCA was normal. The LAD demonstrated proximal
disease with a large diagonal 50% stenosis, then with continued
severe disease and occlusion distally. The proximal LCx has a
60% lesion. The mid RCA has a 95% stenosis. 2. Limited resting
hemodynamic measurement demonstrated a normal systemic arterial
pressure of 135/66 mmHg.
[**2154-12-10**] Intraop TEE:
PREBYPASS
1. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
2. Right ventricular chamber size and free wall motion are
normal.
3. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen.
5. The mitral valve appears structurally normal with trivial
mitral regurgitation.
6. There is no pericardial effusion.
7. The intra-atrial septum is hypermobile
8. Dr. [**Last Name (STitle) 914**] was notified in person of the results during the
operation.
POSTBYPASS
1. Patient is on phenylephrine infusion
2. LV is underfilled and function remains unchanged with an EF
65%
3. MR [**First Name (Titles) **] [**Last Name (Titles) **] are unchanged from prebypass
4. Aortic contours are smooth after decannulation
[**2154-12-14**] 07:15AM BLOOD WBC-10.8 RBC-2.73* Hgb-8.5* Hct-24.8*
MCV-91 MCH-31.2 MCHC-34.3 RDW-14.7 Plt Ct-317
[**2154-12-14**] 07:15AM BLOOD Glucose-92 UreaN-30* Creat-0.6 Na-140
K-3.9 Cl-102 HCO3-30 AnGap-12
Brief Hospital Course:
Ms. [**Known lastname **] was admitted under cardiology following NSTEMI. On
admission she was pain free. She was maintained on intravenous
Integrilin and Heparin. On [**12-6**], she underwent cardiac
catheterization which revealed three vessel coronary artery
disease. Cardiac surgery was consulted and further preoperative
evaluation was performed - see result section. In anticipation
for surgery, Plavix and Warfarin continued to be with held. She
remained pain free on medical therapy, including Heparin.
Integrilin was eventually discontinued. Her preoperative course
was otherwise uneventful and she was cleared for surgery.
On [**12-10**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass
grafting surgery. Given her inpatient stay was greater than 24
hours, she recieved Vancomycin for antibiotic coverage. For
surgical details, please see seperate dictated operative note.
Following the operation, she was brought to the CVICU for
invasive monitoring. Within 24 hours, she awoke neurologically
intact and was extubated without incident.All lines and drains
were removed per protocol. She was transferred to the Step down
unit on POD#1 for further monitoring and telemetry. Beta-blocker
was optimized. She continued to progress and was ready for
discharge on POD 4. All folow up appointments were advised.
Medications on Admission:
1. Digoxin 0.125mg MTWRFS
2. Diltiazem 60mg q8h
3. Zetia 10mg daily
4. Tricor 48mg daily
5. Hydrochlorothiazide 12.5 mg daily
6. Losartan 50mg daily
7. Warfarin 5mg daily
8. ASA 81mg 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 1 months.
Disp:*60 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:*0*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
7. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Hyzaar 50-12.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Non ST-elevation Myocardial Infarction
Paroxsymal Atrial fibrillation
Hypertension
Hyperlipidemia
Discharge Condition:
Good. Hemodynamically stable.
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
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
- Dr. [**Last Name (STitle) 914**], Cardiac Surgeon in [**4-13**] weeks, call for appt
[**Telephone/Fax (1) 170**]
- Dr. [**Last Name (STitle) 81914**] [**Name (STitle) 3503**] at ([**Telephone/Fax (1) 78152**] to make an appt within the
next
2 weeks.
- Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 65597**] at ([**Telephone/Fax (1) **] to make an appt within the
next 2 weeks.
Completed by:[**2154-12-14**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3213
} | Medical Text: Admission Date: [**2149-2-11**] Discharge Date: [**2149-2-14**]
Date of Birth: [**2083-2-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / Detrol / Nitrofurantoin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary catheterization
History of Present Illness:
The patient is a 65 y.o.f. with diverticulitis and IBS who p/w
inferior STEMI. Last night at approximately 10 p.m. she
developed right sided chest discomfort that radiated to the
underside of her right arm. This occurred on and off throughout
the night and was accompanied by diaphoresis. "Breathes fast" at
baseline (improved now with weight loss), but no increasing SOB,
orthopnea, PND, palpitations, or prior episodes of chest pain.
She was able to sleep, but when she awoke this a.m. she
continued to have the chest discomfort and when getting up felt
faint, lightheaded, and nauseated, so she caller her daughter
who is a nurse [**First Name (Titles) **] [**Name (NI) 336**]. EMS was called and BP on the scene was
96/60, HR 52, 99% RA. She was brought to [**Hospital3 **] where
EKG showed ST elevations in II, III, aVF, V6, ST depressions in
I, avL, V2-V5. STEMI protocol was initiated, she was given ASA
324mg, heparin started, atorvastatin 80mg x 1, plavix 600 mg x
1, 500cc NS, 0.5 mg ativan, and she was sent to [**Hospital1 18**] for
cardiac catheterization.
.
Cardiac catheterization showed right dominant system with 95%
lesions in RCA with slow flow, no obstructive disease in LMCA,
LAD, Lcx. She underwent BMS if RCA with temporary pacer
placement. During stent deployment became hypotensive to SBP
60's, given atropine 1 mg IV x 2, and BP responded. Pacer d/c'd
at end of case.
.
Of note her recent history is remarkable for a cough/flu in mid
[**Month (only) 956**]. She then had a precancerous lesion removed and tooth
pulled on [**1-26**]. Subsequent to that she developed loose stools
for the next 2 weeks. Yesterday she was seen at her GI doctor's
office and placed on a brat diet and was prescribed lomotil,
which she took at 3pm and 9pm.
.
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. She denies exertional buttock or calf pain. She has
chronic upper back discomfort x 2 months, felt by her to be d/t
water aerobics, which comes and goes, not worsening. +urinates
frequently. All of the other review of systems were negative.
+recent intentional weight loss of 36 pounds in one year.
.
Cardiac review of systems is notable for absence of chest pain
currently (see above), dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, palpitations, syncope.
Past Medical History:
Diverticulitis - no surgeries
IBS
Radical hysterectomy
UTI's (uretheral narrowing)
PNA
Sciatica
HTN
? CHF - per patient, was in [**Location (un) 5354**] in [**2132**] and developed SOB
and found to have mild CHF, 'd/t stress' - prompted stress test
which was not optimal per patient, but never but on cardiac meds
and never told that she had an MI
.
Cardiac Risk Factors: Hypertension, remote minimal tobacco
.
Cardiac History: Stress test in [**2132**] - could not reach capacity
d/t obesity
Social History:
Social history is significant for the absence of current tobacco
use (very occasional 30 yrs ago, 'didn't inhale', 1 pack would
last 2 weeks). There is no history of alcohol abuse. There is no
immediate family history of premature coronary artery disease or
sudden death. Maternal uncle died of MI at 47, brother with CAD
recently in 60s. Mother with [**Name (NI) 5895**], father deceased at 92.
.
Family History:
Social history is significant for the absence of current tobacco
use (very occasional 30 yrs ago, 'didn't inhale', 1 pack would
last 2 weeks). There is no history of alcohol abuse. There is no
immediate family history of premature coronary artery disease or
sudden death. Maternal uncle died of MI at 47, brother with CAD
recently in 60s. Mother with [**Name (NI) 5895**], father deceased at 92.
.
Physical Exam:
VS: T 96.4 , BP 143/80 , HR 72 , RR 18, O2 100% on 2L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant. Obese.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple without JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits bilaterally. Fresh blood around
groin lines, no hematoma.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
COMMENTS:
1. Selective coronary angiography in this right dominant system
revealed single vessel coronary artery disease. The LMCA had no
obstructive disease. The LAD had no obstructive disease. The
LCx had
no obstructive disease. The RCA had a 95% focal lesion in the
mid
vessel.
2. Left ventriculography was not performed.
3. Central aortic pressure was normal at 120/66
(systolic/diastolic in
mmHg).
4. Successful direct stenting of the mid RCA with a 3.0x18mm
vision stent which was postdilated to 3.5mm. Successful
temporary venous
pacing wire insertion which was subsequently removed. Final
angiography
revealed 0% residual stenosis, no angiographically apparent
dissection
and timi 3 flow. The patient left the lab with persistent st
elevation
but pain free and hemodynamically stable and was transfered to
the CCU
service for further care. (see ptca comments)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Normal ventricular function.
3. Acute inferior myocardial infarction, managed by acute ptca.
PTCA of vessel
Brief Hospital Course:
65 y/o F with hypertension and no previous cardiac history
presenting with IMI.
.
# CAD/Ischemia: EKGs showed inferior STEMI with reciprocal
lateral depressions. Cardiac cath consistent with this, showing
a 95% mid-RCA lesion s/p BMS without complications. Transient
hypotension during deployment of stent that resolved with
atropine. ST changes persist s/p catheterization, but improved,
and patient currently without chest discomfort.
- Aspirin 325mg daily
- Plavix 75mg daily for 12 months
- Atorvastatin 80mg daily
- Added lopressor 12.5 [**Hospital1 **] yesterday, tolerated well
- lipid panel shows LDL 91 on statin now
.
# Pump: Questionable history of episode of CHF, not on cardiac
meds for this as an outpatient. Currently no signs or symptoms
of HF.
- TTE shows EF 40-45, with inferior, inferolateral and basal
inferoseptal hypokinesis
- ischemic dysfunction of the posteromedial papillary muscle
with posterior leaflet tethering and a jet of moderate (2+)
mitral regurgitation
- give trial metoprolol 12.5mg [**Hospital1 **] today, add ACE once patient;s
BP tolerates as an outpatient.
- I/O show patient autodiuresing, euvolemic, no dyspnea or
orthopnea, no furosemide indicated
.
# Rhythm: NSR, bradycardia in setting of IMI. No history of
arrhythmia.
- Telemetry shows PVC's, SR
- replete K and Mg
.
# HTN: On atenolol as outpatient, so presumed HTN.
- trial metoprolol yest tol. well, add ACE as outpatient given
low blood pressure.
.
# Chronic back pain
- Tylenol and codeine PRN
.
# FEN:
- ADAT, follow lytes and replete
.
# Prophylaxis: PPI, SQ heparin
.
# Dispo
- home today, f/u dr/ [**Doctor Last Name **] ([**Telephone/Fax (1) 68572**]
.
# Code: Full, confirmed with patient
.
# Communication: Patient. HCP is daughter, [**Name (NI) **] [**Telephone/Fax (3) 109883**]
Medications on Admission:
Atenolol 50mg daily
Prevacid 30mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
HTN
CAD
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] with an ST elevation myocardial
infarction.
Please take your previous medications as prescribed. The
following changes has been made to your medications:
- Please start taking aspirin 325 mg daily for secondary
cardiovascular prevention (to prevent another heart attack)
- Please start taking atorvastatin 80mg daily for your heart and
for your cholesterol
- Please continue taking Atenolol but change the dosing to 25mg
daily (split the 50mg tablet in half) for your heart and blood
pressure (prevents remodelling of the heart)
- Please start taking clopidogrel (Plavix) 75 mg daily to keep
stents open
- Do NOT take the estrogen patch, this may increase risk of
heart attack
- You have follow scheduled with Dr. [**Last Name (STitle) 1637**] on [**3-3**] at 130PM
If you develop chest pain, jaw pain, or chest pressure with pain
radiating into arm, or if you for any reason become concerned
about your medical condition please call 911 or present to
nearest ED.
- We also gave you Nitroglycerin tablets to take if you
experience chest pain, please call 911 or your doctor if chest
pain recurs even if it dissapears with nitroglycerine.
**DO NOT STOP TAKING THE ASPIRIN OR PLAVIX UNLESS INSTRUCTED TO
DO SO BY YOUR CARDIOLOGIST EVEN IF ANOTHER DOCTOR TELLS YOU TO**
We strongly recommend you stop smoking as discussed.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) 1575**] J. [**Telephone/Fax (1) 14655**] on [**3-3**] at 130PM of Cardiology
ICD9 Codes: 4019, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3214
} | Medical Text: Admission Date: [**2105-12-22**] Discharge Date: [**2106-1-13**]
Date of Birth: [**2052-8-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
intubation
PICC line placement
History of Present Illness:
Mr. [**Known lastname **] is a 53yo quadriplegic male ([**3-13**] motorcycle accident 6
years ago) with h/o frequent UTIs who presented to the ED after
his VNA found him hypotensive this morning with BP 50/30. He
stated he was in his usual state of health (other than a recent
UTI for which he took 10 days of bactrim, ending 5 days prior to
this admission) until a few days ago. He reported feeling
general fatigue/malaise/nausea, with mild abdominal and back
pain (difficult to discuss ascertain given altered sensation).
He also reported mild dizziness when he got out of bed on the
morning of admission. As above, Mr. [**Known lastname **] is dependent on
intermittent urinary catheterization due to his paralysis and
has had frequent UTIs ([**6-14**] in the past year; the last being [**3-13**]
klebsiella pneumoniae resistant to bactrim, cipro,
nitrofurantoin).
In the ED his initial BP was 60's/40's with HR of 64, improving
with IVF to 70's/30's, and finally 80's after 4L IVF bolus. In
the ED a Precept catheter was placed, he was given empiric
ceftriaxone and vancomycin and was started on Levophed after his
CVP>8. SVO2 70
Past Medical History:
- quadriplegia and TBI [**3-13**] MVA several years ago
- h/o DVT's (1 year ago)
- autonomic dysfunction: frequent swings of blood pressure
associated with not having BMs
- urinary retnsion requiring straight cath: frequent UTI's (most
recent due to Klebsiella resistant to ciproflox and
nitrofurantoin)
- chronic cystitis (?cystoscopy at [**Hospital1 2025**] with bladder irritation)
Social History:
Former computer and real-estate executive. Retired wealthy at
age 42 and traveled the country riding his motorcycle and
unfortunately had his accident while on a trip to [**State **]. Has 4
children; now lives with his wife and 2 of his kids at home with
daily VNA. He drinks 5+ shots of gin per day (no h/o
withdrawal); no smoking.
Family History:
mother with cancer, grandmother with [**Name2 (NI) **]
Physical Exam:
T 100.6 BP 116/67 HR 83 CVP6 RR 22 95% on RA
Gen: quadriplegic male, non-toxic appearing, no distress
CV: RRR no m/r/g
Pulm: Lungs CTAB
Abd: S/ND/NT +BS
Flank: no flank TTP
Extremities: mild edema
Pertinent Results:
[**2105-12-22**] 10:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-MOD
[**2105-12-22**] 10:45AM URINE RBC-[**4-13**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**7-19**]
[**2105-12-22**] 10:45AM PT-17.9* PTT-32.9 INR(PT)-1.7*
[**2105-12-22**] 10:45AM WBC-15.7*# RBC-3.34* HGB-10.9* HCT-31.8*
MCV-95 MCH-32.6* MCHC-34.3 RDW-13.4
[**2105-12-22**] 10:45AM NEUTS-73* BANDS-18* LYMPHS-5* MONOS-3 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2105-12-22**] 10:45AM ALT(SGPT)-26 AST(SGOT)-70* LD(LDH)-282* ALK
PHOS-85 AMYLASE-31 TOT BILI-0.5
[**2105-12-22**] 10:45AM LIPASE-21
[**2105-12-22**] 10:45AM ALBUMIN-3.4 CALCIUM-7.8* PHOSPHATE-2.3*
MAGNESIUM-1.4*
[**2105-12-22**] 10:45AM GLUCOSE-71 UREA N-25* CREAT-2.6*# SODIUM-127*
POTASSIUM-4.1 CHLORIDE-89* TOTAL CO2-28 ANION GAP-14
[**2105-12-22**] 10:51AM LACTATE-2.9*
[**2105-12-22**] 12:49PM LACTATE-1.7
[**2105-12-22**] 03:18PM LACTATE-1.4
[**2105-12-22**] 05:33PM LACTATE-1.2
[**2105-12-22**] 06:32PM LACTATE-1.2
[**2105-12-22**] 10:25PM LACTATE-1.0
.
CHEST (PORTABLE AP) [**2105-12-22**] 10:38 AM
IMPRESSION:
No acute intrathoracic process.
.
RENAL U.S. [**2105-12-23**] 9:47 AM
IMPRESSION: Normal renal ultrasound.
.
ECHO [**2105-12-24**]
IMPRESSION: Moderate left ventricular systolic dysfunction with
focal basal to mid hypokinesis and apical sparing, which could
be most consistent with stress induced cardiomyopathy
(reverse-Takostubo type), although multivessel CAD cannot be
ruled out.
.
PORTABLE ABDOMEN [**2105-12-26**] 9:04 AM
IMPRESSION: Dilated colonic bowel loops. Assessment for free air
limited. The findings likely represent a colonic ileus, however,
early distal colonic obstruction is not definitively excluded.
Followup is recommended. Findings were discussed with the
covering resident at the time of dictation on [**2105-12-26**] at 12:15
p.m.
.
[**2105-12-28**] 9:02 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
IMPRESSION:
1. Bilateral basilar consolidation, effusion, and atelectasis,
concerning for multifocal pneumonia.
2. Diffuse fatty infiltration of the liver.
3. No perinephric abscess or evidence of other acute
intra-abdominal pathology.
.
CHEST (PORTABLE AP) [**2105-12-28**] 5:14 AM
IMPRESSION: AP chest compared to [**12-24**] through 18:
Moderately severe pulmonary edema has worsened since [**12-27**]
accompanied by increasing moderate right pleural effusion. There
is also markedly asymmetric pulmonary consolidation strongly
suggestive of pneumonia or pulmonary hemorrhage worsened
particularly in the right upper lobe. Heart size top normal. ET
tube and nasogastric tube in standard placements. Right jugular
line ends in the lower SVC. Findings were discussed by telephone
with Dr. [**Last Name (STitle) **] to report these findings at the time of
dictation.
.
ECHO [**2105-12-28**]
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. There is no aortic valve stenosis. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2105-12-24**],
LVEF is now normal.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2105-12-31**] 2:16 PM
The liver is unremarkable in appearance without focal or
textural abnormalities. No intrahepatic biliary dilatation is
seen. The common bile duct is prominent measuring 9 mm in
greatest diameter in its proximal portion. It is tapering
smoothly distally, and its appearance is stable compared to CT
of [**2105-12-28**]. No common bile duct stones are seen. The
gallbladder is normal. There is no cholelithiasis or evidence of
cholecystitis. There is no gallbladder sludge. The main portal
vein is patent. The pancreas appears unremarkable. There is no
ascites.
IMPRESSION:
No evidence of cholecystitis, cholelithiasis, or sludge.
AEROBIC BOTTLE (Final [**2105-12-28**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2105-12-25**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 101327**] @ 0052 ON [**2105-12-23**].
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2105-12-22**] 10:45 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2105-12-24**]**
URINE CULTURE (Final [**2105-12-24**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
Hospital Course: Mr. [**Known lastname **] is a 53 yo gentleman with
quadriplegia and chronic urinary tract infections presenting
with hypotension, required intubation on [**12-24**] for respiratory
distress with hypoxia.
.
#. Respiratory Failure: Mr. [**Known lastname **] mental status progressively
deteriorated over the first 24 hours of his stay. He developed
respiratory distress in the setting of multiple fluid boluses
given to reach goal hemodynamics in sepsis, and also in the
setting of a witnessed aspiration. His chest xray showed
increasing pulmonary edema and his ECHO showed left ventricular
defect as described above. He was intubated. Attempts at
weening were complicated by polymicrobial ventilator-assisted
pneumonia, notably MRSA cultured on [**12-26**], for which he was
given courses of multiple antibiotics as below. He was also
found to have a right-sided pleural effusion (though there was
not enough by bedside U/S to do a bedside tap with culture). The
patient was successfully extubated and weaned off of
supplemental oxygen with normal saturation on room air at the
time of discharge.
2. Urosepsis: likely cause of his presenting septic shock and
hypotension as he had BCx and UCx growing out e coli sensitive
to antibiotic treatment started empirically upon admission. He
rapidly improved from his original septic presentation and his
white count normalized before rising again as below. No
perinephric abscess by CT per wet read. He finished a total of
12 days of Cipro for his urosepsis on [**1-3**].
3. PNA: MRSA growing in sputum culture although now showing
polymicrobial infection concerning for GNR and anaerobes. There
were consolidations in lung bases per abdominal CT. His PNA
antibiotic coverage included vanc, ceftriaxone, zosyn, and
cipro. He received gram negative coverage with ceftriaxone (for
UTI), though no lab evidence of GNR. Ceftriaxone dc'ed to start
Zosyn as patient was in respiratory distress with high fevers
and worsening rhonchi, but zosyn was discontinued when no GNRs
grew out on culture. He received a 12 day cipro course for
urosepsis and gram negative PNA coverage. He also received a 14
day vancomycin course for MRSA PNA.
4. C. diff: Mr. [**Known lastname **] was found to be c diff positive and had
colonic distension observed by abd film in the setting of a
profound ileus complicated by his quadriplegia. Repeat CT showed
gas filled 7cm colon without thickened wall on wet read. He was
covered with po vanc and IV flagyl (while his bowels were not
moving). His oxybutinin was discontinued for fear that it could
exacerbate his ileus. His abdominal distension improved with
treatment and his ileus resolved. Second stool culture for
cdiff was negative on [**12-31**].
5. Mental status changes: he was acutely delirious several days
into his ICU stay and the differential included infection as
well as etoh withdrawal. These findings resolved upon transfer
to the floor.
6. Hx of DVT: coumadin was initially held for supertherapeutic
INR up to 13 (likely from interraction with Cipro). He was also
given FFP and vit K, after which his INR became subtherapeutic.
Further history revealed that IVC was filter placed
prophylactically after his accident roughly 5-6 years ago, but
then he developed a DVT and was found to be positive for
antiphosolipds Ab's per PCP. [**Name10 (NameIs) **] was started on lovenox for
anticoagulation and then restarted on coumadin. He was
discharged with an INR of 2.5 on a reduced coumadin dose of 2.5.
VNA was set up for the patient to have his INR rechecked on
[**1-15**] with the results sent to his PCP.
7. Quadriplegia: has home regimen of baclofen, valium, etc and
wellbutrin for autonomic disorder, and very detailed bowel
regimen.
Medications on Admission:
1. Ascorbic Acid 500 mg po bid
2. Baclofen 20mg po QAM, 30mg po Q noon, 20mg po Q 4pm, 30mg po
Q 8pm
3. Bupropion SR 200mg PO QAM
4. Bupropion 100 mg SR po Q 4PM
5. Diazepam 10 mg PO QAM ?prn
6. Ditropan XL 20 mg po q AM, 10mg po Q 4pm.
7. Dulcolax 10 mg PR once a day.
8. oxycontin 15mg po q4-6hrs prn pain.
9. Omeprazole 20 mg po daily.
10. Pantoprazole 40 mg po daily.
11. Senna 2 tabs po qhs.
12. Tamsulosin 0.4 mg PO HS
13. Nitroglycerin 2 % Ointment Sig: One (1) application
Transdermal once a day as needed for dysreflexia.
14. Furosemide 40 mg po daily
15. Paroxetine HCl 50 mg PO DAILY
16. Coumadin 5mg
Discharge Medications:
1. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Bupropion 100 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO QAM (once a day (in the morning)).
3. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q4PM ().
4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for autonomic dysreflexia.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Baclofen 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
7. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal DAILY
(Daily) as needed for autonomic dysreflexia.
8. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
12. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day.
13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home With Service
Facility:
Care group home care
Discharge Diagnosis:
urosepsis
quadroplegia
ventilator assoicated pneumonia
autonomic dysreflexia
Etoh withdrawal
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the ICU with hypotension and were found to
have urosepsis. Your hospitalization was complicated by
respiratory failure requiring intubation and you developed a
pneumonia while on the respirator. You have completed your
antibiotic regimens and repeat cultures show no evidence of
infection. You were also observed to undergo Etoh withdrawal
while hospitalized. You should refrain from Etoh use in the
future. You should return to ther ER or call your PCP if you
develop fevers, chills, rigors, abdominal pain or new symptoms.
Followup Instructions:
You will need to follow up with your PCP, [**Last Name (NamePattern4) **].[**Doctor Last Name **] in [**2-10**]
weeks. His number is [**Telephone/Fax (1) 49716**].
If you would like to transfer your urology and neurology care
over to the [**Hospital1 18**], you can call the below numbers and schedule
an appointment:
neurology: [**Telephone/Fax (1) 44**]
urology: [**Telephone/Fax (1) 164**]
The VNA will need to come to your house on [**1-15**] to have your INR
checked with results sent to your PCP.
ICD9 Codes: 5990, 5849, 2761, 4254, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3215
} | Medical Text: Admission Date: [**2170-1-7**] Discharge Date: INTERIM
SUMMARY
Date of Birth: [**2170-1-7**] Sex: M
Service: NEONATOLOGY
This is an interim dictation summary covering the time period
from [**1-7**] to [**2170-1-12**].
Baby [**Name (NI) **] [**Known lastname 53812**] I is a 2315 gram baby boy twin number 1 born
at 33 1/7 weeks gestational age to a 28 year-old gravida II,
para I mother with prenatal screens: maternal blood type A
positive, antibody negative, GBS positive, hepatitis B
surface antigen negative, RPR nonreactive. Prenatal course
was remarkable for a spontaneous twin gestation in an insulin
requiring gestational diabetic mother who suffered from
intermittent maternal bigeminy. Mother was admitted to
[**Hospital3 3765**] five days prior to delivery with preterm
labor. She was started on betamethasone and magnesium
sulfate and transferred to the [**Hospital1 188**]. However, labor progressed and she delivered
vaginally with spontaneous rupture of membranes two hours
prior to delivery. She received intrapartum antibiotics five
hours prior to delivery. Initial Apgars were 8 and 9.
Initial physical examination notable for a plethoric infant
in moderate respiratory distress with ruddy color, soft
anterior fontanelle, normal faces, intact palate, moderate
retractions with fair air entry. A II/VI systolic murmur
with femoral pulses present, benign abdominal examination,
testes descended, stable hips, normal tone and activity.
SUMMARY OF HOSPITAL COURSE BY SYSTEM DURING THIS INTERIM:
Respiratory: The patient was initially grunting, flaring and
retracting and placed on CPAP of 6. However, with worsening
respiratory distress, he was intubated and received one dose
of surfactant. He was extubated by day of life number two to
room air. He subsequently has been comfortable in room air
saturating greater than 94 percent with no increased work of
breathing.
Cardiovascular: He was initially noted to have a murmur, but
that has not been appreciated subsequently. He had initial
blood pressure that was slightly low and received a 10 cc per
kilo normal saline bolus and subsequently blood pressures
have been normal without any further intervention. No active
cardiovascular issues.
Fluids, electrolytes and nutrition: He was initially n.p.o.
for respiratory distress. He was started on enteral feedings
on day of five number two and has advanced without problem to
a current total fluid intake of 150 cc per kilogram per day of
premature Enfamil 22 all gavage. Maternal milk supply has
been scant.
On admission, electrolytes were normal with sodium 142. On
day of life number three, a repeat sodium was elevated at
147, thought due to mild dehydration. The total fluids were
increased, and a repeat sodium on day of life number five was
stable or slightly improved at 146. The weight at the end of
this interim period was 2060 grams, down from a birth weight
of 2315 grams.
Gastrointestinal: Single photo therapy was started on day of
life number two for a bilirubin of 9.5. On single photo
therapy, the bilirubin has continued to rise slowly with the
most recent bilirubin on [**1-12**] of 11.5. He remained on
single photo therapy and plan to check another bilirubin in
two days.
Hematology/infectious disease: Patient was initially quite
plethoric. CBC on admission revealed a white count of 7.7
with 9 percent polys and 0 percent bands, hematocrit elevated
at 68, platelet count of 158. A follow up CBC the next day
showed that the hematocrit had increased to 74. An umbilical
line was placed, intended to be a low UVC, but found on
imaging to be a low UAC line, was used for a partial exchange
transfusion with normal saline, dropping the hematocrit to
61. Follow up hematocrit on day of life number three had
risen slightly to 6.5, but was stable on day of life number
five at 65.9. The patient has not been symptomatic from his
polycythemia.
Because of his respiratory distress, he was initially started
on a 48 hour sepsis evaluation. He was treated with
ampicillin and Gentamicin for 48 hours his blood cultures
were no growth. Blood cultures remained no growth to date.
Neurology: Given his gestational age and benign clinical
course, we do not plan to have ultrasound or ophthalmologic
evaluation.
CONDITION: Stable.
Primary care pediatrician will be Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Hospital **] Pediatrics.
DISCHARGE DIAGNOSIS:
Prematurity at 33 0/7 weeks gestational age,
polycythemia likely due to twin-twin transfusion, status post
partial exchange transfusion,
hyperbilirubinemia,
status post sepsis evaluation,
status post respiratory distress syndrome
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Name8 (MD) 50790**]
MEDQUIST36
D: [**2170-1-12**] 15:33
T: [**2170-1-12**] 16:56
JOB#: [**Job Number 53813**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3216
} | Medical Text: Admission Date: [**2148-2-27**] Discharge Date: [**2148-2-29**]
Date of Birth: [**2093-8-22**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**Known firstname 2534**]
Chief Complaint:
54 yo M found unresponsive at home
Major Surgical or Invasive Procedure:
Organ Harvesting
History of Present Illness:
Found unresponsive at home. Upon EMS arrival pt was reportedly
apneic/asystolic. Resuscitated per ACLS protocol and ROSC
achieved. Brought to OSH where CT showed subarachnoid
hemorrhage, subfalcine herniation with a midline shift of 17 cm
and global edema. Per wife pt had fallen last night
and hit his head on a coffee table. He had been drinking
alcohol. after he hit his head, family observed him to be
disoriented and, at times,
unable to speak. [**Name (NI) 1094**] wife called 911 this morning when she
could
not wake him.
Past Medical History:
non-contributory
Social History:
Daily Etoh
Married, 3 children
Family History:
unknown
Physical Exam:
Admission PE:
Gen NAD, intubated, not on any medication drips
HEENT: Pupils fixed, dilated
Chest: Ctab
Cardio: RRR
Abd: soft, nt/ND
EXT: not moving any extremities, +DP pulses B
Neuro: unresponsive to voice, does not follow commands, not
responsive to pain including sternal rub, no corneal reflex, no
gag reflex, no cough
Brief Hospital Course:
Pt was admitted to the Trauma Sicu on [**2148-2-27**] intubated, on a
ventilator. Pt was a registered donor and the organ bank was
notified/involved. Pt decided to be/confirmed to be DNR with
family. In the ICU Pt became unstable and required pressors for
hemodynamic support. on [**2-29**] pt was extubated, expired and DCD
for organ harvesting.
Medications on Admission:
unknown
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Subdural hematoma, cerebral edema
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
none
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3217
} | Medical Text: Admission Date: [**2109-2-16**] Discharge Date: [**2109-2-22**]
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
male with an unwitnessed fall face forward, no loss of
consciousness. He fell about 3:15 p.m. on the day of
admission, face forward, no loss of consciousness. He was
transferred to [**Hospital6 1597**]. He had a head CT, which
showed a large right chronic subdural hematoma with small
bilateral areas of acute hemorrhage with mass effect and
midline shift. The patient was transferred to [**Hospital1 346**] for further management.
PAST MEDICAL HISTORY:
1. Paget disease.
2. Depression.
3. Benign prostatic hypertrophy.
4. Dementia.
5. Hypertension.
ALLERGIES: The patient has no known allergies.
MEDICATIONS ON ADMISSION:
1. Atenolol.
2. Aspirin.
3. Colace.
4. Celexa.
5. Albuterol.
PHYSICAL EXAMINATION: On examination, the patient was alert,
not oriented, talking clearly, large purple swelling over the
left eye. Pupils left 5 down to 3, right 4 down to 2, face
symmetrical. EOMI full on the right side, unable to assess
on the left because of swelling. Neck in C collar. CHEST:
Bronchial breath sounds. CARDIAC: Irregular. ABDOMEN:
Soft, positive bowel sounds, moving all four extremities, no
pronator drift.
LABORATORY DATA: Labs on admission revealed the white count
of 9.2, hematocrit 43.4, platelet count 185,000, sodium 141,
potassium of 4.4, chloride 103, CO2 19, BUN and creatinine
26.9 and glucose 97.
HOSPITAL COURSE: The patient was admitted to the Surgical
Intensive Care Unit. The patient had subdural drainage at
the bedside without complications. Subdural drain was in
place for two days. The patient had a repeat head CT, which
showed evacuation of the chronic component of the subdural
hematoma. The patient was awake and alert, following
commands, pupils equal, round, and reactive to light. The
spine films were clear. Collar was removed. He was
transferred to the regular floor, where he was seen by
physical therapy and occupational therapy and found to be
safe for discharge back to his rehabilitation.
Vital signs remained stable. He has been afebrile.
MEDICATIONS ON DISCHARGE:
1. Atenolol 25 mg p.o.q.d.
2. Celexa 20 mg p.o.q.d.
3. Zantac 150 mg p.o.b.i.d.
CONDITION ON TRANSFER: The patient in stable condition at
the time of transfer. The patient will followup with
Dr. [**Last Name (STitle) 1132**] in three to four weeks time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2109-2-22**] 09:45
T: [**2109-2-22**] 10:02
JOB#: [**Job Number **]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3218
} | Medical Text: Admission Date: [**2126-9-27**] Discharge Date: [**2126-10-1**]
Date of Birth: [**2053-4-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Bilateral upper arm and throat discomfort
Major Surgical or Invasive Procedure:
[**9-27**] CABG x4 (LIMA->LAD, SVG->Diag, SVG->OM, SVG->PDA)
History of Present Illness:
73 yo M with h/o CAD s/p multiple MIs and angioplasties, now
with exertional angina, referred for cath and surgical
revascularization.
Past Medical History:
Ischemic cardiomyopathy, CAD, VT s/p ablation, complete heart
block, hypothyroidism, multiple MI's, Diastolic Hrt failure, s/p
AICD [**2122**], Lap appy
Social History:
retired
quit tobacco 30 years ago
no etoh
Family History:
Father with CAD age 59
Physical Exam:
NAD 72 145/70
CV No murmur, distant S1S2
Lungs CTAB ant/lat
Abdomen benign
Extrem warm, no edema 1+ pp
Neuro grossly intact
no carotid bruits
Pertinent Results:
[**2126-9-30**] 07:10AM BLOOD WBC-11.7* RBC-3.26* Hgb-9.7* Hct-28.9*
MCV-89 MCH-29.7 MCHC-33.5 RDW-14.8 Plt Ct-130*
[**2126-9-29**] 09:30PM BLOOD WBC-11.4* RBC-3.47* Hgb-10.3* Hct-30.8*
MCV-89 MCH-29.6 MCHC-33.4 RDW-14.7 Plt Ct-107*
[**2126-9-29**] 02:23AM BLOOD PT-15.5* PTT-34.0 INR(PT)-1.4*
[**2126-9-30**] 07:10AM BLOOD Plt Ct-130*
[**2126-9-30**] 07:10AM BLOOD Glucose-133* UreaN-24* Creat-1.2 Na-141
K-4.9 Cl-104 HCO3-31 AnGap-11
[**9-30**] TWO VIEWS OF THE CHEST: There are small bilateral pleural
effusions (L > R). Although the positioning is different when
compared to semi-upright portable radiograph from the previous
day, the postoperative mediastinal widening demonstrates slight
improvement. No pneumothorax is identified. A dual-lead pacer
remains unchanged in position. A right internal jugular central
line has been removed. No pneumothorax is identified.
IMPRESSION: Small bilateral pleural effusions persist. Slight
improvement in postoperative mediastinal widening.
Brief Hospital Course:
On [**9-27**] Mr. [**Known lastname 53270**] was taken to the operating room where he
underwent CABG x 4. He was transferred to the ICU in critical
but stable condition. He was extuabted on POD #1. He was
transferred to the floor on POD #2. He did well post operatively
and was ready for discharge to rehab on POD #4. His
ACE-inhibitor was held in order to increase his beta blocker,
but should be start in the near future if possible.
Medications on Admission:
Zetia 10', Toprol 100', Diovan 80', Metformin 500",
Levothyroxine 0.25', Simvastatin 40', Advair, Avandia 4', ASA
325', MVi
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Colony House Nursing & Rehabilitation Center - [**Location (un) 32775**]
Discharge Diagnosis:
Ischemic cardiomyopathy, CAD, VT s/p ablation, complete heart
block, hypothyroidism, multiple MI's, Diastolic Hrt failure, s/p
AICD [**2122**], Lap appy
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving until follow up with surgeon.
Followup Instructions:
Dr. [**First Name (STitle) **] 1 month
Dr. [**Last Name (STitle) 10543**] 2 weeks
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2126-10-22**]
1:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2126-10-1**]
ICD9 Codes: 4280, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3219
} | Medical Text: Admission Date: [**2163-2-17**] Discharge Date: [**2163-3-4**]
Date of Birth: [**2103-5-16**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Transfer with intracerebral hemorrhage with intraventricular
extension.
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of the right ankle
Doboff tube placement
History of Present Illness:
Mrs. [**Known lastname 52477**] is a 59-year-old woman with possible diabetes,
thyroid disease (unknown type), possible prior stroke,
transferred for further evaluation and management after
intracerebral hemorrhage with intraventricular extension.
The history and sketchy medical details were given by her niece,
who speaks English and Portuguese and her husband, who
predominantly speaks Portuguese.
At home, her son heard a thud from an adjoining room. She had
been in the kitchen preparing dinner, and it was at about 7:30
p.m. on [**2-16**]. She was on the floor, had been incontinent then
vomited with subsequent gurgling respiratory sounds. She was
holding her head, had fallen onto chairs. Her son thought that
she had likely hit her head. She was unable to speak and was not
moving her right arm at all. She was taken to [**Hospital6 **]. It was noted that she was not moving her right side
and
that there was vomitus in her airway. She was intubated, but
pre-intubation GCS is not clear. Blood pressure was 179/81, but
it is not clear when this was taken in relation to medications.
Medications given were propofol bolus and gtt, etomidate 20 mg,
succinylcholine 150 mg, fentanyl 100 mcg, fosphenytoin 1 g IV,
KCl 40 mEq in 250 cc NS. EKG was unremarkable except for QTc
prolonged at 500 ms, and cardiac enzymes were flat. She was then
sent to [**Hospital1 18**] by [**Location (un) **].
On arrival she was seen by Neurology and Neurosurgery.
Her PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 83262**] in [**Location (un) 5503**].
Past Medical History:
- Possible hypertension
- Thyroid disease, on levothyroxine, dose unknown
- Ectopic pregnancy
- Denied diabetes, but glucose elevated in labs
- Hypertension, on medication, unknown
- 'Ministroke' 10 years ago. Right arm weakness improved. Was in
bathroom at onset, felt unwell, Dr. [**Last Name (STitle) **] to ED. Ministroke
diagnosed - all per husband.
Social History:
Lives with her husband, two of her children and two of her
grandchildren - she has custody of these grandchildren. Never
smoked, occasional alcohol.
Family History:
Mother died of stroke at 49 - unclear if infarctive or
hemorrhagic. No other cerebrovascular disease, no known
polycystic disease. Unknown if her family suffered hypertension,
diabetes.
Physical Exam:
Discharge Examination:
VS: 98.1 F, 136-151/83 mmHg, 78 BPM, RR 18, 98% RA, FS 127
Mrs.[**Last Name (un) 90052**] general physical examination is notable for skin
breakdown and erythema under the right breast, right ankle in
cast. Neurologic examination reveals alert mental status with
new (today) attempts to speak with soft phonation - this is
difficult to understand and infrequent, but sometimes will
occur, with appropriate answers, to questioning. She has a dense
right-sided neglect and only looked past the midline on one
occasion when her head was (paradoxically!) turned to the right.
The right arm is flaccid with minimal movement to pain. The
right leg triple-flexes to pain but is not moved spontaneously.
The left leg and left arm move spontaneously and seem full
strength, although examination is limited by mental status.
Admission Examination:
Afebrile; 156/71 mmHg, when moved, 130s when settled, 100% on
CMV intubation w/ RR 15 in ED FiO2 0.4, 64 BPM
Gen: Overweight, well-kept woman lying intubated.
HEENT: No trauma to head noted, but not carefully examined under
rigid collar. No CSF/blood from nose or ears.
Lungs: some transmitted sounds, vent sounds.
Cardiac: RRR. S1/S2.
Abd: Soft.
Extrem: Warm and well-perfused.
Neurological:
Some spontaneous movement, but no response to voice. Sternal rub
results in some movement. Localizes to pain on left. Occasional
movements of right arm with increased tone, but small and
internal rotation to pain, some flexing of finger with hand
stimulation but no grasp.
Cranial Nerves:
II: Pupils equally round and reactive to light, 2.5 to 2
mm bilaterally. No blink to threat.
III, IV, VI: Eyes conjugate, but caloric and doll's eyes not
done.
V, VII: Face symmetric. Corneals bilaterally, normal with
lowered
sedation.
VIII: Hearing untested.
IX, X: No gag on suction.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bulk bilaterally.
XII: Tongue not evaluated, given intubation.
Motor:
Motor: Normal bulk, tone increased in right arm, otherwise
normal. Moves both legs spontaneously with lessened sedation,
but
not with clear purpose. Left arm localizes, but poverty of
movement of right arm.
Sensation: Intact to pain both legs, nipples, left arm with
minimal movement of right arm to pinch of arm or nipple.
Reflexes: Symmetric 2+ at biceps, triceps, brachioradialis. 2+
right knee, 0 at left knee. Ankles absent. Toes mute.
Pertinent Results:
Pertinent Laboratory Data
[**2163-3-4**] 05:50AM BLOOD WBC-10.7 RBC-3.81* Hgb-11.1* Hct-33.2*
MCV-87 MCH-29.1 MCHC-33.4 RDW-14.0 Plt Ct-320
[**2163-3-1**] 05:58AM BLOOD Neuts-74.0* Lymphs-20.6 Monos-3.4 Eos-1.5
Baso-0.5
[**2163-2-26**] 02:52AM BLOOD PT-13.1 PTT-27.4 INR(PT)-1.1
[**2163-3-4**] 05:50AM BLOOD Glucose-98 UreaN-11 Creat-0.4 Na-137
K-4.1 Cl-100 HCO3-26 AnGap-15
[**2163-2-16**] 11:10PM BLOOD ALT-22 AST-23 AlkPhos-67 TotBili-0.4
[**2163-2-17**] 07:09PM BLOOD CK(CPK)-322*
[**2163-2-16**] 11:10PM BLOOD Lipase-28
[**2163-2-17**] 07:09PM BLOOD CK-MB-4
[**2163-2-17**] 12:03PM BLOOD CK-MB-5 cTropnT-<0.01
[**2163-2-17**] 03:34AM BLOOD CK-MB-6 cTropnT-<0.01
[**2163-2-16**] 11:10PM BLOOD cTropnT-<0.01
[**2163-3-4**] 05:50AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.9
[**2163-2-17**] 03:34AM BLOOD %HbA1c-6.9* eAG-151*
[**2163-2-17**] 03:34AM BLOOD Triglyc-88 HDL-49 CHOL/HD-3.6 LDLcalc-109
[**2163-2-17**] 03:34AM BLOOD TSH-3.3
[**2163-2-16**] 11:21PM BLOOD Glucose-169* Lactate-1.3 K-3.7
[**2163-3-3**] 06:03PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.021
[**2163-3-3**] 06:03PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2163-3-3**] 06:03PM URINE RBC-35* WBC-238* Bacteri-FEW Yeast-NONE
Epi-0
Head CT [**2163-2-17**]
COMPARISON: CT head from [**2163-2-16**]. CTA head from
[**2163-2-16**].
FINDINGS: The left temporal lobe and left basal ganglia
intraparenchymal hemorrhage is not significantly changed in size
compared to [**2163-2-16**], measuring 5.8 x 2.4 cm on today's
study. Intraventricular extension of the hemorrhage into the
left lateral ventricle and third ventricle is unchanged.
Redistribution of the intraventricular hemorrhage is noted,
however, and a small amount of hemorrhage is now seen within the
occipital [**Doctor Last Name 534**] of the right lateral ventricle. A small quantity
of intraventricular hemorrhage in the body of the right lateral
ventricle is unchanged. Mild rightward shift of normally midline
structures and mild-moderate cerebral edema are not
significantly changed. There is no evidence of uncal or
transtentorial herniation. There is no obvious evidence of acute
infarction. A minimal degree of mucosal thickening is seen in
the left maxillary sinus. Mucosal thickening is also seen in the
bilateral ethmoidal air cells. The right maxillary sinus is
small and completely opacified. The mastoid air cells are well
aerated bilaterally.
IMPRESSION:
1. Left temporal lobe and left basal ganglia intraparenchymal
hemorrhage is unchanged in size compared to CT from [**2163-2-16**]. Further workup for underlying vascular/neoplastic cause as
clinically indicated after clinical correlation.
MRI w/ and w/out contrast [**2163-2-18**]
IMPRESSION: Left-sided basal ganglia intraparenchymal hematoma
with mass effect and surrounding edema. No distinct intrinsic
enhancement seen with enhancement of the surrounding medullary
veins seen adjacent to the left lateral ventricle which could be
secondary to mass effect. Several other areas of chronic
microhemorrhages are seen which could be secondary to
anticoagulation therapy or due to cavernous malformations. A
chronic-appearing infarct is seen in the mid corpus callosum.
Small vessel disease is noted.
Right Ankle X-ray
IMPRESSION: Fibular fracture with fixation intraoperatively. For
details of the operative procedure, please consult the operative
report.
Pelvic Ultrasound [**2163-2-26**]
PELVIC ULTRASOUND: Transabdominal examination of the pelvis was
performed. Transvaginal examination could not be performed as
the patient was intubated. The uterus measures 7.9 x 3.8 x 4.5
cm. Fibroid uterus is noted, the largest is at the uterine
fundus and measures 2.8 x 2.3 cm. The endometrium measures 13
mm. The left ovary was not clearly visualized; however, left
adnexa showed no evidence of abnormality. The right ovary
measures 2.6 x 1.7 cm. There is no free pelvic fluid.
IMPRESSION:
1. Fibroid uterus.
2. Endometrium measures 13 mm. Given presumed postmenopausal
state, appropriate consultation recommended. Consider
son[**Name (NI) 18556**] or endometrial biopsy to exclude endometrial
carcinoma (hyperplasia favored).
Head CT [**2163-2-28**]
COMPARISON: CT head from [**2163-2-17**].
FINDINGS: There is a slight decrease in the size of the left
putamen hemorrhage compared to [**2163-2-17**]. The overall extent of
intraventricular hemorrhage is markedly decreased, although
there has been a slight increase in the quantity of layering
blood within the occipital [**Doctor Last Name 534**] of the right lateral ventricle.
No new sites of hemorrhage are identified. The degree of
rightward midline shift is not significantly changed. There is
no evidence of uncal or transtentorial herniation. There is no
evidence of acute ischemia. Subcortical white matter
hypodensities are consistent with chronic small vessel ischemic
disease. The visualized portions of the paranasal sinuses are
well aerated. Scattered opacifications in the mastoid air cells
are seen bilaterally. The bony calvarium is intact.
IMPRESSION:
1. Interval decrease in size of the left putamen hemorrhage, the
etiology of which is likely related to chronic hypertension.
2. Marked decrease in the degree of intraventricular hemorrhage.
3. No evidence of new hemorrhage or acute infarction.
4. Bilateral scattered mastoid air cells opacification could
represent an ongoing inflammatory process.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
Intraparenchymal Hemorrhage
Based on the history, this was a spontaneous intracranial
hemorrhage. Given history and location, it seems most likely
hypertensive in etiology. There was intraventricular extension
and edema. No drain was needed and there was no hydrocephalus,
but hyperosmolar agents were briefly used after arrival. Blood
pressure was controlled and her antihypertensive regimen was
adjusted as below. As far as risk factors go, LDL was near goal
of 100 at 109, A1c was elevated at 7.9%, indicating treatment.
The largest modifiable risk factor is hypertension and
aggressive control to 130 mmHg is indicated. Her blood pressure
has been improved, mostly in 130s after we changed medications.
This will need to be followed closely and titrated as necessary.
Hypertension
Medications were adjusted as per medication list below.
Hypertension was controlled to 130s - 140s systolic later in the
admission (earlier with nicardipine also).
Diabetes
HbA1c 7.9 % indicative of diabetes. She did not need very much
sliding scale insulin during the admission - this should be
followed closely in the outpatient setting.
Hypothyroidism
Levothyroxine was continued and TSH was normal range.
Urinary Tract Infection
Diagnosed on the day of discharge given transient leukocytosis
the day prior. Treatment with Bactrim commenced. Culture is
pending.
Medications on Admission:
Levothyroxine 75
Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: Per sliding
scale Injection ASDIR (AS DIRECTED): Has typically not been
requiring insulin. Please stop if not needed.
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO every
eight (8) hours as needed for pain or fever.
7. lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for furry tongue.
11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) as needed for UTI: Course last day
[**2163-3-10**].
12. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Broken skin under right breast.
13. Famotidine 20 mg IV Q12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary
Intracerebral hemorrhage
Hypertension
Endiometrial hyperplasia
Right ankle fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with (complete) assistance to chair
or wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname 52477**],
You came to the hospital after having bleeding in to your
brain (intracerebral hemorrhage) that we attribute to
hypertension. This resulted in right sided weakness, more of the
arm, as well as an inability to pay attention to her right side.
We ensured that bleeding stopped and controlled blood pressure.
When colapsing you also injured your ankle, fracturing a bone,
that required surgery. In addition, you had some post-menopausal
bleeding and were seen by gynecology.
You will need to follow-up with orthopedics, gynecology and
neurology. Please see the list of appointments below.
Followup Instructions:
Neurology:
[**2163-5-24**] 03:30p INTERPRETER,[**Location **]/PORTUGUESE
INTERPRETERS
Create Visit Summary
[**2163-5-24**] 03:30p [**Last Name (LF) **],[**First Name3 (LF) **]
[**Hospital6 29**], [**Location (un) **] NEUROLOGY UNIT CC8 (SB)
Create Visit Summary
Gynecology:
[**2163-4-5**] 10:15a INTERPRETER,[**Location **]/PORTUGUESE
INTERPRETERS
Create Visit Summary
[**2163-4-5**] 10:15a [**Last Name (LF) **],[**First Name3 (LF) **] [**Doctor Last Name **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] OB/GYN CC8 (SB)
Create Visit Summary
Orthopedics:
[**2163-3-17**] 01:40p [**Last Name (LF) **],[**First Name3 (LF) 2191**] A.
[**Hospital6 29**], [**Location (un) **] [**Hospital **] CLINIC (SB)
Create Visit Summary
[**2163-3-17**] 01:30p INTERPRETER,[**Location **]/PORTUGUESE
INTERPRETERS
Create Visit Summary
[**2163-3-17**] 01:20p X-RAY ORTHO SCC2
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] X-RAY ORTHO SCC2
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 5990, 2760, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3220
} | Medical Text: Admission Date: [**2132-8-4**] Discharge Date: [**2132-8-7**]
Date of Birth: [**2054-11-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
endoscopic epinephrine injection, endoscopic cauterization
History of Present Illness:
HPI: 77 yo Spanish speaking male with a h/o htn, DM, prior heavy
EtOH use, who p/w syncope and melena. By report, patient passed
out in bathroom at home with black stool noted. Patient is a
formed heavy drinker but has not drank in the last 3 months. He
has no known liver disease. Patient has had intermittent LLQ
pain for the last week. Then, starting approximately 3 days ago,
he began to pass dark black stools. This am, patient vomited a
small amount of blood but has had no recent vomiting or
wretching prior. This am he awoke to go to the bathroom, felt
lightheaded and fell. His wife then called 911 and he was
brought to the ED by ambulance. Of note, he has not been using
NSAIDs but does take an baby aspirin. [**Name2 (NI) **] otherwise denies
any epigastric pain, chest pain or shortness of breath. Denies
fevers or chills. He does have minimal baseline SOB but can walk
long distances and do stairs as long as he does not go at a fast
pace. He has no history of chest pain. He does have 2 pillow
orthopnea but no PND.
In the ED, no temp performed. BP 101/42, HR 71, RR 13 O2 100% on
2LNC. Hct found to be 18.6 from a baseline in mid to high 30s.
Coags and LFTs were normal. NG lavage was positive for 400-600
cc of gross blood. Rectal exam positive for maroon bloody stools
and melena. Patient type and crossed for 4 units, given 1 L NS,
40 mg IV PPI, and was sent to the ICU with 2 units running for
closer monitoring.
Past Medical History:
DM2
HTN
hypothyroidism
hypercholesterolemia
bilateral cataract surgery
diverticulosis
hemorrhoids
BPH s/p TURP
gout
occupational abdominal trauma 36 years ago
Social History:
Originally from [**Country 7192**]. Former bus driver in [**Country 7192**]. Had
severe accident while driving bus there but outcome unclear.
Moved to [**Location (un) 86**] area in [**2094**]. Worked ironing neckties here. Now
retired. Lives in [**Location (un) 538**] with wife. [**Name (NI) **] children. Former
heavy EtOH use. None in last 3 months. Quit of own [**Location (un) **]. No
h/o smoking or drugs.
Family History:
no cancers, no GI illness or ulcers, no CAD, no DM
Physical Exam:
PE: T 97.1, BP 132/54, HR 73, RR 16, O2 100% 2LNC
Gen: pleasant, laying in bed comfortably, NAD
HEENT: NG tube in place draining small amounts BRB. No icterus.
MMM
NECK: Supple, No JVD.
CV: RRR. NL S1, S2. Soft I/VI blowing sys murmur at base
LUNGS: CTA, BS BL, No W/R/C
ABD: Obese. Midline surgical scar. NABS. Soft, NT, ND. No HSM
EXT: No edema. 2+ DP pulses BL
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all
extremities
Pertinent Results:
[**2132-8-4**] 06:00AM WBC-10.5 RBC-2.20*# HGB-5.9*# HCT-18.6*#
MCV-85 MCH-27.1 MCHC-31.9 RDW-13.3
[**2132-8-4**] 06:00AM NEUTS-54.0 LYMPHS-36.5 MONOS-4.6 EOS-4.4*
BASOS-0.4
[**2132-8-4**] 06:00AM PT-12.4 PTT-22.6 INR(PT)-1.1
[**2132-8-4**] 11:44AM HCT-23.0*
[**2132-8-4**] 04:55PM HCT-26.3*
[**2132-8-4**] 11:24PM HCT-24.9*
[**2132-8-4**] 06:00AM GLUCOSE-262* UREA N-76* CREAT-1.8* SODIUM-138
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-19* ANION GAP-18
[**2132-8-4**] 06:00AM ALT(SGPT)-9 AST(SGOT)-14 CK(CPK)-109 ALK
PHOS-34* AMYLASE-59 TOT BILI-0.2
[**2132-8-4**] 06:00AM LIPASE-59
[**2132-8-4**] 06:00AM CK-MB-4
[**2132-8-4**] 06:00AM ALBUMIN-3.1* CALCIUM-8.5 PHOSPHATE-3.9
MAGNESIUM-1.9
Brief Hospital Course:
# Acute Blood Loss Anemia due to Gastric Hemorage from Gastric
Ulcer- Mr. [**Known lastname 24451**] was started on IV PPI, received 2U pRBC on
hospital day #1, and was admitted to the MICU. His aspirin,
anti-hypertensives, and hypoglycemics were held. Endoscopy
revealed a 2x3 cm punched-out fundal ulcer without heaped up
edges, which was injected with epinephrine due to overlying
clots. Esophagus and duodenum were normal, and no varices were
visualized. He received another 2U pRBCs and underwent repeat
endoscopy on hospital day #2, where a vessel was identified and
cauterized. He was switched to PO PPI. He remained
hemodynamically stable with the exception of mild tachycardia on
hospital day#3, which resolved with fluid bolus. His Hct
remained stable (27-30) for the rest of his hospitalization
without further transfusion. Aspirin and prior EtOH use were
considered possible contributors to his ulcer, and H. pylori
serologies were positive. Therefore he was started on
amoxicillin 1g [**Hospital1 **] and clarithromycin 500 mg [**Hospital1 **] for a planned
14 day course. His PPI was also continued for planned 6 week
course until his follow up endoscopy, scheduled for [**9-18**]. He was counseled to avoid ibuprofen, aspirin, and all
NSAIDs.
.
# Gout- Mr. [**Known lastname 24451**] developed a gout exacerbation during his
hospitalization, with rather painful polyarticular involvement
in his right third PIP, right lateral malleolus, and numerous
toes. Hypovolemia and acute renal failure may have contributed,
and his measured uric acid was 7.5. He reported a year-long
history of gout, for which he had only recently discontinued his
home medication a few weeks earlier. Allopurinal was started and
he was given a short course of colchicine x 3, which did relieve
some of his symptoms. NSAIDS and steroids were not employed on
account of his ulcer. Acetominophen and prn oxycodone were given
for pain relief.
.
# Benign Hypertension- Antihypertensives were held on admission
given his GIB. He remained hemodynamically stable on the floor,
and lisinopril was restarted on hospital day#4. Given his
development of a gout exacerbation, HCTZ was not restarted.
Metoprolol was also held since his SBP ranged 100s-120s at the
time of discharge. He was instructed to hold his metoprolol
until following up with Dr. [**Last Name (STitle) **].
.
# Type 2 DM Controlled: Oral hypoglycemics held for several days
while he was NPO for the GIB. Finger sticks were performed and
he was covered with sliding scale insulin. Dr. [**Last Name (STitle) **] had
recently discussed with Mr. [**Known lastname 24451**] the benefits vs. risks
(especially cardiovascular) of rosiglitazone use, and Mr. [**Known lastname 24451**]
had elected to continue using the drug at present. Therefore he
was restarted on rosiglitazone and acarbose prior to discharge
for follow-up with Dr. [**Last Name (STitle) **].
.
# Acute Renal Failure on CKD II- Creatinine was 1.8 on
admission, up from a baseline of around 1.5, per Dr. [**Last Name (STitle) **].
Creatinine responded well to hydration and transfusions,
decreasing to 1.3 by the time of discharge. ACE inhibitor was
restarted to maximize renal protection.
.
# Hypothyroidism: Outpatient dose of levothyroxine was continued
throughout the hospital course. He remained asymptomatic from
thyroid disease.
Medications on Admission:
lisinopril-hctz 20/25 po qday
hctz 25 po qday
glyburide 6mgpo [**Hospital1 **]
toprol 100mg po qday
lipitor 20mg po qday
levothyroxine 75mcg po qday
ASA 81mg po qday
acarbose 50mg po bid
rosiglitazone 8 mg po qday
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO twice a day for 2 months.
Disp:*240 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*0*
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
6. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 13 days.
Disp:*26 Tablet(s)* Refills:*0*
7. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 13 days.
Disp:*102 Capsule(s)* Refills:*0*
8. Acarbose 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
peptic ulcer disease, upper gastrointestinal bleed
hypertension, type 2 diabetes, hypothyroidism,
hypercholesterolemia
==========================================
enfermidad de ulcera peptica, sangrando [**Doctor First Name **] estomago
[**Female First Name (un) **] presion, diabetes tipo 2, hipotiroidismo, colesterol alto
Discharge Condition:
hemodynamically stable, hematocrit stable, eating, pain well
controlled
====================================================
estable, comiendo, dolor contolado con las medicinas
Discharge Instructions:
You were treated for a bleeding ulcer in the hospital. You
received several new medications, including omeprazole,
clarithromycin, amoxicillin (all for the ulcer), allopurinol
(for gout), and oxycodone (for pain). We also stopped your
hydrochlorothiazide and aspirin for your safety with the ulcer.
You should also stop your toprol as your blood pressures have
been low here.
It is important that you take all your medications as
prescribed. Please do NOT take hydrochlorothiazide, Toprol,
aspirin or any NSAID (including ibuprofin, Motrin, or Advil)
until your doctor says it is safe to do so.
If you see your stool turn very black again, if you see blood in
your stool, or if you have another episode of fainting, extreme
shortness of breath, or any other worrisome symptoms, please
contact your physician or call 911.
==========================================
[**Last Name (un) **] tratamos a usted por una ulcera sangrando. [**Last Name (un) **] usted recibio
algunas medicinas nuevas, incluso omeprazole, clarithromycin,
amoxicillin (todas para [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 24452**]), allopurinol (para el acido
urico, o [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]), and oxycodone (para el dolor). [**First Name9 (NamePattern2) 24453**] [**Last Name (un) **]
terminamos [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 24454**], toprol, y aspirin para [**Doctor First Name **]
seguridad con [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 24452**].
Es importante que usted tome todas las medicinas como recetadas.
Por favor no tomar hidroclorotiazid, toprol, aspirin o algun
"NSAID" (incluso ibuprofin, Motrin, or Advil) hasta que [**Doctor First Name **]
doctor [**First Name (Titles) **] [**Last Name (Titles) **] a usted que [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 24455**].
Si [**Doctor First Name **] excremento se hace muy negro de neuvo [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] con sange, si
se cae [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] de neuvo, si le [**Last Name (un) 24456**] respirar, o si tiene otras
sintomas que le molestan muchissimo, llama [**Doctor Last Name **] [**Doctor First Name **] doctor o 911 o
venga a [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] de urgencies.
Followup Instructions:
Please visit your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within the
next week. You may contact his office at [**Telephone/Fax (1) 14918**].
Please return to [**Hospital1 69**] on
Thursday, [**9-18**], at 9:30am for a follow-up endoscopy. The
office is located on the [**Hospital Ward Name 517**], [**Hospital Ward Name 121**] 8. You may reach the
office at ([**Telephone/Fax (1) 24457**].
===========================
Por favor visitar a Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 14918**]) en [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
semana.
Por favor [**Hospital 24458**] [**Hospital **] Hospital de [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 24459**], Setiembre 20, a las 9:30am para una endoscopia, que [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 24460**] en el campus oeste, edificio [**Hospital Ward Name 121**], [**Hospital Ward Name **] 8.
Completed by:[**2132-8-13**]
ICD9 Codes: 2851, 2762, 5849, 2749, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3221
} | Medical Text: Admission Date: [**2144-11-21**] Discharge Date: [**2144-12-7**]
Date of Birth: [**2090-7-16**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Cipro
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fever, shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
54-year-old gentleman with a history of AML. He is day 508
post-transplant complicated by chronic graft-versus-host disease
manifesting as skin, liver involvement and edema. Pt was most
recently admitted for right leg cellulitis; discharged [**11-4**]
with chronic levofloxacin that per records finished on [**11-19**].
Today the patient describes waking up this AM with chills and
malaise. He reports not being able to get warm; the wife called
the onc fellow on call took his temp-- 99.6. As the day
progressed, his temperature increase and he came to the ER.
.
In addition to the fever, the patient has been having
siginificant fatigue and increased cough with sputum. This
afternoon he also developed severe headache (as is typical with
his acute illness), feeling very weak, acute onset of shortness
of breath and pleuritic chest pain. Of note, his lower
extremities have been more swollen recently, but he has recently
noticed that his L>R has been swollen since yesterday, but
previously the right was more swollen than the left.
.
On presentation to the ER, initial vitals were T 101, HR 104, RR
18 02 95% RA. While in the ED, he became more hypoxic and
required a NRB to keep sats above 93%. He also became
hypotensive to BPs of 80s/50s. His BP was fluid responsive and
the patient received a total of 3L. Additionally, he was seen by
onc who recommended Vancomycin, Zosyn. He also received
azithromycin. CTA was done for pleuritic CP that showed a
subsegmental PE, thus he was started on heparin gtt and given
dilaudid for pain.
.
On arrival to the floor, the patient is feeling well, but feels
fatigued. As well he has a persistent bifrontal headache with
photophobia.
.
ROS: + photophobia, + bilateral chest pressure (chronic)
hyperesthesia. + sick contacts (daughter who lives with him has
had fever and sore throat) Denies dizziness or lightheadedness,
syncope or presyncope. He has had no dysuria, constipation,
melena, hematochezia, diarrhea. He has no blurry vision, neck
stiffness.
Past Medical History:
-AML-M7 ([**3-23**]) [Diagnosed with AML in 04/[**2142**]. Admitted
[**2143-6-24**] for matched unrelated allogenic transplant with
busulfan and
cyclophosphamide as his conditioning regimen. AB0 mismatch and
requiring periodic blood transfusions. Underwent bone marrow
aspirate and biopsy most recently on [**2143-9-2**] which showed
markedly hypercellular bone marrow with opacity of
erythroblasts. Cytogenetics were normal. FISH was normal.
Chimerism testing showed them to be 100% donor. ]
-Hyperlipidemia, HTN
-Nephrolithiasis, lithotrypsy and previous nephrostomy tube
and emergent surgery to repair ureteral damage
-Basal cell carcinoma, resected
-Multiple back surgeries: Lumbar L5-S1 surgery x 3, and cervical
spine fusion (bone graft, no hardware)
- Chronic numbness, neuropathic pain
-Pericardial effusion s/p [**3-23**] drainage
- C5/C6 and C6/C7 secondary to herniation of nucleus pulposus,
s/p
Anterior cervical discectomy and fusion C5-6 and C6-7
Social History:
Mr. [**Known lastname 47367**] lives in [**Location 14840**] with his wife and has three
children, used to work as a [**Company 22957**] technician, but recently was
"forced" to retire. Smoked a pack per day
of cigarettes for many years, but does not currently smoke. He
drinks alcohol socially. He does not use drugs. Walks with
walker and has a cat.
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: 37.2 ??????C (99 ??????F)
Tcurrent: 37.2 ??????C (99 ??????F)
HR: 71 (71 - 86) bpm
BP: 100/64(73) {100/64(73) - 122/78(88)} mmHg
RR: 12 (11 - 13) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 105 kg (admission): 105 kg
Height: 72 Inch
General Appearance: Well nourished, No acute distress, Sleepy
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, neck supple, JVP 10 cm
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , Crackles : in the left lower base)
Abdominal: Soft, Bowel sounds present, Tender: RUQ and
epigastrium
Extremities: Right: 1+, Left: 1+
Skin: Warm, Rash: Hands, erythema of upper abdomen
Neurologic: Follows simple commands, Responds to: Not assessed,
Oriented (to): x3, Movement: Purposeful, Tone: Normal
Pertinent Results:
Heme:
[**2144-11-21**] 03:00PM WBC-6.0 RBC-3.18* HGB-12.6* HCT-36.3*
MCV-114* MCH-39.5* MCHC-34.7 RDW-17.6*
[**2144-11-21**] 03:00PM NEUTS-85.1* LYMPHS-6.9* MONOS-6.8 EOS-0.8
BASOS-0.3
[**2144-11-21**] 03:00PM PT-14.1* PTT-25.6 INR(PT)-1.2*
Chemistries:
[**2144-11-21**] 03:00PM GLUCOSE-135* UREA N-14 CREAT-1.3* SODIUM-139
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-33* ANION GAP-12
[**2144-11-21**] 03:00PM ALT(SGPT)-23 AST(SGOT)-32 ALK PHOS-279* TOT
BILI-0.4
[**2144-11-21**] 03:00PM LIPASE-12
Cultures:
[**2144-11-21**] Blood: No growth
[**2144-11-21**] Urine: < 10,000
[**2144-11-22**] Sputum: contamination
IMAGING:
UPRIGHT AP VIEW OF THE ABDOMEN: No free air is seen under the
diaphragms.
Relative gasless abdomen is present with no air-fluid levels
identified.
Stool and air is seen within the descending colon and sigmoid
colon. No soft tissue calcifications are identified.
IMPRESSION: No air-fluid levels or free intra-abdominal air
identified.
Relative paucity of gas within the abdomen.
UPRIGHT AP VIEW OF THE CHEST: The right PICC has been removed.
Cervical
fusion hardware is present. Cardiac, mediastinal and hilar
contours are
unchanged and within normal limits. The lungs are clear. There
is no
pulmonary vascular congestion. No pleural effusions or
pneumothorax. Osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary abnormality.
.
[**2144-11-21**] CTA:
1. Left lower lobe segmental pulmonary embolism.
2. Wedge-shaped peripheral consolidation in the superior segment
of the right lower lobe. Differential considerations include
infectious or inflammatory processes; atelectasis is less
likely.
3. Thoracic vertebral compression fracture, unchanged in
comparison to
[**2144-9-10**].
.
Portable TTE (Complete) Done [**2144-11-23**] at 10:26:48 AM
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. Left ventricular systolic function
is hyperdynamic (EF>75%). There is no left ventricular outflow
obstruction at rest or with Valsalva. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2144-6-8**], LV
function appears hyperdynamic on the current study. The other
findings are similar.
.
BILAT LOWER EXT VEINS Study Date of [**2144-11-23**] 5:05 PM
IMPRESSION: No DVT in the bilateral lower extremities.
.
CHEST (PORTABLE AP) Study Date of [**2144-11-25**] 5:10 AM
IMPRESSION:
1. Worsening right lower lobe opacity over the period of last
five days most likely representing a worsening infectious
process.
2. Given the presence of pulmonary embolism in left lower lobe
the worsening left lower lobe opacity might represent infarction
as well as atelectasis or infection, determination based on the
chest radiograph cannot be made.
.
CHEST (PORTABLE AP) Study Date of [**2144-11-27**] 4:53 AM
Portable AP chest radiograph was compared to [**2144-11-26**].
There is a slightly improved aeration of lung bases due to
resolution of
atelectasis. Cardiomediastinal silhouette is stable. No
appreciable pleural effusion is seen.
.
[**2144-12-4**] CXR: FINDINGS: Comparison study [**12-3**], there is no
interval change. The two vague bilateral upper lobe opacities
are again seen. These could represent areas related to pulmonary
emboli.
.
[**2144-12-7**] CT chest w/o contrast:
1. Findings are most consistent with cryptogenic organizing
pneumonia, although a component of viral pneumonia is possible.
2. Stable centrilobular emphysema.
3. Multilevel compression fractures are similar to [**2144-11-21**].
Brief Hospital Course:
54 yo M with AML s/p allo-BMT with chronic GVHD of liver, skin
now with fever and pulmonary embolism.
.
Fever/RSV: The patient was admitted to the MICU for inital
hypotension, PE, Acute renal insufficency and increased oxygen
requirement. The patient reported recent sick contacts and due
to his respiratory complaints, a pulmonary process was the most
consistant site of infection. He was treated with Vancomycin and
Zosyn in the ED and this therapy was continued throughout his
ICU course. He was hypotensive in the ED (SBP to 80's), but this
resolved with IV fluids and was felt to be consistant with
pre-septic physiology. Cultures were obtained. Nasal swab was
positive for RSV, sputum with gram positive cocci and yeast.
The patient was treated with Synagist/palivizumab in two
7.5mg/kg doses for RSV. The patient remained febrile over the
first 4 days of hospitalization but defervessed by hospital day
5. He was transferred to the BMT service on ICU Day 6. On the
floor patient was treated with scheduled abuterol and ipatropium
nebs and his supplemental oxygen was weaned down to 2L/min.
Patient's shortness of breath resolved. However, his hypoxia
persisted. Patient was seen by the Pulmonary and physical
therapy. It appears that the RSV infection is primarily an upper
respiratory tract infection as there is no evidence of RSV
pneumonia. There was some concern that his hypoxia may represent
an element of GVHD of the lung so his prednisone dose was
increased to 40mg. He had slight improvement with increased
steroids and was tapered to 30mg at the time of discharge. His
steroid dose will continued to be tapered in the outpatient
setting. He is recommended to continue use of supplemental
oxygen after discharge to maintain oxygen saturations greater
than 94%.
.
PE: LLL pulmonary embolism was identified on CTA. Pt was
started on [**Hospital1 **] lovenox. On the day of discharge he was started
on coumadin 2mg po and instructed to follow up in two days to
have his INR monitored. He is to continue lovenox injections at
the reduced dose of 80 mg [**Hospital1 **] until his INR becomes therapeutic.
.
Chronic Health Issues:
GHVD: The patient was maintained in his home regimen of
cyclosporin and prednisone. A RUQ ultrasound was performed to
assess pt's chronic complaint of RUQ tenderness. Ultrasound was
without evidence of acute processes consistent with this pain.
Liver function tests were monitored throughout hospitalization.
AML: The patient was maintained in his home regimen of
cyclophosphamide, ACV, Bactrim and Voriconazole
Lower Extremity Edema: Has been an issue for several months.
Increased over his initial hospital course due to fluid
resusitation. He underwent gentle diuresis with lasix with
moderate improvement. An Echo was performed which showed
hyperdynamic LVEF. Pt was restarted on home lasix 20 mg po
prior to discharge.
Diabetes: Continued outpatient dose of NPH, lispro ss.
Avascular necrosis of hips bilateral: Outpatient pain regimen
continued.
Obstructive Sleep Apnea: The was given CPAP for his OSA. He
did not tolerate the face mask or nasal mask. He refused to use
CPAP for the remainder of his hospitalizaiton. He is scheduled
for an outpatient appointment with a sleep clinic in [**Month (only) 404**] to
introduce him to CPAP.
Medications on Admission:
Medications:
acyclovir 400mg TID
cyclosporine 50mg [**Hospital1 **]
Valium 5mg daily prn muscle spasm
folic acid 1mg daily
Lasix 20mg daily
Neurontin 300mg QHS
Insulin Lispro per sliding scale, NPH 12units [**Hospital1 **]
levofloxacin 500mg daily - until f/u with Dr. [**Last Name (STitle) 724**]
metoprolol 50mg [**Hospital1 **]
cxycodone 5mg 1-2 tabs Q4-6hr prn pain
OxyContin 20mg Q12hr
Protonix 40mg daily
prednisone 10mg daily
Actonel 35mg weekly
Androgel 50mg to torso daily
Bactrm SS one tab daily
voriconozole 200mg [**Hospital1 **]
Discharge Medications:
1. Supplemental oxygen
Please provide supplemental oxygen and necessary equipment.
Start at 2L/minute oxygen via nasal cannula and titrate oxygen
up to maintain oxygen saturations of greater than 94%.
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
7. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
8. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
11. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain.
15. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for muscle spasm.
16. Insulin
Please resume home insulin regimen:
NPH 12 units [**Hospital1 **]
Lispo per sliding scale
17. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
18. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
19. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
twice a day for 15 days.
Disp:*15 days supply* Refills:*0*
20. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA
Discharge Diagnosis:
Respiratory Syncytial Virus (RSV)
Pulmonary Embolism
Chronic Graft Versus Host Disease
Obstructive Sleep Apnea
h/o Acute Myelogenous Leukemia s/p BMT [**2142**]
Discharge Condition:
Stable; Pt requires supplemental oxygen with ambulation. He is
tolerating po diet and medications well.
Discharge Instructions:
You were admitted to the hospital for fever, low blood pressure,
and difficulty breathing. You were found to have a blood clot
in your left lung as well as an upper respiratory tract
infection with a virus called RSV. You were admitted to the ICU
until you were stabilized. Once you blood pressure returned to
[**Location 213**] and your fever resolved you were transferred to the floor
where you were closely monitored. Your shortness of breath
improved. However, you still required supplemental oxygen to
maintain adequate oxygen levels.
.
The following changes were made to your medications:
1) START Lovenox SC injections 80mg twice a day
2) START Albuterol inhaler 2 puffs every 4 hours as needed for
shortness of breath
3) START Warfarin (Coumadin) 3mg by mouth daily
4) STOP levofloxacin (levoquin)
5) INCREASE prednisone to 30 mg by mouth daily
.
.
Please continue taking all other home medications as previously
prescribed.
.
Please contact your physician or return to the hospital if you
experience fever, chills, chest pain, worsening cough, increased
difficulty breathing or any other symptom that is concerning to
you.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 3236**] in [**Hospital 3242**] clinic on Wednesday
[**2144-12-9**] at 10:30 am.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2144-12-9**] 10:30
ICD9 Codes: 5180, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3222
} | Medical Text: Admission Date: [**2131-12-5**] Discharge Date: [**2131-12-6**]
Date of Birth: [**2064-7-5**] Sex: F
Service: NEUROSURGERY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
[**2131-12-5**]: Right EVD placement
[**2131-12-5**]: Cerebral angiogram with coiling of the L ICA aneurysm
History of Present Illness:
Patient is a 67F with unknown PMH found unresponsive at work
sitting in a chair at her desk. Unknown for how long she was
unconscious. She was BIBA to the ED where she was noted to be
unconscious with decreased respirations. She was intubated,
following a difficult intubation requiring etomidate and succ x
2. On exam she showed no withdrawal to painful stimuli. She was
initially hypertensive with SBP in the 200s and bradycardia down
to 50s, sparking a concern for increased ICP. She was given
mannitol and showed improvement with SBP down to 120 and HR in
the 110's.
Past Medical History:
Unknown
Social History:
Has 1 son (patient's HCP along with his wife). Works as a
program director at a local college. + Tobacco
Family History:
Unknown
Physical Exam:
On admission:
Neuro:
Mental status: Unconscious and unresponsive to noxious stimuli.
Positive corneal and gag reflexes.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Unable to assess due to chemical paralytics and
sedation
V, VII: Unable to assess due to chemical paralytics and sedation
VIII: Unable to assess due to chemical paralytics and sedation
IX, X: Positive gag reflex
[**Doctor First Name 81**]: Unable to assess due to chemical paralytics and sedation
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Unable to assess motor
function due to chemical paralytics and sedation.
Sensation: Unable to assess sensory function due to chemical
paralytics and sedation.
Toes downgoing bilaterally
Pertinent Results:
[**2131-12-5**] Head CT:
1. Large subarachnoid hemorrhage involving the suprasellar
cistern, sylvian cisterns, ambient cisterns, interpeduncular
fossa, cerebral convexities and 4th ventricle.
2. 3mm rightward shift of midline structures.
3. Left temporal lobe intraparenchymal hemorrhage.
[**2131-12-5**] Head CT:
Interval enlargement of the IPH with increase in mass effect and
midline shift.
Brief Hospital Course:
67F who presented to the ER with an extensive SAH. An EVD was
emergently placed and she was taken to angiogram. A left ICA
aneurysm was seen and coiled. Loss of flow occurred in one of
the parent vessels and TPA was administered. Flow was
re-established. Post-angio she was taken to the TSICU. The
family was given an updated and they informed us that they would
want her DNR. Her pupils remained pinpoint. Later that evening
it was noted that her left pupil was 4mm and nonreactive, right
pupil remained pinpoint. She was taken emergently to CT. On
route, her ICPs were [**Location (un) 1131**] in the 60-70's and her SBP was
160-180's. Nicardipine was started and her EVD was lowered to
10. Her CT scan showed worsening IPH, mass effect, and midline
shift. A discussion with the family was held along with social
work and the RN. The family was notified of the events and the
CT findings. They were told that a left sided craniectomy would
be needed as a life saving measure, and given it was the left
side even with a craniectomy her prognosis would be poor. The
family declined further surgical intervention and requested that
the focus of care become comfort. NEOB was called, given patient
was a registered organ donor, the patient was kept intubated
until a rep from NEOB arrived to discuss options with the
family. Nicardipine gtt was restarted as her SBP was now in the
200's.
NEOB discussed organ donation with the family in which they
declined. The family also declined an autopsy.
Her EVD was clamped and she was electively extubated [**12-6**] at
24:50. A morphine drip was initiated and titrated to comfort.
She expired on [**2131-12-6**] at 03:46
Medications on Admission:
Unknown
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Subarachnoid hemorrhage
Left ICA aneurysm (ruptured)
Left intraparenchymal hemorrhage
Interventricular hemorrhage
Cerebral edema with brain compression
Hydrocephalus
Hypertension
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2131-12-6**]
ICD9 Codes: 3051, 4019, 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3223
} | Medical Text: Admission Date: [**2129-4-15**] Discharge Date: [**2129-4-25**]
Date of Birth: [**2058-10-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Syncope and Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History obtained from daughter's translation from this Persian
speaking woman.
70-yo-woman w/ CAD, V tach w/ AICD, and severe COPD was brought
to ED by EMS after falling at home. The pt felt well until early
this AM, when she removed her PM BiPAP and O2 to walk to the
bathroom. On her way the bathroom, her "legs felt wobbly" and
she fell to the floor. Did not strike her head or lose
consciousness. There were no preceding dizziness,
lightheadedness, chest pain, palpitations, or confusion. There
was no bowel or bladder incontinence. No weakness, numbness, or
difficulty speaking/understanding are reported. After her fall,
she was unable to rise from the floor and became increasing
short of breath as she struggled to rise. She called her
Lifeline, who dispatched EMS to her home. ROS further
demonstrates no fever, chills, abd pain, dysuria, melena,
hematochezia, back pain, prior muscle weakness. She did fall
last night as well, though she was able to rise herself and was
not evaluated.
On EMS arrival, pt was dyspnic and hypoxic, w/ O2 sat 80's. She
was brought to the ED, where her initial O2 sat was 83% on 4L/m
O2 by NC.
Past Medical History:
1. CAD: s/p 4-vessel CABG [**2119**]
2. CHF: ECHO [**1-3**] w/ 1+ MR, minimal AS, EF 40% w/ regional wall
motion abnormalities
3. DM Type 2
4. HTN
5. COPD: on home O2 3.5L/m, BIPAP (settings 14/8) with multiple
past admissions w/ pCO2 in the 70-80 range
6. Schizophrenia: initially symptomatic w/ paranoia and
hallucinations, well controlled w/ meds
7. L3 fracture: [**2127**]
8. Symptomatic VT: s/p ICD in [**1-2**]
Social History:
SH: lives alone in [**Hospital3 **] apartment; has home health
aide daily; meals are prepared by the pt's daughter; walks
independently but sometimes uses walker; uses home O2 at all
times and BiPAP at night; smoked 60 pack-years but quit in [**2123**];
no alcohol, IVDU, or cocaine use.
Family History:
1. CAD: mother died of MI at unknown age
Physical Exam:
PE: T 100.4, HR 82, BP 100/43, RR 23, O2 sat 92% on BiPAP 14/8
Gen: obese woman lying flat in bed wearing BiPAP, lethargic but
rousable, mild resp distress.
HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no JVD visible
in obese neck
CV: reg s1/s2, + 2/6 systolic murmur loudest at LLSB, no s3/s4/r
Pulm: mild crackles in bases B/L w/ scattered wheezes over
bases, poor air movement throughout
Abd: obese, +BS, soft, NT, ND
Ext: warm, 2+ DP B/L, no edema
Neuro: a/o x 3, CN 2-12 intact, strength 3/5 throughout LE B/L,
though unsure that pt is awake and understanding of exam
Pertinent Results:
[**2129-4-15**] 06:36PM TYPE-ART PO2-82* PCO2-65* PH-7.35 TOTAL
CO2-37* BASE XS-6
[**2129-4-15**] 06:36PM O2 SAT-96
[**2129-4-15**] 04:25PM TYPE-ART PO2-120* PCO2-76* PH-7.31* TOTAL
CO2-40* BASE XS-8
[**2129-4-15**] 04:25PM O2 SAT-98
[**2129-4-15**] 02:14PM CK(CPK)-36
[**2129-4-15**] 02:14PM CK-MB-NotDone cTropnT-<0.01
[**2129-4-15**] 02:14PM TSH-0.51
[**2129-4-15**] 02:14PM VALPROATE-12*
[**2129-4-15**] 01:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2129-4-15**] 01:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2129-4-15**] 01:43PM URINE RBC-0-2 WBC-[**7-9**]* BACTERIA-MOD
YEAST-NONE EPI-[**4-3**]
[**2129-4-15**] 01:43PM URINE HYALINE->50
[**2129-4-15**] 12:31PM TYPE-ART PO2-65* PCO2-73* PH-7.28* TOTAL
CO2-36* BASE XS-4
[**2129-4-15**] 06:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2129-4-15**] 06:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
[**2129-4-15**] 06:00AM URINE RBC-0-2 WBC-[**12-19**]* BACTERIA-FEW
YEAST-NONE EPI-0
[**2129-4-15**] 05:36AM TYPE-ART PO2-100 PCO2-52* PH-7.33* TOTAL
CO2-29 BASE XS-0
[**2129-4-15**] 04:58AM LACTATE-2.5*
[**2129-4-15**] 04:45AM GLUCOSE-186* UREA N-22* CREAT-0.9 SODIUM-142
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-32 ANION GAP-12
[**2129-4-15**] 04:45AM CK(CPK)-37
[**2129-4-15**] 04:45AM cTropnT-<0.01
[**2129-4-15**] 04:45AM CK-MB-NotDone proBNP-690*
[**2129-4-15**] 04:45AM CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-2.3
[**2129-4-15**] 04:45AM WBC-11.6* RBC-3.54* HGB-10.4* HCT-30.8*
MCV-87 MCH-29.4 MCHC-33.8 RDW-15.6*
[**2129-4-15**] 04:45AM NEUTS-90* BANDS-1 LYMPHS-5* MONOS-2 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2129-4-15**] 04:45AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ STIPPLED-1+
[**2129-4-15**] 04:45AM PLT COUNT-187
[**2129-4-15**] 04:45AM PLT COUNT-187
[**2129-4-15**] 04:45AM PT-12.0 PTT-20.6* INR(PT)-1.0
*
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calHCO3 Base XS Intubat Comment
[**2129-4-22**] 01:41AM ART 67* 67*1 7.39 42*2 11 NOT
INTUBA3
1 VERIFIED BY REPLICATE ANALYSIS
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
3 NOT INTUBATED
[**2129-4-21**] 04:40PM ART 97 62*1 7.42 42*2 12
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-21**] 03:29PM ART 55*1 65*1 7.39 41*2 10
NOT INTUBA3
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
3 NOT INTUBATED
[**2129-4-21**] 02:29PM ART 60* 65*1 7.38 40* 9
1 VERIFIED
PROVIDER NOTIFIED PER CURRENT LAB POLICY
[**2129-4-20**] 12:39PM ART 71* 72*1 7.38 44*2 13
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-20**] 11:28AM ART 59*1 70*1 7.37 42*2 11
1 VERIFIED
PROVIDER NOTIFIED PER CURRENT LAB POLICY
2 PROVIDER NOTIFIED PER CURRENT LAB POLICY
[**2129-4-19**] 02:01PM ART 84* 64*1 7.41 42*1 12 NOT
INTUBA2
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NOT INTUBATED
[**2129-4-19**] 10:44AM ART 84* 76*1 7.35 44*2 11 NOT
INTUBA3
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
3 NOT INTUBATED
[**2129-4-19**] 10:15AM ART 80* 75*1 7.33* 41*1 9
1 VERIFIED
PROVIDER NOTIFIED PER CURRENT LAB POLICY
[**2129-4-17**] 10:53PM ART 36.1 66* 68*1 7.32* 37* 5
NOT INTUBA2
1 PROVIDER NOTIFIED PER CURRENT LAB POLICY
2 NOT INTUBATED
[**2129-4-17**] 07:47AM ART 36.1 62* 67*1 7.36 39* 8
1 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-17**] 05:53AM ART 36.7 66* 71*1 7.35 41*1 9
NOT INTUBA2 VENTIMASK
1 NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
2 NOT INTUBATED
[**2129-4-17**] 02:51AM ART 36.7 53*1 63*1 7.38 39* 8
NOT INTUBA2 [**Hospital1 **] PAP 31 3
1 PROVIDER NOTIFIED PER CURRENT LAB POLICY
2 NOT INTUBATED
3 [**Hospital1 **] PAP 31 ..NP
[**2129-4-16**] 10:52PM ART 36.1 59*1 78*1 7.33* 43*1
10 NOT INTUBA2
1 PROVIDER NOTIFIED PER CURRENT LAB POLICY
2 NOT INTUBATED
[**2129-4-16**] 05:12AM ART 170* 68*1 7.34* 38* 8
1 VERIFIED BY REPLICATE ANALYSIS
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-15**] 06:36PM ART 82* 65*1 7.35 37* 6
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-15**] 04:25PM ART 120* 76*1 7.31* 40* 8
1 VERIFIED
NO CALLS MADE - SAME ABNORMALITY PREVIOUSLY NOTED TODAY
[**2129-4-15**] 12:31PM ART 65* 73*1 7.28* 36* 4
1 VERIFIED
PROVIDER NOTIFIED PER CURRENT LAB POLICY
[**2129-4-15**] 05:36AM ART 100 52* 7.33* 29 0
%
DIABETES MONITORING %HbA1c [Hgb] [A1c]
[**2129-4-16**] 05:24PM 6.5*1 DONE DONE
Admission Chest X ray
Mild cardiac failure and bilateral lower lobe atelectasis
*
[**2129-4-19**]
Chest AP:
Moderate-to-severe cardiomegaly is unchanged. Lungs grossly
clear. There is no pleural effusion or pneumothorax. Transvenous
pacer defibrillator lead projects over the expected course to
the floor of the right ventricle. Mild fullness in the upper
mediastinum with slight leftward deviation of the trachea at the
thoracic inlet is probably due to tortuous or enlarged head and
neck vessels or right lobe of the thyroid.
*
CTA of abdomen and lungs [**2129-4-19**]
IMPRESSION:
1. No evidence of pulmonary embolus or aortic dissection.
2. Diffuse emphysematous changes within the lungs with bilateral
small pleural effusions.
3. Diffuse coronary artery and aortic calcifications.
4. Calcified fibroid uterus.
5. Hypo attenuating lesion in segment VII of the liver which is
too small to characterize.
*
[**2129-4-17**]
ECG:
Sinus bradycardia and atrial ectopy. Diffuse ST-T wave
abnormalities, less
prominent as compared to the previous tracing of [**2129-4-15**]. In
addition, the rate
has slowed. Otherwise, no diagnostic interim change.
Brief Hospital Course:
A/P: 70-yo-woman w/ CAD, CHF, DM2, HTN, COPD on home O2, and
schizophrenia s/p fall, admitted to the MICU w/ and somnolence.
.
1. Hypoxia/respiratory distress:
This was thought to be copd exacerbation (The patient is on 4L
O2 NC at home at rest.) in the setting of a URI worsened by lack
of O2 after fall and complicated by a CHF exacerbation given
initial appearance of pulm edema on CXR. She ruled out for an MI
and interrogation of ICD showed no SVT or VT. She was treated
with a five daz course of azithromycin and a prednisone taper.
She had a nasal congestion which originally may have been
secondary to her URI but was exacerbated by her self medication
with Afrin nasal spray even after her medication was
discontinued. Upon discovery of this the patient agreed to avoid
its use. She developed these episodes of desaturation to 68%
while on her nasal Bipap mask which was thought to be secondary
to a central sleep apnea along with some question of her not
being able to tolerate the nasal bipap mask secondary to her
nasal congestion. When she desated her O2 sats were restored by
placing the patient on a 24% Venturi mask and 6L of O2. She was
seen by pulmonary who recommended incresaing her nocturnal bipap
for obstructive sleep apnea to 14/12 (from 14/8) and
continuation of progresterone for respiratory stimulation. She
was continued on bipap as above (and encouraged to use it during
the day as well as she is suspected of having OSA during day
time during naps). She was also diuresed with IV lasix with good
effect. She was also continued on standing albuterol and
atrovent nebulizers.
.
2. Lethargy:
With initiation of bipap lethargy improved. She was seen by
psychiatry while in the hospital who did not think that her
somnolence was secondary to her medications. It was felt that
this was due to her hypercarbia. Her family thought that she was
close to her baseline and she was cleared for discharge by
psychiatry.
.
3. CAD: h/o 4v CABG in [**2119**], w/ no subsequent symptoms. No
active issues during this hospitalization. She ruled out for
myocardial ischemia with serial negative cardiac enzymes. She
was continued on ASA 325mg daily, lipitor and toprol XL.
.
4. CHF:
She has CHF with an EF 40% secondary to ischemic cardiomyopathy.
She was volume overloaded on admission and was succesfully
diuresed. She was continued on an ACEI for afterload reduction.
.
5. Anemia:
Iron studies c/w Fe deficency. The epogen level was wnl at 25.9.
She was started on iron supplementation. We recommend further
follow up of this as an outpatient.
.
6. Fall:
This appeared to be mechanical without syncope. ICD
interrogation showed no arrhythmia. We suspected that her
unsteadiness might have been secondary to visual problems in
dark - pinpoint pupils from psych meds preventing accomodation.
Her UTI may have also contributed to her instability. Her mental
status cleared without focal neuro deficit.
.
7. UTI:
U/A demonstrated small leukocyte esterase, WBcs and moderate
bacteria. She was initially started on ceftriaxone while in the
ICU and upon discharge to the floor her repeat U/A was negative
and the ceftriaxone was discontinued. Her urine culture was also
negative.
.
8. DM type 2:
Her glyburide was increased to 10 mg [**Hospital1 **] and she was started
metformin 500 [**Hospital1 **]
.
9. HTN:
Her blood pressure was well controlled on her outpatient dose of
Toprol XL.
.
10. FEN: [**Doctor First Name **]/low sodium diet. 1.5 L fluid restriction.
.
11. Proph: heparin sc, PPI.
.
12. Code Status: DNI/DNR: confirmed w/ pt and daughter
.
13. In light of her continued improvement the patient was
discharged to pulmonary rehab.
Medications on Admission:
ASA 81 daily
Toprol 25 daily
Lipitor 10 daily
Lasix 40 daily
Digoxin 0.25 daily
Glyburide 5 [**Hospital1 **]
L-thyrox 125 daily
Medroxyprogesterone 10 qAM
Zoloft 100 qAM
Abilify 40 QHS
Risperdal 2 QHS
Depakote 125 [**Hospital1 **]
Restoril 7.5 QHS prn for sleep
Duo Neb qid
Flovent 4 puffs [**Hospital1 **]
Beconase AQ 2 puffs Nasal [**Hospital1 **]
Folate 1mg daily
PhosLo 2 tabs with meals
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: [**1-31**] Inhalation Q2H
(every 2 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: [**1-31**] NEB Inhalation
Q6H (every 6 hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Medroxyprogesterone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
UNITS Injection TID (3 times a day).
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig:
Two (2) Spray Nasal [**Hospital1 **] (2 times a day).
18. Aripiprazole 10 mg Tablet Sig: Four (4) Tablet PO QHS (once
a day (at bedtime)).
19. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
20. Prednisone 10 mg Tablet Sig: One (1) Tablet PO qd () for 1
doses.
21. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qd () for 1
doses.
22. Insulin Lispro (Human) 100 unit/mL Solution Sig: AS DIRECTED
Subcutaneous ASDIR (AS DIRECTED) for AS DIRECTED ON SHEET
ATTACHED weeks.
23. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every
4 hours) as needed for constipation.
24. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
25. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-31**] Sprays Nasal
QID (4 times a day) as needed.
26. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
27. Albuterol Sulfate 0.083 % Solution Sig: [**1-31**] NEBS Inhalation
Q4H (every 4 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Chronic obstructive pulmonary disease- on home O2 3.5L/m, BIPAP
qhs(settings 14/8) -baseline pCO2 = 60-70
Obstructive sleep apnea
Congestive Heart Failure
Inability to void- requiring foley catherization
Secondary
3. DM Type 2
4. HTN
Schizophrenia: initially symptomatic w/ paranoia and
hallucinations, well controlled w/ meds
L3 fracture: [**2127**]
Symptomatic VT: s/p ICD in [**1-2**]
Discharge Condition:
Good, stable on bipap and supplemental O2.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1500 mL
*
Please take all of your medications as prescribed.
*
Your dose of glyburide has been increased. You have been
started on a new medication metformin.
*
Please seek urgent medical attention should you develop
shortness of breath, chest pain, severe nausea or vomiting or
fevers or chills or other symptoms that concern you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2129-5-4**] 8:45
Provider: [**Last Name (NamePattern4) **]/EYE LIST OR EYE SURGERY Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2129-6-6**] 7:30
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2129-6-7**] 9:00
*
Please follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) 8741**] [**Telephone/Fax (1) 2936**]
within one week of discharge.
*
Please follow up with your cardiologist [**First Name5 (NamePattern1) 65250**] [**Last Name (NamePattern1) 65251**] at [**Telephone/Fax (1) 65252**] within one week of discharge.
*
Please follow up with your psychiatrist Dr. [**Last Name (STitle) 12696**] at [**Telephone/Fax (1) 65253**] within one week of discharge.
ICD9 Codes: 4280, 4240, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3224
} | Medical Text: Admission Date: [**2138-7-25**] Discharge Date: [**2138-7-27**]
Date of Birth: [**2080-5-28**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Rigid bronchoscopy [**2138-7-26**]
History of Present Illness:
58 yo F smoker, COPD not on medications who presented to [**Hospital1 9191**] for bronchoscopy for subacute hemoptysis. She was taken
to the OR and intubated for a flex bronch. A highly vascular,
completely obstructing bronchus intermedius mass was seen and
the scope was unable to be passed. Multiple washings and
brushings were performed, and four endobronchial biopsies.
Minimal amount of bleeding was noted that stopped with chilled
saline and 10 ML of 1:10,000 epi. She was transferred to [**Hospital1 18**]
for rigid bronch and possible staging. She remained intubated
for tranfer.
.
She reportedly developed transient hypotension immediately after
the procedure that was fluid responsive. She required no
pressors or blood products.
.
Upon arrival to the ICU, she is intubated and awake. Upon review
of OSH records and discussion with her husband, she had DOE x 1
year with right back pain that would not resolve with
conventional treatment. Approximately one month ago, she
developed a small amount, less than a teaspoon, of bright red to
dark hemoptysis usually mixed with sputum. She ultimately
presented to pulmonary clinic (Dr. [**First Name (STitle) 32953**] [**Name (STitle) 63685**]) [**7-23**] after an
abormal CT showing some concerning masses. He ultimately
performed the bronch at OSH today. She admits to a 12 pound
weight loss over the past year with decreased appetitie.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
COPD
Depression
Right Hip Replacement [**2135**]
Breast Implants several years ago
Social History:
[**11-23**] to 1 ppd x > 40 years. Cut down to 1/2 pack per day over the
past year. Drinks at least two beers per day. Denies drug use.
Works in an office job. Two grown healthy children.
Family History:
Mother died of lung cancer in her late 60s-early 70s. She was a
smoker. Father died of [**Location (un) 6988**] disease.
Physical Exam:
VS: 98.6 72 109/69 78 99% AC TV: 450, RR: 12, FiO2: 40%
GA: Intubated and awake. Responds appropriately to questions.
Appears comfortable. NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: Diffuse rhonchi in anterior lung fields
Abd: soft, NT, +BS. no g/rt. neg HSM.
Extremities: wwp, no edema. DPs, PTs 2+. clubbing in
fingers/toes
Skin: no rashes
Neuro/Psych: CNs II-XII grossly intact. no focal neurological
deficits.
Pertinent Results:
ADMISSION LABS:
.
[**2138-7-25**] 06:07PM GLUCOSE-85 UREA N-7 CREAT-0.5 SODIUM-138
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12
[**2138-7-25**] 06:07PM CALCIUM-8.3* PHOSPHATE-4.3 MAGNESIUM-1.9
[**2138-7-25**] 06:07PM WBC-4.7 RBC-3.92* HGB-10.8* HCT-34.4* MCV-88
MCH-27.6 MCHC-31.5 RDW-14.7
[**2138-7-25**] 06:07PM PLT COUNT-467*
[**2138-7-25**] 06:07PM PT-12.2 PTT-26.2 INR(PT)-1.0
.
Brief Hospital Course:
58 yo F long time smoker, h/o COPD p/w hemoptysis secondary to
bronchus intermedius mass transferred for endobronchial
intervention and a potential stent placement.
.
# Hemoptysis/Mass: Highly vascular mass concerning for
malignancy was found in bronchus intermedius. Patient underwent
flexible bronchoscopy at [**Hospital3 **] on [**2138-7-25**]. They
performed bronchial washings and biopsies. Due ot the size of
the mass and obstruction of airway she was transferred to [**Hospital1 18**]
for attempted rigid bronchoscopy with stenting. She arrived to
the hospital intubated. The following morning she underwent
rigid bronchoscopy. Her obstructing mass was not amenable to
stenting but she did have biopsies performed. She was extubated
and monitored overnight in the ICU. She tolerated the procedure
well. She did not have further episodes of hemoptysis. She was
continued on her home advair and albuterol. She was started on
codeine for cough suppression. Patient is schedule to call her
outpatient pulmonologist on Tuesday [**2138-7-29**] to review her biopsy
results and discuss further work up and interventions. She
remained hemodynamically stable throughout admission with stable
hematocrit between 30-33. Patient was counseled on warning signs
of infection or increased bleeding. She was given a
prescription for Augmentin to take incase she develops fevers or
other symptoms concerning for infection.
.
# Left Cavitary Lesion: Concerning for malignancy associated
with bronchial mass. However, must consider other possibilities
such as vasculitis/infection if biopsy proves to be negative for
malignancy. Lesion will be followed in outpatient setting by her
pulmonologist.
.
# COPD: Patient continued on home advair regimen.
.
#Code: Full code
#Communication: Husband [**Name (NI) 382**] [**Name (NI) **]: [**Telephone/Fax (1) 87334**]
#Dispo: HOME
Medications on Admission:
Zoloft 100 daily
Advair (does not use on a regular basis)
Albuterol PRN (new medication)
Discharge Medications:
1. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for cough: This medication may cause
drowsiness. Do not drive while taking this medication.
Disp:*60 Tablet(s)* Refills:*0*
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day.
Disp:*30 patches* Refills:*2*
6. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Lung mass
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
SpO2 95% on room air.
Hematocrit stable at 30-33.
Discharge Instructions:
You were transferred to [**Hospital1 18**] for further evaluation of your
recently diagnosed lung mass. You were admitted to the ICU for
monitoring of your airway. You underwent a procedure called a
rigid bronchoscopy that allows the airways to be better
visualized. A stent was not placed in your airway but biopsies
were taken. You were taken off the ventilator after the
procedure and continued to do well. Your blood counts were
monitored closely and remained stable.
.
The following changes have been made to your home medications:
1) START Codeine 30 mg tablet. Take 1 tablet every 4-6 hours as
needed for cough suppression. This medication may make you
drowsy. Please do not drive while taking this medication.
Please do not take more than 4 pills per day.
2) Nicotine patch 14 mg. 1 patch daily. Do not continue to
smoke while using the patch.
.
It is very important that you follow up your biopsy results with
your local pulmonologist in the following week. .
.
We strongly encourage you to stop smoking. You were started on
nicotine patches during your admission and tolerated them well.
Continue to use nicotine patches to help fight your cravings.
If you need additional help please talk to your pulmonologist or
primary care provider.
Followup Instructions:
Please call your pulmonologist's office on Tuesday [**2138-7-29**] to
schedule a follow up appointment to review your results.
ICD9 Codes: 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3225
} | Medical Text: Admission Date: [**2201-4-14**] Discharge Date: [**2201-4-28**]
Date of Birth: [**2127-1-28**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline / Ativan
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
abdominal pain, nausea, emesis
Major Surgical or Invasive Procedure:
[**2201-4-14**] - Endoscopic retrograde cholangiopancreatography
History of Present Illness:
This is a 74 year-old Male with a PMH significant for chronic
lower extremity pain syndrome (on narcotics), HTN, OSA (not on
CPAP), chronic constipation and undefined asymptomatic cardiac
septal defect who presented with acute onset abdominal pain,
nausea and emesis for 1-day who was found to have evidence of
gallstone pancreatitis and transferred from [**Hospital3 3583**] for
further management.
.
The patient notes that he awoke feeling well on [**2201-4-13**] and ate
a hotdog for lunch without issues; however, within an hour of
consumption he felt nausea and generalized malaise with chills.
Following these symptoms, he developed epigastric abdominal pain
that was [**8-4**] in intensity, that was intermittent and achy-dull
in character radiating through to his back. He notes that he had
a similar pain after breakfast a week prior to this episode; but
never before that. The patient also notes associated
non-bilious, non-bloody emesis surrounding his nausea. He denies
fevers. No unintentional weight loss. He notes yellowing of the
skin. He denies headache or vision changes. No loose or bloody
stools, notes recent constipation issues (last BM morning of
admission to OSH was dark, formed and non-bloody). Around 7PM,
his pain worsened and he presented to [**Hospital3 3583**]. Of note,
he has had on-going, bilateral proximal lower extremity pain
issues that has been managed for several months with Percocet
(previously with Celecoxib) and recent he started Prednisone 15
mg PO daily with some improvement.
.
At [**Hospital3 3583**], the patient arrived with VS 98.2 75 169/83
22 94% RA. Exam was notable for epigastric abdominal pain and
yellowing of the skin. Laboratory studies notable for WBC 12.6
(86.9% neutrophilia, no bandemia), HCT 47.5%, PLT 161.
Creatinine 0.87. LFTs: AST 446, ALT 413, AP 59, T-bili 3.8 with
lipase 639. Troponin 0.01. U/A negative. A CT abdomen and pelvis
demonstrated multiple gallstones, a prominent gallbladder
measured to 9-cm with mild stranding. There was also mild
pancreas stranding without evidence of small bowel obstruction.
He received 1L NS x 3, Zosyn 3.375 g IV x 1, Morphine 8 mg IV x
1 and Fentanyl 100 mcg IV x 1 for pain control; he received
Zofran 4 mg IV x 2, Protonix 80 mg IV x 1 with infusion
following. He also received Benadryl 25 mg IV x 1,
Metoclopramide 10 mg IV x 1 and [**Known lastname **] his recent steroid use,
Hydrocortisone 100 mg IV x 1. He was transferred to [**Hospital1 18**] for
further management and ERCP team evaluation.
.
In the [**Hospital1 18**] ED, initial VS 100.5 82 182/84 18 98%RA. Exam
notable for improved abdominal pain. Laboratory data notable for
WBC 9.6 (neutrophilia 89%), HCT 45.7, PLT 173. Creatinine 0.8.
INR 1.2. LFTs: AST 452, ALT 512, AP 73, T-bili 4.1, Albumin 0.8,
lipase 645. Lactate 2.1. An EKG demonstrated NSR @ 85, NA/NI,
IVCD, no ST-changes. ERCP fellow evaluated patient and agreed
with transfer for urgent ERCP needs. He received Dilaudid 2 mg
IV x 1, Zofran 4 mg IV x 1 and a Foley catheter was placed prior
to transfer. He received 1L NS x 2. Vitals prior to transfer,
97.9 149/79 81 15 95%RA.
.
On arrival to [**Hospital Unit Name 153**], he appears non-toxic and stable. He has some
epigastric abdominal complaints with mild nausea.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Chronic proximal lower extremity pain (on chronic narcotic
therapy, has trialed Celecoxib and recently started Prednisone
treatment)
2. Hypertension
3. Chronic constipation ([**Known lastname **] narcotic use)
4. Septal defect in myocardium (stable since childhood, serially
monitored with 2D-Echo)
5. Obstructive sleep apnea (does not tolerate CPAP use)
6. Hypogonadism
7. s/p appendectomy (years prior)
Social History:
Patient lives at home with his wife, [**Name (NI) **]. They have four
children who are grown. He is a retired finance officer. Prior
tobacco use for 20 years (15-20 pack-year); quit 25 years prior.
Recently discontinued alcohol use after his steroid initiation
([**2-27**] mixed drinks daily with 4-5 on weekends). No recreational
substance use.
Family History:
Mother had lung cancer; father with gallstones and aggressive
thyroid carcinoma. No strong cardiovascular history or history
of other malignancies.
Physical Exam:
ADMISSION EXAM:
.
VITALS: 97.9 149/79 81 15 96% RA
GENERAL: Appears in no acute distress. Alert and interactive.
Non-toxic appearing with notable jaundice.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes dry. Scleral icterus noted.
NECK: supple without lymphadenopathy. JVD difficult to assess
[**Known lastname **] body habitus.
CVS: Regular rate and rhythm, II/VII mid-systolic murmur heard
at LLSB without radiation, no rubs or gallops. S1 and S2 normal.
RESP: Decreased breath sounds at bases bilaterally without
adventitious sounds. No wheezing, rhonchi or crackles. Stable
inspiratory effort.
ABD: soft, diffusely tender to deep palpation, non-distended,
with normoactive bowel sounds. No palpable masses or peritoneal
signs. Negative [**Doctor Last Name 515**] sign.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
.
Pertinent Results:
.
IMAGING:
[**2201-4-13**] CT ABDOMEN & PELVIS (from [**Hospital3 3583**]) - multiple
gallstones, a prominent gallbladder measured to 9-cm with mild
stranding. There was also mild pancreas stranding without
evidence of small bowel obstruction (per Radiology report).
.
[**2201-4-19**] 05:50AM BLOOD WBC-10.5 RBC-4.50* Hgb-12.6* Hct-38.5*
MCV-86 MCH-28.0 MCHC-32.7 RDW-15.7* Plt Ct-183
[**2201-4-18**] 05:00PM BLOOD Hct-37.2*
[**2201-4-18**] 10:53AM BLOOD WBC-11.3* RBC-4.41* Hgb-12.5* Hct-38.2*
MCV-87 MCH-28.4 MCHC-32.8 RDW-15.7* Plt Ct-141*
[**2201-4-17**] 05:00AM BLOOD WBC-18.1* RBC-4.97 Hgb-14.0 Hct-43.5
MCV-88 MCH-28.2 MCHC-32.2 RDW-15.4 Plt Ct-146*
[**2201-4-16**] 03:35PM BLOOD Hct-43.8
[**2201-4-16**] 04:17AM BLOOD WBC-18.4* RBC-4.78 Hgb-13.1* Hct-41.4
MCV-87 MCH-27.4 MCHC-31.7 RDW-15.9* Plt Ct-149*
[**2201-4-14**] 09:05PM BLOOD WBC-11.8* RBC-5.05 Hgb-13.6* Hct-44.5
MCV-88 MCH-26.8* MCHC-30.5* RDW-15.9* Plt Ct-149*
[**2201-4-14**] 09:05PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL
[**2201-4-17**] 11:35PM BLOOD Neuts-85.6* Lymphs-5.7* Monos-8.2 Eos-0.4
Baso-0
[**2201-4-16**] 04:17AM BLOOD PT-15.2* PTT-34.6 INR(PT)-1.4*
[**2201-4-14**] 06:09AM BLOOD PT-12.7* PTT-28.2 INR(PT)-1.17*
[**2201-4-19**] 05:50AM BLOOD Glucose-98 UreaN-11 Creat-0.6 Na-142
K-2.8* Cl-101 HCO3-30 AnGap-14
[**2201-4-18**] 07:20PM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-143
K-2.7* Cl-103 HCO3-28 AnGap-15
[**2201-4-18**] 10:53AM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-146*
K-3.2* Cl-104 HCO3-28 AnGap-17
[**2201-4-17**] 11:35PM BLOOD Glucose-88 UreaN-9 Creat-0.6 Na-135
K-3.1* Cl-93* HCO3-27 AnGap-18
[**2201-4-17**] 05:00AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-132*
K-3.4 Cl-93* HCO3-26 AnGap-16
[**2201-4-16**] 07:30AM BLOOD Glucose-88 UreaN-9 Creat-0.7 Na-130*
K-3.3 Cl-94* HCO3-26 AnGap-13
[**2201-4-16**] 04:17AM BLOOD Glucose-97 UreaN-10 Creat-0.6 Na-132*
K-3.5 Cl-98 HCO3-25 AnGap-13
[**2201-4-15**] 06:45AM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-138
K-3.7 Cl-106 HCO3-22 AnGap-14
[**2201-4-14**] 09:05PM BLOOD Glucose-107* UreaN-13 Creat-0.7 Na-140
K-3.9 Cl-109* HCO3-22 AnGap-13
[**2201-4-14**] 06:09AM BLOOD Glucose-119* UreaN-16 Creat-0.8 Na-138
K-4.1 Cl-105 HCO3-22 AnGap-15
[**2201-4-19**] 05:50AM BLOOD ALT-71* AST-18 AlkPhos-54 TotBili-2.5*
[**2201-4-18**] 10:53AM BLOOD ALT-83* AST-22 CK(CPK)-180 AlkPhos-52
TotBili-2.9* DirBili-1.4* IndBili-1.5
[**2201-4-17**] 11:35PM BLOOD ALT-99* AST-25 CK(CPK)-60 AlkPhos-56
TotBili-2.6*
[**2201-4-17**] 11:55AM BLOOD CK(CPK)-83
[**2201-4-17**] 05:00AM BLOOD ALT-148* AST-23 CK(CPK)-86 AlkPhos-57
TotBili-2.6* DirBili-0.8* IndBili-1.8
[**2201-4-16**] 07:30AM BLOOD ALT-225* AST-32 CK(CPK)-109 AlkPhos-65
Amylase-78 TotBili-3.0*
[**2201-4-16**] 04:17AM BLOOD ALT-222* AST-32 AlkPhos-59 Amylase-88
TotBili-2.5*
[**2201-4-15**] 06:45AM BLOOD ALT-332* AST-83* LD(LDH)-291* AlkPhos-71
TotBili-2.4*
[**2201-4-14**] 09:05PM BLOOD ALT-393* AST-139* LD(LDH)-205 AlkPhos-72
TotBili-2.9*
[**2201-4-14**] 06:09AM BLOOD ALT-512* AST-452* AlkPhos-73 TotBili-4.1*
[**2201-4-19**] 05:50AM BLOOD Lipase-37
[**2201-4-17**] 05:00AM BLOOD Lipase-22
[**2201-4-15**] 06:45AM BLOOD Lipase-545*
[**2201-4-14**] 09:05PM BLOOD Lipase-1345*
[**2201-4-14**] 06:09AM BLOOD Lipase-645*
[**2201-4-18**] 10:53AM BLOOD CK-MB-6 cTropnT-<0.01
[**2201-4-17**] 11:35PM BLOOD CK-MB-3 cTropnT-<0.01
[**2201-4-17**] 11:55AM BLOOD CK-MB-3 cTropnT-<0.01
[**2201-4-17**] 05:00AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-3649*
[**2201-4-16**] 07:30AM BLOOD CK-MB-3 cTropnT-<0.01
[**2201-4-19**] 05:50AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.2
[**2201-4-18**] 07:20PM BLOOD Calcium-8.3* Phos-2.2* Mg-2.2
[**2201-4-18**] 10:53AM BLOOD Calcium-8.4 Phos-1.4* Mg-2.2
[**2201-4-17**] 11:35PM BLOOD Calcium-8.6 Phos-1.6* Mg-1.7
[**2201-4-18**] 12:03AM BLOOD Type-[**Last Name (un) **] pO2-140* pCO2-37 pH-7.50*
calTCO2-30 Base XS-5
[**4-14**] ERCP
Impression: Cannulation of the biliary duct was successful and
deep with a sphincterotome after a guidewire was placed.
Contrast medium was injected resulting in complete
opacification.
The common bile duct was dilated to 12 mm.
There were several filling defects in the mid-CBD consistent
with stones and/or sludge.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Balloon sweep x 3 was performed with successful extraction of
copious amounts of sludge and debris.
Final cholangiogram was normal without filling defects.
.
Recommendations: NPO overnight with aggressive IV hydration with
LR at 200 cc/hr.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ([**Pager number 8437**])
Continue aggressive management of pancreatitis.
Continue antibiotics x 7 days.
Consider cholecystectomy.
.
[**4-16**] CT abdomen/pelvis:
IMPRESSION:
1. Findings consistent with reported diagnosis of pancreatitis
with minimally increased peripancreatic and periduodenal fat
stranding as well as interval development of notable
pancreatico-duodenal groove bowel wall thickening likely related
to either groove pancreatitis or duodenal hematoma [**Known lastname **] recent
ERCP. No complications of pancreatitis such as : splenic venous
thrombosis, splenic artery pseudoaneurysm, focal abscess, or
phlegmon formation.
2. New bilateral pleural effusions, both small in size, right
greater than
left.
3. Bilateral hyperdense renal cystic lesions likely represent
hemorrhagic
cysts, could be further evaluated with renal ultrasound.
.
LENI [**4-17**]:
IMPRESSION: No DVT in the left upper extremity.
.
CXR [**4-18**]:
Left PICC line tip is at the mid SVC. NG tube passes below the
diaphragm
terminating most likely in the stomach. There is interval
development of
pulmonary edema on the top of preexisting consolidations in the
lung bases.
Pulmonary hypertension is most likely present [**Known lastname **] the
prominence of
pulmonary arteries.
.
[**4-19**] Head CT:
IMPRESSION: No CT evidence for acute intracranial process.
[**4-19**] CT ABD PELVIS: IMPRESSION:
1. Interval increase in peripancreatic stranding and duodenal
wall
thickening. No pseudocyst or other complication identified.
2. Hypodensities within the portal vein adjacent to the
pancreatic head may
represent flow artifact or less possibly thrombus. Attn on
followup.
3. Poor opacification of SMV does not allow for adequate
assessment.
.
[**2201-4-19**] CXR: FINDINGS: In comparison with the study of [**4-18**],
there is continued
enlargement of the cardiac silhouette with mild improvement in
pulmonary
venous pressure. Prominent pulmonary arteries are again seen
bilaterally.
Little change in the appearance of the nasogastric tube
.
[**4-22**] Video Fluoroscopy:
SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing
videofluoroscopy was
performed in conjunction with the speech and swallow division.
Multiple
consistencies of barium were administered. Barium passed freely
through the
oropharynx without evidence of obstruction. There is penetration
with thin
liquids. There was no gross aspiration. The barium tablet is
held up at the
vallecula but clears with multiple swallows of barium.
Degenerative change is
seen in the cervical spine.
IMPRESSION: Penetration with thin liquids. For details, please
refer to
speech and swallow note in OMR.
[**2201-4-24**] KUB:
FINDINGS: Two upright and two supine frontal views of the
abdomen show
gaseous distention of several loops of small bowel, increased
from [**2201-4-19**].
There is gas in non-dilated loops of large bowel as well as the
rectum. No
air-fluid level or evidence of pneumoperitoneum is detected.
Multiple
calcific densities are noted in the pelvis which may represent
vascular
calcifications seen on recent CT of [**2201-4-19**]. The visualized lung
bases
demonstrate mild atelectasis. The osseous structures are within
normal
limits.
IMPRESSION: Gaseous distention of the small bowel increased from
[**2201-4-19**] most
likely represents ileus; partial small bowel obstruction cannot
be entirely
excluded. No free air.
[**2201-4-25**] KUB
In comparison with the study of [**4-24**], there is gas within mildly
dilated
transverse colon. Remainder of the bowel gas is essentially
within normal
limits, so that the overall pattern most likely reflects
adynamic ileus.
Brief Hospital Course:
74M with a PMH significant for chronic lower extremity pain
syndrome (on narcotics and steroids), HTN, OSA (not on CPAP),
chronic constipation and undefined asymptomatic cardiac septal
defect who presented with acute onset abdominal pain, nausea,
emesis and jaundice for 1-day with CT evidence of obstructing
common biliary duct stone; mild-moderate transaminitis,
hyperbilirubinemia with lipasemia consistent with acute
gallstone pancreatitis now s/p ERCP with successful sludge
extraction. Hospital course was complicated by delirium,
hypertensive urgency with CP but no evidence of ACS. He also
developed pulmonary edema from aggressive hydration for his
pancreatitis, ileus, and required nutritional supplement with
TPN.
.
#Moderate-severe PANCREATITIS, ACUTE/GALLSTONE
PANCREATITIS/CHOLEDOCHOLITHIASIS W/ OBSTRUCTION: Patient
presented with abdominal, nausea, emesis and jaundice for 1-day
with CT imaging evidence of obstructing common biliary duct
stone; mild-moderate transaminitis, hyperbilirubinemia with
lipasemia consistent with gallstone pancreatitis. No prior
history of biliary colic or prior episodes of pancreatitis,
despite significant alcohol history. ERCP evaluated the patient
and felt urgent ERCP was necessary, this was performed with
stone and sludge extraction. Pt was felt to have had a moderate
pancreatitis and the general surgery and ERCP teams followed the
patient. Pt was [**Known lastname **] aggressive IV fluids and zosyn for concern
of possible early cholangitis at OSH prior to admission. Zosyn
was continued for 10 days. Pt was [**Known lastname **] IV narcotics and
antiemetics for pain control. [**Known lastname 227**] continued pain on the
medical floor, pt had a CT scan of the abdomen performed on [**4-16**]
showing concern for possible duodenal hematoma vs. edema from
pancreatitis. Both the ERCP and Surgery teams felt this to be
consistent with edema from pancreatitis [**Known lastname **] stability of Hct.
NG tube was placed [**Known lastname **] ileus. [**Known lastname 227**] prolonged, NPO status PPN
was initiated as there was no central access. Repeat CT scan
showed interval increase in peripancreatic stranding and
duodenal wall thickening. No pseudocyst or other complication
identified. His abdominal pain gradually improved. He had a
PICC line placed for TPN which he pulled out while delirious so
it was replaced and he continued on TPN as his diet was
gradually advanced. He failed a bedside speech and swallow and
underwent video swallow study. Speech and swallow recommended
ground solids and thin liquids. This should also be low fat and
low residue. Unfortunately he re-developed nausea and vomiting
and KUB showed increased gaseous distention. He was made NPO
again. Repeat KUB showed ileus. His diet was slowly advanced,
and he tolerated it well, without nausea or increase in
abdominal pain. At the time of discharge, his diet was low-fat,
no dairy, no coffee (as recommended by GI).
.
#Fever/Leukocytosis-likely due to above. CT scanning showed
acute pancreatitis. No dysuria, diarrhea, or cough to suggest
additional causes. lactate normal. Pt developed fever to 102 on
[**4-19**]. Vancomycin was added to the zosyn regimen. Serial BCX, UCX
were drawn which remained negative. Repeat CXR and CT
Abd/Pelvis did not show any new signs of infection. Vanco was
d/ced on [**4-21**] and the pt was monitored without any further fever
or leukocytosis. Zosyn was d/ced on [**4-24**] after 10 days
(including OSH coverage).
.
#Metabolic encephalopathy-Initially the patient was A&O x 3 but
with developed sundowning and delirium. He denied headache or
signs of meningitis. No evidence for seizures. Etiology was
likely multifactoral related to polypharmacy from opioids,
anti-emetics, age, acute illness, hospitalization. Infectious
work up was unrevealing EKG was not suggestive of ischemia. Pt
was [**Known lastname **] a 1:1 sitter to prevent pulling out of lines. Zyprexa
5mg [**Hospital1 **] was administered. Head CT showed no acute intracranial
abnormalities. His mental status gradually improved and at
discharge he is alert and oriented x3, [**Location (un) 1131**] newspapers.
.
#Chest pain/Hypertensive urgency-Pt developed CP and SOB [**4-16**]
overnight in setting of SBP 180-200. EKG unchanged from prior.
Serial cardiac biomarkers negative. He was [**Known lastname **] aspirin and SL
nitro in that setting. No events were recorded on telemetry.
This was likely due to pain, pulmonary edema and hypertensive
urgency. Pt was placed on standing IV hydralazine and metoprolol
which was later transitioned to PO metoprolol. Lisinopril was
also added later in his hospitalization.
.
#Pulmonary edema/volume overload-Thhis was related to aggressive
fluid resuscitation as recommended for gallstone pancreatitis.
IV fluids were decreased and pt was [**Known lastname **] lasix. He required 2L
of NC but this was weaned off.
.
# POLYMYALGIA RHEUMATICA on SYSTEMIC STEROID THERAPY
CHRONIC LOWER EXTREMITY PAIN - Patient presented with
long-standing history of chronic lower extremity edema which has
been managed with chronic narcotics (Percocet), trial of
Celecoxib and now Prednisone dosing (since [**2201-3-31**]) with
improvement. Pain symmetric and isolated to the proximal lower
extremities concerning for polymylagia rheumatica. His EMG was
reassuring. The differential also includes rheumatoid arhtirits
vs. hypothyroidism vs. spondyloarthropathy vs. fibromyalgia vs.
myopathy. Pt was continued on prednisone 15mg daily which was
converted to hydrocortisone when the pt was NPO. He received
Dilaudid for pain but when his mental status improved, he was
transitioned to oxycodone. He did not have any signs of vascular
compromise. He should follow up with his PCP for further
management.
.
# HYPERTENSION - History of hypertension that has been managed
on ACEI previously, but now only beta-blockers (Atenolol daily).
See above, pt was [**Known lastname **] standing IV hydralazine and metoprolol
but was later restarted on an ACEI. Hydralazine was not
continued.
.
#Duodenal hematoma?-There was concern raised on CT imaging. Hct
remained stable. Other differential included edema related to
acute pancreatitis. Surgery and ERCP teams monitored the
patient.
.
#Acute on chronic CONSTIPATION with ileus - This has been an
on-going issue since his narcotic use for his lower extremity
pain. CT without evidence of bowel obstruction and his last
bowel movement was formed, hard and non-bloody the morning prior
to admission. Aggressive bowel regimen attempted, but pt was
found to have an ileus. NGT was placed and the patient remained
NPO especially as he was also delirious. When his mental status
improved, NGT was d/ced and he was restarted on a PO bowel
regimen. He later developed diarrhea but KUB showed increased
gaseous distention suggestive of an ileus.
.
# Diarrhea - Later in his hospitalization, the pt developed
diarrhea. Cdiff test was negative. Diarrhea improved.
.
#Hyponatremia/hypernatremia - This was managed with IVF
intermittently during his hospitalization.
.
#OSA-does not tolerate CPAP. Outpt f/u.
.
#Thrombocytopenia-could be due to acute illness, vs. medication
effect. Improved.
TRANSITIONAL ISSUES
1. Follow a low-fat diet, avoiding dairy and coffee.
2. Antihypertensives changed to metoprolol 25 mg [**Hospital1 **] and
lisinopril 20 mg daily.
3. Check K and Cr next week (on [**4-26**] here, K was 3.6 and Cr 0.7).
4. Follow-up with Surgery for elective cholecystectomy
5. Other notable labs on last check: Hct 39.4 (borderline low),
ALT 101, AST 41, AlkPhos 65, Total Bili 0.7. Would repeat LFTs
in the outpatient setting.
6. Abd CT on [**4-16**] showed: "Bilateral hyperdense renal cystic
lesions likely represent hemorrhagic cysts, could be further
evaluated with renal ultrasound." Can consider renal ultrasound
in outpatient setting, if clinically indicated.
7. Abd CT on [**4-19**] showed: "Hypodensities within the portal vein
adjacent to the pancreatic head may represent flow artifact or
less possibly thrombus. Attn on followup." Would consider
repeat imaging in follow-up.
Medications on Admission:
HOME MEDICATIONS (confirmed with patient's Pharmacy)
1. Percocet 5/325 mg (1-2 tabs) PO Q6H PRN pain
2. Aspirin 81 mg PO daily
3. Atenolol 50 mg PO daily
4. Prednisone 15 mg PO daily (started [**2201-3-31**])
5. Sennosides 2 tabs PO daily
6. Testosterone (Androgel) 1 application topically daily
7. Citalopram 20 mg PO daily
8. Ergocalciferol 50,000 units PO weekly
9. Lactulose 30 mL ([**1-26**] teaspoons) PO daily
Discharge Medications:
1. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID
(2 times a day).
Disp:*1 BOTTLE* Refills:*0*
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home With Service
Facility:
Gentiva/[**Location (un) 86**]
Discharge Diagnosis:
acute gallstone pancreatitis
choledocholithiasis
delirium
fever
pulmonary edema
ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for further evaluation of gallstone
pancreatitis. For this, you underwent an ERCP which removed
stones from your bile ducts. Ultimately, you will likely need
your gallbladder removed. Your hospital course was complicated
by delirium, fever, hypertension, and ileus. Your symptoms
improved.
.
Medication changes:
1. Lisinopril 20 mg daily for blood pressure
2. Metoprolol 25 mg [**Hospital1 **] for blood pressure (instead of
atenolol).
.
You should have your liver function tests, potassium level, and
creatinine level (kidney function) checked at your visit with
Dr. [**First Name (STitle) **] next week.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 640**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: INTERNAL MEDICINE
Address: [**Apartment Address(1) 63839**], [**Location (un) **],[**Numeric Identifier 40624**]
Phone: [**Telephone/Fax (1) 25821**]
Appointment: WEDNESDAY [**5-6**] AT 2:30PM
**Your appointment for Wednesday [**4-29**] has been cancelled
and the appointment above has replaced it.**
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: [**Last Name (LF) **], [**Name8 (MD) **] MD
When: TUESDAY [**2201-5-26**] at 1:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2201-5-27**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 2761, 2760, 5119, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3226
} | Medical Text: Admission Date: [**2195-12-9**] Discharge Date: [**2195-12-17**]
Date of Birth: [**2116-3-28**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
diverticulitis s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3379**] pouch on [**12-4**]
Major Surgical or Invasive Procedure:
L IJ central line placement
History of Present Illness:
79 yo female with was initially admitted on [**12-1**] to [**Hospital1 **] because of increasing abdominal pain. She was
initially treated with antibiotics, but then underwent
exploratory laporotomy on the [**12-4**] with lysis of adhesions,
repair of an enterocolic fistula and perforated sigmoid colon
from diverticulitis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3379**] pouch. The procedure was
uncomplicated and the intraoperative blood loss was estimated to
be 200cc. She was treated with Ceftazidime and Flagyl
postoperatively.
Notes are indicating positive liquid stool on [**12-7**]. On [**12-8**] she
was noted to be tachycardic, tachypneic and had an increased
temperature. Her WBC was newly elevated to 16.6. On [**12-9**] she was
intubated because of difficult breathing. An infection was
suspected and the patient was changed to Vanco, Zosyn and
Flagyl. She was found to have tachycardia and elevated troponin.
A CXR showed signs of congestive heart failure. An EKG was read
as old RBBB, lef ant hemiblock, sinus tachycardia and diffuse
ST-T changes. Elevated troponin was considered to be demand
versus NSTEMI. Lasix was given for pulm edema.
A CT of the chest was done and showed bilateral pleural
effusions with bibasialr atelectasis as well as multifocal RUL
subsegmental opacities concerning for pneumonitis. CT of the
abdomen showed a fluid collection between the anterior
peritoneal reflection and the transverse colon with two small
gas bubbles, possible postoperative seroma. Also 15cm inferior
fluid collection extending into the pelvis without signs of
infection, possible seroma. No bowel ischemia or evidence of
infection. 1.5 cm focus in the liver is likely a cyst.`
Troponin I continued to trend up from 0.01 on [**12-5**] to 1.98 on
[**12-9**]. Also AST was found to be elevated at 1163. INR was
elevated.
Postoperatively she developed decreased urine output with stable
BUN and creatinine, thought to be due to prerenal etiology with
a component of acute tubular necrosis from volume depletion/
decreased cardiac output in the context of an MI and toxicity
from contrast. A renal ultrasound was negative for obstruction.
Past Medical History:
diverticulitis >> [**12-4**] [**Doctor Last Name 3379**] pouch
HTN
Hypothyroidism
Social History:
non-smoker, drinks occasionally
Family History:
heart disease in mother
Physical Exam:
VS T 98.4 BP 114/71 HR 94 RR 24 O2Sat100 on AC 0.6/450/16/5
Gen: NAD, AAOx3
HEENT: NC/AT, PERRLA, mmm
NECK: no LAD, no JVD, R IJ in place
COR: S1S2, regular rhythm, no m/r/g, laterally displaced PMI
PULM: CTA anteriorly, decreased breath sounds at bases, no
wheezing or rhonchi
ABD: + bowel sounds, soft, nd, nt
Skin: warm extremities, no rash
EXT: 2+ DP, no edema/c/c, warm peripheral extremities
Neuro: moving all extremities, following commands, PERRLA,
reflexes 2+ b/l
Pertinent Results:
[**2195-12-9**] 04:32PM FIBRINOGE-523*
[**2195-12-9**] 04:32PM PT-20.5* PTT-30.0 INR(PT)-2.0*
[**2195-12-9**] 04:32PM PLT COUNT-292
[**2195-12-9**] 04:32PM NEUTS-91.8* LYMPHS-5.9* MONOS-2.1 EOS-0.1
BASOS-0.1
[**2195-12-9**] 04:32PM WBC-15.2* RBC-3.51* HGB-10.6* HCT-30.1*
MCV-86 MCH-30.2 MCHC-35.2* RDW-15.4
[**2195-12-9**] 04:32PM ALBUMIN-2.7* CALCIUM-8.4 PHOSPHATE-2.9
MAGNESIUM-2.0
[**2195-12-9**] 04:32PM CK-MB-NotDone cTropnT-0.31*
[**2195-12-9**] 04:32PM LIPASE-35
[**2195-12-9**] 04:32PM ALT(SGPT)-281* AST(SGOT)-379* LD(LDH)-360*
CK(CPK)-50 ALK PHOS-86 AMYLASE-48 TOT BILI-0.4
.
CXR [**12-9**]
1. Lines and tubes as described above. Nasogastric tube needs
advancement as its tip is at the gastroesophageal junction.
2. Mild pulmonary edema.
3. Retrocardiac left lower lobe opacity could represent
atelectasis or
consolidation
.
ECHO:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and
cavity size are normal. No masses or thrombi are seen in the
left ventricle. Overall left ventricular systolic function is
severely depressed. Tissue velocity imaging E/e' is elevated
(>15) suggesting increased left ventricular filling pressure
(PCWP>18mmHg). Resting regional wall motion abnormalities
include severe hypokinesis of the entire mid to distal LV with
apical and anterior wall akinesis. Right ventricular chamber
size and free wall motion are normal, but the RV apex may be
hypokinetic. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction c/w
multivessel coronary artery disease. No LV thrombus is
appreciated. Moderate to severe tricuspid regurgitation and mild
mitral regurgitation. Mild pulmonary hypertension.
.
CT abdomen/pelvis:
1. Several small mesenteric fluid pockets, too small for
percutaneous
drainage. No drainable fluid collection.
2. Diffuse bowel wall thickening, which is of uncertain
clinical significance in the setting of recent bowel surgery and
mesenteric fluid.
3. Bilateral pleural effusions and bibasilar atelectasis.
Superimposed
pneumonia cannot be excluded by imaging.
4. Bilateral adrenal fullness.
5. Scoliosis and spondylosis with grade 1 anterior listhesis at
L3/4 and
L5/S1.
.
EKG: SR, HR 90, RBBB, LAFB, TWI in V3-V6, I, II and aVL.
Brief Hospital Course:
79 yo diverticulitis s/p hartmann operation c/b post-operative
fever, leukocytosis and elevated troponin with subsequent
reintunation for respiratory distress.
.
# Respiratory failure: multifactorial with component of
infection given RUL, RML infiltrate, as well as evidence of
pulmonary edema. A PE was considered low likelyhood. CVP on
admission was low suggesting against R heart failure. ECHO
showed EF of 20% with severe MR, leading to pulmonary edema. She
was empirically started on Vanco/ZOsyn, mainly for possible
intraabdominal infection but also treating a possible PNA
underlying the pulmonary edema. LENIs were negative for DVT
suggesting against a PE as an etiology. The patient was
aggressively diuresed over severeal days and was slowly weaned
from the vent. She was extubated on the 7 and tolerated it well.
She was mainainted on 2lO2 postextubation.
.
# SIRS: pt with leukocytosis, temperature spike at OSH,
tachypnea, meets [**3-7**] criteria for SIRS. Possible infection could
be pulmonary, given CT findings. Also, intrabdominal infection
postoperatively needs to be considered. While CT of the abdomen
did not show any abscess it was not an ideal study with
contrast. No evidence of wound infection. POssible line sepsis.
Central line was resited. All cultures were negative. The
patient was given Vanco+Zosyn for a ten day course as
recommended by surgery.
.
# Acute myocardial infarction before transfer: likely MI several
days prior. Eccho with Severe regional left ventricular systolic
dysfunction c/w multivessel coronary artery disease. No LV
thrombus is appreciated. Moderate to severe tricuspid
regurgitation and mild mitral regurgitation. Mild pulmonary
hypertension. Cardiology was consulted, and she was started on
afterload redcution for severe mitral regurgitation as well as
metoprolol and Plavix (Aspirin-allergic)
.
# ARF: most likely prerenal from borderline hypotension,
possible poor cardiac froward flow, early sepsis. Also possible
component of ATN. Continues to maintain good urine flow.
Creatinine improved rapidly.
.
# Elevated INR: likely depletion of Vitamin K. No evidence of
DIC as fibrinogen elevated. Vitamin K was given.
.
# S/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] resection. Pain regimen. Surgery was consult for
postoperative management. Tube feed were slowly advanced to
goal. TPN was given for 2 days. CT abdomen was consistent with
post-op changes.
.
# FEN: s/p OG tube placment via endoscopy. Tube feeds were
adanced to goal. TPN for two days to bridge. Post-extubation
swallow eval suggested nectar thickened liquids, pureed slids,
alternate between bites and sips, check oral cavity for
residues.
.
# Code: full
Medications on Admission:
Meds on admission to OSH:
Hyzaar 25/12.5
Synthroid 0.088mg
Augmentin and Flagyl
Lactobacillus
.
Meds on transfer:
Metoprolol iv 5mg Q6h
Heparin sc 5000 BID
Vancomycin 1000 Q24h
Zosyn 3.375 Q6h
Flagyl 500 Q8h
Nitro paste
ISSC
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: [**1-5**] Injection
TID (3 times a day).
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Puff Inhalation every six (6) hours as needed.
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed for fever or pain.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Captopril 12.5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
12. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 1 days.
13. Morphine 10 mg/mL Solution Sig: Two (2) mg Intravenous
every 4-6 hours as needed for pain.
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 1 days.
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
s/p Hartmann procedure
Respiratory failure due to hypoxia
Hospital acquired pneumonia
NSTEMI
CHF, systolic with decreased ejection fraction
Discharge Condition:
Fair, able to tolerate po, 2L oxygen requirement, able to
transfer from bed to chair with support
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Please notify your providers if you have any chest pain,
shortness of breath, fevers, abdominal pain or any other
concerns.
Followup Instructions:
Please follow up with a cardiologist to optimize your cardiac
regimen.
Please follow up with you primary care doctor.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 0389, 5185, 5849, 486, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3227
} | Medical Text: Admission Date: [**2185-8-25**] Discharge Date: [**2185-8-28**]
Date of Birth: [**2119-4-16**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
right HNP of C5-C6 with compression of exiting nerve root
Major Surgical or Invasive Procedure:
right ACDF C5-C6
History of Present Illness:
66-year-old man with a history of diabetes type 2, CAD, status
post RCA PTCA, PVD, status post bilateral lower extremity PTCAs,
hypercholesterolemia
and a-fib who had presented to the hospital for elective ACDF of
C5-6.
Physical Exam:
Neuro:
Motor strength 5/5 deltoid, biceps, triceps, and hand intrinsics
bilaterally.
Sensory: decreased appreciation to pinprick in 1st 2 digits of
right hand.
Reflexes: 2+ in triceps and left biceps, but right biceps was
un-elicitable.
Lhermitte's phenomenon present.
No point tenderness or clonus.
Pertinent Results:
[**2185-8-25**] 10:27PM TYPE-ART PO2-332* PCO2-51* PH-7.32* TOTAL
CO2-27 BASE XS-0
[**2185-8-25**] 09:57PM GLUCOSE-187* UREA N-20 CREAT-1.3* SODIUM-141
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-12
[**2185-8-25**] 09:57PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-1.6
[**2185-8-25**] 09:57PM PT-13.9* PTT-23.6 INR(PT)-1.2*
[**2185-8-25**] 05:34PM GLUCOSE-146* UREA N-20 CREAT-1.3* SODIUM-144
POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-24 ANION GAP-12
[**2185-8-25**] 05:34PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-1.6
[**2185-8-25**] 05:34PM WBC-8.5 RBC-3.83* HGB-11.7* HCT-33.3* MCV-87
MCH-30.6 MCHC-35.1* RDW-14.3
[**2185-8-25**] 05:02PM TYPE-ART PO2-304* PCO2-45 PH-7.34* TOTAL
CO2-25 BASE XS--1 INTUBATED-INTUBATED
[**2185-8-25**] 05:02PM GLUCOSE-124* LACTATE-2.3* NA+-143 K+-3.8
CL--112
[**2185-8-25**] 05:02PM HGB-11.4* calcHCT-34
[**2185-8-25**] 05:02PM freeCa-1.11*
Brief Hospital Course:
Patient is 66 year old male with h/o right NHP of C5-C6. He was
taken to the OR on [**2185-8-25**] where he had a right ACDF of C5-C6.
There were no complications during the procedure. However,
postoperatively, he experienced left hemiparesis and underwent
MRI/MRA of head and neck which were all within normal limits. He
remained intubated and in SICU overnight. The next morning his
motor function returned to almost normal with the exception of
left deltoid weakness. He was extubated. He was transferred out
of the ICU. Diet and activity were advanced. He continued to
improve. He was seen by PT who felt he would benefit from some
outpt PT. His incision was clean and dry with steristrips.
Medications on Admission:
levothyrox
lipitor
amiodarone
atenolol
Discharge Medications:
1. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours)
as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
HNP C5-C6 on the right with compression of the exiting C6 nerve
root
Discharge Condition:
neurologically stable
Discharge Instructions:
You may shower and pat dry but do not submerge in water for 2
weeks. Watch for bleeding, redness, swelling, drainage. Remove
steristrips in 10 days if they have not yet fallen off.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 548**] in 4 weeks. Call for appointment
[**Telephone/Fax (1) 2992**]
Completed by:[**2185-8-28**]
ICD9 Codes: 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3228
} | Medical Text: Admission Date: [**2177-4-29**] Discharge Date: [**2177-4-30**]
Date of Birth: [**2104-11-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72F AFib, COPD, h/o SBO, HTN, breast and thyroid CA, s/p
tracheostomy several years ago after breast cancer surgery and
hysterectomy presenting from [**Hospital3 **] with respiratory
distress found to have sigmoid volvulus. Initially she was noted
to be desatting to the 70s on 2L o2 at her [**Hospital1 1501**]. There is no
other documentation of the details prior to being [**Last Name (un) 4662**] tot he
ED and the patient is nonverbal and responds only by nodding or
shaking head. Her sister says that she usually does speak.
She was brought into the ED where initial vitals were: 97.2 137
123/108 22 96% 15L. She was noted to have mucus plugging of her
trach and was suctioning with improvement of her respiratory
status and satting 100% on 15L trach mask. However in the ED she
was noted to have a rigid abdomen and dilated bowel on initial
CXR. A KUB again demonstrated dilated loops of bowel with
multiple air fluid levels very suggestive of sigmoid volvulus.
CT abd was performed which again demonstrated volvulus. Surgery
was consulted and after discussion with the pt the decision is
that the pt would not want to live with a colostomy which would
be the outcome of the surgery but this was not definitive.
Notable labs were Lactate 3.6, WBC count 14.9, elevated
creatinine from baseline 0.7->1.3. She was given vanc and zosyn
for possible evolving sepsis and was admitted to the MICU.
She was then admitted to the MICU. Vitals on transfer were:
Vitals on transfer were: 98.9 rectal, Afib - low 100s, 122/72,
95% on trach mask RR 30. GI was consulted who recommended
emergent sigmoidoscopy for decompression. The sister and HCP
agreed with this plan and sigmoidoscopy was performed. She
complains of moderate abd pain as well as SOB.
.
Of note the patient was recently admitted [**Date range (3) 100915**] for
multifocal PNA treated with vancomycin, zosyn for 10 day course.
.
Review of systems:
(+) Per HPI
(-) Unable to ellicit.
Past Medical History:
Depression
Bilateral breast CA
Thyroid CA (had short term trach after this, was removed at age
29)
Movement disorder (blepharospasm)
psychosis
bilateral blindness (retinal detachments from trauma)
HTN
atrial fibrillation
hypercholesterolemia
hypoparathyroidism
s/p tracheostomy (complication of intubation from lumpectomy
about 4 years ago)
Social History:
lives at [**Hospital3 2558**], sister and brother-in-law live nearby
but spend the summers in [**Country 6607**]. Retired in [**2165**], social worker.
Quit tobacco in [**2134**]. Rare EtOH.
Family History:
maternal aunt with [**Name (NI) **]
[**Name (NI) **] heart failure in his 60s
Physical Exam:
Vitals: T98.9 110, 122/72, 95% on trach mask RR 30
General: Daiphoretic, drowsy but arousable, Does not speak
without trach valve, nodding or shaking head in response to
questions but somewhat slow to respond
HEENT: Sclera anicteric, dMM, oropharynx clear, both pupils
dilated and nonresponsive (legally blind)
Neck: supple, JVP not elevated, no LAD
CV: Tachy, irreg irreg, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diminished breath sounds at bases, high pitched breath
sounds from trach projecting throuighout otherwise clear
Abdomen: Firm and rigid, no bowel sounds, breath sounds heard
over abdomen. Does not appear very tender but difficult to
ascertain
GU: no foley
Ext: warm, well perfused, no clubbing, cyanosis or edema
Pertinent Results:
[**2177-4-29**] 10:09PM BLOOD WBC-3.9*# RBC-4.47 Hgb-12.3 Hct-40.8
MCV-91 MCH-27.5 MCHC-30.1* RDW-13.7 Plt Ct-162
[**2177-4-29**] 11:50AM BLOOD WBC-14.9*# RBC-4.43 Hgb-12.7 Hct-41.8#
MCV-94# MCH-28.7 MCHC-30.5*# RDW-14.1 Plt Ct-267
[**2177-4-29**] 11:50AM BLOOD Neuts-86.8* Lymphs-8.2* Monos-4.7 Eos-0.1
Baso-0.2
[**2177-4-29**] 10:09PM BLOOD Glucose-122* UreaN-50* Creat-1.4* Na-138
K-6.3* Cl-111* HCO3-20* AnGap-13
[**2177-4-29**] 11:50AM BLOOD Glucose-147* UreaN-53* Creat-1.3* Na-143
K-3.5 Cl-104 HCO3-21* AnGap-22*
[**2177-4-29**] 11:50AM BLOOD ALT-50* AST-41* AlkPhos-81 TotBili-0.4
[**2177-4-29**] 10:09PM BLOOD Mg-6.5*
[**2177-4-29**] 11:50AM BLOOD Albumin-4.9
[**2177-4-29**] 10:20PM BLOOD Type-ART pO2-52* pCO2-39 pH-7.23*
calTCO2-17* Base XS--10
[**2177-4-29**] 10:20PM BLOOD Lactate-5.1*
[**2177-4-29**] 12:12PM BLOOD Lactate-3.6*
CXR 11:30am
FINDINGS: Lung volumes are very low likely due to severe
abdominal distention from dilated large bowel. There are
bibasilar opacities, which likely represents atelectasis;
however, pneumonia cannot be ruled out. The patient has
tracheostomy in appropriate position. No evidence of
pneumothorax. No large pleural effusion identified. Please see
dedicated abdominal films for better characterization of the
abdominal findings.
.
IMPRESSION:
1. Very low lung volumes, likely given distention of abdomen.
This is
causing bibasilar atelectasis, however, pneumonia or aspiration
cannot be
ruled out given the basilar opacities. No free air identified.
.
KUB 11:30 am
FINDINGS: The large bowel is dilated and filled with air. There
is no
definite air-fluid level seen. There is consolidation or
atelectasis seen in the right lower lobe. No free air is
identified.
IMPRESSION: Dilated large bowel in a configuration that may
represent a
sigmoid volvulus, see subsequent CT.
.
CT ABD 12:00pm
IMPRESSION:
1. Sigmoid volvulus. Markedly distended loops of large bowel
with thin wall, can not exclude ischemia. Lack of IV contrast;
can not evaluate wall enhancement.
2. Bibasilar opacities may represent atelectasis or
pneumonia/aspiration.
3. Nonobstructing stone in the left renal pelvis.
4. Stable hypodensities in the liver compared to [**2176-10-1**].
.
KUB [**2177-4-29**] 5:52 pm
FINDINGS: Two supine frontal views of the abdomen demonstrate
increased
lucency in the right abdomen and [**Last Name (un) 100916**] sign consistent with a
large amount
of intraperitoneal free air. Massive dilatation of the large
bowel is not
improved from the preceding radiograph, consistent with sigmoid
volvulus,
better seen on CT performed at 13:50 p.m. The visualized osseous
structures
are within normal limits.
IMPRESSION:
1. Large amount of free intraperitoneal air consistent with
perforated
viscus. 2. Persistent massive dilatation of large bowel
consistent with sigmoid volvulus, unchanged from preceding
radiographs and CT.
.
CXR [**2177-4-29**] 9pm
FINDINGS: Large free pneumoperitoneum is present causing
elevation of
bilateral hemidiaphragms. Left-sided subclavian line ends at mid
SVC. Lung
volumes are low. [**Hospital1 **]-basal atelectasis is present and upper lungs
are clear.
Cardiomediastinal silhouette is normal. A tracheostomy tube is
present in
situ. The findings regarding the pneumoperitoneum and subclavian
line was
already communicated by Dr. [**Last Name (STitle) 1603**] with Dr. [**First Name (STitle) 1743**] by phone
at 10:54 p.m. on [**2177-4-29**].
Brief Hospital Course:
72F AFib, COPD, h/o SBO, HTN, breast and thyroid CA, s/p
tracheostomy several years ago after breast cancer surgery and
hysterectomy presenting from [**Hospital3 **] with respiratory
distress found to have sigmoid volvulus.
.
#Signoid Volvulus: She presented with shortness of breath from
sigmoid volvulus with massive distension causing lung
compression. The surgical team recommended surgery for
decompression and likely colectomy. There was a discussion with
the patient and her sister who is her HCP with the decision that
she would not want to live with a colostomy which would be the
likely result of a surgery and that she would prefer less
invasive option. They expressed understanding that her condition
was very serious and that not undergoing surgery would expose
her to the risk of death. The GI team was then consulted who
performed a successul reduction by sigmoidoscopy. However, she
became hypotensive and tachycardic later that evening and KUB
showed free air in the peritoneum. A central line was placed and
vasopressor medications were started. A repeat CXR showed
massive free air in the peritoneum from a ruptured viscous.
Despite aggressive IV fluids and multiple vasopressor
medications she was unable to maintain an adequate blood
pressure and she passed away.
Medications on Admission:
#. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
#. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic TID
#. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
#. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
#. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
#. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **]
#. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
#. perphenazine 8 mg Tablet Sig: Two (2) Tablet PO BID
#. levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY
#. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
#. diltiazem HCl 45 mg PO QID
#. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H
#. Bisacodyl 10mg PR QD PRN
#. Milk of magnesia 30mls daily PRN
#. Gabapentin 100mg TID
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
ICD9 Codes: 0389, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3229
} | Medical Text: Admission Date: [**2132-6-19**] Discharge Date: [**2132-6-26**]
Date of Birth: [**2062-10-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
chest pain, ruled in for myocardial infarction, transfer for
cardiac catheterization
Major Surgical or Invasive Procedure:
s/p emergent cabg x3
History of Present Illness:
Pt is a 69 yo female who is was transferred from [**Hospital **]
Hospital with an NSTEMI. Pt began having chest pain 2-3 weeks
ago with exertion, while cleaning out the fridge. Pain is
midsternal, and radiates below arms and to back. Pain is
squeezing sensation, not sharp. Occurs with physical activity,
and bending over, and at night, which keeps her from sleeping.
Pain has been intermittent, but as of late, is more constant.
Pain was associated with nausea, vomiting, weakness, and
diaphoresis. Upon arrival to [**Name (NI) **], pt was pain free. She had
+ enzymes with abnl ecg. Pt received ASA, heparin, KCL. Denies,
syncope, urinary symptoms, fevers, chills, constipation,
abdominal pain, orthopnea, PND, or claudication. Transferred to
[**Hospital1 18**] for cardiac cath.
Past Medical History:
hypertension, elevated cholesterol, peripheral vascular disease
- s/p left iliac stent, s/p right CEA, hyperthyroidism,
scoliosis
Social History:
Smoked 4 cigarettes per day. No ETOH. Lives alone, no children.
She is a telephone operator.
Family History:
No premature CAD
Physical Exam:
Afebrile, BP 121/80, Pulse 68 regular, Resp 20 with 93% RA sats.
She is alert and oriented. No focal motor deficits. Lungs were
CTA. Heart sounds were regular, no murmur or gallop. Wounds were
clean, dry and intact. Abdomen was benign. Extremities were warm
with trace edema.
Pertinent Results:
[**2132-6-19**] 11:37PM WBC-9.8 RBC-4.22 HGB-12.8 HCT-37.5 MCV-89
MCH-30.4 MCHC-34.2 RDW-13.1
[**2132-6-19**] 11:37PM GLUCOSE-101 UREA N-26* CREAT-1.3* SODIUM-140
POTASSIUM-2.9* CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
[**2132-6-19**] 11:37PM PT-13.5* PTT-64.0* INR(PT)-1.2
[**2132-6-23**] 07:30AM BLOOD WBC-13.3* RBC-3.51* Hgb-10.4* Hct-30.2*
MCV-86 MCH-29.6 MCHC-34.4 RDW-15.7* Plt Ct-157
[**2132-6-23**] 07:30AM BLOOD Plt Ct-157
[**2132-6-23**] 07:30AM BLOOD Glucose-118* UreaN-25* Creat-1.2* Na-138
K-3.6 Cl-104 HCO3-26 AnGap-12
[**2132-6-20**] 10:45AM BLOOD ALT-15 AST-33 CK(CPK)-118 AlkPhos-41
Amylase-34 TotBili-0.8
[**2132-6-20**] EKG
Sinus tachycardia
Probable left atrial abnormality
Borderline low QRS voltage - is nonspecific
Probable prior inferior myocardial infarction
Probable anterior myocardial infarction possible acute/recent/in
evolution
Since previous tracing of same date, sinus tachycardia present
[**2132-6-20**] Cardiac Catheterization
1. Selective angiography of this right dominant system revealed
severe
left main and three vessel coronary artery disease. The LMCA was
calcified and had an ostial 50-60% stenosis. The LAD was a large
wraparound vessel that had a 95% proximal stenosis and supplied
two
modest-sized diagonal branches, which had mild diffuse disease.
The LCx
was occluded in its mid-portion, and supplied two obtuse
marginal
branches. The first OM was a small vessel that had a 90%
stenosis. The
second moderate-sized OM filled via left-to-left collaterals.
The RCA
had moderate diffuse disease up to 80% in the mid and distal
vessel
before the takeoff of a small PDA.
2. Resting hemodynamic measurements revealed mildly elevated
left-sided
filling pressures, with an LVEDP of 20-22 mm Hg. The central
arterial
pressure was mildly elevated at 140/61 (mean 77) mm Hg. There
was no
gradient across the aortic valve upon catheter pullback from the
LV to
the ascending aorta.
3. Left ventriculography revealed mildly depressed systolic
function,
with a calculated ejection fraction of 40%. Global hypokinesis
and
apical akinesis was present. No mitral regurgitation was
visualized.
4. Distal aortography revealed diffuse bilateral iliac disease
with
focal 80% right external iliac disease and diffuse (up to 50%)
left
iliac disease.
Brief Hospital Course:
Patient was admitted on [**6-19**] with NSTEMI. She was started on
Integrilin and Plavix. She otherwise remained pain free on
medical therapy. Cardiac catheterization on [**6-20**] was
significant for left main and severe three vessel CAD.
Ventriculography showed depressed LV systolic function with mild
global hypokinesis, apical akinesis, and an EF of 40%.
Catheterization was also notable for diffuse bilateral
peripheral vascular disease. Based on the above results, cardiac
surgery was urgently consulted for revascularization surgery.
That same day, emergent three vessel coronary artery bypass
grafting was performed(LIMA to LAD, SVG to PDA, SVG to Diagonal)
by Dr. [**Last Name (STitle) **]. Following the operation, she was brought to
the CSICU. She was extubated on POD #1. Chest tubes were removed
on POD #2 without incident. She maintained good hemodynamics as
Lopressor was resumed. She remained in a normal sinus rhythm
with occasional PVC's. On POD #2, she transferred to the SDU.
Lopressor was advanced as tolerated. Given her depressed LV
function, an ACEI was eventually resumed. She remained in a NSR
without atrial or ventricular dysrhythmias. With diuresis, she
continued to make clinical improvements. At discharge, she was
tolerating room air(with 91-93% saturations) but remained
several pounds above her preoperative weight. She will continue
gentle diuresis while at rehab. She was discharged to rehab on
POD #6 in stable condition.
Medications on Admission:
HCTZ 50 mg Qd
Quinipril 20 mg Qd
Toprol XL 25 mg Qd
Slow KCL 20 meq Qd
ECASA 325 mg Qd
MVI
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
6. Quinipril Sig: One (1) 10 mg once a day.
7. Slow KCL Sig: One (1) 20 meq PO once a day for 7 days: Slow
release. Take with Lasix.
Discharge Disposition:
Extended Care
Facility:
tt
Discharge Diagnosis:
s/p cabg x3 on [**6-20**]
elev. chol.
hypertension
peripheral vascular disease; s/p left iliac stent
s/p R CEA
hyperthyroidism
scoliosis
bronchitis
Discharge Condition:
stable
Discharge Instructions:
may shower over incisions; pat dry
may not drive for one month
may not lift greater than 10 pounds for 10 weeks
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 8521**] in [**1-13**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**1-13**] weeks
follow up with Dr. [**Last Name (STitle) 70**] in office for postop visit at 4
weeks [**Telephone/Fax (1) 170**]
Completed by:[**2132-6-26**]
ICD9 Codes: 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3230
} | Medical Text: Admission Date: [**2179-6-3**] Discharge Date: [**2179-6-11**]
Date of Birth: [**2118-6-22**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This 60-year-old female had a
known history of hypertension and angina with elevated
cholesterol and had increasing chest pain over the past 4
months. She describes her episodes as occurring with exertion
and it is approximately 8 out of a scale of 10, squeezing,
nonradiating, and resolved with rest. She had a positive
exercise tolerance test and ejection fraction of 65%. Had a
cardiac catheterization at [**Hospital1 **] prior to admission to
[**Hospital1 **] [**First Name (Titles) **] [**2179-6-3**]. Cardiac
catheterization revealed a 90% distal left main, 70% ostial
LAD, normal circumflex, normal right, and ejection fraction
of 60%. She was transferred into [**Hospital1 18**] for CABG and referred
to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Angina.
4. GERD.
5. Stress incontinence.
6. Depression.
7. Lupus.
8. Status post bilateral knee surgery.
ALLERGIES: She is allergic to penicillin.
MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o. once a day,
atenolol 25 mg p.o. once a day, Protonix 40 mg p.o. once a
day, Ditropan 10 mg p.o. once a day, Lipitor 20 mg p.o. once
a day, [**Location (un) 63735**] Wort daily, and fish oil daily.
FAMILY HISTORY: She had a positive family history for
coronary artery disease.
SOCIAL HISTORY: She lives alone and had no tobacco or
alcohol history.
PHYSICAL EXAM: On exam, she was in no apparent distress, 5
feet tall, 86.2 kilograms with noted obesity. Pupils are
equal, round, and reactive to light and accommodation. EOMs
are intact. Her oropharynx was unremarkable. Her neck was
supple with full range of motion, no lymphadenopathy or
thyromegaly. Her carotids are 2+ bilaterally without bruits.
Her lungs were clear to A and P. Her heart was regular rate
and rhythm without any murmurs, rubs, or gallops and normal
S1, S2 tones. Her abdomen was obese, soft, nontender with
positive bowel sounds and no masses or hepatosplenomegaly.
Her extremities had no clubbing, cyanosis, or edema. She had
pulses 2+ bilaterally and bilateral groin sheaths were in
place. Her neuro exam was nonfocal.
LABORATORIES: Preop labs are as follows: White count 5.7,
hematocrit 39.8, platelet count 222,000. Sodium 140, K 5.5,
which corrected overnight, chloride 109, bicarbonate 27, BUN
14, creatinine 0.7, blood sugar of 118. PT 12.2, PTT 26.1
with an INR of 1.0. ALT 29, AST 45. CK 102. Alkaline
phosphatase 72, total bilirubin 0.4. Troponin 1.0. Magnesium
1.9, calcium 9.1, phosphorus 4.7. HBA1c 6.1%. Urinalysis was
positive for blood, but negative for bacteria.
Chest x-ray preoperatively showed minimal patchy atelectasis
with suboptimal views. Official report of chest x-ray dated
[**2179-6-3**].
Carotid ultrasound performed preoperatively showed less than
40% bilateral ICA stenoses and bilateral antegrade vertebral
flow. She also had an EKG done preoperatively, which showed
sinus bradycardia at 58, which was otherwise normal.
HOSPITAL COURSE: Patient was admitted to the hospital after
transfer in from [**Hospital1 **] to our coronary care unit where
the rest of her preoperative workup was completed. On
hospital day 1, she was hemodynamically stable. Cardiology
was consulted. Patient was transferred onto the floor.
Creatinine was stable at 0.7, K 4.0. Hematocrit 39.8. She was
seen and evaluated by case management. Carotid studies were
completed the following day. See above results as dictated,
and the patient was transferred out to [**Hospital Ward Name 121**] 2 on the 15th for
continued monitoring over the weekend.
On hospital day 3, she was in sinus rhythm. Echocardiogram
was ordered. Her exam was unremarkable. Remained in sinus
rhythm at a rate of 65. Preliminary echocardiogram showed no
MR, normal LV function. Apical window was poor and unable to
assess a gradient across the aortic valve. Please refer to
the official report dated [**2179-6-5**].
On[**6-7**], patient underwent coronary artery bypass grafting
x2 by Dr. [**Last Name (Prefixes) **] with a LIMA to the LAD and a vein graft
to the ramus. Patient was transferred to the cardiothoracic
ICU in stable condition on a propofol drip and sinus rhythm.
On postoperative day 1, patient had been extubated the
evening before. She remained on an insulin drip at 2.2. units
per hour. Was hemodynamically stable with a pressure of
133/59, in sinus rhythm at 96. Creatinine was stable
postoperatively at 0.6 with a hematocrit of 30 and a white
count of 13.7. Chest tubes were removed. Swan was removed.
Beta-blockade began with Lopressor, and the patient was
transferred out to the floor.
On postoperative day 2, patient's exam was unremarkable other
than an ecchymotic area around her sternum, but incision was
clean, dry, and intact. Right lower extremity was clean, dry,
and intact. Central venous line was removed. Pacing wires
remained in place. Patient began IV Lasix diuresis and
continued completing her perioperative vancomycin. Creatinine
remained stable at 0.7 with a hematocrit of 27.3. Patient was
encouraged to begin ambulating, increasing her activity level
with nursing and physical therapists as well as encouraged to
work harder on her pulmonary toilet. Patient was seen and
evaluated by physical therapy, and transitioned to p.o.
Percocet for pain management.
On[**Last Name (STitle) 14810**]perative day 3, there were no events overnight.
Lopressor was increased to 25 mg p.o. b.i.d. Aspirin was
started for her anemia. Hematocrit had dropped from 27.3 to
25.4, and pacing wires were discontinued. On [**6-11**], patient
was discharged to home in stable condition with VNA services
with the following follow-up instructions: Patient was
instructed to followup with primary care physician in
approximately 2 weeks postdischarge, to followup with
patient's cardiologist 2 weeks postdischarge, and to see Dr.
[**Last Name (Prefixes) **] in the office in 4 weeks for postop surgical
visit.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x2.
2. Hypertension.
3. Hypercholesterolemia.
4. Gastroesophageal reflux disease.
5. Stress incontinence.
6. Status post bilateral knee surgeries.
7. Depression.
8. Lupus.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Protonix 40 mg p.o. once a day.
3. Enteric-coated aspirin 81 mg p.o. once a day.
4. Percocet 5/325 one to 2 tablets p.o. p.r.n. q.4h. as
needed for pain.
5. Lipitor 20 mg p.o. once a day.
6. Metoprolol 25 mg p.o. twice a day.
7. Ferrous sulfate 325 mg tablet p.o. twice a day.
8. Vitamin C 500 mg p.o. twice a day.
9. Lasix 20 mg p.o. twice a day x7 days.
10. Potassium chloride 20 mEq p.o. twice a day x7 days.
DISPOSITION: Again, the patient was discharged to home with
VNA services in stable condition on [**2179-6-11**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2179-7-13**] 16:39:37
T: [**2179-7-14**] 07:03:09
Job#: [**Job Number 63736**]
ICD9 Codes: 4111, 2720, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3231
} | Medical Text: Admission Date: [**2192-10-3**] Discharge Date: [**2192-10-8**]
Date of Birth: [**2134-8-4**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with
known coronary artery disease, who had been offered coronary
artery bypass graft in the past but had refused, who had had
angioplasty and stenting in [**Month (only) 547**], followed by brachytherapy,
who now presented with chest pain and congestive heart
failure, presented to an outside hospital and was taken to
the cardiac catheterization laboratory, which showed
progression of his disease. The patient was transferred to
[**Hospital1 69**] for evaluation and
coronary artery bypass graft.
Several weeks prior to admission, the patient had developed
chest pain and dyspnea on exertion. The patient now is
willing to have the coronary artery bypass graft, and was
transferred here for that. Cardiac catheterization at the
time revealed a 90% left anterior descending stenosis, 80%
diagonal stenosis, an ejection fraction of 65%.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Significant for coronary artery
disease status post angioplasty and stent, status post
brachytherapy, high cholesterol, borderline diabetes.
MEDICATIONS ON ADMISSION: Lipitor 40 mg by mouth once daily,
Plavix 75 mg by mouth once daily, atenolol 25 mg by mouth
once daily, enteric-coated aspirin 325 mg by mouth once
daily.
His electrocardiogram was sinus bradycardia at 50 beats per
minute, with some lateral ST/T wave changes which were
stable.
SOCIAL HISTORY: Significant for significant alcohol abuse,
six to seven drinks per day, and tobacco one to one and a
half packs per day for many years.
LABORATORY DATA: On admission, white count was 5.6,
hematocrit 40.4, platelets 494. PT 12.8, PTT 27.6, INR 1.1.
Sodium 137, potassium 4.2, chloride 104, bicarbonate 23, BUN
27, creatinine 1.0, glucose 110. ALT 27, AST 16, alkaline
phosphatase 83, total bilirubin 0.4.
PHYSICAL EXAMINATION: He was afebrile, vital signs stable.
He was in no apparent distress. His pupils were equally
round and reactive to light. His extraocular muscles were
intact. He had no lymphadenopathy. His neck was supple,
with no bruits. His lungs were clear to auscultation
bilaterally. His heart had distant heart sounds, regular
rate and rhythm, with no murmurs, gallops or rubs. His
abdomen was soft, obese, nontender, nondistended. His bowel
sounds were present. He had no hepatosplenomegaly. His
extremities were warm and well perfused, with no edema, and
2+ dorsalis pedis pulses bilaterally.
HOSPITAL COURSE: The patient was admitted to the hospital
and we planned for coronary artery bypass graft at that time.
The patient consented to the coronary artery bypass graft,
and chest x-ray and preoperative laboratories were done.
The patient was taken to the operating room on [**2192-10-5**], where
a coronary artery bypass graft x 2 was performed. The
patient did well postoperatively, and was slowly weaned from
his ventilator and was extubated. He continued to do well.
He was kept on an alcohol drip for prevention of delirium
tremens. He was started on beta blockers and lasix, and he
was transferred to the floor.
On the floor, his chest tubes were removed. His Foley was
removed, and his wires were also removed. Physical Therapy
was consulted for ambulation and endurance. He did quite
well, and it was felt that he could quickly achieve Level V
and be discharged home. The patient, when transferred to the
floor, was also given as needed alcohol at his request, in
order to request delirium tremens. He was continued on his
Plavix postoperatively for an off-pump coronary artery bypass
graft. All of his lines were removed, as stated previously,
and he continued to improve.
On postoperative day number three, he achieved Level V of
physical therapy, and was discharged home in stable
condition.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg by mouth once daily
2. Percocet one to two tablets by mouth every four hours as
needed
3. Enteric-coated aspirin 325 mg by mouth once daily
4. Zantac 150 mg by mouth twice a day
5. Potassium chloride 20 mEq by mouth twice a day
6. Colace 100 mg by mouth twice a day
7. Lasix 20 mg by mouth twice a day
8. Lopressor 25 mg by mouth twice a day
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass graft, status post angioplasty, status post stenting,
status post brachytherapy
2. High cholesterol
3. Borderline diabetes; blood sugars in-hospital were within
the normal range, without requiring treatment
The patient is discharged in stable condition, and instructed
to follow up with Dr. [**Last Name (STitle) 70**] in four weeks, and with his
primary care physician in one to two weeks. The patient is
discharged home in stable condition.
Please see addendum for any changes in medications or change
in discharge date.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 10459**]
MEDQUIST36
D: [**2192-10-7**] 22:14
T: [**2192-10-8**] 00:15
JOB#: [**Job Number 40683**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3232
} | Medical Text: Admission Date: [**2109-1-10**] Discharge Date: [**2109-1-18**]
Date of Birth: [**2109-1-10**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 24049**] is a former 3.20
kilogram product of a 38 [**1-7**] week gestation pregnancy born to
a 38 year old gravida V, now P III woman. Prenatal screens:
Blood type A positive, anti-[**Doctor Last Name **] antibody positive, Rubella
immune, RPR nonreactive, hepatitis B surface antigen
negative, group beta strep status unknown. The pregnancy was
complicated by hypertension for two weeks prior to delivery.
The mother had an elective induction which resulted in a
vaginal delivery under epidural anesthesia. Apgars were 9 at
one minute and 9 at five minutes. The infant was admitted to
the newborn nursery. Course was notable for significant
jaundice. Blood type was A positive, Coombs negative.
Phototherapy was initiated for a peak serum bilirubin of
12.9/0.4 mg per dl. On day of life number 4 he developed a fever
to 101.3 degrees Fahrenheit and he was admitted to the neonatal
Intensive Care Unit for evaluation for sepsis. Of note his 18
year old brother had been to visit and held him. He later
reported sore throat and fever.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit weight 3.095 kilograms, head
circumference 35 cm. In general nondysmorphic term male.
Head, eyes, ears, nose and throat: Anterior fontanelle soft
and flat, nondysmorphic facies. Palate intact. Chest:
Clear breath sounds. Cardiovascular: No murmur. Femoral
pulses plus 2. Abdomen soft with normal bowel sounds, no
hepatosplenomegaly. Genitourinary: Normal male genitalia.
Testes descended bilaterally. Musculoskeletal: No hip
click, no sacral dimple. Neurologic: Active with normal
tone, cries but easily consoled. Normal activity.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. RESPIRATORY: [**Known lastname **] was on room air for his entire
Neonatal Intensive Care Unit admission. There was no
evidence of respiratory distress.
2. CARDIOVASCULAR: [**Known lastname **] maintained normal heart rates and
blood pressure. No murmurs were noted.
3. FLUIDS, ELECTROLYTES AND NUTRITION: [**Known lastname **] continued to
ad lib P.O. feed breastfeeding or Similac formula. He had
normal urine and stool output.
4. INFECTIOUS DISEASE: Due to the fevers [**Known lastname **] was
evaluated for sepsis. A complete blood count was within
normal limits. Blood and cerebrospinal cultures were
obtained. He was started on intravenous ampicillin,
gentamicin and Acyclovir. The bacterial cultures were no
growth at 48 hours and the ampicillin and gentamicin were
discontinued. The herpes simplex virus PCR was obtained
at the time of the lumbar puncture and was negative with
the results reported on [**2109-1-18**]. Upon performance of
the lumbar puncture there were 311,000 red blood cells and
3,000 white blood cells. There were no bacterial
organisms seen on the gram stain and as both cultures were
negative the possibility of meningitis was ruled out. At
the time of discharge [**Known lastname **] continued to have a higher
than normal body temperature with baseline temperatures
98.6 to 99.6 degrees Fahrenheit. The parents are
instructed to call the pediatrician if the fever is over
101 degrees Fahrenheit.
5. GASTROINTESTINAL: As previously noted [**Known lastname **] was treated
for unconjugated hyperbilirubinemia with phototherapy.
His rebound bilirubin was 10.5/0.8 on day of life number
three. Liver function tests were sent as part of his
sepsis evaluation and were within normal limits.
6. HEMATOLOGY: [**Known lastname **] is blood type A positive and is
Coombs negative.
7. NEUROLOGY: [**Known lastname **] has maintained a normal neurological
examination during admission. There were no concerns at
the time of discharge. Due to the bloody (reportedly non-
traumatic) LP, HUS was done to rule out intracranial
hemorrhage. HUS was normal. Subarachnoid hemorrhage is
possible, and would not have been picked up on HUS alone, but
would not have necessitated further clinical management,
therefore further imaging was not done.
8. AUDIOLOGY: Hearing screen was performed with automated
auditory brain stem responses. [**Known lastname **] passed in both
ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents. The primary
pediatrician is either Dr. [**Last Name (STitle) 38832**] or Dr. [**First Name (STitle) 4223**] [**Hospital 59106**], [**Hospital1 59107**], [**Location (un) 686**],
[**Numeric Identifier 59108**]. Phone number [**Telephone/Fax (1) 7976**]. Fax number
[**Telephone/Fax (1) 12895**].
1. Feeding ad lib breast feeding.
2. No medications.
3. Car seat position screening not indicated.
4. State newborn screen was sent on [**2109-1-12**] with no
notification of abnormal results to date.
5. Hepatitis B vaccine administered on [**2109-1-12**].
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 of:
1) born at less than 32 weeks; 2) born between 32 and 35
weeks with two of the following: Day care during RSV
season, a smoker in the household, neuromuscular disease,
airway abnormalities, or school age siblings; 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:
1) [**Hospital6 407**] will be making home visits to
check temperature and support mother with breast feeding.
2) Appointment [**Location **] within
three days of discharge.
DISCHARGE DIAGNOSES:
1. Fever likely secondary to viral illness.
2. Suspicion for sepsis, ruled out.
3. Suspicion for HSV infection, ruled out.
4. Unconjugated hyperbilirubinemia, treated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) 59109**]
MEDQUIST36
D: [**2109-1-18**] 13:26:59
T: [**2109-1-18**] 14:46:16
Job#: [**Job Number 59110**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3233
} | Medical Text: Admission Date: [**2159-11-19**] Discharge Date: [**2159-11-28**]
Date of Birth: [**2119-8-19**] Sex: F
Service:
ADDENDUM TO HOSPITAL COURSE: The patient was kept for
several days in the hospital in order to achieve a INR of
2.5. The patient's goal for her INR for her mechanical valve
is 2.5 to 3.5. She was discharged on 5 mg of Coumadin po q
day and will be followed by her cardiologist for INR levels.
The patient has a St. [**Male First Name (un) 1525**] mitral valve.
DISCHARGE MEDICATIONS: Warfarin 7.5 mg po q day, nicotine 14
mg t.d. q day for two weeks and then 7 mg t.d. q day for
another two weeks and then stop. Sertraline 50 mg po q day,
Lopressor 25 mg po b.i.d., Colace 100 mg po b.i.d., Zantac
150 mg po b.i.d., aspirin 325 mg po q day.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 8455**]
MEDQUIST36
D: [**2159-11-28**] 14:01
T: [**2159-11-28**] 15:18
JOB#: [**Job Number **]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3234
} | Medical Text: Admission Date: [**2134-1-18**] Discharge Date: [**2134-1-19**]
Service: MEDICINE
Allergies:
Valproic Acid
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
respiratory distress, fever, afib/flutter with rapid ventricular
response, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 yo F with Ushers syndrome (deafness, retinitis pigmentosa,
vestibular symptoms), [**Hospital **] rehab patient who presented to ED
in respiratory distress, fever, afib/flutter with rapid vent
response, hypotension. She was found to have multifocal pna on
CXR and floridly positive u/a. She was given a dose of ceftaz
and vanco. The pateint is DNR/DNI and discussion was had with
family to defer aggressive measures. She arrived to [**Hospital Unit Name 153**] in
respiratory distress and was given morphine. Per report she was
taken off digoxin and changed from verapamil to lopressor
yesterday.
Past Medical History:
# [**Doctor Last Name 21568**] syndrome characterized by deafness, retinitis
pigmentosa and vestibular symptoms.
# Schizophrenia.
# Depression.
# Hypertension.
# Cerebrovascular accident involving the left sylvan
fissure.
# Right breast cancer, status post lumpectomy in [**2120**]
# h/o pulmonary embolism [**2126**]
# atrial fibrillation
# Osteoporosis, status post left hip surgery in [**2122**].
# Morbid obesity.
# Chronic obstructive pulmonary disease.
# Degenerative joint disease with spinal stenosis.
# Status post lip cancer and basal cell carcinoma skin cancer.
Social History:
Retired school teacher. [**Hospital 100**] Rehab resident. Daughter, [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 11309**], lives in area and is responsible for patient's care.
Family History:
Noncontributory
Physical Exam:
Tm 104, BP95/43, HR 80, RR 40, o2sat 97%NRB
GENL: ill appearing, appears tachypneic with audible rhonchi
HEENT: dry MM
CV: RRR
Lungs: diffusely rhonchorous
Abd: distended, soft, nontender
Ext: no edema
Pertinent Results:
[**2134-1-18**] 02:00AM BLOOD WBC-9.9 RBC-5.25# Hgb-16.7*# Hct-50.7*#
MCV-97 MCH-31.8 MCHC-32.9 RDW-14.5 Plt Ct-224
[**2134-1-18**] 02:00AM BLOOD Neuts-72* Bands-15* Lymphs-5* Monos-6
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 NRBC-1*
[**2134-1-18**] 02:00AM BLOOD PT-25.9* PTT-57.8* INR(PT)-2.6*
[**2134-1-18**] 02:00AM BLOOD Glucose-175* UreaN-77* Creat-2.8*#
Na-151* K-7.5* Cl-111* HCO3-23 AnGap-25*
[**2134-1-18**] 02:00AM BLOOD cTropnT-0.17* proBNP-7523*
Brief Hospital Course:
85 yo F with h/o [**Doctor Last Name 21568**] syndrome (deafness, retinitis
pigmentosa, vestibular symptoms), who presented to ED in
respiratory distress, fever, afib/flutter with rapid vent
response, hypotension, found to have multifocal pneumonia and
UTI and sepsis.
# Sepsis: Pt septic and family deferred aggressive measures.
Gave morphine to alleviate respiratory distress, lorazepam for
agitation, scopolamine for secretions. Daughter at bedside. The
pt expired.
Medications on Admission:
Lopressor 25 mg [**Hospital1 **]
Lasix 40 IV
Wellbutrin 50 TID
Coumadin
Albuterol Nebs
Atrovent Nebs
Morphine 2 mg SL PRN
Ativan 0.25 PO Q6 hr PRN
Tylenol
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pt expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 0389, 486, 5849, 5990, 2761, 496, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3235
} | Medical Text: Admission Date: [**2150-8-7**] Discharge Date: [**2150-8-10**]
Date of Birth: [**2072-3-16**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Isosorbide / quinidine gluconate
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
VT storm
Major Surgical or Invasive Procedure:
cardioversion
History of Present Illness:
78F with coronary artery disease s/p remote inferior MI, CABG,
and ICD implant originally in [**2136**] transferred from [**Hospital3 **]
with VT@180 refractory to cardioversion. Per the patient her ICD
fired "more times that I can count." Estimate by EP and EMS is
that it fired 15 times today. In the field she was found to have
Vtach at 180 and underwent 2 cardioversions at 100J and 150J
(with Versed sedation) then broke with Amiodarone 150 mg bolus
f/b amio gtt. In the ED the amio gtt was continued. She was seen
by EP who interrogated her ICD and changed several of her
settings. EPS reccomended DC'ing amio and starting lidocaine
bolus + gtt however when the ED stopped the amiodarone she had
20 beats of asymptomatic VT that was terminated with overdrive
pacing from her ICD. She was restarted on amiodarone and
transferred to the CVICU under the care of the CCU team.
Of ntoe she underwent EP study in [**2149-11-15**] for recurrent VT
and found to have larve inferior scar. No ablation becaue of
multiple runs of HD unstable VT during catheter manipulation.
She has actually been off of all antiarhythmic drugs due to
intolerance of quinidine, maxelitine and amiodarone).
She has had the ICD in place since 2/[**2136**]. By report her last
firing was 8 months ago. She denies any recent syncope or
presyncope, chest pain or SOB. She does endorse some fatigue.
Past Medical History:
Hypertension
Hyperlipidemia
CAD s/p 3 MIs
Cardiomyopathy, EF 25%
NSVT with easily inducible sustained VT on EP study in [**3-/2136**]
-CABG: x2 [**2126**], [**2132**], both done at NEDH
-PACING/ICD: [**Company 1543**] Micro [**Female First Name (un) 19992**] 2 ICD placed on [**2136-3-29**].
Exchanged for [**Company 1543**] ICD, EnTrust D154VRC ?in [**2143**] (last
interrogation per [**Hospital1 18**] webOMR notes [**2145-9-7**]).
Depression s/p ECT
S/p cholecystectomy
S/p hysterectomy
S/p thyroid surgery for a benign mass
S/p cataract surgery
Social History:
Married. Lives at home with her husband and her brother.
[**Name (NI) 1139**] history: remote smoking history from age 20 to 30
ETOH: occasional social drinking
Illicit drugs: none
Family History:
Mother died of MI at age 38, brother at age 37. Other brother MI
at age 60. Father lived to age [**Age over 90 **] and was healthy. No family
history of arrhythmia, cardiomyopathies.
Physical Exam:
Admission Physical:
VS: 66 133/79 98%on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT.
NECK: Supple with no JVD
CARDIAC: RRR S1 S2 no MRG
LUNGS: CTA BL
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: AAOx3
.
Discharge Physical:
Gen:Aox3, NAD,
Cardio: RRR, no murmurs, rubs or gallops
Lungs: CTAB
Abd: NT/ND. Soft. NBS.
Extremities: No peripheral edema appreciated.
Peripheral Vascular: 2+ radial and PT pulses
Neuro: AOX3. MAE.
Pertinent Results:
ADMISSION/DISCHARGE LABS:
CBC
[**2150-8-7**] 09:20AM BLOOD WBC-9.0# RBC-4.73# Hgb-14.1 Hct-43.1
MCV-91 MCH-29.8 MCHC-32.7 RDW-16.0* Plt Ct-220
[**2150-8-10**] 07:00AM BLOOD WBC-7.3# RBC-4.86 Hgb-14.6 Hct-44.0
MCV-91 MCH-30.0 MCHC-33.1 RDW-16.0* Plt Ct-213
COAGS:
[**2150-8-7**] 09:20AM BLOOD PT-10.9 PTT-28.3 INR(PT)-1.0
[**2150-8-9**] 05:05AM BLOOD PT-12.2 PTT-29.6 INR(PT)-1.1
CMP:
[**2150-8-7**] 09:20AM BLOOD Glucose-121* UreaN-9 Creat-0.7 Na-141
K-4.0 Cl-106 HCO3-25 AnGap-14
[**2150-8-10**] 07:00AM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-140 K-4.1
Cl-105 HCO3-27 AnGap-12
[**2150-8-8**] 04:09AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.4
[**2150-8-10**] 07:00AM BLOOD Calcium-9.6 Phos-3.5 Mg-1.9
.
.
IMAGING:
NONE
Brief Hospital Course:
78 [**Last Name (un) 9232**] with history of CAD and cardiomyopathy with EF 25% and
recurrent VT's presenting with VT storm, now in sinus rhythm
admitted to the CVICU under care of CCU team for monitoring and
manasgement.
.
# VTACH- The patient was initially stabilized on lidocaine gtt.
She was seen by EP and went for mapping and VT ablation. She
had multiple areas ablated, but there were numerous areas of
ectopy that could have been the source of her VT that it was
felt they were not all captured. As a result, she was continued
on lidocaine when she returned from the lab. She started
mexiletine and the dose was titrated to 150mg PO BID. She did
well on that dose and was subsequently sent home with the
appropriate follow up.
.
Inactive Issues:
# CAD: Continue statin, asa and beta blocker. Mild troponin
elevation is likley secondary to multiple shocks. It improved
without any issues.
.
# HTN: Continue home antihypertensives
.
# HLD: Continue atorvastatin
.
Transitional ISSUES:
- Follow up with EP regarding further management of her
Ventricular Tachycardia
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Atorvastatin 20 mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. HydrALAzine 10 mg PO TID
4. Isosorbide Dinitrate 10 mg PO TID
5. Metoprolol Tartrate 50 mg PO TID
6. Oxazepam 30 mg PO TID
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
8. Aspirin 81 mg PO DAILY
9. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP Frequency is
Unknown
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Ezetimibe 10 mg PO DAILY
4. HydrALAzine 10 mg PO TID
5. Isosorbide Dinitrate 10 mg PO TID
6. Metoprolol Succinate XL 100 mg PO BID
RX *metoprolol succinate 100 mg one Tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
8. Oxazepam 30 mg PO TID
9. Docusate Sodium 100 mg PO BID
10. Dofetilide 125 mcg PO Q12H VT
Please check ECG 2h after EVERY dose and FAX ECG to [**Telephone/Fax (1) 20093**]
RX *Tikosyn 125 mcg one Capsule(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
11. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
chronic systolic congestive heart failure
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Your defibrillator fired at least 15 times because of
ventricular tachycardia and your were transferred from [**Hospital 6451**] Hospital for treatment. We started a new medicine,
dofetalide, to prevent the ventricular tachycardia and this
seems to be working well. WE also made some adjustments to your
ICD to prevent any unnecessary firing. You will need to take
Dofetalide twice daily and will see Dr. [**Last Name (STitle) **] in 2 weeks.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **]
When: Dr. [**Last Name (STitle) 20094**] office is working on a follow up appointment
you in [**5-24**] days after your hospital discharge. You will be
called by the office with your appointment date and time. If you
have not heard from the office in 2 business days please call
the office number listed below.
Location: [**Hospital **] HEALTH CENTER
Address: 200 [**Last Name (un) 12504**] DR, [**Location (un) **],[**Numeric Identifier 18464**]
Phone: [**Telephone/Fax (1) 18462**]
.
Department: CARDIAC SERVICES
When: office will call you with an appt at home for this week
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
.
Department: CARDIAC SERVICES
When: FRIDAY [**2150-8-21**] at 11:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: FRIDAY [**2151-1-29**] at 10:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: FRIDAY [**2151-1-29**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4271, 4254, 4280, 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3236
} | Medical Text: Admission Date: [**2196-8-9**] Discharge Date: [**2196-8-12**]
Date of Birth: [**2151-11-26**] Sex: M
Service: MEDICINE
Allergies:
Piroxicam / Tramadol / gabapentin
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Chief Complaint: AMS
Reason for MICU transfer: AMS
Major Surgical or Invasive Procedure:
Interventional radiology guided replacement of urostomy tube
History of Present Illness:
44M from home with end stage bladder cancer with mets. Pt is a
poor historian at baseline. Per wife, increased confusion,
altered from his baseline. Not confused at baseline. No new med
changes. He had a ct scan of the head that was neg. He was found
to be in massive renal failure and a ct scan of his abd showed
that there was a nectoric tumor mass that is compressing the
ileal conduit that is causing hypronephrosis and obstruction to
the kidneys bilaterally. Urology was consulted and they were
able to place a red rubber in stoma with return of urine and
good urine output.
.
In the ED, initial VS were: 23:45 4 98.4 115 127/79 18 98%
.
Patient was given cipro 400mg IV x1, Flagyl 500mg IV x1, 1mg
dilaudid x3, Calcium gluconate 1amp x1, 1 amp dextrose, 10 units
insulin
.
Admission Vitals: 98.4; 115; 127/79; 18; 98%
Past Medical History:
PAST MEDICAL HISTORY
- Bladder cancer
- Radical cystoprostatectomy with ileal conduit urinary
diversion
([**2195-8-28**])
- Lymphedema of lower extremity, left; scrotal/phallus edema
- GERD
- PTX in [**2176**], [**2180**] s/p chest tube
- C3-7 laminectomy with fusion for stenosis
- Bilateral PE dx [**9-3**] after surgery - on Lovenox
.
Onc PMhx:
- Muscle invasive bladder cancer-TURB at [**Hospital1 18**] on
[**2195-2-27**]-poorly differentiated, sarcomatoid. S/p neoadjuvant
Cisplat/Gemzar, followed by cystectomy [**2195-8-28**] at [**Hospital1 **] (above)
- [**2196-2-25**] B12 1000mcg im
- [**2196-3-15**] C1D1 Taxol (25% dose reduction)
- [**2196-3-22**] C1D8 Taxol + Alimta (25% dose reduction)
- [**2196-5-12**] C2D1 Taxol (25% dose reduction)
- [**2196-5-13**] B12
- [**2196-5-19**] C2D8 Taxol + Alimta (25% dose reduction)
- [**2196-6-2**] C3D1 Taxol + Alimta (100%)
- [**2196-6-9**] C3D8 Taxol + Alimta (100%)
Social History:
Lives in [**Location 745**] with his wife and step daugther. Has 2 other
sons. [**Name (NI) 3003**] [**Name2 (NI) 1818**], no current alcohol use.
Family History:
- Mother: COPD, Cervical CA
- Father: CAD/PVD (early, angina @ 55yo, prostate CA, substance
abuse, lung CA), deseased from prostate ca.
- hemochromatosis, paternal cousin
Physical Exam:
Admission Exam:
Vitals: P 113 BP 130/76 Temp 99 RR 21
General: Cachetic appearing
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
w/ 3->2mm
Neck: supple, JVP not elevated, no LAD
CV: Tachycardia regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Large RLQ fungating mass that appears to be partial
necrotic mass with red [**Doctor First Name **] foley sutured in place with bag
covering.
GU: edmatous penis
Ext: warm, well perfused, 2+ pulses for UE, 1+ for
RLE,Dolparable for LLE, LLE is edematous
Neuro: CNII-XII intact, follows commands, axox3, tic throughout
no asterixis
.
Discharge Exam:
Vitals: P 106 BP 139/73 Temp 98.8 RR 14
General: Cachetic appearing
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
w/ 3->2mm
Neck: supple, JVP not elevated, no LAD
CV: Tachycardia regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Large RLQ fungating mass that appears to be partial
necrotic mass, now with large-bore catheter tube draining from
ileal urinary diversion site.
Ext: warm, well perfused, 2+ pulses for UE, 1+ for
RLE,Dolparable for LLE, LLE is edematous
Neuro: CNII-XII intact, follows commands, a+ox3, no asterixis,
not able to recall all the events of past few days
Pertinent Results:
[**2196-8-9**] 01:37PM LACTATE-0.9
[**2196-8-9**] 01:18PM GLUCOSE-102* UREA N-58* CREAT-6.1*#
SODIUM-134 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-22 ANION GAP-18
[**2196-8-9**] 01:18PM ALT(SGPT)-8 AST(SGOT)-10 LD(LDH)-159 ALK
PHOS-131* TOT BILI-0.1
[**2196-8-9**] 01:18PM ALBUMIN-3.0* CALCIUM-8.5 PHOSPHATE-5.5*
MAGNESIUM-1.8
[**2196-8-9**] 01:18PM WBC-18.3* RBC-2.87* HGB-9.5* HCT-28.3*
MCV-99* MCH-33.2* MCHC-33.7 RDW-15.9*
[**2196-8-9**] 01:18PM PLT COUNT-385
[**2196-8-9**] 01:18PM PT-14.7* PTT-30.1 INR(PT)-1.4*
[**2196-8-9**] 09:35AM LACTATE-1.0
[**2196-8-9**] 09:05AM WBC-19.5* RBC-2.98* HGB-9.8* HCT-29.4*
MCV-99* MCH-33.0* MCHC-33.5 RDW-15.9*
[**2196-8-9**] 09:05AM PT-14.3* PTT-29.7 INR(PT)-1.3*
[**2196-8-9**] 04:40AM PT-15.2* PTT-28.4 INR(PT)-1.4*
[**2196-8-9**] 04:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2196-8-9**] 04:15AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2196-8-9**] 04:15AM URINE RBC-<1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-0
[**2196-8-9**] 02:43AM LACTATE-3.7*
[**2196-8-9**] 12:50AM URINE OSMOLAL-289
[**2196-8-9**] 12:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2196-8-9**] 12:50AM URINE COLOR-RED APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2196-8-9**] 12:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
[**2196-8-9**] 12:50AM URINE RBC-23* WBC-81* BACTERIA-MOD YEAST-NONE
EPI-8
[**2196-8-9**] 12:15AM GLUCOSE-111* UREA N-71* CREAT-9.9*#
SODIUM-127* POTASSIUM-6.1* CHLORIDE-89* TOTAL CO2-20* ANION
GAP-24*
[**2196-8-9**] 12:15AM estGFR-Using this
[**2196-8-9**] 12:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-8-9**] 12:15AM NEUTS-90.4* LYMPHS-3.5* MONOS-3.5 EOS-2.6
BASOS-0.1
[**2196-8-9**] 12:15AM PLT COUNT-439
Labs on discharge:
[**2196-8-11**] 03:45AM BLOOD WBC-17.9* RBC-2.85* Hgb-9.3* Hct-28.3*
MCV-99* MCH-32.5* MCHC-32.7 RDW-15.9* Plt Ct-377
[**2196-8-11**] 03:45AM BLOOD PT-15.6* PTT-22.4* INR(PT)-1.5*
[**2196-8-11**] 03:45AM BLOOD Glucose-121* UreaN-29* Creat-2.6* Na-137
K-4.3 Cl-104 HCO3-19* AnGap-18
Radiology
CT A/P: 7.6 x 5.5 cm heterogeneous subcutaneous high density
area is concerning for a complex fluid collection, possibly an
abscess at the ostomy site. This causes compression of the
exiting ileal loop that causes dilatation of the small bowel and
bilateral hydronephrosis. Recommend urgent urology consult.
Additionally the suture material around the side to side bowel
anastamosis more proximally is different in configuration to
the prior CT examination though the area is incompletely
evaluated due to the lack of IV contrast.
.
CT Head: no acute changes
.
CXR: The lungs are low in volume and show three right lung
nodules measuring 14 mm the right upper lobe and 19 and 16 mm in
the right lower lobe. A left lower lobe lesion is better seen on
the concurrently performed abdomen and pelvis CT. The
cardiomediastinal silhouette and hilar contours are normal. No
pleural effusion or pneumothorax is present. An anterior
cervical fusion device is partially imaged.
IMPRESSION:
No acute intrathoracic process. Right pulmonary metastases have
increased in size
.
Repeat CT (after red [**Doctor First Name **] tube placed)
1. Interval partial decompression of the ileal conduit, status
post percutaneous placement of a large-bore conduit catheter.
The degree of moderate hydronephrosis, bilaterally, is not
significantly changed over the short interval.
2. Large parastomal mass, several omental metastases, and
retroperitoneal/pararectal lymphadenopathy, though unchanged
compared to CT from earlier today, are new compared to the [**3-26**], [**2196**] study.
3. Unchanged small-to-moderate volume ascites.
4. Asymmetric subcutaneous edema involving the visualized
portion of the proximal left thigh, increased compared to the
prior study from [**2196-3-26**], with no (non-contrast) CT
evidence of DVT. This finding should be interpreted in the
context of known left lower extremity lymphedema, as discussed
on the prior ultrasound report from [**2196-4-8**].
5. Unchanged small fluid collection anterior to the pubic
symphysis, in continuity with a probable large hydrocele.
Brief Hospital Course:
44 year old man with past medical history of metastatic bladder
cancer s/p neoadjuvant chemo, followed by radical
cystoprostatectomy with ileal conduit urinary diversion,
radiation who was brought in for AMS and found to have [**Last Name (un) **] and
bilateral hydronephrosis secondary to a high density obstruction
temporarily relieved with red [**Doctor First Name **] catheter awaiting further
management.
.
#AMS: Pt was initially somnolent but improved to A&Ox3 on ICU
day 1 after red [**Doctor First Name **] cath placed to relieve the obstructive
uropathy. Likely was secondary to uremia. CT head did not show
evidence of metastases. His mental status improved and remained
stable throughout ICU course.
.
#Acute renal failure, postrenal: Necrotic tumor next to ileal
conduit causing obstruction, obstruction as evidenced by b/l
hydronephrosis, baseline Cr is 0.9. Upon admission, Cr>9. After
red [**Doctor First Name **] cath placed into ileal conduit, repeat CT showed mild
improvement of hydronephrosis. The patient was treated with IV
fluids. Cr improved and trended down to 3.4 on Hospital Day 2
and to 2.6 on [**2196-8-11**]. Pt had IR placement of percutaneous
catheter into ileal conduit on [**2196-8-11**]. The patient was
followed by the Nephrology Consult Service, who signed off on
[**8-10**], when the patient's GFR returned to [**Location 213**].
.
#Leukocytosis: white count elevated >19 and persistent while on
ciprofloxacin. Urine culture eventually grew out Enterococcus,
but only 10k-100k colonies, and the patient did not have
symptoms of sepsis. Sensitivities showed VRE, and Linezolid was
not an option given multiple interactions with patient's other
medications. Therefore, the patient was offered the option of
having a PICC placed for home IV therapy. He declined this
option, and, therefore, will not go home on any antibiotics.
.
#Metabolic Derangments: Patient initially presented with anion
gap metabolic acidosis, hyperkalemia, and hyponatremia. The
acidosis and hyperkalemia were likely due to the acute renal
insufficiency. They resolved when the obstruction was fixed and
when renal function returned to baseline. The hyponatremia was
likely due to volume depletion leading to ADH release. It
resolved after volume resuscitation.
.
#Goals of Care / Pain Management: Goals of care were discussed
between the patient, his family, the MICU team, the [**Location (un) 2274**]
Palliative Care attending, the Hospice nurse, the Urology team,
the patient's primary urologist Dr. [**Last Name (STitle) **], the Hem/Onc Consult
Service, Interventional Radiology, and the patient's primary
oncologist Dr. [**Last Name (STitle) **]. The goal of this hospitalization was
to clear the patient's urinary obstruction in a more permanent
way with the least invasive procedure possible. Therefore,
percutaneous catheter was placed by IR, as discussed above. The
patient and his wife expressed their desire to pursue Hospice
care after discharge from the hospital. The patient's pain was
managed with fentanyl patch, which we increased in dose from
150mcg Q72H to 200mcg Q72H at the recommendation of the Atrius
Palliative Care attending. For break-through pain, the patient
was first treated with IV fentanyl, then with PO oxycodone
(which was discontinued due to myoclonus), and finally PO
Dilaudid 4mg 1-2 tabs q4h PRN. He was discharged with Hospice
care.
.
***Transitional issues:
#The patient and his wife expressed that it is not in their
interest for the patient to be readmitted into the hospital in
the future. Patient is to return home with hospice services.
#The patient has requested home O2, a wheelchair, and a hospital
bed at home.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR His palliative care doctor.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. butalbital-acetaminophen-caff *NF* 50-325-40 mg Oral q8h PRN
headache
3. BuPROPion (Sustained Release) 150 mg PO BID
4. Prochlorperazine 5 mg PO Q4-6H PRN nausea
5. Quetiapine Fumarate 100 mg PO QHS:PRN insomnia
6. Mineral Oil Dose is Unknown PO BID
7. Lorazepam 0.5 mg PO Q8H:PRN nausea/ anxiety
8. Docusate Sodium 100 mg PO BID
9. Senna 1 TAB PO BID:PRN constipation
10. Enoxaparin Sodium 80 mg SC BID
11. OxycoDONE (Immediate Release) 60 mg PO Q3H:PRN pain
12. Omeprazole 40 mg PO DAILY
13. Citalopram 30 mg PO DAILY
14. FoLIC Acid 1 mg PO DAILY
15. Fentanyl Patch 150 mcg/hr TP Q72H
Discharge Medications:
1. Atropine Sulfate 1% 2 DROP SL Q4H:PRN secretions
RX *atropine sulfate (PF) 1 % 2 drops SL Q4H PRN Disp #*30
Milliliter Refills:*0
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Citalopram 30 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Prochlorperazine 5 mg PO Q4-6H PRN nausea
9. Quetiapine Fumarate 100 mg PO QHS:PRN insomnia
10. Senna 1 TAB PO BID:PRN constipation
11. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth Daily PRN Disp #*30
Tablet Refills:*0
12. butalbital-acetaminophen-caff *NF* 50 mg ORAL Q8H PRN
headache
13. Mineral Oil 15-30 mL PO BID
14. Lorazepam 0.5 mg PO Q8H:PRN nausea/ anxiety
15. Fentanyl Patch 200 mcg/hr TP Q72H
RX *fentanyl 100 mcg/hour Apply 2 patches Q72H Disp #*20
Transdermal Patch Refills:*0
16. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth q4h PRN Disp #*42
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Acute kidney injury
Bladder cancer
Lymphedema of lower extremity
GERD
Pulmonary emboli
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 60816**],
It was our pleasure to care for you at [**Hospital1 18**]. You were admitted
for obstruction of your ureters. We were able to place a tube
to drain out the urine and relieve the stress on the kidneys.
We made the following changes to your medications:
STOP taking enoxaparin
STOP oxycodone
START taking atropine sublingually as needed for secretions
use two FENTANYL patches (100mcg each) at an INCREASED DOSE of
200mcg every 72 hours
START Dilaudid 4mg 1-2 tablets by mouth every 4 hours as needed
for pain
Please take all other medications as previously prescribed.
ICD9 Codes: 5849, 2762, 2761, 5990, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3237
} | Medical Text: Admission Date: [**2146-11-24**] Discharge Date: [**2147-1-12**]
Date of Birth: [**2081-2-8**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Headache, LOC
Major Surgical or Invasive Procedure:
[**11-24**]: Left Burr Hole and placement of External Ventricular
Drain(EVD)
[**12-1**]: Removal of EVD, Cyst Aspiration, [**Last Name (un) **] catheter
placement.
[**12-14**]: scalp wound revision
History of Present Illness:
65M presented to OSH this am after complaining of headache on
[**11-24**]. Per reports from ED records, and parents(with whom he
resides), he then went upstairs to the bathroom when a "thump"
was heard. His mother went upstairs into the bathroom and found
him on the floor, incontinent of urine and unresponsive. She
then called 911, and was taken to OSH. Upon presentation to
OSH, he was found to be hypertensive to 230/150, started on
Nipride. His head was scanned and revealed a "Massive Head
Bleed, without midline shift". He was then subsequently
transferred to [**Hospital1 18**] for definitive care and Neurosurgical
evaluation. In the duration of transfer, per EMS noted, started
decorticate posturing and they began infusion of 25 gm Mannitol
IV.
Past Medical History:
None; per mother
Social History:
Resides at home with parents
Family History:
Non-contributory
Physical Exam:
On Admission:
BP:143/68(off Nipride) HR:79 RR:25 O2 Sats: 100% CMV
Gen: WD/WN,indigent appearing gentleman.
HEENT:normocephalic, atraumatic.
Pupils: Symmetric EOMs: Unable to assess
Neuro:
+Corneals, +Swallowing, intubated at OSH. Spontaneous movement
of
left side observed, ?purposeful. No observed mvmt of the right
side. Pupils: Lt 3mm, minimally reactive, Rt 3mm non-reactive.
On Discharge:
AOx3, moving all extremities, ambulating in [**Doctor Last Name **] with assistance
Pertinent Results:
Labs on Admission([**11-24**]):
138 101 15 184
-------------/
3.5 22 0.9
estGFR: >75 (click for details)
CK: 175 MB: Pnd
Ca: 8.4 Mg: 2.1 P: 3.1
ALT: 14 AP: 62 Tbili: 0.7 Alb: 4.6
AST: 28 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 26
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc:
Urine Benzos: Pos
Urine Barbs, Opiates, Cocaine, Amphet, Mthdne: Negative
WBC:20.6 Hgb:12.9 Plt:242 Hct:35.9
N:92.2 L:3.5 M:4.0 E:0.2 Bas:0.1
PT: 14.5 PTT: 23.0 INR: 1.3
Imaging:
NON-CONTRAST HEAD CT [**11-24**]: There is a large amount of acute
hemorrhage centered at the level of the mid brain with blood
filling the lateral, third, and fourth ventricles. Dilatation of
the ventricles and transependymal migration of CSF is consistent
with obstructive hydrocephalus. There is 8 mm rightward shift of
normally midline structures. Grey-white matter differentiation
remains preserved. Secretions in the nasopharynx may be related
to NG tube. Ethmoidal, maxillary, and sphenoidal mucosal
thickening is mild. The mastoid air cells remain normally
aerated. The surrounding osseous structures are unremarkable.
Note is made of prominent CSF space in the suprasellar
cistern,which can be seen with marked obstructive hydrocephalus,
but a suprasellar arachnoid cyst can have a similar appearance.
CXR [**11-24**]:
FINDINGS: There is an endotracheal tube whose tip is
approximately 2.4 cm
above the level of the carina. There is a nasogastric tube that
courses below the diaphragm and lies within the stomach. The
stomach, however, remains moderately distended with gas. The
lungs are clear. There is no evidence of congestive heart
failure or pneumonia. There is no evidence of pleural effusions
or pneumothorax. The cardiac and mediastinal contours are normal
in appearance. The visualized osseous structures are
unremarkable.
MRI Head +/- [**11-25**]:
IMPRESSION:
1. Extensive intraventricular hemorrhage involving all the
ventricles as
described above, predominantly in the acute stage with a small
subacute
component.
2. Obstructive hydrocephalus, with dilatation of the left
lateral ventricle
and moderate on the right.
3. While there is no obvious abnormal enhancement noted within
the area of
hemorrhage, small neoplastic or vascular causes within the
ventricles cannot be excluded. Repeat evaluation can be
considered after evacuation or
resolution of the hematoma.
4. Subarachnoid hemorrhage, in both cerebral hemispheres.
Given the presence of intraventricular and subarachnoid
hemorrhage, patient
needs further evaluation to exclude a vascular cause like an
aneurysm by CT
angiogram. The intracranial arteries are not adequately assessed
on the
present study. Displacement of the right internal carotid artery
termination and the anterior cerebral arteries on both sides
related to the enlarged ventricles is noted.
CTA Head [**11-25**]:
IMPRESSION:
1. No evidence of aneurysm, arteriovenous malformation or other
vascular
abnormality as source of massive intraventricular hemorrhage.
There is also no focal contrast extravasation to suggest a
bleeding source or risk of continued hemorrhage.
2. Only scant subarachnoid hemorrhage, unchanged, with no
evidence of
cerebral vasospasm.
3. Extensive intraventricular hemorrhage, with severe
obstructive
hydrocephalus, unchanged.
4. Persistent dilatation of the left lateral ventricle, despite
the
ventriculostomy catheter, whose tip may abut or even transgress
the lateral
ventricular wall.
5. Persistent disproportionate and cystic-appearing dilatation
of the 3rd
ventricle (despite presence of lateral ventriculostomy) which
may,
effectively, be "trapped."
CT Sinus [**11-27**]:
IMPRESSION: Panmucosal thickening within the paranasal sinuses,
increased
compared to the CT of [**2146-11-24**]. Obstruction of the ostiomeatal
units
bilaterally. Extensive nasal secretions. Left frontal
ventricular catheter
appears to terminate in brain parenchyma as discussed on
concurrent head CT.
Head CT [**11-27**]:
FINDINGS: A ventricular catheter entering from a left frontal
approach appears to terminate within the left frontal lobe
(2:13). The left lateral ventricle remains extremely dilated but
not significantly changed compared to the examination two days
prior. Large amount of blood within the lateral
ventricles and the third ventricle is essentially unchanged.
Scattered foci
of subarachnoid hemorrhage throughout both cerebral hemispheres
are unchanged. Thickening of the ethmoid, sphenoid, and
maxillary sinuses of the mucosal surface is stable compared to
the most recent exam.
MRI [**12-1**]:
FINDINGS: There has been a reduction in the volume of hemorrhage
present
within the bodies of the lateral ventricles. The large
suprasellar cyst,
previously identified, has enlarged dramatically in this
interval. A left
frontal ventricular catheter is again identified. No
pre-contrast imaging was performed. It is unclear whether
hyperintensity of the lateral ventricular margins represent
enhancement or subacute hemorrhage.
HeadCT IMPRESSION [**12-1**]:
1. Status post drain placement in the previously noted large
suprasellar/prepontine cyst, change in the shape of the cyst,
and possible
mild or no significant change in the overall size. Close f/u.
2. Extensive intraventricular, some amount of subarachnoid and
subdural
hemorrhage partially imaged and not significantly changed.
Head CT [**12-4**]:IMPRESSION:
1. No change in position of left frontal approach catheter
terminating within
a large cyst centered in the suprasellar/pre-pontine cistern.
2. No definite change in size of cyst.
3. Similar extensive hemorrhage within the lateral ventricles,
and smaller
subarachnoid hemorrhage in bilateral sylvian fissures.
4. Slight decrease in degree of hemorrhage within the cyst or
third
ventricle.
Brief Hospital Course:
The patient arrived to [**Hospital1 18**] as transfer from OSH for a
significantly sized intracerebral hemorrhage. On initial exam,
he was following some commands after receiving 20gm Mannitol en
route to hospital. He was emergently take to the OR for EVD
placement after CT findings. His exam post drain did improve and
MRI showed no obvious mass. CT showed with decrease in size of
IVH and stable ICPs. CTA of head was done showed no AVM, however
bleeding was likely due to arachnoid cyst. On [**12-1**], he was
again taken to the OR for endoscopic cyst aspiration and Rickham
catheter placement. Post-operatively he continue to improved
markedly. On his examination on [**12-6**], he was found to have
gross visual field deficits and ophthalmology was consulted. He
was found to be blind with some light awareness bilaterally.
This was thought to be secondary to vitreous hemorrhage of
unclear origin. He was also able to see shadows towards the end
of his hospital course. Ophthamology would like to see him on
follow up.
The patient was able to be extubated and was breathing well on
his own and his diet was advanced to regular. He was eating and
drinking without difficulty. He did have hyponatremia for
several days for which he was placed on salt tablets and kept on
a fluid restriction. On [**12-22**] his sodium was improving and the
salt tabs were decreased. They were decreased again on [**12-23**] and
his fluid restriction was liberalized. Since that time his
sodium has normalized, without any recurrance of issue.
Guardianship was pursued. The patient continued to have daily PT
while waiting for guardianship. The papers were drawn up by the
legal department, signed by Dr. [**Last Name (STitle) **], and given to the family
on [**2147-1-7**].
Throughout the duration of his hospital stay, Mr [**Known lastname **] worked
daily with PT and was determined to be an appropriate rehab
candidate. He was discharged to an appropriate facility on
[**2147-1-12**].
Medications on Admission:
None
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/headache.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38076**] House - [**Location (un) 47**]
Discharge Diagnosis:
Massive Central Intraparenchymal Hemorrhage
Arachnoid Cyst
Acute Sinusitis
Right sided weakness
Acute blindness / bilaterally
Bilateral foot drop
Discharge Condition:
Neurologically Significantly improved
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.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????You haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????Make sure to continue to use your incentive spirometer while at
home, unless you have been instructed not to.
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 call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 3 months.
??????You will need an MRI scan of the brain with/without contrast.
- You need to be seen in the [**Hospital 40791**] Clinic by Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 7572**]. Please hit option #1 and then option #3 to get to
[**Hospital 40791**] clinic
Completed by:[**2147-1-12**]
ICD9 Codes: 431, 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3238
} | Medical Text: Admission Date: [**2125-9-3**] Discharge Date: [**2125-9-6**]
Date of Birth: [**2046-3-14**] Sex: F
Service: MEDICINE
Allergies:
Senna / Iodine / Optiray 350
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
BiPap
History of Present Illness:
79 yo F with hx of DM2, HTN, Ao Stenosis s/p AVR and now has
bioprothetic AS and pacemaker (complete heart block w/100%
Vpacing) presenting on admission from wards floor with acute
respiratory distress and flash pulmonary edema. Patient was
found in resp distress by nursing; ABG demonstrated
7.30/55/68/28, and stat CXR showed interval changes with BL
pulmonary congestion.
.
According to history taken earlier today with Russian
interpreter, the patient was presented to ED [**2125-9-3**] by
ambulance after becoming unresponsive at elderly day care
facility. Patient was found by staff with LOC for unknown
duration. Prior to this episode she was having cold sweats,
shaking and nausea. No CP, SOB, loss of bowel or bladder
continence or post-ictal state. For the past week she has been
experiencing fatigue. Per ED report hypoglycemic BS 60 in field,
received OJ x 2 -> BS 101.In ED VS were 97, 72, 150/76, 19,
99%RA. She received fluids and missed PM doses of meds (inc
Lasix).
.
On floor at [**2144**], was feeling well, started having respiratory
distress. On exam appeared wet, 218/118 L arm, gave her hydral
10mg IV x1, 40mg IV lasix, NRB 80%, and transferred to CCU.
Past Medical History:
1. Complete Heart Block s/p DDDR pacemaker placement [**2120**]
2. CAD status post CABG x1 (SVG to PDA during AVR with porcine
valve) on [**2119-1-31**]. s/p cypher stent to LAD [**7-19**]
3. Diabetes mellitus type 2 on insulin and oral agents.
4. Hypertension.
5. Hypercholesterolemia.
6. Schwanomma T11 to T12 s/p resection ([**2-16**]).
7. PVD with bilateral sublavian stenosis
8. Depression
9. Left atrial thrombus noted on TEE at SEMC [**12-23**] now on
coumadin
Social History:
lives with husband
Former agriculture worker. Son is involved in her care ([**Doctor First Name **]).
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse
Family History:
Brother who died of an MI at the age of 65 and had CVA. Both
parents with CVA.
Physical Exam:
On admission:
VS: T=afebrile BP= R 106/doppler, L 207/57 HR=90 R=24O2 sat= 99%
GENERAL: Respiratory distress, on BiPAP. Oriented x3.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa
NECK: Supple with JVP elevation.
CARDIAC: RR, normal S1, S2. [**2-17**] RUSB systolic murmur radiating
to carotids, [**1-20**] Apical murmur. No thrills, lifts.
LUNGS: Resp were labored, on BiPAP. Anterior exam soft diffuse
crackles BL
ABDOMEN: Soft, NTND. No HSM or tenderness. +BS
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial +2, pedal +1/doplar
Left: Radial +2, pedal +1/doplar
On discharge:
VS: T=36.7 BP= L 136/40 HR=65 R=20 sat= 95% on RA
GENERAL: NAD,. Oriented x3. Russian speaking, with limited
English
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa
NECK: Supple with JVP elevation to 8cm.
CARDIAC: RR, normal S1, S2. [**2-17**] LUSB late peaking systolic
murmur radiating to carotids and [**1-20**] diastolic murmur at RUSB,
No thrills, lifts.
LUNGS: Resp were unlabored, on nasal canula. Crackles at bases
bilaterally, improved from yesterday
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. +BS
EXTREMITIES: trace edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial +2, pedal +1/doplar
Left: Radial +2, pedal +1/doplar
Pertinent Results:
[**2125-9-3**] 11:38PM BLOOD Type-ART pO2-68* pCO2-55* pH-7.30*
calTCO2-28 Base XS-0
[**2125-9-4**] 12:51AM BLOOD Type-ART pO2-121* pCO2-44 pH-7.39
calTCO2-28 Base XS-1 Intubat-NOT INTUBA
[**2125-9-3**] 03:30PM BLOOD cTropnT-<0.01
[**2125-9-4**] 12:34AM BLOOD CK-MB-5 cTropnT-0.02*
[**2125-9-4**] 06:50AM BLOOD CK-MB-6 cTropnT-0.05*
[**2125-9-4**] 06:50AM BLOOD PT-30.6* PTT-28.2 INR(PT)-3.0*
[**2125-9-4**] 06:50AM BLOOD Plt Ct-191
[**2125-9-3**] 03:30PM BLOOD Neuts-82.4* Lymphs-11.5* Monos-4.4
Eos-1.1 Baso-0.5
[**2125-9-3**] 03:30PM BLOOD WBC-7.4 RBC-4.17* Hgb-11.6* Hct-33.8*
MCV-81* MCH-27.8 MCHC-34.3 RDW-14.3 Plt Ct-201
[**2125-9-4**] 06:50AM BLOOD WBC-7.1 RBC-4.23 Hgb-11.5* Hct-33.6*
MCV-80* MCH-27.1 MCHC-34.1 RDW-14.3 Plt Ct-191
.
CXR [**2125-9-3**]:
FINDINGS: There is a left-sided pacemaker with leads ending at
the right
atrium and right ventricle. There are intact sternal wires.
There is mild
cardiomegaly and mild pulmonary edema without evidence of large
pleural
effusions. There is calcification of the aortic arch and the
mitral annulus
as well as of the trachea. There is no pneumothorax or focal
consolidation.
.
IMPRESSION: Mild cardiomegaly and mild pulmonary edema.
.
CXR [**2125-9-4**]:
FINDINGS: There are low lung volumes. There is mild
cardiomegaly, stable. A dual-lead pacemaker is unchanged. There
has been interval improvement in pulmonary edema with minimal
interstitial opacities and blunting of the
costophrenic angles. Severely calcified mitral annulus is noted.
No focal
consolidation or pneumothorax.
.
IMPRESSION:
1. Interval improvement in pulmonary edema.
Brief Hospital Course:
79 yo F with hx of DM2, HTN, Aortic Stenosis s/p AVR and now has
bioprosthetic critical AS and pacemaker presenting on admission
from wards floor with acute respiratory distress and flash
pulmonary edema.
.
# Pulmonary Edema/diastolic CHF: Patient has a history of
multiple CHF exacerbation admissions in the past. On this
admission, patient reportedly missed PM medications (lasix) and
received some IVF when she was being admitted for episode of
hypoglycemia. She was found by nursing after transfer to the
wards floor to be in respiratory distress, and CXR showed BL
flash pulmonary edema, hypertensive to sBP200s, and ABG
7.30/55/63/28. She was placed on BiPAP, morphine, Hydralizine
IVx1, Lasix IV40mg, and transferred to the CCU. Troponins were
0.01->0.02->0.05. She was diuresed with IV lasix, then
transitioned to home Lasix, and her respiratory status improved
to baseline. On discharge, the patient was oxygenating well on
room air.
.
# Hypertension: On transfer to the CCU, patient was found to
have sBP in 200s. When remeasured, had L arm sBP 207 and R arm
sBP 106, however, history of BL subclavian stenosis (R-80%;
L-40%) therfore opted not to get CT to check for aortic
dissection; CXR did not show evidence of dissection/widened
mediastinum. She had received hydralizine 20mg IV prior to
transfer. Her home medications were reconciled with her
pharmacy, and she was placed on Valsartan 120mg [**Hospital1 **] and
Carvedilol 25mg [**Hospital1 **]. Her home nifidipine and hydralizine were
held since her BP was well controlled with a range of
106-135/40-53, and concern for afterload reduction in critical
AS.
.
# Ao Stenosis: patient has hx of critical bioprosthetic AS s/p
AVR [**2118**]. According to TTE of [**3-22**] and [**1-23**]: patient has high
transvalvular gradient and valve area of 0.7. No further ECHOS
have been done, per Dr. [**Last Name (STitle) **], as patient will not proceed
with any intervention anyway. Discussed with patient and
family, and confirmed that she would not like to pursue surgical
correction. Therefore, no ECHO or pre-operative evaluation was
performed on this admission.
.
# Diabetes: patient originally presented with low blood sugars
to the 60s and LOC. Typically on Lantus 35U at home, and Lispro.
In the hospital, she was started on Lantus 20U and insulin
sliding scale to estimate her insulin requirements. Her final
Lantus dose at discharge was titrated at 23U in addition to ISS.
She will be discharged on this regimen, in addition to Lispro
for extra mealtime coverage.
# CAD s/p CABG: Patient has known long-standing disease CAD.
CABG x 1 with SVG to PDA in [**2118**], PCI to LAD [**2119**]. Recent flash
pulmonary less concerning for possible ischemic event, CE normal
range and no associate CP. She was continued on ASA 81mg,
Carvedilol 25mg [**Hospital1 **], Simvastatin 40mg PO daily, and Zetia 10mg
during hospitalization, and at discharge.
# History of left atrial appendage thrombus: Patient was
started on Coumadin 5mg on admission, due to unknown home
amount. Coumadin was held for INR 3.1, and medication
reconcilation started on home dose of 4mg the following day. On
discharge, patient is on Coumadin 4mg with INR 1.9 (related to
held dose).
# Mild Dementia: per patient's son, she has mild dementia at
baseline. She was continued on Aricept 10mg daily. During
hospitalization, she appeared oriented and appropriate.
#FEN: she was continued on a heart healthy diabetic diet.
#Prophylaxis:
-DVT ppx with coumadin
-Pain management with tylenol
-Bowel regimen with colace, miralax (unknown allergy to senna)
Medications on Admission:
On transfer:
DONEPEZIL [ARICEPT]10mg daily
EZETIMIBE - 10 mg daily
FUROSEMIDE [LASIX] - 80 mg [**Hospital1 **]
INSULIN GLARGINE [LANTUS] 30 units SC once a day
INSULIN LISPRO - (- Dosage uncertain
IRBESARTAN [AVAPRO] - 150 mg daily
METOPROLOL SUCCINATE -- 100 mg SR 1.5 Tablet(s) daily (Total
150mg daily)
NIFEDIPINE - 60 mg Tablet XR daily
PANTOPRAZOLE - 40 mg Tablet (E.C) daily
POTASSIUM CHLORIDE - 20 mEq Tab Sust.Rel. 1 Tab(s) [**Hospital1 **]
SERTRALINE - 100 mg Tablet - 1 Tablet(s) by mouth every morning
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth every morning
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth daily
TRAZODONE - 50 mg Tablet QHS for insomnia
WARFARIN - Dosage uncertain
.
ACETAMINOPHEN [TYLENOL] -
ASPIRIN [ASPERDRINK] 81mg PO
DOCUSATE SODIUM [COLACE] - 100 mg Capsule qday
FERROUS SULFATE - 325 mg ( Sustained Release) daily
OMEGA-3 FATTY ACIDS - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO QAM.
5. Lantus 100 unit/mL Solution Sig: Twenty Three (23)
Subcutaneous once a day.
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Valsartan 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
16. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO QAM.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
19. Omega-3 Fatty Acids Oral
20. Acetaminophen Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Hypoglycemia
Acute exacerbation of chronic diastolic congestive heart failure
(EF 75%)
Hypertension
Aortic Stenosis
DM II - insulin dependent
CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital because you were found to be
unresponse in your day home facility and had a very low blood
sugar level. You were taken to the hospital and given juice and
fluids to improve your blood sugar level. Because of these
symptoms you also missed your evening dose of lasix. Overnight
while in the hospital you had worsening symptoms of shortness of
breath and high blood pressure. This was believed to be an acute
exacerbation of you chronic known congestive heart failure. You
were admitted to the ICU to treat these symptoms. You were given
medications (IV lasix) to help remove excess fluid from your
lungs and also treated with a specially oxygen mask. Your
symptoms improved quickly with these treatments and you were
able to be discharged home.
.
The following changes were made to your medication:
- Please take Valsartan 120 mg twice daily
- Please take Furosemide (lasix) 120 mg in the morning and 80mg
in the evening. Please be sure to take this medication as
prescribed and to never miss a dose as it could result in sudden
worsening of your chronic congestive heart failure.
- Please start taking Carvedilol 25 mg twice daily
- Please decrease your lantus dose to 23units per day as your
previously higher dose may be contributing to your episodes of
hypoglycemia
- Please stop taking Nifedipine XL 60mg twice daily
- Please stop taking Toprol XL 50mg three times daily
- Please stop taking Hydralazine 10mg PO twice daily
- Please stop taking Irbesartan 150mg PO daily
Please continue to take your other home medications as
prescribed.
Please be sure to take all medications as prescribed.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
Please be sure to keep all follow-up appointments with your
doctors. (see below)
.
It was a pleasure taking care of you and we wish you a speedy
recovery.
Followup Instructions:
Please be sure to keep all follow-up appointments with your
doctors.(See below)
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**]
Phone: [**Telephone/Fax (1) 4606**]
Appt: [**9-20**] at 2:45pm
Department: CARDIAC SERVICES
When: FRIDAY [**2125-10-12**] at 3:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: PODIATRY
When: TUESDAY [**2125-9-18**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Psychiatry:
Department: HMFP
When: TUESDAY [**2125-9-25**] at 3:20 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 15631**], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
.
Completed by:[**2125-9-6**]
ICD9 Codes: 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3239
} | Medical Text: Admission Date: [**2131-6-17**] Discharge Date: [**2131-6-19**]
Date of Birth: [**2055-3-21**] Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Norvasc / Zestril / Bactrim Ds
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
inability to swallow
Major Surgical or Invasive Procedure:
EGD and intubation for EGD
History of Present Illness:
76 yo woman with Schatzki's ring s/p dilation in [**2129**] with no
symptoms until 1 mo ago, noticed increased time to pass food
below LES (15 minutes) but night prior to presentation developed
inability to pass food/liquids one hour after eating a meal of
fish and chinese noodles.
In the ED: She was given glucagon, nitro, and zofran. GI was
consulted and requested ICU admission for monitoring, planning
EGD for day of admission.
Past Medical History:
hypertension
schatzki's ring
anemia
s/p hysterectomy
depression
Social History:
remote (quit 30-40 years ago) smoking history, drinks a glass of
wine with dinner, lives with husband, retired.
Family History:
noncontributory
Physical Exam:
Flowsheet Data as of [**2131-6-17**] 06:02 PM
Vital Signs Hemodynamic monitoring Fluid Balance 24 hours Since
12 AM
Tmax: 36.6 ??????C (97.8 ??????F)
Tcurrent: 36.6 ??????C (97.8 ??????F)
HR: 100 () bpm
BP: 156/70
RR: 16 ()
SpO2: 97
Heart rhythm: SR (Sinus Rhythm)
Respiratory
O2 Delivery Device: None
Physical Examination
General Appearance: Well nourished, No acute distress, Anxious,
spitting into emesis basin
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Musculoskeletal: No(t) Muscle wasting
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): person, place, and time, Movement:
Purposeful, Tone: Normal
Pertinent Results:
[**2131-6-17**] 11:45AM WBC-7.4 RBC-3.91* HGB-12.9 HCT-38.9 MCV-100*
MCH-33.0* MCHC-33.2 RDW-13.8
[**2131-6-17**] 11:45AM NEUTS-84* BANDS-0 LYMPHS-10* MONOS-3 EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2131-6-17**] 11:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2131-6-17**] 11:45AM PLT COUNT-385
[**2131-6-17**] 11:45AM PT-12.8 PTT-22.9 INR(PT)-1.1
[**2131-6-17**] 11:45AM GLUCOSE-118* UREA N-13 CREAT-0.8 SODIUM-141
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-22 ANION GAP-17
Brief Hospital Course:
76 F w/ Shatzki's ring presents with acute dysphagia s/p
endoscopic disimpaction, now with evidence of new LLL infiltrate
on CXR and slight drop in O2 sat concerning for possible
aspiration pna
.
# Acute dysphagia
s/p endoscopic disimpaction of food proximal to the shatzki's
ring. Continuing liquid diet X 3 days followed by soft
mechanical X 1 wk, plan for dilation procedure next week.
.
# Aspiration pneumonia
New LLL process with mild hypoxia, new leukocytosis and low
grade temperature
concern for aspiration pna, especially in the setting of
intubation for procedure, mediastinitis or micro perf
possibility with small effusion, atelectasis. 7 day course of
antibx for aspiration PNA.
Medications on Admission:
ocuvite daily
xanax 0.125mg qhs
premarin 0.3mg daily
mirtazipine 15mg qhs
cozaar 100mg daily
aspirin 81mg daily
amlodipine, pt unsure of dose
Discharge Medications:
No changes to above, the following added:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Food impaction proximal to Shatzki Ring requiring intubation and
endoscopic disimpaction
.
Aspiration pneumonia
Discharge Condition:
Stable, afebrile, room air saturations normal, culture negative,
tolerating clear liquid diet, ambulatory and voiding without
difficulty.
Discharge Instructions:
Take all medications as prescribed. Resume your home
medications as you were taking them, we have added only two
antibiotics, prescriptions are included.
Take liquid diet only for the next three days, if this goes
well, may advance to a pureed diet.
Return to the Emergency Room at [**Hospital1 18**] for: severe difficult
swallowing, fevers, shortness of breath
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5085**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2131-6-26**] 11:30
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 1641**] (ST-3) GI ROOMS Date/Time:[**2131-6-26**] 11:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2131-7-10**]
2:20
ICD9 Codes: 5070, 4019, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3240
} | Medical Text: Unit No: [**Numeric Identifier 65049**]
Admission Date: [**2149-10-24**]
Discharge Date: [**2149-10-29**]
Date of Birth: [**2149-10-24**]
Sex: F
Service: Neonatology
IDENTIFICATION: Baby Girl [**Known lastname **] [**Known lastname 65050**] is a 5-day old
former 33-4/7 week premature infant being transferred from
the [**Hospital1 69**] NICU to [**Hospital3 38285**] Special Care Nursery.
HISTORY: Baby Girl [**Known lastname 65050**] was born on [**2149-10-24**] at
1:08 AM as the 1875 gram product of a 33-4/7 weeks gestation
pregnancy to a 41-year-old Gravida 1, para 0 mother. Prenatal
laboratory studies included blood type A+, antibody negative,
RPR nonreactive, hepatitis B surface antigen negative, rubella
immune and GBS unknown. Pregnancy was uncomplicated
until the day prior to delivery when mother presented with
headache, epigastric pain and hypertension. Due to
significant hypertension mother was taken for cesarean
section delivery. There was no labor and membranes were
intact at the time of delivery. Infant emerged vigorous with
Apgar scores of 7 and 9. She required suctioning of a large
amount of oral secretions but no other notable resuscitation.
She was brought to the NICU for further care.
PHYSICAL EXAMINATION: On admission: Weight was 1875 grams,
the length was 39.5 cm, head circumference was 31 cm. Infant
was a well developed premature infant, active with
examination with mild respiratory distress. Fontanels were
soft and flat. The facies was nondysmorphic. The palate was
intact. Ears and nares were normal. Neck was supple without
lesions. Cardiac examination was regular rate and rhythm
without murmur. Chest was clear with moderate aeration and
mild retractions. Abdomen was soft and nontender with no
palpable masses. Hips and back were normal. Extremities were
well perfused. Tone and activity were appropriate for
gestational age. Genitalia were that of a premature female.
Anus was patent.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Infant exhibited mild increase work of breathing
upon admission and was placed on nasal cannula for a mild oxygen
requirement. Infant weaned to room air by 24 hours of life
and has remained in room air since that time. The patient had
mild apnea and desaturation spells over the first 48 hours of
life. By the time of transfer, the infant had not had any spells
or desaturations for over 72 hours. At the time of transfer the
infant is breathing comfortably in room air with mild
intermittent retractions and oxygen saturation is greater
than 92%.
Cardiovascular: Infant has remained hemodynamically stable
throughout admission. No murmur has been heard. Examination
has been within normal limits throughout.
Fluids, electrolytes and nutrition: Infant was initially
maintained on intravenous fluids. Enteral feedings were
introduced at day one of life and advanced without difficulty. At
the time of discharge the infant is receiving 140 cc per kilo per
day of PE20 given mostly by gavage with occasional small amounts
taken p.o. Calories were increased to 24 calories per
ounce on the day of transfer. Infant had been voiding and
stooling throughout. D-sticks and chemistries were within
normal limits over the first 48 hours of life.
GI: Infant was noted to be mildly jaundiced during admission.
Bilirubin peaked at 6.0/0.2 on [**2149-10-27**] and remained
stable at 6.0/0.2 on [**2149-10-28**]. Infant did not receive
phototherapy.
Infectious Disease. The initial CBC and blood culture were
sent at the time of admission with CBC revealing white count
of 10.9, hematocrit 47.8, platelets of 225 with a
differential of 38% poly's and 0% bands. The infant received
ampicillin and gentamicin for 48 hours at which time they
were discontinued with negative blood cultures and benign
clinical course.
Hematology: As mentioned initial hematocrit was 47.8. Infant
has not been started on iron supplementation at the time of
transfer.
Neurology: The infant has maintained a normal neurologic exam
throughout admission. A hearing screen has not yet been
performed at the time of transfer.
Routine health care maintenance: Infant has not received
hepatitis B vaccine at the time of transfer. Newborn screen
was sent on [**2149-10-27**] and no abnormal result has been
reported to date.
DISPOSITION: The infant is being transferred to [**Hospital3 38285**] special care nursery.
PRIMARY PEDIATRICIAN: Not yet identified. Parents are
interested in [**Hospital 2436**] Pediatrics.
CARE RECOMMENDATIONS:
1. Diet: 140 cc kilo per day of premature Enfamil 24
calories per ounce given p.g. and p.o.
2. Medications: None.
3. Car seat position screening: Not yet performed but
recommended prior to discharge.
DISCHARGE DIAGNOSIS:
1. Prematurity at 33-4/7 weeks.
2. Transitional respiratory distress consistent with transient
tachypnea of the newborn.
3. Sepsis evaluation.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2149-10-29**] 10:13:08
T: [**2149-10-29**] 11:08:43
Job#: [**Job Number 65051**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3241
} | Medical Text: Admission Date: [**2132-6-11**] Discharge Date: [**2132-6-19**]
Date of Birth: [**2068-1-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Endoscopy [**2132-6-13**]
History of Present Illness:
Mrs [**Known lastname 84796**] is a 64 yo F who presented to her PCP on the day
of admission for eval of LE edema. Pt also endorsed
non-melanotic diarrhea and vomiting x 1-2 months, without abd
pain, fevers, chills. Also c/o rash over trunk/arms x1-2
months. At her PCP's office, she was noted to have SBP of 50
and therefore sent to the ED for further evaluation.
In the ED, the patient triggered for hypotension in the 80s,
improved to the 90s after 1 L NS. Exam was notable for open
lesions in b/l lower extremities, significant lymphedema, guiac
positive stool. Labs were notable for new renal failure with
creatinine of 7.4, hyperkalemia, leukocytosis to 17, positive
urine. Blood cultures were sent, CXR was negative for
intrathoracic process. She was given vancomycin, calcium
carbonate, zosyn, 2U PRBCs and 2L fluids and transferred to the
ICU. EKG was normal. The patient was evaluated by renal in the
ED who felt that the most likely cause of renal failure was ATN,
recommended Ca repletion and bicarb.
On the floor patient has no complaints other than LE edema/pain.
ROS: Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, neck stiffness/pain. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations.
Past Medical History:
-OBESITY, MORBID
-ARTHRALGIA OF KNEE
-HYPERTENSION, ESSENTIAL
-OSTEOARTHRITIS
-LYMPHEDEMA
-HLD
Social History:
Pt is a retired bookeeper and nursing assistant from Liverpool.
She denies EtOH, tobacco, IVDU. Walks with a walker. Lives
alone. Performs all ADLs however has had increasing difficulty
recently due to lymphedema.
Family History:
No known cardiac, pulm disease
Physical Exam:
On Admission:
VS: Temp:97.6 BP: 100/51 HR:95 RR:20 O2sat 100% RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, unable to visualize
JVD, no carotid bruits, no thyromegaly or thyroid nodules, no
neck stiffness or pain with movement
CV: RRR, nl S1 and S2, no m/r/g
RESP: distant BS with good air movement throughout
ABD: obese, NT, nd, +b/s, soft, nt, no masses or
hepatosplenomegaly
EXT: bilateral non-pitting LE edema, multiple areas of skin
breakdown on the anterior aspect of the lower extremity with
mild surrounding errythema
SKIN: diffuse rash across chest/back/arms consisting of small
errythematous papules, some with hemorrhagic crusts.
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
On Discharge:
VS: T 97.4-98.6 BP 113-153/69-101 HR 71-110 RR 18 O2 Sat 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes
Neck: Supple, JVP difficult to asses [**1-16**] habitus, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: cool, well perfused, Significant bilateral non-pitting
edema, R>L, tender to touch. Pulses unable to be palpated due to
edema. Small resolving palpable cord in the RUE consistent with
resolving thrombophlebitis.
Skin: Multiple excoriations of upper arms with small
erythematous nodules along upper back, markedly improved since
admission. BLEs wrapped in pressure dressings.
Neuro: Grossly intact
Pertinent Results:
Blood Counts
[**2132-6-11**] 11:53AM BLOOD WBC-17.0* RBC-2.72* Hgb-7.3* Hct-22.4*
MCV-82 MCH-26.8* MCHC-32.5 RDW-15.5 Plt Ct-392
[**2132-6-12**] 07:07PM BLOOD WBC-14.1* RBC-3.76* Hgb-10.8* Hct-31.0*
MCV-82 MCH-28.8 MCHC-35.0 RDW-15.4 Plt Ct-281
[**2132-6-16**] 07:05AM BLOOD WBC-11.3* RBC-4.48 Hgb-13.0 Hct-38.6
MCV-86 MCH-29.1 MCHC-33.7 RDW-15.9* Plt Ct-234
[**2132-6-19**] 07:00AM BLOOD WBC-8.6 RBC-4.36 Hgb-12.5 Hct-37.7 MCV-86
MCH-28.8 MCHC-33.3 RDW-15.5 Plt Ct-189
Chemistry
[**2132-6-11**] 11:53AM BLOOD Glucose-130* UreaN-173* Creat-7.4*
Na-125* K-5.5* Cl-90* HCO3-15* AnGap-26*
[**2132-6-12**] 02:13AM BLOOD Glucose-209* UreaN-130* Creat-4.7* Na-135
K-3.2* Cl-102 HCO3-17* AnGap-19
[**2132-6-14**] 05:31PM BLOOD UreaN-44* Creat-2.7* Na-140 K-2.8* Cl-106
HCO3-21* AnGap-16
[**2132-6-19**] 07:00AM BLOOD Glucose-95 UreaN-24* Creat-1.7* Na-138
K-3.6 Cl-101 HCO3-27 AnGap-14
MICRO:
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2132-6-13**]): NEGATIVE BY
EIA.
URINE CULTURE (Final [**2132-6-14**]): ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
STUDIES:
RENAL U/S [**2132-6-12**]:
Echogenic kidneys, consistent with medical renal disease. No
evidence of hydronephrosis.
EGD ([**2132-6-13**]):
? ulceration at the GEJ
Erosions in the lower third of the esophagus c/w erosive
esophagitis
Denuded mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
1. Severe sepsis (UTI): Presented with leukocytosis, grossly
positive UA, Ucx growing pansensitive Ecoli. Initially managed
in ICU with broad-spectrum abx, once stable with culture data,
narrowed to PO cipro, with plan to continue for course of 14
days.
2. Erosive Esophagitis: Admitted with Hct 22, guaiac positive
stool. Required 9 units pRBCs in ICU. EGD demonstrated erosive
esophagitis. Patient started on omeprazole and sucralfate. Hct
subsequently remained stable w/o signs of bleeding.
3. Acute Renal failure: Pt admitted w Cr >7 (baseline ~1.0) w/o
major electrolyte abnormalities in setting of urosepsis. Urine
sediment c/w ATN, likely in setting of hypotension. At discharge
Cr had trended down to 1.7. Patient's lisinopril was held
pending resolution of renal failure.
4. RUE Thrombophlebitis: Patient noted to have RUE
thrombophlebitis at prior site of IV. Area was treated
conservatively w warm packs and cleaning. At discharge area was
clean without erythema, exudate or TTP. A palpable cord was
still present but improved.
CHRONIC
5. Chronic Lymphedema complicated by Leg ulcer: Wound care
followed and provided regular ace wraps.
TRANSITIONAL
1. Transition of Care - Pt discharged to rehab for PT. She will
need follow-up with gastroenterologist as well as PCP to discuss
erosive esophagitis, acute kidney injury.
Medications on Admission:
-Lisinopril 20 mg daily
-Simvastatin 10 mg daily
-Atenolol-chlorthalidone 50-25
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for fungal rash .
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
10. atenolol-chlorthalidone 50-25 mg Tablet Sig: One (1) Tablet
PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare of [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
Urosepsis
Erosive Esophagitis
Acute Kidney Injury
Secondary:
Lymphedema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms [**Known lastname 84796**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted with low blood pressure. You
were found to have a very serious infection in your blood as
well as a low blood count. You were treated with antibiotics
and your infection improved. Your low blood count was caused by
irritation of your esophagus. You were started on medications
to treat this irritation and transfused with blood. Your blood
levels improved and you remained stable.
.
As a result of your infection, your kidneys received some
damage. They are now recovering. Until they are fully
recovered, you should not take your lisinopril.
.
During this hospitilization, we made the following changes to
your medications:
- STARTED Ciprofloxacin for your infection
- STARTED Omeprazole and sucralfate for your esophagus and
stomach
- STARTED Ipratroprium and albuterol for your breathing
- STOPPED Lisinopril
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 2890**] M.
Location: [**Hospital1 641**]
Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 2115**]
**Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge**
ICD9 Codes: 5845, 5789, 2851, 5990, 2761, 2768, 2767, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3242
} | Medical Text: Admission Date: [**2117-4-3**] Discharge Date: [**2117-4-6**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old
[**Last Name (un) 18159**]-speaking female with a history of hypertension and
elevated cholesterol who presented on [**4-3**] at 4 a.m.
complaining of chest pain which awoke her from sleep.
She states that she has crescendo anginal symptoms, dyspnea
on exertion, and increasing fatigue over the past week, with
severe impairment of her exercise tolerance. It takes her
greater than three hours to walk four blocks. Today, with
worsening symptoms and substernal chest pain with radiation
to her neck and left arm. There was associated shortness of
breath. There was no diaphoresis, nausea, vomiting, or
palpitations.
The patient was given three sublingual nitroglycerin tablets,
aspirin, morphine, and Lopressor in the Emergency Department
and became pain free. She was started on heparin and
Integrilin, and the Catheterization Laboratory was activated.
The patient's electrocardiogram showed ST elevations in leads
II, III, and aVF of about 2 mm with greater than ST
elevations in lead III than II. There were reciprocal ST
depressions of about 2 mm in leads I and aVL with right-sided
V4 lead without any ST elevations.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was
afebrile, her heart rate was 80, and her blood pressure was
160/70. In general, she was in no acute distress. Head,
eyes, ears, nose, and throat examination revealed the mucous
membranes were moist. Cardiovascular examination revealed a
regular rate and rhythm. No murmurs, rubs, or gallops.
Pulmonary examination revealed clear to auscultation
bilaterally. The abdomen was soft, nontender, and
nondistended. There were normal active bowel sounds. The
extremities were without edema. Peripheral pulses were 2+.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's
white blood cell count was 8.7, her hematocrit was 40.1, and
her platelets were 219. Her INR was 1.4. Sodium was 141,
potassium was 4.3, chloride was 103, bicarbonate was 23,
blood urea nitrogen was 20, creatinine was 0.7, and her blood
glucose was 98. Creatine kinase was 197, MB was 10, and her
troponin was 0.18. Her creatine kinase peaked at about 400.
PERTINENT RADIOLOGY/IMAGING: Cardiac catheterization on
[**4-3**] revealed a 90% mid right coronary artery ulcerated
plaque, 20% left main ostial lesion, and a 30% ostial left
anterior descending artery, with diffuse 50% proximal, with
70% focal mid stenosis. The patient received percutaneous
transluminal coronary angioplasty and cypher stent of her
right coronary artery lesion with small proximal dissection
and subsequent overlapping proximal cypher stent to her right
coronary artery lesion. Right atrial pressure was 5. Right
ventricular pressure was 23/3. Pulmonary artery pressure was
24/10. Pulmonary capillary wedge pressure was 10.
An echocardiogram revealed an ejection fraction of greater
than 55%. There was no evidence of akinesis. Otherwise, a
normal echocardiogram.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR/ISCHEMIA ISSUES: The patient with an
inferior ST-elevation myocardial infarction without evidence
of right ventricular infarction. She had a mid right
coronary artery 90% ulcerated lesion which was stented with
two cypher stents. She was chest pain free with resolution
of her ST elevations after her catheterization. Her creatine
kinase levels peaked at 400. Her echocardiogram revealed no
evidence of left ventricular dysfunction and no need for
anticoagulation. She was to continue on aspirin, Plavix,
Lipitor, Toprol, and lisinopril as an outpatient.
2. HYPERTENSION ISSUES: The patient's blood pressure was
well controlled on Toprol and lisinopril while in the
hospital. She was to discontinue her home
hydrochlorothiazide and continue these medications.
3. HYPERCHOLESTEROLEMIA ISSUES: In terms of her
hypercholesterolemia, she was to continue on Lipitor but her
dose will be increased to 80 mg once per day. The patient
has an unclear history of liver function tests abnormalities
associated with Lipitor. We will start the full dose at this
point, and the patient will need to follow up with liver
function tests within the next month.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient was to be discharged to home
after clearance by Physical Therapy.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Last Name (NamePattern1) 5819**]
MEDQUIST36
D: [**2117-4-6**] 14:04
T: [**2117-4-6**] 15:04
JOB#: [**Job Number 18160**]
ICD9 Codes: 9971, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3243
} | Medical Text: Admission Date: [**2133-7-12**] Discharge Date: [**2133-7-15**]
Service: CCU
CHIEF COMPLAINT: Fall, question of stroke.
HISTORY OF PRESENT ILLNESS: This 82 year old female is a
resident of [**Hospital3 24509**] Home with a history of
paroxysmal supraventricular tachycardia and diabetes who was
found down in a puddle of urine the morning of admission.
There was no evidence of trauma and the patient was alert and
oriented at least according to her baseline mental status. A
few hours later she was noticed to have a left facial droop,
dysarthria and left-sided weakness as well as diaphoresis and
being cold to touch. She had a glucose of 404 for which she
received 4 units of insulin with no improvement and was
brought to the [**Hospital6 256**] Emergency
Room for a concern of possible cerebrovascular accident. The
stroke fellow saw her in the Emergency Room and found her
examination showing no evidence of cerebrovascular accident
but noticed bradycardia with pauses of up to 4 seconds. The
Coronary Care Unit Team was called to see her and she was
brought to the Coronary Care Unit for urgent transvenous
pacer placement with a [**Hospital1 1516**] pad placed prophylactically on
her chest. A transvenous pacemaker was introduced through a
right IJ Cordis with good capture with a rate of 70. Post
procedure the patient denied chest pain, shortness of breath,
reported mild nausea but no diarrhea, constipation, abdominal
pain, cough or fevers or chills, but she does not remember
her fall. She has mild pain at the transvenous pacer
insertion site.
PAST MEDICAL HISTORY:
1. Dementia of vascular type also with history of
Alzheimer's type although it is not clear how the latter can
be confirmed given the former.
2. Diabetes Type 2 on Glyburide
3. Degenerative joint disease
4. Anemia
5. Status post hysterectomy
6. History of alcohol abuse, sober times 30 years
7. History of paroxysmal atrial tachycardia/paroxysmal
supraventricular tachycardia for which she takes atenolol and
digoxin.
8. Low back pain with spinal decompression in [**2128**] and
epidural steroid injections.
9. Per nursing home a history of personality disorder.
SOCIAL HISTORY: The patient was at [**Hospital3 24509**]
Home and smokes no tobacco and has a history of distant
history of alcohol abuse. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is her daughter.
She has power of attorney. Phone #s include [**Telephone/Fax (1) 29986**] and
[**Telephone/Fax (1) 29987**] on her cell phone. The patient is
Do-Not-Resuscitate, Do-Not-Intubate but other intervention
including pressors are okay.
FAMILY HISTORY: The patient denies and she may be an
unreliable historian in this regard.
ALLERGIES: Aspirin and codeine, unknown reactions.
MEDICATIONS:
1. Digoxin 0.125 mg q.d.
2. Prn Trazodone
3. Zyprexa 15 mg q.h.s.
4. Glyburide 10 mg q.d.
5. TUMS 500 mg b.i.d.
6. Colace 100 mg b.i.d.
7. Tylenol 650 mg b.i.d.
8. Aricept 10 mg q.h.s.
9. Neurontin 400 mg t.i.d.
10. Atenolol 25 mg q.d.
11. Effexor 37.5 mg q.d.
12. Multivitamin
13. Zestril 20 mg q.d.
PHYSICAL EXAMINATION: Temperature 98.3, pulse 70, blood
pressure 105/37, respiratory rate 19, sating 96% on 3 liters.
Head, eyes, ears, nose and throat reveals oropharynx clear,
mucous membranes dry and the patient was edentulous. Could
not assess jugulovenous distension secondary to pacer
insertion. In general the patient was in no acute distress
and answered questions intermittently, was insulting to staff
with occasional inappropriate comments, otherwise was an
elderly well developed, well nourished female.
Cardiovascular, the patient was in a regular rate and rhythm
with a normal S1 and S2 without murmurs, rubs or gallops.
Pulmonary, crackles at the bases, left greater than right.
Extremities, 1+ edema, nonpitting, no cyanosis or clubbing.
Neurological, alert and oriented times one. Sensation was
intact. Strength 5/5 bilaterally. Cranial nerves II through
XII were intact.
LABORATORY DATA: White count 39.7, hemoglobin 10.6,
hematocrit 31, platelets 576. Differential, 87 PMNs, 9
bands, 4 lymphs, INR 1.2, PTT 27.7. Arterial blood gases
7.42/37/89/25. Sodium 139, potassium 4.8, chloride 100,
bicarbonate 20, BUN 21, creatinine 1.5, glucose 392, calcium
9.1, magnesium 1.6, phosphate 4.1, Digoxin 1.2, CK 554, MB
fraction 8. Troponin mildly positive at .8. Chest x-ray
showed right middle lobe, +/- right lower lobe, pneumonia
consistent with aspiration. The patient was status post
transvenous pacemaker placement with no pneumothorax or
complication. Electrocardiogram, sinus arrest with asystole,
poor junctional escape without ischemia, however, with 3 to 4
second pauses, long QT. After pacemaker was placed,
electrocardiogram showed V-paced rhythm at 70, left axis
deviation, wide QRS with reciprocal changes and a left bundle
branch pattern.
HOSPITAL COURSE: Cardiology, electricity, for the patient's
initial intermittent sinus arrest with long pauses and
unreliable junctional escape she was admitted to the Coronary
Care Unit and had an urgent transvenous pacemaker placed
[**7-12**] with recapture. There was no clear etiology.
Digoxin level was normal and there was no evidence of
ischemia. The next morning she was noticed to be
intermittently pacer independent but still having long pauses
at times requiring pacer function. Further although her
Digoxin and atenolol were held, since the pacemaker could
have ceased functioning and her nodal blockers would have
produced an intrinsic rate, she was going to need these for
the history of paroxysmal supraventricular tachycardia and
paroxysmal atrial tachycardia, therefore permanent pacemaker
was placed [**2133-7-14**] when her pneumonia was under good
control. This continued to function well throughout her
stay. The type was [**Company 1543**] Stigma SVR 303, Mode DDD, rate
set 60 to 100, serial #[**Serial Number 29988**]. On [**7-15**], the patient
did have several runs of nonsustained ventricular tachycardia
but the significance of this without known coronary artery
disease and reduced ejection fraction is unknown. Further
the patient is not an implantable cardioverter defibrillator
candidate as she is Do-Not-Resuscitate. She also had [**7-15**], AM a run of paroxysmal supraventricular tachycardia with a
rate of 100 to 120s which self-terminated and as a result the
team increased her atenolol her 50 mg. This medication was
reintroduced after the permanent pacemaker was in place. She
also needed further blood pressure control with systolic
blood pressures in the 140s to 160s that day. This will
require follow up as an outpatient. She currently remains on
atenolol 50 and Zestril. Atenolol rather than digoxin is
being used for rate control.
Coronaries and pump - No known issues. The patient tolerated
rehydration without desaturation. CKs dropped with time, MB
fractions were never positive and CKs were assumed to be from
a long lie and not from a coronary source.
Pulmonary - The patient was felt to have pneumonia, right
middle lobe and right lower lobe, possibly secondary to
aspiration, see infectious disease for details. Oxygen was
weaned off with good saturations on room air and no shortness
of breath, also with resolution of infiltrates, at least
partially on post pacemaker films which may indicate a
resolving pneumonitis rather than an actual pneumonia.
Renal - Initially high creatinine to 1.5 normalized to .7
with rehydration. She is on an ACE inhibitor which will help
control a decline in function of her diabetes mellitus.
Diabetes control will assist with this as well.
Infectious disease - Given Levofloxacin and Flagyl in the
Emergency Room for aspiration pneumonia this was renally
dosed and then doses were increased after her creatinine was
normalized. Flagyl was not continued because of the very low
incidents of anaerobic infections and aspiration pneumonia
and her good pulmonary function. White blood cell count fell
from 40 to 20 then to 10 and then to 7.5 at the time of
discharge. Levofloxacin was to be continued for two doses
for a total of five day course given her good room air
status, decrease in abnormal chest x-ray and lack of
shortness of breath or fever at any point. The patient was
given a heart-healthy diabetic diet. For low urine output
and concentrated urine, initially she was rehydrated with
result of increased clear urine output and normalization of
creatinine.
Endocrine - The patient's diabetes Type 2 was managed with
q.i.d. fingersticks and regular insulin, sliding scale with
good control. Glyburide was stopped given the long QT on her
initial electrocardiogram. TSH was checked secondary to
elevated CK but the CKs normalized as expected as they would
from a long lie at the nursing home and TSH was normal at
1.6. Metformin may be initiated if replacement for Glyburide
is required.
Psyche - The patient was kept on her home Aricept, Effexor
and after the first day her Zyprexa. She required a sitter
at points while she had the transvenous pacer and restraints
to keep this device in but otherwise was cooperative. The
patient's daughter has the power of attorney and confirmed
the patient's Do-Not-Resuscitate, Do-Not-Intubate status and
signed a consent for pacemaker placement.
Neurology - The patient had no facial asymmetry or weakness
detected throughout her hospital stay and therefore no head
computerized tomography scan was obtained. The patient
presumably had a transient ischemic attack representing acute
illness bringing out chronic cerebrovascular disease. Her
multi-infarct dementia would best be preventively managed
with aspirin if her presumed allergy is not significant and
blood pressure and glucose control and an ACE inhibitor which
she is already on.
Musculoskeletal - The patient remained immobile in bed
throughout her stay but had no decubiti ulcers. Mild sacral
edema was noted the day of discharge. Mobility is a primary
goal at the nursing home post discharge but she is a
recurrent [**Last Name (un) 29989**].
DISCHARGE MEDICATIONS:
1. Atenolol 50 mg q.d. which may be increased for blood
pressure control as well as control of her paroxysmal
supraventricular tachycardia.
2. Zyprexa 50 mg q.h.s.
3. TUMS 500 mg b.i.d.
4. Colace 100 mg b.i.d.
5. Aricept 10 mg q.h.s.
6. Zestril 20 mg q.d. which is to be increased if she is
hypertensive on a good dose of Atenolol
7. Effexor XR 37.5 mg q.d.
8. Neurontin 400 mg t.i.d.
9. Multivitamin q.d.
10. Milk of magnesia 30 cc q. 4 to 6 hours prn constipation
11. Levofloxacin 500 mg q.d. for two to three more days after
[**2133-7-15**]
12. Sliding scale insulin prn
13. Vancomycin 1 gm 10 AM given on [**2133-7-16**] only to
complete a perioperative course
FOLLOW UP: Follow up is with the Device Clinic in one week,
so the patient is to call for appointment and is given the
number. She is to resume care under her prior primary
medical doctor.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Do-Not-Resuscitate, Do-Not-Intubate and
the daughter has power of attorney.
DISCHARGE DIAGNOSIS: (As admission plus)
1. Status post DDD pacemaker for intermittent sinus arrest
and bradycardia
2. Pneumonia versus aspiration pneumonitis
[**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 12203**], MD [**MD Number(1) 12204**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2133-8-20**] 17:26
T: [**2133-8-25**] 16:26
JOB#: [**Job Number 29990**]
ICD9 Codes: 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3244
} | Medical Text: Admission Date: [**2170-6-6**] Discharge Date: [**2170-6-9**]
Date of Birth: [**2106-8-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 63-year-old male who
was admitted to the Medical Intensive Care Unit on [**6-6**] for
bright red blood per rectum and melena. Review of systems
was otherwise negative.
PAST MEDICAL HISTORY:
1. Type 2 diabetes.
2. Hypertension.
3. Elevated cholesterol.
4. Diverticulosis.
5. Obstructive sleep apnea.
MEDICATIONS ON ADMISSION: Norvasc 10 mg p.o. q.d.,
labetalol 800 mg p.o. q.d., Mavik 8 mg p.o. q.d.,
hydrochlorothiazide 25 mg p.o. q.d., Glucophage 1000 mg p.o.
b.i.d., Glucotrol 10 mg p.o. q.d., Actos, Prilosec 20 mg p.o.
q.d., Lipitor 20 mg p.o. q.d., enteric-coated aspirin 81 mg
p.o. q.d., Aleve 200 mg p.o. q.d.
FAMILY HISTORY: The patient has no family history of colon
cancer.
SOCIAL HISTORY: No intravenous drug use. No ethanol use.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was
transferred to the floor on [**6-8**]. Vital signs upon
transfer revealed a temperature of 97.4, pulse of 72, blood
pressure of 158/80, respiratory rate of 20. He was pleasant
male in no acute distress. Mucous membranes were moist.
Lungs were clear to auscultation bilaterally. Heart had a
regular rate and rhythm. Normal first heart sound and second
heart sound. The abdomen was soft and nontender, positive
bowel sounds. No rebound or guarding. Pedal edema of 1+.
The patient was awake, alert and oriented times three. No
jugular venous distention.
RADIOLOGY/IMAGING: A chest x-ray showed no pneumothorax with
an internal jugular in the subclavian vein.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed a white blood cell count of 6.4,
hematocrit of 32.5, platelets of 233. Chem-7 revealed a
sodium of 140, potassium of 4.1, chloride of 102, bicarbonate
of 29, blood urea nitrogen of 31, creatinine of 1, blood
glucose of 263.
HOSPITAL COURSE: A nasogastric lavage in the Emergency
Department was negative. Hematocrit on admission was 32.5.
Subsequent hematocrits were 32 and 28. The patient received
2 units of packed red blood cells with a repeat hematocrit of
31.6 on [**6-8**].
Colonoscopy on [**6-7**] revealed nonbleeding grade 1
hemorrhoids, multiple diverticula in the descending sigmoid
colon, with no evidence of bleed; otherwise was normal. No
bright red blood and melena with bowel movements since
admission.
Assessment revealed this was a 63-year-old male with
diverticulosis and lower gastrointestinal bleed who was
transfused 2 units of packed red blood cells and had a
negative colonoscopy. He was transferred from the Medical
Intensive Care Unit to the floor.
1. GASTROINTESTINAL: The patient's hematocrit was stable on
this admission, and he had a colonoscopy which was noted
above.
2. CARDIOVASCULAR: The patient has a history of
hypertension and was continued on his cardiac medications
over the course of his admission with no significant
cardiovascular events.
3. ENDOCRINE: The patient has a history of diabetes and was
continued on his diabetic medications.
DISCHARGE DIAGNOSES: Lower gastrointestinal bleed.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Good.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 26586**]
Dictated By:[**Name8 (MD) 4575**]
MEDQUIST36
D: [**2170-7-12**] 17:24
T: [**2170-7-17**] 20:45
JOB#: [**Job Number 26587**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3245
} | Medical Text: Admission Date: [**2200-4-21**] Discharge Date: [**2200-4-25**]
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 22705**] is an 89 year-old
lady seen on [**3-18**] with increased difficulty ambulating,
incontinence, headache, falls and left sided weakness. She
was found to have right sided subdural hematoma on the [**3-20**]. secondary to increased lethargy and mild
showed increased volume of subdural hematoma on the left side
with compression of the lateral ventricles and subfalcine
herniation. She also had elevated blood pressures at this
time. This had been drained and she was discharged to rehab.
She was brought back to the hospital on the [**3-22**] by
her son, because of increasing lethargy and weakness. Repeat
head CT showed an enlarged subdural hematoma, which required
PAST MEDICAL HISTORY: Significant for coronary artery
disease status post coronary artery bypass graft, congestive
heart failure with an ejection fraction of 30%, atrial
fibrillation, hypertension, has a pacemaker and diabetes
mellitus.
MEDICATIONS: She is on Synthroid 25 micrograms q day,
atenolol 25 mg q day, Glipizide 5 mg q.d., Lisinopril 10 mg
q.d., Lipitor 10 mg q.d., Zantac 150 mg b.i.d. and sliding
scale insulin.
SOCIAL HISTORY: She is a nonsmoker and she does not drink
alcohol.
PHYSICAL EXAMINATION ON ADMISSION: Her temperature was 98.6.
Blood pressure 139/64. Heart rate was 73 and in atrial
fibrillation. Respiratory rate was 18 and a saturations were
98% on room air. She was elderly and reasonably nourished.
She was alert and oriented times two and she was incorrect of
the year and month. She is status post right craniotomy,
which had healed well. She has also had a recent left crani
with a bur hole and sutures, which had healed well. The
pupils are post surgical. Extraocular movements intact. the
neck was supple. There was full range of motion bilaterally.
Neurological she was attentive to examination, follows only
single, but she was progressively getting drowsy. Strength
was 5 out of 5 to gross examination on all extremities. She
had an increased tone in the right upper extremity. The
Babinski was down going and the deep tendon reflexes were
diminished or absent throughout. There was no clonus.
Tongue was midline.
The head CT done on the [**3-22**] showed a large residual
left sided subdural hematoma with minimum midline shift.
HOSPITAL COURSE: She was admitted in the Neurosurgical Floor
for observation. Eye opening was a bit slow. She had some drift
in the right arm. The plan was
to rule out a metabolic encephalopathy and also to do an
electroencephalogram. Repeat head scan was performed,
because the patient was found to be more lethargic on the
[**3-24**] and the drift was worse. Therefore repeat head
CT was performed and this showed an increase in the subdural
hematoma with an acute compliment to it, which was drained on
the [**3-24**]. In the immediate postoperative period she
opened her eyes to voice. She was more alert and awake then
in the preoperative period and moved all extremities. She
was oriented to time and place, but not the year and month.
There was no facial asymmetry and tongue was midline. Ms.
[**Known lastname 22705**] was transferred to the neurosurgical floor on the
23 and she has remained stable in the neurosurgical floor.
CONDITION ON DISCHARGE: She is stable. She is awake, alert,
follows single commands. She shows her tongue, moves all
extremities. Can grip hands, can show one or two fingers on
request. She is not oriented to the month and year.
MEDICATIONS ON DISCHARGE: Levothyroxine 25 micrograms po q
day, atenolol 75 mg po q day, Glipizide 5 mg po q day,
Lisinopril 10 mg po q day, Ranitidine [**Age over 90 **] m po q day.
Insulin sliding scale as per the flow sheet, Metoprolol 5 mg
intravenous q 3 to 4 hours prn if the heart rate is
continuously more then 130 beats per minute. She is on
Ciprofloxacin 500 mg po for a urinary tract infection for the
duration of five days, which was started on the [**3-25**].
Dilantin 300 mg po q.d. She is also receiving normal saline
70 cc per hour. Nutrition, she receives house diet with full
liquids and soft consistency. She has been seen by the
physical therapist and the occupational therapist during her
stay here. She has urinary retention, therefore she had a
Foley placed with a residual of 800 cc therefore the Foley
catheter is draining the bladder at present.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Doctor Last Name 22706**]
MEDQUIST36
D: [**2200-4-25**] 09:03
T: [**2200-4-25**] 09:40
JOB#: [**Job Number 22708**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3246
} | Medical Text: Admission Date: [**2157-8-22**] Discharge Date: [**2157-9-1**]
Date of Birth: [**2103-9-28**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old
woman with metastatic renal cell cancer status post radical
nephrectomy, high dose chemotherapy and biliary obstruction,
who presents with nausea and poor p.o. intake. Her last
chemotherapy prior to admission was in [**2156-8-29**] with five
cycles of CC1-779. The patient had a neck mass resection in
[**3-29**] which was harvested for dendritic cell vaccine. The
patient received her first dose of dendritic cell vaccine in
[**4-29**]. She had disease progression in [**2157-6-29**] with
biliary obstruction status post failed ERCP with subsequent
PTC internalization of the stent. Since her last discharge
from [**Hospital1 18**], the patient continued to have fatigue, poor p.o.
intake and nausea. She denies fever, chills, vomiting,
diarrhea, melena, bright red blood per rectum. The patient
was admitted for hydration and further management of biliary
obstruction.
PAST MEDICAL HISTORY: Renal cell CA metastatic to cervical
and paracaval nodes, status post right nephrectomy in 5/98,
status post IL2 in 7/98, status post CC1-779 in 10/00, status
post dendritic cell vaccine in [**4-29**]. Hypertension. Biliary
obstruction status post failed ERCP, PTC with internalization
of stent.
MEDICATIONS ON ADMISSION: Atenolol 25 p.o. q.d., Reglan 10
q.i.d., Prilosec 20 q.d., Benadryl p.r.n., Compazine p.r.n.,
Dilaudid p.r.n.
ALLERGIES: Morphine and Demerol.
PHYSICAL EXAMINATION: On admission temperature was 98.9,
pulse 99, respirations 20, blood pressure 124/70, O2 sat 97%
in room air. In general, the patient was alert and oriented
times three, jaundiced. HEENT: pupils equally round and
reactive to light and accommodation, extraocular movements
intact, scleral icterus. Oropharynx clear, mucous membranes
dry. Supraclavicular lymphadenopathy on the right, no JVD.
Cardiovascular S1, S2, normal, no murmurs, rubs or gallops.
Lungs clear to auscultation bilaterally. Abdomen a bit
gastric and right upper quadrant tenderness. Extremities had
no clubbing, cyanosis or edema. On neuro exam cranial nerves
II-XII were intact, no sensory deficits.
LABORATORY DATA: On admission white count was 25, hematocrit
34.5, platelets 257, neutrophils 73, bands 16, lymphs 4,
monocytes 5. Sodium was 129, potassium 4.8, chloride 93,
bicarb 20, BUN 29, creatinine 1.0, glucose 166. Calcium 9.1,
phosphate 4.2, mag 1.9, ALT 31, AST 18, LDH 408, alka phos
634, total bili 208.
HOSPITAL COURSE:
1. Biliary obstruction. The patient underwent tube
injection that showed no biliary ductal dilatation, distal
flow, but slow flow likely secondary to extrinsic duodenal
compression from tumor. The patient was transferred to the
MICU because during an interventional radiology procedure the
patient developed stridor, shortness of breath. In the MICU
the patient was started on IV antibiotics. She was then
transferred out of the unit on the 26th. Interventional
radiology did not recommend changing the patient's internal
drainage tube, however, recommended letting it drain through
an external drain. The patient did have increased abdominal
distension and fluid. She had paracentesis on the 28th where
650 cc were drained. The patient was continued on Aldactone.
Her ascites slowly reaccumulated. The patient was treated
for SBP. She did grow out Pseudomonas and alpha and beta
strep from her intestinal fluid. She was on vanco, Cipro,
ceftriaxone and Flagyl. She was also on Aldactone for
ascites, but it was held secondary to hypotension. The
patient continued to have increased ascites and secondary to
the patient's hypotension, paracentesis was not able to be
performed. The patient was medicated via her PCA to keep her
discomfort at a minimum and to improve her shortness of
breath.
2. ID. The patient was admitted with leukocytosis.
Eventually her intestinal fluid grew out Pseudomonas and
alpha and beta hemolytic strep. The patient was on Cipro,
Flagyl, ceftriaxone and vancomycin.
3. Fluids, electrolytes and nutrition. The patient's fluid
status was very difficult to manage. All IV fluids that were
put in were being third spaced. However, the patient was
hypotensive and it was a precarious balance between volume
overload and hypotension. The patient was medicated on
Dilaudid PCA. She was continued on antibiotics.
On the 4th the patient was found to have stopped breathing.
She expired at 2:30 p.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], M.D. [**MD Number(1) 7782**]
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2157-11-24**] 12:53
T: [**2157-11-28**] 11:46
JOB#: [**Job Number 23337**]
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3247
} | Medical Text: Admission Date: [**2118-11-17**] Discharge Date: [**2118-11-28**]
Date of Birth: [**2037-4-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain.
Major Surgical or Invasive Procedure:
[**11-21**] Coronary artery bypass graft x4 (Left internal mammary
artery -> left anterior descending, saphenous vein graft ->
obtuse marginal, saphenous vein graft -> diagonal, saphenous
vein graft -> term circumflex)
History of Present Illness:
This 81M has no previous cardiac history and the morning of
admission he experienced exertional CP and had ST elevations on
and EKG at the [**Hospital6 5016**] ER. He went directly to the
cath lab and was found to have: 90%LAD lesion, 90%LCX, and a
normal LVEF. He was transferred to [**Hospital1 18**] for surgical
management.
Past Medical History:
HTN
Hematuria
B12 deficiency
s/p penetrating trauma to L side during war w/ retained shrapnel
in L knee
Rosacea
s/p bil. IHR
Social History:
Retired mechanical engineer, lives w/ wife.
Cigs: none
ETOH: occ.
Family History:
+CAD, father died in 50's
Physical Exam:
Elderly [**Male First Name (un) 4746**] in NAD
AVSS
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= without bruits
Lungs: Clear to A+P
Abd: +BS, soft, nontender without masses or hepatosplenomegaly
Ext.: without C/C/E, pulses 2+= bilat. throughout.
Neuro: nonfocal
Pertinent Results:
[**2118-11-26**] 07:20AM BLOOD WBC-7.9 RBC-2.97* Hgb-9.4* Hct-26.2*
MCV-88 MCH-31.8 MCHC-36.0* RDW-14.7 Plt Ct-176
[**2118-11-28**] 06:40AM BLOOD PT-12.8 INR(PT)-1.1
[**2118-11-28**] 06:40AM BLOOD Glucose-104 UreaN-27* Creat-1.1 Na-142
K-4.0 Cl-105 HCO3-29 AnGap-12
RADIOLOGY Final Report
CHEST (PA & LAT) [**2118-11-28**] 10:53 AM
CHEST (PA & LAT)
Reason: evaluate pleural effusion - please do this am thank you
[**Hospital 93**] MEDICAL CONDITION:
81 year old man with CAD s/p CABGx4
REASON FOR THIS EXAMINATION:
evaluate pleural effusion - please do this am thank you
THIS IS A TWO VIEW CHEST X-RAY DATED [**2118-11-28**]
COMPARISON: [**2118-11-25**].
INDICATION: Status post coronary artery bypass surgery. Pleural
effusions.
Cardiac and mediastinal contours are stable. Pulmonary
vascularity is normal. Bilateral pleural effusions are again
demonstrated, small on the right, and small to moderate on the
left. The left pleural effusion has apparently slightly
increased in the interval as manifested by increased distance
between the superior aspect of the gastric bubble and apparent
level of the left hemidiaphragm. Minor basilar atelectasis is
present adjacent to the pleural effusions.
IMPRESSION: Persistent pleural effusions, stable on the right
and slightly increased on the left.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2118-11-28**] 12:29 PM
Cardiology Report ECHO Study Date of [**2118-11-21**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for CABG procedure
Height: (in) 69
Weight (lb): 140
BSA (m2): 1.78 m2
BP (mm Hg): 145/89
HR (bpm): 64
Status: Inpatient
Date/Time: [**2118-11-21**] at 13:17
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW3-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Valve Level: 2.4 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 1.00
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thicknesses and cavity size. Overall
normal LVEF
(>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter. Mildly
dilated descending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
Conclusions:
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left
ventricular systolic function is normal (LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.The descending thoracic aorta is mildly dilated. There are
simple atheroma
in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is
not present. Mild (1+) aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7.There is no pericardial effusion.
Post Bypass
1. Patient is being AV paced.
2. Biventricular systolic function is unchanged.
3. Mild Mitral regurgitation persists.
4. Aorta intact post decannulation.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2118-11-21**]
16:11.
Brief Hospital Course:
The pt. was admitted on [**2118-11-17**] and had an echo and vein
mapping. Carotid U/S revealed no significant stenosis. His preop
work up was unremarkable and on [**2118-11-21**] he underwent
CABGx4(LIMA->LAD, SVG->OM, Diag, LCX). Cross clamp was 90 mins,
total bypass time was 105 mins. He was transferred to the CSRU
in stable condition on Propofol and Neo. He was extubated on
his post op night on POD#1 and was transferred to the floor. His
chest tubes and wires were d/c'd on POD#3. He then went into
rapid AF and was treated with Lopressor and Amiodorone. He
converted to SR and was anticoagulated with coumadin. He
developed a L arm cellulitis which was treated with vancomycin
and was changed to Doxycycline and Levoquin. He continued to
progress and was discharge to home on POD#7. He was discharged
on 3 mg coumadin and will be followed by Dr. [**Last Name (STitle) 4783**] (I spoke
with [**Doctor First Name 698**] at his office).
Medications on Admission:
Diovan/HCTZ 160/125 PO daily
Felodipine 10 mg PO daily
Centrum Silver
B12 shot q month
Metronidazole cream for rosacea
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
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:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metronidazole 0.75 % Cream Sig: One (1) Topical twice a day
as needed for rosecea.
Disp:*qs * Refills:*0*
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
7. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 7 doses.
Disp:*21 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: Decrease to 400 mg PO daily after 7 day dose
completed. Then decrease dose to 200 mg PO daily.
.
Disp:*60 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: Take as directed by Dr. [**Last Name (STitle) 4783**] for an INR goal of
[**3-3**].5.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Coronary Artery Disease
Elevated cholesterol
B12 deficiency anemia
Rosacea
Inguinal hernia
Discharge Condition:
good
Discharge Instructions:
[**Month (only) 116**] shower, 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
Warm packs to R arm QID
Make sure you take all your antibiotics.
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 5017**] [**Name (STitle) 4597**] ([**Telephone/Fax (1) 5424**]) please call for appointment
Cardiologist at VA in [**3-4**] weeks - please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2118-11-28**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3248
} | Medical Text: Admission Date: [**2140-10-4**] Discharge Date: [**2140-10-8**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
Fever and hypotension
Major Surgical or Invasive Procedure:
Right IJ central line placed then removed
History of Present Illness:
This is a 88 year old female with hx addison's, PE [**2127**], HTN,
mild AS s/p recent femur fx and ORIF p/w fevers and hypotension
from [**Hospital6 459**]. The patient underwent ORIF on [**9-26**].
She then developed renal failure, transfered to medicine
service, given IVF and tx'd for klebsiella UTI for 4 days.
Discharged to [**Hospital6 459**] on [**9-30**]. Per [**Hospital1 100**] Rebah
call in, the patient had temp 102.9, HR 110, SO2 sat 91-95% on
2L NC, BP 74/48--> 60/40 on manual BP. Per rehab, pt was alert
and asympomatic but SBP generally in 140-170 range, but
PCP [**Name Initial (PRE) 96993**] 112/60. The patient herself is a limited historian.
She denies any complaints, no SOB, no CP, no N/V/D, no cough, no
dysuria.
.
In the ED: The pt arrived with SBP 60-70's. Given fevers, she
was thought to be septic. A CXR showed RLL infiltrate and the
patient was tx'ed with Vanc, CTX - did not receive Levoflox yet.
She received an rt IJ, 2 liters IVF and started on levophed
(small amount). CVP 6, MAP's 55. lactate 1.4. She was also
hypoxic to 88% RA, 97%2lNC. A CTA was performed showing a large
PE but no RV strain. Trop 0.2.
.
ROS:
(+)
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Addison's disease
Hypertension
Seasonal allergies
Osteoporosis
s/p R hip fracture s/p total hip replacement
s/p bilateral total knee replacements
Lower back pain
Anemia
Spinal stenosis
DJD
h/o PE post-operatively
h/o lower extremity edema
s/p CCY
GERD
CRI (baseline Cr 1.1-1.4)
Social History:
Her son does her grocery shopping. She goes to
church every weekend and takes The Ride for that. She tries to
do some mild stretches at home. She does not smoke, drink or use
herbal substances.
Family History:
non-contributory. Denies early family h/o MI, sudden cardiac
death.
Physical Exam:
Vitals: T:98.6 P:88 BP: 104/42->81/36 R:23 SaO2:88% RA, 96%2LNC
CVP 14
General: sleeping, in NAD, easily arousable
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD but diff to assess with right IJ and full
neck
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, 3/6 systolic murmur (old)
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted, warm well perfused, no cold or
clammy
Neurologic:
-mental status: Alert, oriented x 3, asnwering some questions
appropriately but drowsy
Pertinent Results:
[**2140-10-4**] 02:30AM PT-15.7* PTT-36.0* INR(PT)-1.4*
[**2140-10-4**] 02:30AM WBC-7.4 RBC-3.20* HGB-10.2* HCT-30.4* MCV-95
MCH-32.0 MCHC-33.7 RDW-14.8
[**2140-10-4**] 02:30AM CRP-51.9*
[**2140-10-4**] 02:30AM CORTISOL-159.9*
[**2140-10-4**] 02:30AM CALCIUM-7.8* PHOSPHATE-2.4* MAGNESIUM-0.9*
[**2140-10-4**] 02:30AM CK-MB-4 cTropnT-0.20*
[**2140-10-4**] 02:30AM proBNP-[**Numeric Identifier 75896**]*
[**2140-10-4**] 02:30AM ALT(SGPT)-18 AST(SGOT)-31 CK(CPK)-138 ALK
PHOS-58 TOT BILI-0.8
[**2140-10-4**] 02:30AM GLUCOSE-71 UREA N-14 CREAT-1.4* SODIUM-133
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-20* ANION GAP-14
[**2140-10-4**] 02:48AM LACTATE-1.4
[**2140-10-4**] 03:51AM LACTATE-1.8
[**2140-10-4**] 05:07AM LACTATE-0.7
[**2140-10-4**] 12:00PM CK-MB-10 MB INDX-1.6 cTropnT-0.11*
[**2140-10-4**] 12:00PM GLUCOSE-128* UREA N-17 CREAT-1.4* SODIUM-134
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-19* ANION GAP-15
[**2140-10-4**] 08:27PM CK-MB-9 cTropnT-0.08*
[**2140-10-5**] 07:40AM BLOOD Hct-24.9*
[**2140-10-6**] 06:15AM BLOOD WBC-15.6* RBC-2.61* Hgb-8.2* Hct-25.6*
MCV-98 MCH-31.4 MCHC-32.1 RDW-15.1 Plt Ct-345
[**2140-10-7**] 06:15AM BLOOD WBC-14.0* RBC-2.41* Hgb-7.8* Hct-23.7*
MCV-99* MCH-32.5* MCHC-32.9 RDW-15.3 Plt Ct-417
[**2140-10-6**] 12:50PM BLOOD PT-15.5* PTT-58.6* INR(PT)-1.4*
[**2140-10-7**] 06:15AM BLOOD PT-24.6* PTT-43.7* INR(PT)-2.4*
[**2140-10-7**] 06:15AM BLOOD Glucose-89 UreaN-21* Creat-1.0 Na-137
K-3.5 Cl-107 HCO3-23 AnGap-11
[**2140-10-4**] 12:00PM BLOOD CK(CPK)-633*
[**2140-10-4**] 08:27PM BLOOD CK(CPK)-574*
Micro
[**10-4**] Blood cx NGTD x 2
[**10-4**] urine cx: 10,000-100,000 yeast
Imaging
Chest CTA
IMPRESSION:
1. Bilateral pulmonary embolism in right main pulmonary artery,
right upper
lobe and right lower lobe segmental and subsegmental arteries,
subsegmental
left upper lobe arteries, and segmental and subsegmental left
lower lobe
arteries.
2. Probable pulmonary hypertension, chronicity indeterminate.
Possible right
ventricular strain.
3. Aortic valvular calcification of unknown hemodynamic
significance.
Atherosclerotic coronary artery calcifications.
4. Mild pulmonary edema.
5. Kyphosis and degenerative changes of the right shoulder.
6. Right breast calcification, should be correlated with regular
mammogram.
TTE [**10-4**]:
The left atrium is moderately dilated. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction. The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic valve
leaflets (3) are mildly thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2140-9-28**],
estimated pulmonary artery systolic pressure is now slightly
lower. The right ventricle appears similar to slightly less
dilated.
Brief Hospital Course:
88 year old female with a past medical history of addison's, PE
[**2127**], HTN, mild AS s/p recent femur fx and ORIF p/w fevers,
hypotension, PE and elevated troponin concerning for PE vs
sepsis.
.
# Hypotension / Sepsis / Pulmonary Embolism: The pt arrived with
SBP 60-70's. Given fevers, she was thought to be septic. A CXR
showed ? RLL infiltrate and the patient was treated with Vanc
and CTX initially then coverage for HAP was broadened to vanc,
zosyn, and levo. Blood cultures show no growth to date and
urine was negative for a UTI. As the patient was hypoxic on
arrival and has a history of PE, CTA was performed and revealed
large bilateral PE, concerning for cardiogenic shock also
contributing to hypotension. She received an rt IJ, 2 liters
IVF and started on a small amount of levophed. CVP 6, MAP's 55.
lactate 1.4. She was also hypoxic to 88% RA, 97%2lNC. Trop 0.2.
The patient was weaned off of pressors and maintained good blood
pressures. Echo showed mild RV dilation, but only mild systolic
dysfunction, and improved pulmonary htn compared to last echo.
EKG did not show ischemic changes, but trop of 0.2 and BNP of
[**Numeric Identifier **] suggest strain. Per cardiology IVF were stopped to avoid
volume overload and maintain a CVP 10-12. She has remained off
pressors since [**2140-10-5**] and was transferred to floor evening of
[**10-5**]. Blood pressures have been stable and O2 saturations have
improved, now satting in mid 90s on room air. Patient started on
Heparin gtt for anticoagulation for PE with bridge to Coumadin.
She was given Coumadin 5mg on [**10-5**] and [**10-6**] with INR 2.4 ON
[**10-7**] from 1.4 [**10-6**]. Since this was a rapid rise, her INR as
well as any signs of bleeding should be monitored closely at
rehab since INR will likely be supratherapeutic. She should be
given 2mg Coumadin on [**10-7**] with dose adjusted according to INR
levels with goal [**1-10**]. Heparin gtt was changed to Lovenox on
[**10-6**]. She will need 48 hours of therpeutic INR and then Lovenox
may be discontinued. Also, antibiotics were stopped since
concern for infection was low but threshold for treating
hospital acquired pneumonia if she spiked a fever or developed
cough would be low. On day of discharge INR supratherapeutic
at 3.5, coumadin should be held tonight and restarted the
following day at 1mg per day, INR should be monitored regularly
until stable. Lovenox discontinued on day of discharge as pt
therapeutic on coumadin x 48 hours.
#) Arrhythmia- Patient had narrow QRS tachycardia in MICU which
responded to metoprolol. Differential included AVRT, AVNRT,
atrial tachycardia. Pt chronically on atenolol which was d/c??????d
on admission for hypotension, so arrhythmia may have been the
result. The patient was restarted on atenolol on discharge.
#) Hct drop- pt??????s hct has decreased from 31.3 on admission to
25.3 to 24.9. Guaiac was trace positive. Most likely was [**1-9**]
fluids and hemodilution, less likely GI bleeding. It stabilized
prior to discharge. HCT slightly down to 23.7 on [**10-7**] so
repeated in afternoon and was 26.1. B12, folate were normal.
Stable on day of discharge
#) Femur fx: Oxycodone was held initially due to concern for
mental status. Tylenol was continued. The orthopedics service
followed the patient. Since she did not complain of pain or
require pain medication during stay she was discharged without
oxycodone and on tylenol prn. She has ortho follow up arranged
and was cleared by PT for rehab. Touch down weight bearing.
# Depression: qhs nortriptylline was initially held for
drowsiness, restarted on discharge, pt A+O x 3.
#) ARF: baseline 1.1, was as high as 1.6. Likely pre-renal
since improved to 1.0-1.1 prior to discharge after IVF.
#) Code: Full
On day of discharge pt was alert and oriented, no pain at rest,
all vital signs stable, breathing comfortable on room air with
02 sat 96%.
Medications on Admission:
Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2.Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3.Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4.Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
5.Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
6.Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7.Clarinex 5 mg Tablet Sig: One (1) Tablet PO once a day.
8.Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9.Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10.K-Dur 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day.
11.Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12.Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
13.Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection (30
units) Subcutaneous Q24H (every 24 hours) for 4 weeks: To be
continued for 4 weeks for the date of the surgery ([**2140-9-26**]).
14.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15.Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16.Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
17.Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) for 10 days.
18.Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days: To be continued until [**2140-10-3**].
Discharge Medications:
1. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
5. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day.
6. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO at
bedtime as needed.
7. Clarinex 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. K-Dur 10 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab
Sust.Rel. Particle/Crystal PO once a day: Hve your potassium
levels checked every 1-2 weeks .
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO three 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: One (1) Tablet PO BID (2 times a
day).
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-15**]
hours as needed for fever or pain.
16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Check INR daily until stable and adjust coumadin dose prn for
goal INR [**1-10**], coumadin should be held on [**10-8**] for INR of 3.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis
1. Pulmonary Embolism
Secondary Diagnosis
1. Addison's disease
2. Hypertension
3. Seasonal allergies
4. Osteoporosis
5. s/p R hip fracture and ORIF [**2140-9-26**]
6. s/p bilateral total knee replacements
7. h/o PE post-operatively in [**2127**]
Discharge Condition:
Hemodynamically stable, afebrile, shortness of breath improved
Discharge Instructions:
You were admitted to the hospital with low blood pressure and
found to have low oxygen levels and blood clots in your lungs.
We started you on blood thinning medication for the blood
clots. We were initially concerned you had pneumonia because you
had a fever so started you on antibiotics but there was no
evidence of pneumonia on your CAT scan so we stopped your
antibiotics on [**10-7**].
We made the following changes to your medications
1. We changed your Lovenox dose. You will only need the Lovenox
for a few days while the Coumadin is starting to work. Your
lovenox has been stopped at time of discharge as your coumadin
levels were adequate.
2. We started you on Coumadin. Your INR level will be followed
and the dose adjusted accordingly.
3. You were started on potassium supplement, you should have
your potassium levels checked regularly.
4. Your nifedipine from home has been held since your last
admission, you and your doctor may consider restarting this
should your blood pressure remain consistently elevated above
140.
Please return to the ER or call your primary care doctor if you
develop shortness of breath, chest pain, fever>100.4, chills or
any other concerning symptoms.
Please take all medications as prescribed and attend all
scheduled follow up appointments.
Followup Instructions:
Please follow up in ortho clinic on [**2140-10-11**] 10:20am for staple
removal. You also have a follow-up appointment in ortho clinic
on [**2140-11-1**] at 10:00am. ([**Telephone/Fax (1) 5238**] if you have any questions
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the nurse practitioner in
Dr.[**Name (NI) 29254**] office, on Friday [**10-14**] at 11am.
ICD9 Codes: 5849, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3249
} | Medical Text: Admission Date: [**2176-11-10**] Discharge Date: [**2176-12-13**]
Date of Birth: [**2158-1-17**] Sex: M
Service:
ADDENDUM: The patient was set for discharge on [**2176-11-26**] but
discharge was delayed secondary to left hip and cervical
wound infection. The patient was taken back to the OR on
[**2176-12-2**] for an I&D and primary closure of his iliac crest
graft site and his cervical wound. His cultures were sent
which all came back negative. The patient has been on
vancomycin and ceftazidime for antibiotic coverage.
The patient began having temperatures on [**2176-12-6**]. CBC with
differential was sent which showed a high eosinophil count.
Therefore, the antibiotic ceftazidime was discontinued,
continued on IV vancomycin. No other cultures came back
positive. It is felt that this temperature was a drug fever.
The patient's wound was clean, dry, and intact. There was no
drainage, redness or erythema around the wounds. His vital
signs are stable. He has been out of bed to chair with
physical therapy. He is on a q. four hour straight catheter
regimen to keep his urine volumes less than 400 cc and has a
condom catheter on in between for persistent dribbling of
urine. His condition has otherwise been stable. He is going
to have a new PICC line placed to be on six weeks of
vancomycin IV antibiotic coverage. He is to follow-up with
Dr. [**Last Name (STitle) 1327**] in two weeks for staple removal.
CONDITION ON DISCHARGE: Stable at the time of discharge.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1339**] 14-127
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2176-12-11**] 11:33
T: [**2176-12-11**] 13:29
JOB#: [**Job Number 50400**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3250
} | Medical Text: Admission Date: [**2106-5-27**] Discharge Date: [**2106-6-1**]
Service:
HISTORY OF THE PRESENT ILLNESS: This is a [**Age over 90 **]-year-old woman
who is a resident of the [**Hospital3 1186**] who has a history of
Alzheimer's dementia, tardive dyskinesia, at baseline
nonverbal, and was noted at the nursing home to be having
increasing wheezing with 02 saturations in the 80s to low
90s. Given Albuterol nebulizers and was still with wheezing.
Respiratory rate was noted to be in the 20-26 range, blood
pressure 112/60, heart rate 120s. Of note, the patient was
on tube feeds. She has stage III left heel ulcer and was on
morphine for pain management during dressing changes for
them. Per son, the patient currently appears near her normal
self.
While she was in the Emergency Room, the blood pressure was
in the 90s, temperature of 102 and the patient was started on
ceftriaxone and Flagyl for a urinary tract infection as she
was noted to have pus in her Foley. She was continued on
nebulizers and Solu-Medrol was started while in the Emergency
Room. She received fluids and had improvement in her blood
pressure.
PAST MEDICAL HISTORY:
1. Cataracts.
2. Alzheimer's dementia.
3. Tardive dyskinesia secondary to Haldol.
4. Status post PEG.
5. Hypertension.
6. Dysphagia.
7. Esophagitis.
8. History of duodenal ulcer.
9. History of left hip fracture, status post ORIF.
10. Status post TAH.
11. History of urinary incontinence.
SOCIAL HISTORY: She is a [**Hospital3 1186**] resident.
FAMILY HISTORY: Unknown secondary to mental status.
ALLERGIES: The patient is allergic to Haldol.
ADMISSION MEDICATIONS:
1. Colace.
2. Duragesic patch.
3. Dulcolax p.r.
4. Multivitamin with minerals.
5. Oyster shell with vitamin D.
6. Valproic acid.
7. Tylenol.
8. Morphine sulfate prior to dressing changes.
DIET: ProMod with fiber times 18 hours.
PHYSICAL EXAMINATION: Vital signs: Temperature 99 going up
to 102.8 in the Emergency Room, blood pressure 94/66, pulse
122-125, respiratory rate 30, saturations 82% on room air,
100% later on 3 liters. General: The patient was alert,
opens eyes to pain and verbal stimuli. HEENT: Normocephalic
and atraumatic. The extraocular muscles were grossly intact.
Neck: Supple. Cardiovascular: Tachycardiac, I/VI systolic
ejection murmur. Respiratory: Diffuse wheezing bilaterally,
upper airway sounds bilaterally. Abdomen: Soft, positive
bowel sounds, positive PEG. No erythema. Normal appearing
PEG site. No pain around her left hip. Extremities: No
edema, stage III decubitus ulcer on the left foot of 5 cm by
7 cm. Neurologic: Contracted extremities, both arms and
legs.
LABORATORY AND RADIOLOGIC DATA: White count 12.4, 83%
neutrophils, 9% lymphs, hematocrit 31.5, platelets 449,000.
Chem-7 137, potassium 5.7, chloride 99, bicarbonate 27, BUN
44, creatinine 0.7, glucose 117, calcium 9.1, magnesium 2.2,
phosphorus 0.8. INR 1.0.
The U/A on admission revealed a specific gravity of 1.014,
hazy, small leukocyte esterase, small blood, positive
nitrates, trace protein, negative glucose, negative ketones,
greater than 50 white blood cells and a few bacteria.
EKG was sinus tachycardia at 119. Lactate of 3.0.
HOSPITAL COURSE: This is a [**Hospital 93961**] nursing home
resident, at baseline nonverbal secondary to dementia, who
was initially admitted for hypoxia and UTI, initially found
to be in sepsis and transferred to the VICU on the day of
admission.
1. SEPSIS: The patient was stable and initially admitted
under sepsis protocol to the VICU where she received
aggressive hydration, transfused 2 units of blood for a
hematocrit less than 30. She was temporarily on Levophed and
eventually this was weaned off. She also had a subclavian
line placed for access for neurosepsis protocol. The
patient's CVPs were monitored and were otherwise stable. The
patient initially had some respiratory distress after her
fluid hydration but this improved and was stable with minimal
02 by nasal cannula.
Under sepsis protocol, the patient was started on broad
antibiotics including ceftazidime and levofloxacin. The
patient was noted to have gram-negative rods growing from her
urine culture and eventually this grew out Citrobacter
.................... which was sensitive to levofloxacin and
ceftazidime and was the likely source of her sepsis. There
was also initial concern for pneumonia; however, the patient
continued to improve, had follow-up chest x-rays. The chest
x-ray on [**2106-5-28**] showed just mild CHF and no evidence of
pneumothorax. The patient had a follow-up chest x-ray on
[**2106-5-31**] which was also consistent with CHF versus pneumonia.
However, the patient's oxygenation improved with diuresis and
was otherwise stable.
The patient was adrenally insufficient on the admission to
the VICU and is to complete a five day course of
hydrocortisone and fludrocortisone for adrenal insufficiency.
The patient's blood pressure remained stable. The patient
was weaned off pressors pretty quickly and did not require
further fluid boluses to maintain blood pressure.
2. HYPOXIA: Initially came in hypoxic on room air. This
improved with 3 liters of 02 and then after aggressive
hydration for her blood pressure was in mild respiratory
distress, transferred to the VICU but remained respiratory
stable on 2 liters and a cool nebulizer face mask. She had a
blood gas of 7.40/37/185 and was oxygenating well. She was
continued on nebulizers throughout her admission and her
wheezing improved. She did continue to have some upper
airway sounds, some cough to help mobilize some of her
airways. Otherwise, she was stable from a respiratory
standpoint. She was eventually transferred to the floor and
continued to wean down her 02. She was on [**3-9**] liters of
nasal cannula, continued on Albuterol and Atrovent
nebulizers. She was given three doses of 10 mg of IV Lasix
throughout her stay on the floor and was weaned off oxygen
and was saturating 97% on 1 liter with minimal 02
requirements, very comfortable respiratory rate.
However, the plans are to complete a ten day course of
levofloxacin for the urinary tract infection, discontinue the
ceftazidime.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2106-6-1**] 10:03
T: [**2106-6-1**] 10:05
JOB#: [**Job Number 93962**]
ICD9 Codes: 0389, 5990, 4280, 486, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3251
} | Medical Text: Admission Date: [**2148-6-15**] Discharge Date: [**2148-6-21**]
Date of Birth: [**2064-2-1**] Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending:[**Doctor Last Name 1857**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
This is a 84 yo man with H/O ESRD on HD, hypertension, renal
cell carcinoma s/p radiofrequency ablation, atrial fibrillation
on Coumadin, and CAD who presented to [**Hospital3 3583**] on [**6-13**]
with severe chest pain and nausea. EKG on admission notable for
atrial fibrillation with rapid ventricular rate without ischemic
changes. Initial troponin-I 0.06 was attributed to renal disease
and atrial fibrillation, however troponin-I peaked at 17.45,
consistent with NSTEMI. He had a diagnostic catheterization
showing 50% ostial LMCA, 100% occlusion of OM3, 90% PDA,
moderate LAD disease, lateral wall abnormalities on
ventriculogram; no intervention was performed. He was started on
a heparin gtt, Plavix, and beta-blockade. The cardiologist at
[**Hospital3 3583**] planned to transfer to [**Hospital1 18**] on Monday for
intervention (coronary angioplasty with stents vs. CABG),
however, he experienced a run of tachycardia (HR 120s) with
nausea and vomiting with troponin re-elevation and oyxgen
desaturation. Temp was 102.5 and chest X-ray showed LLL
pneumonia for which he received 1 dose of vancomycin and Zosyn
for aspiration pneumonia. He was pan-cultured. [**6-14**]
dipyridamole-MIBI reportedly showed a fixed inferolateral
defect. He was transferred to [**Hospital1 18**] for additional medical
management. Vitals on transfer notable for HR 80s and SaO2 100%
on 2 Lpm nasal cannula.
Past Medical History:
ESRD on HD MWF
Atrial fibrillation, on Coumadin
Renal cell carcinoma s/p RFA [**2143**] at [**Hospital1 2025**]
Glaucoma
Anemia
Hypertension
R TKR
R AV fistula for HD
Mild/moderate dementia
BPH
Social History:
Lives with Wife [**Name (NI) **] in [**Location (un) 3320**]. 3 grown children, daughters
very involved. Retired manager for telephone laboratories
company.
Family History:
Both parents deceased, mother renal cell carcinoma; father
pulmonary embolus.
Physical Exam:
Admission
GENERAL: Well-appearing elderly Caucasian man in NAD,
comfortable, appropriate.
VS: T 97.7 BP 122/69 HR 79 RR 20 SaO2 100% on 2 Lpm NC
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: irregularly irregular rhythm, normal rate; no murmurs,
rubs or gallops; nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: Soft, non-tender, not distended, no masses or HSM, no
rebound/guarding.
EXTREMITIES: warm and well-perfused; no clubbing, cyanosis or
edema; 2+ peripheral pulses.
SKIN: No rashes or lesions. Mild erythema at old PIV site.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact
Discharge exam
Good O2 saturation on room air. LUE PICC clean, dry and intact.
Regular rate and rhythm.
Examination otherwise unchanged.
Pertinent Results:
Admission Labs
[**2148-6-16**] 12:04AM BLOOD WBC-11.9* RBC-2.97* Hgb-10.2* Hct-31.4*
MCV-106* MCH-34.2* MCHC-32.3 RDW-13.5 Plt Ct-171
[**2148-6-16**] 12:04AM BLOOD PT-20.8* PTT-34.7 INR(PT)-2.0*
[**2148-6-16**] 12:04AM BLOOD Glucose-79 UreaN-41* Creat-5.7* Na-136
K-4.8 Cl-94* HCO3-26 AnGap-21*
[**2148-6-16**] 06:45AM BLOOD CK(CPK)-198 CK-MB-3 cTropnT-3.85*
[**2148-6-16**] 12:04AM BLOOD Calcium-7.9* Phos-6.7* Mg-2.0
Pertinent Labs
[**2148-6-16**] 06:45AM BLOOD CK-MB-3 cTropnT-3.85*
[**2148-6-16**] 05:20PM BLOOD CK-MB-4 cTropnT-4.24*
[**2148-6-16**] 11:57PM BLOOD CK-MB-2 cTropnT-4.69*
[**2148-6-17**] 07:12AM BLOOD CK-MB-2 cTropnT-5.09*
[**2148-6-17**] 07:40PM BLOOD CK-MB-2 cTropnT-5.02*
[**2148-6-18**] 06:55AM BLOOD CK-MB-1 cTropnT-5.37*
[**2148-6-19**] 07:15AM BLOOD ALT-20 AST-23 LD(LDH)-230 AlkPhos-93
TotBili-0.4
[**2148-6-17**] 07:12AM BLOOD VitB12-1288* Folate-GREATER TH
[**2148-6-16**] 12:04AM BLOOD TSH-0.96
[**2148-6-17**] 12:30PM BLOOD PTH-332*
Discharge labs:
[**2148-6-21**] 05:48AM BLOOD WBC-6.4 RBC-2.70* Hgb-9.2* Hct-28.2*
MCV-105* MCH-34.2* MCHC-32.7 RDW-14.2 Plt Ct-194
[**2148-6-21**] 05:48AM BLOOD PT-22.4* PTT-36.8* INR(PT)-2.1*
[**2148-6-21**] 05:48AM BLOOD Glucose-90 UreaN-35* Creat-6.3*# Na-137
K-5.1 Cl-97 HCO3-26 AnGap-19
[**2148-6-21**] 05:48AM BLOOD Calcium-8.6 Phos-5.1* Mg-2.0
Micro:
Blood cultures ([**6-16**], [**6-17**], [**6-18**]): no growth
Stool ([**6-20**]): c. diff negative
ECG [**2148-6-16**] 4:49:52 PM
Atrial flutter versus atrial tachycardia with variable
conduction pattern. Left anterior fascicular block.
Intraventricular conduction delay. Non-specific anterolateral
ST-T wave changes. No previous tracing available for comparison.
Echocardiogram [**2148-6-17**]:
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 5-10 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size is normal. with borderline normal free
wall function. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion. There are bilateral pleural effusions.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved regional and low normal
global systolic function. Dilated ascending aorta. Mild
pulmonary artery hypertension. Left atrial enlargement.
These findings are c/w hypertensive heart.
Video Swallow [**2148-6-18**]:
Video swallow fluoroscopy was completed in conjunction with the
speech and swallow division. Multiple consistencies of barium
were administered. Barium passed freely through the oropharynx
without evidence of obstruction. There was intermittent trace
aspiration of thin liquids, nectar-thick liquids, and pureed
solid consistencies and risk of aspiration with all other
consistencies due to laryngeal penetration.
Left Upper Extremity Non-invasive [**2148-6-18**]:
Focused son[**Name (NI) 493**] evaluation demonstrates a small thrombus
along the course of the left cephalic vein at the level of the
left elbow joint. There are no fluid collections identified in
this region. The cephalic vein above and below the level of the
left elbow is patent.
Brief Hospital Course:
84 yo man with H/O ESRD on HD, hypertension, renal cell
carcinoma s/p radiofrequency ablation, and [**Hospital **] transferred from
[**Hospital3 3583**] for further management of NSTEMI and pneumonia.
# Bacteremia: Fever spiked to 102.5 on [**6-15**] and found to have
gram positive cocci in clusters in 2 of 2 bottles at [**Hospital1 3325**], subsequently speciated as MSSA. Patient noted to have
thrombophlebitis in left antecubital from IV placed at [**Hospital1 3325**], which is the suspected source. He was initially on
vancomycin, but once sensitivities showed MSSA, he was
transitioned to nafcillin q4 hrs. He will need 2 weeks total
(last day [**6-29**]). TTE was negative for vegetation. PICC line was
placed with blood culture from [**Hospital3 3583**] on [**6-13**] no growth
on final report. Six sets of blood cultures at [**Hospital1 18**] were
negative.
# Aspiration pneumonia: Evidence of evolving LLL pneumonia on
portable chest X-ray taken prior to transfer at [**Hospital3 3583**]
in setting of fever and hypoxia. Patient asymptomatic now but
given recent vomiting (on arrival), highest concern was for
aspiration pneumonia. He was placed on levofloxacin for planned
10 days total (last day [**6-25**]). The patient was on RA with good
O2 saturation at time of discharge.
# Abnormal swallowing: Video swallow study confirmed aspiration.
The risks related to this were explained to patient and family,
but he stated his wishes to continue eating (as opposed to
nutrition solely via feeding tube). Recommendations on safest
food consistencies were provided by the Speech and Swallowing
Service.
# NSTEMI: Patient already on medical management. Peak TnT 5.37
(in setting of hemodialysis) with normal CK-MB at [**Hospital1 18**]. There
was initial reluctance to proceed with any type of
revascularization given aspiration pneumonia and bacteremia. As
patient had history of anaphylaxis to aspirin, aspirin
desensitization in the CCU would be required prior to planned
PCI. The patient had no symptoms suggestive of ischemia since
his infarct. His dipyridamole-MIBI images were reviewed with the
nuclear cardiologist at [**Hospital1 18**] and felt to show a fixed
inferolateral wall defect (likely due to the abrupt occlusion of
the OM3 seen on angiography). As the patient was asymptomatic
with no objective evidence of post-infarct ischemia (spontaneous
or inducible), it was decided not to proceed with either
angioplasty or bypass surgery. He was initially changed from
atenolol to metoprolol to avoid build-up of atenolol and its
metabolites given his renal failure. Although he was
bradycardic, low dose metoprolol was attempted for secondary
prevention post-MI. He was also given long-acting nitrates for
treatment of his residual CAD. We continued lisinopril 20 mg,
Plavix 75 mg, and atorvastatin 80 mg daily. He was desensitized
to ASA in the CCU and tolerated the desensitization process
without incident; he will need to be on uninterrupted ASA for
life to avoid recurrence of his allergy. The plan to continue
triple therapy with low dose aspirin and Plavix for CAD (dual
anti-platelet therapy as medical therapy for MI for at least a
few weeks) and Coumadin (for atrial fibrillation) was discussed
with his outpatient cardiologist, Dr. [**First Name (STitle) **]. He agreed with a
brief triple therapy regimen with subsequent discontinuation of
Plavix to lessen the bleeding risk associated with dual
anti-platelet plus anti-coagulant therapy.
# Atrial fibrillation: Episodes of RVR on arrival and prior to
transfer likely precipitated by NSTEMI and evolving pneumonia.
His TSH was normal at 0.95. Patient reverted to NSR and was in
sinus bradycardia at discharge. He was bridged back on Coumadin
with a heparin gtt. The patient was therapeutic at time of
discharge with an INR of 2.1.
# ESRD on HD: MWF schedule. The patient was continued on his
home Phoslo.
Transitional Issues:
- The patient will need to complete 10 days total of Levaquin
(last day [**6-25**]) and 14 days total of nafcillin (last day [**6-29**])
- The pt will need to see his outpatient cardiologist about
changes in his anticoagulation and antiplatelet therapy as
appropriate.
- The rehabilitation facility will need to schedule a follow-up
appointment with his PCP
Medications on Admission:
Aricept 5 mg [**Hospital1 **]
Mom[**Name (NI) 6474**] 1 inh daily
Avodart 0.5 mg daily
(Coumadin, on hold)
Flomax 0.4 mg daily
Flonase inh daily
Hydroxyzine 25 mg TID
Lexapro 10 mg daily
Namenda 5 mg daily
Nephrocaps 1 cap daily
Clopidogrel 75 mg daily
Vit D and C
Preservision softgel 1 tab [**Hospital1 **]
Prontonix 40 mg IV daily
Prostat liquid 30 mg TID
Sensipar 30 mg daily
Ultram 50 mg daily prn
Xalatan 0.005% solution 2 drops both eyes qhs
Zestril 20 mg daily
Atenolol 50 mg daily
Heparin gtt at 1200 u/hr
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*2*
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily). Tablet(s)
3. donepezil 5 mg Tablet Sig: One (1) Tablet PO twice a day.
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
11. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*2*
14. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day). Disp:*90 Tablet(s)* Refills:*2*
17. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM. Disp:*90 Tablet(s)* Refills:*2*
18. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
19. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 4 days: administer after HD on HD days;
last dose [**2148-6-25**].
20. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2)
grams Intravenous Q4H (every 4 hours) for 8 days: last dose
[**2148-6-29**].
21. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): Patient may refuse. Hold if patient has loose
stools.
22. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
Patient may refuse. Hold if patient has loose stools.
23. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: do not exceed 4g in 24hrs.
24. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for SBP < 100 and HR < 60.
25. Asmanex Twisthaler 110 mcg (7 [**Month/Day/Year 4319**]) Aerosol Powdr Breath
Activated Sig: One (1) puff Inhalation once a day.
26. Namenda 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 3320**]
Discharge Diagnosis:
Non-ST segment elevation Myocardial Infarction
Coronary artery disease
Methicillin sensitive Staphylococcus aureus Bacteremia
Left upper extremity thrombophlebitis, presumed septic
Aspiration Pneumonia
Recurrent aspiration with abnormal video swallowing study
Aspirin allergy, now status post successful desensitization
Atrial fibrillation
End-stage renal disease on hemodialysis
Atrial fibrillation on long term use of anti-coagulants
Glaucoma
Anemia
Hypertension
Mild-moderate dementia
Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were transferred from another hospital for management of
your heart attack. After reviewing your studies, our
cardiologists felt it would be appropriate for you to be managed
medically instead of pursuing surgery or cardiac
catheterization. Your medications were adjusted appropriately
and you were densensitized to aspirin. Do not stop taking
aspirin unless specifically instructed to do so by a physician.
You were also found to have aspiration pneumonia. You were
started on antibiotics for treatment. Speech and swallow
evaluated you, and found that you were indeed aspirating
silently. The risks were explained to you in detail about
eating, but you chose to continue eating despite the ongoing
risk for aspiration pneumonia.
You were also found to have bacteria in your bloodstream. You
will be continued on IV antibiotics with the PICC line for
treatment.
While at rehab, an appointment with your PCP will need to be
scheduled.
Medications:
CHANGE Coumadin 7mg to 3mg once daily
CHANGE Metoprolol to 12.5mg [**Hospital1 **]
START Aspirin 81mg daily (do NOT miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**])
START Nafcillin 2g IV every 4 hours (last day [**2148-6-29**])
START Levofloxacin 500 mg PO every 48 hours administer after HD
on HD days (last day [**2148-6-25**])
START Atorvastatin 80mg once daily
START Isosorbide Dinitrate 10 mg PO three times daily
If you experience any fevers, chills, chest pain, increased
shortness of breath, or any other symptoms concerning to you,
please call or come into the ED for further evaluation.
Thank you for allowing us at the [**Hospital1 **] to participate in your care.
Followup Instructions:
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 111869**],MD
SPECIALTY: Cardiology
Address: [**Apartment Address(1) 43403**], [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 26647**]
When:Tuesday,[**7-2**] at 10:45am
[**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339
ICD9 Codes: 5856, 5070, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3252
} | Medical Text: Admission Date: [**2108-6-15**] Discharge Date: [**2108-6-17**]
Date of Birth: [**2040-8-19**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a healthy 67-year-old
white male without prior cardiac history with a history of
hyperlipidemia, who was transferred from [**Hospital3 **] Medical
Center status post cardiac catheterization for Coronary Care
Unit monitoring prior to a planned coronary artery bypass
graft. Patient was admitted to the outside hospital on [**2108-6-14**] experiencing a sudden onset of [**6-14**] midsternal chest
pressure associated with dyspnea while doing yard work. This
pain had no radiation and no relief. Patient called his wife
and was seen by his primary care physician, [**Name10 (NameIs) 1023**] sent him
straight to the Emergency Department, where he had blood
pressure of 138/58, pulse of 86. At that time, patient had
been experiencing pressure in both arms. Patient had an
electrocardiogram done which showed questionable new left
bundle branch block. It was new since [**2096**]. He had not had
any subsequent electrocardiograms to that. Patient's chest
pain was relieved with four sublingual nitroglycerins.
Patient was started on a heparin drip, nitroglycerin drip,
beta-blocker and was taken to catheterization which showed RA
pressures of 4, RV pressures of 23/14, PA 23/67, pulmonary
capillary wedge pressure of [**5-12**]. LV gram showing ejection
fraction of 50%, apical and anteroapical hypokinesis, left
dominant system, 80% ostial left anterior descending, 90%
ramus with TIMI 1 flow, large dominant circumflex, normal
nondominant right coronary artery. Patient has had no
complications after catheterization. Patient's serial
cardiac enzymes were CKs of 238, 15, 1306, MB of 12.2, 73.6,
149, troponin T of 0.19, 0.28, 0.99, respectively.
Patient was transferred to [**Hospital6 2018**] today for planned coronary artery bypass graft.
Patient was chest pain free upon arrival to the Coronary Care
Unit.
PAST MEDICAL HISTORY: Hyperlipidemia. Total cholesterol of
270, HDL of 71. Patient has had similar episodes in [**2096**]
which was evaluated in the Emergency Department and thought
to be related to gastroesophageal reflux disease. Per
patient, he had a negative exercise stress test in [**2096**].
PAST SURGICAL HISTORY:
1. Appendectomy as a child.
2. Vasectomy.
MEDICATIONS: Aspirin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a retired civil engineer. He
is married. Wife works at [**Hospital3 **] Medical Center. Has
three kids, never smoked, drinks 4-5 drinks a week. No
history of detoxifications. Runs [**2-8**] miles several times a
week.
FAMILY HISTORY: No history of sudden cardiac death. No
history of premature heart disease.
On admission to the Coronary Care Unit, patient had a
temperature of 99.5. Pulse 65. Blood pressure 107/46.
Respiratory rate of 20. Oxygen saturation of 98% on two
liters. General exam, patient was lying in bed in no
apparent distress. Head, eyes, ears, nose and throat: His
pupils are equal, round, and reactive to light and
accommodation. Extraocular muscles were intact. He had
moist mucous membranes. Neck: No bruits. Jugular venous
distention of [**1-9**] cm above the clavicle. Pulmonary: Patient
is clear to auscultation bilaterally. Good inspiratory
effort. Cardiovascular system: Regular rate and rhythm,
normal S1, S2, no murmurs, rubs or gallops were appreciated.
Abdominal exam: Patient had good bowel sounds, abdomen was
soft, nontender, nondistended without organomegaly.
Extremities: No cyanosis, clubbing or edema. Patient's
right groin was nontender without bruits. There was no
hematoma. Patient had 2+ peripheral pulses bilaterally.
Neurological exam: Alert and oriented times four. Cranial
nerves II through XII are grossly intact. No motor or
sensory deficits.
INITIAL LABORATORY VALUES: White blood cell count of 7.5,
hemoglobin 12.3, hematocrit 37.1, platelet count 179,000, INR
of 1.1. Chem-10: Sodium of 139, potassium 3.9, chloride
103, bicarbonate 31, BUN 12, creatinine 0.9, glucose 110.
Calcium of 9.3, phosphorus of 2.6, magnesium 1.8. Patient
had ALT of 43, AST of 166, alkaline phosphatase 63, total
bilirubin 0.8. Patient had a CK of 1001, MB of 87, index
8.7, troponin T 3.04. Patient's electrocardiogram showed
normal sinus rhythm with rate of 63, normal axis, normal
intervals, left bundle branch block.
HOSPITAL COURSE:
1. Cardiovascular system: Patient has two vessel coronary
disease as shown by cardiac catheterization at the outside
hospital. Patient is status post myocardial infarction with
80% ostial left anterior descending, occluded of 90% ramus
including TIMI 1 flow. This made it difficult to
re-vascularize angiography, therefore, patient was
transferred from the outside hospital to [**Hospital6 1760**] for planned cardiac bypass
surgery.
Patient was continued on aspirin, nitroglycerin drip, heparin
drip, was given a beta-blocker and a statin. The objective
was to keep the patient chest pain free, which we were able
to achieve. Patient has done very well overnight and has
been asymptomatic, therefore, patient has not required an
intraaortic balloon pump. Patient was monitored for any
signs of dysrhythmias, since patient has a question of left
bundle branch block. Patient's overall systolic function,
ejection fraction of 50% by LV gram without evidence of
congestive heart failure. Patient was weaned off
nitroglycerin drip and was started on an ACE inhibitor, which
patient tolerated well. Patient is to be transferred to the
regular nursing floor for a planned coronary artery bypass
graft on Monday.
2. Gastrointestinal: Patient has increased LFTs likely
secondary to being status post myocardial infarction.
Patient's LFTs will be followed as an outpatient after
discharge.
3. Renal: Electrolytes. Patient received appropriate post
catheterization hydration.
4. Pulmonary: Patient obtained a chest x-ray as a part of
preoperative evaluation per the cardiac bypass surgery.
5. Patient was instructed to follow cardiac/low sodium diet.
6. Prophylaxis: Patient was receiving Protonix as part of
gastrointestinal prophylaxis.
THIS DICTATION IS TO BE FOLLOWED BY AN ADDENDUM.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2108-6-17**] 05:27
T: [**2108-6-17**] 18:07
JOB#: [**Job Number 51256**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3253
} | Medical Text: Admission Date: [**2183-7-29**] Discharge Date: [**2183-8-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Lower GI Bleed
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
Pt is a 86 yo F with h/o PE/DVT on coumadin, diverticulosis
complicated by BRBPR in [**2177**], who presents with BRBPR in the
setting of a supratherapeutic INR.
.
Pt was in her USOH until she noticed what she thought was
vaginal bleeding in the bathtub with her [**Year (4 digits) 269**]. On closer
inspection she realized it was from her rectum. She noticed
bright/dark red blood in her pad. She does not recall the
amount. Her [**Year (4 digits) 269**] called her PCP who referred her to the ED.
During this episode, she denied any lightheadedness, dizziness,
CP, SOB, abd pain, n/v. Her BMs recently have been of normal
caliber daily. She denies any recent BRBPR, melena, pain on
stooling. She otherwise felt well. Her INR has been stable for
many years and she has not changed her diet or other medications
.
In the ED, her VST 97.8, HR 64, BP 124/65, RR 16, 02 sat 99% RA.
Exam in the ED noted a normal pelvic exam without blood or
masses. Rectal exam was notable for BRBPR with clots, too
difficult to assess for hemorroids or fissures. 2 PIV were
established. Her Hct was 28.4, her INR was 3.8 and was given
Vit K 5mg PO. Repeat Hct prior to her transport was 25.
.
ROS: As per HPI, otherwise negative for f/c, HA, palps,
hematemesis/hemotpysis, easy bruising from her baseline.
Past Medical History:
PMH/PSH:
1. Pulmonary embolus [**7-16**], DVT [**11-16**] on Coumadin.
2. Osteoporosis.
3. Arthritis.
4. Left breast mass status post lumpectomy.
5. Hypertension.
6. BRBPR in [**2177**] s/p EGD/Colonoscopy in [**2177**] with
Diverticulosis, polyps
7. s/p Hip replacement
8. s/p Hysterectomy
Social History:
Lives at home with husband. [**Name (NI) **] [**Name2 (NI) 269**]. Limited in her daily
activities and uses a walker. Denied tobacco/alcohol.
Family History:
Non-contributory. No h/o clots, easy bruising, bleeding, or GI
issues
Physical Exam:
VS: T 97.9, BP 165/83, HR 62, RR 17, 98%RA
Gen: Alert, talkative, well appearing in NAD
HEENT: EOMI, pERRL, anicteric sclera, MMM with slight
conjunctival pallor
Neck: supple, no LAD or bruits
Lung: CTAB no wheezes or crackles
Heart: RRR no m/r/g, nl S1 S2
Abd: well healed surgical scar noted. soft NT/ND + BS, no HSM,
right suprapubic reducible soft hernia
Back: No focal tenderness
Rectal: normal rectal tone
Ext: warm, well perfused, no edema 2+ DP pulses
Skin: no rashes
Neuro: alert, oriented, moving all extremities
Pertinent Results:
HCT on day of discharge 29, lowest had been hct 22 requiring 2
units prbc.
Colonoscopy wih divertucli in sigmoid. Could not get beyond
sigmoid.
CT abd without GI masses.
Brief Hospital Course:
1)GIB: Thought due to sigmoid diverticular bleeding in setting
of supratherapuetic INR. Colonoscopy could not eval beyond
sigmoid, as colon difficult to navigate [**Doctor Last Name **] to being "tacked
down" likely from prior scar tissue. Gastroenterology felt that
the bleed was likely from the sigmoid diverticuli, and requested
a CT abd to r/o any masses. Hct remained stable, and she was
discharged with coumadin restarted and new goal of INR 1.5 to
2.5.
2)DVT/PE: Pt with PE in [**2176**] and additional DVT in [**2177**] in the
setting of R ductal carcinoma of the breast and subtherapeutic
INR. Pt with h/o surgeries, malignancy, stasis. Currently
supratherapeutic, so coumadin was held with vitamin K given, as
above. Restarting coumadin at lower dose of coumadin 2 mg po
daily from prior of coumadin 5 mg po daily for INR goal of under
2.5.
3)Dispo: To rehab for PT.
4)HTN: Well controlled on home regimen of Diovan, HCTZ,
Metoprolol.
5)Dementia: Continue namenda, donepezil.
Medications on Admission:
Aricept 10mg daily
Namenda 10mg daily
Coumadin 5mg daily
Hydrochlorothiazide 25mg daily
Metoprolol 25mg [**Hospital1 **]
Ranitidine 150mg [**Hospital1 **]
Diovan 80mg daily
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily ().
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
6. Diovan 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Gastrointestinal bleed
Discharge Condition:
stable
Discharge Instructions:
Please alert your primary care doctor with any bleeding from the
rectum, dizziness, or other concerning symptoms.
Followup Instructions:
Appointment - Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Last Name (NamePattern1) 12160**]Date/Time:[**2183-10-22**] 12:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2183-8-6**]
ICD9 Codes: 2851, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3254
} | Medical Text: Admission Date: [**2109-10-15**] Discharge Date: [**2109-10-25**]
Date of Birth: [**2034-5-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
found by family member after suicidal attemp/overdose
Major Surgical or Invasive Procedure:
Intubation for airway protection.
Right subclavian central line placement.
EGD/colonoscopy on [**2109-10-22**] with gastric biopsy and polypectomy.
History of Present Illness:
75 yo Asian woman brought in after an overdose of beta blocker
and valium tablets. Apparently the patient is a victim of
domestic violence and composed a suicide note prior to taking "a
handful" of pills, including Lopressor and valium. She was found
by her daughter and brought into the [**Hospital1 18**] [**Name (NI) **].
In the ED, the patient was oriented and moderately somnolent.
Her blood pressure dropped to 71/41 with pulse in the 50s. She
was given activated charcoal and subsequently vomited. She was
started on glucagon and dopamine drips. The patient was
incontinent of stool and urine and intermittently had slurred
speech. Given persistently low BP, she was placed on Levophed.
Once she became bradycardic to the 30s with SBP in 60s, she was
intubated and given calcium. Toxicology recommended insulin gtt
and D5.
The patient was admitted to the MICU on dopamine and
norepinephrine, as well as insulin and bicarb. She was given
epinephrine to maximally support BP and one amp of atropine for
continued bradycardia. The patient's clinical status improved
and she was extubated on [**2109-10-17**]. The patient spiked a fever to
104.2 and was started on Vanc/Levo/Flagyl empirically for
presumed aspiration pneumonia during charcoal administration.
She had a transient episode of hypotension considered secondary
to early sepsis. A CXR revealed a left retrocardiac opacity. She
was continued on Levofloxacin and Flagyl.
Past Medical History:
1. HTN
2. Hypercholesterolemia
3. Anxiety
4. Depression
5. Shingles
Social History:
The patient is Japanese-born. She is a victim of both physical
and emotional domestic violence by her husband and a daughter.
[**Name (NI) **] husband was recently admitted to an institution. There is a
restraining order against him. She has another daughter who is
involved in her care. The patient is a smoker- has smoked for 55
years 1 [**11-23**] ppd, now down to 1/2 ppd.
Family History:
NC
Physical Exam:
Vitals: T 98.6 BP 150/64 HR 74 RR 28 94% 5L
Gen: elderly woman in NAD
HEENT: PERRL, EOMI, dry mucous membranes, OP clear
Neck: supple, FROM, no LAD, no JVD
Lung: bronchial BS left middle lung field, otherwise CTA
Card: RRR, nml S1S2,
Abd: NABS, soft ND, mildly tender throughout
Ext: no clubbing or cyanosis, trace bilateral LE edema
Neuro: alert, mildly confused, moving all extremities
Pertinent Results:
Admission:
[**2109-10-15**] 09:46PM BLOOD WBC-15.7* RBC-3.31* Hgb-11.0* Hct-31.0*
MCV-94 MCH-33.2* MCHC-35.4* RDW-12.6 Plt Ct-362
[**2109-10-15**] 09:46PM BLOOD Neuts-91.7* Bands-0 Lymphs-6.2*
Monos-1.8* Eos-0.2 Baso-0.1
[**2109-10-15**] 09:46PM BLOOD Plt Smr-NORMAL Plt Ct-362
[**2109-10-15**] 09:46PM BLOOD PT-13.0 PTT-27.0 INR(PT)-1.1
[**2109-10-17**] 11:48AM BLOOD Fibrino-406* D-Dimer-1649*
[**2109-10-18**] 04:30AM BLOOD Ret Aut-2.0
[**2109-10-19**] 06:11AM BLOOD Lupus-NEG
[**2109-10-15**] 09:46PM BLOOD Glucose-170* UreaN-19 Creat-1.6* Na-135
K-4.0 Cl-102 HCO3-15* AnGap-22*
[**2109-10-15**] 09:46PM BLOOD ALT-19 AST-32 AlkPhos-78 Amylase-62
TotBili-0.5
[**2109-10-15**] 09:46PM BLOOD Lipase-43
[**2109-10-16**] 01:30AM BLOOD CK-MB-4 cTropnT-<0.01
[**2109-10-16**] 05:15AM BLOOD CK-MB-6 cTropnT-<0.01
[**2109-10-16**] 02:47PM BLOOD CK-MB-8 cTropnT-<0.01
[**2109-10-15**] 09:46PM BLOOD Albumin-4.0
[**2109-10-16**] 01:30AM BLOOD Calcium-11.8* Phos-2.8 Mg-1.8
[**2109-10-18**] 03:12PM BLOOD calTIBC-150* Hapto-175 Ferritn-1075*
TRF-115*
[**2109-10-19**] 06:11AM BLOOD Triglyc-66 HDL-30 CHOL/HD-3.3 LDLcalc-57
[**2109-10-18**] 03:12PM BLOOD TSH-0.076*
[**2109-10-19**] 02:51PM BLOOD Free T4-0.8*
[**2109-10-21**] 05:26AM BLOOD TSH-0.50
[**2109-10-21**] 05:26AM BLOOD Free T4-0.7*
[**2109-10-17**] 05:00PM BLOOD Cortsol-33.4*
[**2109-10-23**] 12:45PM BLOOD PEP-NO SPECIFI
[**2109-10-15**] 09:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2109-10-16**] 01:01AM BLOOD Type-ART Temp-34.9 O2-100 pO2-356*
pCO2-31* pH-7.08* calHCO3-10* Base XS--20 AADO2-336 REQ O2-60
[**2109-10-16**] 01:01AM BLOOD Glucose-248* Lactate-5.9*
[**2109-10-16**] 01:01AM BLOOD freeCa-1.67*
Discharge:
[**2109-10-24**] 05:11AM BLOOD WBC-7.4 RBC-3.08* Hgb-9.5* Hct-28.1*
MCV-91 MCH-30.9 MCHC-33.9 RDW-15.1 Plt Ct-328
[**2109-10-24**] 05:11AM BLOOD Plt Ct-328
[**2109-10-24**] 05:11AM BLOOD Glucose-97 UreaN-16 Creat-0.5 Na-136
K-3.5 Cl-107 HCO3-24 AnGap-9
[**2109-10-18**] 03:12PM BLOOD LD(LDH)-206 TotBili-0.2
[**2109-10-24**] 05:11AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.3*
EKG ([**10-17**]): NSR at 78 bpm, PR 182, nml axis, no ST-T wave
changes
CXR ([**10-18**]): persistent left retrocardiac opacity with
associated abrupt termination of left lower lobe bronchus
suggesting collapse due to mucous plugging. Underlying infection
in this region cannot be excluded. Moderate left and small right
pleural effusions.
Microbiology data:
Blood cultures - no growth [**12-24**] sets
Urine - E coli, Levofloxacin sensitive
Sputum - E coli, Levofloxacin sensitive
Brief Hospital Course:
1. Overdose: The patient overdosed with beta blocker and valium,
complicated by cardiogenic shock. Toxicology, psychiatry and
social work were involved. She was initially admitted to the
intensive care unit and was treated with glucagon, calcium
gluconate. She was on pressors for hypotension and was intubated
for airway protection. Once she became hemodynamically stable,
she was transferred to the general medical floor where she was
monitored on telemetry and has remained hemodynamically stable.
1:1 sitter was initially continued for patient's safety and was
discontinued once cleared by psychiatry.
2. Psychiatric issues: Patient has been very anxious and
depressed. Psychiatry has been following her. She was started on
Celexa 10 mg po qhs on [**2109-10-23**]. Psychiatry recommended
Haldol prn and Quetiapine prn for agitation and anxiety. Patient
is being discharge to pshyciatric inpatient facility where she
will be closely followed and her medications will be adjusted as
needed.
3. Pneumonia: Patient likely aspirated following charcoal
administration due to bouts of emesis. She spiked fever,
developed cough and new oxygen requirements. CXR showed left
retrocardiac opacity. Levofloxacin and metronidazole were
started empirically for presumed aspiration pneumonia on
[**2109-11-16**]. Sputum and urine grew E coli that was Levofloxacin
sensitive. Blood cultures had no growth. The patient improved
over her stay. Prior to discharge, she was satting >93% on room
air and has been afebrile without leukocytosis for several day.
She should complete a 10 day course of Abx. Would recommend
checking Ua and culture after 10-day course of Abx is completed
to ensure that UTI has cleared.
4. ARF: Pt presented with creatinine of 1.9, elevated from
baseline. Likely secondary to ATN from prior hypotension. FENa
calculated from urine electrolytes on [**2109-10-16**] was 24%,
suggesting intrarenal process. Patient's renal failure has
resolved and Cr was 0.5 prior to discharge.
5. Elevated PTT: Unclear etiology for transiently elevated PTT x
several days. Likely due to contamination with heparin.
Coagulation studies have normalized prior to discharge.
6. Afib, newly diagnosed: Patient has had several episodes of
atrial fibrillation since resolution of bradycardia. When her
blood pressure has stabilized she was started on lopressor 25 mg
po qd. While the possibility that a fib was in the setting of
cardiogenic shock/synmpathetic overdrive, it was felt that
anticoagulation is warranted. The patient should be
anticoagulated with warfarin (goal INR [**12-25**]) starting 7 days post
her colonoscopy/EGD which were done on [**2109-10-22**]. She will follow
up with cardiology for Holter monitoring to address whether she
need to continue anticoagulation.
7. Anemia, unclear etiology: Hct 31 on admission dropped
precipitously to 25-26 and nas remained stable at that level.
Hemolysis work up was unrevealing. Iron studies were consistent
with ACD but appears that these were drawn after blood
transfusion and may not be reliable. Patient's Hct has been
stable. The cause of her anemia is not entirely clear. SPEP was
negative. UPEP was pending at the time of this dictation.
Because she had several guaiac positive stools, gastroenterology
was consulted and they performed EGD/colonoscopy with biopsy and
polypectomy [**2109-10-12**]. The patient should follow up with
gastroenterology regarding her biopsy results and should be seen
in 4 weeks for possible SBFT/capsule enteroscopy.
Medications on Admission:
Lipitor
Lopressor
Valium
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
1. Suicide Attempt - ingestion Beta-Blocker and Valium.
2. Cardiogenic Shock secondary to #2.
3. Atrial Fibrillation, newly diagnosed.
4. Ventilator Associated Pneumonia.
5. Acute Renal Failure.
6. Anemia.
Secondary:
1. Depression.
2. Hypertension.
3. Hypercholesterolemia.
Discharge Condition:
Medically stable but requiring psychiatric hospitalization to
address mental health issues.
Discharge Instructions:
Please continue to monitor patient's electrolytes, Hct
periodically.
Please start anticoagulating the patient with warfarin with
heparin bridging on [**2109-10-28**] (weeks after EGD and
colonoscopy with biopsies/polypectomy) for atrial fibrillation.
Goal INR [**12-25**].
Please fihish full 10 day course of antibiotics for aspiration
pneumonia.
Followup Instructions:
Please follow up with cardiology Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**],
M.D. Where: [**Hospital6 29**] CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2109-12-25**] 11:00
Please follow up with gastroenterology regarding biopsy results
and possible small bowel FT or caplule enteroscopy. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] Where: [**Hospital6 29**] MEDICAL SPECIALTIES
Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2109-11-20**] 2:00
Please schedule follow up appointment with primary care
physician one week after discharge from psychiatric hospital.
Thyroid function tests should also be rechecked once the patient
is over acute illness.
Completed by:[**2109-10-25**]
ICD9 Codes: 5070, 2851, 5789, 5990, 5845, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3255
} | Medical Text: Admission Date: [**2129-7-5**] Discharge Date: [**2129-7-14**]
Date of Birth: [**2071-2-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
pre syncope
Major Surgical or Invasive Procedure:
[**2129-7-8**] Aortic valve replacement(25-mm Onyx mechanical)
History of Present Illness:
Mr. [**Known lastname 85735**] has known aortic stenosis for a couple of years and has
been followed by echocardiograms. He had a negative stress test
in [**2128**], cardiac catheterization in [**9-15**] demonstrated clean
coronaries and moderated aortic stenosis. A few days ago he
became dizzy, lightheaded and diaphoretic while installing a
cabinet door without chest pain and he did not pass out. It was
thought that his stenosis is now worse and was the cause.
Cardiac surgery was consulted for surgical correction.
Past Medical History:
aortic stenosis
hypertension
hyperlipidemia
s/p multiple head and neck injuries from skydiving
s/p occipital CVA w/L quadrantanopia
Social History:
Race:white
Last Dental Exam:>1.5 years ago
Lives with:wife
Occupation:[**Name2 (NI) 85736**] designer
Tobacco:quit 11 years ago 60-90pky
ETOH:rare
Family History:
Mother had CHF and died at [**Age over 90 **]yrs
Father had CA
Gradfather had MI at 71 yrs
Physical Exam:
admission:
Pulse:80 Resp: 18 O2 sat:97% on Ra
B/P Right:127/72 Left:
Height: Weight:300#
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] decreased flexion/extension[]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [**3-12**] harsh SEM radiating to
carotids
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 except L visual field cut as described
above
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid BruitRight: tansmitted murmur Left:transmitted murmur
Pertinent Results:
06/29/106/29/10 %HbA1c-6.7*
[**2129-7-13**] 09:26AM BLOOD WBC-8.7 RBC-2.98* Hgb-9.2* Hct-26.9*
MCV-90 MCH-30.9 MCHC-34.2 RDW-13.3 Plt Ct-344
[**2129-7-14**] 05:52AM BLOOD PT-22.8* PTT-95.4* INR(PT)-2.2*
[**2129-7-13**] 09:26AM BLOOD PT-18.4* PTT-85.8* INR(PT)-1.7*
[**2129-7-12**] 09:47PM BLOOD PT-15.3* PTT-38.0* INR(PT)-1.3*
[**2129-7-12**] 01:52PM BLOOD PT-13.9* PTT-38.9* INR(PT)-1.2*
[**2129-7-12**] 04:55AM BLOOD PT-13.6* PTT-39.3* INR(PT)-1.2*
[**2129-7-14**] 05:52AM BLOOD Na-136 K-4.3 Cl-100
[**2129-7-13**] 09:26AM BLOOD Glucose-151* UreaN-28* Creat-1.3* Na-136
K-3.9 Cl-97 HCO3-29 AnGap-14
Brief Hospital Course:
Mr.[**Known lastname 85735**] was admitted to [**Hospital Ward Name 121**] 6 for preoperative admission
testing which included dental clearance and a neurology
evaluation for his history of occipital stroke of unknown
etiology.
On [**2129-7-8**] he went to the Operating Room and underwent aortic
valve replacement with a size 25-mm Onyx mechanical valve.
Please refer to Dr[**Doctor First Name **] operative report for further
details. He tolerated the procedure well and was transferred to
the CVICU in critical but stable condition. He awoke
neurologically intact and was extubated without incident. All
lines and drains were discontinued in a timely fashion. He was
weaned off all drips.
Beta-blockade/Statin/ASA and diuresis were initiated.
Anticoagulation with Coumadin was begun for the mechanical valve
with an INR goal of 2.5-3.5. On POD#3 he was transferred to the
step down unit. Physical Therapy was consulted for evaluation of
strength and mobility. A Heparin drip was initiated to bridge
until the INR was therapeutic. He transiently had a
postoperative burst of atrial fibrillation that was treated with
beta-blockade.
He continued to progress and he was cleared by Dr.[**First Name (STitle) **] for
discharge to home with VNA on [**7-14**] when the INR was therapeutic
and Heparin was stopped. All follow up appointments were
advised. Arrangements for Coumadin management were made with
his primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
Medications on Admission:
Plavix 75'
bisoprolol/HCTZ 10/6.25'
lipitor 20'
benazepril 10'
ambien at night
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-12**]
hours as needed for pain.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
6. Aspirin, Buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Omega-3 Fatty Acids 300 mg Capsule Sig: One (1) Capsule PO
twice a day.
8. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day:
goal INR 2.5-3.5 for mechanical valve.
Disp:*100 Tablet(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. Outpatient [**Name (NI) **] Work
PT/INR on [**2129-7-14**] and prn while on Coumadin therapy.
Please FAX results to Dr.[**Name (NI) 55597**] office at [**Telephone/Fax (1) 55598**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 487**] [**Hospital6 486**],
Discharge Diagnosis:
Aortic Stenosis
s/p Aortic valve replacement(25-mm Onyx mechanical)
hypertension
hyperlipidemia
s/p occipital CVA w/L quadrantanopia w/migraines migraines
Discharge Condition:
Alert and oriented x3, nonfocal exam
Ambulating with steady gait
Incisional pain managed with: Percocet
Incisions: Sternal -healing well, no erythema or drainage
Edema:trace
Alert and oriented x3, nonfocal exam
Ambulating with steady gait
Incisional pain managed with: Percocet
Incisions: Sternal -healing well, no erythema or drainage
Edema:trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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:
Surgeon Dr. [**Last Name (STitle) 7772**] on [**8-22**] @ 1:15 [**Telephone/Fax (1) 170**]
Please call to schedule appointments
Primary Care Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 70836**]) in [**1-8**] weeks
Cardiologist Dr.[**Last Name (STitle) 85737**] in [**1-8**] weeks
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 55598**] fax) to follow INR/Coumadin
INR 2.5-3.5 goal for mechanical valve
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2129-7-14**]
ICD9 Codes: 4241, 9971, 2761, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3256
} | Medical Text: Admission Date: [**2186-11-29**] Discharge Date: [**2187-1-26**]
Date of Birth: [**2127-6-10**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Benzocaine
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
Left foot swelling x 2 weeks
Major Surgical or Invasive Procedure:
Incision and dranage and debridement of ankle
Thoracotomy, Left, with Debridement and Internal fixation and
grafting L1-L2, partial vertebrectomy
Posterior spinal fusion with instrumentation T8-L2
History of Present Illness:
59 yo NIDDM with left ORIF (25 years ago), chronic BLE edema,
chronic back pain s/p hardware placement and neuropathy who
presented with left medial malleolus pain x 2 weeks. Notes that
this was a site where he had a recent ulcer. He states that he
has chronic LE edema, but awoke this AM with increased pain and
swelling in his left leg and was unable to bear weight on the
leg. Denies trauma. Has had fevers at home to 101. The patient
was intially admitted to medicine for a cellulitis and started
on zosyn.
The initial presentation was followed by a very complicated
hospital course.
- [**12-4**] the pt underwent incision and drainage with hardware
removal from his left ankle. Subsequent TTE and TEE were
negative for endocarditis.
- [**12-15**], the pt had an episode of desaturation and
methemoglobinemia during TEE secondary to the use of benzocaine.
This required [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] admission but the pt returned to the floor
on [**12-16**]. During this time, the pt was experiencing increased
back pain.
- [**12-19**] Spine MR [**First Name (Titles) 654**] [**Last Name (Titles) 97910**]/osteomyelitis with an adjasent
psoas infection. L spine films obtained on [**12-21**] were highly
suggestive of osteomyelitis/diskitis at L1-2 with accompanying
indistinct appearance of the vertebral bodies from L2 to S1.
- [**1-9**], the pt was taken to the OR for hardware removal from
the back secondary to these findings. This debridment was
accompanied by L1 vertebrectomy and L1-L2 fusion. He received 3
U PRBC intraop and 1 U PRBC following the procedure. Initially,
the pt did well overnight in the PACU on SIMV.
- [**1-10**], he became tachypnic when his sedation was decreased.
Other hemodynamic markers were stable. Pt was seen by the pain
clinic at that time and he was changed to a dilaudid drip for
pain control. The pt also spiked to 102.4 in the PACU. He was
pan cultured. At that time, the pt was transferred to the MICU
for further care.
- The pt self extubated in the early morning hours of [**1-12**].
- Transferred to floor where his course was unremarkable
- Taken back to OR for posterior stabilization on [**1-16**].
- Uneventful post op course until [**1-23**] PM when he was found
transiently unresponsive, hypotensive and hypoxic - all of which
spontaneously resolved within minutes. Transferred to medicine
for ROMI and further w/u; thought to have had a mucous plug.
- Ruled out, no PE, did have UTI
Past Medical History:
1. Diabetes II
2. Hypertension
3. GERD
4. Mild anemia
5. Lower back pain s/p multiple back surgery (L4-S1 fusion '[**80**],
[**4-/2183**] he had a L3 laminectomy and medial fasciectomy with L3
to L4 bilateral fusion with pedicle screws and bone grafting. On
[**2184-9-27**] he had a left L2-L3 microdiscectomy and right L2-L3
laminectomy. On [**2185-10-3**] he underwent decrompression at L2 to L3
and an L2, L3 fusion using pedicle screws and iliac crest line
graft.)
6. Dyslipidemia
7. Hypertension
8. S/P retinal detachment repair in [**2176**]
Social History:
Lives alone, denies etoh, rare pipe, no illicit drug use
Family History:
Father w/ MI at age 72
Physical Exam:
T 98.6 (Tm 103.6 in ED) BP 130/84 HR 96 96% RA
General: NAD
Pulm: cta B
CV: s1 s2 reg
Abd: NABS, soft, NT
Ext: no edema
2+ DP on right and 1+ on left. Erythema from midfoot to shin
with tenderness at ankle and with dorsiflexion.
Pertinent Results:
Initial labs:
CBC
[**2186-11-29**] 04:15AM WBC-15.1*# RBC-3.63* HGB-11.6* HCT-34.5*
MCV-95 MCH-32.0 MCHC-33.7 RDW-14.5, NEUTS-79* BANDS-13*
LYMPHS-2* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1*, PLT
COUNT-228
Chemistries
[**2186-11-29**] 04:15AM GLUCOSE-141* UREA N-45* CREAT-1.7* SODIUM-138
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-29 ANION GAP-14
[**2186-11-29**] 01:10PM GLUCOSE-150* UREA N-34* CREAT-1.3* SODIUM-139
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-25 ANION GAP-18
Micro
- Resp culture ([**1-10**]) Strep, not group A, but repeat on [**1-11**] OP
flora
- Swab ([**12-4**]) strep not group A, MSSA
- BCx ([**11-30**] and [**11-29**]) MSSA
- [**2187-1-17**] L1 gross diagnosis "osteomyelitis"
- [**1-24**] U/A negative, UCx Gram negative rods
L foot xray:
1. Old fractures of the distal tibia and fibula.
2. Marked abnormality of the tibiotalar joint which requires
additional
clinical information for full assessment. Differential diagnosis
includes
posttraumatic, Charcot neuropathy, and changes related to
infection and
inflammation.
3. Fracture involving the first proximal phalanx extending to
the IP joint,
ECHO
Conclusions:
1. The left atrium is mildly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
normal
(LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic root is moderately dilated. The ascending aorta is
moderately
dilated.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation. 6.The mitral valve
leaflets are mildly
thickened. Trivial mitral regurgitation is seen.
7.There is mild pulmonary artery systolic hypertension.
8.There is a small pericardial effusion. There are no
echocardiographic signs
of tamponade.
9. No echocardiographic evidence of endocarditis. Would
recommend a TEE if
clinically indicated.
TEE
IMPRESSION: Mild aortic valve sclerosis. Trace aortic
regurgitatio. No echo evidence of endocarditis.
MR [**Name13 (STitle) **]
IMPRESSION:
Abnormal signal at the L1-L2 level and within the L1 vertebral
body with abnormal enhancement in the adjacent psoas muscles,
consistent with a [**Name13 (STitle) 97910**]/osteomyelitis with adjacent psoas
infection. Limited evaluation of the spinal canal suggests
epidural infection at L1-2. If there is a decline in neurologic
function, a repeat study is recommended.
MR Hip
IMPRESSION:
1) Bilateral psoas abscesses, worse on the left than the right,
unchanged. Erosion of the anteroinferior aspect of the body of
L1 likely relates to infection and is unchanged in appearance.
Paraspinal collection in the posterior paraspinal soft-tissues,
unchanged.
Right iliac [**Doctor First Name 362**] fracture, unchanged.
Unremarkable bilateral hip joints. No hip effusion.
CT LE
IMPRESSION:
1) Status post debridement in the medial malleolar region, with
a VAC dressing in place, contacting the distal tibia.
2) Erosive and destructive changes involving the distal tibia
and fibula, talus, and calcaneus; osteomyelitis is not. In
particular, there are foci of gas and fluid in the lateral
aspect of the foot (distant from the VAC dressing), raising the
concern for presence of a gas-producing infection or abscess
formation.
3) Scattered tiny pockets of fluid with no drainable fluid
collection.
[**1-23**] CT LE
IMPRESSION:
1) Erosive and destructive changes involving the ankle, which
may be consistent with the stated history of osteomyelitis. No
discrete fluid collections are identified. The soft tissue
defect at the medial malleolus is grossly unchanged when
compared to the prior study.
Brief Hospital Course:
Ankle and Lumbar Spine Osteomyelitis
The patient initially presented with what was thought to be a
left ankle cellulitis and was started on unasyn with vancomycin
given risk for MRSA. When the sensitivities grew out MSSA,
antibiotics were changed to oxacillin. He had hardware in place
from a prior injury of his left ankle. He continued to have
fevers and given staph bacteremia was at risk of osteomyelitis
or hardware seeding. Orthopaedic service consulted and
proceeded with a left ankle I&D with removal of hardware on
[**12-4**]; wound cultures grew out MSSA. The wound was kept open
with temporary VAC dressing and plastics followed the patient
during hospitalization; he will follow up after discharge for
VAC removal and flap coverage.
The patient was also thought to have osteomyelitis of L1 based
on MRI and underwent debridement and spinal fusion of T12 to L2
on [**1-9**]; vertebral tissue sent from the OR was consistent with
infection. He was taken back to the OR for posterior fusion on
[**2187-1-16**]. Ortho spine and neurosurgery followed the patient while
admitted. He was treated with oxacillin and rifampin added per
ID recommendations for osteomyelitis in his ankle as well as his
spine. These antibiotics should continue until his appointment
with Dr. [**Last Name (STitle) 11382**] in [**Month (only) 958**].
CV
Pt with h/o hypertension and had been on univasc at last visit.
Initially the patient remained on moexipril and labetolol with
good control. During his hospitalization, he was transitioned
to metoprolol and continued on this until discharge. He had an
episode of hypotension on [**2187-1-23**] that spontaneously resolved
after minutes. But given flattening of T waves laterally on
EKGwith this, he was ruled out for a myocardial infarction with
three sets of cardiac enzymes. He was started on 325mg aspirin.
Other ID issues
The patient had diarrhea off and on during his hospitalization;
c difficile toxins were negative consistently. Given this, he
was started on imodium prn for symptoms. Additionally, a urine
culture was sent on [**1-24**] and grew gram negative rods (U/A
negative). His foley was removed and he was started on
ciprofloxacin for a 5 day course (ID felt this could be
colonization); on discharge further speciation and sensitivities
were pending. A urine culture will be repeated [**Hospital **] rehab once
the cipro is completed.
Heme
Pt with anemia of unclear cause. SPEP is negative as are his B12
and folate levels. Followed by PCP; baseline 29-35 which
remained stable during most of his hospital stay. After his
third surgery, his HCT fell to 26 and remained stable between
26-28. Because of his history of transfusion reactions, he was
not transfused but rather was started on tid iron
supplementation.
Derm
Pt with right arm and bilateral thigh (left > right) ulcers and
excoriations. Dermatology consulted who were of the impression
that the lesions were consistent with neurotic excoriations and
purigo nodules from chronic excoriation. Management goals were
to prevent secondary infection. Bactroban cream started [**Hospital1 **]
with clean dressings. Further along during his hospitalization,
he was also placed on nystatin and miconazole treatments.
Psychiatry
The patient had a h/o depression treated with home regimen of
Paxil 30mg po qd. After his third surgery he was restarted on
paxil at10mg daily and this can be titrated up. Social work was
consulted regarding patient's concerns over financial issues
given his long hospital stay.
NIDDM
On admission, he stated that he was taking glyburide 7.5mg po
qAM and 5mg po qPM. He was initially continued on this regimen
with an additional RISS, but during his course was NPO and was
then kept only on the sliding scale with a goal of tight
glycemic control.
FEN
After his first spinal surgery, the patient was kept NPO except
meds with water as he was unable to sit upright. He was briefly
given TPN via his PICC line until his second spinal surgery.
After that surgery, once extubated his diet was advanced without
difficulty.
Proph
The patient was maintained on a PPI; DVT prophylaxis; bowel
regimen; and the pain service followed him to ensure appropriate
pain control. His pain meds were tapered off after his final
surgery. On discharge he was on prn tylenol and prn [**Hospital1 **]
(but was not requiring it).
Access
The patient had a CVL and arterial line while in the ICU; he
then had a PICC inserted for long term IV antibiotics and was
discharge to rehab with this in place.
FULL CODE.
Medications on Admission:
MS [**First Name (Titles) **]
[**Last Name (Titles) 1756**]
Lodine
Glyburide
Paxil
Moexipril
Discharge Medications:
1. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
2. Multi-Vitamin Hi-Po Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Glutamine 10 g Packet Sig: 0.5 Packet PO BID (2 times a
day).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
units per sliding scale Injection ASDIR (AS DIRECTED).
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
14. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
15. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
16. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for diarrhea.
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
20. [**Last Name (Titles) 1756**] HCl 5 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for pain.
21. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: hold for diarrhea.
23. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
24. Oxacillin 2 gm IV Q4H
25. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO once a
day.
26. Imodium 2 mg Capsule Sig: One (1) Capsule PO four times a
day as needed for diarrhea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses
MSSA Osteomyelitis of the Spine L1-L2
MSSA Ankle Pyarthrosis and chronic wound left ankle
MSSA bacteremia
Secondary Diagnoses
Diabetes II
Hypertension
GERD
Mild anemia
Low back pain s/p multiple surgeries
Dyslipidemia
Discharge Condition:
Hemodynamically stable and neurologically intact. Wounds from
spinal surgery healing primarily. Resumed oral intake. Vac
dressing in place left foot per plastics until flap procedure.
Discharge Instructions:
Keep wounds clean and dry. Use topicals for rash.
Please alert your care providers if you have fevers, chills,
nausea, vomiting, persistent diarrhea, worsening chest or
abdominal pain, worsening ankle pain, or any other symptoms
concerning to you.
Followup Instructions:
Dr. [**Last Name (STitle) 363**] (orthopedic surgery) on Wednesday [**2-21**] 9:15AM
for X-Ray, [**Hospital Ward Name 23**] [**Location (un) **], [**Telephone/Fax (1) **]
Dr. [**Last Name (STitle) 11382**] (ID) on Tuesday [**3-6**] 11AM, [**First Name8 (NamePattern2) **]
[**Hospital Ward Name **] Bldg, Suite G, [**Telephone/Fax (1) **]
Plastic surgery followup on Tuesday [**2-6**] at 10AM,
[**Telephone/Fax (1) **], Hand and [**Hospital 3595**] clinic
ICD9 Codes: 7907, 5185, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3257
} | Medical Text: Admission Date: [**2119-12-13**] Discharge Date: [**2119-12-17**]
Date of Birth: [**2045-1-6**] Sex: F
Service: Medicine
NOTE: This is an incomplete Discharge Summary. Please see
Discharge Summary Addendums for completion of the [**Hospital 228**]
hospital course, discharge diagnoses, and discharge
medications.
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
woman with a history of aortic stenosis and anxiety who is
status post right total hip replacement on [**2119-11-14**]
at [**Hospital6 2910**] who was at the [**Hospital3 98565**] Home rehabilitation facility when she experienced the
onset of a painful right thigh with swelling and warmth for
three days.
The patient was taking Coumadin at the rehabilitation
facility for deep venous thrombosis prophylaxis.
Additionally, the patient was mobilizing the leg.
The [**Hospital 228**] rehabilitation physician sent the patient to
the [**Hospital1 69**] on the day of
admission of an outpatient lower extremity edema noninvasive
ultrasound. The ultrasound revealed the presence of a right
superficial femoral vein deep venous thrombosis.
The patient was sent to the Emergency Department where her
prothrombin time was noted to be 38, INR was 9.6, and partial
thromboplastin time was 73.8. These values were repeated,
and her prothrombin time was 36.8, partial thromboplastin
time was 73.8, and INR was 9. The patient was started on
intravenous heparin initially.
The patient denies any chest pain, shortness of breath,
history of prior clots, and a history of malignancy. She
denies any nausea, vomiting, constipation, diarrhea, bright
red blood per rectum, and melena. She does notice some
bleeding from her gums while brushing her teeth and a bruise
on the posterior left calf, but no epistaxis.
Of note, on [**2119-10-26**], the patient's prothrombin time
was 12.2, partial thromboplastin time was 29.4, and INR was 1
prior to the initiation of Coumadin. On [**2119-11-18**],
status post total hip replacement surgery, the patient's
prothrombin time was 24.2 and INR was 3.4. On [**11-23**]
(at the rehabilitation facility), the patient's INR was 2.89.
PAST MEDICAL HISTORY:
1. Status post right total hip replacement on [**2119-11-14**].
2. Aortic stenosis.
3. Recurrent urinary tract infections.
4. Dobutamine echocardiogram in [**2119-11-5**] revealed no
ischemia. Left ventricular hypertrophy with normal systolic
function and aortic stenosis with an aortic valve area of
1.1 cm2 and mild mitral regurgitation.
5. Status post renal cyst removal.
6. Anxiety.
7. Bronchitis.
MEDICATIONS ON ADMISSION:
1. Norvasc 5 mg p.o. q.d.
2. Vicodin p.o. as needed.
3. Senokot.
4. Librium 5 mg p.o. q.a.m. and as needed (for anxiety).
5. Coumadin 1.5 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is widowed. A former secretary.
She has a 50-pack-year tobacco history (which she quit in
[**2119-10-6**]). She denies any alcohol use. She has one
daughter and two sons.
FAMILY HISTORY: No history of clots.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed, in general, the patient was a pleasant elderly
woman in no acute distress. Temperature was 98.4, blood
pressure was 122/62, heart rate was 94, respiratory rate was
18, oxygen saturation was 97% on room air. Head, eyes, ears,
nose, and throat examination revealed pupils were equal,
round, and reactive to light. The oropharynx was clear.
Mucous membranes were moist. Questionable dried blood on
lips. The neck was supple. No lymphadenopathy. No jugular
venous distention. Chest examination revealed clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. Normal first heart sound
and second heart sound. A 3/6 systolic ejection murmur at
the right upper sternal border. The abdomen was soft,
nontender, and nondistended. Positive bowel sounds.
Extremity examination revealed right thigh tenderness with
swelling, but no erythema, with 1+ pedal edema in the right
lower extremity. The left lower extremity without clubbing,
cyanosis, or edema. Neurologic examination revealed alert
and oriented times three. In no acute distress.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed white blood cell count was 15.4 (with a differential
of 72 neutrophils, 0 bands, 18 lymphocytes, 7 monocytes, and
3 atypical cells), hematocrit was 26.3, and platelets were
238. Prothrombin time was 36.8, INR was 9, and partial
thromboplastin time was 73.8. Sodium was 136, potassium was
3.9, chloride was 99, bicarbonate was 24, blood urea nitrogen
was 15, creatinine was 0.8, and blood glucose was 108.
RADIOLOGY/IMAGING: Lower extremity noninvasive ultrasound
revealed intraluminal thrombus throughout the length of the
superficial femoral vein.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. HEMATOLOGIC SYSTEM: The patient presented with the
presence of a right superficial femoral deep venous
thrombosis while supratherapeutic on Coumadin. In addition,
the patient's partial thromboplastin time was also elevated
on admission which was thought to be secondary to the
elevated INR and Coumadin overdose.
Initially, it was thought that the patient was a failure on
Coumadin therapy, and it was felt that the patient would
benefit from treatment of the deep venous thrombosis with
intravenous heparin with a goal partial thromboplastin time
of approximately 100.
However, on the night of admission, the patient's partial
thromboplastin time rose to greater than 150 with the
patient's INR rising to 15. Subsequently, the patient's
hematocrit dropped from 26 to 21 on hospital day two, and
there was a concern for retroperitoneal or bleeding into the
patient's hip.
A computed tomography of the abdomen and pelvis was performed
which showed a 5-cm hematoma in the right thigh with tracking
down to the knee. At this time, the heparin was stopped and
a STAT Hematology consultation was obtained.
The patient was then reversed with 4 units of fresh frozen
plasma as well as 1 mg of vitamin K intravenously. In
addition, the patient was to be transfused 2 units of packed
red blood cells; however, upon initiation of the blood
transfusion, the patient became tachycardic and developed the
onset of substernal chest pressure with shortness of breath
and hypotension with systolic blood pressures in the 90s to
100s.
An electrocardiogram was obtained at this time which revealed
deeper ST depressions in leads II, III, aVF, V4, and V6;
suggestive of demand ischemia. The patient then went into
respiratory distress as a result of fluid overload and
congestive heart failure in the setting of aortic stenosis.
The patient was then intubated and transferred to the Medical
Intensive Care Unit.
After the patient had received her 4 units of fresh frozen
plasma and vitamin K, the patient's INR was noted to be 1.2.
Interventional Radiology was consulted for placement of an
inferior vena cava filter.
An inferior vena cava filter was placed on [**2119-12-14**]
and was again repositioned on [**2119-12-15**].
Hematology/Oncology felt that because the inferior vena cava
filter was not 100% effective against propagation of the deep
venous thrombosis to the lungs, it was felt that the patient
should be restarted on anticoagulation. As a result, Lovenox
was started on [**2119-12-16**].
In addition, a computed tomography angiogram of the chest was
performed to assess for the presence of a pulmonary embolism.
The computed tomography angiogram was performed on [**12-15**]
which revealed no evidence of pulmonary embolism.
After intubation, the patient received 5 units of packed red
blood cells in total with an increase in her hematocrit from
21 to 30 on the day of transfer from the Medical Intensive
Care Unit. In addition, the patient's INR upon transfer was
1.9, and her partial thromboplastin time was 36.2.
Heparin-induced antibodies were also checked which were
negative.
2. CARDIOVASCULAR SYSTEM: As noted above, the patient
developed demand ischemia in the setting of severe anemia.
The patient's cardiac enzymes were cycled, and the patient's
creatine kinase peaked at 822 (on [**2119-12-14**]), with a
CK/MB of 20, and a troponin level of 15.
This non-ST-elevation myocardial infarction was thought to be
secondary to demand ischemia in the setting of anemia and
aortic stenosis.
The patient was started on a cardiac regimen of aspirin 81 mg
p.o. q.d. and Lopressor 12.5 mg p.o. b.i.d. on [**2119-12-16**]. The patient should undergo an outpatient stress test
for further risk stratification.
As noted above, as well, the patient went into pulmonary
edema and congestive heart failure given the patient's aortic
stenosis and fluid resuscitation. The patient was gently
diuresed with Lasix; however, it was noted that the patient
is preload dependent given her aortic stenosis. The patient
was to be continued on Lasix as needed for now.
3. PULMONARY SYSTEM: The patient was intubated for
respiratory distress and pulmonary edema on [**2119-12-14**]
and successfully extubated on [**2119-12-16**].
As noted above, a computed tomography angiogram was negative
for evidence of pulmonary emboli. The computed tomography
scan also showed evidence of bilateral pleural effusions as
well as left lower lobe pneumonia. Initially, the patient
was started on broad spectrum antibiotics for a question of
aspiration pneumonia; however, these antibiotics have since
been changed to not cover for aspiration pneumonia since the
patient's sputum culture was unremarkable; as well, the
patient's oxygenation remained stable.
4. INFECTIOUS DISEASE ISSUES: Upon admission to the Medical
Intensive Care Unit, the patient spiked a temperature to
101.9, and the patient's white blood cell count was elevated
at 20.3.
The patient was initially started on broad spectrum
antibiotics with vancomycin, ceftriaxone, and Flagyl for
possible aspiration pneumonia and possible infection of her
prosthetic hip hardware. As well, blood cultures were
obtained which were negative to date on the day of this
dictation.
On [**2119-12-17**], the patient's white blood cell count
continued to improve, and the patient's temperature
defervesced. As a result, the patient's antibiotic regimen
was switched to Keflex to cover for a possible prosthetic
infection. Ceftriaxone and Flagyl were discontinued since it
was unlikely that the patient had an aspiration pneumonia.
5. PSYCHIATRIC ISSUES: Initially, the patient was
maintained on librium for an anxiety disorder, but then the
patient was switched to a shorter-acting benzodiazepines
(Serax) after transfer from the Medical Intensive Care Unit.
NOTE: This is an incomplete Discharge Summary. Please see
Discharge Summary Addendums for completion of the hospital
course, discharge diagnoses, and discharge medications.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 1336**]
MEDQUIST36
D: [**2119-12-17**] 22:16
T: [**2119-12-20**] 11:53
JOB#: [**Job Number **]
ICD9 Codes: 4241, 4280, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3258
} | Medical Text: Admission Date: [**2156-3-1**] Discharge Date: [**2156-3-6**]
Date of Birth: [**2086-7-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain, fatigue
Major Surgical or Invasive Procedure:
coronary artery bypass x 4 (LIMA-LAD, SVG-Dx, SVG-OM, SVG-PDA)
[**2156-3-1**]
History of Present Illness:
Very nice 69 year old gentleman with a known history of coronary
artery disease status post PCI in [**2147**] and again this past
[**Month (only) 404**]. He developed anginal symptoms this past [**Month (only) 404**] and
subsequently underwent a cardiac catheterization. The culprit
proximal RCA was stented however multivessel disease was noted.
It was decided that he would be best served with surgical
revascularization and subsequently was referred for surgical
evaluation. He has felt well since his stent without any
symptoms
of angina, dyspnea or decreased physical capacity.
Past Medical History:
coronary artery disease, s/p coronary artery bypass [**2156-3-1**]
PMH:
myocardial infarctionx2 [**2147**] and [**1-/2156**]
Hyperlipidemia
Hypertension
Hyperparathyroid s/p resection
Social History:
Lives with: Wife in [**Name2 (NI) 2498**]
Occupation: Retired
Tobacco: Denies
ETOH: Denies
Family History:
non-contributory
Physical Exam:
Pulse: 51 SB Resp: 16 O2 sat: 100% RA
B/P Right: 150/81 Left: 140/81
Height: 65" Weight: 152 BSA 1.78m2
General: WDWN in NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X] Sclera anicteric, OP Benign.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, No M/R/G
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2 Faint right femoral bruit
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:
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are 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 simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results in the operating
room at the time of the study.
POST BYPASS Normal biventricular systolic function. Mitral
regurgitation may be slightly worse but still mild. Thoracic
aorta appears intact. No other significant changees from
pre-bypass study.
[**2156-3-5**] 05:35AM BLOOD WBC-12.0* RBC-3.25* Hgb-9.4* Hct-28.7*
MCV-89 MCH-29.1 MCHC-32.9 RDW-14.5 Plt Ct-176
[**2156-3-4**] 05:04AM BLOOD WBC-12.3* RBC-2.71* Hgb-8.1* Hct-24.0*
MCV-88 MCH-29.9 MCHC-33.9 RDW-13.7 Plt Ct-164
[**2156-3-5**] 05:35AM BLOOD UreaN-20 Creat-1.0 Na-140 K-5.0
[**2156-3-4**] 05:04AM BLOOD Glucose-123* UreaN-21* Creat-1.0 Na-134
K-4.0 Cl-99 HCO3-32 AnGap-7*
[**2156-3-5**] 05:35AM BLOOD Mg-2.3
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2156-3-1**] where he underwent coronary artery
bypass x 4. Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition on titrated neo for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on no inotropic or vasopressor
support. The patient was transferred to the telemetry floor for
further recovery. Pacing wires were discontinued without
complication. The patient did have a small pneumothorax which
was followed by CXR. Chest tubes were eventually discontinued
without complication. Free water restriction was implemented
for transient hyponatremia. The patient received 1 unit of
packed red blood cells for a hematocrit of 24. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
POD 4 the patient was ambulating freely, the wound was healing
and pain was controlled with oral analgesics. POD#5 Mr.[**Known lastname 4401**]
was discharged home in good condition with appropriate follow up
instructions.
Medications on Admission:
Lisinopril 30mg QD
Plavix 75mg daily
Zetia 10mg QD
HCTZ 25mg QD M/W/F and 12.5mg Tue/[**Last Name (un) **]/Sat)
Clonidine 0.1mg (One tab in AM and 2 tabs in PM)
Lovastatin 40mg QD
Paxil 10mg QD
Aspirin 325mg QD
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for hiccups.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
coronary artery disease, s/p coronary artery bypass [**2156-3-1**]
PMH:
myocardial infarctionx2 [**2147**] and [**1-/2156**]
Hyperlipidemia
Hypertension
Hyperparathyroid s/p resection
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] [**2156-4-8**] 1pm [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) 19512**] [**Telephone/Fax (1) 62315**] in [**1-10**] weeks
Cardiologist Dr. [**Last Name (STitle) 8098**] in [**1-10**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2156-3-6**]
ICD9 Codes: 2761, 412, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3259
} | Medical Text: Admission Date: [**2146-8-18**] Discharge Date: [**2146-8-23**]
Date of Birth: [**2085-2-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**8-18**] CABG x 3 LIMA->LAD, SVG->Ramus, SVG-> RCA
History of Present Illness:
61 yo M with exertional SOB.
Past Medical History:
htn, hyperlipidemia, DM, MI, R knee arthritis, tonsillectomy,
appy
Social History:
works in sales
quit tobacco 20 years ago
[**8-5**] drinks per week
Family History:
Brother deceased from IMI at age 42
Physical Exam:
61 yo NAD
Lungs CTAB
RRR 3/6 SEM
Abdomen soft, non tender, obese
Extrem warm, no edema
bilateral varicosities
Pertinent Results:
[**2146-8-23**] 06:30AM BLOOD Hct-34.1*
[**2146-8-20**] 05:15AM BLOOD WBC-11.1* RBC-3.62* Hgb-11.9* Hct-34.4*
MCV-95 MCH-32.9* MCHC-34.7 RDW-14.2 Plt Ct-148*
[**2146-8-22**] 03:10PM BLOOD PT-14.7* INR(PT)-1.3*
[**2146-8-21**] 05:05AM BLOOD PT-12.5 INR(PT)-1.1
[**2146-8-20**] 05:15AM BLOOD Plt Ct-148*
[**2146-8-23**] 06:30AM BLOOD K-4.2
[**2146-8-21**] 05:05AM BLOOD UreaN-11 Creat-0.6 K-3.5
[**2146-8-20**] 05:15AM BLOOD Glucose-165* UreaN-8 Creat-0.7 Na-136
K-4.3 Cl-98 HCO3-33* AnGap-9
[**2146-8-17**] 01:00PM BLOOD ALT-20 AST-21 LD(LDH)-195 AlkPhos-88
Amylase-24 TotBili-0.9
Brief Hospital Course:
Mr. [**Known lastname 1458**] was taken to the operating room on [**2146-8-18**] where he
underwent a CABG x 3. He was transferred to the ICU in ciritcal
but stable condition on propofol and insulin. He was extubated
later that same day. He was transferred to the floor on POD #1.
He was started on plavix for poor distal targets. He had atrial
fibrillation for which he was started on amiodarone and
coumadin. He converted to normal sinus rhythm. He was ready for
discharge [**Last Name (un) **] on POD # 5.
Medications on Admission:
januvia, metformin, lopressor, lipitor, zetia, niacin, asa, vit
c, MVI, glucosamine
Discharge Medications:
1. JANUVIA 100 mg Tablet Sig: One (1) Tablet PO daily ().
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] x 4 days then 400 mg daily x 1 week, then 200
mg daily ongoing.
Disp:*60 Tablet(s)* Refills:*0*
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD
HTN
Hyperlipidemia
DM
MI
Right knee arthritis
tonsillectomy
appy
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Completed by:[**2146-8-23**]
ICD9 Codes: 4280, 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3260
} | Medical Text: Admission Date: [**2176-6-28**] Discharge Date: [**2176-7-5**]
Date of Birth: [**2116-8-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hypoxia, pulmonary HTN
Major Surgical or Invasive Procedure:
right heart catheterization
Swan Ganz catheter placement
History of Present Illness:
59 yo F with PMH cirrhosis and tobacco admitted at OSH on [**6-25**]
with progressive dyspnea on exertion. She initially noticed
developing DOE on long walks about 1 month PTA, shortly after
quitting cigarettes. This progressed over the following weeks
until she became winded even while walking to the bathroom. She
also developed a mild cough productive of white frothy sputum as
well as a sensation of lightheadedness when extremely dyspneic.
She denies LOC, fevers, chills, sweats, chest pain, hemoptysis,
dyspnea at rest, orthopnea, platypnea, or PND.
On admission to OSH, she was afebrile with RR 26 and breathing
94% on room air. Inital ABG was notable for pH 7.58/pCO2
23.4/pO2 54/HCO3 21 on 2L of supplemental oxygen. She was
treated with albuterol and ipratropium nebs and 4L O2. Work-up
at the OSH included an elevated d-dimer, a V/Q scan that was low
probability for PE, a LE US negative for DVT, a CT-angiogram
that was negative for PE with incidental finding of RUL
infiltrates, and TTE which revealed severe pulmonary
hypertension with mild R heart dysfunction and TR. The patient
was started on levofloxacin and was weaned 3L supplemental
oxygen via NC. Follow up high-res chest CT showed progressive
ground glass infiltrates in upper lobes bilaterally. She reports
improvement of her dyspnea but continued cough with green sputum
production throughout the hospitalization. She was transferred
to [**Hospital1 18**] for further evaluation and pulmonary consultation.
Past Medical History:
chronic venous insufficiency
cirrhosis, admitted for hematemesis ~6 yrs ago
uterine fibroid with high grade dysplasia, recently referred to
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] at [**Hospital1 18**]
LLE cellulitis several months ago, treated with IV abx as outpt
Social History:
Used to work placing wrappers on crayons, now unemployed after
company shut down last year. Divorced with 3 children who live
nearby and are very supportive. Tobacco use 60 pack yrs, quit
about 1 mo ago. Heavy EtOH use (~[**6-28**] drinks daily x 35 yrs),
recently quit with help from family, no sx of withdrawal. Only
alcohol use in last month is [**11-21**] beer 2 wks ago. Occasional
marijuana use, no cocaine or IVDU.
Family History:
CAD, asthma. No known h/o pulmonary hypertension or
rheumatological diseases.
Physical Exam:
T 97.5 HR 92 BP 120/88 RR 16 SAO2 95%@3L
Gen: pleasant, conversant with hoarse voice, in no acute
distress
HEENT: PERRLA, sclerae anicteric, MMM, 1x1 mm white lesion on
soft palate L of midline
Neck: supple, no JVD
Chest: breathing comfortably, moves air well, diffuse dry
crackles bilaterally
Cor: RRR, +RV heave, prominent S2, +S4, no S3, no murmurs
appreciated
Abd: +BS, soft, NT, ND, no HSM or masses appreciated, no
shifting dullness
Extr: compression stockings in place, pitting edema on [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]>L,
non-tender, no clubbing or cyanosis
Skin: varicosities and telangectasias, no spider angiomata on
face/chest, no skin thickening on hands or face
Neuro: alert and fully oriented, CN II-XII grossly intact,
muscle strength and light touch sensation normal in all limbs,
no tremor or asterixis
Pertinent Results:
[**2176-6-29**] 09:00AM BLOOD WBC-6.3 RBC-4.51 Hgb-15.6 Hct-45.9
MCV-102* MCH-34.6* MCHC-34.0 RDW-14.5 Plt Ct-114*
[**2176-6-29**] 09:00AM BLOOD Neuts-57.8 Lymphs-30.3 Monos-5.8 Eos-5.5*
Baso-0.6
[**2176-6-29**] 09:00AM BLOOD PT-17.6* PTT-41.1* INR(PT)-1.6*
[**2176-6-29**] 09:00AM BLOOD Glucose-87 UreaN-14 Creat-0.9 Na-137
K-4.1 Cl-102 HCO3-28 AnGap-11
[**2176-6-29**] 09:00AM BLOOD ALT-23 AST-44* LD(LDH)-315* CK(CPK)-44
AlkPhos-123* TotBili-1.5
[**2176-6-29**] 09:00AM BLOOD Albumin-2.8* Calcium-9.4 Phos-3.6 Mg-1.7
[**2176-6-28**] 08:10PM BLOOD Type-ART pO2-80* pCO2-30* pH-7.53*
calTCO2-26 Base XS-2
[**2176-6-29**] 05:15PM BLOOD Type-ART pO2-60* pCO2-30* pH-7.55*
calTCO2-27 Base XS-4 Intubat-NOT INTUBA
[**2176-6-29**] 09:00AM BLOOD HIV Ab-NEGATIVE
.
EKG [**2176-6-28**]
Sinus rhythm. Right axis deviation. Non-specific ST segment
depressions in
leads V5-V6 accompanied by low amplitude T waves in these leads.
T wave
inversions in leads III and aVF possibly related to right axis
deviation.
.
CARDIAC CATH [**2176-7-1**]
COMMENTS:
1. A swan was placed using the right internal jugular vein.
Resting hemodynamics revealed severely elevated right-sided
pressures with a RVSP of 90 mm Hg and PASP of 95 mm Hg with a
mean of 58 mmHg. There was also evidence of left ventricular
diastolic dysfunction with an elevated wedge pressure of 16 mm
Hg.
2. Coronary angiography was deferred.
3. Cardiac output is reduced at 3.4 l/min with an index of 1.8
l/min/m2.
FINAL DIAGNOSIS:
1. Moderate systolic and diastolic ventricular dysfunction.
2. Severe primary pulmonary hypertension.
.
CT CHEST W/O CONTRAST [**2176-7-3**]
IMPRESSION:
-No evidence of interstitial fibrosis.
-Ground-glass opacity in the upper lobes has improved from CXR
of four days ago, consistent with an acute process. Given the
rapid improvement, differential diagnoses include infection,
asymmetrical pulmonary edema, and, in the appropriate clinical
setting, pulmonary hemorrhage.
-Enlarged main pulmonary arteries in keeping with the patient's
known pulmonary hypertension.
-Coronary calcifications.
-Shrunken liver associated with mild splenomegaly.
.
ABDOMEN U.S. (COMPLETE STUDY) [**2176-7-3**]
IMPRESSION: Normal abdominal ultrasound with normal liver
Doppler study.
.
ECHO [**2176-7-3**]
IMPRESSION: Small secundum atrial septal defect with
right-to-left flow at rest and with maneuvers. Right ventricular
cavity enlargement with severe free wall hypokinesis. Moderate
pulmonary artery systolic hypertension. Normal left ventricular
cavity size and globa/regional systolic function.
CLINICAL IMPLICATIONS:
Based on [**2175**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
Pulmonary hypertension: Diagnosed by TTE at [**Hospital3 417**]
Hospital, where chest CT showed no evidence of PE, only mild
interstitial lung opacities R>L. Upon transfer to [**Hospital1 18**], she was
clinically stable, satting in the mid 90s% on 3-4L supplemental
O2 by nasal cannula. Pulmonology and hepatology were consulted.
Testing for secondary causes of pulmonary hypertension included
HIV, which was negative, scleroderma, which was weakly positive
(see below), pulmonary function tests for COPD, which did not
show any significant obstructive disease, and doppler abdominal
ultrasound, which showed normal portal venous flow, making
portopulmonary HTN unlikely. She underwent right heart
catheterization with Swan-Ganz cath placement on hospital day#3,
which confirmed elevated pulmonary artery pressures (PASP 98,
mean 58). Following this, she was transferred to the MICU with a
PA catheter for a monitored two-day sildenafil trial, which
showed minimal response in PAP but more impressive symptomatic
response in her exertional dyspnea and oxygen requirement.
Bubble echocardiagraphy demonstrated right to left interatrial
flow at rest and with maneuvers, c/w Eisenmanger's syndrome
through an apparent secundum ASD, thus implicating congenital
heart disease as the most likely etiology of her pulm HTN. After
transfer to the floor, she was weaned off supplemental O2 and
maintained O2 sats of 94-5% on room air at rest and 90-2% on
room air with ambulation. Given this improved performance, she
was discharged to home without supplemental oxygen for
outpatient follow-up at the [**Hospital1 18**] Pulmonary clinic.
.
Cirrhosis: She presented with elevated LFTs, coags, low albumin,
and a nodular liver on imaging, all consistent with cirrhosis.
Hepatology was consulted, and testing for other causes of liver
disease besides past alcohol use included hepatitis A, which was
positive likely from prior infection, hepatitis B, which showed
no evidence of prior exposure, and hepatitis C, which was
positive with a viral load of 28,500. Other tests recommended by
Hepatology included [**Doctor First Name **], soluble liver Ag, and ANCA, which were
negative, and anti-smooth muscle antibodies, Scl-70, and ACE,
which were mildly positive. She also had elevations of IgG,IgM,
and IgA. In the setting of HCV, these elevations of Igs and
auto-Abs could suggest mixed cryoglobulinemia, although further
evaluation and HCV subtyping was not pursued during this
admission. Per Hepatology, she is not currently a good candidate
for interferon treatment given its toxicity and the severity of
her lung disease. She will follow-up as an outpatient at the
[**Hospital 18**] [**Hospital 3585**] clinic.
.
Interstitial lung opacities: In addition to DOE, she presented
with cough productive of white followed by green sputum.
Consecutive CTs at [**Hospital3 417**] Hospital revealed progressing
ground glass opacities bilaterally. Opacities were considered
most likely part of an infectious process such as atypical
pneumonia, and she was started empirically on a week-long course
of levofloxacin. Her sputum production improved over this time,
and CT at [**Hospital1 18**] showed interval improvement of the opacities.
Sputum and urinary testing did not show any evidence of
bacterial or legionella infection. She remained afebrile with a
normal white count through her hospitalization at [**Hospital1 18**].
.
Oropharyngeal lesions: Initial oropharyngeal exam revealed
non-painful, non-tender, white lesions on the soft palate that
did not scrape off. These lesions spread over several days
across her oral mucosa, and then had nearly resolved by the time
of discharge. Transient oropharyngeal petechiae were also noted.
She was completely asymptomatic throughout, and these lesions
were thought most likely due to a viral syndrome.
.
Thrombocytopenia: Platelet counts during her hospitalization at
[**Hospital1 18**] were low but stable, ranging from 94 to 115. This was
attributed largely to her lung disease (splenomegaly,
thrombopoietin, etc), with possible contribution from a viral
syndrome. No evidence of HIT was observed while on prophylactic
heparin.
.
Reflux: She experienced several episodes of reflux that were
treated with tums and a couple doses of ranitidine. Ranitidine
was not continued at discharge given her thrombocytopenia.
.
Vaginal spotting: She reported occasional vaginal spotting
during this admission, secondary to her known cervical HGSIL.
She is scheduled to follow up in [**Hospital 74214**] clinic as
an outpatient.
Medications on Admission:
Meds at home:
Lasix
Meds on transfer:
albuterol nebs, ipratropium nebs, levofloxacin 500 qd, heparin
SC, tylenol, colace
Discharge Medications:
1. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed for dyspnea.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
primary pulmonary hypertension
chronic hepatitis C with cirrhosis
community-acquired pneumonia
Secondary diagnoses:
chronic venous insufficiency
cervical high grade squamous intraepithelial lesion
Discharge Condition:
blood pressure and breathing stable, eating, walking, pain well
controlled
Discharge Instructions:
You have been diagnosed with pulmonary hypertension, hepatitis C
virus, and pneumonia.
You have been started on sildenafil for treatment for your
pulmonary hypertension. You have also been started on an
inhaler, which you may use as needed every 6 hours for your
breathing.
We have also stopped your Lasix water pill. Please do not take
this medication until you are instructed by your doctors.
Please take all medications as prescribed.
You should have an echocardiogram of your heart performed in 1
months time. You need to call ([**Telephone/Fax (1) 19380**] to schedule an
appointment in ~ 1 month.
If you experience worsening shortness of breath, chest pain,
cough, lightheadedness, or any other alarming symptoms, please
contact your primary care physician or go to your local
emergency room.
Followup Instructions:
You have been scheduled to see your gynecologist-oncologist, Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 1022**], on [**Name (STitle) 16337**], [**2176-7-11**] at 8am. You may contact the
office at [**Telephone/Fax (1) 7614**].
You have been scheduled to see your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 20426**] on [**7-15**] at 9:45am.
You have been scheduled to see a pulmonary hypertension
specialist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at the [**Hospital Ward Name 23**] Clinical Center at
[**Hospital1 **], [**Hospital Ward Name 516**], on Wednesday, [**7-24**],
at 10am. Please arrive at 9:30am for breathing tests. You may
contact the office at ([**Telephone/Fax (1) 513**].
You have been scheduled to see a liver specialist, Dr. [**Last Name (STitle) **],
at [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 16337**], [**8-22**], 9:30am. The
liver center is located at [**Last Name (NamePattern1) 439**], [**Location (un) 86**], [**Hospital Unit Name 3269**], [**Location (un) 858**]. You may contact the office at ([**Telephone/Fax (1) 16686**].
Please call ([**Telephone/Fax (1) 19380**] to schedule an appointment for a
repeat echocardiogram of your heart in ~1 month.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2176-7-9**]
ICD9 Codes: 4280, 486, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3261
} | Medical Text: Admission Date: [**2102-3-14**] Discharge Date: [**2102-3-21**]
Date of Birth: [**2049-1-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Problems with speech
Right sided clumsiness
Major Surgical or Invasive Procedure:
IR guided PICC
History of Present Illness:
The pt is a 53 year-old right-handed man with a PMH of afib off
coumadin, HTN, HLD, DM and EtOH use who presented to the ED with
difficulty with his speech and clumsiness.
He states that he stopped coumadin several months ago as he ran
out. He did not pursue a refill. This morning he woke in his
USOH. He watched TV in the morning and noticed intermittent
episodes of problems with his vision on the R side. It was not
complete visual loss and he is unable to describe if it was a
portion of vision missing vs blurriness. This resolved, however
around 3 pm he had abrupt onset difficulty with his speech. He
states the he was barely able to speak but was clear about what
he wanted to say. He also noticed that his R hand was very
clumsy. He denied numbness or focal weakness however. He waited
for several hours and went to the grocery store. He then called
his recently separated wife around 7 pm. She noticed that he
speech was non-fluent with very limited phrases and was
concerned. She thought he had either consumed EtOH or "was
sick". She picked him up and brought him to the ED.
Past Medical History:
- DM
- HTN
- HLD
- CAD
- afib off coumadin
Social History:
-currently disabilty, former [**Company 2318**] driver
-EtOh: 6-8 beers per night and "hard Alcohol" (unspecified
amount, no hx of DT's, sz or withdrawal)
-tobacco:
-drugs: denies
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals: T: 99.2 P: 82 R: 16 BP: 132/80 SaO2: 99% on RA BS 258
NIH SS: 3
1a. Level of Consciousness: 0
1b. LOC questions: 0
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 0
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 1
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb ataxia: 0
8. Sensory: 0
9. Best language: 1
10. Dysarthria: 0
11. Extinction and inattention: 0
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Pansystolic murmur in the mitral area
Abdomen: Hepatosplenomegaly with ascites.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Pulses: all peripheral pulses present
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive. Language is non-
fluent with frequent pauses. [**3-19**] words sentences. Repetition is
almost intact "No ifs ands and buts". Intact comprehension.
Normal prosody. There intermittent paraphasic errors
("captus").
Pt. was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was minimally dysarthric. Able
to
follow both midline and appendicular commands. The pt. had good
knowledge of current events. There was no evidence of apraxia or
neglect.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally, fundi
normal
III,IV,V: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: R NLF flattening
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**4-18**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone; no asterixis or myoclonus. + R
pronator drift.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 5 5 5
R 5 5 5 5 5 5
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0-------------- Flexor
R 0-------------- Flexor
-Sensory: No deficits to light touch. No extinction to DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Pertinent Results:
TTE from [**12-18**]
The left atrium is normal in size. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-20mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. There is severe
global left ventricular hypokinesis (LVEF = [**9-28**] %). A left
ventricular mass/thrombus cannot be excluded. Transmitral
Doppler and tissue velocity imaging are consistent with Grade
III/IV (severe) LV diastolic dysfunction. The right ventricular
cavity is mildly dilated with depressed free wall contractility.
There is abnormal diastolic septal motion/position consistent
with right ventricular volume overload. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
to moderate ([**12-16**]+) mitral regurgitation is seen. Moderate to
severe [3+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Severely depressed left ventricular systolic and
diastolic dysfunction. Depressed right ventricular function.
Mild to moderate mitral regurgitation. Moderate to severe
tricuspid regurgitation. Cannot exclude left ventricular apical
thrombus.
[**2102-3-14**] CThead/CTA - prelim read
Stroke in the left MCA superior division territory.Left
fronto-temporal hypodensity with increased MTT, decreased blood
flow. No cut off seen on vessels.
Brief Hospital Course:
2D-ECHOCARDIOGRAM performed on [**2102-3-15**] demonstrated:
The left atrium is normal in size. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-20mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. There is severe
global left ventricular hypokinesis (LVEF = [**9-28**] %). A left
ventricular mass/thrombus cannot be excluded. Transmitral
Doppler and tissue velocity imaging are consistent with Grade
III/IV (severe) LV diastolic dysfunction. The right ventricular
cavity is mildly dilated with depressed free wall contractility.
There is abnormal diastolic septal motion/position consistent
with right ventricular volume overload. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
to moderate ([**12-16**]+) mitral regurgitation is seen. Moderate to
severe [3+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Severely depressed left ventricular systolic and
diastolic dysfunction. Depressed right ventricular function.
Mild to moderate mitral regurgitation. Moderate to severe
tricuspid regurgitation. Cannot exclude left ventricular apical
thrombus.
[**2102-3-14**] CTA head: No acute intracranial process with no abnormal
enhancement, infarction or hemorrhage.
#. CAD: Pt has h/o CAD per records. He had a cath sometime in
the past at [**Hospital1 2177**] which showed 90% LAD lesion but not stented.
Started coreg for BP control as well as captopril. Continued ASA
81. Held statin in setting of transaminitis but may consider
starting as o/p if liver function tests wnl.
#. Pump: Pt has severe systolic and diastolic CHF and
cardiomyopathy with LVEF of 10. The cardiomyopathy is likely
from CAD and alcohol use. Initially, pt seemed volume overloaded
and at that point on his starling curve where is not able to
mainten enough cardiac output. On lasixc gtt patient was
diuresed. He then was put on a PO dose of lasix for maintenance
once he was euvolemic. He was started on an ace inhibitor and
coreg. He was continued on asa. Statin was held as below. He
will discuss with his cardiologist whether he may benefit from
an AICD if on follow up TTE's he continues to have low EF.
Coreg, lisinopril, and spironolactone were initiated as well.
#LV thrombus: Pt has sever global hypokinesis. He ran out of
coumadin a few months back and has not been taking it. Likely
source of embolic stroke. Was placed on heparin gtt and then
bridged onto coumadin. INR was not therapeutic prior to
discharge so he was discharged on lovenox with coumadin. He will
follow up with Dr. [**Last Name (STitle) 5456**] for INR checks in 2 days.
#Elevated liver enzymes: Pt had acute elevation of AST, ALT (to
1000s range), AP, LDH and Tbili. Liver US didnt show e/o
cirrhosis or portal vein thrombosis. Denied any h/o recent ETOH
binge, mushroom consumption, herbal supplements. No past h/o
viral hepatitis. No h/o acetaminophen overdose. The enzyme
pattern was concerning for shock liver in the setting of poor
forward flow from his cardiomyopathy. There was also concern for
viral hepatitis. Viral serologies were negative. Transaminitis
trended down over course of his stay with diuresis/treatment of
CHF.
# DM2: Uncontrolled with A1C 8.2%. Monitored with FSBS. Given
20units lantus per his home regimen (per patient) plus ISS.
[**Last Name (un) **] was consulted and titrated his diabetic regimen further.
Will likely need further titration of diabetic regimen as
outpatient as was uncontrolled pre A1C.
# Elevated Cr: 1.3 on admission from 0.8 baseline. Thought
likely from poor perfusion. Doesnt seem dehydrated. Improved to
baseline with diuresis.
# Alcohol abuse: Initially had CIWA scale. Never had signs of
withdrawal and this was eventually d/c'd. Social work was
consulted and worked with the patient. He understands the
dangers of continuing to drink and has said he will not drink in
the future.
# Code: full
Medications on Admission:
None - the medications provided in the HPI were not what he was
taking
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Outpatient Lab Work
Please check INR/Coumadin level on Thursday [**3-23**] at Dr. [**Name (NI) 52848**] office. Results to Dr. [**Last Name (STitle) 5456**] at [**Telephone/Fax (1) 5457**]
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous twice a day for 2 days.
Disp:*4 doses* Refills:*2*
7. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day:
Check coumadin level on [**2102-3-23**]. .
Disp:*90 Tablet(s)* Refills:*2*
8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime.
Disp:*1 bottle* Refills:*2*
11. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale units Subcutaneous four times a day: Please check Blood
sugar 4 times a day and take Lispro right before each meal. .
Disp:*1 bottle* Refills:*2*
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
left superior MCA stroke
Left Ventricular thrombus
severe acute on chronic systolic and diastolic congestive Heart
Failure with Ejection Fraction 10%
atrial fibrillation
Secondary diagnoses:
uncontrolled type 2 diabetes
Hypertension
Discharge Condition:
The patient was afebrile and hemodynamically stable prior to
discharge.
Discharge Instructions:
You were admitted with a stroke which affected your speech and
gave some mild weakness in your right arm. Your symptoms have
improved.
.
The stroke was likely caused from a clot in your heart. You will
need to remain on anticoagulation with warfarin (coumadin) and
have your lab test called INR monitored for how thin your blood
is. Do not stop taking your coumadin or you risk having another
stroke. Your primary care doctor, Dr. [**Last Name (STitle) 5456**], [**First Name3 (LF) **] check your
INR test 2-3 days after you leave the hospital and help you
change your coumadin dose appropriately. You should also take
aspirin daily.
You have congestive heart failure. This can make you become
fluid overloaded. You must maintain a low salt diet (less than 2
grams per day) and restrict your fluid intake to 1.2 liters per
day. You have been started on a medication called spironolactone
and your furosemide (lasix) was continued to help keep the fluid
off. You were also started on Lisinopril to keep your blood
pressure low and carvedilol to help your heart pump better. Your
new cardiologist, Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] follow your heart function and
possibly put in a defibrillator to make sure you do not have a
cardiac arrest in the future. You can discuss this with him at
your follow up appointment. You will also be seen in the heart
failure clinic here at [**Hospital1 18**] to help adjust your medicines.
.
You were seen by the [**Hospital **] clinic to help with improving your
blood sugars. This will help prevent another stroke and possible
kidney failure. Take your long acting insulin at night and take
the short acting insulin before each meal according to your
blood sugar level. A sliding scale for the short acting insulin
was given to you on discharge.
Medication Changes:
START: Warfarin
START: Lisinopril
START: Carvedilol
START: Aspirin
START: Spironolactone
CONTINUE: Vitamin B6 and B12 as prescribed by Dr. [**Last Name (STitle) 5456**]
CONTINUE: Lantus insulin at bedtime 20 units
CONTINUE: Humalog insulin before meals as per sliding scale.
Please check your blood sugar before each meal and at bedtime.
You should measure your weight daily. If you gain more than 3
pounds in a week or less, please call Dr. [**Last Name (STitle) 5456**]. Please follow
a low sodium diet to prevent the accumulation of fluid.
Information was given to you regarding a low sodium diet, daily
wieghts and symptoms to watch for on discharge.
.
Please call Dr. [**Last Name (STitle) 5456**] if you notice any trouble breathing,
cough, lying flat at night, swelling in your ankles, chest pain,
nausea or any other concerning symptoms.
Followup Instructions:
Neurology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 2532**] Date/Time: Friday [**4-21**]
at 2:00pm. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]. [**Location (un) **], [**Location (un) 86**].
.
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 52849**] Date/Time: Monday [**4-24**] at
3:15pm. [**Location (un) 10877**], [**Street Address(1) **].
.
Primary Care:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5456**] Phone: ([**Telephone/Fax (1) 32099**] Thursday [**3-23**] at
2:30pm. Please have your INR level checked and coumadin dosed
appropriately.
.
Diabetes:
Dr. [**Last Name (STitle) **] Phone: [**Telephone/Fax (1) 12068**] Date/time: Office will call you
with an appt in the next 2-3 weeks. If you do not hear from Dr. [**Name (NI) 52850**] office in the next week, please call [**0-0-**] to
schedule an appointment with any of the providers.
.
Congestive Heart Failure Clinic:
Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**MD Number(3) 1240**]: [**Telephone/Fax (1) 62**]
Date/Time: [**4-10**] at 2:30pm. [**Hospital Ward Name 23**] clinical Center, [**Location (un) **]. [**Hospital Ward Name 516**], [**Location (un) **].
Completed by:[**2102-3-22**]
ICD9 Codes: 5849, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3262
} | Medical Text: Admission Date: [**2189-6-20**] Discharge Date: [**2189-6-24**]
Date of Birth: [**2145-10-16**] Sex: F
Service: MEDICINE
Allergies:
Seroquel / Codeine / Sulfa(Sulfonamide Antibiotics) / latex
Attending:[**First Name3 (LF) 8928**]
Chief Complaint:
Dyspnea, Right upper quadrant pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43F with h/o COPD, HepC, DM, and schizoaffective disorder
presents today with difficulty breathing and right upper
abdominal pain. She was recently discharged after a 5 days stay
at [**Hospital 189**] Hospital with a RUL pneumonia after presenting with
hemoptysis, treated with unknown antibiotics, PPD negative. She
returned to her psych facility yesterday, but was brought to [**Hospital1 **]
today with c/o RUQ/R flank pain and SOB and she was found to
have SpO2 87-90% on RA.. In addition to the SOB, she has chest
tenderness over right chest wall and has been febrile. She
denies characteristics of aspiration, does not have HIV to her
knowledge. She reports ongoing RUQ pain, possibily associated
with food. The patient says the pain goes to her right flank.
She has previously had a cholecystectomy. She denies dysuria,
but is having urgency.
In the ED, initial VS: 101.3 86 107/73 95% 6L NC. She denied SI
but was assigned a 1:1. SBPs were in the 90s (baseline per pt)
so given 1L NS. Labs notable for WBC 11.4 with 73N, ALT 49, AST
41, AP 145, Tbili 0.4, lipase 17, HCO3 32, TroT <.01 x1, CK-MB
1, d-dimer 2810, lactate 1.3, UA negative, ABG 7.36/61/117/36
after she was started on BiPAP. CXR showed patchy consolidation
in the mid/lower R lung c/f pneumonia, low lung volumes,
bibasilar atelectasis. CTA chest done for elevated d-dimer,
showed no PE but did reveal cavitating hypodense pneumonia in
the right lower lobe, concerning for necrotizing pneumonia,
prominent axillary, mediastinal, hilar and inguinal lymph nodes,
and prominent CBD at 12mm. Blood cultures were drawn. She was
given Vancomycin 1gram, Toradol 30mg, Cefepime 2g, Ativan 2mg IV
x1, Tylenol 1g, Methylpred 125mg, 2 ipratropium nebs, 1
albuterol neb x1. VS at transfer: 85/52 60 91% on BiPAP 12/6 80%
FiO2.
On arrival to the MICU, she reports breathing is much improved
since initiating BiPAP, denies CP, N/V, R flank/RUQ pain
resolved. Denies SI or HI. Per report from [**Hospital1 **], SBP in low
100s at baseline.
Past Medical History:
COPD/asthma
HepC
NIDDM, diet-controlled
HL
h/o Grave's disease
Hypothyroidism
s/p CCY
s/p hysterectomy
h/o seizures
Schizoaffective disorder
h/o opioid dependence, Habit [**First Name9 (NamePattern2) **] [**Hospital1 189**] [**Telephone/Fax (1) 16205**]
Social History:
Former heroin use (last 4yrs ago), cocaine, MJ use. Single.
Family History:
Grandmother and aunt with DM.
Physical Exam:
Admission:
General: Alert, oriented x3, no acute distress, BiPAP in place
HEENT: Sclera anicteric, hemorrhagic blister on R lower lip,
EOMI, PERRL, extremely poor dentition
Neck: supple, JVP not seen, no LAD
CV: Distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: Crackles at R upper lung zones posteriorly, also focal
crackles in L mid lung zone, diminished air entry at bases B/L,
no wheezes, moderate air entry
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, liver non-palpable
GU: no foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities, answering questions appropriately
Discharge:
afebrile normotensive, no tachycardia, 16, 92% on 3L
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, hemorrhagic blister on R lower lip,
EOMI, PERRL, extremely poor dentition
Neck: supple, JVP not seen, no LAD
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: decreased breath sounds at the R base, also basilar
crackles on left, no wheezes
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, liver non-palpable
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, nonfocal exam, moving all extremities,
answering questions appropriately
Pertinent Results:
ADMISSION
[**2189-6-20**] 04:20PM BLOOD WBC-11.4* RBC-4.26 Hgb-12.6 Hct-38.7
MCV-91 MCH-29.7 MCHC-32.7 RDW-15.3 Plt Ct-422
[**2189-6-20**] 04:20PM BLOOD Neuts-73.2* Lymphs-19.8 Monos-5.1 Eos-1.3
Baso-0.6
[**2189-6-20**] 04:20PM BLOOD Glucose-101* UreaN-16 Creat-1.0 Na-137
K-4.1 Cl-92* HCO3-35* AnGap-14
[**2189-6-20**] 04:20PM BLOOD ALT-49* AST-41* CK(CPK)-112 AlkPhos-145*
TotBili-0.4
[**2189-6-20**] 04:20PM BLOOD Lipase-17
[**2189-6-20**] 04:20PM BLOOD CK-MB-1
[**2189-6-20**] 04:20PM BLOOD cTropnT-<0.01
[**2189-6-21**] 04:13AM BLOOD Calcium-8.1* Phos-4.5 Mg-2.3
[**2189-6-20**] 04:20PM BLOOD D-Dimer-2810*
[**2189-6-20**] 06:57PM BLOOD Type-ART Temp-39.0 PEEP-6 FiO2-100
pO2-117* pCO2-61* pH-7.36 calTCO2-36* Base XS-6 AADO2-539 REQ
O2-89 Vent-SPONTANEOU
[**2189-6-20**] 04:29PM BLOOD Lactate-1.3
DISCHARGE
[**2189-6-24**] 05:51AM BLOOD WBC-7.7 RBC-3.87* Hgb-11.6* Hct-35.3*
MCV-91 MCH-30.0 MCHC-32.9 RDW-15.6* Plt Ct-382
[**2189-6-24**] 05:51AM BLOOD Glucose-89 UreaN-13 Creat-0.8 Na-142
K-4.0 Cl-99 HCO3-35* AnGap-12
[**2189-6-21**] 04:13AM BLOOD ALT-49* AST-51* CK(CPK)-60 AlkPhos-112*
TotBili-0.4
[**2189-6-24**] 05:51AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.4
[**2189-6-21**] 06:25AM BLOOD Type-ART Temp-36.3 Rates-/13 Tidal V-615
PEEP-8 FiO2-80 pO2-71* pCO2-62* pH-7.33* calTCO2-34* Base XS-3
AADO2-441 REQ O2-75 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2189-6-20**] 10:58PM BLOOD Lactate-1.1
MICRO
GRAM STAIN (Final [**2189-6-21**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN
All blood cultures negative to date
CT C/A/P
1. Cavitating hypodense pneumonia in the right lower lobe,
concerning for
necrotizing pneumonia.
2. Prominent axillary, mediastinal, right hilar and inguinal
lymph nodes, some
of which may be reactive, but follow up is recommended after
treatment to
ensure resolution.
3. Prominent 12-mm common bile duct, which may be secondary to
cholecystectomy, but ampullary pathology cannot be excluded.
CXR
FINDINGS: AP upright portable chest radiograph obtained. Lung
volumes are
low. There is patchy consolidation in the right mid and lower
lung concerning
for pneumonia. Left basal opacity is most compatible with
atelectasis given
the associated volume loss. No pneumothorax. Heart size cannot
be assessed.
Bony structures are intact.
IMPRESSION: Patchy consolidation in the right mid to lower lung
concerning
for pneumonia. Low lung volumes with basilar atelectasis also
noted.
Brief Hospital Course:
43F with COPD/asthma, HCV, schizoaffective disorder who was
recently admitted to OSH with hemoptysis and treated for CAP,
now presenting with dyspnea, hypoxia, and RUQ pain and found to
have evidence of necrotizing pneumonia on chest imaging.
ACUTE
# Necrotizing pneumonia: Possible pathogens include anaerobes
given poor dentition, Strep. milleri, MRSA, Klebsiella,
Acinetobacter. Unknown what most recent antibiotic regimen was,
but given recent admission to [**Hospital6 204**] and
failure of oral antimicrobial regimen, the patient was treated
as a necrotizing healthcare associated pneumonia. No PE seen on
CTA. CHF seemed less likely given lack of known cardiac history
or evidence of volume overload though does raise concern with
furosemide on home med list. No isolated upper lobe cavitation
to suggest TB, PPD neg per report at OSH. She was started on
Clindamycin, Vancomycin, Cefepime. Sputum culture and blood
cultures sent but contaminated with upper airway flora. Placed
on standing bronchodilators but no empiric systemic steroids.
She was weaned off BiPAP and titrated to 4LNC. Transitioned to
Vancomycin and Zosyn. Will have received 3 days of IV
antibiotics on discharge, with resolution of fever, white count,
and improvement in oxygenation status and pain. She will need 3
more weeks of IV [**Last Name (LF) 112289**], [**First Name3 (LF) **] follow-up with her primary
care physician [**Last Name (NamePattern4) **] 2 weeks, then with pulmonolgy in about a month
(scheduling in process at time of discharge).
# Hypotension: SBPs seemed to be slightly below baseline in the
80s-90s with normal HR, not on beta blockade. Differential
diagnosis includes hypovolemia vs evolving sepsis. Cardiogenic
shock seemed less likely given warm extremities, no known h/o
CHF. She was fluid responsive and blood pressures stabilized.
She remained normotensive during the remainder of her hospital
stay.
# COPD: In the setting of worsening respiratory status on
presentation, she was continued on her home spiriva and given
albuterol nebs.
# Hepatitis C: LFTs mildly elevated. CBD dilated on CT. Will
need outpatient evaluation, probably by MRCP.
# Schizoaffective disorder: denied SI/HI at presentation,
appeared stable. Continued doxepin, citalopram, venlafaxine,
Zyprexa while in house.
CHRONIC
# Hypothyroidism: stable, continued levothyroxine.
.
# Hx of IVDA: Patient on methadone as outpatient. COntinued on
methadone 90 daily.
.
TRANSITIONAL
# Will need f/u with new PCP [**Last Name (NamePattern4) **] ~ 2wks
# WIll need 3 weeks of IV antibiotics
# Will need f/u regarding dilated common bile duct with MRCP
# Followed in [**Hospital 2514**] clinic
# Will need home O2
# Will need pulmonary follow-up in ~ 1month (will likely need
rpt CT for eval of Necrotizing PNA)
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Clonazepam 1 mg PO BID
2. Doxepin HCl 200 mg PO HS
3. Citalopram 15 mg PO DAILY
4. Venlafaxine XR 37.5 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Methadone 90 mg PO DAILY
8. Gabapentin 600 mg PO TID
9. Omeprazole 40 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Vitamin D [**2176**] UNIT PO DAILY
12. OLANZapine 10 mg PO HS
13. Azithromycin 500 mg PO Q24H
Discharge Medications:
1. Citalopram 15 mg PO DAILY
2. Clonazepam 1 mg PO BID
3. Doxepin HCl 200 mg PO HS
4. Ferrous Sulfate 325 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Methadone 90 mg PO DAILY
7. OLANZapine 10 mg PO HS
8. Omeprazole 40 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Venlafaxine XR 37.5 mg PO DAILY
11. Vitamin D [**2176**] UNIT PO DAILY
12. Docusate Sodium 100 mg PO BID
hold for loose stools
13. Gabapentin 600 mg PO TID
14. Furosemide 40 mg PO DAILY
15. Vancomycin 1000 mg IV Q 12H
D1=[**6-20**]
16. Senna 1 TAB PO BID
17. Polyethylene Glycol 17 g PO DAILY
18. Piperacillin-Tazobactam 4.5 g IV Q8H
19. Bisacodyl 10 mg PO ONCE Duration: 1 Doses
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
1. Hypoxia
2. Hypotension
3. Cavitary Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname **],
It was a pleasure taking care of you while you were here at
[**Hospital1 18**]. You were admitted because of worsened shortness of
breath, low oxygen saturation, and right sided chest pain, all
of which were attributed to a right sided pneumonia. You
initially required BiPAP and you were started on IV antibiotics.
We have been slowly weening your oxygen, now to 3L. You will
need 3 weeks of IV antibiotics at your rehab facility. You will
continue vancomycin and zosyn. We also will be giving you
senna, docusate, and miralax to improve your constipation. All
of your remaining medications should be continued.
Followup Instructions:
We are working on a follow up appointment for your
hospitalization in Pulmonary. It is recommended you be seen
within 1 week. The office will contact you at the facility with
the appointment information. If you have not heard within 2
business days please call the office at [**Telephone/Fax (1) 612**].
Please obtain a primary care physician. [**Name10 (NameIs) **] you are interested
in coming to [**Hospital1 18**], you can be seen in the [**Hospital3 **]
clinic. You can request to be seen by me, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 112290**] or
another provider. [**Name Initial (NameIs) **] [**Telephone/Fax (1) 2010**] to schedule an appointment
in ~2 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8931**]
ICD9 Codes: 5180, 4589, 2449, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3263
} | Medical Text: Admission Date: [**2170-5-12**] Discharge Date: [**2170-5-28**]
Date of Birth: [**2146-1-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Intubation
Right sided tunneled line
Removal of right sided tunneled line
History of Present Illness:
24 y/o female with long-standing history of EtOH abuse and
pancreatitis (drinks approximately 1 gallon of vodka per day),
who has been attempting to self detox, transferred from [**Hospital **]
Hospital, after found down at home.
It appears that her mother may have called 911. When EMS
arrived, her house was noted to be disordered with feces on
floor. She was felt to be intoxicated, but arousable. She
reported her last drink as 12 pm today. She denied other toxin
ingestions. Vitals were HR 160s, SBP 80s for EMS. An IO was
placed in the right tibia. There was also ? of black stools and
coffee ground emesis.
She was transferred to OSH [**Hospital **] Hospital, where she was
tachycardic to HR 130s. She also had dark emesis and dark stool.
Quantitative hcG < 2. Head/Cspine negative. IO attempted to be
removed, but unable to be done. Reportedly, the plastic part was
broken off, but the metal needle remained in the tibia. She was
given zofran and benzodiazepines. She received a dose of zosyn
3.375 mg. Labs were notable for low potassium, high Cr.
As no ICU beds were available, she was transferred to [**Hospital1 18**].
Here, she was tachycardic, but not hypotensive. She was easily
arousable, answering questions appropriately, stating she "felt
unwell."
Urine sample here with ? infection. Stox and Utox negative. Hct
here 28.6, down from [**Hospital1 **] Hct 44.8. This Hct drop was felt to
be inappropriately low for the degree of IVF she received (4L
IVF). This in combination with her reported dark stool and
emesis, led to guiac exam here, which showed guaiac positive
stool. She was started on protonix gtt. NGT deferred given low
suspicion for active bleeding. Labs here notable for mildly
elevated lactate, bandemia, and given concern for sepsis, she
received vancomycin and clindamycin.
Toxic shock syndrome was considered as a diagnosis. Pelvic exam
showed no CMT or adnexal tenderness. Rectal probe was placed.
She received reglan, ativan 2 mg x 2 doses, 1 gram tylenol, and
4L IVF in our ED.
EKG notable for sinus tachycardia without ischemic changes.
CXR without evidence for infiltrate.
Vitals on transfer: 101.9, HR 130, RR 24, BP 140/86, 100% 2L NC.
Mental status: arousable, sleepy/somnolent
Access: 18 G, 20 G, 22 G
On arrival to the MICU, patient's VS: 101.6, HR 133, BP 161/91,
RR 24, 100% 2L NC
Past Medical History:
- EtOH abuse
- pancreatitis
- [**Last Name (un) **]-Calve-Perthes disease
Social History:
extensive history of EtOH use and abuse. Denies illicit drugs.
Not sexually active. Mother is currently hospitalized for etoh
related issues.
Family History:
ETOH abuse in mother. otherwise non-contributory
Physical Exam:
Admission exam
Vitals: 101.6, 133, 161/91, 16, 100% 2L NC
General: sleepy/somnolent, arousable, no acute distress
HEENT: anicteric sclera, MMM, OP clear, PERRL
Neck: supple, JVP difficult to estimate given body habitus but
not felt to be elevated, no LAD
CV: tachycardic, Regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mildly distended, reports some discomfort upon
palpation of epigastric and RUQ region, bowel sounds present but
hypoactive, liver edge felt 1-2 cm below costal margin, no
rebound or guarding
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, PERRL, grossly normal sensation,
not cooperative with strength exam due to sleepy/somnolence, no
neck stiffness, 2+ reflexes bilaterally, gait deferred.
Skin: erythematous blanching rash on waist
Discharge exam
Vitals: Temp: 99.3 BP: 166/114 (112/84-180/110) 120 (74-120) 93%
RA
I/O: 1688/1900+
General: Alert and oriented in no acute distress, slightly
tremulous
HEENT: anicteric sclera, MMM, OP clear, PERRL
Neck: supple, JVP no elevated, no LAD
Chest Wall: right sided tunneled line with blood around the
insertion site
CV: Regular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, No wheezes, rales,
ronchi
Abdomen: NABS, mildly distended, no tenderness to palpation,
Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis, 1+
edema
Neuro: CNII-XII grossly intact, no nystagmus noted, PERRL,
intact EOM, grossly normal sensation, strength 5/5 bil,
Pertinent Results:
On Admission:
[**2170-5-12**] 01:30AM WBC-5.5 RBC-2.78* HGB-9.4* HCT-28.6* MCV-103*
MCH-33.8* MCHC-32.9 RDW-13.9
[**2170-5-12**] 01:30AM NEUTS-83* BANDS-9* LYMPHS-3* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2170-5-12**] 01:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2170-5-12**] 01:30AM GLUCOSE-188* UREA N-23* CREAT-2.6*
SODIUM-132* POTASSIUM-3.1* CHLORIDE-94* TOTAL CO2-13* ANION
GAP-28*
[**2170-5-12**] 01:30AM ALT(SGPT)-209* AST(SGOT)-930* LD(LDH)-663*
CK(CPK)-2465* ALK PHOS-84 TOT BILI-5.0* DIR BILI-4.1* INDIR
BIL-0.9
[**2170-5-12**] 01:30AM LIPASE-4680*
[**2170-5-12**] 01:30AM ALBUMIN-3.5 CALCIUM-6.0* PHOSPHATE-1.5*
MAGNESIUM-1.4* IRON-78
[**2170-5-12**] 01:30AM TRIGLYCER-627*
[**2170-5-12**] 01:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-5-12**] 01:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2170-5-12**] 01:05AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017
[**2170-5-12**] 01:05AM URINE BLOOD-LG NITRITE-NEG PROTEIN-300
GLUCOSE-70 KETONE-10 BILIRUBIN-SM UROBILNGN-2* PH-6.0 LEUK-TR
[**2170-5-12**] 01:05AM URINE RBC-1 WBC-47* BACTERIA-MANY YEAST-NONE
EPI-4 TRANS EPI-1
Trends:
[**2170-5-14**] 03:44AM BLOOD WBC-6.9 RBC-2.45* Hgb-8.3* Hct-26.6*
MCV-109* MCH-33.7* MCHC-31.0 RDW-15.0 Plt Ct-34*
[**2170-5-15**] 03:33AM BLOOD WBC-7.1 RBC-2.74* Hgb-8.8* Hct-28.3*
MCV-103* MCH-32.1* MCHC-31.1 RDW-17.8* Plt Ct-85*
[**2170-5-17**] 03:00AM BLOOD WBC-9.8 RBC-2.56* Hgb-8.2* Hct-26.4*
MCV-103* MCH-32.0 MCHC-31.0 RDW-18.2* Plt Ct-153
[**2170-5-18**] 01:25PM BLOOD WBC-11.5* RBC-2.69* Hgb-8.7* Hct-27.3*
MCV-102* MCH-32.6* MCHC-32.1 RDW-18.1* Plt Ct-175
[**2170-5-20**] 02:07AM BLOOD WBC-12.9* RBC-3.05* Hgb-9.6* Hct-30.0*
MCV-99* MCH-31.7 MCHC-32.1 RDW-18.5* Plt Ct-174
[**2170-5-12**] 08:12PM BLOOD Neuts-85* Bands-5 Lymphs-6* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2170-5-14**] 06:09PM BLOOD Neuts-80.7* Lymphs-9.3* Monos-5.9 Eos-3.5
Baso-0.5
[**2170-5-20**] 02:07AM BLOOD Neuts-77* Bands-1 Lymphs-8* Monos-13*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2170-5-21**] 04:01AM BLOOD Neuts-PND Lymphs-PND Monos-PND Eos-PND
Baso-PND
[**2170-5-12**] 01:15PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL
[**2170-5-19**] 04:19AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Target-1+
Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2170-5-18**] 04:35AM BLOOD PT-13.4* PTT-28.7 INR(PT)-1.2*
[**2170-5-19**] 03:30PM BLOOD Plt Ct-164
[**2170-5-15**] 03:33AM BLOOD Glucose-86 UreaN-44* Creat-5.8* Na-142
K-3.2* Cl-105 HCO3-16* AnGap-24*
[**2170-5-17**] 03:00AM BLOOD Glucose-77 UreaN-62* Creat-8.1* Na-141
K-3.4 Cl-106 HCO3-13* AnGap-25*
[**2170-5-18**] 04:35AM BLOOD Glucose-106* UreaN-37* Creat-5.3* Na-140
K-3.1* Cl-98 HCO3-21* AnGap-24*
[**2170-5-19**] 04:19AM BLOOD Glucose-130* UreaN-47* Creat-6.4* Na-143
K-3.2* Cl-102 HCO3-27 AnGap-17
[**2170-5-20**] 02:07AM BLOOD Glucose-98 UreaN-26* Creat-4.6* Na-138
K-3.6 Cl-97 HCO3-24 AnGap-21*
[**2170-5-14**] 06:09PM BLOOD Glucose-69* UreaN-44* Creat-5.7* Na-138
K-3.6 Cl-113* HCO3-13* AnGap-16
[**2170-5-14**] 09:56PM BLOOD Glucose-151* UreaN-43* Creat-5.7* Na-139
K-3.3 Cl-103 HCO3-17* AnGap-22*
[**2170-5-20**] 02:07AM BLOOD Glucose-98 UreaN-26* Creat-4.6* Na-138
K-3.6 Cl-97 HCO3-24 AnGap-21*
[**2170-5-20**] 03:05PM BLOOD Glucose-96 UreaN-31* Creat-5.1* Na-137
K-3.7 Cl-97 HCO3-24 AnGap-20
[**2170-5-14**] 03:44AM BLOOD ALT-317* AST-942* CK(CPK)-1158*
AlkPhos-93 TotBili-3.5*
[**2170-5-15**] 03:33AM BLOOD ALT-191* AST-310* LD(LDH)-453*
AlkPhos-115* TotBili-3.6*
[**2170-5-16**] 04:00AM BLOOD ALT-131* AST-118* LD(LDH)-421*
AlkPhos-126* TotBili-2.1*
[**2170-5-17**] 03:00AM BLOOD ALT-91* AST-67* LD(LDH)-426* AlkPhos-123*
TotBili-1.7*
[**2170-5-18**] 04:35AM BLOOD ALT-70* AST-50* AlkPhos-141* TotBili-1.7*
[**2170-5-19**] 04:19AM BLOOD ALT-58* AST-41* LD(LDH)-459* AlkPhos-129*
TotBili-1.2
[**2170-5-20**] 02:07AM BLOOD ALT-52* AST-50* AlkPhos-122* TotBili-1.5
[**2170-5-12**] 01:30AM BLOOD Lipase-4680*
[**2170-5-12**] 01:15PM BLOOD Lipase-1734*
[**2170-5-12**] 08:12PM BLOOD Lipase-1270*
[**2170-5-13**] 03:04AM BLOOD Lipase-1052*
[**2170-5-14**] 03:44AM BLOOD Lipase-390*
[**2170-5-18**] 01:25PM BLOOD Calcium-8.7 Phos-1.1* Mg-1.9
[**2170-5-19**] 04:19AM BLOOD Calcium-8.6 Phos-2.3* Mg-1.8
[**2170-5-19**] 03:30PM BLOOD Calcium-8.9 Phos-1.8* Mg-1.8
[**2170-5-20**] 02:07AM BLOOD Calcium-8.8 Phos-2.2* Mg-1.7
[**2170-5-20**] 03:05PM BLOOD Calcium-9.0 Phos-4.2# Mg-2.4
[**2170-5-12**] 01:30AM BLOOD calTIBC-200* Ferritn-1175* TRF-154*
[**2170-5-12**] 01:15PM BLOOD Ferritn-1531*
[**2170-5-12**] 01:30AM BLOOD Triglyc-627*
[**2170-5-12**] 08:12PM BLOOD Triglyc-771*
[**2170-5-13**] 03:04AM BLOOD Triglyc-704*
[**2170-5-14**] 03:44AM BLOOD Triglyc-269*
[**2170-5-12**] 06:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2170-5-12**] 08:12PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2170-5-12**] 08:12PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2170-5-12**] 08:12PM BLOOD IgG-626*
[**2170-5-12**] 08:12PM BLOOD HIV Ab-NEGATIVE
[**2170-5-15**] 06:47AM BLOOD Vanco-26.9*
[**2170-5-12**] 01:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2170-5-17**] 06:18PM BLOOD Type-CENTRAL VE Temp-38.3 Rates-26/ Tidal
V-400 PEEP-5 FiO2-40 pO2-47* pCO2-32* pH-7.46* calTCO2-23 Base
XS-0 Intubat-INTUBATED
[**2170-5-18**] 06:06PM BLOOD Type-[**Last Name (un) **] Temp-37.7 Rates-/20 Tidal V-350
PEEP-0 FiO2-40 pO2-52* pCO2-46* pH-7.42 calTCO2-31* Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
[**2170-5-20**] 02:22AM BLOOD Type-CENTRAL VE Temp-37.2 pO2-39* pCO2-35
pH-7.49* calTCO2-27 Base XS-3
[**2170-5-20**] 03:10PM BLOOD Type-CENTRAL VE Temp-38.1 Rates-/26
FiO2-40 O2 Flow-12 pO2-52* pCO2-43 pH-7.42 calTCO2-29 Base XS-2
Intubat-NOT INTUBA
[**2170-5-13**] 03:18PM BLOOD Lactate-1.0
[**2170-5-15**] 07:20AM BLOOD Lactate-1.0
[**2170-5-16**] 06:03AM BLOOD Lactate-0.5
[**2170-5-16**] 04:40PM BLOOD Lactate-0.6
[**2170-5-13**] 03:18PM BLOOD freeCa-1.12
[**2170-5-14**] 01:35PM BLOOD freeCa-1.22
[**2170-5-18**] 08:44AM BLOOD freeCa-1.08*
[**2170-5-16**] 05:07PM URINE RBC-18* WBC->182* Bacteri-FEW Yeast-NONE
Epi-31 TransE-1
[**2170-5-18**] 05:45AM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-MANY Epi-7 TransE-1
[**2170-5-20**] 10:10AM URINE RBC-32* WBC-61* Bacteri-FEW Yeast-NONE
Epi-2 TransE-2 RenalEp-<1
MICROBIOLOGY
[**2170-5-20**] URINE URINE CULTURE-PENDING INPATIENT
[**2170-5-20**] STOOL C. difficile DNA amplification
assay-FINAL INPATIENT
[**2170-5-18**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2170-5-18**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST} INPATIENT
[**2170-5-18**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2170-5-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2170-5-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2170-5-16**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2170-5-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2170-5-13**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2170-5-12**] IMMUNOLOGY HCV VIRAL LOAD-FINAL INPATIENT
[**2170-5-12**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2170-5-12**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
INPATIENT
[**2170-5-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2170-5-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
RUQ US
IMPRESSION:
1. Echogenic liver consistent with fatty deposition. Other forms
of liver
disease including significant hepatic cirrhosis/fibrosis cannot
be excluded on this examination.
2. Splenomegaly.
3. Normal appearance of the gallbladder. No free fluid.
4. Normal ultrasound appearance of the kidneys.
.
CXR
FINDINGS: Single portable AP chest radiograph was obtained. Low
lung volumes accentuate interstitial markings and the pulmonary
vasculature. Despite these limitations, the lungs are clear. No
nodule, consolidation, effusion, or pneumothorax is present. The
heart and mediastinal contours are normal.
IMPRESSION: Low lung volumes.
Imaging
TIB/FIB (AP & LAT) RIGHT PORT Study Date of [**2170-5-12**] 1:20 AM
IMPRESSION: No evidence of osteomyelitis surrounding retained
intraosseous
needle.
ABDOMEN U.S. (COMPLETE STUDY) PORT Study Date of [**2170-5-12**] 11:14
AM
IMPRESSION:
1. Echogenic liver consistent with fatty deposition. Other forms
of liver
disease including significant hepatic cirrhosis/fibrosis cannot
be excluded on this examination.
2. Splenomegaly.
3. Normal appearance of the gallbladder. No free fluid.
4. Normal ultrasound appearance of the kidneys.
CHEST (PORTABLE AP) Study Date of [**2170-5-17**] 2:06 AM
FINDINGS: As compared to the previous radiograph, the
endotracheal tube, the two feeding tubes, and the left internal
jugular vein catheter are unchanged.
The extent of bilateral pleural effusions has substantially
increased, leading to widespread and relatively severe
homogeneous opacification of the right and left hemithorax.
Extensive subsequent atelectasis must be suspected. Borderline
size of the cardiac silhouette, unchanged.
PORTABLE ABDOMEN Study Date of [**2170-5-17**] 6:30 AM
RESSION: Dobbhoff tube terminates in the second portion of the
duodenum.
RENAL U.S. PORT Study Date of [**2170-5-17**] 11:22 AM
PRESSION:
No evidence of perinephric abscess or fluid collection.
PORTABLE ABDOMEN Study Date of [**2170-5-17**] 12:29 PM
PRESSION: Dobbhoff tube terminates near the ligament of treitz
in the
proximal jejunum.
CHEST (PORTABLE AP) Study Date of [**2170-5-20**] 2:41 AM
Compared with [**2170-5-19**] at 7:18 a.m., the ET tube and
nasogastric-type tubes have been removed. Right IJ and left
subclavian central lines both overlie the distal SVC.
There are low inspiratory volumes. Cardiomediastinal silhouette
is prominent, but unchanged. There is upper zone
re-distribution, vascular plethora and diffuse vascular
blurring, consistent with CHF. There is increased opacity at the
left base, likely representing a combination of a moderate-sized
pleural effusion and underlying collapse and/or consolidation.
There is atelectasis at the right base and possible minimal
blunting at the right costophrenic angle.
Compared with the earlier film, the CHF findings are similar,
possibly
slightly worse. The changes at the left base are stable.
Chest X-Ray [**5-28**]:
IMPRESSION: Marked improvement since [**2170-5-20**], with
improved pulmonary vascular congestion, marked decrease in
pleural effusions, and improving aeration of both lung bases.
Discharge Labs:
[**2170-5-28**] 06:10AM BLOOD WBC-7.1 RBC-2.70* Hgb-8.6* Hct-27.6*
MCV-102* MCH-31.9 MCHC-31.2 RDW-15.8* Plt Ct-286
[**2170-5-22**] 02:21AM BLOOD PT-11.3 PTT-26.2 INR(PT)-1.0
[**2170-5-28**] 06:10AM BLOOD Glucose-107* UreaN-24* Creat-1.8* Na-140
K-4.3 Cl-110* HCO3-21* AnGap-13
[**2170-5-23**] 06:50AM BLOOD ALT-42* AST-47* AlkPhos-89 TotBili-1.0
[**2170-5-28**] 06:10AM BLOOD Calcium-8.7 Phos-5.5* Mg-1.2*
Brief Hospital Course:
24 y/o female with history of EtOH abuse and pancreatitis
transferred after being found down at home, and noted to be
disoriented with fever, hypotension, tachycardia, oliguric acute
renal failure, with ? of black stools, and found to have severe
pancreatitis.
# Alcoholic Pancreatitis and Shock/Respiratory Failure: Pt
presented w/ severe pancreatitis, w/ BISAP score 4 (did not meet
age criteria). Also w/ hypoperfusion, elevated lactate, and
oliguric renal failure (for which HD was eventually started).
Given fever, altered mental status, and elevated bilirubin with
? RUQ discomfort, cholangitis and cholecystitis were initially
considered but a RUQ showed no abnl gallbladder. Also had a UTI
so urosepsis may have played some role, and she was treated with
Cefepime x4d then ceftriaxone x3 days. Blood cultures negative.
Given her very elevated lipase (4300) and shock picture,
pancreatic necrosis and/or infection was on the differential;
was initially given Vancomycin/Clinda in the ED. She was then
placed on Vancomycin/Cefepime/Flagyl and eventually received 2
days of Vancomycin, 3 days of Flagyl and 4 days of Cefepime plus
3 more days of ceftriaxone. Her hemodynamics were confounded by
alcohol withdrawal (likely contributed to her tachycardia and
hypertension).
On [**5-13**] she became tachycardic to 160's, desatted to low 70's
laying flat, in respiratory distress with withdrawal symptoms so
she was intubated for airway management. Post-pyloric tube feeds
started while intubated. Significantly fluid overloaded in the
setting of receiving IVF for her hypotension and shock,
complicated by ATN (see below) and poor urine output. Patient
was eventually started on dialysis and fluid was ultrafiltrated
off and she was able to be extubated on [**2170-5-19**] with this
intervetion. Patient initially continued to be hypertensive to
SBPs 150s, tachycardic to 120s and tachypneic in 40s after
extubation. Patient had been on midazolam and fentanyl while
intubated for sedation, thus concern patient may both be having
etoh and narcotic withdrawl. Patient's CIWA scale was adjusted
and was placed on clonidine with improvement of her vital signs.
By the time she was called out of the MICU, she was 80-90's
bpm's and frequency of CIWA > 10 was down, still mildly
hypertensive. She was discharge on clonidine 0.1mg twice a day
with planned follow up with her PCP on [**Name9 (PRE) 2974**] [**6-1**].
# Altered mental status: Initially a broad differential. CT head
without contrast at outside hospital prior to transfer was
without acute process. Patient's mental status improved
throughout her course with improvement of her electrolytes and
LFTs. Likely it was related to pancreatitis and toxic/metabolic
encephalopathy. She was mentating normally when called out of
the MICU and at discharge.
# Acute renal failure: likely ATN in setting of severe
pancreatitis/hypoperfusion. Her Cr peaked around 8. She was
started on hemo-dialysis while in the unit with a temporary HD
line. On the floor, she received a tunneled line with plans for
continued dialysis as an outpatient however the patient improved
and started making adequate amounts of urine. The tunneled line
was removed the day of her discharge. Her creatinine at the time
of discharge was 1.8 with no electrolyte abnormalities.
# Anion gap metabolic acidosis: likely multifactorial from
uremia, lactate, and EtOH. Respiratory compensation was adequate
initially. However, as her renal function worsened her acidosis
was managed by ventilation. After dialysis this improved. She
had no AG when called out of MICU and upon discharge.
# Elevated LFTs: likely alcohol induced, but differential
diagnosis also includes acute viral hepatitis as well as shock
liver. Stox and Utox are negative, and tylenol level negative.
At peak these were AST 1238 ALT 239. Hepatitis serologies were
sent are were negative. Abdominal US showed fatty liver vs
cirrhosis. These were trended and were well trended down when
she left the MICU (52/50). Her LFTs were last check on [**5-23**] and
her AST was 47 and ALT 47.
# ?GIB/Anemia: noted to have anemia and a reported history of
black stools at home. Suspect UGIB from chemical gastritis (i.e.
EtOH). Low suspicion for variceal bleed. Started on protonix gtt
in ED. Patient was maintain on IV protonix [**Hospital1 **] and HCTs were
trended she did required a total of 3 U PRBCs. Her HCT
stabilized over her MICU stay and was 29.1 on transfer to the
floor. Her Hct upon discharge was 27.6. She was discharged on
pantoprazole 40mg twice a day and was advised to follow up with
a gastroenterologist for possible endoscopy/colonoscopy.
# UTI. As above patient had positive UCx for E Coli treated with
Cefepime then Ceftriaxone for a week long course. Patient then
had several fevers in MICU, where her urine taken at that time
was + with >182 WBCs but urine cultures grew yeast x3. For this
she was given a 3 day course of fluconazole and her foley was
changed.
# Social issues: pt has unstable home situation and severe etoh
abuse (drinks 1 gallon vodka daily). Social work and psychiatry
were consulted. Social work felt that the patient was benefit
from an inpatient setting the patient preferred being treated as
an outpatient.
# Code: full this admission
===============================================
TRANSITIONAL ISSUES
# Patient has a follow up appointment with her PCP on [**Name9 (PRE) 2974**] [**6-1**]
and should have her electrolytes including creatinine checked at
that time.
# She will need to follow up with gastroenterology for suspected
GI bleed during her MICU course
# She will need to follow up with a nephrologist to ensure that
she will no longer need dialysis
# She plans on scheduling an outpatient psychiatry appointment
Medications on Admission:
- denies taking any medications with exception of intermittent
ativan
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg twice a day Disp #*60 Tablet Refills:*0
(Zero)
2. CloniDINE 0.1 mg PO BID
Please hold for SBP <100 or HR <60
RX *clonidine 0.1 mg twice a day Disp #*10 Tablet Refills:*0
(Zero)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Alcohol Withdrawal
- Acute Renal Failure requiring dialysis
- GI bleed
- Complicated UTI
- Pancreatitis
Secondary Diagnosis
- Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were were admitted to the hospital on [**5-12**] after you were
found unresponsive. You were transferred to the ICU and you
required a breathing tube. You were in the ICU for approximately
2 weeks. This occurred because of the amount of alcohol you were
consuming. You were going through severe withdrawal during your
time in the ICU. You have opted to go to an outpatient alcohol
treatment program. Please make an appointment as soon as
possible. You will be continued on Clonidine 0.1mg twice a day
for withdrawal and should continue until you meet with your PCP
on [**Name9 (PRE) 2974**] [**6-1**].
You were noted to have kidney failure. You required dialysis and
your kidney function improved. Prior to your dishcharge you did
not require any more dialysis. You should have your kidney
function/ creatinine checked during your visit with your primary
care doctor.
You were noted to have some gastrointestinal bleeding during
your hospitalization. You did not have any more bleeding after
you left the ICU. You should follow up with a gastroenterologist
as an outpatient.
Medications Changed:
Start Clonidine 0.1 mg [**Hospital1 **] (please discuss continuing this with
your PCP on [**Name9 (PRE) 2974**])
Start Pantoprazole 40mg [**Hospital1 **]
Followup Instructions:
You have an appointment with you PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42600**] MD [**First Name (Titles) **] [**Last Name (Titles) 30786**] [**6-1**] at the Beacon Family Practice.
Please call [**Doctor First Name **] at [**Telephone/Fax (1) 5685**] on [**5-29**] when your insurance has
started.
It is strongly recommended that you enroll in an out patient
alcohol treatment program. Please contact the following agency
to enroll:
Health and Education Services
[**Street Address(2) 110091**]
[**Location (un) 13011**], [**Numeric Identifier 83648**]
[**Telephone/Fax (1) 110092**]
Please make an appontnment with psychiatry as soon as possible.
You have information regarding scheduling this appointment.
Please make an appointment with a nephrologist as soon as
possible as well. Please make this appointment within 1 week of
discharge.
([**Telephone/Fax (1) 10135**].
Please make an appointment with gastroenterology as soon as your
insurance is processed.
Phone: ([**Telephone/Fax (1) 2233**]
Description: Gastroenterology
Department of Medicine Location: LMOB 8E/West Organization:
[**Hospital1 18**] Phone: ([**Telephone/Fax (1) 2233**]
ICD9 Codes: 5845, 5789, 2762, 5990, 2859, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3264
} | Medical Text: Admission Date: [**2119-6-14**] Discharge Date: [**2119-6-28**]
Date of Birth: [**2047-1-18**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins / Lipitor
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Left knee pain with failed total knee replacement
Major Surgical or Invasive Procedure:
TKR revision
Left knee removal of total knee, left knee hinged prosthesis
History of Present Illness:
72 yo male with history of DMII, HTN and h/o Left TKR who
initially was admitted to the orthopedic service for revision of
TKR on [**6-14**]. Patient had a failed TKR due to massive osteolysis
and extensive synovitis which was found intraoperatively. The
procedure was complicated by hypotension which was thought to be
[**3-7**] to blood loss during the surgery. He was transferred to the
ICU for monitoring overnight. Patient was transferred back to
the medical floor and was taken for revision of TKR today.
Patient tolerated the procedure well. After the procedure, the
patient was difficult to arouse and was noted to be tachycardic.
He was then tranferred to the ICU for overnight monitoring.
On arrival to the ICU, the patient was alert and oriented. He
complaned of some itching in the back at the site of his
epidural catheter. Denied pain in his knee. Otherwise, no
other complaints.
.
.
Review of sytems:
(+) Per HPI
(-) Denies cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria
Past Medical History:
T2DM
HTN
Hepatitis B (carrier)
Hyperlipidemia
Gout
Nephrolithiasis
Osteoarthritis (R hip)
Allergic rhinitis
Sciatica
L knee replacement [**2115**]
s/p screw removal in L femur before [**2109**].
Social History:
The patient grew up in [**Location (un) **], now lives in [**Location 4310**] with his
life partner. [**Name (NI) **] quit smoking 30 yrs ago, denies EtOH or
recreational drug use. He used to be a hairdresser, retired
four years ago.
Family History:
Father died at 55 of an MI. Mother died of breast CA at 56.
Sister has diabetes.
Physical Exam:
GEN: NAD, lying comfortably in bed, AAOx3
HEENT: dry MM, OP clear
NECK: no LAD
CVS: +S1/S2, no M/R/G, RRR
LUNGS: CTAB , no wheezes, crackles or ronchi
ABD: +BS, NT/ND
BACK: Epidural cathether in place, no erythema or rash
EXT: +2 pedal edema of LLE, +Left leg immobilizer in place, no
pedal edema in right leg.
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* 5/5 strength TA/GS/[**Last Name (un) 938**]/FHL
* SILT DP/SP/T/S/S
* Toes warm
Pertinent Results:
[**2119-6-27**] 09:20AM BLOOD WBC-6.2 RBC-4.25* Hgb-12.4* Hct-38.9*
MCV-92 MCH-29.1 MCHC-31.7 RDW-14.9 Plt Ct-584*
[**2119-6-27**] 09:20AM BLOOD PT-24.0* INR(PT)-2.3*
Brief Hospital Course:
72 yo male with history of DMII, HTN and h/o Left TKR who
initially was admitted to the orthopedic service for revision of
TKR on [**6-14**] which failed [**3-7**] osteolysis and synovitis who
returned to the OR for revision of TKR. The patient was
admitted to the orthopaedic surgery service and was taken to the
operating room for above described procedure. Please see
separately dictated operative report for details. The surgery
was complicated by bleeding and the decision was made to stage
his reimplantation by one week. Post opertively he went to the
ICU. He was then taken back for reimplantation of a hinged knee
prosthesis. Post operative he again was transferred to the ICU
for monitoring. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
Small PE diagnosed by CT scan, patient started on coumadin for a
total of 6 weeks.
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications. The patient received
lovenox for DVT prophylaxis starting on the morning of POD#1 and
transitioned to coumadin after the PE was discovered. The foley
was removed and the patient was voiding independently
thereafter. The surgical dressing was changed on POD#2 and the
surgical incision was found to be clean and intact without
erythema or abnormal drainage. The patient was seen daily by
physical therapy. Labs were checked throughout the hospital
course and repleted accordingly. At the time of discharge the
patient was tolerating a regular diet and feeling well. The
patient was afebrile with stable vital signs. The patient's
hematocrit was acceptable and pain was adequately controlled on
an oral regimen. The operative extremity was neurovascularly
intact and the wound was benign.
At time of discharge, patient was deemed stable for safe
discharge to home.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity
Medications on Admission:
Medications on floor:
Insulin SC (per Insulin Flowsheet)
Lisinopril 15 mg PO/NG DAILY
Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **]
Milk of Magnesia 30 ml PO BID:PRN Constipation
Acetaminophen 650 mg PO Q6H:PRN pain,fever
Multivitamins 1 CAP PO DAILY
Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO Q6H:PRN
Dyspepsia Niacin SR [**2109**] mg PO QHS
Allopurinol 150 mg PO/NG DAILY
Ondansetron 8 mg IV Q8H:PRN nausea/vomiting
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Senna 1 TAB PO BID:PRN Constipation
Calcium Carbonate 500 mg PO TID
CefazoLIN 2 gm IV Q8H
Docusate Sodium 100 mg PO BID
Famotidine 20 mg PO/NG Q12H
Vitamin D 400 UNIT PO DAILY
Fish Oil (Omega 3) 1000 mg PO DAILY
traZODONE 25 mg PO/NG HS:PRN insomnia
Fluticasone Propionate NASAL 2 SPRY NU DAILY
.
Medication in PACU:
Odansetron 4mg IV x 1 PRN
Haldol 0.25-0.5mg IV MRx1 PRN
Prochloperazine 2.5-5mg IV MRx1 PRN
Promethazine 6.25-12.5mg IV MRx1 PRN
Labetalol 5mg IV q15min:prn
Hydromorphone 10mcg/ml + Bupivicaine 0.1% 1mg/md at 12u/hr
.
Discharge Medications:
1. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM for 6 weeks: INR [**3-8**]
PCP to manage coumadin.
Disp:*120 Tablet(s)* Refills:*0*
2. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
4. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Left failed total knee arthroplasty
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool
softener (such as colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may shower starting five
days after surgery, but no tub baths or swimming for at least
four weeks. No dressing is needed if wound continues to be
non-draining. Any stitches or staples that need to be removed
will be taken out by the visiting nurse or rehab facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your coumadin
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four week
checkup. Please place a dry sterile dressing on the wound each
day if there is drainage, otherwise leave it open to air. Check
wound regularly for
signs of infection such as redness or thick yellow drainage.
Staples will be removed by the visiting nurse or rehab facility
in two weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. No strenuous exercise or heavy lifting until follow
up appointment.
Physical Therapy:
ROM as tolerated, WBAT
Treatments Frequency:
Daily dry dressing changes
home INR checks
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2119-7-14**] 1:00
Completed by:[**2119-6-28**]
ICD9 Codes: 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3265
} | Medical Text: Admission Date: [**2142-4-1**] Discharge Date: [**2142-4-3**]
Date of Birth: [**2069-7-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug eluting stent to the right
coronary artery
History of Present Illness:
72-year-old male history of prior MI ([**2116**]) and h/o
esophagectomy for ?esophageal CA (not confirmed on path)
presents with midline chest squeezing and pressure with
diaphoresis and nausea since [**41**]:00 AM yesterday. The pain was
more severe yesterday and has gradually diminished, but did not
resolve until he was take for cath this AM. The patient had an
MI in [**2116**]. He has hypertension but denies hypercholesterolemia
or diabetes.
.
Initial VS at [**Hospital1 **] were T 97.9 HR 60 RR 12 BP 115/68 pOx 98
RA. Labs at [**Hospital1 **] were significant for WBC 9.2, Hgb 13.7, Hct
38.6, MCV 92.9, Plt 202 with normal differential. ECG was
significant for HR 55 bpm, NSR, ST changes 1-1.[**Street Address(2) 1755**]
elevations in II,III and aVF with subtle ST depressions in V5,V6
concerning for acute inferior wall MI.
The patient was given asa 325, plavix 600mg, heparin 4000 U
bolus then started on 1000U /hr gtt. Patient was transferred to
[**Hospital1 18**] for ACS and emergent coronary revascularization.
.
At [**Hospital1 18**], patient was taken to c. cath lab immediately for late
presentation/CTO proximal RCA with export and DES to proximal
RCA with 6F RFA Angioseal. He was transferred to the CCU on an
Eptifibatide gtt.
.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- CAD
- hypertension
- esophagectomy (patient unsure of the pathology)
Social History:
Tobacco: quit 35 years ago. smoke between 0/5-4 packs per day x
25 years.
Alcohol: averagesglass of wine daily
Recreational Drugs: cocaine and pot in his 20's
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory except a
maternal uncle that had MI in 40's
- Mother: alive, s/p CVA, dementia
- Father: died at 93, dementia
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
GENERAL: NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVP.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. midline epigastric
hernia
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
PHYSICAL EXAMINATION ON DISCHARGE:
GENERAL: NAD, AAOx3
HEENT: NCAT, Sclera anicteric, wearing glasses, mucus membranes
moist
NECK: Supple with no JVP visualized with pt. in 90 degree
upright position
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities. Unlabored work of breathing,
no accessory muscle use or retractions, no cough. CTAB, good
aeration, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Active bowel sounds heard in chest and neck
d/t esophagectomy. No HSM or tenderness. midline epigastric
hernia
EXTREMITIES: Warm, no edema
SKIN: No sores or lesions, right cath site with mild echymosis
and small knot underneath the skin, no tenderness.
PULSES: Bilaterally, carotid, radial, femoral, DP, and PT 2+
Access/devices: Right AC PIV without erythema or edema
Pertinent Results:
LABS ON ADMIT:
[**2142-4-1**] 01:12PM BLOOD WBC-7.7 RBC-4.08* Hgb-12.9* Hct-38.3*
MCV-94 MCH-31.5 MCHC-33.6 RDW-13.4 Plt Ct-217
[**2142-4-1**] 01:12PM BLOOD Glucose-117* UreaN-17 Creat-0.9 Na-137
K-3.7 Cl-100 HCO3-30 AnGap-11
[**2142-4-1**] 05:59PM BLOOD CK-MB-145* MB Indx-11.7* cTropnT-4.72*
[**2142-4-2**] 05:49AM BLOOD CK-MB-45* MB Indx-7.3* cTropnT-3.26*
[**2142-4-1**] 01:12PM BLOOD Calcium-8.6 Phos-2.6* Mg-1.8 Cholest-187
[**2142-4-1**] 02:36PM BLOOD %HbA1c-6.0* eAG-126*
[**2142-4-1**] 01:12PM BLOOD Triglyc-127 HDL-66 CHOL/HD-2.8 LDLcalc-96
LDLmeas-109
LABS ON DC:
[**2142-4-3**] 07:55AM BLOOD WBC-4.8 RBC-3.79* Hgb-11.8* Hct-35.5*
MCV-94 MCH-31.2 MCHC-33.3 RDW-13.5 Plt Ct-166
[**2142-4-3**] 07:55AM BLOOD Glucose-111* UreaN-19 Creat-1.0 Na-139
K-4.1 Cl-104 HCO3-31 AnGap-8
[**2142-4-3**] 07:55AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.0
ECG [**2142-4-1**]:
Sinus rhythm. ST segment elevation in leads III and aVF up to
two millimeters with Q waves in the inferior leads consistent
with inferior wall myocardial infarction in evolution. ST
segment depressions in leads I and aVL consistent with
reciprocal changes.
CATH [**2142-4-1**]:
1. Selective coronary angiography in this right dominant system
demonstrated single vessel coronary artery disease. The LMCA
was free
of angiographically significant coronary artery disease. The
LAD had a
50% lesion in its mid segment. The LCX had mild, diffuse
non-obstructive coronary artery disease. The RCA was totally
occluded
proximally and filled distally with left to right collaterals.
2. Limited resting hemodynamics revealed normal systemic
arterial blood
pressure with a central aortic blood pressure of 117/61.
3. Successful aspiration thrombectomy and PCI of the proximal
and mid
RCA with 3.5x28mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-dilated to 4.0mm (see PTCA comments).
4. Successful right groin closure with 6F AngioSeal device.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Acute STEMI due to thrombotic occlusion of the RCA
3. Normal systemic arterial blood pressure.
4. Successful PCI of the proximal RCA with DES.
5. Continue aspirin and plavix.
6. Admit to CCU for post-STEMI care including statins,
beta-blocers, and
ACE inhibitors.
ECHO [**2142-4-2**]:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 5-10 mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with near
akinesis of the basal 2/3rds of the inferior wall. The remaining
segments contract normally (LVEF = 45 %). 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 (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
estimated pulmonary artery systolic pressure is normal. There is
a trivial/physiologic pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD (PDA distribution). Dilated
ascending aorta.
Brief Hospital Course:
HOSPITAL COURSE: This is a 72 y/o male with h/o CAD, prior MI
([**2116**]), HTN, and esophagectomy for ? esophageal CA (not
confirmed on path) admitted with STEMI of II, III, AVF and STD
of V5-6 s/p DES to RCA.
#. STEMI/CAD: The patient presented with STEMI of II, III, aVF
and STD of V5-6, with q-waves in II,III, and aVF already
present. He was taken to the cath and was found to have a
complete thrombotic occlusion to the RCA, now s/p DES. The
patient was not taking ASA or a statin even though he had a
prior MI in [**2116**]'s. The patient received ASA, Plavix, heparin
gtt prior to OSH transfer and was started on intergralin prior
to cath. Post-cath echo with EF 45%. Pt. was stable without CP
or SOB, VSS on d/c. We started ASA 325 mg PO daily, clopidogrel
75 mg PO daily, Lisinopril 2.5 mg po daily and Metoprolol
Tartrate 6.25mg po BID.
#. HTN- Patient reports baseline BP is 120-140 at home. Current
BP 90-110's/50-70's and mentating well. We held home amlodipine
and started Lisinopril and Metoprolol Tartrate.
#. HLD- not on a statin at home, does take a number of
supplements, including Vitamin E and Niacin. We started
atorvastatin 80mg and suggested pt. stop taking his Niacin and
Vitamin E d/t interactions. Suggested the pt. consider d/cing
the other supplements, with the exception of Vitamin D and any
others that were prescribed by his PCP
#. esophagectomy for ? esophageal CA. performed in 3/[**2132**]. The
path report did not confirm a cancer, but pt. wanted the
operation just in case
Contact: Wife, [**Name (NI) **] [**Telephone/Fax (1) 52956**]
CODE: full (confirmed with pt/family)
DISPO: Home. Lives with his wife at home, is retired, but active
with projects around the home. Has 5 grown children, some in the
area.
Medications on Admission:
- folate 800mg
- amlodipine 5mg
- vitamin D 2,000 units
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. folic acid 800 mcg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
3. cholecalciferol (vitamin D3) 2,000 unit Tablet Sig: One (1)
Tablet PO once a day.
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO once a day.
Disp:*15 Tablet Extended Release 24 hr(s)* Refills:*2*
7. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain: Take 1 tablet
under tongue for chest pain, wait 5 mins, then take 1 more tab.
If you still have chest pain after two tabs, call 911. .
Disp:*25 tab* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
acute inferior ST elevation myocardial infarction
Hypertension
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It has been a pleasure caring for you at [**Hospital1 18**]. After about 24
hours of chest pain, you went to an [**Hospital3 **] on [**2142-4-1**], where you were diagnosed with an inferior heart attack
with ST wave elevations. You were transferred to [**Hospital1 18**], where
you had a cardiac catheterization, which diagnosed that your
right coronary artery was blocked. You were given medication to
thin your blood and a drug-eluding stent was placed to keep the
vessel open. You spent the night in the intensive care unit for
monitoring and you were transferred to the cardiac step down
unit the next day ([**4-2**]), as you were doing very well. Your stay
has been without fevers or other complications and you are ready
to return home today. A number of medications have been added to
your list, and you should continue to take these once you return
home to protect your heart and prevent further cardiovascular
complications. We have stopped your Amlopidine and instead
started you on Lisinopril and Metoprolol Extended Release for
blood pressure control, as these medications are recommended
after a heart attack. We have also started you on Aspirin 325 mg
daily following your stent placement, your cardiologist will
decide how long you need this dose and when you may take Aspirin
81 mg. Clopidogrel (Plavix) is another blood-thinning medication
and should be taken for one year to protect your stent. Please
do not stop taking the Aspirin or Plavix for any reason unless
directed to by your cardiologist. These medications are
absolutely necessary to protect you from another heart attack.
For cholesterol control, you have been started on Atorvastatin
(Lipitor). Regarding your multiple supplements, we recommend
that you stop the Niacin and Vitamin E, as they can interact
with the Atorvastatin. Please speak with your PCP regarding the
need/benefit of the other vitamins.
You have a prescription for nitroglycerin to use for chest pain.
Please call 911 if you still have chest pain after 2 tablets.
Call Dr. [**Last Name (STitle) **] if you use any nitroglycerin at all.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Location: [**Hospital1 **] HEALTHCARE - CROWN COLONY
Address: [**Street Address(2) 52957**], [**Apartment Address(1) 52958**], [**Hospital1 **],[**Numeric Identifier 20089**]
Phone: [**Telephone/Fax (1) 52959**]
Appointment: Tuesday [**2142-4-10**] 11:00am
Department: CARDIAC SERVICES
When: THURSDAY [**2142-5-10**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3266
} | Medical Text: Admission Date: [**2195-4-27**] Discharge Date: [**2195-5-15**]
Date of Birth: [**2134-11-14**] Sex: F
Service: ORTHOPEDIC
HISTORY OF PRESENT ILLNESS: The patient is a 60 year-old
female with a history of scoliosis and spinal stenosis with
degenerative disc changes with significant lateral listhesis
of L2 and L3 who was seen in the past by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] who
recommended the patient to consider anterior and posterior
spinal fusion procedure. The patient was given information
regarding this surgical intervention including risks and
benefits, and opted for surgery, which was scheduled for the
day of admission [**2195-4-27**].
PAST MEDICAL HISTORY: Hypertension, insulin dependent
diabetes, thoracolumbar scoliosis 63 degrees with mild
kyphosis at L2-L3 level. Stenosis at the same L2-L3 level
with lateral disc protrusion at L3-L4 and degenerative
changes of the facet joints at L4-L5-S1 bilaterally.
PAST SURGICAL HISTORY: Knee surgery in [**2186**]. Appendectomy,
colonoscopy.
FAMILY HISTORY: Hypertension, cancer, diabetes and
arthritis.
ALLERGIES: Sulfa drugs, adhesive tape, Vicodin, Percocet and
Cipro.
PHYSICAL EXAMINATION ON PRESENTATION: Well developed, well
nourished white female, was moving with severe discomfort to
and from the examination table, complaining of pain in her
lower back and severe limitation in axial rotation, flexion
and extension and lateral side bending. The patient had
evidence of thoracolumbar scoliosis. The patient stood deviated
to the right. She had good
strength in terms of hip flexion, abduction, adduction, knee
extension, flexion, dorsiflexion and plantar flexion. She had
a positive straight leg raise on the left side. She is
clear to auscultation bilaterally. Heart normal S1 and S2
without murmur. Abdomen soft, nontender, nondistended.
HOSPITAL COURSE: The patient underwent T10 to L4 anterior
spinal fusion, partial vertebrectomy of L1, L2 and L3 and
anterior allograft placement at L4-L5 with autograft on the
day of admission [**2195-4-27**]. The surgery was done by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 363**]. Post surgery the patient was followed by the acute
pain service and was managed on Dilaudid PCA. The patient
was also followed by [**Last Name (un) **] Diabetes Center physicians for
management of her brittle diabetes. The patient had been on
an insulin pump prior to the operation.
Postoperatively, the insulin pump was discontinued and the
patient was placed on an insulin drip. The plan was to restart
the insulin pump when the patient was ready for self management.
During her first surgery the patient had a chest tube placed.
In the posterior procedure, she had
fusion of T10 to L5, with multiple thoracic and lumbar
laminotomies, and segmental instrumentation application from T10
to L5 with autograft, osteotomy of L2 and L3, and had an epidural
catheter placed. The description of the procedure may be
found in the operative notes.
Postoperatively, the patient was transferred to the Trauma
CICU. She continued to be intubated and sedated.
Postoperative day two the patient was intubated but alert.
The patient was extubated on [**2195-5-4**] and continued to
be on a face mask. The patient was on tube feeds and
monitored by nutritional services. Pain was controlled with
Dilaudid drip. The patient was managed on the PCA for pain
control with Dilaudid . The pain control was monotored by
the acute pain
service. The Hemovac drain was removed on postoperative day six.
The following day the Foley catheter was discontinued and the
patient was transferred to the medical surgical floor from
the Trauma CICU. Bilateral pneumoboots were continued for
prophylaxis of deep venous thrombosis.
The patient was intermittently after the second surgery and
medical consult was requested. The confusion was attributed to
the effect of analgesia, Dilaudid, which was discontinued on
[**2195-5-9**]. The patient's mental status slowly improved.
Along with improvement the patient brought her concern
regarding visual loss. Both ophthalmology and
neuro-ophthalmology consults were requested. The patient was
seen by Dr. [**Last Name (STitle) 10030**] from neurology who found no evidence of
cortical blindness but an ischemic optic neuropathy. MRI with
angiography of the head and neck was obtained
and finally a brain scan was obtained. It showed mild
symmetric decreased perfusion to the primary and secondary
visual cortex. The patient was seen by Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 2523**] from
Neuro-ophthalmology. His impression was the patient had
bilateral posterior ischemic optic neuropathy with
hallucinations. Recommended to follow up with him in six to
eight weeks. His phone number is [**Telephone/Fax (1) 49741**]. Also needs
to follow up with Dr. [**Last Name (STitle) **] ophthalmology in [**Last Name (un) **] Diabetes
Center.
The patient continued to be mobilized by physical therapy
daily. She was able to ambulate with TLSO brace with
assistance supervision 75 feet. On day before discharge the
patient was screened and accepted by rehabilitation center on
[**Hospital3 **]. She will be discharged today [**2195-5-15**].
DISCHARGE DIAGNOSES:
1. Posteroanterior thoracolumbar fusion T10-L5 with
instrumentation.
2. Bilateral blindness.
DISCHARGE MEDICATIONS:
1. Sliding scale insulin.
2. Tylenol 325 mg po q 4 hours, please crush pill.
3. Tramadol 50 mg po q 4 to 6 hours prn.
5. Benadryl 25 mg intravenous q 6 hours prn.
6. Heparin 5000 units subq q 12 hours.
7. Ativan 1 to 2 mg intravenous q 2 to 4 hours prn
agitation. The patient must have adequate AOA support prior
to administration of the dose.
8. Magnesium sulfate 2 gram per 100 milliliters of D5W
intravenous prn for magnesium level less then 1.8.
9. Calcium gluconate 2 grams/100 milliliters of D5W
intravenous prn for calcium ionized less then 1.12.
10. Potassium chloride 40 milliequivalents per 100 ml SWIV
prn for potassium less then 4.0. Call for potassium lower
then 3.0.
11. Bisacodyl 10 mg po/pr q.d. prn.
12. Flexeril 10 mg po t.i.d. prn.
13. Docusate 100 mg po b.i.d.
14. Gabapentin 300 mg po b.i.d.
15. Medroxyprogesterone 2.5 mg po q.d.
16. Estradiol 0.5 mg po q.d.
17. Lisinopril 10 mg po q.d.
The patient will need to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] in
one to two weeks after discharge. Please call [**Telephone/Fax (1) 3573**]
for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**]
Dictated By:[**Last Name (NamePattern1) 4307**]
MEDQUIST36
D: [**2195-5-15**] 10:10
T: [**2195-5-15**] 10:28
JOB#: [**Job Number 49742**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3267
} | Medical Text: Admission Date: [**2103-3-6**] Discharge Date: [**2103-3-10**]
Date of Birth: [**2023-7-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Malaise, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 27925**] is a 79F with a PMH s/f dementia, who was in her USOH
until four days prior to admission when she began experiencing
increasing weakness, malaise, and fatigue. She also appeared to
be slightly more altered than usual and had an episode of
urinary incontinence on the evening prior to admission. Her
temperature at home was reportedly 100F on the day of
presentation, as taken by her home health aide. She then
brought Ms. [**Known lastname 27925**] to the ED.
.
On presentation to the ED, she was afebrile, with a systolic
blood pressure of 110. She complained of abdominal pain.
Laboratory data was significant for the absence of a
leukocytosis, or abnormal chemistry. A lactate was 1.6. UA was
floridly positive. CT Abdomen and pelvis showed perinephric
stranding on the left kidney. She was given one dose of IV
cipro, blood and urine cultures are sent. Despite two liters of
NS, her SBP transiently dipped to 70s, with no tachycardia. She
was given a third liter of NS and her BP came up to the 90s.
Current vital signs are: BP=92/49, HR=80s, RR=18, 97% 2L.
.
Past Medical History:
1. Dementia:
-Mixed alzheimers and vascular types
-Requires 24h care at home
-Managed by gerontology and behavioral neurology
-Baseline mental status:
2. Osteopenia
3. Hypercholesterolemia
4. Depression
5. H/o herpes zoster in [**2101**]
.
PAST SURGICAL HISTORY:
1. Appendectomy.
2. Cataract surgery.
Social History:
Widowed, lives with a male companion and her son and
daughter-in-law in [**Name (NI) 745**], requires 24hour home care. Former
smoker but quit years ago. No alcohol or other drugs.
Family History:
NC
Physical Exam:
T 99.1 BP 110/70 P 90 RR 18 O2SAT 94%ra
GENERAL: Pleasant, well appearing woman in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=5
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&O to person but not to place or time. Appropriate. CN
[**3-1**] grossly intact. Preserved sensation throughout. [**5-22**]
strength throughout. [**1-19**]+ reflexes, equal BL. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2103-3-6**] 02:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
[**2103-3-6**] 02:30PM URINE BLOOD-LG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2103-3-6**] 02:19PM LACTATE-1.6 K+-3.7
[**2103-3-6**] 02:11PM GLUCOSE-64* UREA N-12 CREAT-1.0 SODIUM-138
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-28 ANION GAP-12
[**2103-3-6**] 02:11PM ALT(SGPT)-15 AST(SGOT)-26 LD(LDH)-267*
CK(CPK)-195* ALK PHOS-87 AMYLASE-63 TOT BILI-0.5
[**2103-3-6**] 02:11PM WBC-8.1 RBC-4.18* HGB-12.7 HCT-36.3 MCV-87
MCH-30.3 MCHC-34.8 RDW-13.6
CT ABDOMEN [**2103-3-6**]:
TECHNIQUE: Contrast-enhanced axial images of the abdomen and
pelvis were
obtained with multiplanar reformatted images.
CT ABDOMEN WITH CONTRAST: The lung bases demonstrate minimal
hypoventilatory changes. There is no pericardial or pleural
effusion. Note is made of a small-to-moderate axial hiatal
hernia.
6-mm hypodensity in hepatic segment II (2:11) is too small to
characterize. No other focal hepatic lesions are seen. The
gallbladder contains a few small stones but is otherwise
unremarkable. The spleen, pancreas, and adrenal glands appear
unremarkable.
There is partial duplication of the left renal collecting
system. Mild
perinephric inflammatory stranding is noted with mild
hydronephrosis and
hydroureter involving the upper and lower pole collecting
systems. Urothelial enhancement also involves the upper and
lower pole moieties. The right kidney appears unremarkable
without hydronephrosis or hydroureter. There may be a mildly
delayed left nephrogram.
Intra-abdominal loops of large and small bowel are of normal
caliber and there is no evidence for obstruction. Minimal
atherosclerotic changes involve the abdominal aorta, though it
is of normal caliber. No pathologically enlarged retroperitoneal
or mesenteric lymph nodes are identified. There is no evidence
for free air.
CT PELVIS WITH CONTRAST: Scattered descending colon and sigmoid
diverticula are noted without evidence for acute diverticulitis.
The rectum, uterus, and adnexa are unremarkable.
The upper and lower pole moieties fuse in the distal ureter with
mild
hydronephrosis persisting to the left ureterovesicular junction.
The bladder contains a Foley and is collapsed. No free pelvic
fluid or pathologically enlarged lymph nodes are identified.
Bone windows reveal no worrisome lytic or sclerotic lesions.
Multilevel
moderate-to-severe degenerative changes of the thoracolumbar
spine are noted.
IMPRESSION:
1. Partially duplicated left renal collecting system with
hydronephrosis and urothelial enhancement involving upper and
lower pole moieties with
perinephric inflammatory stranding noted. No definite
obstructing lesion
identified; however, the bladder is collapsed and poorly
evaluated.
Findings may be due to a recently passed calculus. Clinical
correlation is
recommended, and further evaluation with a dedicated MR urogram
or CT urogram is recommended.
2. Cholelithiasis without acute cholecystitis.
3. Diverticulosis without acute diverticulitis.
[**2103-3-6**] 2:30 pm URINE Site: CATHETER
**FINAL REPORT [**2103-3-8**]**
URINE CULTURE (Final [**2103-3-8**]):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
79F with a PMH of dementia who presented to the ED complaining
of increasing weakness and malaiase, found to have
pyelonephritis on CT and admitted to [**Hospital Unit Name 153**] because of
hypotension.
#. Hypotension/Pyelonephritis: Patient admitted to MICU for
concern for sepsis in setting of hypotension to SBP 70s in ED.
However, she did not meet SIRS criteria. Her hypotension was
initially thought to be secondary to hypovolemia in the setting
of decreased po intake. Moreover, the patient's baseline
systolic BP was in the 100s per report. She was given 3L NS in
the ED and 1L NS while in the [**Hospital Unit Name 153**]. She had another episode of
transient hypotension that responded to fluids in the ICU.
Patient had a positive UA and perinephric stranding with mild
left hydronephrosis on abdominal CT. She developed a
temperature to 101 on the day after admission ([**2103-3-7**]) and was
cultured. She was started on cipro in the ED and this was
continued. Her BP remained stable upon admit to [**Hospital Unit Name 27926**]
transferred to medical floor with stable vital signs. Her urine
culture grew Proteus resistant to ciprofloxacin. She was then
given ceftriaxone. She remained afebrile and hemodynamically
stable throughout the remainder of the hospitalizaiton and was
transitioned to po antibiotics at discharge.
#. Dementia: Acute on chronic worsening in setting of
infection. Continued on galantamine, Namenda. IMproved to
baseline to by admission per home health aide.
#. Hyperlipidemia: continued atorvostatin
#. Depression: continued seroquel.
#. Osteopenia: continued calcium/vitamin D.
# CODE STATUS: DNI/DNR, discussed with daugther who is HCP.
Medications on Admission:
EFFEXOR XR 150mg daily
GALANTAMINE 16 mg sustained release daily
LIPITOR 10mg daily
MEMANTINE 10 mg [**Hospital1 **]
QUETIAPINE 50 mg daily, 25mg additionally at 2PM
ASPIRIN 81 mg daily
CALCIUM 500mg [**Hospital1 **]
CHOLECALCIFEROL 1000 units daily
GLUCOSAMINE 500mg daily
MULTIVITAMIN
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY AT 2PM
().
4. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
5. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Cefuroxime Axetil 250 mg Tablet Sig: One (1) Tablet PO twice
a day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Pyelonephritis
2) Dementia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for an infection in your kidney.
You should take your antibiotics as prescribed and continue all
of your usual home medication.
You should call your doctor or return to the emergency room if
you develop fevers, chills, altered mental status or any other
concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2103-3-20**] 2:00
ICD9 Codes: 4589, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3268
} | Medical Text: Admission Date: [**2133-11-25**] Discharge Date: [**2133-11-30**]
Date of Birth: [**2070-11-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors / Metformin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional chest pressure
Major Surgical or Invasive Procedure:
[**2133-11-26**] Coronary artery bypass grafting x5 with a left internal
mammary artery to left anterior descending coronary; reverse
saphenous vein single graft from aorta to the first diagonal
coronary artery; reverse saphenous vein single graft from aorta
to first obtuse marginal coronary; reverse saphenous vein single
graft from aorta to distal right coronary artery; as well as
reverse saphenous vein graft wide from the proximal portion of
the right coronary graft to the second posterior left
ventricular coronary artery
[**2133-11-25**] Cardiac cath
History of Present Illness:
62 year old male with 1 year history of exertional chest
pressure occuring on his daily walks. The discomfort occurred
while walking on inclines and would be able to continue walking
through the pain. PCP had sent him for stress test that was
positive for inferolateral EKG ischemic changes with chest pain.
He was referred for cardiac catheterization that revealed
Coronary artery disease and is now being admitted for surgical
evaluation.
Past Medical History:
Hyperlipidemia
Hypertension
Diabetes Mellitus type 2
Thalassemia trait
Anemia
Varicose Veins
Dyspepsia
Plantar Fascitis
Benign Prostatic Hypertrophy
Gallstones
Arthritis
Past Surgical History:
Appendectomy
Social History:
Lives with: wife, [**Name (NI) 85766**] in [**Hospital1 **].
Occupation:Currently not working- was manufacturing engineer
previously.
Tobacco:
ETOH: 2 beers a day
Enrolled in any clinical/research study?
Family History:
Family History: Father with MI at 75. Two brothers with
hypertension.
Physical Exam:
Pulse:69 Resp:18 O2 sat: 99%
B/P Right: 138-156/76 Left:
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
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: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: cath site Left:+2
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2133-11-26**] Echo Pre-CPB: No spontaneous echo contrast is seen in
the left atrial appendage. A tiny patent foramen ovale is
present. Overall left ventricular systolic function is normal
(LVEF>55%). with normal free wall contractility. There is a
small, complex (mobile) atheroma in the distal aortic arch.
There are simple atheroma in the descending thoracic aorta.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion. Post-CPB: The patient is A-Paced, on
no inotropes. Preserved biventricular systolic fxn. Trace MR, no
AI. There is no evidence of flow through the atrial septum.
Aorta intact.
[**2133-11-25**] Cath: 1. Coronary angiography in this right dominant
system demonstrated triple vessel disease. The LMCA was
diffusely diseased with a 20% stenosis. The LAD had 80% lesion
in the middle segment of the vessel and 50% distally. The D1
was occluded with filling via left to left and right to left
collaterals. The S1 had a 70% stenosis. The LCX was normal with
an 80% stenosis of the OM1. The RCA had a 80% distal stenosis
and a 70% lesion in the r-pl branch. 2. Limited resting
hemodynamics revealed moderate hypertension with a centralized
systolic pressure of 154mm Hg.
[**2133-11-25**] Carotid U/S: There is no evidence of significant
stenosis within the right internal carotid artery. There is less
than 40% stenosis within the left internal carotid artery.
[**2133-11-25**] Vein mapping: Patent bilateral greater saphenous veins
with diameters as described above.
[**2133-11-25**] 01:15PM BLOOD WBC-6.3 RBC-5.28 Hgb-11.7* Hct-35.4*
MCV-67* MCH-22.2* MCHC-33.2 RDW-13.5 Plt Ct-186
[**2133-11-30**] 06:40AM BLOOD WBC-10.3 RBC-4.34* Hgb-9.7* Hct-29.8*
MCV-69* MCH-22.3* MCHC-32.5 RDW-13.6 Plt Ct-261#
[**2133-11-25**] 01:15PM BLOOD PT-13.3 PTT-150* INR(PT)-1.1
[**2133-11-26**] 01:24PM BLOOD PT-13.8* PTT-30.0 INR(PT)-1.2*
[**2133-11-25**] 01:15PM BLOOD Glucose-138* UreaN-12 Creat-0.5 Na-137
K-3.3 Cl-101 HCO3-29 AnGap-10
[**2133-11-30**] 06:40AM BLOOD UreaN-18 Creat-1.2 Na-139 K-4.1 Cl-101
[**2133-11-25**] 01:15PM BLOOD %HbA1c-8.3* eAG-192*
[**2133-11-25**] 01:15PM BLOOD ALT-21 AST-21 CK(CPK)-66 AlkPhos-48
Amylase-61 TotBili-0.4
[**2133-11-30**] 06:40AM BLOOD WBC-10.3 RBC-4.34* Hgb-9.7* Hct-29.8*
MCV-69* MCH-22.3* MCHC-32.5 RDW-13.6 Plt Ct-261#
[**2133-11-30**] 06:40AM BLOOD UreaN-18 Creat-1.2 Na-139 K-4.1 Cl-101
[**2133-11-30**] 06:40AM BLOOD Mg-2.0
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] was admitted following his
cardiac cath for surgical management. In addition to undergoing
usual pre-operative work-up, he had carotid U/S, vein mapping
and echo. On [**11-26**] he was brought to the operating room where he
underwent a coronary artery bypass graft x 5. Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one he was
started on beta blockers and diuretics and diuresed towards his
pre-op weight. Also on this day he was transferred to step-down
floor for further care. Chest tubes and epicardial pacing wires
were removed per protocol. He continued to make good progress
while working with physical therapy for strength and mobility.
Only concern was his post-op blood sugars that continued to be
quite high despite being on home doses of oral meds and Lantus.
He was set up with an outpatient endocrinologist for further
management. On post-op day 4 he appeared to ready for discharge
home with VNA services and the appropriate follow-up
appointments.
Medications on Admission:
Atenolol 50 mg daily
Glipizide 10 mg twice a day
Avapro 300 mg daily
Simvastatin 40 mg daily
ECASA 81 mg daily
Multivitamin daily
Fish Oil 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. metoprolol tartrate 25 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. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 7 days.
Disp:*7 Packet(s)* Refills:*0*
10. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary artery bypass graft x 5
Past medical history:
Hyperlipidemia
Hypertension
Diabetes Mellitus
Thalassemia trait
Anemia
Varicose Veins
Dyspepsia
Plantar Fascitis
Benign Prostatic Hypertrophy
Gallstones
Arthritis
s/p Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
The following appointments have been scheduled for you with:
Your surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] [**12-22**] at 1:45
Your Cardiologist Dr [**Last Name (STitle) 1923**] on [**12-31**] at 11:10 in her office in
[**Location 4288**] [**Telephone/Fax (1) 2258**]
Endocrinologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 88508**] on [**2133-12-3**] at 11 AM at [**Location (un) **]
[**University/College **] Vangard Office
Call and schedule an appointment with your primary care doctor
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 12775**] to be seen in [**3-2**] weeks
Completed by:[**2133-11-30**]
ICD9 Codes: 2724, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3269
} | Medical Text: Admission Date: [**2161-11-11**] Discharge Date: [**2161-11-18**]
Date of Birth: [**2088-11-29**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Flagyl
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
weakness and productive cough
Major Surgical or Invasive Procedure:
Trach change, R IJ placement, L radial arterial line
History of Present Illness:
Mrs. [**Known lastname **] is a 72 y/o F with a past hx of asthma, COPD, OSA,
s/p recent long hospitalization for respiratory failure which
eventually required a trach who was admitted to [**Hospital3 25357**] on [**11-10**] with weakness and productive cough. She
reports feeling well up until 2 days ago, when she noticed that
she felt weak and was having increasing shortness of breath.
She developed a productive cough at that time as well, with a
low-grade temp to the 99s. She has had diminished appetite
since prior to her [**Month (only) **] hospitalization, and currently endorses
decreased po intake. She denies chills, dysuria, chest pain, or
increasing pain at the site of her pressure ulcer. She has not
noticed any increase in her peripheral edema. She has not been
able to weigh herself every day, but she does report a possible
increase in sodium intake (although not more than her 2g/day
limit).
During her hospitalization (which began in [**2161-5-12**]), it was
felt that her respiratory failure was due to a combination of
COPD, LLL pna, and OSA (as she had been unable to reliably use
her Bipap while in the hospital). She also has a hx of R sided
diastolic failure (cor pulmonale [**1-12**] long hx COPD/OSA), and was
diuresed with natrecor and bumex at that time.
Past Medical History:
1. CHF (R sided diastolic failure). Last echo [**9-13**] showed
dilated LA, mild LVH, dilated RV with depressed RV fxn, [**12-12**]+MR,
2+TR, small pericardial effusion. EF 50-55%
2. asthma
3. COPD FEV1 35%, FVC 38%, ratio 91%
4. OSA (on home BIPAP)
5. HTN
6. Afib
7. remote h/o colon ca at age 29, with partial colectomy
8. s/p trach placement [**2161-6-23**] by CT [**Doctor First Name **], followed by
interventional pulmonary here
Social History:
Divorced, with four children. Retired software engineer. 25
pack years, quit 10 years ago. Denies EtOH, other illicit
drugs. Has VNA and full time health aides.
Family History:
Multiple members with colon CA
Physical Exam:
T: 99.5 BP: 78/57 RR: 26 P: 80 90% on 4L NC Wt: 124 kg
Gen: alert and oriented pleasant female, becomes short of breath
upon speaking, has to pause every few words. does not appear in
any acute distress.
HEENT: mucus membranes dry
Neck: difficult to assess JVD given large amount of soft tissue
in neck. tracheal stoma in place without surrounding erythema
or drainage
Lungs: bronchial breath sounds throughout, with mild inspiratory
wheeze heard only at L base, no rales or crackles
CV: irreg irreg, no murmurs, rubs, or gallops
Abd: obese, nontender, normoactive bowel sounds.
Ext: severe lymphedema bilateral LE, with erythema on feet and
ankles that does not extend in skin folds. Nontender, no
warmth.
Skin: no yeast seen under pannus
Pertinent Results:
[**2161-11-11**] 08:30PM GLUCOSE-108* UREA N-19 CREAT-1.0 SODIUM-145
POTASSIUM-3.2* CHLORIDE-102 TOTAL CO2-32* ANION GAP-14
[**2161-11-11**] 08:30PM CALCIUM-7.2* PHOSPHATE-2.8 MAGNESIUM-1.3*
[**2161-11-11**] 08:30PM WBC-23.7* RBC-4.42 HGB-10.6* HCT-35.1*
MCV-79* MCH-23.9* MCHC-30.0* RDW-16.9*
[**2161-11-11**] 08:30PM PLT COUNT-328
[**2161-11-11**] 08:30PM PT-19.7* PTT-34.2 INR(PT)-2.4
[**2161-11-18**] 05:18AM BLOOD WBC-16.9* RBC-3.87* Hgb-9.5* Hct-32.0*
MCV-83 MCH-24.6* MCHC-29.7* RDW-17.4* Plt Ct-303
[**2161-11-15**] 03:18AM BLOOD Neuts-92* Bands-0 Lymphs-4* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2161-11-18**] 05:18AM BLOOD Plt Ct-303
[**2161-11-18**] 05:18AM BLOOD PT-16.3* PTT-27.6 INR(PT)-1.7
[**2161-11-18**] 05:18AM BLOOD Glucose-132* UreaN-19 Creat-0.9 Na-148*
K-3.6 Cl-107 HCO3-34* AnGap-11
[**2161-11-15**] 03:18AM BLOOD ALT-13 AST-20 LD(LDH)-372* CK(CPK)-14*
AlkPhos-65 Amylase-52 TotBili-0.3
[**2161-11-18**] 05:18AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.7
[**2161-11-15**] 03:18AM BLOOD Hapto-275*
[**2161-11-13**] 04:45AM BLOOD Cortsol-141.8*
[**2161-11-14**] 05:29AM BLOOD Digoxin-1.7
[**2161-11-17**] 06:46PM BLOOD Type-ART Rates-/18 FiO2-50 pO2-204*
pCO2-59* pH-7.36 calHCO3-35* Base XS-6 Intubat-NOT INTUBA
Comment-TRACH MASK
[**2161-11-16**] 04:05AM BLOOD Lactate-2.0
[**2161-11-15**] 03:33AM BLOOD freeCa-1.20
Echo [**2161-11-13**]
1. The left atrium is mildly dilated. The right atrium is
moderately dilated.
2. The left ventricular cavity size is normal. Due to suboptimal
technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall
left ventricular systolic function is normal (LVEF>55%).
3. The right ventricular cavity is dilated. Right ventricular
systolic
function appears depressed.
4. The aortic valve leaflets (3) are mildly thickened. Trace
aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
6. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension.
7. Compared with the findings of the prior study of [**2160-9-24**],
there has been
no significant change.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted from an OSH to the general medical
floors and started on azithromucin and ceftriaxone initially.
THe night of admission she developed hypostension and hypoxia.
She was transferred to the MICU on [**2161-11-12**] for this hypoxia and
hypotension. Her respiratory decompensation was thought to be
secondary to pneumonia given that she was having thick
secretions from her trach.
1. Hypoxia: Given pt's low grade fever, leukocytosis, and new
productive cough, most likely diagnosis is pneumonia. SHe was
started on zosyn and vancomycin for a possible nosocomial
pneumonia. Her sputum was postive for pseudomonas. She required
ventilation via her trach to keep her oxygenation up. Initially
she required high FiO2 on the ventoilator to maintain
oxygenation. She was also treated with nebulizers and albuteral
inhalers prn and tiatroprium. She continued to produce white
sputum. On [**2161-11-17**] she tolerated being of the ventilator for 5
hours. On day of discharge she was tolerating being off the
ventilator and recieved supplemental oxygen via trach mask. Her
most recent ABG was 7.36/50/204 on FiO2 0.5, pressure support
ventilation 13/10 on [**2161-11-17**].
2. Hypotension: She was admitted to the MICU with systolic blood
pressures in the 90's. There was concern for sepsis as her
lactate was 3.7 and an elevated WBC at 23. She was given
intravenous fluids (5Liters on HD 2), stress dose steroids, and
started on neosynephrine to keep MAPS>65. She was then
transitioned to vasopressin and neosynephrine weaned off. She
also required levophed for a short period of time. Her lactate
levels decreased over several days. The vasopressin was weaned
off by [**2162-11-15**] and her blood pressure remianed stable.
3. Weakness/Electrolytes: This was felt to be due to her
hypokalemia and respiratory decompensation. She had Mg of 0.5
at outside hospital and was repleted on the ambulance ride over
here. Her elctrolytes were repleted.
4. CHF: Pt has not had Echo since [**11-13**], may have had
significant decline in EF given her extended hospitalization and
respiratory failure. Her echo showed and aef of 55% that was
unchanged from previous. She was diuresed with lasix
periodically and responded well once her blood pressure
stabilized.
5. ID: SHe was treated with zosyn for pneumonia. She was treated
with vancomycin as well for empiric coverage of gram postive
organisms. Her cultures never grew gram positives, so that was
discontinued on HD 7. She has been on po vancomycin since early
[**10-15**] for history of CDiff at [**Hospital3 **] (did not tolerate
Flagyl [**1-12**] rash). We continued oral vancomycin and her c
difficile tests were negative here. She did have mild diarrhea
here. Her urine cultrue was negative and blood cultures remained
negative.
6. Endocrine: She was treated with stress dose steroids. She
should continue on a prednisone taper.
6. FEN: She was treated aggressively with IVF initially for
concern of sepsis. She became mildly fluid overloaded toward the
end of her hospitazization and was diuresed with lasix. She had
a normal speech and swallow evaluation and ate a cardiac diet.
7. Access: She had a R IJ placed and a L radial arterial line
during her hospitalization.
8. Prophylaxis: She was treated with lansoprazole and was
anticoagulated on coumadin, no need for bowel regimen given
chronic diarrhea. Of note, her INR remained elevated even when
the coumadin was discontinued for being suprstherapeutic likely
due to antiobiotic use. She will be discharged on her home dose
of 1 mg daily.
Medications on Admission:
Digoxin 0.125 mg daily
Mirtazapine 15 mg daily
Bumex 1 mg daily
Metoprolol 50 mg daily
Vancomycin 250 mg tid po x 3 months
Advair [**Hospital1 **]
Spiriva daily
Warfarin 1 mg qhs
Ambien 5 mg qhs
Combivent
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Sepsis
Pneumonia
Respiratory decompensation
Secondary: Atrial fibrillation, CHF, COPD, OSA s/p trach, C
difficile, adrenal insufficiency.
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Discharge
Worksheet-Followup-Instructions-Finalized:[**Last Name (LF) **],[**Name8 (MD) **], MD
on [**11-18**] @ 1355
Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week.Scheduled
Appointments :
Provider [**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**Name Initial (PRE) **].D. Where: [**Hospital6 29**] WOMEN'S
HEALTH CENTER Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-11-30**] 12:10
ICD9 Codes: 0389, 486, 4280, 2762, 2760, 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3270
} | Medical Text: Admission Date: [**2172-12-4**] Discharge Date: [**2172-12-11**]
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2172-12-5**]: Right hip hemiarthroplasty
History of Present Illness:
The patient is a 88 year old male who fell sustaining a right
femoral neck fracture. He was initially seen at [**Hospital3 635**]
hospital. There he was seen by cardiology for elevated
troponins. He was found to be a moderate high risk for surgery.
At the request of the patient's daughter, he was transferred to
[**Hospital1 18**] for fixation of his fracture.
Past Medical History:
CAD, s/p CABG [**2145**]
CVA
HTN
h/o SBO
CHF
PVD
s/p appy
s/p ccy
s/p hernia repair
Social History:
Lives alone
Family History:
NC
Physical Exam:
Upon arrival:
NAD
RRR, 2/6 systolic murmur
CTA b/l
S/NT/ND +BS
RLE: shortened, externally rotated
NVI distally
Pertinent Results:
[**2172-12-9**] 10:12AM BLOOD WBC-10.6 RBC-3.64* Hgb-12.0* Hct-34.6*
MCV-95 MCH-32.9* MCHC-34.6 RDW-13.5 Plt Ct-393
[**2172-12-8**] 09:38AM BLOOD WBC-15.8* RBC-3.52* Hgb-11.6* Hct-33.4*
MCV-95 MCH-32.9* MCHC-34.7 RDW-13.5 Plt Ct-366
[**2172-12-7**] 06:05AM BLOOD WBC-15.8* RBC-3.53* Hgb-11.6* Hct-33.2*
MCV-94 MCH-32.7* MCHC-34.8 RDW-13.6 Plt Ct-297
[**2172-12-6**] 03:09AM BLOOD WBC-15.2* RBC-4.02* Hgb-13.9* Hct-37.2*
MCV-93 MCH-34.5* MCHC-37.2* RDW-14.1 Plt Ct-326
[**2172-12-5**] 11:01AM BLOOD WBC-15.8* RBC-4.19* Hgb-13.8* Hct-39.5*
MCV-94 MCH-33.0* MCHC-35.0 RDW-13.7 Plt Ct-317
[**2172-12-5**] 06:30AM BLOOD WBC-13.1* RBC-4.66 Hgb-15.3 Hct-43.8
MCV-94 MCH-33.0* MCHC-35.1* RDW-13.8 Plt Ct-314
[**2172-12-4**] 03:00PM BLOOD WBC-13.5* RBC-4.68 Hgb-15.5 Hct-44.3
MCV-95 MCH-33.1* MCHC-35.0 RDW-13.9 Plt Ct-279
[**2172-12-9**] 10:12AM BLOOD Neuts-82.1* Lymphs-10.8* Monos-6.1
Eos-0.9 Baso-0.2
[**2172-12-9**] 10:12AM BLOOD PT-14.3* INR(PT)-1.3*
[**2172-12-7**] 06:05AM BLOOD PT-15.8* PTT-38.8* INR(PT)-1.4*
[**2172-12-5**] 06:30AM BLOOD PT-13.9* PTT-34.1 INR(PT)-1.2*
[**2172-12-4**] 03:00PM BLOOD PT-14.6* PTT-34.1 INR(PT)-1.3*
[**2172-12-8**] 09:38AM BLOOD Glucose-148* UreaN-19 Creat-0.7 Na-138
K-4.1 Cl-102 HCO3-27 AnGap-13
[**2172-12-7**] 06:05AM BLOOD Glucose-134* UreaN-17 Creat-0.7 Na-135
K-4.1 Cl-101 HCO3-27 AnGap-11
[**2172-12-6**] 03:09AM BLOOD Glucose-143* UreaN-16 Creat-0.9 Na-134
K-4.3 Cl-101 HCO3-23 AnGap-14
[**2172-12-5**] 11:01AM BLOOD Glucose-167* UreaN-21* Creat-0.9 Na-134
K-4.5 Cl-104 HCO3-22 AnGap-13
[**2172-12-5**] 06:30AM BLOOD Glucose-140* UreaN-22* Creat-0.9 Na-134
K-4.5 Cl-102 HCO3-24 AnGap-13
[**2172-12-4**] 03:00PM BLOOD Glucose-141* UreaN-24* Creat-0.9 Na-136
K-4.9 Cl-101 HCO3-24 AnGap-16
[**2172-12-6**] 10:15AM BLOOD CK-MB-8 cTropnT-0.15*
[**2172-12-6**] 03:09AM BLOOD CK-MB-7 cTropnT-0.19*
[**2172-12-5**] 08:47PM BLOOD CK-MB-6 cTropnT-.30*
Brief Hospital Course:
The patient was transferred to [**Hospital1 18**] on [**2172-12-4**] and admitted to
the orthopedic service. He was seen by both medicine and
cardiology for pre-operative risk assessments. On [**2172-12-5**] he
was taken to the operating room for a right hip
hemiarthroplasty. Intra-operatively the patient had a NSTEMI.
He was brought to the SICU post-operatively. His troponins
trended down from 0.3 to 0.15 and he was stable enough to be
transferred to the floor. On the floor he was evaluated by
physical therapy and progressed well. Cardiology saw the
patient daily and adjusted his lopressor to control his heart
rate adequately. On [**2171-12-9**] his incision was found to have
increased erythema and warmth. Ancef was started for this
cellulitis and the erythema improved. A repeat echocardiogram
was done which was unchanged from previous. His hospital course
was otherwise without incident. His pain was well controlled.
His labs and vital signs remained stable. He is being
discharged today to rehab in stable condition.
Medications on Admission:
nitro 0.4mg SL prn
isosorbide 60mg PO daily
digitek 0.025mg PO daily
citalopram 20mg PO daily
propranolol 20mg PO daily
lisinopril 7.5mg PO daily
lasix 20mg PO every other day
lipitor 10mg PO daily
Vitamin B complex daily
Imodium prn
Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 7 days.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg syringe
Subcutaneous DAILY (Daily) for 4 weeks.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day): hold for SBP<100, HR<55.
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for standing.
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Right femoral neck fracture
NSTEMI
Cellulitis
Discharge Condition:
Stable
Discharge Instructions:
Pleae continue with the weight bearing as tolerated on your
right leg.
Please keep incision clean and dry. Dry sterile dressing daily
as needed. If you notice any increased redness, swelling,
drainage, temperature >101.4, or shortness of breathe please
[**Name8 (MD) 138**] MD or report to the emergency room.
Please take all medications as prescribed. You need to take the
lovenox shots for 4 weeks to prevent blood clots. You may
resume any normal home medication.
Please follow up as below. Call with any questions.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Treatment Frequency:
Dry sterile dressing daily as needed.
Staples may be removed 2 weeks post-op ([**2172-12-20**])
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] at the [**Hospital1 18**] orthopedic clinic
in 4 weeks. Please call [**Telephone/Fax (1) **] to make an appointment.
Please follow up with your cardiologist Dr. [**Last Name (STitle) 20948**] soon after
your discharge.
Completed by:[**2172-12-11**]
ICD9 Codes: 4280, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3271
} | Medical Text: Admission Date: [**2148-7-9**] Discharge Date: [**2148-8-5**]
Date of Birth: [**2086-4-8**] Sex: F
Service: SURGERY
Allergies:
Levaquin
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Gallbladder adenomyomatosis
Major Surgical or Invasive Procedure:
[**2148-7-9**]:
1. Laparoscopic cholecystectomy.
2. Laparoscopic lysis of adhesions.
[**2148-7-13**]:
1. Exploratory laparotomy after recent laparoscopy.
2. Small-bowel resection with primary anastomosis.
3. Adhesiolysis
[**2148-7-24**]:
1. IR guided drainage pelvic cul de sac fluid collection
History of Present Illness:
62 y/o female with persistent elevation of alk phos and a RUQ
ultrasound concerning for a GB mass. She underwent an MRCP which
demonstrated a mass in the gallbladder fundus with features
consistent with adenomyomatosis. Because of these findings she
was scheduled for an elective laproscopic cholecystectomy. Her
previous surgical history include an urgent exploratory
laparotomy and splenectomy [**2-27**] a splenic laceration during a
colonoscopy.
Past Medical History:
HTN
Hyperlipidemia
osteoporosis
GERD
D&C [**11-28**] [**2-27**] vag bleeding: Path non-diagnostic
Splenectomy [**8-25**] (perforated during colonoscopy)
Social History:
no tobacco
rare EtOH (1 glass of wine with dinner)
works in Dr[**Doctor Last Name **] office (urology)
Family History:
Mother - DM2, galucoma, breast Ca Mother in her 60's and 70's.
[**Name (NI) 8962**] brother with prostate cancer
Physical Exam:
97 97 81 106/66 16 98RA
NAD, comfortable
RRR no m/r/g
Breath sounds clear to bases b/l
ABd - moderate tenderness over RUQ, port sites c/d/i no
drainage. No erythema. ABd soft, non-distended, wound vac in
place over 6cm long by 6 cm deep midline incision, with well
granulating tissue
Ext: no edema or erythema
On Discharge:
VSS, Afebrile
Gen: NAD
CV: RRR
Lungs: Diminished bilateraly on bases
Abd: Midline abdominal incision with VAC dressing.
Ext: Warm, no c/c/e. Right UE PICC line.
Pertinent Results:
[**2148-7-13**] WBC-10.1 Hgb-13.4 Hct-40.0 Plt-540*
[**2148-7-13**] Lipase-36
[**2148-7-13**] Calcium-8.6 Phos-3.1 Mg-2.1
Microbiology:
[**2148-7-13**] 11:20 pm SWAB Site: PERITONEAL
**FINAL REPORT [**2148-7-21**]**
GRAM STAIN (Final [**2148-7-14**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2148-7-18**]):
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2148-7-20**]):
CLOSTRIDIUM PERFRINGENS. MODERATE GROWTH.
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
[**2148-7-16**] URINE CULTURE: NO GROWTH.
[**2148-7-18**] SWAB Source: Abdomen.
**FINAL REPORT [**2148-7-22**]**
GRAM STAIN (Final [**2148-7-18**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
WOUND CULTURE (Final [**2148-7-22**]):
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 299-9426M [**2148-7-14**].
ANAEROBIC CULTURE (Final [**2148-7-22**]): NO ANAEROBES ISOLATED
[**2148-7-20**] 6:40 pm BLOOD CULTURE: No Growth
[**2148-7-24**] 11:00 am ABSCESS Site: PELVIS PELVIC
COLLECTION.
**FINAL REPORT [**2148-7-31**]**
GRAM STAIN (Final [**2148-7-24**]):
4+ (>10 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..
WOUND CULTURE (Final [**2148-7-31**]):
[**Female First Name (un) **] ALBICANS. RARE GROWTH.
[**2148-7-13**] PATHOLOGY:
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
SPECIMEN SUBMITTED: GALLBLADDER.
DIAGNOSIS:
Gallbladder, cholecystectomy:
Chronic cholecystitis with focal pyloric metaplasia and focal
adenomyomatous hyperplasia.
Clinical: Adenomyomatosis of gallbladder.
[**2148-7-13**]: Pathology Examination
SPECIMEN SUBMITTED: Small Bowel.
DIAGNOSIS:
Small bowel, resection (A-H):
Segment of small intestine with perforation most consistent with
localized ischemia. Margins viable.
RADIOLOGY:
[**2148-7-13**] ABD CT:
IMPRESSION:
1. Findings consistent with small bowel obstruction with
probable transition point in anterior mid abdomen adjacent to
which is extensive focal stranding and locally more prominent
free air.
2. Free fluid along the inferior tip of the liver tracking along
the right and mid abdomen and into the pelvis where there is
peripheral enhancement and layering density.
[**2148-7-14**] EKG:
Sinus tachycardia. Non-specific ST-T wave changes. Compared to
the previous tracing of [**2148-7-4**] the rate has increased.
[**2148-7-22**] ABD CT:
IMPRESSION:
1. Multiple intra-abdominal fluid collections, as detailed, with
a collection inferior to the liver demonstrating a hematocrit
level, likely reflective of a small hematoma. Superinfection of
these small collections are not excluded.
[**2148-7-25**] 06:10
Report Comment:
Source: Line-PICC
COMPLETE BLOOD COUNT
White Blood Cells 18.6* 4.0 - 11.0 K/uL
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.01* 4.2 - 5.4 m/uL
PERFORMED AT WEST STAT LAB
Hemoglobin 8.9* 12.0 - 16.0 g/dL
PERFORMED AT WEST STAT LAB
Hematocrit 26.8* 36 - 48 %
PERFORMED AT WEST STAT LAB
MCV 89 82 - 98 fL
PERFORMED AT WEST STAT LAB
MCH 29.5 27 - 32 pg
PERFORMED AT WEST STAT LAB
MCHC 33.2 31 - 35 %
PERFORMED AT WEST STAT LAB
RDW 14.4 10.5 - 15.5 %
PERFORMED AT WEST STAT LAB
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 732* 150 - 440 K/uL
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On [**2148-7-9**], the patient underwent
laparoscopic cholecystectomy and an extensive laparoscopic lysis
of adhesions, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor on
clear liquid diet, with a foley catheter, and Oxycodone PO for
pain control. The patient was hemodynamically stable. On POD #
1, patient complained increased pain, abdominal discomfort; she
was kept in hospital for observation. Diet was increased to
regular, but patient had very low PO intake. On POD#2, patient
continue to experiencing abdominal pain/discomfort, poor PO, and
general weakness/malaise. On POD # 4, patient did not improved
in her condition, she underwent abdominal CT, which demonstrated
small bowel perforation and obstruction. Patient was taken back
in OR, she underwent emergent exploratory laparotomy,
small-bowel resection with primary anastomosis, and
adhesiolysis. The patient was transferred to the PACU after
surgery and was tachycardic and had respiratory distress.
Patient was transferred into ICU for further management. Patient
was NPO with NGT, started on Vanco/Aztreonam/Zosyn, she had
Foley catheter and IV fluids for hydration. Patient's ICU course
was complicated by wound infection, her midline incision was
open. Wound dressing was changed twice a day with Dakins
wet-to-dry dressing. Patient was started on IV Zosyn and
Aztreonam, wound cultures came back positive for Pseudomonas
Aeruginosa. For detailed ICU course please refer to ICU notes.
.
On [**2148-7-19**] (POD# [**10-30**]), patient was transferred to the floor on
full liquids diet, she was continued on IV Abx., Foley to
gravity and telemetry. Patient's diet was advanced to regular,
and Foley was d/cd on [**7-23**]. On [**7-22**] patient wound was started
on VAC dressing with black sponge. On [**7-23**] patient underwent
abdominal CT scan which demonstrated multiple intra-abdominal
fluid collections. On [**7-24**] she underwent Ultrasound guided
drainage of the intraabdominal fluid collection, fluid was sent
in microbiology lab for cultures. Patient tolerated procedure
well, she returned on the floor in stable condition. Patient was
evaluated by PT and they recommended discharge in Rehab. Prior
discharge, patient was continued on VAC dressing and IV
antibiotics. Patient was discharge in Rehab on [**2148-8-5**] in
stable condition. On discharge he VAC dressing was replaced with
wet-to-dry for transport.
.
Neuro: The patient received Dilaudid PCA and Ketorolac IV for
pain control postoperatively with good effect and adequate pain
control. When tolerating oral intake, the patient was
transitioned to oral pain medications. After transferred on the
floor, and started VAC dressing, patient reported increased
abdominal pain. Pain medication was changed from Oxycodone to
Dilaudid, she was started on Tylenol around the clock. Patient
also received IV Dilaudid prior VAC dressing changes, her pain
was adequately controlled since that.
CV: Patient had episode of tachycardia post operatively, which
were treated with IV/PO Metoprolol. The patient remained stable
from a cardiovascular standpoint; vital signs were routinely
monitored.
Pulmonary: Post operatively patient was required supplemental O2
via tent mask. When stable, patient was continue to receive
supplemental O2 via nasal cannula. Chest xrays and CT were
negative for PE, patient had atelectasis s/t fluid overload. She
was treated with PO diuretics and extensive chest PT. Also, good
pulmonary toilet, early ambulation and incentive spirrometry
were encouraged throughout hospitalization. Currently patient's
O2 sats stable on room air, her atelectasis improved on
radiogram.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: After second surgery, patient's WBC raised to 14.0. She
developed purulent discharge from her abdominal incision, and
incision was open. Wound cultures were sent and came back
positive with Pseudomonas Aeruginosa. Patient was started on
antibiotics. Wound dressing was changed [**Hospital1 **] with Dakins
solution. Patient's WBC was continued to rise with max 21.3, on
[**7-25**] WBC finally started to decline and was 18.6. Patient
wet-to-dry dressing was changed to VAC dressing with continuous
suction on [**2148-7-22**]. Patient continue on Zosyn and Aztreonam IV.
Abscess fluid cultures came back positive for [**Female First Name (un) 564**] Albicans,
patient was started on Micafungin 100 mg qd, switched to
Fluconazole 200 mg qd, her Aztreonam was d/cd, and Zosyn dose
was increased per ID recommendations. Patient's WBC continue to
improve and was 10.2 on [**8-3**]. On time of discharge patient
continue to receive IV Zosyn, PO Cipro and Fluconazole. Abx will
be discontinue per ID recommendations.
Endocrine: The patient's blood sugar was monitored throughout
her stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; her Hct continue to decline post operatively from
40.1 on [**7-14**] to 26.8 on [**7-25**]. Patient remained asymptomatic
with stable vital signs, her Hct remains stable low. No blood
transfusion was required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible with assist. Physical
therapy evaluated the patient and recommended discharge her in
Rehab to continue PT.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with minimal assist, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety.
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety.
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
10 days: While on narcotic pain meds.
Disp:*20 Capsule(s)* Refills:*0*
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
10. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours) for 2 days.
11. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): last dose on [**2148-8-14**].
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
15. HYDROmorphone (Dilaudid) 0.5-1.0 mg IV Q6H:PRN breakthrough
pain
give prior VAC change
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 1887**]
Discharge Diagnosis:
1. Gallbladder mass--adenomyomatosis
2. Small bowel obstruction.
3. Perforated small bowel with peritonitis
4. Wound infection
5. Respiratory distress
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-3**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
You will continue to have VAC dreesing on your abdominal
incision. Dressing will be changed by the nurses in Rehab.
Followup Instructions:
Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2148-7-25**] 9:45
.
Provider: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2148-11-8**] 8:00
.
Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2149-3-20**] 8:30
Completed by:[**2148-8-5**]
ICD9 Codes: 5185, 5849, 5180, 5119, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3272
} | Medical Text: Admission Date: [**2125-4-11**] Discharge Date: [**2125-4-15**]
Date of Birth: [**2048-4-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Disopyramide
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
s/p MVR/(33Onx),CABG-0m,MAZE,repair AV groove.IABP,open chest
[**4-13**]
History of Present Illness:
76-year-old woman who previously had been admitted for
management of atrial fibrillation and polymorphic ventricular
tachycardia. The latter was thought to
be due to QT prolongation from disopyramide, leading to torsade
de pointes. She had no further episodes of VT. Regarding her
atrial fibrillation, this was managed with both amiodarone and
diltiazem to control her rate. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor after
discharge on [**2125-2-13**], showed atrial fibrillation at rates
of 60-110. During the hospitalization also, she was discovered
to have severe mitral and tricuspid regurgitation.
Past Medical History:
DM2
dyslipidemia
hypertension
CVA, residual L-sided weakness, on warfarin
hypothyroidism
CARDIAC RISK FACTORS: Diabetes(+), Dyslipidemia(+),
Hypertension(+)
Social History:
Occupation: retired school teacher
Lives Alone Race caucasian
Tobacco 18 pack year history - quit in her 30's
ETOH occassional glass wine
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
Pulse: 80 Resp: 18 O2 sat: 98%
B/P 134/89
Height: 5'4" Weight: 60.7 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]no lymphademopathy
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur 3/6 systolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] last bm [**4-9**]
Extremities: Warm [x], well-perfused [x] Edema + 2 pitting in
ankles Varicosities: None []
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2125-4-11**] 11:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2125-4-11**] 04:15PM GLUCOSE-70 UREA N-18 CREAT-1.2* SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
[**2125-4-11**] 04:15PM ALT(SGPT)-18 AST(SGOT)-16 LD(LDH)-218 ALK
PHOS-104 TOT BILI-0.3
[**2125-4-11**] 04:15PM ALBUMIN-4.6
[**2125-4-11**] 04:15PM %HbA1c-6.6*
[**2125-4-11**] 04:15PM TSH-1.9
[**2125-4-11**] 04:15PM WBC-10.1 RBC-4.42 HGB-11.7* HCT-36.6 MCV-83
MCH-26.4* MCHC-31.9 RDW-16.0*
[**2125-4-11**] 04:15PM PLT COUNT-438
[**2125-4-11**] 04:15PM PT-15.9* PTT-21.4* INR(PT)-1.4*
[**2125-4-15**] 04:08PM BLOOD WBC-20.4* RBC-3.95* Hgb-11.6* Hct-33.7*
MCV-85 MCH-29.2 MCHC-34.3 RDW-17.1* Plt Ct-29*#
[**2125-4-15**] 04:08PM BLOOD Plt Ct-29*#
[**2125-4-15**] 04:08PM BLOOD PT-90* PTT-150* INR(PT)-11.7*
[**2125-4-15**] 04:08PM BLOOD Glucose-56* UreaN-26* Creat-1.9* Na-145
K-6.0* Cl-104 HCO3-14* AnGap-33*
[**2125-4-15**] 04:08PM BLOOD ALT-2939* AST-4633* LD(LDH)-6005*
AlkPhos-54 Amylase-68 TotBili-8.5*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 20437**], [**Known firstname 8207**] [**Hospital1 18**] [**Numeric Identifier 20438**]
(Complete) Done [**2125-4-13**] at 9:17:13 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2048-4-24**]
Age (years): 76 F Hgt (in): 64
BP (mm Hg): 125/78 Wgt (lb): 130
HR (bpm): 78 BSA (m2): 1.63 m2
Indication: Intraoperative TEE for Mitral valve replacement ,
MAZE procedure and left atrial appendage ligation.
ICD-9 Codes: 427.31, 786.05, 440.0, 424.0, 424.2
Test Information
Date/Time: [**2125-4-13**] at 09:17 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine: [**Last Name (un) 20439**] 3D
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 50% >= 55%
Aorta - Annulus: 1.6 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Mitral Valve - MVA (P [**11-24**] T): 1.4 cm2
Findings
LEFT ATRIUM: Dilated LA. Depressed LAA emptying velocity
(<0.2m/s) No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal regional LV
systolic function. Low normal LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Characteristic rheumatic deformity of the mitral
valve leaflets with fused commissures and tethering of leaflet
motion. Moderate mitral annular calcification. Moderate valvular
MS (MVA 1.0-1.5cm2) Moderate (2+) MR.
TRICUSPID VALVE: Moderate [2+] TR.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. Results were personally reviewed with
the MD caring for the patient.
Conclusions
Prebypass
1. The left atrium is dilated. The left atrial appendage
emptying velocity is depressed (<0.2m/s). No thrombus is seen in
the left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler.
2. Left ventricular wall thicknesses are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). with mild global
RV free wall hypokinesis.
3.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
4. The mitral valve shows characteristic rheumatic deformity.
There is moderate valvular mitral stenosis (area 1.0-1.5cm2).
Moderate (2+) mitral regurgitation is seen.
5. Moderate [2+] tricuspid regurgitation is seen. The tricuspid
regurgitation is 3 + when the blood pressure is 135/80 and the
PA pressures are 60/26. Findings discussed with Drs [**Last Name (STitle) 914**] and
[**Name5 (PTitle) 171**] ( present in the room). Decision made to leave the
tricuspid valve alone.
6. There is a small pericardial effusion.
7. Dr. [**Last Name (STitle) 914**] was notified in person of the results on
[**2125-4-13**] at 800am.
Post bypass
First attempt at separation from CPB complicated by AV
dissociation. Emergently went back on CPB.
Patient is AV paced and receiving an infusion of epinephrine,
milrinone and norepinephrine.
1. Unable to assess LV systolic function due to very poor
transgastric views.
2. Mechanical valve seen in the mitral position. Leaflets move
well and valve appears well seated. Washing jets seen.
3. Tricuspid regurgitation is mild to moderate.
4. Aorta is intact post decannulation.
5. The left atrial appendage has been ligated.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2125-4-13**] 16:45
CXR
Final Report
REASON FOR EXAMINATION: Followup of the patient after extensive
thoracic
surgery.
Portable AP chest radiograph was compared to [**2125-4-14**],
obtained 09:30 a.m.
The intra-aortic balloon pump was repositioned and is currently
approximately 1.8 cm below the expected position of the roof of
the aortic arch. The Swan-Ganz catheter tip is at the right main
pulmonary artery. The position of the chest tubes, mediastinal
drains and NG tube is unchanged. It is difficult to evaluate the
pr?cised location of the ET tube. The left retrocardiac opacity
has not been significantly changed, consistent with atelectasis.
No evidence of pneumothorax is present.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
============================================
Brief Hospital Course:
Ms [**Known lastname **] was admitted ot the operating room for
MVR/CABG/maze. She experienced difficulties in the operating
room, please see the OR report for details.
She was transferred from the operating room to the ICU in
critical condition with an IABP and open chest. She improved
hemodynamically over the next few days but then took a turn for
the worse and on POD 2 she developed mesanteric ischemia. After
detailed discussions with the family she was made comfort
measures only and expired a short time later.
Medications on Admission:
Amiodarone 200 mg daily
amoxicillin prn
Lipitor 20 mg daily
Cardizem 240 mg twice daily
Glyburide 5 mg daily
Levoxyl 50 mcg daily
Losartan 25 mg daily
metformin 500 mg daily
Coumadin 1-4 mg dose changing - last dose sunday [**4-8**]
calcium with vitamin D.
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2125-5-1**]
ICD9 Codes: 4271, 9971, 2724, 4019, 2449, 4280, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3273
} | Medical Text: Admission Date: [**2171-2-16**] Discharge Date: [**2171-2-25**]
Date of Birth: [**2133-7-4**] Sex: M
Service:
CHIEF COMPLAINT: Nausea, vomiting, and acute pancreatitis.
HISTORY OF PRESENT ILLNESS: A 38-year-old gentleman with
history of hypothyroidism and acid reflux who presented with
acute abdominal pain, nausea, and vomiting times one day.
Pain began a day prior to admission after eating tuna fish
and having a glass of wine. He described the pain as severe
and crampy with nausea and vomiting, it is bilious. No
hematemesis or diarrhea. Denies heavy alcohol use or
gallstones or diuretic use. Also denies
hypertriglyceridemia. Of note, had recent URI with symptoms
of sinusitis and bronchitis and sent home on Advair and
Augmentin. On arrival to the emergency room, the patient was
afebrile, hypertensive at 160/96 with severe abdominal pain.
Labs notable for white count of 19, 79 percent neutrophils, 5
percent bands, and lipase of 1291. All other lab values
within normal limits. CT of the abdomen revealed
pancreatitis with stranding and abrupt tapering of major
papillae, but no visible stones. The patient received
Zofran, morphine, levofloxacin, and Flagyl in the emergency
room as well as IV fluids.
PAST MEDICAL HISTORY: Hypothyroidism.
Acid reflux.
Recent history of bronchitis.
Sinusitis.
MEDICATIONS: At home,
1. Synthroid 125 mcg q.d.
2. Nexium q.d.
3. Hydrocodone and Vicodin just times a few days with a
recent dental procedure.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Denies heavy alcohol use, drinks
occasionally. Denies tobacco use. Married. Lives in [**State 16269**].
FAMILY HISTORY: No significant past family medical history.
PHYSICAL EXAMINATION: Temperature 97 degrees, blood pressure
160/96, heart rate 96, and respiratory rate 16, oxygen
saturation 98 percent on room air. Physical exam within
normal limits, but with abdominal pain with positive
hepatomegaly about 3 cm below the costal margin. Also
abdomen was tender throughout especially in the epigastric
region. The patient, of note, was not jaundiced and without
stigmata of chronic liver disease. Positive [**Doctor Last Name 515**] sign.
No abdominal distention or fluid shift or hypoactive bowel
sounds. Lungs were clear. Cardiac exam within normal
limits. Neuro exam within normal limits.
DIAGNOSTIC STUDIES: On admission, white count 19, hematocrit
50, and platelets 230. Chemistries within normal limits.
Lipase 1291, total bilirubin 0.6, ALT 35, AST 25, and
alkaline phosphatase 110. ECG within normal limits except
for tachycardiac at 100. Abdominal x-ray without
obstruction. Chest x-ray within normal limits. CT of the
abdomen was consistent with pancreatitis as mentioned in the
HPI.
CONCISE SUMMARY OF HOSPITAL COURSE: A 38-year-old man
without known risk factors with acute onset of nausea,
vomiting, and abdominal pain and workup consistent with acute
pancreatitis.
Pancreatitis: The patient was admitted to the medical
intensive care unit on the [**Hospital Ward Name 516**] for close monitoring.
The patient received aggressive IV fluids as well as pain
control and blood pressure control in the ICU. The patient
improved and was transferred to the medicine floor on
[**2171-2-11**] approximately five days after being admitted.
Unclear etiology of the pancreatitis. The patient may have
passed a stone, also may have more alcohol use than he is
admitting to. MRCP was performed and was normal except for 1
cm common bile duct. The patient's CMV and EBV IgM are both
negative. The patient was initially n.p.o. with aggressive
IV fluids and then tolerated clear liquids for comfort
without pain. The patient had an NG tube placed, but this
was discontinued on the medicine floor. Abdominal exam
improved dramatically and was within normal limits at the
time of discharge. The patient was initially on Dilaudid PCA
and switched to oral agents with good pain control.
The patient and his family requested discharge from the
hospital on [**2171-2-25**] stating that he would seek further
medical care in [**State 531**] City. The patient did not want to
stay in the [**Location (un) 86**] area any further. Due to this, some
medical records were faxed over to the patient's doctor in
the [**State 531**] area, and he was discharged. Plan, outpatient
followup with his regular PCP as well as a
gastroenterologist.
Hypertension and sinus tachycardia thought to be related to
pain and dehydration, but continued despite PCA and IV
fluids. Concern over alcohol withdrawal, but the patient was
covered with CIWA scale, but did not require any
benzodiazepine. ECG was also within normal limits. The
patient was started on metoprolol, which was continued with
good effect. Plan, outpatient followup with this.
Pulmonary: Patient tachypneic with supplemental O2 needed
initially likely related to abdominal distention and pain,
may also be due to lung injury from pancreatitis, pleural
effusion, or atelectasis from pleuritic pain. Repeat chest x-
ray after admission showed a left lower lobe
collapse/consolidation as well as small pleural effusion.
The patient was continued on supplement oxygen, but was
stable on room air at the time of discharge. Pain was
controlled well. No signs or symptoms of pneumonia.
Infectious disease: No signs or symptoms of an acute
infection; however, the patient did have a fever of 101 while
on the medicine floor likely related to atelectasis. Blood
cultures and urine cultures were without growth to date at
the time of discharge.
Hypothyroidism: The patient was continued on Synthroid and
clinically euthyroid.
Fluids, electrolytes and nutrition: Positive for about 16
liters in the ICU. Patient with good urine output. The
patient was on TPN in the ICU, however, was transitioned over
to POs on the medicine floor.
The patient's NG tube was initially at low suction, but this
was discontinued on the medicine floor.
The patient and family was requesting discharge from the
hospital, although we recommended further continued hospital
stay for close monitoring. The patient refused this stating
that he wanted to go back to [**Location 8398**]where he lives and
that he would seek medical attention there. Records were
faxed over to his primary care physician there who agreed to
see the patient upon arrival there.
DISCHARGE CONDITION: Fair.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Acute pancreatitis.
Malignant hypertension.
Hypothyroidism.
Hypoglycemia.
Fever.
DISCHARGE MEDICATIONS:
1. Albuterol p.r.n.
2. Synthroid 125 mcg q.d.
3. Atenolol 100 mg q.d.
4. Hydralazine 25 mg q.6 h.
FOLLOW UP: Patient to follow up with the primary care
physician as soon as he arrived back in [**State 531**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**]
Dictated By:[**Last Name (NamePattern1) 4959**]
MEDQUIST36
D: [**2171-8-13**] 14:21:35
T: [**2171-8-14**] 03:57:31
Job#: [**Job Number 52740**]
ICD9 Codes: 2765, 5119, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3274
} | Medical Text: Admission Date: [**2148-8-16**] Discharge Date: [**2148-8-21**]
Service: MEDICINE
Allergies:
Dicloxacillin / Beta-Blockers (Beta-Adrenergic Blocking Agts) /
Shellfish / Aspirin / Epinephrine / Cefaclor / Neomycin /
clindamycin / Bacitracin / Clavulanic Acid / Latex
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Chief Complaint: s/p fall, hypoxia, agitation
.
Reason for MICU Admission: hypoxia
Major Surgical or Invasive Procedure:
staples to repair right forehead laceration
History of Present Illness:
This is a [**Age over 90 **] yo female with history of diastolic CHF, COPD, ?
dementia who presents from [**Hospital1 1501**] s/p fall. Patient was overtly
delirious on admission and unable to provide history.
Information was obtained from records provided.
.
Apparently patient was found on floor today with head
laceration, and it is unknown if LOC occurred. She was noted to
be anxious and agitated. According to HCP, patient [**Name2 (NI) 102738**]
becomes hypoxic when she becomes agitated. Given fall patient
was sent to ED for further evaluation.
.
In the ED, initial vs were: 90 152/90 24 92% 4L Nasal Cannula.
Pt initially was very agitated and was given haldol 5 mg x 2, as
well as lorazepam 2 mg x 1. Primary trauma survey was
unremarkable. CXR was significant for bilateral pleural
effusions and possible evidence of pneumonia. CT of head and
C-spine was limited, but patient was cleared. Patient was given
vancomycin and levofloxacin for HCAP coverage and was also given
methylprednisolone 125mg x1 for COPD exacerbation. She also
received lasix 40 mg IV x 1, producing about 250 mL urine. The
patient's laceration was repaired. Tetanus shot was given to
patient. According to ED signout, patient became more hypoxic to
70s while agitated and was placed on NRB with recovery of sats
to low 90s. Attempts were made to place patient on BiPAP however
the patient did not tolerate this intervention. VS prior to
transfer were VS: 96.5, 91, 157/114, 30, 100% NRB. Patient was
placed on 4 point restraints prior to transfer.
.
On arrival to the ICU, patient continued to be agitated and
immediately required another 0.5 mg lorazepam IV x 2. She
presented on non-rebreather and was unable to answer questions.
.
Review of systems: Unable to obtain due to agitation
Past Medical History:
COPD
Diastolic congestive heart failure
Hypertension
Hyperlipidemia
Obstructive sleep apnea
GERD
Anemia
Monoclonal gammopathy
Gait disturbance
Atrial fibrillation (not on anticoagulation)
h/o Subdural hematoma s/p fall
Restless leg syndrome
Hypothyroidism
Depression/anxiety
Basal cell carcinoma of bilateral lower legs s/p radiation
therapy
Dry macular degeneration
Multiple falls c/b fractured nose, left rib fractures
Umbilical hernia
s/p Appendectomy
s/p TAH/BSO
Social History:
Ambulates with walker with assitance.
Family History:
unable to obtain
Physical Exam:
Admission Exam:
Vitals: T 96.9 P 90 BP 144/60 R 30 Sat 99% on NRB
General: Elderly woman, agitated, appears uncomfortable, using
accessory muscles to breathe
HEENT: Sclera anicteric, left eye with edema and conjunctivae
diffusely erythematous, MMM, oropharynx appears clear
Neck: supple, JVP difficult to assess given agitation and use of
accessory muscles to breathe, no LAD
Lungs: rhonchorous sounds and rales bilaterally on anterior
exam, no wheezes audible, using neck and abdominal muscles to
breathe
CV: irregular rhythm, no murmurs, rubs, gallops audible
Abdomen: soft, non-tender, non-distended, umbilical hernia
present, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley catheter in place
Ext: warm, well perfused, 2+ pulses, trace edema bilaterally
.
Discharge Exam
T 98.7, HR 92, BP 122/52, RR 24, sat 89% on 2L
General: Elderly woman, sitting up in chair. Alert, talkative,
appropriate
HEENT: Sclera anicteric, left eye with edema and conjunctivae
diffusely erythematous, MMM, oropharynx appears clear
Lungs: Bibasilar crackles, no wheezes audible
CV: irregular rhythm, no murmurs, rubs, gallops audible
Abdomen: soft, non-tender, non-distended, umbilical hernia
present, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, trace edema bilaterally
Pertinent Results:
Admission Labs:
[**2148-8-16**] 06:18PM BLOOD WBC-8.7# RBC-3.19* Hgb-10.9* Hct-33.8*
MCV-106* MCH-34.2* MCHC-32.3 RDW-19.4* Plt Ct-326
[**2148-8-16**] 06:18PM BLOOD Neuts-86.8* Lymphs-7.2* Monos-3.3 Eos-1.4
Baso-1.3
[**2148-8-16**] 06:18PM BLOOD PT-12.6 PTT-22.7 INR(PT)-1.1
[**2148-8-16**] 06:18PM BLOOD Fibrino-342
[**2148-8-16**] 06:18PM BLOOD Glucose-110* UreaN-33* Creat-0.9 Na-144
K-5.2* Cl-102 HCO3-36* AnGap-11
[**2148-8-16**] 06:18PM BLOOD CK-MB-3 proBNP-5091*
[**2148-8-16**] 06:18PM BLOOD cTropnT-0.02*
[**2148-8-16**] 06:18PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
CT Head [**2148-8-16**]: No acute intracranial process. Moderate-sized
hematoma overlying the left frontal bone. Evidence of prior
right frontoparietal craniotomy
.
CT CAP [**2148-8-16**]: 1. Exam is severely limited by motion. No
evidence of acute trauma. Multiple left-sided rib and transverse
process fractures identified with varying degrees of healing. No
acute fracture identified. Correlate with exam and mechanism.
2. Small right pleural effusion.
3. Cardiomegaly.
4. Bilateral adrenal gland hyperplasia.
.
CT C-spine [**2148-8-16**]: 1. Severely limited exam. No evidence of
gross acute fracture or malalignment.
2. T2 compression deformity with morphology suggests chronicity
but no prior studies available for comparison.
.
CXR [**2148-8-16**]
Marked volume overload evident by moderate pulmonary edema,
likely cardiogenic in etiology. Recommend appropriate diuresis
and repeat
radiography to assess for underlying infection. There are at
least fractures involving the left third, fourth, and fifth
ribs. No pneumothorax is seen.
.
Discharge Labs:
[**2148-8-21**] 05:24AM BLOOD Glucose-138* UreaN-38* Creat-1.0 Na-150*
K-4.5 Cl-102 HCO3-43* AnGap-10
[**2148-8-21**] 05:24AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.4
Brief Hospital Course:
[**Age over 90 **] yo female with history of diastolic CHF and COPD who
presented with hypoxia and agitation.
.
# Hypoxemic Respiratory Distress: Her admission CT chest was
fairly unremarkable. However, she spiked a fever and developed
bilateral infiltrates; she was started on Vanc, [**Last Name (un) 2830**], levo for
HCAP. Cultures were sent, but did not grow an organism. Her
antibiotics were tapered to levofloxacin only with the plan to
continue for an 8 day course for HCAP. She improved clinically
and had resolution of fevers on levofloxacin alone.
.
#Hypercarbic respiratory failure: Pt became somnolent in setting
of antipsychotics/benzos. Per discussion with her family and her
MD at rehab, there is a very narrow therapeutic window which
such medications in this patient. PCO2 was grossly elevated
indicating hypoventilation. She was placed on BiPAP with
improvement in mental status. Ativan was d/ced and only
risperidone (home med) was used to manage her anxiety. This a
uptitrated to 1.5mg nightly.
.
# Hypernatremia: Likely hypovolemia hyponatremia after Lasix
given concentrated appearance of urine. Pt is taking good po
free water, and Dr. [**First Name (STitle) 3646**] at rehab will be monitoring lytes. She
appears euvolemic on exam and is at baseline mental status.
.
# S/P Fall with Head Laceration: Initial trauma survey negative.
Unremarkable CT head on admission. Head laceration was repaired
in the ED. Will need staples removed 7 days from placement
(placed [**2148-8-16**]).
.
# Atrial fibrillation: patient not on anticoagulation given past
history of subdural hematoma. She is also not currently on rate
control. Heart rate was < 100 throughout her hospital stay.
.
Code status: DNR/DNI. The patient and her family would prefer
she stay at [**Hospital 100**] Rehab and not come to the hospital. If there
is some issue that cannot be managed at [**Hospital 100**] Rehab and the pt
is brought to the ED, they request she not be admitted to the
ICU in the future.
Medications on Admission:
Furosemide 60 mg PO daily Sunday, Tuesday, Thursday, Saturday
Furosemide 80 mg PO daily Monday, Wednesday, Friday
Fluticasone 50 mcg actuation spray 1 spray nasal daily
Sertraline 125 mg PO daily
Risperidone 1 mg PO daily
Albuterol sulfate 2.5 mg/3 mL solution for neb 1 IH q2h PRN
shortness of breath
Lorazepam 0.5 mg PO q6h PRN
Tylenol 650 mg PO q4-6h PRN pain
Ergocalciferol 50,000 units 1 capsule PO monthly
Sodium chloride 0.65% aerosol spray [**12-31**] sprays QID PRN dry nose
Phenylephrine HCl 0.5% spray non-aerosol 1 spray q4h PRN dry
nose
Polyethylene glycol 1 dose PO daily PRN constipation
Aluminum-magnesium hydroxide-simethicone 200-200-20 mg/5 mL
suspension 15-30 mL PO QID PRN upset stomach
Fluticasone-salmeterol 250-50 mcg/dose Disk with device [**12-31**] IH
[**Hospital1 **]
Levothyroxine 112 mcg PO daily
Ipratropium bromide 0.02% solution 1 IH q6h PRN wheezing
Guaifenesin/dextromethorphan 100 mg/5 mL syrup [**5-7**] mL PO q6h
PRN cough
Pramixpexole 1.25 mg PO daily
Camphor-menthol 0.5-0.5% lotion 1 appl topical QID PRN itching
Artificial tears 1 drop each eye apply daily
Discharge Medications:
1. sertraline 50 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray/nostril Nasal once a day.
3. risperidone 0.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): At 8pm.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation q2 hours as needed for
shortness of breath or wheezing.
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety: .
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-3**]
hours as needed for fever or pain.
7. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
8. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-31**] Sprays Nasal
every four (4) hours as needed for nasal dryness.
9. phenylephrine HCl 0.5 % Spray, Non-Aerosol Sig: One (1) spray
Nasal every four (4) hours as needed for nasal dryness.
10. Miralax 17 gram/dose Powder Sig: One (1) dose PO once a day
as needed for constipation.
11. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 mL PO four times a day as needed for indigestion.
12. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
13. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a
day.
14. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
15. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-7**]
mL PO every six (6) hours as needed for cough.
16. pramipexole 1 mg Tablet Sig: 1.25 mg PO HS (at bedtime).
17. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for eye dryness.
18. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) application
Topical once a day as needed for itching.
19. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 doses: To finish [**2148-8-23**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: s/p fall
head lacteration
altered mental status
health-care associated pneumonia
.
Secondary: anxiety
COPD
sleep apnea
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:
Ms. [**Known lastname **],
.
It has been a pleasure taking care of you here at [**First Name (Titles) **] [**Last Name (Titles) 64579**]. You came to the hospital after a fall.
There was no break in your skull or spine, and you had a
laceration stapled. You were admitted to the ICU because you
were confused and your oxygen was low. Some of this may have
been related to medication you recieved. You are much more
yourself and will be going back to [**Hospital 100**] Rehab.
.
We made the following changes to your medications:
- Please increase your risperidone to 1.5mg daily, to be taken
at 8pm (instead of 6pm). This should help you sleep.
- Please STOP taking Lasix for now. You are a bit dehydrated.
Dr. [**First Name (STitle) 3646**] will watch you closely and decide when to restart this
medicine.
- Please tale levofloxacin 750mg once daily for 2 days to finish
treatment for pneumonia.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Pt to be follwed closely by Dr. [**First Name (STitle) 3646**] at rehab.
ICD9 Codes: 486, 2760, 2930, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3275
} | Medical Text: Admission Date: [**2112-7-15**] [**Month/Day/Year **] Date: [**2112-8-5**]
Date of Birth: [**2065-5-16**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2112-7-15**] Bilateral External Ventricular Drain placement
[**2112-7-15**] Diagnostic Cerebral Angiogram
History of Present Illness:
47F who was in her usual state of health until around 3pm this
afternoon when she c/o a severe headache, she than began
vomiting. She was taken to [**First Name4 (NamePattern1) 11560**] [**Last Name (NamePattern1) **] where a head CT
showed IVH, she was intubated and medflighted to [**Hospital1 18**]. Upon
arrival to the ER, her head CT was reviewed and bilateral EVDs
were placed given the significant IVH.
Past Medical History:
[**2109**]: Thalamic bleed, admitted to [**Hospital1 18**] Stroke, angio showed
[**Last Name (un) **]
[**Last Name (un) **] and 2 small aneurysms near the ventricles. Patient was seen
at [**Hospital1 112**] and underwent bypass surgery with Dr [**Last Name (STitle) **] for [**Last Name (un) **] [**Last Name (un) **].
Depression- was on medication but discontinued secondary to side
effects.
Social History:
Lives at home with husband and young child. Denies EtOH,
tobacco, substance abuse. Was never a smoker, family denies
ETOH.
Family History:
Unknown hx of vascular anomalies
Physical Exam:
ADMISSION PHYSICAL EXAM:
Gen: Intubated, sedated for EVD placement
HEENT: Old R temporal crani scar
Neuro:
No [**Last Name (LF) **], [**First Name3 (LF) 2995**] to stim, bringing torso off the bed, no commands,
PERRL but sluggish, + cough.
[**First Name3 (LF) 894**] PHYSICAL EXAM:
General: thin F in NAD, opens eyes to voice, speaks softly,
often tearful
HEENT: R and L EVD scars well-healed. Staples in place over R
EVD scar. PERRL, mild photophobia (significantly improved).
Negative Kernig/Brudzinski.
Neuro:
-Mental status: AAOx2 (person, place). Comprehension intact.
Follows simple commands, midline and appendicular.
-Cranial nerves: CN II-XII grossly intact. +mild photophobia,
significantly improved.
-Strength: [**5-21**] all extremities
-Sensation: intact throughout
Pertinent Results:
[**7-15**] CT head:
Bilateral IVH, left ventricle fully casted, right ventricle
appears about 80% casted, blood noted in third and fourth
ventricle. No SAH can be appreciated in the OSH scan. Some edema
near the pons.
[**7-16**] CT head: 1. No change in extensive intraventricular blood,
status post bilateral ventricular drain placements.
2. Effacement of the basal cisterns and sulci of the occipital
lobe. Low
lying cerebellar tonsils is concerning for herniation, unchanged
from prior study.
3. Diffuse subarachnoid hemorrhage, slightly increased from
prior.
[**7-16**] Portable CXR:
IMPRESSION:
1. Nasogastric tube courses below the diaphragm with its tip
coiled likely within the stomach. An endotracheal tube remains
in place in satisfactory position. The lungs are well inflated
without evidence of focal airspace consolidation, pleural
effusions, or pneumothorax. Overall, cardiac and mediastinal
contours are within normal limits.
[**7-18**] CT head: IMPRESSION:
1. Interval improvement in hydrocephalus and intraventricular
hemorrhage. No new hemorrhage.
2. Unchanged position of bifrontal approach EVDs.
3. Subarachnoid hemorrhage is no longer visualized, compatible
with evolution of blood products.
[**7-22**] head CT
IMPRESSION:
1. Interval evolution of blood products with improvement in
intraventricular
hemorrhage and no significant change in size of ventricles.
2. Unchanged position of bifrontal approach EVDs.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2112-7-24**]
9:52 AM
IMPRESSION:
Interval removal of a left frontal approach EVD with
post-procedural small
amount of air in the right frontal [**Doctor Last Name 534**] and moderate amount of
air in the
right temporal [**Doctor Last Name 534**].
1. Allowing for the new air in the ventricular system, the right
lateral
ventricle is unchanged and there is no evidence of hydrocephalus
or new mass effect.
2. Right frontoparietal subarachnoid hemorrhage is stable-more
conspicuous on prior exam from [**2112-7-22**]- attention on f/u.
CHEST (PORTABLE AP) Study Date of [**2112-7-25**] 12:48 AM
FINDINGS: In comparison with the study of [**7-21**], there is no
change or evidence of acute cardiopulmonary disease.
Specifically, no pneumonia, vascular congestion, or pleural
effusion.
CHEST PORT. LINE PLACEMENT Study Date of [**2112-7-25**] 8:56 AM
Right PICC line has been inserted with the tip at the level of
mid SVC. Heart size and mediastinum are unremarkable. Lungs
are essentially clear.
[**2112-7-25**] PORTABLE ABDOMEN: Air is seen throughout non-distended
loops of small and large bowel. There is moderate amount of
dense stool throughout colon, particularly at the cecum. No
evidence of pneumoperitoneum on this single supine film.
Osseous structures are unremarkable.
IMPRESSION: Non-obstructive bowel gas pattern.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2112-7-27**]
3:15 PM
CONCLUSION: Status post revision of EVD. Increased air in
frontal [**Doctor Last Name 534**] of the lateral ventricle. Decreased air in the
temporal [**Doctor Last Name 534**] of the right
lateral ventricle. Small amount of blood seen in the bilateral
occipital
horns of the lateral ventricle is unchanged compared to prior
study. No
evidence of hydrocephalus. No evidence of new hemorrhage.
[**2112-7-31**] CT Head w/o Contrast: Decrease in right lateral
ventricular gas and decreased intraventricular blood. Unchanged
position of a right frontal approach ventriculostomy catheter in
the parenchyma adjacent to the left side of third ventricle.
Correlate clinically if this is the desired position. No new
acute hemorrhage is detected
PORTABLE CHEST X-RAY ([**2112-8-4**]): As compared to the previous
radiograph, there is no relevant change. Normal size of the
cardiac silhouette. No acute changes such as pneumonia or
pulmonary edema. No pleural effusions.
NONCONTRAST HEAD CT ([**2112-8-4**]): Status post removal of VP shunt.
Normal postsurgical change. No evidence of acute hemorrhage or
findings to suggest hydrocephalus.
MICROBIOLOGY:
[**2112-7-21**] 11:36 am URINE Source: Catheter.
URINE CULTURE (Final [**2112-7-23**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
[**2112-7-23**] 1:09 pm URINE Source: Catheter.
URINE CULTURE (Final [**2112-7-25**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
[**2112-7-25**] 12:52 am URINE Source: Catheter.
**FINAL REPORT [**2112-7-26**]**
URINE CULTURE (Final [**2112-7-26**]):
GRAM POSITIVE COCCUS(COCCI). ~8OOO/ML.
[**2112-7-25**] 9:55 am CSF;SPINAL FLUID Source: Shunt.
GRAM STAIN (Final [**2112-7-25**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
Reported to and read back by DR. [**First Name (STitle) **] [**Numeric Identifier 82429**], [**2112-7-25**],
1:30PM.
FLUID CULTURE (Final [**2112-7-29**]):
STAPHYLOCOCCUS EPIDERMIDIS. MODERATE GROWTH.
SPECIATION REQUESTED BY DR. [**Last Name (STitle) **] #[**Numeric Identifier 82430**] [**2112-7-27**].
ENTEROCOCCUS SP.. SPARSE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
Sensitivity testing performed by Sensititre.
STAPH AUREUS COAG +. RARE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SECOND MORPHOLOGY.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
| ENTEROCOCCUS SP.
| |
CORYNEBACTERIUM SPECIES (DI
| | |
STAPH AUREUS COA
| | | |
STAPH
| | | |
|
AMPICILLIN------------ <=2 S
GENTAMICIN------------ <=0.5 S <=2 S <=0.5 S
<=0.5 S
OXACILLIN-------------<=0.25 S 0.5 S
=>4 R
PENICILLIN G---------- 8 S 0.25 S
RIFAMPIN--------------
<=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S 1 S <=1 S
1 S
[**2112-7-25**] 1:50 pm CSF;SPINAL FLUID Source: Shunt.
GRAM STAIN (Final [**2112-7-25**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
Reported to and read back by [**First Name8 (NamePattern2) **] [**Doctor Last Name 5445**] @ 1645,
[**2112-7-25**].
FLUID CULTURE (Final [**2112-7-28**]):
STAPHYLOCOCCUS EPIDERMIDIS. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-3181N [**2112-7-25**].
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-3181N [**2112-7-25**].
ENTEROCOCCUS SP.. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-3181N [**2112-7-25**].
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2112-7-26**] 2:08 pm FOREIGN BODY Site: CATHETER
EXTERNAL VENTRICULAR DRAIN CATHETER.
**FINAL REPORT [**2112-7-28**]**
WOUND CULTURE (Final [**2112-7-28**]): NO GROWTH.
[**2112-7-31**] 5:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-PICC.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2112-7-31**] 4:42 pm URINE Source: Catheter.
**FINAL REPORT [**2112-8-1**]**
URINE CULTURE (Final [**2112-8-1**]): NO GROWTH.
[**2112-7-31**] 5:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-PICC.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2112-7-31**] 5:00 pm BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Pending):
[**2112-8-1**] 11:17 am CSF;SPINAL FLUID Source: Shunt.
GRAM STAIN (Final [**2112-8-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2112-8-4**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2112-8-4**] 5:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
On [**2112-7-15**], Ms. [**Known lastname **] required urgent placement of bilateral
EVDs for obstructive hydrocephalus in the setting of bilateral
intraventricular hemorrhage. The EVDS were placed emergently in
the ED and she was subsequently transferred to the Neuro-ICU
intubated.
The patient was extubated on [**2112-7-16**], HD #2, without event. Her
total drain output was maintained at > 20 mL/hr. On [**2112-7-17**], it
was noted that right EVD drained well with left EVD having
minimal output. Protocol drain trouble shooting efforts,
improved the left EVD output.
On HD #4, [**2112-7-18**], bleeding from EVD site was observed on rounds.
PTT was elevated at 64.8. Patient's subcutaneous heparin was
temporarility discontinued. The head CT remained stable.
On HD #5, [**2112-7-19**], patient's subcutaneous heparin was
re-initiated with a [**Hospital1 **] dosing schedule rather than tid. On
examination, patiet appeared delerious, which was attributed to
sleep deprivation.
On HD #6, [**2112-7-20**], patient remained agiated on examination. We
continued to monitor her closely in the neuro-ICU.
On [**7-21**], PTT was elevated to 57.1, SQH was decreased to 2500
units. She was febrile to 101.1 overnight, urine culture was
sent. Patient reported significant headache and toradol was
added. Her L EVD was clamped in attempt to remove and R drain
remained open.
On [**7-22**], there were no issues with elevated ICPs while L EVD
clamped. A head CT was done which showed stable ventricle size
and L EVD was removed. R EVD was clamped in attempt to removed
as well. She was afebrile overnight. Patient reported pain and
aggitation, she was placed on standing toradol and prednisone.
On [**7-23**],The patient was found to have an enterococcus UTI and was
started Vancomycin. The patients Intercranial pressures were
25-30 and the EVD was opened.
On [**7-24**], The External Ventricular Drain was open and the ICP was
10. The patient had complaints of severe headache and a Head Ct
was performed which was consistent with interval removal of a
left frontal approach EVD with post-procedural small
amount of air in the right frontal [**Doctor Last Name 534**] and moderate amount of
air in the
right temporal [**Doctor Last Name 534**]. Allowing for the new air in the ventricular
system, the right lateral ventricle is unchanged and there is no
evidence of hydrocephalus or new mass
effect. Right frontoparietal subarachnoid hemorrhage is stable.
Ampicillin was added by ICU for the UTI. On exam, the patient
opened eyes to command, exhibited signs of photophobia. The
patient was not answering questions secondary to pain, but did
follow commands in all 4 extremities.
On [**7-25**], The patient had a temperature of 101 overnight and
urine/blood/Cerebral SpinalFluid cultures were sent. The CSF
culture prelim findings were consistent with +3Gram Postive
Cocci and 2+Gram Negative Rods. There was a question that this
may have been a contaminant and a second CSF culture was sent.
The patient was more lethargic in am and this was thought to be
due to fever and lack of sleep. The neurological assessment was
changed to every four hours to allow for sleep. The patient
became more alert as the day progresses and followed command
more readily. The serum sodium was 129. Urine lytes were send
dueto urine output of 200cc /hr for repeated hours and were
consistent with Creatinine of 15, serum sodium 10, potassium 9,
chloride of 16, and Osmolality of 92. Due to poor nutritional
intake the patient was initiated on IVF at 75cc/hr. The
External ventricular drain was open and draining well. The EVD
was level at 10 above the tragus. A Infectious Disease consult
was called to recommend planning for laproscopic Ventricular
Peritoneal shunt and steroid therapy for headache given fevers
101-103 and infection. The White Blood Count was slightly
elevated at 11.1. The patient continued to complain of servere
headache and neck pain. Topiramate (Topamax) 25 mg PO/NG [**Hospital1 **] for
headache was initiated perthe ICU team. A KUB was performed
given temperature of 103 for abdominal tenderness. On exam, the
patient opened eyes to voice and followed intermitent commands.
The pupils were equal reactive. The patient briskly localized.
The patient moved the bilateral lower extremities to command
intermitently.
On [**7-26**], pt continued spiking fevers (Tmax 102.8). Her
antibiotics were switched to Vanc/Meropenam per ID recs for
empiric treatment of meningitis (Vanc also covering her
pan-sensitive UTI). Her EVD was replaced in the OR out of
concern that EVD contamination had caused the meningitis.
On [**7-27**], pt remained confused with persistent photophobia and
meningismus. Head CT assessing EVD position showed Status post
revision of EVD. Increased air in frontal [**Doctor Last Name 534**] of the lateral
ventricle. Decreased air in the temporal [**Doctor Last Name 534**] of the right
lateral ventricle. Small amount of blood seen in the bilateral
occipital
horns of the lateral ventricle is unchanged compared to prior
study. No
evidence of hydrocephalus. No evidence of new hemorrhage. The
Cerebral Spinal Fluid preliminary culture grew gram negative
staph, cornyebacterium (diptheroids), enterococcus (rare
growth). Per infectious disease recommendations antibiotics were
narrowed to Vancomycin 1g every 8 hrs for External Ventricular
Drain-associated meningitis. Severe headaches persist and
patient pain managed with fioricet/dilaudid/topomax.
On [**7-28**], The patient exam was slightly improved exam improved
and the patient was noted to have multiple loose stools. A urine
culture was sent which was negative.
On [**7-29**], The patient experienced fever to 101.8 overnight, The
external ventricular drain was clamped as a trial to see if the
patient would tolerate it. The Intercranial Pressures were low
0-3 in the morning. Intercranial pressures rose, prompting the
right EVD to be re-opened wtih 5 mL of drainage. Pysical
Therapy and Occupational Therapy orders were placed. The foley
catheter was discontinue. The patient has had poor po intake due
to pain and delerium and was initiated on intravenous fluid at a
rate of 75cc/hr.
On [**7-30**], the patient remained agitated during examination. As
her ICPs were [**2-19**], her EVD was reclamped. ICPs remained near 3.
Ms. [**Known lastname **] Foley was replaced per nursing request to optimize
care.
On [**7-31**], patient's examination was dramatically improved.
Agitation was substantially decreased and patient was able to
move all four extremities to command. The EVD remained clamped
with tolerable ICP. Repeat head CT revealed decrease in right
lateral ventricular air and decreased intraventricular blood.
In the afternoon, the patient was febrile to 100.3, a fever
workup was institued and CSF cultures were obtained.
[**8-1**], patient spiked to Tm 102.8. As per ID's recommendations we
change her antibiotics from Vancomycin to Linezolid to rule out
Vancomycin as the source of her fevers. Her EVD was removed and
a CSF sample was sent again. Patient no longer requires ICU
level care and is ready for transfer to a SD unit.
On [**8-2**], patient remained afebrile on the floor; photophobia
mildly improved but still confused and oriented only to self.
Her right EVD staples were removed. CSF cultures have shown no
growth to date since the positive cultures on [**7-25**].
On [**8-3**], Patient self-DC'd her PICC twice, so her Linezolid was
switched to PO (confirmed OK with ID).
On [**8-4**], patient spiked fever to 102.3. Blood cultures were sent
(no growth to date). Chest x-ray showed no infiltrate. Unable to
obtain urine culture as patient incontinent and refusing
straight cath.
On [**8-5**], patient was discharged to rehab.
=====================================
TRANSITION OF CARE:
-Studies pending on [**Month/Year (2) **]: blood cx ([**7-31**], [**8-4**])
-If spikes fever, consider UTI (unable to obtain UCx after pt
spiked fever on [**8-4**])
-Needs right-sided head staples removed on [**2112-8-8**]
-Needs follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 4 weeks
(phone # [**Telephone/Fax (1) 4296**]). Will need head CT prior to appointment.
Medications on Admission:
none
[**Telephone/Fax (1) **] Medications:
1. Acetaminophen-Caff-Butalbital [**1-18**] TAB PO Q4H:PRN pain
max apap 4g/day
2. Heparin 2500 UNIT SC BID
3. Linezolid 600 mg PO Q12H
Use while patient has no IV access instead of IV dosing
4. Topiramate (Topamax) 25 mg PO BID
5. DiphenhydrAMINE 25 mg PO Q6H:PRN Itch
6. Docusate Sodium 100 mg PO BID
7. Senna 1 TAB PO BID Constipation
[**Month/Day (2) **] Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
[**Hospital3 **] Diagnosis:
Intraventricular hemorrhage
Cerebral AVM
UTI
EVD-associated meningitis
Chronic pain
Hypertention
Acute confusion/delerium
Altered mental status
[**Hospital3 **] Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Hospital3 **] Instructions:
Ms. [**Known lastname **],
It was a pleasure participating in your care at [**Hospital1 **] Hospital. You were admitted to the hospital with
headache, nausea and vomiting. You were found to have
intraventricular hemorrhage (bleeding into the ventricles of
your brain), caused by your [**Last Name (un) 24206**] [**Last Name (un) 24206**] disease. Extraventricular
drains (EVDs) were placed for monitoring and drainage, and you
were admitted to the ICU. In the ICU you developed meningitis -
infection of the fluid surrounding the brain. You were treated
with antibiotics and your meningitis resolved. Your EVDs were
then removed and you were transferred to the medical floor where
your symptoms continued improving. Because you are still too
weak to go home alone, you are being discharged to rehab.
We made the following changes to your medications:
1. STARTED Linezolid 600mg by mouth every 12 hours for your
meningitis. (Last day = [**2112-8-7**])
2. STARTED Fioricet (acetaminophen-caffeine-butalbital) 1-2 tabs
every 4 hours as needed for headache
3. STARTED Topomax (topiramate) 25mg by mouth twice daily for
headache
4. STARTED Benadryl 25mg by mouth every 6 hours as needed for
itching
5. STARTED Heparin subcutaneous 2500mg twice daily to prevent
blood clots in the legs until you are able to walk independently
6. STARTED Colace (docusate) and Senna for constipation
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????New onset of tremors or seizures.
??????Any confusion, lethargy or change in mental status.
??????Any numbness, tingling, weakness in your extremities.
??????Pain or headache that is continually increasing, or not
relieved by pain medication.
??????New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 11314**] to schedule an appointment with Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
ICD9 Codes: 431, 5990, 2930, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3276
} | Medical Text: Admission Date: [**2184-6-2**] Discharge Date: [**2184-6-14**]
Date of Birth: [**2115-6-2**] Sex: M
CHIEF COMPLAINT: Patient presents with shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
male well known to the cardiothoracic service after a
had initially presented with aortic insufficiency and aortic
root dilation with shortness of breath. The patient had a
Bentall procedure performed on [**2184-5-19**] and underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3928**]
postoperative course including mental status confusion,
reintubation for pulmonary secretions, and chest tube for a
worsening right sided pleural effusion. After postoperative
day seven the patient's mental status cleared and the patient
postoperative day 11. Initially at home the patient was
doing well without complaints. However, the patient soon
developed progressive shortness of breath. The patient
presented to the emergency department in the evening of
[**2184-6-2**] where Cardiology performed an echocardiogram which
showed a moderately large circumferential pericardial
effusion, moderate right ventricular invagination, no overt
evidence of cardiac tympanode, and no significant aortic
regurgitation.
PAST MEDICAL HISTORY: Hypertension, DDD pacemaker placed
three years ago for AV block
PAST SURGICAL HISTORY: Bentall procedure performed [**2184-5-19**].
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 q day.
2. Lopressor 35 mg b.i.d.
3. Coumadin 5 mg q day.
4. Colace 100 mg b.i.d.
5. Levofloxacin 400 mg q day.
6. Norvasc 10 mg q day.
7. Combivent inhaler.
8. Lasix 40 mg b.i.d.
9. KCL 20 mg b.i.d.
10. Captopril 25 mg q day.
11. Amiodarone 400 mg q day.
11. P.r.n. Percocet and Ativan.
ALLERGIES: None.
SOCIAL HISTORY: Remote use of alcohol and tobacco.
PHYSICAL EXAMINATION: The patient presents as a well
developed elderly male, appearing stated age in mild
respiratory distress and mildly tachypneic. Lungs showed a
right sided rub at the base with decreased bilateral breath
sounds. Heart was regular rate and rhythm with distant heart
sounds. JVD was noted upon neck examination. Abdomen was
normal, nontender, nondistended and with positive bowel
sounds External examination did not show evidence of an
obvious click. There was no signs of erythema or tenderness
at the sternal wound. Extremities showed no signs of edema
and were warm and well perfused.
ADMITTING LABORATORIES: White count of 14, hematocrit of 27.
Chem 7 showed a glucose of 120, sodium 130, potassium 4.5,
chloride 100, bicarb 20, BUN 37 and a creatinine of 1.3.
ADMISSION RADIOLOGY:
1. Cardiac echo as described above.
2. Chest x-ray showed a moderate right sided pleural
effusion, increased cardiac size and a displaced sternal
wire in the mid to lower sternal pole.
HOSPITAL COURSE: The patient was admitted to the
Cardiothoracic surgery service for follow-up of presenting
signs and radiologic findings. Over night the patient had
large amounts of serous drainage from his right chest tube
site without symptomatic change. The patient was afebrile
with stable vital signs. The patient was transfused a total
of six units of FFP as well as .5 mg of Vitamin K in order to
correct a coagulopathy of an INR of 3.6 so that a right sided
chest tube could be placed to drain the right side of the
pleural effusion.
On [**2184-6-4**] it was noted that the patient developed an area of
induration and erythema at the inferior pole of the sternal
incision. This area had not been identified on the initial
emergency room evaluation. It was felt this was of
significant concern for infection of the sternal wound,
although there was no expressible puffs from the wound site.
Upon re-examination of the sternal wound there was an audible
click indicating probable sternal instability.
An echocardiogram of [**2184-6-4**] which showed an enlarged
pericardial effusion. A CAT scan with contrast was obtained
at this time which helped to distinguish between pleural
effusion and pericardial effusion for this patient. It
became obvious after the CAT scan that most of the fluid
visualized on initial chest x-ray was essentially
representative of pericardial fluid. It was also noted that
the sternal edges did not align properly, though there was no
free fluid or signs of infection present along the sternal
incision.
Plans were made to perform pericardial window the following
day given the size of the pericardial tympanode, the
symptomatic state of the patient, and the recorded EF of 20
to 30% on the most recent echocardiogram.
On [**2184-6-6**] the patient underwent pericardial window requiring
a sternal Robeicek weave. The patient tolerated the
procedure well and was transferred in stable condition to the
cardiothoracic care unit.
The patient was extubated on postoperative day one and did so
without any difficulties. Operative wounds appeared to be
clean, dry and intact and the patient sternum was no longer
unstable. The patient's cardio and respiratory status were
both fine.
The patient continued to improve the following days and
worked well with physical therapy. He was noted to be
afebrile with stable vital signs. The patient walked with
physical therapy, regular diet and was able to void on his
own. The patient remained having a small O2 requirement of
two liters nasal cannula which maintained his O2 saturations
in the mid 90's.
The patient was continued on antibiotics (Vancomycin) for a
total of one week. Operative cultures as well as other
cultures taken at the time of admission all turned out to be
negative. Therefore, the patient did not require any further
antibiotic therapy.
The patient was noted to develop atrial flutter as early as
[**6-6**] and was seen by the electrophysiology staff on [**2184-6-11**].
The patient was started on Amiodarone 400 mg p.o. q day for
the treatment of this arrhythmia. The patient was also begun
back on his anti-coagulation and was said to be followed by
the EP staff. The EP staff would follow the patient and
possibly cardiovert the patient in four weeks if the
arrhythmias still persisted at that point.
On [**2184-6-6**] the patient was afebrile with stable vital signs.
The patient completed full work out with physical therapy
without any oxygen requirement. The patient
s wounds were clean, dry and intact and there was no sternal
click. The patient had no complaints, said he was breathing
well and appeared to be doing quite well. The patient was
therefore, felt to be stable from medical standpoint to be
discharged home. The patient's INR at the time of discharge
was 1.4. The patient had been taking 5 mg of Coumadin per
night. The patient was started on Lovenox 30 mg subq b.i.d.
in replacement of his Heparin drip which he had been on
during the hospital stay. The patient would be taking this
Lovenox subcutaneously until his Coumadin became therapeutic.
DISCHARGE DISPOSITION: Home.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. In addition to preoperative - Zantac 150 mg p.o. b.i.d.,
2. Aspirin 81 mg p.o. q day.
3. Norvasc 10 mg p.o. q day.
4. Captopril 25 mg p.o. t.i.d.
5. Lopressor 75 mg p.o. b.i.d.
6. Lasix 40 mg p.o. b.i.d.
7. Potassium 40 mEq p.o. b.i.d.
8. Colace 100 mg p.o. b.i.d.
9. Coumadin 5 mg p.o. q day.
10. Amiodarone 400 mg p.o. q day.
11. Albuterol inhaler two puffs q 4 hours p.r.n.
12. Atrovent inhaler two puffs q 4 hours
13. Percocet one p.o. q 4 to 6 hours p.r.n.
14. Lovenox 30 mg subq b.i.d. until INR is between 2.5 to
3.
DISCHARGE INSTRUCTIONS: The patient is to take Lovenox
injections b.i.d. through the [**Hospital6 407**]
until his INR is between the therapeutic range of 2.5 and 3.
The patient is to have blood drawn on [**2184-6-16**] for an INR
level and then as needed afterwards. The patient is then to
have his INRs monitored through his primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 11139**], [**0-0-**], who will adjust his Coumadin
appropriate to maintain an INR of 2.5 to 3.
The patient is to take all his other medications as outlined
above. The patient is to follow-up with Dr. [**Last Name (STitle) 1537**] in one week
in order to get wound check and a white blood cell count.
The patient was instructed upon the precise types of symptoms
and signs which would necessitate the patient coming in to
see a cardiothoracic surgeon.
[**Last Name (LF) **],[**First Name3 (LF) **] E. M.D.02-248
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2184-6-14**]
T: [**2184-6-14**] 19:58
JOB#: [**Job Number 21642**]
1
1
1
R
ICD9 Codes: 9971, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3277
} | Medical Text: Admission Date: [**2178-6-27**] Discharge Date: [**2178-7-2**]
Date of Birth: [**2104-1-2**] Sex: M
Service: MED
Allergies:
Penicillins / Cephalosporins / Neurontin
Attending:[**First Name3 (LF) 8684**]
Chief Complaint:
Bilateral pulmonary emboli and COPD flare
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 yo male NH resident, h/o COPD (on O2), type 2 DM, presenting
with lethargy, hypoglycemia, and SOB; pt was 83-84% with
FSBG=59. Pt improved with dextrose, O2, and sat's went up to
91%. Given pt's lethargy, HCT was performed which was negative
for mass effect or bleed. CXR on admission showed possible
RUL/RML PNA, but was concerning for endobronchial lesion. F/U
Chest CT showed bilateral PE's, and patient was started on
anticoagulation with coumadin and lovenox. Pt's vitals o/w
stable. Pt was on Prednisone taper on admission and got
stress-dose solumedrol in ED. Pt was initially stable on the
floor, but on hospital day [**1-13**], he had an acute desaturation,
was working hard to breathe/using accessory muscle, and was
transferred to the MICU at this time where he was stabilized
using non-invasive measures (O2 mask, frequent nebs). Pt
transferred back to floor when he was more stable from a
respiratory standpoint.
Past Medical History:
PMH: COPD-on O2, type 2 DM, MRSA, prostate cancer,
diverticulitis, glaucoma, is legally blind,
hypercholesterolemia.
Social History:
SH: married, has been in a NH for the past 2-3 weeks after a
recent hospital admission to [**Hospital1 336**], likely with MID. No Etoh,
former smoker, was DNR/DNI in nursing home.
Family History:
non-contributory
Physical Exam:
VS: 97.9 103 138/64 22 97% 4L
Gen: mild respiratory distress, pleasant, slightly disoriented,
appropriate responses
HEENT: dilated pupils (bland)
CV: tachycardic S1/S2, no m/r/g
Lungs: prolonged expiratory phase, wheezing, rhonchi in right
base
Abd: soft, NT/ND, no HSM, NABS
Extr: no edema/cyanosis/clubbing, DP and PT intact bilaterally
Neuro: grossly intact
Pertinent Results:
[**2178-6-27**] 03:00AM PT-13.4* PTT-28.5 INR(PT)-1.2
[**2178-6-27**] 03:00AM PLT SMR-LOW PLT COUNT-144*
[**2178-6-27**] 03:00AM WBC-9.0 RBC-3.39* HGB-9.9* HCT-33.0* MCV-97
MCH-29.3 MCHC-30.1* RDW-15.4
[**2178-6-27**] 03:00AM GLUCOSE-196* UREA N-11 CREAT-0.7 SODIUM-143
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-35* ANION GAP-9
Brief Hospital Course:
1. Severe B PE. Pt was initially put on Lovenox 70 [**Hospital1 **] with
coumadin when PE's discovered on chest CT. Pt was stable for 2
days and then had an acute episode of desaturation, O2 sats
83-84% on 4L, minimal improvement with nebs and 50% facemask.
Chest X-ray did not show any acute process, but patient was
laboring to breathe, using accessory muscles, and was not moving
air very well. ABG showed some CO2 retention, a normal pH, but
inadequate O2 sat given the amount of facemask O2. He was
transferred to the MICU at this time where he was managed and
stabilized without intubation (frequent nebs, O2). TTE showed
possible left mobile PA mass/clot; suggestion was patient was
throwing new clots even though on Lovenox. Pt started on
Heparin drip, became more stable from a respiratory standpoint,
and he was transferred back to the floor where he has remained
stable on 2 L NC O2, nebs, hep gtt, antibiotics, and steroid
taper. Heparin was discontinued after 48 hour overlap
(therapeutic on both coumadin and heparin), and patient
discharged on coumadin for lifelong anticoagulation. IVC filter
should be considered if this anticoagulation is inadequate.
2. COPD: Pt continued on a prednisone taper (2wks) for possible
COPD flare, likely one of the reasons for his respiratory
distress. Pt also with frequent nebs and O2 as needed (pt has
baseline 2 L O2 requirement).
3. ?PNA-normal cxr, afebrile, but did have bandemia on
admission and now with pseudomonas in sputum, resistent to
quinolones. Given allergy to pcn, ceph, wills start aztreonam
for presumptive coverage since he has poor respiratory status.
14-d course of Aztreonam with a 7-day course of Levo for
possible pneumonia with COPD flare.
4. DM- restart 70/30 at 1/2 dose; will cover with SSI, and cked
FSBG in house.
5. Psych: continue Effexor, give Ambien for insomnia; hold
Xanax, monitor for signs of benzo withdrawal
6. FEN- gave boluses as necessary, no standing IVF
7. PPX- Zantac, MRSA precautions
8. Pt is now Full code; reversed code status in-house given
possibly reversible cause of respiratory distress. This should
be reviewed upon return to rehab facility, for patient was
DNR/DNI prior to this admission.
Medications on Admission:
Prednisone 30 mg (taper)
Humulin 70/30, 55 QAM, 28 QPM
Trisoptin drops
Alphagen drops
Colace
Albuterol
Xanax 0.25 TID
SQ heparin
Flutamide 250 TID
KCL
Zantac 150 [**Hospital1 **]
Effexor 75 QD
Verapamil 120 TID
Ambien 10 mg QHS
Vit C
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
3. Dorzolamide HCl 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
6. Flutamide 125 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Venlafaxine HCl 75 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-12**]
Puffs Inhalation Q6H (every 6 hours).
13. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
14. Verapamil HCl 120 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
15. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO QD (once a
day) for 13 days: Take 60 mg until [**7-5**], take 40 mg until [**7-10**],
take 20 mg until [**7-14**], then off.
Disp:*23 Tablet(s)* Refills:*0*
16. Insulin 70/30 70-30 unit/mL Suspension Sig: 25 U
Subcutaneous QAC.
17. Insulin 70/30 70-30 unit/mL Suspension Sig: 15 U
Subcutaneous at bedtime.
18. Levofloxacin 500 mg IV Q24H Duration: 1 Days
Continue until [**7-3**]
19. Aztreonam [**2173**] mg IV Q8H Duration: 11 Days
Continue until [**7-13**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Bilateral Pulmonary emboli, COPD flare
Discharge Condition:
Good
Discharge Instructions:
Please let staff at acute rehab know if you are experiencing
chest pain, shortness of breath, fevers, chills, or any other
concerns.
1. Pt needs monitoring of his coumadin; pt found to have
bilateral severe PE's on chest CT, thought to be chronic. He
will need lifelong anticoagulation with coumadin. His goal INR
is [**1-13**]. He will need an INR ck in the morning of [**7-3**]; pt
currently on 5mg coumadin each day. If lifelong anticoagulation
proves to be inadequate, an IVC filter should be considered.
2. Pt was DNR/DNI before this hospitalization; code status was
reversed given the possibly reversible nature of his pulmonary
emboli. This should be rediscussed; it is reasonable to resume
patient's prior code status.
3. Pt has a relatively new diagnosis of [**Name (NI) **] dementia
(from last 1-2 months).
Followup Instructions:
Will have f/u at rehabilitation facility
Need INR checks regularly for coumadin therapy
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3278
} | Medical Text: Admission Date: [**2115-10-25**] Discharge Date: [**2115-10-29**]
Date of Birth: [**2030-1-23**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
right facial droop, inability to speak
Major Surgical or Invasive Procedure:
tPA
Angiogram with attempted clot retrieval
History of Present Illness:
History of the Present Illness: Ms. [**Known lastname 101996**] is an 85 year-old
right-handed (although uses left hand now due to RA) woman with
a
history including Rheumatoid Arthritis, hypertension, and spinal
stenosis who presents from her nursing facility as a code
stroke.
She was last seen normal at approximately 5pm. Then at 5:30
p.m.
(this is all by report) one of the facility nurses noted that
she
had a new-onset right facial droop and she wasn't speaking or
following commands. EMS was called and she was brought in as a
code stroke. Pt currently unable to provide history.
Past Medical History:
-RA x 30 years, deforming; s/p multiple surgeries including R
wrist and right shoulder
-HTN
-osteoporosis
-chronic osteomyelitis of knee - on Bactrim and amoxicillin; an
infection complicated her hardware, required revision and
currently she is on therefore on long-term suppressive abx
therapy.
-knee replacement x 2 on right, x 1 on left
-spine surgery
-depression
Social History:
Pt lived in [**Hospital3 **] until approx 3 months ago when she
moved to LTC at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Disabled from chronic RA. Her
daughter and son live in the area. Son is HCP -[**Name (NI) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 101997**], cell: [**Telephone/Fax (1) 101998**]). No smoking, alcohol, or
illicits.
Family History:
No known contributory conditions
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
General Appearance: Comfortable, no apparent distress.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits.
Lungs: CTA bilaterally.
Cardiac: RRR. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 2+.
Multiple joint deformities from RA
Neurologic:
Mental status: Decreased alertness, will open eyes briefly to
vigorous stimulation, no spontaneous speech, forcefully closes
eyes when attempted.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields unable to be tested.
III, IV, VI: Unable to fully test EOM, left eye exotropia
V, VII: Right nasolabial flattening, muscle activation strong
when grimacing to painful stimuli.
VIII: unable to assess
IX, X: Palatal elevation symmetric.
[**Doctor First Name 81**]: unabl to assess
XII: Tongue midline without fasciculations.
Flaccid tone of right upper and lower extremities
Power: No spontaneous movement of the right arm or leg. Uses
left arm antigravity to pick at clothing, but will not hold it
antigravity for examination.
Reflexes: B T Br Pa Ac
Right 1 1 1 1 1
Left 2 2 2 2 1
Toes mute bilaterally
Withdrawal to sensation of the left arm and leg, no grimace to
pain with nailbed pressure of the right upper extremitiy,
+grimace to pain of the right LE
Coordination: unable to assess
Gait: Unable to assess
PHYSICAL EXAM ON DISCHARGE:
General Appearance: Sleeping, appears comfortable, no apparent
distress.
HEENT: NC, MMM.
Lungs: CTA bilaterally.
Cardiac: RRR. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 2+.
Multiple joint deformities from RA
Neurologic:
Mental status: Sleeping, arouses to voice, able to state name,
speech otherwise unintelligible, unable to name or repeat
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields unable to be tested.
III, IV, VI: R gaze preference, extraocular movements appear
intact with somewhat limited assessment
V, VII: Right nasolabial flattening
VIII: unable to assess
IX, X: Palatal elevation symmetric.
[**Doctor First Name 81**]: unabl to assess
XII: Tongue midline without fasciculations.
Flaccid tone of right upper and lower extremities
Power: No spontaneous movement of the right arm or leg. Raises
left arm antigravity.
Reflexes: B T Br Pa Ac
Right 1 1 1 1 1
Left 2 2 2 2 1
Toes mute bilaterally
Withdrawal to sensation of the left arm and leg
Coordination: unable to assess
Gait: Unable to assess
Pertinent Results:
[**2115-10-25**] 10:20PM TYPE-ART PO2-104 PCO2-35 PH-7.42 TOTAL CO2-23
BASE XS-0
[**2115-10-25**] 10:20PM GLUCOSE-100 LACTATE-0.8 NA+-136 K+-4.2
CL--108
[**2115-10-25**] 10:20PM HGB-8.4* calcHCT-25
[**2115-10-25**] 10:20PM freeCa-1.22
[**2115-10-25**] 08:00PM URINE HOURS-RANDOM
[**2115-10-25**] 08:00PM URINE GR HOLD-HOLD
[**2115-10-25**] 08:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2115-10-25**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
[**2115-10-25**] 08:00PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2115-10-25**] 07:31PM COMMENTS-GREEN TOP
[**2115-10-25**] 07:15PM UREA N-21* TOTAL CO2-23
[**2115-10-25**] 07:15PM CREAT-1.0
[**2115-10-25**] 07:15PM estGFR-Using this
[**2115-10-25**] 07:15PM cTropnT-0.02*
[**2115-10-25**] 07:15PM CALCIUM-9.6 PHOSPHATE-2.7 MAGNESIUM-1.7
[**2115-10-25**] 07:15PM WBC-3.9* RBC-2.81* HGB-9.3* HCT-28.9*
MCV-103* MCH-32.9* MCHC-32.0 RDW-12.3
[**2115-10-25**] 07:15PM NEUTS-62.6 LYMPHS-26.9 MONOS-7.1 EOS-2.4
BASOS-1.1
[**2115-10-25**] 07:15PM PLT COUNT-231
[**2115-10-25**] 07:15PM PT-12.8 PTT-33.9 INR(PT)-1.1
CXR [**10-25**]:
IMPRESSION: Patient rotated to the right and low lung volumes.
Possible
right upper lobe consolidation could be due to infection or even
aspiration.
Pulmonary vascular engorgement.
CT/CTA/CTP [**10-25**]:
IMPRESSION:
1. Head CT shows suspicion for early left middle cerebral artery
infarct.
2. CT perfusion shows a large area of delayed transit time and a
small blood volume defect indicative of large area of ischemia
with a small infarct.
3. CT angiography of the neck demonstrates no carotid or right
vertebral
abnormalities but diffuse atherosclerotic disease are seen
involving the left vertebral artery.
4. CT angiography of the head demonstrates filling defect and
occlusion of
the M1 segment of the left middle cerebral artery with distal
partial filling of the M3 segment of the left middle cerebral
artery likely secondary to collateral circulation.
CT head [**10-26**]:
IMPRESSION:
1. No significant change in appearance in the region of
hypodensity involving the left basal ganglia, consistent with
evolving infarction. No evidence of hemorrhagic transformation.
2. No new acute large vascular territorial infarction.
CT head [**10-27**]:
IMPRESSION:
1. New large parenchymal hemorrhage in the right semicentrum
ovale, with
likely small subarachnoid component and acute blood/[**Last Name (un) 3041**] level.
2. No significant change in the appearance of the region of
hypodensity
involving the left basal ganglia, consistent with evolving
infarct. No
evidence of hemorrhagic transformation of this infarct.
Brief Hospital Course:
Ms. [**Known lastname 101996**] presented to the ED as a code stroke on [**2115-10-25**]
and was found to have global aphasia and right arm flaccid
paresis. CT showed large area of hypodensity in the L MCA
territory. CTA showed an abrupt occlusion of the M1 segment of
the left MCA. She received tPA beginning just at the end of the
3 hour window. Following tPA administration she developed some
spontaneous movement of the right arm, briefly antigravity, but
remained globally aphasic and unable to follow commands. After
discussion with her son and daughter, it was decided to reverse
her DNR/DNI status to go ahead with attempted clot retrieval.
Unfortunately, clot retrieval failed due to significant
tourtuosity of her vasculature, and the embolus remained in the
left M1 segment. She was monitored in the ICU and her exam
remained stable. CT head 24 hrs post-tPA was stable and she was
transferred to the step-down unit on the evening of [**10-27**].
On the morning of [**10-28**] she was noted to have significant
left-sided neglect on exam. Repeat CT head showed a large right
frontal hemorrhage. She remained aphasic with flaccid right
hemiparesis and severe left-sided weakness as well. Per
discussion with family she was made CMO. Palliative care was
consulted. She was maintained on morphine, ativan, and
scopolamine prn for comfort.
She was discharged back to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] on [**2115-10-29**] under
hospice care.
Medications on Admission:
ALENDRONATE - (Prescribed by Other Provider) - 70 mg Tablet - 1
Tablet(s) by mouth QSAT (every Saturday)
AMOXICILLIN-POT CLAVULANATE - (Prescribed by Other Provider) -
500 mg-125 mg Tablet - 1 Tablet(s) by mouth every twelve (12)h
ATENOLOL - (Prescribed by Other Provider) - Dosage uncertain
DULOXETINE [CYMBALTA] - (Prescribed by Other Provider) -?Dosage
FENTANYL - 50 mcg/hour Patch 72hr - every 72hours to be changed
FOLIC ACID - 1 tab qd
GABAPENTIN - (Prescribed by Other Provider) - Dosage uncertain
HYDROMORPHONE - prn
OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg
Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a
day
SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth once a day
SULFAMETHOXAZOLE-TRIMETHOPRIM - (Prescribed by Other Provider)
-
400 mg-80 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) for
chronic osteomyelitis
ACETAMINOPHEN - (Prescribed by Other Provider; OTC) - 500 mg
Tablet - 2 Tablet(s) by mouth every six (6) hours as needed
CALCIUM CARBONATE-VITAMIN D3 [OYST-CAL D] -
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg Tablet Extended
Release - 1 Tablet(s) by mouth once a day
FERROUS SULFATE - (Prescribed by Other Provider; OTC) -? dose
IBUPROFEN
MULTIVITAMIN
Discharge Medications:
1. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane QID (4 times a day).
3. acetaminophen 325 mg/10.15 mL Solution Sig: [**1-13**] PO every six
(6) hours as needed for fever or pain.
4. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for discomfort or agitation.
5. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal every seventy-two (72) hours as needed for increased
secretions.
6. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
0.5-1 PO Q1hr as needed for pain or respiratory distress:
Please give 10-20 mg PO Q1H PRN pain, respiratory distress.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Left MCA infarct
R frontal intraparenchymal hemorrhage
Discharge Condition:
Mental Status: Lethargic, nonfluent aphasia, does not follow
commands.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 101996**],
You were admitted to [**Hospital1 69**] on
[**2115-10-25**] with drooping of the right side of your face and
difficulty speaking. You were found to have a stroke in the left
side of your brain caused by a blood clot in the left middle
cerebral artery. You received tPA, a clot busting medication,
and then underwent a procedure to try to remove the clot which
was unfortunately unsuccessful. You were monitored in the
intensive care unit and then transferred to the neurology floor.
On the morning of [**10-28**] a repeat CT scan showed bleeding in your
right frontal lobe, on the opposite side from your stroke. Per
discussion with your family the decision was made to pursue
comfort care measures.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2115-11-14**] 1:00
ICD9 Codes: 431, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3279
} | Medical Text: Admission Date: [**2146-4-1**] Discharge Date: [**2146-5-11**]
Date of Birth: [**2115-12-27**] Sex: F
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Headache, fevers
Major Surgical or Invasive Procedure:
Intubation with endotracheal tube
Central line placement
History of Present Illness:
Ms. [**Known lastname **] is a 30 yo female who presented to [**Hospital3 19345**] on the day of admission for evaluation of headache,
subjective fevers. Per the original admission note, the headache
and fever had been occurring for 6 days. She also had
photophobia and intermittent nausea associated with the HAs.
Over the past 2-3 days, she had noted increasing
fatigue/malaise.
At [**Hospital3 **], she had a temp of 100.9 and a WBC was
322,000. A head CT was performed which was reportedly negative
for acute bleed/mass. A CXR showed infiltrates throughout the
lung. She was transferred to [**Hospital1 18**] for further care.
On arrival to [**Hospital1 18**], she was given a dose of allopurinol and
started on D5W w/ 3amps bicarb. A bm bx was done. Her peripheral
smear was reviewed and felt to be c/w blast crisis. Surgery was
called for placement of a pheresis catheter. She was given 3 gms
hydrea. Her BPs remained 80s-90s/50s-60s. As the surgeon
attempted to place the line, the patient desatted to 80% RA.
Anesthesia was paged for a stat intubation. Intubation occurred
without complication and the pt was transferred to the [**Hospital Unit Name 153**].
MICU course:
[**4-2**] Pt was pheresed overnight, and WBC was reduced to approx
100/microL. Hydroxyurea was given [**Hospital1 **]. Once flowcytometry
identified [**Name (NI) 72473**], pt was started L-Asp, Cytoxan, Danarubicin,
Vincristin. PT was frequently monitored for tumor lysis
syndrome. Family was informed about poor prognosis.
[**4-3**] In the morning changed to PS 5/5, excellent RSBI. No
significant tumor lysis overnight. Clincially stable. did not
extubate as Pt. failed PS trial (ABG 7.28/51/63). Chemo day 2.
Past Medical History:
Craniotomy [**2132**] for brain tumor no chemotherapy or radiation
Social History:
She denies h/o alcohol/tobacco/IVDU. She lives with her brother
and mother. She works in a restaurant.
Family History:
No family history of blood disorder or cancer.
Physical Exam:
Upon transfer out of the intensive care unit:
Gen: Sleeping. Arousable, but clearly fatigued. Responds
appropriately to voice commands to open her eyes, open her
mouth, etc.
HEENT: MMM w/small thrush
CV: Nl S1/S2; tachy
Pulm: Suble diffuse ronchi; [**Last Name (un) 72474**] LLL
Abd: Soft, nt, nd, +BS although exam limitted by position
Ext: WWP X 4 w/bil edema
Neuro: Responds to voice commands. Moves all four extremities
to command, but not sufficiently responsive to allow testing of
strength or sensation.
Physical exam
VS: Temp 98.4, Pulse 60-80, BP 80-100/57-62, RR 20, O2 Sat -
100% - AC FIO2 100% 14 TV 450 5/0
Gen: intubated, sedated
HEENT:PERRL, sclera anicteric
Chest: decreased BS throughout, rhonchi throughout
CV: RRR, nl S1S2 no murmers
Abd: soft, non-tender, positive BS, spleen palpated at 4cm below
costal margin
Groin: left inguinal lymphadenopathy
Ext: no edema, wwp
Skin: no rashes, no petechiae
Neuro: toes downgoing 2+ reflexes throughout
Pertinent Results:
Laboratory results:
Labs at OSH:
WBC 322.9, HCT 31.4, HGB 10.1, Plt 47 (diff 1N, 29L, 1B,
69blasts)
Smear - showed numerous blasts associated with some
metamyelocytes, myelocytes, and bands. No schistocytes, some
teardrop cells. No platelets visualized.
[**2146-4-1**] 09:10PM GLUCOSE-78 UREA N-8 CREAT-0.9 SODIUM-133
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-9
[**2146-4-1**] 09:10PM ALT(SGPT)-65* AST(SGOT)-124* LD(LDH)-1248*
ALK PHOS-485* AMYLASE-44 TOT BILI-1.1
[**2146-4-1**] 09:10PM LIPASE-22
[**2146-4-1**] 09:10PM ALBUMIN-3.1* CALCIUM-7.3* PHOSPHATE-1.1*
MAGNESIUM-1.6 URIC ACID-3.5
[**2146-4-1**] 09:10PM HAPTOGLOB-<20*
[**2146-4-1**] 09:10PM WBC-229* RBC-2.76* HGB-7.9* HCT-23.5* MCV-85
MCH-28.6 MCHC-33.6 RDW-16.8*
[**2146-4-1**] 09:10PM NEUTS-3* BANDS-0 LYMPHS-13* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-82*
[**2146-5-11**] 12:00AM BLOOD WBC-8.4 RBC-2.93* Hgb-8.7* Hct-25.6*
MCV-88 MCH-29.8 MCHC-34.0 RDW-15.2 Plt Ct-238
[**2146-5-10**] 12:00AM BLOOD PT-14.4* PTT-37.3* INR(PT)-1.3*
[**2146-5-10**] 12:00AM BLOOD Gran Ct-6700
[**2146-5-11**] 12:00AM BLOOD Glucose-88 UreaN-21* Creat-1.6* Na-135
K-4.2 Cl-101 HCO3-25 AnGap-13
[**2146-5-11**] 12:00AM BLOOD ALT-101* AST-78* LD(LDH)-565*
AlkPhos-170* TotBili-0.8
[**2146-5-11**] 12:00AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0 UricAcd-2.8
Brief Hospital Course:
Ms. [**Name14 (STitle) 72475**] is a 30 yo female with history of prior pituitary
mass s/p transphenoidal resection presenting with ALL. Per
report: Acute lymphoblastic Leukemia CD 10+, CD 19+, CD 20+ with
some aberrant monocytic markers but not a bilineage leukemia.
She has had vision problems and per Dr. [**First Name (STitle) **], worrisome for CNS
involvement.
1)B-ALL with Blast crisis. The smear on presentation showed
numerous blasts associated with some metamyelocytes, myelocytes,
and bands. She also has diffuse pulmonary infiltrates and
hypoxia likely due to white thrombi. The patient was emergently
intubated, underwent plasmapheresis and started on Cytoxan,
Danarubicin, Vincristin, L-Asp on [**4-2**]. She had a marked
response, developing neutropenia. Tumor lysis labs were
monitored without significant findings. Around day +21, the
patient developed a transaminitis. Vincristine therapy was held
at this time but then completed few days prior to discharge.
2)Respiratory failure. Likely due to tumor infiltration, white
thrombi +/- HSV pneumonia vs. pneumonitis (see below). The
patient was succesfully extubated but then required
re-intubation for airway protection in the setting of declining
mental status. The patient was again succesfully extubated but
was found on ABG to be hypercarbic and acidotic. She required
intubation and was successfully extubated one day later. Chest
x-ray after extubation suggests aspiration pneumonia. Her
respiratory status remained tenuous for most of her hospital
stay likely in the setting of CHF. She was diruesed agressively
and her breathing improved significantly.
3)Febrile neutropenia. Etiology not entirely clear. The patient
had blood, urine, CSF cultures without growth to date. HSV
pneumonia (as below) was confirmed on BAL. Beta-glucan and
galactomannan were negative. The patient was initiated on broad
antibiotics, including Caspofungin, Vancomycin, Meropenem and
Acyclovir. Upon transfer out of the ICU, the patient was no
longer neutropenic and no longer febrile. She completed a 10 day
course of treatment dose (10mg/kg) IV acyclovir. She also
completed course of Vanc/Meropenem by time of discharge. Culture
data remained negative.
4)Decreased mental status. The patient developed declining
mental status in the early days of [**Month (only) 958**]. The patient had
multiple CT scans and MRI's without signs of pathology.
Specifically, the patient had no signs of intracranial bleeding
or temporal hemorrhage or enhancement (out of concern for HSV
encephalitis). The patient underwent LP with 1 WBC, 1RBC and
negative HSV PCR. Of note she underwent intrathecal methotrexate
therapy. The patient was keppra loaded out of concern for
seizure activity though quickly discontinued as EEG x2 revealed
no evidence of seizure activity, instead suggesting non-specific
encephalopathy. Given her diffusely altered mental status
without focal neurologic deficits, it was felt (in consultation
with neuro-oncology) that the patient likely had a
toxic-metabolic explanation for her symptoms. Specifically, the
patient was markedly hypophosphatemic at the time. In addition,
L-asp could have contributed. The patient's mental status
continued to wax and wane though she became more interactive. On
[**2146-4-22**] the patient underwent repeat LP. This tap was traumatic
and did not clearly show infection. HSV, HHV-6, EBV, [**Male First Name (un) 2326**] and BK
virus PCR's were sent. The fluid was also sent for regular
culture, cytometry and cytology, all of which was unrevealing.
On [**2146-4-27**] after an apparent grand mal seizure, the patient
underwent another LP revealing RBC's in tube 4 on a
non-traumatic tap. CT head revealed an occipital hypodensity. MR
brain suggested diffuse bilateral occipital lobe haziness of
unclear significance. Her mental status improved significantly
and she was at baseline at time of discharge.
5)Renal Failure. FENA of .4% c/w pre-renal etiology in the
setting of new-onset CHF. Urine eos negative. Prior sediment in
the ICU with hyaline and granular casts. The patient had a renal
ultrasound in early [**Month (only) 958**] revealing no hydronephrosis. Caspo
considered as contributing factor, though ID recommended
continuing. The patient was diuresed for volume overload. The
renal team was consulted and this was felt to be consistent with
volume overload and likely secondary to relative hypotension.
The patient continued to receive diuresis. Her Cr trended
downwards and was 1.6 at time of discharge.
6)CHF. EF 30% on echo [**2146-4-13**], new onset. Likely secondary to
Anthracycline toxicity. The patient was started on Metoprolol
and Furosemide. She was monitored closely with daily weights and
strict I/O's. Repeat echo on [**2146-4-21**] revealed a normalized EF
and beta blocker was discontinued. During the remainder of her
stay on the BMT floor her respiratory status worsened. Cxrays
suggested bilateral pulmonary infiltrates. She was started on
heart failure regimen including Metoprolol, Lisinopril, and
aggressively diuresed with Lasix. She responded appropriately
and her respiratory status improved. Repeat ECHO was consistent
with depressed EF.
7)HSV pneumonia. Confirmed on BAL growth. Likely contributing
factor to respiratory failure (in addition to
leukostasis/leukothrombosis of pulmonary vessels). The patient
received treatment dose acyclovir (10mg/kg) for 10 days with
improvement in respiratory status.
8)Transaminitis. The patient developed a marked transaminitis at
the time of transfer out of the intensive care unit with AST and
ALT to >200. The etiology was felt most likely a drug effect,
including a possible delayed chemotherapy effect. Much less
likely is a meropenem effect. Further Vincristine therapy was
held. The patient's meropenem was discontinued. Discontinuation
of the acyclovir was considered, but, this medication was
continued as it very rarely causes liver toxicity and its
clinical benefit in the setting of a likely HSV pneumonia
confirmed by BAL was clear (and indeed the patient was
improving). At the time of onset, the patient was off of
caspofungin. Fungal infection of the hepatobiliary system was
entertained as a diagnosis. The patient had a right upper
quadrant ultrasound revealing no disease. She underwent an MRI
of the liver revealing no signs of hepatosplenic candidiasis or
other pathology. On further history taking, the patient's family
described multiple episodes of jaundice in the past. The
patient's hepatitis serologies revealed prior Hep A infection,
negative Hep C and past immunization for Hep B. HIV serology was
negative. The patient's LFT's trended downward without
intervention. Vincristine was held in the setting of a
transaminitis.
9)Pancreatitis. Likely medication related, secondary to
L-asparaginase. This chemotherapy [**Doctor Last Name 360**] was held. The patient's
amylase/lipase were trended and normalized by time of discharge.
10)Hypopituitarism. The patient has a history of transphenoidal
resection of an intracranial mass. She presented with
hypotension. Her low bp was felt possibly secondary to early
sepsis, however cortisol testing revealed very low cortisol
levels (0.8). The patient also failed her cortisol stim test.
She was noted to have normal TSH, though low T4 consistent with
central deficit. The patient's prolactin was mildly decreased
below normal. FSH and LH were normal. Endocrine was consulted.
The patient was maintained on hydrocortisone and levothyroxine
replacement therapy.
11)Mucositis with oral lesions. The patient had HSV swabs sent
and were positive for the virus. She continued on antifungals
for possible thrush.
12)Hyperglycemia. On TPN and steroids. The patient was placed on
an insulin sliding scale. Blood sugars normalized after she came
off TPN and was able to take in sufficient PO.
13)Movement disorder. The patient developed extrapyramidal signs
with rigidity, cogwheeling and masked facies. The patient was
seen by movement disorder service and this was felt consistent
with Haldol-induced parkinsonism exacerbated by liver
dysfunction. All antidopaminergic agents, including haldol and
zyprexa were held. The patient's parkinsonian symptoms resolved.
14)Seizure. The patient had a likely grand mal seizure witnessed
by nursing staff on [**2146-4-27**]. This occurred despite 2 prior
negative EEG's. The patient was Keppra loaded and started on a
standing dose. She was placed on continuous EEG though failed to
tolerate the test due to agitation. Review of the limited EEG
obtained revealed encephalitis pattern without apparent seizure
activity. EEG monitoring closer to discharge was unchanged. She
was weaned off Keppra prior to discharge.
Medications on Admission:
Medications at home: None
Medications on transfer:
Cefepime 2gm IV q8h
Allopurinol 300 mg daily
s/p 3gms hydrea
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*90 Tablet(s)* Refills:*1*
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*120 Capsule(s)* Refills:*1*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Acute lymphocytic leukemia
Congestive heart failure
Pneumonia
Pancreatitis
Acute renal failure
Discharge Condition:
Stable
Discharge Instructions:
1)Please take all medications as listed in the discharge
medications. Many of these medications are new.
2)You will be admitted for chemotherapy on Tuesday, [**5-17**].
Please come to the hospital at 9am to be admitted.
3)If you experience any fevers, chills, chest pain, SOB,
abdominal pain, dizziness, or any other concerning symptoms
please return to the emergency department.
Followup Instructions:
Please come to the [**Location (un) 436**] of the [**Hospital Ward Name 1826**] Building on
Tuesday, [**5-17**] at 9am.
ICD9 Codes: 4280, 5849, 2762, 5070, 4254, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3280
} | Medical Text: Admission Date: [**2115-9-10**] Discharge Date: [**2115-9-13**]
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Dypnea on Exertion
Major Surgical or Invasive Procedure:
1. cardioversion ([**9-11**])
History of Present Illness:
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**], MD
This is an 83 year old male who was in his usual state of health
until this morning when he awoke with shortness of breath and
epigastric "pressure". He called 911 and was brought to [**Hospital **]
Hospital where T:98.1 BP:210/110, HR:92, RR:40. 91% on
non-rebreather. CK:86, MB:1.6 TN>0.02. ECG with Afib at 99,
non-specific ST-T changes, and PVCs. BNP of 1370. He was
placed on CPAP, then IV nitroglycerin, morphine and 80 IV lasix
with some relief of symptoms. The nitro drip was titrated off
but given persistent oxygen requirement he was transferred to
[**Hospital1 18**] for further evaluation.
ROS: Denies fevers, chills, worsening reflux, lightheadedness,
LOC, vision changes, palpitations, pleuritic pressure/pain,
lower extremity edema, now bowel or urinary changes (except the
proctitis), nocturia, chest pain.
POSITIVE: nausea (no vomiting) x 1 day, changed from HCTZ to
Lisinopril two weeks ago and sotolol increased to 120 [**Hospital1 **], 2
pillow orthopnea, worsening abdominal distention over the past
few weeks, lower extremity fatigue with
exercise over the past 3 days.
Past Medical History:
1. Atrial Fibrillation - discovered approx 4 years ago,
cardioverted and has been maintained on sotolol; 2 weeks ago at
his visit with Dr. [**Last Name (STitle) 73**] he was noted to be in afib again.
2. Prostate Cancer s/p xray therapy with radiation prostatitis
3. Recent ECHO [**4-30**] with preserved EF; recent catheterization
without significant disease
4. Hypertension
Social History:
Former smoker.
Occasional alcohol.
Denies IVDU.
Lives with wife, son and daughter in law in [**Name (NI) 86**] area.
Family History:
CAD in father (died MI age 80).
Physical Exam:
VITALS (at [**Hospital1 18**]): afebrile, BP 140/50, P 70's irregular, RR 20,
99% facemask
Gen: reclining in bed with facemask initially but then switched
over to 2L NC and maintained sats in high 90s, in NAD, speaking
in full sentences, not using any accessory muscles.
HEENT: MMM, OP clear
Neck: moderate JVD
CV: irregularly irregular, no murmurs appreciated
Lungs: crackles [**1-29**] of the way up lung fields R>L
Abd: distended, soft, NT, +BS
Ext: right foot cooler than left with more discoloration [**1-28**]
venous stasis changes, strong pulses bilaterally, good strength,
1+ edema to mid shin.
Neuro: aox3.
Pertinent Results:
CBC
[**2115-9-10**] 04:11PM WBC-5.5 RBC-4.41* HGB-14.1 HCT-40.0 MCV-91
MCH-32.0 MCHC-35.3* RDW-14.1
[**2115-9-10**] 04:11PM PLT COUNT-166
Chemistries
[**2115-9-10**] 04:11PM GLUCOSE-97 UREA N-17 CREAT-0.7 SODIUM-141
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
[**2115-9-10**] 04:11PM CALCIUM-9.5 PHOSPHATE-3.9 MAGNESIUM-2.0
[**2115-9-12**] 06:45AM BLOOD Glucose-99 UreaN-27* Creat-0.8 Na-140
K-3.7 Cl-100 HCO3-31* AnGap-13
[**2115-9-13**] 09:25AM BLOOD Glucose-136* UreaN-33* Creat-1.2 Na-140
K-4.0 Cl-101 HCO3-27 AnGap-16
Coags
[**2115-9-10**] 04:11PM PT-19.4* PTT-28.8 INR(PT)-2.4
[**2115-9-11**] 03:49AM BLOOD PT-24.9* PTT-33.3 INR(PT)-3.9
[**2115-9-12**] 06:45AM BLOOD PT-20.2* PTT-30.1 INR(PT)-2.6
[**2115-9-13**] 09:25AM BLOOD PT-19.0* INR(PT)-2.3
Cardiac Enzymes
From OSH: CK 86 MB 1.6 TnT <0.02
[**2115-9-10**] 04:11PM CK(CPK)-62
[**2115-9-10**] 04:11PM CK-MB-NotDone cTropnT-0.04*
[**2115-9-11**] 03:49AM BLOOD CK-MB-NotDone cTropnT-0.02*
Lipid Panel
[**2115-9-10**] 04:11PM TRIGLYCER-127 HDL CHOL-54 CHOL/HDL-3.8
LDL(CALC)-127
LFTs
[**2115-9-11**] 03:49AM BLOOD ALT-23 AST-23 LD(LDH)-207 CK(CPK)-42
AlkPhos-36* TotBili-0.7
TSH 2.1
Hemolysis Labs
[**2115-9-11**] 03:49AM BLOOD Fibrino-217
[**2115-9-11**] 03:49AM BLOOD Hapto-126
CXR ([**9-10**]):
pulmonary edema
ECHO ([**9-10**]):
Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy with normal cavity size and moderate
global
hypokinesis. The right ventricular cavity is mildly dilated with
mild global
free wall hypokinesis. The aortic root and ascending aorta are
mildly dilated.
The aortic valve leaflets are mildly thickened but not stenotic.
Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Trivial mitral regurgitation is seen. There is mild pulmonary
artery systolic
hypertension. There is no pericardial effusion.
Compared with the report of the prior study (tape unavailable
for review) of
[**2115-5-13**], left ventricular systolic function is now reduced -
35% - (global) and mild mitral regurgitation is present.
Brief Hospital Course:
83 year old man with a history of atrial fibrillation s/p
cardioversion and maintained on sotolol and coumadin (recently
therapeutic INR), presented to OSH in afib with respiratory
distress, HTN (210/110) and mild tachycardia (90-100s). Sx
improved with diuresis.
1. Cardiovascular
-- CAD: There was no evidence of significant CAD from a cardiac
catheterization in [**1-30**]. Serial EKGs did not show any
concerning ST-T wave changes. Cardiac enzymes were negative x3.
The patient's LDL was high at 127, so he was started on
atorvastatin 20mg daily.
-- Rate/rhythm: The patient presented in atrial fibrillation
with rates in the 70-90s. He was initially diagnosed with afib
4 years ago, and at the time of initial diagnosis had similar
symptoms to the ones that brought him to the hospital this time
(shortness of breath and fatigue). He is s/p cardioversion and
maintained on sotolol and coumadin. He has been therapeutic on
his coumadin for at least the past one month, and ECHO shows no
thrombus in the LV. Therefore, initially the plan was to DC
cardiovert him, but overnight on his first hospital day he
spontaneously converted to sinus rhythm. Approximately 16 hours
later he returned to a fib with rates in the 60-70s, and
converted spontaneously again after that. He was asymptomatic
as he was in and out of afib. He was continued on sotolol and
coumadin per outpatient doses. He was discharged in sinus
rhythm, with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor which he was going to
telephone in twice a day until he followed up with Dr. [**Last Name (STitle) 73**]
in two weeks ([**9-27**] at 11:30am).
-- Pump: The patient's last EF at [**Hospital1 18**] in [**4-30**] was 60%; EF done
as OSH today was estimated to be 20%. Repeated on admission to
[**Hospital1 18**] and revealed an EF of 35%. The cause of the decreasing EF
was unclear - tachycardia associated cardiomyopathy vs. viral
cardiomyopathy vs. stunning. The patient presented in pulmonary
edema per exam and CXR, and was bolused with Lasix IV 40 twice a
day with good urine output, and was transitioned over to 40mg po
twice a day. Spironolactone was also added to his regimen. He
was negative approximately 4.5 liters during his stay. He was
discharged home on 20mg lasix PO as well as spironolactone
12.5mg daily. He was initially continued on Lisinopril 5mg
daily per outpatient regimen, and this was increased to 10mg
daily. The patient tolerated these medication additions and
changes well, his blood pressure remained in the 110-130s
systolic. He will follow up with his primary care physician
next week ([**9-19**] at 9:15am) to get his INR checked as well as to
assess how he is tolerating his medications. He has a follow up
appointment in the [**Hospital 1902**] clinic on [**10-21**] at 9AM.
2. Respiratory: The patient arrived from OSH on a 100% facemask
with sats in the high 90s. That night he was transitioned to 4L
NC without difficulty and continued to maintain sats in the high
90s. He was able to be weaned off of oxygen over the next
couple of days as his diuresis progressed. This respiratory
distress was presumed to be due to his volume overload. He was
discharged with sats in the mid 90s on room air.
3. Renal: The patient came in with a creatinine of 0.7. This
was stable as he was diuresed until the day of discharge when it
rose to 1.2. Therefore his lasix was cut back on discharge to
20mg daily from 40mg twice a day, and he will follow up with his
primary physician next week to recheck his labs. A U/A was sent
and was negative.
4. GI: The patient was kept on a low salt cardiac diet. He has
a h/o proctitis and went to ED last week for blood he noticed in
his stool and was found to be stable. Here he had a stable HCT,
and reported a recent negative colonoscopy in past 3 months. He
was continued on his hydrocortisone PR while admitted for the
proctitis. He has a gastroenterologist and will follow up on
this issue as an outpatient.
5. GU: Initially a foley was placed given the aggressive
diuresis, this was discontinued after two days and the patient
had no difficulty urinaring subsequently.
6. Heme: The patient had stable HCT and platelets. He was
continued on coumadin; initially his INR was therapeutic at 2.4,
the day after admission it was 3.6 and his coumadin was held
that day. The following day he was once more therapeutic. On
discharge, his INR was 2.3.
7. FEN: The patient's potassium was repleted, but otherwise his
electrolytes were normal.
8. Proph: He tolerated an oral diet, was placed on a bowel
regimen, was ambulatory, and was on coumadin.
9. Dispo: He was given [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor; he will follow
up with his PCP for INR and check up next week, he will follow
up with Dr. [**Last Name (STitle) 73**] in two weeks, he has an appointment in the
[**Hospital 1902**] clinic in one month.
Medications on Admission:
Sotolol 120mg [**Hospital1 **]
Lisinopril 5mg daily
Coumadin 2.5mg daily 5 days a week; 5mg daily thursday and
friday
Discharge Medications:
1. Sotalol 120 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO QD (once a
day).
Disp:*15 Tablet(s)* Refills:*2*
5. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 1 doses.
6. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
([**Doctor First Name **],MO,TU,WE,SA).
7. Hydrocortisone Acetate 25 mg Suppository Sig: One (1)
Suppository Rectal QID (4 times a day).
8. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Congestive Heart Failure
2. Atrial Fibrillation
Discharge Condition:
Stable, ambulatory, tolerating an oral diet, afebrile.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Please use your [**Doctor Last Name **] of hearts monitor. Send information over
phone twice a day until you see Dr. [**Last Name (STitle) 73**].
Please take your prescribed medications including: Lasix 20mg
daily, Spironolactone 12.5 daily, Lisinopril 10mg daily (it was
increased during admission), Sotalol 120mg twice a day,
Atorvastatin 20mg daily, and Coumadin as previously prescribed.
Followup Instructions:
1. Please keep your appointment with Dr. [**Last Name (STitle) 5435**] on Thursday
[**9-19**] at 9:15am, [**Telephone/Fax (1) 5436**]. Bring your list of new
medications with you.
2. Please keep your appointment with Dr. [**Last Name (STitle) 73**] on [**9-27**]
at 11:30am, [**Hospital Ward Name 23**] 7 ([**Hospital Ward Name 516**]), [**Telephone/Fax (1) 902**]. Please
follow up with Dr. [**Last Name (STitle) 37078**] about a repeat ECHO in
approximately 2 months.
3.Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 9486**] Date/Time:[**2116-3-13**] 10:00
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3281
} | Medical Text: Admission Date: [**2140-8-21**] Discharge Date: [**2140-8-26**]
Date of Birth: [**2071-10-11**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old
male with cardiac risk factors of age, male gender and
hypertension who was transferred from [**Hospital3 **] after
presenting there on the [**10-21**] at 2230 complaining of
half an hour of substernal chest pain. He described the pain
as sharp associated with diaphoresis and radiating to the
left arm. He reports having previous episodes of similar
chest pain which resolved spontaneously after a short period.
The patient denied shortness of breath, nausea or vomiting.
EKG at the outside hospital showed ST elevations in the
anterior leads in V1 and V2, lead 1 and lead aVL with
reciprocal depressions in leads 2, 3 and aVF, V5 through V6.
The patient was given aspirin and sublingual nitroglycerin
times three and started on heparin with bolus and Integrilin
with bolus, Lipitor 20 loaded and was transferred to the [**Hospital1 1444**] for emergent cardiac
catheterization. A second electrocardiogram showed new left
bundle branch block, worsening ST elevations, found to have
multivessel disease in catheterization with intra-aortic
balloon pump (IABP) placed for high risk percutaneous
transluminal coronary angioplasty. Review of systems was
positive for chest pain and denied shortness of breath,
syncope or presyncope.
The patient was sent for emergent catheterization at the [**Hospital1 1444**] and was found to have a right
coronary artery/left anterior descending disease. The
patient had a stent placed in the proximal LAD and the mid
RCA. An intra-aortic balloon pump was placed as described
above. A Temp wire was placed for left anterior fascicular
block/right bundle branch block. In addition patient was
found to have a right pulmonary capillary wedge pressure of
10. Angiography showed that the patient had a right dominant
heart and a left ventricular ejection fraction was not noted.
The patient was given [**Last Name (un) **]-coated stent.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Osteoarthritis.
3. Seasonal allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Arthrotek 75 q. day.
2. Diovan.
3. Hydrochlorothiazide.
SOCIAL HISTORY: The patient has a history of tobacco use but
quit 25 years ago. Reports occasional alcohol use. Denies
intravenous drug abuse. The patient is married.
FAMILY HISTORY: Remarkable for coronary artery disease in
his father, mother and brother.
PHYSICAL EXAMINATION: Temperature 93.4, heart rate 87, blood
pressure 148/89. Mean arterial pressure 94, respiratory rate
19. The intra-aortic balloon pump: AD: 125. AS: 126.
ED: 86. M: 1:1. General: A comfortable male in no
apparent distress. HEENT: Normocephalic, atraumatic.
Pupils equal, round and reactive to light. Oral mucosa
moist. Neck supple. No masses, no lymphadenopathy and no
jugular venous distention. Lungs clear to auscultation
bilaterally with decreased breath sounds at the bases.
Question bibasilar rales. Coronary: Regular rate and rhythm
with normal S1, S2. Question of S3. No murmurs, rubs or
gallops appreciated. Abdomen soft, non-tender,
non-distended, positive bowel sounds. Left groin arterial
sheath in place with pressure dressing with blood soaked
through. Extremities: No clubbing, cyanosis or edema, 2+
distal pulses.
LABORATORY EXAMINATION: Notable for potassium of 3.2,
creatinine 1.2, glucose of 147, hematocrit of 39.0, CK 905.
ELECTROCARDIOGRAM: NO. 1: Normal sinus rhythm 84, normal
axis and intervals, 1-[**Street Address(2) 1766**] elevations in leads V1 and V2,
1 and aVL and 1-[**Street Address(2) 1766**] depressions in 2, 3, aVF, V5 and V6.
ELECTROCARDIOGRAM: NO. 2: Anterior ST elevation 1 mm in V1,
4-5 mm in V2 and 1-2 mm in V3. Q's in V1, V2 and V3 and left
anterior descending with new left anterior fascicular and
right bundle branch block.
HOSPITAL COURSE: The patient was taken to the
Catheterization Laboratory as above with placement of the
proximal left anterior descending and mid right coronary
artery with the placement of an intra-aortic balloon pump to
maximize perfusion for the territory at risk. A Temp wire
was placed due to a transient block and hemodynamics were
consistent with low normal filling pressures and a preserved
cardiac index. On arrival to the Coronary Care Unit after
the procedure, there was continuous oozing at the
intra-aortic balloon pump size which progressed to arterial
bleeding around the sheath. Given the hemodynamic
instability, the intra-aortic balloon pump was pulled and the
patient experienced a profound vagal episode with blood
pressures decreased down to 70/40 requiring the patient to
receive two amps of atropine and fluid resuscitation with
only minor effect. The patient was started on a dopamine
drip. The patient also experienced severe nausea and was
treated with ondansetron which relieved his nausea and
vomiting and subsequently the dopamine was shut off. Later
during the morning the patient experienced an episode of
atrial fibrillation. The patient had a stable rate and a
stable blood pressure. At about 6:00 a.m. the patient
experienced another vagal episode with blood pressure in the
50-60's. Patient was given continuous intravenous fluids,
another milligram of atropine times one with elevation of his
blood pressure. The dopamine was increased again to 20 and
subsequently decreased off. The patient was maintained on
intravenous fluids. Pacing wires were kept intact and the
intra-aortic balloon pump was off. Post-catheterization the
patient was maintained on Plavix 75, Integrilin, aspirin and
atorvastatin. An echocardiogram performed on hospital day
two showed an estimated left ventricular ejection fraction of
25% with global hypokinesis, particularly in the anterior and
apical walls, positive aortic regurgitation and positive
atrial insufficiency. On hospital day two the patient
spontaneously reconverted to normal sinus rhythm and
throughout the night experienced atrial fibrillation again
with a spontaneous reconversion back to normal sinus rhythm.
The patient was eventually weaned off pressors on hospital
day two and hematocrit showed that the patient had a decrease
in his hematocrit to 30.2. Given the concern for bleed, a CT
scan of the pelvis and abdomen was performed which showed no
evidence of a retroperitoneal bleed. The patient was
transfused one unit of packed red blood cells for a decrease
of his hematocrit to 31.4. At this time the patient was
taken off the pressors and CK was trending down from a peak
of 4467 on hospital day two. Integrilin was discontinued 18
hours after the catheterization procedure. On hospital day
two the patient was started on captopril 6.25.
On hospital day three the patient was increased on his
captopril to 25 and a recent hematocrit was 33.1 after the
transfusion. Given the concern for paroxysmal atrial
fibrillation, the patient was started on amiodarone 400 mg q.
day and was started on heparin for prophylaxis as well and
Coumadin 5 mg q. hs. On hospital day three the patient
experienced a severe bilateral groin bleed and was found to
have a PTT of 100, supratherapeutic INR and the heparin was
shut off and the patient had a pressure dressing placed on
the groin with relief of the bleeding diathesis. The patient
received another unit of packed red blood cells for an
hematocrit of 28.8 with a return to 29 on hospital day four
without any further episodes of groin bleed off the heparin.
The patient complained of some shortness of breath and was
found to have some mild congestive heart failure for which he
improved and his oxygen saturation was 92% to 95% and
improvement of his shortness of breath with Lasix 20 times
two and improvement of his orthopnea. On hospital day four
the patient was switched from captopril to lisinopril and
from metoprolol to carvedilol and the amiodarone was
discontinued. Electrophysiology staff was consulted given
his history of atrial fibrillation in house although the
patient did not have atrial fibrillation 48 hours after his
episode and a signal averaging EKG was performed.
Recommendations were for the patient to follow up in two
weeks after discharge with Holter monitoring and exercise
tolerance test with T-wave alternans in two weeks here at the
[**Hospital1 69**] to determine the need
for an ICD implantation. The patient tolerated his
medications well.
CONDITION AT DISCHARGE: Stable. Patient was hemodynamically
stable on the current medications. Patient's INR was
improving to therapeutic levels of 1.5 to 2 while he was on
Plavix with a heparin bridge and the patient was seen by
Physical Therapy for conditioning purposes.
DISCHARGE DIAGNOSES:
1. Acute coronary syndrome.
2. Hypertension.
3. Congestive heart failure.
4. Osteoarthritis.
DISCHARGE MEDICATIONS:
1. Coumadin 5 mg p.o. q. hs.
2. Lisinopril 5 mg one tab p.o. q. day.
3. Carvedilol 3.125 mg one tab p.o. b.i.d.
4. Aspirin 325 q. day.
5. Plavix 75 mg tabs q. day.
6. Atorvastatin 20 mg one tab q. day.
FOLLOW-UP PLANS:
1. The patient will follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18323**], on Tuesday, [**2140-8-30**].
2. Patient will also follow up with his cardiologist of
choice at [**Hospital **] [**Hospital 1459**] Hospital.
3. The patient will follow up with exercise tolerance test
and T-wave alternans test in two weeks here at the [**Hospital1 1444**] with Electrophysiology
Service following him.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Last Name (NamePattern1) 52217**]
MEDQUIST36
D: [**2140-8-25**] 15:17
T: [**2140-8-25**] 15:30
JOB#: [**Job Number 52218**]
ICD9 Codes: 9971, 4280, 4241, 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3282
} | Medical Text: Admission Date: [**2179-4-15**] Discharge Date: [**2179-5-15**]
Date of Birth: [**2103-10-19**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 75-year-old male who
was transferred from [**Hospital6 2561**] to [**Hospital1 346**] on [**2179-4-15**] for evaluation of a
basilar artery aneurysm.
The patient has a significant history of coronary artery
disease, status post coronary artery bypass graft, mitral
valve regurgitation, hypertension, peripheral vascular
disease, and stroke, as well as a history of rectal cancer
(status post resection and colostomy).
The patient was at his Winter home in [**State 108**] when he
experienced two weeks of worsening shortness of breath,
orthopnea, and chest pain. Because his family lives in
[**Hospital1 3494**], [**State 350**] the patient requested transfer to
[**Hospital6 2561**] for mitral valve surgery.
As part of his presurgical evaluation, the patient underwent
a head computed tomography which was worrisome for fusiform
basilar artery aneurysm which was confirmed by magnetic
resonance angiography to be 1.3 cm X 2.1 cm in diameter
aneurysm.
The patient was subsequently transferred to [**Hospital1 346**] for definitive treatment prior to
mitral valve replacement.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post coronary artery
bypass graft and mitral valve disease.
2. Hypertension.
3. Hypothyroidism.
4. Gout.
5. Peripheral vascular disease.
6. Rectal cancer; status post colostomy.
7. History of burns as a child; he has had bilateral upper
extremity with skin grafting.
MEDICATIONS ON ADMISSION: Home medications included Zocor,
Elavil, Synthroid, Lasix, potassium chloride, Colace,
lactulose, amiodarone, Protonix, allopurinol, and captopril.
ALLERGIES: ASPIRIN (which produces a rash).
SOCIAL HISTORY: He lives in [**Hospital1 3494**] with his wife.
PHYSICAL EXAMINATION ON PRESENTATION: Examination on
admission revealed the patient was afebrile with stable vital
signs. General examination revealed an elderly male in no
apparent distress. Head and neck examination demonstrated
normocephalic and atraumatic. The neck was supple with
proptotic eyes. Cardiovascular examination demonstrated a
regular rate with a systolic murmur. The lung examination
demonstrated good air movement with bibasilar crackles.
Abdominal examination was soft, nontender, and nondistended
with a functional colostomy noted in the left lower quadrant.
Extremity examination demonstrated 2 to 3+ edema; right
greater than left. Pulses were palpable throughout. Old
burn injuries were noted in both bilateral upper extremities.
The patient was noted to be missing the fifth digit on his
right hand and had a .................... left hand.
HOSPITAL COURSE: The patient was admitted to the [**Hospital1 1444**] on [**2179-4-15**] under the
Neurosurgery Service directed by Dr. [**Last Name (STitle) 1132**].
Shortly following angiography to fully study the extent of
his basilar artery aneurysm on hospital day two, the patient
experienced an episode of acute respiratory distress
requiring emergency reintubation and was subsequently
transferred to the Coronary Care Unit on [**2179-4-17**].
In the Intensive Care Unit, the patient's pulmonary status
was responsive to aggressive diuresis. The patient was
successfully extubated on [**2179-4-18**] and continued to
demonstrate improving failure signs with aggressive diuresis.
With continued with improvement in his respiratory status,
the patient was able to be transferred back to the regular
floor on [**4-19**] where he remained until the day of his
surgery.
An Infectious Disease consultation was obtained given reports
of a positive catheter tip culture at [**Hospital6 2561**]
which reportedly demonstrated Pseudomonas and Escherichia
coli, as well as a reported recent history of Clostridium
difficile colitis. Although no evidence of bacteremia was
noted at that time, the patient was prophylactically begun on
perioperative Flagyl for Clostridium difficile prophylaxis
beginning on [**2179-4-19**].
A cardiac catheterization conducted on [**2179-4-22**]
demonstrated elevated left-sided and right-sided filling
pressures and preserved cardiac output. In addition,
moderate pulmonary hypertension with large V waves and
pulmonary capillary wedge pressure tracing was noted. 40% to
50% serial stenoses in the proximal and medial portions of
the left anterior descending artery were noted. Nonselective
renal angiography demonstrated only mild bilateral stenosis
(less than 40%).
Following stabilization of the patient's respiratory status,
extensive conversations were held with the patient and his
family with regard to the risks of additional cardiac surgery
given his fusiform basilar artery aneurysm. Following
extensive discussions surrounding the risks of potential
stroke during the course of his procedure, the patient and
his family agreed to mitral valve replacement on [**4-26**],
and the patient was subsequently scheduled for a mitral valve
replacement on [**2179-4-27**].
On [**4-27**], the patient underwent a right thoracotomy with
mitral valve replacement with a 31 Mosaic porcine valve. The
patient tolerated the procedure well with a bypass time of
100 minutes. The patient's pericardium was reapproximated.
Lines placed included a right radial arterial line, a right
internal jugular with a Swan-Ganz catheter. Two atrial wires
were placed and two right pleural tubes were additionally
placed during the course of the procedure. On transfer to
the Recovery Room, the patient's mean arterial pressure was
60. His central venous pressure was 12. His PAD was 28, and
his [**Doctor First Name 1052**] was 36. The patient was noted to be a normal sinus
rhythm at a rate of 80. Drips on transfer included Milrinone
and Levophed.
The patient was initially weaned and extubated shortly
following his procedure; however, he required reintubation
for respiratory distress and atrial fibrillation on
postoperative day one. A follow-up chest x-ray demonstrated
evidence of volume overload with questionable acute
respiratory distress syndrome.
An Infectious Disease consultation obtained at that time
recommended starting the patient on empiric Zosyn coverage in
addition to his standing Flagyl dosage. Further consultation
with Pulmonary Medicine resulted in continued aggressive
diuresis of the patient with good effect. Further evaluation
of the patient's chest film demonstrated the presence of
bilateral pleural effusions with increasing evidence of
underlying newly diagnosed pulmonary fibrosis. Intermittent
temperature spikes resulted in the addition of vancomycin to
the patient's antibiotic regimen with continued aggressive
respiratory care.
A screening transesophageal echocardiogram obtained on [**5-5**] demonstrated no evidence of endocarditis as a potential
source of the patient's elevated temperature.
The patient demonstrated gradual improvement in his
respiratory status with aggressive diuresis and continued
antibiotic therapy through [**5-6**], at which point he was
successfully extubated while in the Cardiothoracic Surgery
Recovery Unit.
Following extubation, an oropharyngeal speech and swallowing
study was obtained which cleared the patient for oral intake
on [**5-6**].
The patient continued to demonstrate an improving clinical
examination and diminishing signs of respiratory distress
through postoperative day 13 ([**5-10**]), at which point he
was transferred to the floor and admitted to the
Cardiothoracic Service under the direction of Dr. [**First Name (STitle) **]
[**Last Name (Prefixes) **].
Extensive review by Physical Therapy recommended the patient
for rehabilitation placement following discharge.
On the floor, the patient continued to demonstrate a
gradually improving clinical examination with continued
aggressive diuresis. A follow-up chest computed tomography
demonstrated no evidence of a pulmonary infectious process;
however, it did demonstrate evidence of progressive pulmonary
fibrosis; right greater than left.
On postoperative day 17 ([**2179-5-14**]), the patient was being
planned for transfer to rehabilitation when he demonstrated
an episode of tachypnea with associated diaphoresis. An
electrocardiogram and chest x-ray at this time demonstrated
no evidence of acute myocardial event or flash pulmonary
edema. At this time, the emergence of a left facial tick was
also noted, and a Neurology consultation was obtained.
On further review, the patient described a history of
intermittent left facial ticks; however, a head computed
tomography was obtained at this time under the advice of the
Neurology Service which demonstrated no evidence of acute
cerebrovascular injury. The patient was noted to demonstrate
increasing respiratory status once again with aggressive
diuresis and was subsequently cleared for discharge to a
rehabilitation facility on [**2179-5-15**].
DISCHARGE DISPOSITION: The patient was to be discharged to a
rehabilitation facility for further care and management with
instructions for followup.
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE:
1. Levothyroxine sodium 25 mcg p.o. once per day.
2. Docusate sodium 100 mg p.o. twice per day.
3. Plavix 75 mg p.o. once per day.
4. Ranitidine 150 mg p.o. twice per day.
5. Amitriptyline 10 mg p.o. q.h.s.
6. Flagyl 500 mg p.o. three times per day (times seven
days).
7. Percocet 5/325 one to two tablets p.o. q.4h. as needed
(for pain).
8. Vancomycin 1 g intravenously q.24h. (times seven days).
9. Potassium chloride 20 mEq p.o. twice per day.
10. Lasix 80 mg p.o. twice per day.
11. Captopril 18.75 mg p.o. three times per day.
12. Lopressor 12.5 mg p.o. twice per day.
13. Procainamide 500 mg p.o. twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to maintain his incisions clean and dry
at all times.
2. The patient may shower but should pat dry his incisions
afterwards. No bathing or swimming until further notice.
3. The patient was to complete an entire prescribed course
of vancomycin and Flagyl.
4. The patient may resume a regular diet.
5. The patient was to limit physical activity; no heavy
exertion.
6. No driving while taking prescription pain medications.
7. The patient was to follow up with his primary care
provider within one to two weeks following discharge.
8. The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] from
Neurosurgery within one to two weeks following discharge for
further neurosurgical evaluation.
9. The patient was to follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]
within four weeks following discharge for re-evaluation.
10. The patient was to call to schedule all follow-up
appointments.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36
D: [**2179-5-15**] 04:24
T: [**2179-5-15**] 04:49
JOB#: [**Job Number 35806**]
ICD9 Codes: 4240, 4280, 5119, 5185, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3283
} | Medical Text: Admission Date: [**2197-11-21**] Discharge Date: [**2197-12-19**]
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 77-year-old
woman, who was here, visiting her nephew from [**State 2690**]. In the
middle of the night, she got up to go to the bathroom and
opened the basement door, instead of the bathroom door, and
fell down the stairs. The patient was intubated at the
to two minutes. This was preceded by combative behavior.
The head CT revealed an intraparenchymal bleed and left
subarachnoid bleed with a question of midline shift. The
head CT also revealed right skull fracture from the parietal
occipital juncture, extending to the skull, base, and foramen
Magnum; also with left temporal attenuation, may be an
interparenychmal hemorrhage and left frontal-lobe density
HOSPITAL COURSE: The patient was admitted to the ICU. The
patient had a vent drain placed. The patient was sent to the
surgical ICU for close monitoring.
PAST MEDICAL HISTORY: The patient has a past medical history
of hypertension for which she was taking Atenolol and Vasotec
prior to admission to the hospital. The patient has no other
past medical history.
PAST SURGICAL HISTORY: The patient has no other past
surgical history.
On arrival to the ER the GCS score was 70. She had no other
obvious injuries.
PHYSICAL EXAMINATION: On examination, the heart rate was 69,
blood pressure 141/62, temperature 96.8, respiratory rate 16,
saturation 99%. Pupils were 4:6 on the left and 4:3 and
brisk on the right. She had hemotympanum on the right, large
right scalp laceration. She was intubated and sedated,
following no commands and not responding to pain.
Repeat head CT on [**11-22**] showed contusion and subarachnoid
hemorrhage, left anterior temporal, interparenchymal
hemorrhages, right frontal lobe hemorrhage, left greater than
right and right subdural hematoma, which was small. The
cervical spine films revealed a C6 fracture. The patient
also had thoracic spine films, which revealed a T3 fracture.
PHYSICAL EXAMINATION: Neurological examination on [**2197-11-23**]
revealed that the patient was still intubated. She had
partial localization of the left upper extremity and question
of extension posturing on the right upper extremity and brisk
withdrawal of the lower extremities. Pupils were 3 down to 2
bilaterally. Head CT revealed partial blossoming of the
frontal bleed. The patient CTA of the brain, which showed no
evidence of aneurysm for cause of subarachnoid blood.
On [**2197-11-25**], the patient's sputum culture came back with
gram-negative rods. The patient was started on
Ciprofloxacin. Neurologically, pupils equal, round, and
reactive, but withdrawing in the upper extremities and
flexing in the lower extremities bilaterally. The patient
was on CPAP at 40%.
On [**2197-11-26**], neurological examination revealed the
following: Pupils remained 4-mm and reactive bilaterally.
She has an impaired corneal on the right and intact corneal
on the left, positive gag, positive cough. The patient was
unresponsive, except to withdrawal on all four extremities to
nail bed pressure. Minimal spontaneous movement noted and
the patient did open eyes half way with logrolling. The
patient was unable to focus on the examination. The ICP
drain remains in place at 20 cm above the tragus with ICPs 17
to 20. The patient was loaded on Dilantin on admission and
Dilantin was continued until [**2197-12-11**], when it was
discontinued. The ICP drain remained in place until
[**2197-12-5**]. The patient was fitted, TLSO brace arrived. The
patient was in TLSO brace at all times, head of the bed
greater than 45 degrees. While in bed, the patient should be
logrolled only. The patient was treated with Acyclovir for
herpes zoster on her lips. She also had yeast in her urine,
for which she received a full treatment of Diflucan. She was
also treated for an MRSA pneumonia.
Currently, the patient is receiving IV Vancomycin, 1-gram IV
q 12 hours and p.o. Levaquin 500 mg p.o.q.d.
The patient was Oxacillin from [**11-21**] to [**12-5**], Ciprofloxacin
from [**11-21**] to [**12-6**], Diflucan from [**12-4**] to [**12-9**] and
Ceftazidime from [**12-7**] to the current time. The patient had
tracheostomy tube and PEG tube on [**2197-12-7**]; tracheostomy
mask at 40% on [**2197-12-11**]. Neurologically, as of [**2197-12-18**],
the patient opened her eyes; was able to say her name;
moving the upper extremities strongly; lower extremities
flexing minimally to pain. The patient remained at flat bed
rest, otherwise, in TLSO brace. The patient is having a MRI
of the thoracic and cervical spine on [**2197-12-18**]; results
pending.
MEDICATIONS ON DISCHARGE:
1. Atenolol 100 mg p.o.q.d.
2. K-Dur 20 mg per G-tube q.d.
3. Vancomycin 1-g IV b.i.d., which was started on
[**2197-12-7**].
4. Levaquin 500 mg per G-tube q.d. begin on [**2197-12-8**].
5. Salt tabs per G-tube q.d., 2-g.
6. NPH Insulin, two units subcutaneously q.m. and q.p.m.
7. Nystatin powder to the groins.
8. Promote tube feeding at 60 cc per hour via her J-tube.
The patient has a Passy-Muir valve for her tracheostomy. She
was on log-roll precautions whenever the brace is off. The
brace must be on at all times if head of bed is greater than
45 degrees or patient is out of bed. C-collar must remain in
place due to the C6 fracture at all times for twelve-week
total. The patient is on MRSA precautions for the MRSA in
her sputum.
The patient is being transferred to an acute hospital in
[**State 2690**] with followup rehabilitation postoperatively and
followup with the neurosurgeon in [**Location (un) 36413**], TX.
The patient's condition was stable at the time of discharge.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2197-12-18**] 13:36
T: [**2197-12-18**] 13:34
JOB#: [**Job Number 36414**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3284
} | Medical Text: Admission Date: [**2159-11-29**] Discharge Date: [**2159-12-4**]
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
[**Hospital Ward Name **] HOSPITALIST ADMISSION HISTORY AND PHYSICAL
.
CC: bright red blood per rectum
.
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6700**]
GI surgeon: Dr. [**Last Name (STitle) 1120**]
Major Surgical or Invasive Procedure:
Tagged RBC scan X2
PRBC transfusion X4 units
History of Present Illness:
86year old pleasant female with h/o colon ca s/p R hemicolectomy
[**9-10**], hemmoroids, PVD/CVA s/p [**Country **] stent on ASA/plavix comes to
ER for evaluation of episode of brbpr associated with
lightheadedness. Was doing well until this am. Felt nauseous,
LH, weak, then proceeded to have bloody BM mixed with some
stool. Has h/o hemmorhoids but no h/o bleed, no recent
constipation. No emesis. no epigastric pain. No further BMs
since the episode this am. Baseline dark to black stools, on
iron. Had blood transfusion recenlty [**11-2**] (1U) for anemia and
cramps.
.
In ER, marroon stool on rectal, GI/Surgery consulted, 1.5L IVF,
1U prbc, Protonix. Hemodynamically stable, admitted to Gen Med.
Past Medical History:
hx of C Diff
carotid artery disease s/p L CVA on [**2157-1-2**] (thought to be
embolic [**2-3**] PFO) with residual R sided [**Last Name (LF) 66413**], [**First Name3 (LF) **] [**2152**], R ICA
stenosis s/p PTCA/stent [**3-8**], residual disease
HTN
Colon Cancer T3No, right sided, dx [**7-10**], s/p R lap
hemicolectomy [**9-10**], clear margins, Dr. [**Last Name (STitle) 1120**]
Anemia (?chronic blood loss), gets intermittent blood t/f as
outpt, last [**11-2**]
h/o GIB (on coumadin)
hemmoroids
Dementia, mild AD and vascular
LBP
s/p Laminectomy in [**2151**]
s/p L ankle ORIF
s/p cataract surgery
s/p lap hemicolectomy [**9-10**]
Social History:
Past smoker 1/2ppd x 40 years, quit 20 years ago. Was living
with daughter in [**State 350**], recently moved in with son and
daughter in law. baseline, ambulates independently or with
walker, has minimal residual weakness, activity limited by
arthritis. No etoh use.
Family History:
No family history of CAD, CVA, DM, colon Ca
Physical Exam:
Physical Exam:
Vitals in ER: 95.0 65 158/64 18 100%RA
vitals on arrival: 98.0 160/60 62 18 95%RA
Gen: pleasant elderly female, nad
Eyes: EOMI, anicteric, pale conjunctiva
ENT: mm dry
Neck: no jvd, bilateral bruits
CV: RRR, [**2-7**] SM USB to carotids
Resp: CTAB, slight scattered crackles, no wheezing
Abd: soft, nontender, nondistended, +BS, no HSM
Lymph: no cervical, axillary, inguinal LAD
Ext: no edema, good peripheral pulses, no cyanosis, arhtritis
changes
Neuro: A&OX3, CNII-XII intact, gait not assessed, strength LUE
[**5-7**], RUE 5-/5, intact sensation
Skin: warms, scattered ecchymosis b/l UE
psych: appropriate, pleasant
.
.
ROS: All 10 systems were reviewed and are otherwise negative
unless noted in above HPI.
.
Pertinent Results:
White count 6.6
Hgb 8.8 (was [**10-13**] in [**9-10**])
INR 1.3
chem panel unremarkable except BUN 21
.
EKG: NSR, nonspecific TW changes
[**2159-11-29**] 11:15AM BLOOD WBC-6.6 RBC-2.91* Hgb-8.8* Hct-27.0*
MCV-93 MCH-30.3 MCHC-32.6 RDW-13.5 Plt Ct-236#
[**2159-11-29**] 07:25PM BLOOD WBC-8.5 RBC-2.75* Hgb-8.5* Hct-25.5*
MCV-93 MCH-31.0 MCHC-33.4 RDW-14.3 Plt Ct-162
[**2159-11-30**] 03:14AM BLOOD WBC-7.9 RBC-3.44*# Hgb-10.6* Hct-30.2*
MCV-88 MCH-30.8 MCHC-35.1* RDW-14.8 Plt Ct-148*
[**2159-11-30**] 08:00AM BLOOD Hct-29.8*
[**2159-11-30**] 01:41PM BLOOD Hct-29.7*
[**2159-11-30**] 09:12PM BLOOD Hct-24.8*
[**2159-12-1**] 05:59AM BLOOD WBC-6.9 RBC-3.39* Hgb-10.2* Hct-28.5*
MCV-84 MCH-30.0 MCHC-35.8* RDW-15.2 Plt Ct-125*
[**2159-12-1**] 02:30PM BLOOD Hct-27.1*
[**2159-12-1**] 10:25PM BLOOD Hct-26.1*
[**2159-12-2**] 06:45AM BLOOD WBC-6.5 RBC-3.02* Hgb-9.0* Hct-26.2*
MCV-87 MCH-29.7 MCHC-34.3 RDW-15.0 Plt Ct-119*
[**2159-12-2**] 02:57PM BLOOD Hct-27.7*
[**2159-12-3**] 06:25AM BLOOD WBC-5.8 RBC-2.72* Hgb-8.4* Hct-23.9*
MCV-88 MCH-30.8 MCHC-35.1* RDW-14.9 Plt Ct-130*
[**2159-12-3**] 04:30PM BLOOD WBC-7.2 RBC-3.09* Hgb-9.3* Hct-28.2*
MCV-91 MCH-30.0 MCHC-32.9 RDW-14.5 Plt Ct-134*
[**2159-12-4**] 08:45AM BLOOD WBC-6.6 RBC-3.05* Hgb-9.3* Hct-26.9*
MCV-88 MCH-30.4 MCHC-34.4 RDW-14.6 Plt Ct-163
[**2159-12-4**] 08:45AM BLOOD Glucose-87 UreaN-4* Creat-0.5 Na-140
K-4.0 Cl-106 HCO3-30 AnGap-8
[**2159-11-29**] 07:25PM BLOOD Lipase-23
[**2159-12-4**] 08:45AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9
Nuc tagged RBC scan: [**11-30**]
"HISTORY: 86 year-old female with history of R colectomy [**9-10**],
now with
persistent lower GI bleeding.
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for minutes were obtained. A left lateral
view of the pelvis was also obtained.
Blood flow images show normal blood flow and tracer
distribution.
Dynamic blood pool images were initially unremarkable, but
subsequently
demonstrated brisk bleeding first noticed at approximately 70
minutes. Focus of bleeding appears to be located in the left
upper quadrant. The serpiginous nature of visualized bowel, and
lack of progression to the rectum at 130 minutes, suggests site
of bleeding is likely in the proximal small bowel. There is,
however, no evidence of bleeding proximal to the ligament of
Treitz.
IMPRESSION: GI bleeding study is positive for bleed, which
appears located in the left upper quadrant, most likely in small
bowel. "
Brief Hospital Course:
This is an 86 yo F with a hx of recent R colectomy for Tumor
T3N0 in [**9-10**] who presented with 1 episode of BRBPR on [**11-29**]. Pt
was initially maintained on ASA 81 qd and plavix but later those
were held. In the ED, she received 1 unit PRBCs. On the floor,
she was noted to have 2 more episodes of bloody stools. Her HCT
decreased and was transferred to the ICU for closer monitoring.
She received 2nd unit of PRBCs prior to transfer with 3rd
hanging on transfer. In the ICU she continued to have bleeding
and underewent a tagged RBC scan which was positive and
demonstrated bleeding in the jejunum at 70 mins. The patient
declined angiography and thus no procedure was performed. GI
thinks that the source is AVM and felt strongly that the patient
needed a therapeutic intervention. IR angio was willing to
intervene but patient was nervous about signing consent.Then
patient began to have hourly large maroon and red bowel
movements. This was re-addressed with angio who then asked her
to be re-RBC scanned. She again had a positive scan but this
time bleeding was seen in the colon and it was unclear if the
bleeding was new or residual blood from earlier bleeding passing
into the colon. Patient returned to the floor stable and
frequency and amount of stools decreased. Patient's HCT then
remained stable since her last transfusion at 2:00 1 am on
[**2159-12-1**]. She has received a total of 4 PRBCs during this
hospitalization. On the floor, she was monitored and remained
stable, her last bm was on [**12-2**] which was guaiac pos (her
stools will likely remain guaiac + given recent bleed) but did
not show obvious bleeding. Her HCT also remained stable. GI did
not think an EGD or colonoscopy would be of benefit given that
the RBC scan was + at jejenum. After discussion w GI and her
cardiologist, Dr. [**First Name (STitle) **], it was decided to restart pt on
aspirin alone (at 325mg dose). Pt and family told that it is not
possible if and when this will happen again but if she starts to
have GI bleeding again, she should go to ED right away.
Addendum - right before dicharge, pt had a dark BM which was
guaiac pos. there was no fresh blood and stool was formed.
Vitals were stable and this was thought to likely stool w some
old blood from prior bleed. A repeat CBC was done and it was
stable and so was pt's blood pressure. Pt was discharged to
rehab.
#HTN - her bp meds initially held, at discharge bp stable (sBP
in 120-140 range)and home dose metoprolol restarted. Pt should
have bp checked at rehab and if stable to high, after a few
days, pt's home dose norvasc of 5mg QD can be restarted.
#Dementia - pt contined on Aricept and celexa. Pt did not
develop any delirium issues during hospitalization
#hx of CVA/Carotid stenosis/PFO - per Cards, not on coumadin
given hx of bleeding before. Was on ASA/PLavix until this
admission, now being discharged on ASA alone. This can be
readdressed by PcP and or Cardiology as to when/if plavix should
be restarted.
#FEN - Low salt, low fat diet
#DVT pro - Ambulate frequently, pneumatic boots while in bed
#Code status - DNR/DNI
#Dispo - pt was weak and using cane/walker at home at baseline
and after hospital stay, had more deconditioning. Per PT recs
and at family request, pt being discharged to [**Hospital1 1501**]/Rehab
Medications on Admission:
per d/c summary [**9-10**], pt not sure of all her meds:
ASA 81
plavix 75
lipitor 20-recently d/c'd per pt
metoprolol 25mg [**Hospital1 **]
norvasc 5
Fe 160mg qd
mvi
neurontin 100qhs
celexa 20
donezepil 5mg qhs
tylenol prn
protonix 40mg qd
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare of [**Location (un) **]
Discharge Diagnosis:
GI bleed - likely source from small bowel
Discharge Condition:
Good
Discharge Instructions:
You were admittd to the hospital with GI bleeding. We did a
nuclear study that showed that bleeding is likely occuring in
your small bowel. The next step would have been to do an
angiography and clot off the bleeding vessel but you were not
sure if you wanted the procedure. Your bleeding has stopped now.
The GI doctors [**Name5 (PTitle) **] not [**Name5 (PTitle) 9004**] to do any procedures. You were an
aspirin and plavix but both were initially held. After
discussion w GI doctors and your cardiologist, we decided to
resume your aspirin only.
Please return to ED if the bleeding recurrs, or if you have
fevers, dizziness, abdominal pain
Followup Instructions:
1. Dr. [**Last Name (STitle) 66414**], [**First Name3 (LF) 518**], ph: [**Telephone/Fax (1) 6699**], Appt is on [**12-19**], 11:OO am, at the [**Location (un) **] office. [**2159**]. Fax: [**Telephone/Fax (1) 66415**] w
CBC check
2. Dr. [**First Name8 (NamePattern2) 11560**] [**Last Name (NamePattern1) **], ph: [**Telephone/Fax (1) 62**], [**1-28**], 3:40pm.
ICD9 Codes: 2851, 4439, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3285
} | Medical Text: Admission Date: [**2162-11-2**] Discharge Date: [**2162-11-18**]
Service: CARDIAC SURGERY
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is an 86 year old gentleman
who has a recent history of increasing shortness of breath
and dyspnea on exertion. The patient is status post coronary
artery bypass graft times four in [**2150**], with known aortic
stenosis followed by serial echocardiograms. The patient
underwent cardiac catheterization on [**2162-10-6**], which showed
severe native three vessel disease, moderately increased left
ventricular end diastolic pressure at 26 with mild pulmonary
hypertension as well as an occluded saphenous vein graft to
R1, patent saphenous vein graft to OM with moderate
anastomotic lesion, patent left internal mammary artery to
left anterior descending with severe native lesion distal to
the anastomosis. The patient was referred to Dr. [**Last Name (Prefixes) **]
for aortic valve replacement and coronary artery bypass
graft.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Coronary artery disease.
3. Aortic stenosis.
4. Benign prostatic hypertrophy.
5. Status post coronary artery bypass graft in [**2150**].
6 Status post tonsillectomy.
7. Status post right below the knee amputation secondary to
a war injury in [**2103**].
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS:
1. Aspirin 81 mg p.o. twice a day.
2. Zocor 20 mg p.o. once daily.
3. Flomax 0.4 mg p.o. once daily.
4. Propranolol 10 mg p.o. twice a day.
5. Multivitamin.
6. Aciphex 20 mg p.o. once daily.
SOCIAL HISTORY: The patient denies tobacco or ETOH. The
patient is married and lives with his wife.
PREOPERATIVE LABORATORY DATA: White blood cell count was
6.0, hematocrit 35.4, platelet count 162,000. Sodium 134,
potassium 4.0, chloride 103, bicarbonate 27, blood urea
nitrogen 16, creatinine 0.9, glucose 176. INR 1.2.
PHYSICAL EXAMINATION: Preadmission physical examination was
significant for a heart rate of 66, blood pressure in the
left arm of 226/85 and in the right arm 200/88, oxygen
saturation 95% in room air. The patient was awake, alert and
oriented times three and neurologically nonfocal. Head,
eyes, ears, nose and throat examination - The neck is supple.
Mucous membranes are moist. Upper and lower dentures. Heart
- S1 and S2 with audible harsh blowing systolic murmur and a
well healed surgical scar over his sternum. The lungs were
clear to auscultation bilaterally. The abdomen is soft,
positive bowel sounds, nontender, nondistended, no
hepatosplenomegaly. Pulses - carotids were 2+ bilaterally
with radiating murmur. All other peripheral pulses were
equal bilaterally with the exception of his right lower
extremity due to his previous below the knee amputation.
The patient underwent carotid ultrasound on [**2162-10-14**], which
showed minimal bilateral internal carotid artery plaque
without any appreciable associated stenosis and the patient
was scheduled for surgery.
HO[**Last Name (STitle) **] COURSE: The patient was admitted on [**2162-11-2**], and
taken to the operating room with Dr. [**Last Name (Prefixes) **] for an
aortic valve replacement and an attempted coronary artery
bypass graft through a redo sternotomy. Upon opening the
sternum, it was found that the patient had dense adhesions
and the cardiac surgery team was unable to obtain adequate
access to perform a bypass graft. It was decided at that
time that the patient postoperatively would be taken to the
Cardiac Catheterization Laboratory for a percutaneous
coronary intervention. The patient, however, did have an
aortic valve replacement with a 23 millimeter Bovine
pericardial valve. Please see operative note for further
details. The patient was transferred to the Intensive Care
Unit in stable condition on a Milrinone infusion. The
patient was weaned and extubated from mechanical ventilation
on the first postoperative day. The Milrinone was weaned to
off for a good cardiac index. It was noted on postoperative
day number two that the patient had mild thrombocytopenia
with a platelet count of 85. Heparin antibody was sent at
the time which was subsequently negative. The patient was
again on Lopressor and Captopril for blood pressure control.
The patient also required Nipride infusion to maintain
systolic blood pressure less than 140. The patient was taken
to the Cardiac Catheterization Laboratory on postoperative
day number two and underwent a percutaneous transluminal
coronary angioplasty and stent to the left anterior
descending distal to the previous left internal mammary
artery graft. The patient tolerated this procedure well and
returned to the Intensive Care Unit. Over night on
postoperative day number two, the patient had increasing
confusion and was started on some Haldol. The patient
continued to improve during the day. However, on the evening
of postoperative day number three, the patient began
experiencing rigors with a low grade fever as well as labored
respirations. The patient was electively intubated. After
intubation, the patient became severely hypotensive and
required large amounts of volume resuscitation and pressors.
The patient had a pulmonary artery catheter placed at this
time which showed hyperdynamic numbers consistent with
sepsis. The patient underwent bronchoscopy which showed
dense secretions in the right upper lobe and left lower lobe.
This was sent for culture. The patient was pancultured at
this time. Subsequent cultures grew out gram negative rods.
The patient was started on broad spectrum antibiotics and the
cultures grew out Serratia which was pansensitive. Serratia
was found in the sputum, the blood and on the right internal
jugular introducer. The patient also had an urgent bedside
echocardiogram performed by the cardiology fellow which
showed an ejection fraction that was well preserved,
hyperdynamic left ventricle and no pericardial effusion, no
obvious wall motion abnormalities. The patient continued to
require pressors to maintain adequate blood pressure as well
as volume resuscitation. It was noticed on the evening of
postoperative day number three that the patient had a large
amount of subcutaneous emphysema across his chest. The
patient had been noticed to have an air leak from one of his
chest tubes presumed from a lung injury intraoperatively.
Chest x-ray at that time showed no pneumothorax and bilateral
pleural chest tubes. The infectious disease team was
consulted and the patient's antibiotics were changed to
Ceftazidime and Levofloxacin for the gram negative rods. The
patient also received one dose of Gentamicin and continued on
Flagyl and Vancomycin which were subsequently discontinued
when all remaining cultures were negative for anything but
gram negative rods. The patient continued to have fevers.
On postoperative day number five, the patient had a fever of
101.7. The patient remained intubated with minimal
ventilatory support. The patient underwent a CAT scan of his
abdomen and pelvis that showed a right pneumothorax with
bilateral chest tubes and bilateral lower lobe
consolidation/collapse, bilateral pleural effusions, and no
intra-abdominal pathology noted. The patient continued to
remain intubated and required frequent suctioning of his
endotracheal tube for moderate amount of thick white
secretions. It was decided on [**2162-11-8**], after the patient
had a subsequent positive blood culture on [**2162-11-6**], that the
patient should have all central lines removed. The patient
had no bedside access for a PICC, however, the patient went
to interventional radiology for placement of a PICC catheter
in the right basilic vein for long term antibiotic therapy.
On postoperative day number seven, infectious disease team
discontinued the Vancomycin and Flagyl and recommended
continuing the Levofloxacin and Ceftazidime for a total of
three week course. The patient had a bronchoscopy on
[**2162-11-9**], which showed minimal amount of whitish secretions
bilaterally. The patient continued to have an air leak from
the left pleural chest tube. The patient required
intermittent doses of Haldol for agitation. The patient
underwent a repeat bronchoscopy on [**2162-11-11**], which showed
scant secretions in the right lower lobe. The patient was
weaned and extubated from mechanical ventilation on the
afternoon of [**2162-11-11**], and required a fair amount of
pulmonary toilet, however, was quickly weaned down to nasal
cannula. The patient was coughing on his own. Off sedation,
the patient was awake, alert and oriented times three. On
[**2162-11-12**], the patient underwent a bedside speech and swallow
evaluation which showed no evidence of aspiration or
dysphagia. On [**2162-11-13**], the patient was transferred from the
Intensive Care Unit to the regular floor. The patient
continued to have an air leak from his chest tube. The chest
tube was taken off suction and placed on water seal, however,
it did continue to have an air leak. On [**2162-11-16**], thoracic
surgery was consulted for the continued air leak. They
recommended clamping the chest tube and repeating the chest
x-ray in 24 hours. If there as no pneumothorax in 24 hours
with the chest tube clamped, to discontinue the chest tube.
A chest x-ray was performed on [**2162-11-17**], after 24 hours of
chest tube clamp that showed no pneumothorax. The chest tube
was removed without difficulty. At this time, the patient
had been evaluated by physical therapy and it was determined
due to the patient's age, the patient's disability of his
right lower extremity amputation, the patient would benefit
from short term rehabilitation. On [**2162-11-17**], postoperative
day number fifteen, the patient was cleared for discharge to
rehabilitation.
CONDITION ON DISCHARGE: Temperature maximum 98.8, pulse 100,
sinus rhythm, blood pressure 107/60, respiratory rate 16,
oxygen saturation 95% in room air. The patient is awake,
alert and oriented times three, occasionally repeating
himself and occasionally forgetful. Strength in his
bilateral upper extremities is equal and strength of his
bilateral thighs is equal. The heart is regular rate and
rhythm without rub or murmur. Breath sounds are clear
bilaterally without wheezes or rhonchi. There is no
subcutaneous air palpated across his chest. Gastrointestinal
positive bowel sounds, soft, nontender, nondistended,
tolerating a regular diet, having normal bowel movements.
Chest x-ray on [**2162-11-17**], showed no pneumothorax, no
subcutaneous air. Lower extremities without edema. Sternal
incision Steri-strips are intact. The incision is clean and
dry and sternum is stable. White blood cell count is 6.8,
hematocrit 32.0, platelet count 311,000. Sodium 137,
potassium 3.9, chloride 102, bicarbonate 26, blood urea
nitrogen 18, creatinine 0.9, glucose 99.
DISCHARGE DIAGNOSES:
1. Aortic stenosis.
2. Status post aortic valve replacement via redo sternotomy
with a 23 millimeter [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve.
3. Coronary artery disease, status post coronary artery
bypass graft in the past, now status post percutaneous
transluminal coronary angioplasty and stent to the left
anterior descending.
4. Postoperative gram negative rods/Serratia sepsis.
5. Postoperative confusion.
6. PICC insertion.
7. Prolonged air leak from chest tube.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o. twice a day.
2. Lasix 20 mg p.o. once daily times seven days.
3. Potassium Chloride 20 meq p.o. once daily times seven
days.
4. Colace 100 mg p.o. twice a day.
5. Enteric Coated Aspirin 325 mg p.o. once daily.
6. Tylenol 650 mg p.o. q4-6hours p.r.n.
7. Levofloxacin 500 mg p.o. once daily times two weeks.
8. Ceftazidime one gram intravenously q8hours times two
weeks.
9. Plavix 75 mg p.o. once daily.
10. Zocor 20 mg p.o. once daily.
11. Flomax 0.4 mg p.o. once daily.
12. Haldol 1 mg p.o. twice a day.
13. Prevacid 30 mg p.o. once daily.
FO[**Last Name (STitle) **]P: The patient is to be discharged to rehabilitation
in stable condition. The patient is to follow-up with Dr.
[**Last Name (STitle) 52103**] in two weeks. The patient is to follow-up with Dr.
[**Last Name (STitle) 52104**] in two weeks, and the patient is to follow-up with Dr.
[**Last Name (Prefixes) **] in three to four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2162-11-17**] 17:21
T: [**2162-11-17**] 18:03
JOB#: [**Job Number 52105**]
ICD9 Codes: 2720, 4241, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3286
} | Medical Text: Admission Date: [**2161-3-17**] Discharge Date: [**2161-3-31**]
Date of Birth: [**2111-9-15**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Groin swelling, pain and drainage for one week
Major Surgical or Invasive Procedure:
[**3-17**] Left peroneal groin abscess incision and drainage complex.
[**3-20**] Re-debridement of fat necrosis and drainage of soft tissue
infection of the left perineum and groin
[**3-21**] Repeat incision and drainage of labia and anterior
abdominal wall and vaginal exam with speculum
History of Present Illness:
[**Known firstname **] is a pleasant 49-year-old female with type 1 diabetes who
presented with almost a week history of left groin perineal
pain. It worsened over the course of several days. She was seen
in the emergency room and had a white blood cell count of
30,000, a blood sugar of 650 and a raging soft tissue infection
with crepitus in the left lateral labial groin area. She was
given intravenous antibiotics. Central venous access was
obtained and aggressive sugar control was administered with an
insulin drip.
Past Medical History:
1. DM type 2 c/b retinopathy and neuropathy
2. h/o esophageal candidiasis
3. h/o benign abdominal mass s/p excision [**2158**]
4. h/o colonic polyps
5. s/p cholecystectomy
Social History:
Lives with husband and daughter. [**Name (NI) **] been receiving social
security disability insurance since [**2-1**], used to work as a
welder. + tob [**4-4**] cig x25y, no EtOH or recreational drugs.
Family History:
M - liver Ca, MI, died at 66y/o
F - CAD - CABG x3 at 65y/o
PGM - MI at 27y/o
2uncles - lung Ca
mat aunt - lung Ca
Physical Exam:
PE:
moderately distressed woman
tachypnic
decreased breath sounds at bases
tachycardic, regular
soft abdomen
pelvis: left groin, 10cm area of induration, fluctuance, open
sinus tract lateral to left labia majora, +crepitus left groin
ext: warm trace edema
Pertinent Results:
[**2161-3-17**] 10:15AM WBC-30.8 Hgb-15.2# Hct-45.7# Plt Ct-370
[**2161-3-19**] 04:08AM BLOOD WBC-25.8* Hgb-10.6*# Hct-31.3* Plt Ct-313
[**2161-3-20**] 03:49PM BLOOD WBC-30.9* Hgb-11.0* Hct-31.8* Plt Ct-334
[**2161-3-21**] 02:05AM BLOOD WBC-30.0* Hgb-10.2* Hct-29.4* Plt Ct-340
[**2161-3-22**] 01:35PM BLOOD WBC-25.9* Hgb-8.2* Hct-23.6* Plt Ct-380
[**2161-3-24**] 02:07AM BLOOD WBC-22.0* Hgb-8.3* Hct-24.6* Plt Ct-445*
[**2161-3-26**] 04:31AM BLOOD WBC-23.2* Hgb-7.5* Hct-22.5* Plt Ct-452*
[**2161-3-28**] 04:18PM BLOOD WBC-21.5* Hgb-7.9* Hct-24.3* Plt Ct-584*
[**2161-3-30**] 04:22AM BLOOD WBC-12.5* Hgb-5.9* Hct-19.2* Plt Ct-461*
[**2161-3-17**] 10:15AM BLOOD Neuts-91.2* Bands-0 Lymphs-4.3* Monos-4.0
Eos-0.3
[**2161-3-17**] 10:15AM BLOOD PT-11.8 PTT-20.7* INR(PT)-1.0
[**2161-3-17**] 10:15AM BLOOD Glucose-687* UreaN-19 Creat-0.9 Na-130*
K-4.2 Cl-87* HCO3-20* AnGap-27*
[**2161-3-17**] 06:27PM BLOOD Glucose-126* UreaN-17 Creat-0.5 Na-140
K-3.5 Cl-108 HCO3-24 AnGap-12
[**2161-3-19**] 04:08AM BLOOD Glucose-204* UreaN-13 Creat-0.4 Na-135
K-4.2 Cl-102 HCO3-25 AnGap-12
[**2161-3-21**] 12:41PM BLOOD Glucose-155* UreaN-8 Creat-0.3* Na-134
K-3.9 Cl-99 HCO3-23 AnGap-16
[**2161-3-24**] 02:07AM BLOOD Glucose-195* UreaN-8 Creat-0.4 Na-132*
K-3.9 Cl-96 HCO3-28 AnGap-12
[**2161-3-29**] 04:25AM BLOOD Glucose-140* UreaN-9 Creat-0.5 Na-141
K-4.2 Cl-107 HCO3-27 AnGap-11
[**2161-3-19**] 04:08AM BLOOD Vanco-8.6*
[**2161-3-22**] 01:35PM BLOOD Vanco-17.8*
[**2161-3-29**] 03:22PM BLOOD Vanco-18.6*
~
~
~
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~
~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
RADIOLOGY
~
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~
~
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~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
PELVIS (AP ONLY) PORT [**2161-3-17**] 10:10 AM
IMPRESSION: Heterogeneous air collection overlying left groin
region. The finding is not well localized on this single view.
If indicated, further assessment with CT of the pelvis could be
obtained.
~
~
~
~
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~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT 150CC NONIONIC CONTRAST [**2161-3-21**] 3:11 PM
IMPRESSION:
1. Extensive lower anterior abdominal wall subcutaneous soft
tissue defect extending into the pelvis and inguinal regions
consistent with the patient's history of Fournier's gangrene.
There does not appear to be any focal fluid collections or
intra-abdominal or intrapelvic extension of the disease.
2. Anasarca.
3. Small bilateral pleural effusions, right greater than left,
with bibasilar atelectasis vs. developing infection.
4. Small amount of pelvic free fluid.
5. Bilateral inguinal lymphadenopathy.
6. No evidence of diverticulitis.
~
~
~
~
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~
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~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
PICC LINE PLACMENT SCH [**2161-3-23**] 10:17 AM
IMPRESSION: Placement of a double lumen PICC line into the left
basilic vein with the tip in the superior vena cava under
ultrasound and fluoroscopic guidance. The line is ready for use.
~
~
~
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~
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~
~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MICROBIOLOGY
WOUND CULTURE (Final [**2161-3-25**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
PROTEUS MIRABILIS. SPARSE GROWTH. PRESUMPTIVE
IDENTIFICATION.
**Pansensitive**
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
GRAM POSITIVE RODS. GROWING IN BROTH ONLY.
NONVIABLE FOR IDENTIFICATION.
ANAEROBIC CULTURE (Final [**2161-3-23**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES. MODERATE
GROWTH.
TISSUE Culture (Final [**2161-3-26**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH SKIN FLORA.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
ENTEROCOCCUS SP.. RARE GROWTH. **Pansensitive, Not
VRE**
Brief Hospital Course:
49-year-old female with diabetes mellitus who was taken to the
operating room on [**2161-3-17**] with the possibility of
necrotizing fasciitis. She had to be taken back on [**2161-3-20**] for a worsening infection. The cultures were growing
Proteus and gram-positive cocci as well as gram-negative rods,
staph, and strep viridans. She has been on aztreonam, vanco, and
Flagyl. On examination on the morning of [**2161-3-21**], she had
evidence of worsening infection with pockets draining up the
anterior abdominal wall. She was again taken to the OR for
further debridement. Following this she was managed with local
wound care and antibiotics and did not require further OR
debridement. Throughout her course to this point her blood
sugars were managed aggressively with an insulin drip. She was
followed by [**Last Name (un) **] for diabetes management. The infectious
disease service was also highly involved in the care of this
patient. Vanco, aztreonam, and flagyl were continued throughout
the [**Hospital 228**] hospital stay for a course that will extend two
weeks beyond the 3rd and last debridement.
Wet-to-dry dressing changes were carried out [**Hospital1 **] by housestaff
and the wound was noted to debride and granulate well with the
dressing changes. She was managed in the surgical ICU during
the course of the initial debridment procedures but was
transfered to the surgical floor on [**3-24**] no longer requiring an
insulin drip. She continued to be followed by [**Last Name (un) **] and she
was managed with a sliding scale and lantus. She remained on IV
antibiotics with a persistent leukocytosis. Her WBC eventually
began to decrease by POD12/9/8. Her hematocrit was noted to
slowly drift down and she was transfused 1unit PRBC on
POD14/11/10 with an adequate response. She was ambulating well
with minimal assistance and was pain controlled with
premedication for dressing changes.
She was evaluated for rehab placment and was discharged on
another 4days of antibiotics with instructions to continue
wet-dry dressing changes [**Hospital1 **]. She will follow-up with Dr.
[**First Name (STitle) 2819**]...
Medications on Admission:
neurontin 800 tid
metformin 500 [**Hospital1 **]
lantus 40 U Qam
humalog SS
ativan
paxil 60 daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Left groin / perineal abscess
Discharge Condition:
good
Discharge Instructions:
Change abdominal dressing twice daily with wet-to-dry dressings.
[**Name8 (MD) **] M.D. for redness around abdominal wound, drainage from
wound, fevers, chills, increase in abdominal pain, questions or
concerns.
Continue taking Beta-Blocker medication for 1 month from
discharge (Metoprolol 25 mg by mouth twice daily).
Do not drive while taking narcotic pain medications.
Continue taking anti-biotics (vancomycin and aztreonam) for 1
week after discharge (until [**2161-4-7**]) and antibiotic (flagyl) for
8 days after discharge (until [**2161-4-8**]).
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) 2819**] in 1 week, please call clinic to
confirm/schedule ([**Telephone/Fax (1) 6347**].
Completed by:[**2161-3-31**]
ICD9 Codes: 3572, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3287
} | Medical Text: Admission Date: [**2185-7-19**] Discharge Date: [**2185-8-12**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Intracranial hemorrhage - transfer from
[**Hospital3 1280**] Hospital in [**Location (un) 47**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 85 yo Russian speaking only man w/ PAF, HTN,
chronic anemia, recent E. coli sepsis presenting with ICH in the
setting of altered mental status earlier today. Pt was admitted
to [**Hospital6 1109**] [**7-14**] with fever and found to be
septic w/ E-coli. He was treated with Ceftriaxone and was
improving. He transferred to the floor 2 days prior. This
afternoon he had a change in MS from being completely alert and
oriented to starting to talk to himself. Before the transfer,
he
was more confused and agitated, requiring medical intervention
for sedation.
Per EMS report, he was given 0.5 of Haldol IV. Non-contrast
head
CT was done at 3pm to assess the change in mental status and
found intracranial hemorrhage in the R hemisphere measuring 3.7
x
6.6 cm with associated midline shift at the OSH. Neurosurgery
here was called and recommended neurology consultation there and
admission to the neuro ICU.
He is on Arixta and Trental at home. PTT 26 INR
1.6. For the past 2 days he's been back on Arixtra. On
admission
to [**Hospital1 **] they noted him to be thrombocytopenic to 86. This
has improved gradually to 163. He had a normal UA. During his
work up for a source of bacteremia he had an abdominal CT w/
possible air behind duodenum. His abdominal exam remained
benign
by report. He was planned for EGD today and then discharge home
but this was delayed by altered mental status. No source for
sepsis has been found but given possible GI source, his ABX was
switched to Unasyn as of [**7-18**].
Past Medical History:
1. Paroxysmal Atrial fib - in sinus whole hospitalization - Not
on Coumadin for unclear reasons
2. Hypertension
3. Chronic anemia
4. BPH
5. s/p Pacemaker
6. L knee replacement
7. Dementia
8. s/p appendectomy
Social History:
Lives at home with wife. Denies tobacco, drug
use but occasional EtOH use. HCP listed as [**Name (NI) **] [**Name (NI) **]
[**Telephone/Fax (1) 83293**] or [**Telephone/Fax (1) 83294**]
Family History:
Father had breast cancer.
Physical Exam:
Physical Exam:
T C HR /min, RR/min BP / mmHg Pulse ox 100%RA
Gen: Awake - talks to himself but unclear if dysarthria present
or fluent given only in Russian.
Neck: Supple, no meningismus.
CVR: RRR, no murmurs, rubs, or gallops
Lung: Clear
Abd: +BS, soft, non-tender, non-distended.
Extrem: No edema
Neuro:
MS - Awake and continually talks to self but unclear if speech
coherent, fluent or dysarthric since only in Russian. Does seem
oriented to self.
Cranial Nerves ?????? Keeps eyes closed - difficult to pry them open,
+Bell's phenomenon more on R than L. Face appears symmetric and
does appear to blink to threat on both sides. Both pupils small
but reactive. Difficult to assess EOM given that its difficult
to pry eyes open. +Gag.
Motor: Tone ?????? Does appear to move all extremities but LE not
antigravity and moves both UEs spontaneously and anti-gravity.
Increased tone in both lower extremities but LUE>RUE.
Reflexes -
[**Hospital1 **] Tri BR Pat Ach Toes
R 2 2 2 0 0 up
L 2+ 2+ 2+ 2- 0 up
Sensation - Appears intact to noxious stim.
Impression: Patient is a 85 yo Russian-speaking man initially
admitted to [**Hospital1 **] with fever and found to be septic who was
improving with IV ABX but found to have change in ME with NCHCT
revealing R tempo-occipital hemorrhage.
On exam, patient appears confused and does not follow commands
although there is a severe language barrier. He is moving all
extremities but only UEs are anti-gravity. No clear difference
in tone but L side reflexes > R.
Pertinent Results:
CT CNS w/o contrast: 06/ 30
There is a very large lobar-type hematoma spanning the right
parietal, temporal and occipital lobes, with internal layering
of blood
products suggesting a hematocrit effect. It is not significantly
changed
since the previous study. Surrounding edema is relatively mild,
given the
size of the hematoma. There is associated 2-mm left shift of the
third
ventricle and inferior anterior falx, as well as mild narrowing
of the right limb of the quadrigeminal plate cistern. The
posterior right lateral
ventricle is effaced. While the third ventricle is partially
compressed, the left lateral ventricle is normal in size.
Extracranial soft tissue structures and bones are unremarkable.
Repeat Ct CNS on 07/ 01: unchanged.
CT abd/pelvis [**2185-7-21**];
A 6 x 7 mm ground-glass nodule in the right lower lobe. [**First Name8 (NamePattern2) **]
[**Last Name (un) 8773**]
guidelines, recommend chest CT followup in [**7-1**] months or if
high risk (for example, a smoker) in three to six months.
2. Bilateral pleural effusions and associated atelectasis.
3. Sigmoidal colonic wall thickening without signs of acute
inflammation
indicative of circular muscle hypertrophy associated with
diverticulosis.
4. Sigmoidal diverticulosis without evidence of diverticulitis.
No abscess.
5. Gas in the bladder likely secondary to Foley instrumentation.
EEG [**2185-7-26**]
BACKGROUND: There is a localized posterior quadrant polymorphic
delta
slowing of [**2-23**] Hz on the right that seems to obliterate the
occipital
region on the right. There is a 10 Hz posterior predominant
rhythm seen
in the left hemisphere.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This is an abnormal EEG due to the localized
posterior
quadrant slowing on the right with associated obliteration of
the
occipital rhythm which suggests cortical involvement. There was
no
seizure activity detected.
[**2185-7-19**] 09:59PM GLUCOSE-95 UREA N-13 CREAT-0.7 SODIUM-141
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-22 ANION GAP-13
[**2185-7-19**] 09:59PM ALT(SGPT)-18 AST(SGOT)-32 ALK PHOS-66 TOT
BILI-0.6
[**2185-7-19**] 09:59PM ALBUMIN-3.2* CALCIUM-7.6* PHOSPHATE-2.2*
MAGNESIUM-1.7
[**2185-7-19**] 09:59PM WBC-14.6* RBC-4.62 HGB-13.4* HCT-40.0 MCV-87
MCH-29.0 MCHC-33.5 RDW-13.7
[**2185-7-19**] 09:59PM PLT COUNT-216
[**2185-7-19**] 09:59PM PT-14.3* PTT-22.6 INR(PT)-1.2*
BCx [**7-19**], [**7-21**] x2 negative to date
Urine culture [**7-21**] negative.
LDL 93, HDL 45, trig 80
HbAlc 5.9
Brief Hospital Course:
The patient was asssessed by neurosurgery (Dr. [**First Name (STitle) **] who feels
there is no current benefit from a possible surgical
intervention.
The neuro-ICU team (Dr. [**Last Name (STitle) 1794**] has discussed the situation and
prognosis with the family (daughter) and patient was transferred
to the Neurology floor [**7-20**].
A CT of the head was obtained on [**2185-7-19**], which revealed a
large lobar hematoma in the right cerebral hemisphere. Given
the
patient's age, it was felt to be most likely secondary to
amyloid
angiopathy. In addition to this underlying potential etiology,
Mr. [**Known lastname 83295**] was also noted to be on both Arixtra and Trental at
home both of which are antiplatelet agents. Of note, he had
been
thrombocytopenic actually at the outside hospital, his platelets
were down to 86. This was of unclear etiology and had actually
gradually improved. Since admission in the ICU, Mr. [**Known lastname 83295**] has
remained stable. He was initially treated with Dilantin
empirically, although did not have a history of seizures. This
was, however, discontinued. A CT of the head was repeated [**7-20**]
for further comparison. This unfortunately revealed significant
motion artifact. There was, however, noted again blood in the
third ventricle. His platelet count also improved after
admission when compared to the previous hospitalization.
Aspirin 81 mg was resumed [**7-23**].
In regards to further evaluation for his etiology of bleed, MRI
brain could
not be obtained due to his pacemaker. He is not being
anticoagulated for his paroxysmal afib, but has been in sinus
rhythm since he has been here.
On [**7-21**] patient was found to have temp of 100.6, leukocytosis,
worsening mental status, and possible nuchal rigity on
examination. He had been completing a course of unasyn for e
coli bacteremia noted from outside hospital. He was empirically
treated with ceftriaxone, vancomycin, and ampicillin due to
suspicion of meningitis. An LP was not performed due to the
large hemorrhage and mass effect on CT head. Blood cultures,
urine culture, and CXR, as well as CT abd/pelvis showed no
obvious infectious source. Clinically patient improved over the
next several days, leukocytosis continued to resolve and was
afebrile. Therefore antibiotics were narrowed and unasyn was
resumed [**7-25**]. It is anticipated this can be discontinued [**7-29**].
Patient had an NG tube placed and was receiving tube feeds
during hospitalization. Speech/swallow re-eval [**7-25**] recommended
ground diet with thin liquids. Patient is tolerating this well.
On [**7-26**] AM patient was noted to have brief episode (20 seconds)
of left gaze deviation, decreased responsiveness and rhythmic
eye blinking. Given size and location of hemorrhage, EEG was
performed with results reported above. The patient was also
started on keppra for seizure prophylaxis. This will be
continued upon discharge but may be re-evaluated in outpatient
follow up. He has not shown any further activity concerning for
seizure since this episode.
Also, on [**8-8**], patient was found by RN on floor next to bed. He
had a repeat CT head which showed no new hemorrhage and x-ray of
rib and R shoulder which did not show a fracture. His pain has
resolved with tylenol, and he is currently pain-free.
Patient will be discharged home on aspirin and keppra for
seizure prophylaxis. The family has arranged elder services for
support at home and arrange for physical therapy at home. He
will follow up with Dr. [**Last Name (STitle) **] (neurology) as well as his PCP.
Medications on Admission:
1. Trental 400 [**Hospital1 **]
2. Flomax 0.4 qhs
3. Folate 1 daily
4. Simvastatin 20 daily
5. Lisinopril 15mg daily
6. Aricept 10mg daily
7. Atenolol 25mg daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day). Tablet(s)
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily) as needed for stroke.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
5. Ampicillin-Sulbactam 1.5 gram Recon Soln Sig: One (1) 1.5 g
Injection Q6H (every 6 hours): To be completed [**7-29**].
6. Aricpet 10 mg daily
7. Simvastatin 20 mg qhs
8. Folate 1 mg daily
9. Keppra 500 mg b.i.d.
10. Hospital Bed Diagnosis; right-sided temporal occipital
stroke Reason for hospital bed; the patient has very limited
movement of his left arm and leg. Necessary for patient safety,
mobility and transfers.
Discharge Disposition:
Home
Discharge Diagnosis:
1) R temporal occipital hemorrhage, likely secondary to amyloid
angiopathy.
2) HTN
3) Dementia
Discharge Condition:
Awake, arousable to voice, follows commands and verbalizes.
Pinpoint pupils, moves all extremities against gravity (but
minimally on left), increased tone L > R, mild left sided
neglect.
Discharge Instructions:
Please continue your medications as prescribed. Please return
to the emergency department immediately for any changes in
mental status, speech, or motor function. Follow up with Dr.
[**Last Name (STitle) **] (neurology) as instructed below.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2185-8-26**] 1:30. [**Hospital1 18**], [**Hospital Ward Name 23**] 8.
ICD9 Codes: 5119, 5180, 4019, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3288
} | Medical Text: Admission Date: [**2167-8-29**] Discharge Date: [**2167-9-9**]
Date of Birth: [**2096-2-18**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Penicillins
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
altered mental status; transfer from MICU
Major Surgical or Invasive Procedure:
intubation; now s/p extubation
History of Present Illness:
71M with multiple myeloma currently on Velcade, mixed
obstructive-restrictive lung disease, PAF, presented to the ED
on [**2167-8-29**] complaining of polyuria. Per sister, patient has
been fatigued with poor po intake for several weeks. She is not
aware of any acute changes in his health. She took him to his
Velcade appointment on Friday, where he felt fatigued but was of
normal mood and behavior. He received day 4 of his Velcade at
this time as well as 1u PRBCs.
.
His VS on presentation to the ED were T 99.6, HR 68, BP 106/56,
RR 25, O2sat 97% RA. His K was 6.0, so he was given Kayexalate
30g. On exam, he had RUQ tenderness with a normal RUQ
ultrasound. He was also noted to be somewhat dyspneic with an
elevated D-dimer so he was sent for a V/Q scan to rule out a PE.
.
Halfway through the scan, he became agitated and combative and
had stool incontinence. His VS upon return were HR 110, BP
144/65, O2sat 89% NRB. He was dyspneic, diaphoretic, and
nonverbal. He was given Ativan 1mg IV for agitation. On lung
exam, he had very poor air movement. He was intubated in the ED
for airway protection with altered mental status and hypoxic
respiratory failure. CXR showed clear lungs. He was given
Solumedrol 125mg IV, Benadryl 50mg IV, and Pepcid 20mg IV to
treat possible allergic reaction to the radionuclide material.
He was also started on a propofol gtt for sedation and 2L NS. He
was admitted to the MICU for further management.
.
In the MICU, he was quickly weaned off of the ventilator and on
to a nasal cannula at 2L/min on the morning of [**2167-8-31**]. His
mental status remained somewhat impaired in that he was never
fully oriented to place. He had 2 sets of blood cultures sent
(though it's unclear if he was ever febrile) and grew gram(+)
cocci in pairs/clusters from 3/4 bottles; he was started on
vancomycin. His sputum culture also had 4+ gram(+) cocci in
pairs/chains. His warfarin was initially held due to the
possibility of an LP but this was never done since his mental
status seemed to be improving.
Past Medical History:
Oncologic History:
Multiple myeloma diagnosed in [**12/2164**] after presenting with
several months of diffuse bony pain; found to have numerous
lytic bony lesions and a monocloncal kappa protein in his UPEP
(>8 grams of kappa proteinuria); diagnosed with stage IIIB kappa
light chain multiple myeloma. He initially responded well to
Decadron and was then intolerant to thalidomide/Decadron; he
subsequently responded well to Cytoxan/Decadron with a marked
decrease in his kappa excretion and improvement inhis renal
function. In [**7-/2165**], he underwent an autologous SCT after
treatment with high-dose melphalan. He went into remission at
this time which he maintained until [**7-/2167**] when he presented to
the ED with dyspnea on exertion; he was found to have 20 grams
of Bence [**Doctor Last Name **] proteinuria and new diabetes insipidus. A bone
marrow biopsy showed >60% plasma cells. He was pulsed with
Decadron and discharged on po Decadron for his MM and intranasal
ddAVP for his DI. On [**2167-8-25**], he was started on Velcade (in
addition to his [**Hospital1 **] Decadron). He received days 1 and 4 of
Velcade prior to this presentation.
.
.
PMH:
1. Multiple myeloma?????? Stage IIIA with kappa light chains,
diagnosed in [**12-27**]. Extensive lytic bone lesions (mostly in
pelvis and legs) without renal involvement. s/p autologous stem
cell transplantation in [**7-27**]. Was in remission with Zometa
qo month until [**8-18**] when he had a marrow biopsy showing relapse.
Started on Velcade on [**8-25**] (last dose 10/6). Followed by Dr
[**First Name (STitle) 1557**]. Baseline creatinine 1.9-2.0.
2. Diabetes insipidus- dx during [**7-29**] hosp., + water deprivation
test and response to ddAVP (thus, likely central)
3. Hypertension
4. Restrictive/Obstructive lung disease: Followed by Dr.
[**Last Name (STitle) **].
5. Paroxysmal AFib- on Coumadin and rate-controlled
6. Hypercholesterolemia
7. Osteoarthritis s/p bilateral knee replacements in [**2160**], [**2161**]
8. MVA [**2147**]--> Multiple bilateral fractured ribs, lumbar
diskectomy
.
Social History:
The patient is divorced. He currently lives alone. He has no
children. He has a sister who lives nearby. Both he and his
sister live in Mission [**Doctor Last Name **]. He has another sister who lives in
[**Name (NI) 15076**], who will be staying with him during his transplant
recovery to help assist with meals and housekeeping. Retired
meatworker originally from [**Doctor Last Name 15076**] with extensive travel
history. Occ EtOH. No tobacco
Family History:
No known family history of cancer, hypertension, or DM. Mother
died at 36 and father at 65 of unknown causes. Brother and
sisters have heart disease.
Physical Exam:
PHYSICAL EXAM (upon transfer out of MICU):
T 97.7 HR 62 BP 137/76 Sat 96% 2L
Weight 156.2 lbs
Gen: elderly man in NAD, intermittently somnolent
HEENT: no obvious trauma, OP dry with no lesions
Neck: JVP flat with no carotid bruits
Pulm: poor inspiratory effort, no wheezes/rales/ronchi heard
CV: regularly irregular, nl s1s2, no m/r/g
Abd: soft, nondistended, moderate tenderness to deep palpation
in RUQ, no [**Doctor Last Name 515**], nl BS, tympanitic, no
hepatosplenomegaly/masses, no rebound/guarding
Extr: no clubbing, cyanosis, or edema; cool feet
Skin: dry, cool, scaling; no rashes/breakdown
Neuro: alert but mildly somnolent; oriented to self, "[**Month (only) **]
[**2166**]", and oriented to "hospital" only when given choices; CN
[**1-4**] intact; 5/5 strength in all extremities
Pertinent Results:
[**2167-8-28**] 01:10PM NEUTS-84.7* BANDS-0 LYMPHS-10.4* MONOS-3.8
EOS-1.0 BASOS-0.1
[**2167-8-28**] 01:10PM WBC-7.2 RBC-2.91* HGB-9.0* HCT-27.5* MCV-95
MCH-30.9 MCHC-32.6 RDW-18.6*
[**2167-8-28**] 01:10PM IgG-376* IgA-32* IgM-13*
[**2167-8-28**] 01:10PM ALBUMIN-3.8 PHOSPHATE-3.3 MAGNESIUM-2.4
[**2167-8-28**] 01:10PM ALT(SGPT)-58* AST(SGOT)-33 LD(LDH)-504* ALK
PHOS-83 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1
[**2167-8-28**] 01:10PM GLUCOSE-116* UREA N-44* CREAT-1.6* SODIUM-143
POTASSIUM-5.5* CHLORIDE-105 TOTAL CO2-31 ANION GAP-13
[**2167-8-29**] 02:55PM ALT(SGPT)-67* AST(SGOT)-212* ALK PHOS-79
AMYLASE-46 TOT BILI-0.2
[**2167-8-29**] 02:55PM GLUCOSE-174* UREA N-50* CREAT-1.5* SODIUM-138
POTASSIUM-6.0* CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
[**2167-8-29**] 10:45PM TYPE-ART TIDAL VOL-550 PO2-461* PCO2-48*
PH-7.32* TOTAL CO2-26 BASE XS--1 INTUBATED-INTUBATED
VENT-CONTROLLED
Brief Hospital Course:
In the MICU, he was quickly weaned off of the ventilator and on
to a nasal cannula at 2L/min on the morning of [**2167-8-31**]. His
mental status remained somewhat impaired in that he was never
fully oriented to place. He had 2 sets of blood cultures sent
(though it's unclear if he was ever febrile) and grew gram(+)
cocci in pairs/clusters from 3/4 bottles; he was started on
vancomycin. His sputum culture also had 4+ gram(+) cocci in
pairs/chains. His warfarin was initially held due to the
possibility of an LP but this was never done since his mental
status seemed to be improving.
.
Upon transfer to the floor:
.
A/P: 71M with multiple myeloma, mixed obstructive-restrictive
lung disease, ? DI, and PAF, admitted after acute episode of
altered mental status (of unclear etiology) now extubated and
transferred out of the MICU. Gram (+) cocci growing from blood.
.
## ID:
- [**1-24**] blood culture bottles from admission grew vanc-sensitive
coag negative Staph; he completed a 10-day course of IV
vancomycin and remained afebrile
- sputum culture grew non-Pseudomonas gram negative rods (CXR
normal); completed course of levofloxacin
- ceftriaxone was added for 3 days ([**Date range (1) 18881**]) due to concern
for meningitis with his second change in mental status (see
below) and was stopped once mental status returned to baseline
and it became clear there was no meningitis
.
# Mental status change:
-On the night of [**9-3**], the patient became acutely psychotic and
agitated. He was very worried that people were smoking crack in
the halls and that there were people trying to hurt the nurses
and sabotage Dr[**Name (NI) 6168**] practice. His warfarin and steroids
were stopped at this time. A psych consult was obtained the next
morning who recommended Haldol/Cogentin. He required sedation
with Haldol/Ativan/Dilaudid to get a head CT (which was negative
for a bleed). Following sedation, the next evening, he was
noted to be very rigid and received an additional dose of
Cogentin. A neuro consult was obtained the next day who
recommended stopping Haldol due to the rigidity. Per neuro
consult, an LP was attempted twice to rule out CNS infection,
but the patient was too agitated; he was treated empirically
with vanco/ceftriaxone until it was clear that there was no
meningitis; he had a persistently non-focal neuro exam with no
menigeal signs. An EEG showed nonspecific slowing consistent
with his sedation. Infectious workup (CXRs, cultures) remained
negative and he remained afebrile. His mental status slowly
returned to baseline overnight on [**2171-9-6**], presumably as the
effects of the steorids wore off. He was taken off of 1:1
observation and remained calm and cooperative. Further
psychoactive meds (except for pain control meds) were held.
.
## Multiple myeloma: Currently on Velcade, last dose 10/6, and
dexamethasone.
- he was continued on his outpatient dexamethasone regimen (8mg
po bid) but this was stopped on [**9-6**] when he developed
psychosis; there were some indications that he might not have
been taking this at home, and his self-limited psychosis was
thought to be secondary to the steroids
.
## ?DI/endocrine:
- during previous admission there was a reported history of
diabetes insipidus; a water deprivation test was done during
that admission, though endocrine did not see the patient.
Endocrine was consulted this time and recommended a pituitary
MRI which showed a lack of expected hyperintensity in the
neurohypophysis. No water deprivatino test was done, though his
ddAVP was stopped when he became psychotic and his sodium
remained normal with normal urine output. Per endo, he does not
need to be on ddAVP. Also noted were low TSH, T4, T3, fT4
levels. A rT3 was slightly high and endocrine recommended
repeat thyroid functino tests in [**12-26**] weeks (suspect sick
euthyroid) for follow-up with no thyroid replacement at this
time.
.
## Obstructive/restrictive lung disease: Unclear etiology. MRI
chest showed no PE and PA hypertension
- continued Advair
- weaned off of O2 as tolerated
.
## PAF: Currently rate-controlled.
- cont metoprolol and short-acting diltiazem for rate control
- warfarin was stopped due to mental status changes; with his
continued gait instability, it was deemed too unsafe for him to
continue warfarin, especially since he was not in AFib at all
during the admisison
.
## Endocrine
- dexamethasone as above
- TSH, T4, fT4 all low; ?sick euthyroid
.
## Hypertension:
- continued on his metoprolol and diltiazem
.
## FEN: Poor po intake x weeks per sister; NPO in MICU
- 500cc NS bolus then NS at 125cc/hr; check fluid status closely
- daily lytes; watch for rising sodium
- dysphagia diet, thickened liquids; may need speech/swallow
eval
.
## Code status: with his psychosis, he was made DNR/DNI by his
sister (due to his advanced myeloma) when he did not have
capacity to make medical decisions
.
## Communication: sister [**Name (NI) 18882**] [**Name (NI) 634**] ([**Telephone/Fax (1) 18883**]
.
## Dispo: pt is deconditioned and unsteady on his feet and, per
primary team and PT, needs rehab
Medications on Admission:
Atorvastatin 20 mg qd
Diltiazem SR 240 mg Capsule qd
OxyContin 20 mg Q12H
ddAVP [**Hospital1 **]
Dexamethasone 8 mg [**Hospital1 **]
Metoprolol 100mg tid
Warfarin 2.5mg qd
Advair 250-50mcg [**Hospital1 **]
Oxycodone prn
Albuterol MDI prn
Atrovent MDI prn
Senna prn
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours): give
with 10mg tablet for total dose of 30mg q12h.
5. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO twice a day: give with 20mg
tablet for total dose of 30mg q12h.
6. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: Three (3)
Tablet Sustained Release 24HR PO once a day.
7. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): hold for HR<55, SBP<100.
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Living
Discharge Diagnosis:
Primary diagnosis: change in mental status, multiple myeloma,
steroid psychosis
Secondary diagnosis: paroxysmal atrial fibrillation,
hypertension, osteoarthritis s/p bilateral knee replacements,
restrictive and obstructive pulmonary disease
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital after an acute change in your
mental status which required intubation in order to protect your
airway. After you were extubated, you were sent from the
intensive care unit to the floor. While on the floor, you again
had an abrupt change in your mental status where you were
hallucinating and feeling very paranoid; it is thought that this
was due to your high steroid dose which has since been stopped.
Your warfarin (Coumadin) has been stopped due to bleeding risks.
Your intranasal ddAVP was stopped since we do not believe that
you need it. You are being discharged to a rehab facility so
that you may regain your strength.
Please attend all follow-up appointments. Please take all
medications as prescribed.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2167-9-15**] 11:00
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2167-9-15**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11755**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3237**]
Date/Time:[**2167-9-15**] 11:00
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3289
} | Medical Text: Admission Date: [**2127-9-16**] Discharge Date: [**2127-9-19**]
Date of Birth: [**2065-7-9**] Sex: M
Service: CCU
CHIEF COMPLAINT: Chief complaint was chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male with a history of hypertension who presented to the
[**Location (un) 47**] Emergency Department on the day of admission with
the gradual onset of chest pain since earlier that morning.
This was an [**6-28**] constant pain without radiation. There was
weakness, dyspnea, and diaphoresis. The patient was
diagnosed at that time with an inferior myocardial infarction
and treated with sublingual nitroglycerin, aspirin, and was
begun on a nitroglycerin drip. He was also put on a heparin
drip and received thrombolytics and morphine. The patient
subsequently had nonsustained ventricular tachycardia lasting
less than one minute. He remained alert throughout the
episode and was hemodynamically stable. He was treated with
150 mg of intravenously amiodarone with no further ectopy of
hypotension, but the patient did have less than one minute of
bradycardia down to the 40s. He was continued on heparin and
nitroglycerin, and his pain decreased to [**12-29**]. At that time,
he was transferred to [**Hospital1 69**].
Prior to that morning's episode, the patient had no history
of chest pain. No history of orthopnea or paroxysmal
nocturnal dyspnea. He did have one episode of dyspnea on
exertion on the day prior to admission while walking with his
wife in the morning.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Hypertension.
2. Increased cholesterol.
3. He has no history of diabetes; however, his glucose at
the outside hospital was 276.
4. He is status post appendectomy.
MEDICATIONS ON ADMISSION: Medications prior to admission
included aspirin, hydrochlorothiazide 25 mg p.o. q.d., and
Accupril 1 mg p.o. q.d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: The patient's father died of a myocardial
infarction at the age of 58. He has three healthy children.
SOCIAL HISTORY: The patient was a smoker until the [**2094**].
He has no history of alcohol use. He is unemployed currently
but was previously in electronic consulting.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission included vital signs of temperature of 97.5,
heart rate was 55, blood pressure was 107/56, respiratory
rate was 17, oxygen saturation was 100% on room air. General
appearance revealed a well-appearing male in no apparent
distress. Mucous membranes were moist. No jugular venous
distention. No carotid bruits. No masses. Cardiovascular
examination revealed a regular rate and rhythm. No murmurs,
rubs, or gallops. Pulmonary examination revealed lungs were
clear to auscultation bilaterally with good breath sounds.
The abdomen revealed positive bowel sounds. Soft, nontender,
and nondistended. Extremity examination revealed no bruits.
Good femoral pules. Dorsalis pedis and posterior tibialis
pulses were 2+ bilaterally. No cyanosis, clubbing, or edema.
Skin examination revealed ruddy color on the face, trunk, and
back; question of tinea vesicular.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
from the outside hospital included a white blood cell count
of 16.2, hematocrit was 45.4, and platelets were 330.
Electrolytes included sodium was 135, potassium was 4.2,
chloride was 102, bicarbonate was 29, blood urea nitrogen was
15, creatinine was 1, and blood glucose was 276. Total
protein was 8.2, albumin was 4.7, calcium was 10.3. Total
bilirubin was 0.7, AST was 81, ALT was 101, alkaline
phosphatase was 63. The first set of cardiac enzymes
revealed creatine kinase was 382, MB was 27.6, and troponin
was 5.36.
RADIOLOGY/IMAGING: Electrocardiogram showed ST elevations in
II, III, and aVF with reciprocal changes in V2 and V3 and
Wenckebach block.
Subsequent electrocardiogram showed ventricular tachycardia
at 160.
Final electrocardiogram showed ST elevations in II, III, and
aVF of 3 mm to 4 mm, reciprocal changes in V1 and V2, and a
rate of 82 after amiodarone.
Cardiac catheterization results showed a thick cardiac output
of 3.83, cardiac index of 1.93.
Angiography showed a right-dominant system with a normal left
main coronary artery, left anterior descending artery with
moderate disease, left circumflex with moderate disease, and
right coronary artery with total mid occlusion and
collaterals from the left coronary artery. Percutaneous
transluminal coronary angioplasty and stenting was done of
the right coronary artery. Hemodynamics were consistent with
an sizeable left ventricular and right ventricular
infarction.
HOSPITAL COURSE: Given the above, the patient was admitted
to the Coronary Care Unit.
1. CARDIOVASCULAR SYSTEM: (a) Pump: The patient was
continued on dopamine initially to keep his mean arterial
pressure above 60. Afterwards, he was started on a beta
blocker and ACE inhibitor and subsequently had an
echocardiogram checked which showed that the left atrium was
mildly dilated. There was moderate regional left ventricular
systolic dysfunction with severe hypokinesis and akinesis of
the inferior septum and inferoposterior wall. The right
ventricular cavity was moderately dilated with severe global
right ventricular free wall hypokinesis. The aortic valve
leaflets appeared structurally normal with good leaflet
excursion, and no aortic regurgitation. There was no
pericardial effusion. His ejection fraction was estimated at
35% to 40%.
(b) Rhythm: The patient remained in normal sinus rhythm
throughout his hospital stay.
(c) Ischemia: The patient was continued on aspirin and
Plavix.
2. PULMONARY SYSTEM: No issues.
3. RENAL SYSTEM: The patient was rehydrated given the
setting of right ventricular infarction. He was diuresed as
his wedge pressure subsequently increased.
4. ENDOCRINE SYSTEM: The patient had no known history of
diabetes, but his fingersticks remained elevated. Therefore,
a hemoglobin A1c was checked and Chemistry-6 was checked
regularly. The patient was maintained on a regular insulin
sliding-scale and was instructed to follow up with his
primary care physician regarding oral hypoglycemics and diet.
5. PROPHYLAXIS: The patient was maintained on Protonix.
DISCHARGE STATUS: The patient was eventually discharged to
home.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was given instructions to follow up with his
primary care physician regarding his diabetes and his recent
heart attack.
2. He was provided with copies of all of his studies
including his cardiac catheterization and echocardiogram
report so that he could follow up with an electrophysiology
specialist near [**Location (un) 47**] regarding his episode of
ventricular tachycardia and his history of Wenckebach block.
CONDITION AT DISCHARGE: The patient was discharged in stable
condition.
DISCHARGE DIAGNOSES: Inferior myocardial infarction.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Name8 (MD) 10249**]
MEDQUIST36
D: [**2127-10-30**] 10:26
T: [**2127-11-3**] 02:13
JOB#: [**Job Number 45662**]
ICD9 Codes: 4271, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3290
} | Medical Text: Unit No: [**Numeric Identifier 75428**]
Admission Date: [**2160-12-14**]
Discharge Date: [**2161-1-20**]
Date of Birth: [**2160-12-14**]
Sex: F
Service: NB
IDENTIFICATION: Baby Girl [**Known lastname 75429**] ("[**Known lastname 15406**]") is a 36 day old
former growth-restricted 36 week twin who is being discharged
from the [**Hospital1 18**] NICU.
HISTORY OF PRESENT ILLNESS: [**Known lastname 15406**] [**Known lastname 75429**] is a 36 week,
twin number 2, admitted to the NICU for monitoring due to
small for gestational age at birth. She is a 1465 gram, 36
week twin, born to a 33 year-old, gravida 3, para 1 to 3
woman with the following prenatal screens: Blood type A
positive, antibody negative, RPR nonreactive, Rubella immune,
hepatitis B surface antigen negative, group B strep unknown.
Pregnancy complicated by spontaneous di/di twin gestation and
intrauterine growth restriction of this twin. Mother presented in
active labor without maternal fever. Twin I was in the breech
position, therefore, delivery was by Cesarean section under
spinal anesthesia. Rupture of membranes occurred at delivery.
This twin was delivered from the vertex position, cried
spontaneously, was suctioned, dried and given blow-by oxygen
to improve color. After she was shown to her [**Known lastname **], she was
brought to the NICU for monitoring secondary to small for
gestational age status. Her Apgars were 7 and 8 at 1 and 5
minutes.
Anthroprometic measures at birth: Weight 1465 gm (<10%ile),
Length 41.5 cm (<10%ile), Head circumference 30 cm (10%ile).
PHYSICAL EXAMINATION: Physical examination at discharge: Wt
2685 grams. She is a small, well-appearing infant, nondysmorphic,
pink and well perfused in room air. Anterior fontanel open and
flat. Eyes are clear. Nares patent. Intact palate. Mucous
membranes moist and pink. Respiratory: Comfortable effort.
Breath sounds equal, well aerated. Rate 30 to 70. CV: No
murmur appreciated. Heart rate 140 to 160, pink and well-
perfused. Pulses +2 and equal. Gastrointestinal: Abdomen soft
with active bowel sounds, nondistended, nontender.
Voiding and passing stool. Genitourinary: Normal appearing
female. Neuro: Quiet, responsive. Reflexes and tone are
symmetric. Active and alert when awake.
HOSPITAL COURSE BY SYSTEMS:
Respiratory: The infant has been comfortable in room air since
birth, without evidence of significant pulmonary insufficiency.
However, immaturity of respiratory control was noted, with
occasional desaturation or bradycardic spells noted. These
appeared associated both with apnea and with feedings, and they
gradually improved. Given the advanced gestational age at which
these spells were occuring, a pneumogram was considered, but by
41 weeks post-menstrual age, the spells had largely resolved. At
the time of discharge, the infant had been 5 days without
significant apnea or bradycardic episode. Of note, the infant
does have occasional brief dips in heart rate to 60s to 80s that
are not accompanied by apnea or desaturation and that are always
brief (less than 10 seconds) and self-resolving; these are
thought to be vagal in origin, perhaps associated with mild
reflux or passing of stool, and are not considered clinically
significant.
CV: Hemodynamically, she has remained stable without murmur
throughout hospitalization.
Fluids, electrolytes and nutrition: The infant was begun on
enteral feeds on day of life 0, and did not require IVF. She did
require PG supplements, and reached a maximum intake of 150
mL/kg/day of BM 28 calories per oz. By the time of discharge,
infant has been all PO feeding for approx 2 weeks, with intake of
approximately 130-160 mL/kg/day. Caloric density had been
decreased to 26 cals/oz, and infant has maintained excellent
weight gain; calories can likely further be reduced in the near
future. Weight at discharge is 2685 grams. Infant was begun on
iron and MVI supplementation.
Gastrointestinal: She had serum bilirubins followed but did
not require phototherapy.
Hematology: Initial CBC revealed a white count of 10.5 with
a hematocrit of 41.8 and 288,000 platelets. Her hematocrit
on [**2161-1-10**] showed a hematocrit of 31.5 and a reticulocyte
count of 3.5%. She has been treated with supplemental iron.
Infectious disease: CMV was collected from the urine which
was negative. There was sepsis evaluation performed as there
were no sepsis risk factors. The IUGR status was thought to
be due to placental insufficiency.
Neurology: An ultrasound was obtained on [**2160-12-19**] due to the
infant's small size, and this was normal. Neurologic exam has
been normal throughout hospitalization.
Sensory: An audiology automated brain stem response was
performed and the infant passed in both ears. Ophthalmology
examination was performed on [**12-22**] revealing mature retinas.
Psychosocial: This twin was cared for in the NICU. The other
baby went to the newborn nursery, went home with mother.
[**Name (NI) 6961**] are married and have a 2 year old at home as well.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home with family.
NAME OF PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 34570**], telephone
number [**Telephone/Fax (1) 47109**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
Feeds: Currently p.o. ad lib breast, supplementation provided
with EnfaCare powder to 26 calories per ounce. Caloric density
can likely be weaned soon.
Medications: Ferinsol, 0.4 mL po daily. MVI 1 mL po daily.
Car seat position screening was performed and infant passed.
State newborn screening: Sent per protocol, no abnormal results
reported.
Immunizations received:
Hepatitis B vaccine administered on [**1-7**].
Infant was not considered to be a candidate for Synagis.
Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease or (4) hemodynamically significant
congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
FOLLOWUP:
Primary pediatrician in [**3-1**] days.
VNA referral made.
DISCHARGE DIAGNOSES:
1. Late preterm female infant, twin #2.
2. Small for gestational age, symmetric growth restriction.
3. Apnea of Prematurity.
4. Immaturity Respiratory Control.
5. Anemia of prematurity.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) 64470**]
MEDQUIST36
D: [**2161-1-12**] 03:14:10
T: [**2161-1-12**] 03:48:43
Job#: [**Job Number 75430**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3291
} | Medical Text: Admission Date: [**2200-10-7**] Discharge Date: [**2200-11-7**]
Date of Birth: [**2152-10-23**] Sex: M
Service: CARD [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 47 year old male
patient with a known history of coronary artery disease who
had been medically managed for the past few years. He
recently had a positive exercise tolerance test in [**Month (only) 359**] of
this year due to increasing dyspnea on exertion. He was then
admitted to the [**Hospital6 3872**] on [**2200-10-3**], due to shortness of breath and palpitations accompanied
by lightheadedness. He was ruled out for myocardial
infarction and underwent cardiac catheterization on [**2200-10-6**], which revealed significant three vessel coronary
artery disease with a left ventricular ejection fraction of
50%. He was transferred to the [**Hospital1 188**] for a possible coronary artery bypass graft.
The patient has a known right femoral arteriovenous fistula
which was found at the [**Hospital6 3872**].
PAST MEDICAL HISTORY:
1. Known coronary artery disease.
2. Poorly controlled type 2 diabetes mellitus.
3. Gastroesophageal reflux disease.
4. Hypertension.
5. Hypercholesterolemia.
6. Asthma.
7. Diabetic retinopathy; diabetic neuropathy.
8. Obesity.
9. Former smoker.
SOCIAL HISTORY: The patient denies alcohol use. He is
married and lives with his wife.
PAST SURGICAL HISTORY: He is status post right vitrectomy
and laser surgery both eyes.
ALLERGIES: The patient states and allergy to
Hydrochlorothiazide.
MEDICATIONS:
1. Lantus insulin 20 units q. a.m.; 120 units q. h.s.
2. Humalog sliding scale insulin six times per day.
3. Glucophage SR 1500 mg q. p.m.
4. Norvasc 10 mg q. day.
5. Atenolol 50 mg q. h.s.
6. Lipitor 10 mg q. day.
7. Tricor 160 mg q. day.
8. Covera 240 mg q. h.s.
9. Pepcid 20 mg twice a day.
10. Singulair.
11. Prednisolone eye drops to the right eye six times a day.
LABORATORY: Upon admission, white blood cell count 4,600,
hematocrit 32.9, platelet count 201. Sodium 134, potassium
4.5, chloride 101, CO2 27, BUN 10, creatinine 1.7, glucose
339 and hemoglobin A1C of 10.2%.
PHYSICAL EXAMINATION: On admission, neurologically he was
grossly intact. His lungs were clear to auscultation
bilaterally. Coronary examination was regular rate and
rhythm. Abdomen was soft, obese, nontender. Extremities
were warm and well perfused.
HOSPITAL COURSE: The patient had a Vascular Surgical
Consultation the following day due to the arteriovenous
fistula in the patient's right groin and since the patient
was not symptomatic with that and his examination was not
remarkable, it was their recommendation to evaluate him once
he had recovered from his cardiac surgery and to be followed
in the Vascular Surgery Clinic.
The patient was taken to the Operating Room on [**2200-10-10**], by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], where he underwent coronary
artery bypass graft times four with a left internal mammary
artery to the left anterior descending, saphenous vein graft
to the PDA, saphenous vein graft to the obtuse marginal;
saphenous vein graft to the ramus. Postoperatively, the
patient was on Propofol, insulin and Neo-synephrine
intravenous drips and he required a temporary epicardial
pacing at that time. He was transported from the Operating
Room to the Cardiac Surgery Recovery Unit in good condition.
On the morning of postoperative day one, it was noted that
the patient had spontaneously dislodged his endotracheal tube
and was ultimately reintubated by the Anesthesia Service.
Over the next two to three days in the Intensive Care Unit,
the patient was maintained on Neo-Synephrine, insulin and
propofol drips. He remains intubated, on a ventilator. He
had some significant problems with restlessness and
agitation, requiring continued sedation at that time.
The patient was noted to have elevated temperatures in the
101.0 to 102.0 F. range, and Infectious Disease consult was
obtained on [**10-13**] and the patient was pan cultured as
well at that time. It was their recommendation to
empirically treat him with board spectrum antibiotics and he
was placed on Vancomycin and Zosyn at that time. He was also
fully cultured.
The patient had multiple attempts at weaning from mechanical
ventilation through the course of the next few days. He self
extubated a few times as well and failed, requiring urgent
reintubation and he has ultimately undergone tracheostomy
performed by Dr. [**Last Name (STitle) 952**] on [**2200-10-23**].
Initial cultures from the fever spikes postoperatively were
negative. He did, however, wind up having Methicillin
resistant Staphylococcus aureus in his sputum, although when
that was ultimately found he did not have a fever or white
count at the time. He was placed on intravenous Vancomycin
for an approximately two week period when that was initially
discovered.
The patient had been started on tube feeds which he had been
tolerating quite well and was increased to goal. The [**Hospital **]
Clinic Service was following him for diabetes mellitus
management throughout his Intensive Care Unit stay. The
patient was begun on beta blockers increased and has been
tolerating those well.
On [**10-31**], the Skin Care Nursing Service was consulted
because the patient had a progressively increasing coccygeal
decubitus ulcer. He started with some redness prior to going
to the Operating Room but this progressed throughout his
postoperative course. It was their recommendation to cleanse
the wound and to place an Aquagel dressing over the open area
and to cover that with a Tegaderm over that.
The patient has progressed with ventilator weaning. He
tolerated CPAP with minimal levels of pressure support for
prolonged periods. He also tolerates tracheostomy collar for
varying lengths of time without getting tired, anywhere from
two to six hours at a time. The patient has also progressed
well from a Physical Therapy standpoint. He does ambulate.
With some assistance, he ambulated approximately 100 feet.
The patient underwent a bedside Swallow evaluation
approximately a week ago which he passed very well and his
tube feeds have been discontinued. He underwent a calorie
count and he is taking in an adequate amount of calories
orally without the need for tube feed. He is, however,
receiving supplements of Boost Plus three times a day to meet
his caloric needs.
The patient has remained afebrile. He has remained
hemodynamically stable and he is ready to be transferred to a
rehabilitation facility to progress with his Physical Therapy
and Ventilator weaning needs.
His physical examination today, [**11-7**], is as follows:
His weight today is 108.2 kilograms; his preoperative weight
was 112. His vital signs include a temperature of 97.2 F.;
pulse of 82 in normal sinus rhythm; blood pressure 110/47;
respiratory rate 24; oxygen saturation 99%.
Most recent laboratory values include a white blood cell
count of 9,200, hematocrit of 32.7 and a platelet count of
371. Sodium 138, potassium 4.6, chloride 99, CO2 31, BUN 24,
creatinine 0.9, glucose 121.
The patient is neurologically alert and oriented. He moves
all extremities well and he follows commands appropriately.
On his respiratory examination, his lungs are clear to
auscultation bilaterally. Coronary examination is regular
rate and rhythm. His sternum is stable. His incision is
healing well. His abdomen is obese, soft, nontender, with
positive bowel sounds. Extremities are warm and well
perfused. The right leg saphenous vein harvest site is also
healing well and he has no peripheral edema. The patient has
a #8 Shiley tracheostomy in place and he is varying between
the ventilator CPAP with pressure support mode and a
tracheostomy collar.
DISCHARGE MEDICATIONS:
1. Prednisolone acetate 1% eye drops to the right eye four
times a day.
2. Hydralazine 20 mg p.o. four times a day.
3. Clonazepam 1 mg three times a day.
4. Colace 100 mg twice a day.
5. Zantac 150 mg twice a day.
6. Aspirin 325 mg q. day.
7. Heparin 5000 units subcutaneously q. eight hours.
8. Metoprolol 100 mg q. eight hours.
9. Lasix 80 mg q. day.
10. Zinc 220 mg q. day.
11. Vitamin C 500 mg twice a day.
12. Multivitamin one p.o. q. day.
13. Lantus insulin 100 units subcutaneously at bed time q.
h.s.
14. Sliding scale Humalog coverage as follows: For coverage
for breakfast and lunch are as follows: Glucose 100 to 150,
4 units; 151 to 200 8 units; 201 to 250, 14 units; 251 to
300, 18 units; 301 to 400, 20 units; greater than 400, 24
units. Coverage before dinner is: Glucose 150 to 200, 4
units; 201 to 250, 6 units; 251 to 300, 8 units; 301 to 400,
10 units; greater than 400, 12 units. Coverage at bed time
is: Glucose of 150 to 200, 2 units; 200 to 250, 3 units; 250
to 300, 4 units; 300 to 400, 5 units and greater than 400, 6
units.
15. Atrovent and Albuterol Metered-Dose Inhalers on a p.r.n.
basis.
CONDITION AT DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass graft.
2. Respiratory failure status post tracheostomy placement.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2200-11-7**] 14:41
T: [**2200-11-7**] 16:43
JOB#: [**Job Number 32777**]
ICD9 Codes: 5185, 9971, 4111 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3292
} | Medical Text: Admission Date: [**2162-5-1**] Discharge Date: [**2162-5-5**]
Date of Birth: [**2082-3-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Aricept
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Upper GI Bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 80 year old woman with history of GERD,
hypertension, dementia, CAD, and esophageal strictures who was
admitted with upper GI bleed.
She presented to OSH for evaluation of nausea/vomiting x 3 days,
with coffee ground emesis for the last day. Per the records, NG
lavage x 2.5L was performed (with no documentation of whether
coffee grounds cleared), and she was given esomeprazole and 2L
IVF. Hematocrit there was 44%. She was guaiac negative at OSH.
She was transferred to [**Hospital1 18**] for further evaluation.
In the ED, her triage vitals were T97.4F, BP 129/68, HR 62, RR
20, Sat 95%2L. She was lavaged another 250cc with 300cc coffee
grounds return (no bright red blood). Her NGT was placed to
suction, and another 500cc of coffee grounds were suctioned out.
GI fellow was made aware, and she was transferred to the ICU for
further management.
On the floor, she reports feeling well. She is A&O x 1 (knows
year, but not date, does not know place). She denies feeling
nauseated, vomiting, or having abdominal pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, (despite
HPI) diarrhea, constipation or abdominal pain. No recent change
in bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
- Depression
- Dementia
- OCD
- Hypertension
- GERD
- CAD
- Esophageal stricture
Social History:
Lives in [**Hospital **] nursing home in [**Location (un) 620**]. Per NH chart, no
EtOH, tobacco, drugs.
Family History:
Non-contributory.
Physical Exam:
VS: T: 98.4 HR 80 SR BP: 130/64 Sats: 93% RA
General: NAD
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR, normal S1,S2, no murmur or gallop
Resp: clear lungs
GI: obese, bowel sounds hypoactive, G-tube site clean & clamped
Incision: 3 hole abdominal clean dry no erythema
Neuro: at baseline
Pertinent Results:
[**2162-5-4**] WBC-10.0 RBC-4.65 Hgb-13.8 Hct-40.5 Ct-154
[**2162-5-3**] WBC-12.8* RBC-4.44 Hgb-13.1 Hct-39.0 Plt Ct-175
[**2162-5-1**] WBC-11.3* RBC-4.66 Hgb-13.3 Hct-40.4 Plt Ct-208
[**2162-5-4**] K-3.9
[**2162-5-3**] Glucose-123* UreaN-21* Creat-1.1 Na-142 K-3.2* Cl-106
HCO3-28
[**2162-5-1**] Glucose-108* UreaN-26* Creat-1.0 Na-145 K-3.4 Cl-102
HCO3-34*
[**2162-5-3**] Amylase-161*
[**2162-5-4**] Calcium-8.6 Phos-2.5* Mg-2.6
[**2162-5-3**] BC x 3 NGTD
[**2162-5-2**] BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
OF THREE COLONIAL MORPHOLOGIES. ISOLATED FROM ONE SET
ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2162-5-2**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) **] ON [**2162-5-2**] @1045PM.
Anaerobic Bottle Gram Stain (Final [**2162-5-3**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2162-5-2**] URINE CULTURE (Final [**2162-5-3**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
MRSA negative
[**2162-8-4**] Esophagus : Successful passage of contrast beyond the
stomach into the small bowel with no evidence of obstruction or
leak.
CCT w/contrast: [**2162-5-2**] . Massive distention of the stomach
with mesentero-axial rotation. This has resulted in small
obstruction. The vascular supply of the stomach appears normal.
Although no definite evidence of perforation or vascular
compromise is noted, a small amount of free fluid is noted
adjacent to the right distal paraesophageal region.
2. Colonic diverticulosis with no signs of diverticulitis.
3. Simple cyst of the right kidney and small hypodense lesion of
the left
kidney which is too small to characterize.
4. Small fat containing umbilical hernia.
Brief Hospital Course:
Ms. [**Known lastname **] [**Last Name (Titles) **] an 80yF with history of GERD, hypertension, CAD,
OCD, and dementia, who presents after three days of N/V with one
episode of coffee ground emesis i.e. Upper GI Bleed. NG lavage
in ICU with clearing after 1000cc lavage. GI was consulted
recommended a CT and PPI [**Hospital1 **]. A CT done [**2162-5-2**] showed
Massively distended stomach with abnormal orientation consistent
with gastric volvulus resulting in obstruction. On [**2162-5-3**]
Thoracis surgery was consulted and proceeded to the operating
room for Laparoscopic reduction of giant paraesophageal hernia.
Primary repair of diaphragmatic hiatus. Placement of
percutaneous endoscopic gastrostomy tube under laparoscopic
supervision. and Esophagogastroduodenoscopy. She was extubated
in the operating room, monitored in the PACU prior transfer to
the floor. The G-tube was to gravity overnight. She had no
nausea or vomiting. On [**2162-5-3**] an esophagus study revealed
successful passage of contrast beyond the stomach into the small
bowel with no evidence of obstruction or leak. The G-tube was
clamped, she remained asymptomatic, tolerated a full liquid
diet. She restarted her previous medications, remained
hemodynamically stable and discharged back to rehab.
Medications on Admission:
- Cytomel 25mcg daily
- ASA 81mg daily
- Prilosec 20mg daily
- Miralax 17g daily
- Escitalopram 40mg daily
- HCTZ 12.5mg daily
- Lisinopril 5mg daily
- Ritalin 10mg daily
- Namenda 10mg daily
- Simvastatin 20mg daily
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for itching.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. Escitalopram 20 mg Tablet Sig: Two (2) Tablet PO once a day.
4. Ritalin 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Namenda 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Polyethylene Glycol 3350 100 % Powder Sig: One (1) scoop
scoop PO DAILY (Daily).
9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
10. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
Northhill
Discharge Diagnosis:
Giant paraesophageal hernia with gastric volvulus.
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills. Difficulty or painful swallowing.
Nausea, vomiting, diarrhea.
Followup Instructions:
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**2163-5-20**]:30 am on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 6163**]
Completed by:[**2162-5-11**]
ICD9 Codes: 5789, 5990, 2760, 2768, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3293
} | Medical Text: Admission Date: [**2100-8-11**] Discharge Date: [**2100-8-16**]
Date of Birth: [**2065-10-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Drug ingestion, altered MS
Major Surgical or Invasive Procedure:
Intubation for Airway protection
History of Present Illness:
34 yo male with a history of narcotic abuse who was attempting
to detox himself at home who presented to OSH ED with altered
MS. Following history from patient's parents: He had been on
OxyContin 80-100 mg tid for ~1 year. On Monday (2d pta) he
began an outpatient detox program (Primary Care Associates
[**Telephone/Fax (1) **]). Medications listed below, he was given a 1d
prescription and the medications were administered by his
mother. On the 1st night he was restless and did not sleep
well, therefore on Tuesday his regimen was changed to an
increased dose of doxepin, librium, and neurontin and ambien and
baclofen were added. Last night, he was well at 10pm, then his
parents were awoken by the alarm system and found [**Known firstname 17766**] in the
garage - he was agitated and delerius. They called the
treatment program who recommended they take him to the ED. At
[**Hospital1 46**], he was agitated, HR 120-130s, SBP 130-150s. He was
given ativan, fentanyl, haldol, versed and was eventually
intubated and paralyzed (given etomidate, succinylcholine).
Also given banana bag and ancef (unclear etiology). Of note,
parents are reasonably sure that he did not take any medications
other than those prescribed by the detox program - in the house
they have Tylenol, Lipitor, Detrol.
Past Medical History:
Heart Murmur
Dysphagia (?)
Social History:
lives alone, works as [**Doctor Last Name 19914**]
OxyContin as above, social Etoh, no tobacco; parents think he
may have done cocaine in the past
Family History:
F- colon ca; M - healthy
-no h/o premature cad
Physical Exam:
On admission:
PE: 98.4, 108, 122/67, 16, 99%; on AC 750/12/5/40%
Gen: Intubated and sedated
HEENT: pupils 2->1 b/l, anictric
Neck: supple; dry axilla
CV: tachycardic, regular; no murmur appreciated
Lungs: cta b/l
Abd: +bs, soft, ntnd
Ext: warm, well-perfused, no rash
Neuro: arousable, moving all extremities
Pertinent Results:
[**2100-8-11**] 09:53AM GLUCOSE-109* UREA N-10 CREAT-0.9 SODIUM-143
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-25 ANION GAP-15
[**2100-8-11**] 09:53AM CALCIUM-9.5 PHOSPHATE-4.7* MAGNESIUM-2.4
[**2100-8-11**] 09:53AM WBC-17.1* RBC-4.85 HGB-14.2 HCT-41.2 MCV-85
MCH-29.3 MCHC-34.5 RDW-13.4
[**2100-8-11**] 09:53AM PLT COUNT-309
[**2100-8-11**] 09:43AM TYPE-ART PO2-167* PCO2-43 PH-7.38 TOTAL
CO2-26 BASE XS-0
OSH:
LFT: WNL
TCA level: 92.3 (upper limit 50)
Tox screen: negative for opioids, BZD, cocaine, salicylates,
amphetamines
ECG:
OSH: nsr, nl axis, qrs 92, QTc 450; R in avr 2mm
[**Hospital1 18**]: nsr, nl axis, QRS 100, QTc 430, R in avr 1mm
Brief Hospital Course:
The pt came intubated and sedated with propofol into the ICU.
The pt was not responsive and did not follow commands. He moved
all four extremities and did not seem in any acute distress. The
pt was switched from AC to CPAP with mmHg of PS before he
extubated himself about one hour into his stay in the ICU. He
was able to maintain good saturations and did not have any
respiratory distress. The propofol was stopped and the pt was
put on lorazepam for sedation. He was able to follow commands
and was orientated to time and person. He did not answer any
questions about the medications he took, but denied taking any
additional drugs apart from the ones that were prescribed for
detoxication. The pt was kept on supportive care to allow time
for the metabolism of the drug OD.
Later in his admission the patient became agitated and
disoriented. It was unclear as to whether this was stil related
to his initial drug intoxication or if he was undergoing
possible withdrawal. It was also possible that the patient was
oversedated from the large quantities of ativan he had received
since admission.
The dose of Ativan was reduced and Haldol was added to the
regimen.
On day three of the hospital course the patient became oriented
X3 and was now following commands appropriately.
.....
After [**Hospital Unit Name 153**] course.
.
A/P: 34 yom with h/o opoid abuse admitted with change in MS with
likely opoid withdrawl and anticholinergic toxicity.
.
1) Anticholinergic toxicity/opoid withdrawl - Resolved signs of
anticholinergic toxicity. Initially had diahrrea and anxiety in
the [**Hospital Unit Name 153**] likely secondary to opoid withdrawl. On the floor the
symptoms improved during the course. Psych consult was
requested which recommended using clonidine 0.1mg [**Hospital1 **], ativan
1mg prn and tappered off. Pt improved and chose to continue in
a outpt detox program after discharge.
.
2. Substance abuse
- Seen by addiction team in the ICU, Patient will need to
coopearate with outpatient detox and substance abuse facility.
.
3. Leucocytosis - 14.6, patient afebrile and no symptoms of
caugh so less likely to be PNA. Does have urinary symptoms so
?UTI. However urine culture was negative and patient remained
afebrile. leucocytosis improved.
.
4. Acidosis - Bicarb 21. likely from diahrrea. Resolved.
Medications on Admission:
Meds:
-was not any medications prior to Detox
.
hydroxyzine qid
neurontin 400mg qid
flexeril 5mg tid
clonidine patch and 0.1mg tid
chlordiazepoxide 20mg tid (?increased from 10mg qid)
baclofen tid - added [**8-10**]
nabumetone 500mg tid
bentyl 20mg tid
doxepin 50 mg qhs
ambien 10mg qhs
.
Discharge Medications:
1. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for anxiety,agitation.
Disp:*14 Tablet(s)* Refills:*0*
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO QD () for 1
days.
Disp:*1 Tablet(s)* Refills:*0*
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO taper as
directed as needed for nausea,vomiting,diahrrea,craving: Take
one dose tonight ([**8-16**]) for a total of three times a day.
Take twice a day on [**8-17**]. Then, take once a day on [**8-18**]. Then,
discontinue the medication.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Narcotic withdrawal
Anticholinergic toxicity
Mental status change
Intubation for respiratory protection
Discharge Condition:
Stable, without evidence of withdrawal
Discharge Instructions:
If you develop symptoms of narcotic withdrawal such as
aggitation, nausea, vomiting, diarrhea, runny nose; or if you
develop any symptoms of benzo withdrawal such as confusion,
tremulousness, rapid breathing call your doctor or return to the
emergency room immediately.
Please be sure to follow up with the outpatient narcotics
withdrawal program at [**Hospital 882**] Hospital
Followup Instructions:
Follow up with your primary care doctor within 2 weeks of
discharge. Please have them follow up on your elevated calcium
level and abnormal liver function tests.
Completed by:[**2100-8-21**]
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3294
} | Medical Text: Admission Date: [**2167-4-30**] Discharge Date: [**2167-5-4**]
Service: MEDICINE
Allergies:
Codeine / Vasotec / Cortisporin / Ciloxan / Atenolol
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
extubation (intubation occurred at OSH)
History of Present Illness:
85 yo F w/recent dx from [**Hospital Unit Name 196**] after cath last month, hx CHF,
PVD, DM, HTN, initially presented to [**Hospital3 **] for SOB.
At [**Name (NI) **], pt acutely decompensated requiring
intubation. Labs were sig for Hct 26 and BNP of 1600. UA there
was positive for leuk est, WBCs, Bacteria. She was given
Ceftriaxone and 60mg of IV lasix.
On transfer to [**Hospital1 18**], pt afebrile 97.3, HR 71, BP 133/59, RR 20,
satting 100% intubated. She had diffuse rhonchi on exam. She was
transfused 1U pRBCs for Hct 24. Other significant labs include
tropT 0.14 with flat CK. Was given vancomycin and Zosyn for
asymmetric infiltrate on CXR. No additional lasix or IVF given.
.
Unable to obtain ROS.
Past Medical History:
1. CAD, status post cardiac catheterization in [**2167-3-15**]
with bare metal stenting and PTCA of an ostial 90% RCA lesion,
complicated by dissection and pseudoaneurysm .
2. Peripheral [**Year (4 digits) 1106**] disease with lower extremity c/b
neuropathy
3. Insulin-dependent diabetes mellitus.
4. Hypertension.
5. Hyperlipidemia.
6. Asthma.
7. GERD.
8. Osteoarthritis.
9. Recent contrast-induced nephropathy after cardiac
catheterization with a peak creatinine of 4.4 requiring
transient
renal replacement therapy.
10. CRI baseline 1.1 - 1.2
11. Hyperparathyroidism
12. B12 deficiency anemia
13. Appendectomy
14. Bladder suspension
15. Right meniscectomy in [**2161-1-11**]
16. Excision of benign breast mass times two
Social History:
The patient currently lives in [**Location 107641**] with her [**Age over 90 **] year old
Husband. She has 1 son who lives in [**Name (NI) 701**]. At baseline she
walks with a cane, she is otherwise independent in all ADl
although looking to get an aid to help clean soon.
Tobacco: None
ETOH: None
Illicits: None
Family History:
Non-Contributory
Physical Exam:
VITAL SIGNS:
T= 95.9 BP= 128/58 HR= 57 RR= 15 O2= 100%
.
.
PHYSICAL EXAM
GENERAL: Intubated sedated
HEENT: ETT in place
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: sedated
Pertinent Results:
[**2167-4-30**] 09:00PM BLOOD WBC-6.8 RBC-UNABLE TO Hgb-7.5* Hct-24.0*
MCV-UNABLE TO MCH-UNABLE REP MCHC-32.6 RDW-UNABLE TO Plt
Ct-267
[**2167-4-30**] 09:00PM BLOOD Neuts-84.7* Bands-0 Lymphs-8.7* Monos-5.3
Eos-1.0 Baso-0.3
[**2167-5-1**] 02:55AM BLOOD PT-12.9 PTT-24.4 INR(PT)-1.1
[**2167-4-30**] 09:00PM BLOOD Glucose-344* UreaN-50* Creat-1.4* Na-136
K-5.0 Cl-103 HCO3-23 AnGap-15
[**2167-4-30**] 09:00PM BLOOD ALT-43* AST-38 CK(CPK)-131 AlkPhos-164*
Amylase-36
[**2167-4-30**] 09:00PM BLOOD CK-MB-8 proBNP-[**Numeric Identifier 107642**]*
[**2167-4-30**] 09:00PM BLOOD cTropnT-0.14*
[**2167-5-1**] 02:55AM BLOOD CK-MB-8 cTropnT-0.12*
[**2167-5-1**] 02:55AM BLOOD Calcium-7.9* Phos-3.4 Mg-3.0*
[**2167-4-30**] 09:00PM BLOOD TSH-3.0
[**2167-5-1**] 02:19AM BLOOD Lactate-1.3
.
Studies CXR [**4-30**]:
FINDINGS: Previously, the bilateral perihilar opacities have
been decreasing, there is worsening opacity predominantly in
bilateral hila on the current study. There are profoundly low
lung volumes. The distribution favors superimposed acute
pulmonary edema. There may be residual opacity from underlying
infection. There are likely small bilateral pleural effusions
and significant left lower lobe atelectasis. Consistent with the
given history, an endotracheal tube is present. The distal tip
is on the order of 2 cm from the carina which is satisfactory in
placement. The nasogastric tube is in place with the side hole
in the region of the gastroesophageal junction. No pneumothorax
is noted. There is atheromatous disease of the aorta. The
cardiac silhouette size is difficult to assess but is likely
stable. There is a rounded density projecting over the left
medial hemithorax, presumably extrinsic to the patient.
.
IMPRESSION: Overall, there is likely superimposed acute
pulmonary edema,
moderate-to-severe in nature, both interstitial and alveolar
which represents a worsening since the prior study. More
confluent opacities noted in the background may be the residual
of prior infection or recurrent aspiration or pneumonia. Repeat
radiography following appropriate diuresis recommended to assess
for underlying infection. Small bilateral pleural effusions are
also evident. Please advance nasogastric tube 5-10 cm.
.
TTE [**5-1**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
near akinesis of the distal half of the anterior septum and
hypokinesis of the distal half of the anterior wall and apex
(mid-LAD distribution). The remaining segments contract normally
(LVEF = 40 %). No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are mildly thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2167-4-11**],
the severity of mitral regurgitation is reduced and the
estimated pulmonary artery systolic pressure is higher. Minimal
aortic stenosis is now suggested. Left ventricular systolic
function is similar.
.
RLE US [**5-1**]:
IMPRESSION: No evidence of DVT in the right lower extremity
Brief Hospital Course:
85 yo F with h/o Diabetes, cardiac disease, presents with acute
shortness of breath to OSH, requiring intubation for respiratory
distress.
.
#. Respiratory distress: Differential included CHF, infection,
PE. Primary etiology was felt to be most likely CHF rather than
infection given significantly elevated BNP >23,000 and fluid
overload on CXR. Asymmetry had been present on prior recent CXR,
and diffuse congestion is noteably new. Based on recent
discharge summary and follow up cardiology appointments, it
appeared that the patient was no longer taking her lasix at
home. She received 60mg IV lasix at [**Hospital3 **]. She was
placed on lasix gtt and diuresed well overnight >2,5L. She was
quickly weaned off the vent and extubated without complication
on [**5-1**]. There was initial concern for concurrent PNA (had
received course of azithro on recent hospitalization for ?
atypical PNA). She was noted to have a rising WBC count as well
as hypothermia which was concerning for possible early sepsis
and she was started on vanc/cefipime for possible HAP. She had
received vanc/zosyn and the OSH. After extubation the patient's
CXR was significantly improved and she did not have significant
cough, sputum or SOB and there was low suspicion for a pulmonary
infection and therefore vanc/cefepime was stopped. The lasix gtt
was discontinued after extubation and she was restarted on PO
lasix of 40 mg [**Hospital1 **] once on the medical [**Hospital1 **]. She had repeat TTE
performed which showed stable EF of 40%.
.
# Leukocytosis: Patient's WBC was normal on admission, however
rose to 8.7 the day after. She was also hypothermic and
therefore there was concern for an infectious process. There
was some concern for HAP as above and therefore vanc/cefipime
was started. She then had low grade temp of 100. UA was
negative here, however reports from OSH showed dirty UA.
Culture at OSH grew >100,000 cfu of lactose-fermenter. Per OMR
she has a h/o pan-sensitive Klebsiella UTI. Given preliminary
culture reports she was started on cipro PO empirically for UTI.
Given UTI was more likely source of infection her vanc/cefepime
was discontinued. Her WBC normalized and she will complete a
total of 7 days of ciprofloxacin orally.
# NSTEMI - Trop T peaked at 0.14 on admission which was stable
from OSH in setting of normal renal function. She had recent
RCA stents placed last admission. Her CK and MB remained flat.
EKG was without significant changes. Her troponin leak was felt
to be demand in the setting of CHF exacerbation. She was
continued on medical management with ASA and statin. When she
was extubated her home amlodipine, metoprolol and valsartan were
restarted. TTE was repeated and showed stable EF.
# Chronic Renal insufficiency - Cr was 1.4 on admission which
was improved from recent hospitalization. Cr peaked at 4.4
during the hospital stay due to contrast exposure and required
temporary CVVH. Cr remained stable, however bumped slightly to
1.5 after diuresis and then remained stable. Medications were
renally dosed.
#. Anemia - within pt's baseline of known anemia of chronic
disease
#. Hypertension - not active issue, continue home meds
(amlodipine, BB, valsartan)
#. Diabetes: Sugars were initially elevated on admission to
300s-400s. Thought to be due to not taking home meds vs
infection. She was placed on Humalog sliding scale and her BS
quickly corrected.
# Lt ankle pain - on [**5-3**] she developed severe acute lt ankle
pain without known trauma. Examination of the ankle was
unrevealing. This was felt to possibly represent an acute gouty
attack given her aggressive diuresis - plain films showed no
fracture, uric acid was slightly elevated. Given her recent
acute on chronic renal fialure, NSAIDs and colchicine were
avoided, and her pain was treated with Percocet.
Medications on Admission:
Pre recent d/c summary:
1. Acetaminophen 325 mg PO Q6H as needed.
2. Aspirin 325 mg Daily
3. Amlodipine 5 mg daily
4. Multivitamin daily
5. Cyanocobalamin 100 mcg daily
6. Atorvastatin 80 mg daily
7. Clopidogrel 75 mg daily
8. Metoprolol Tartrate 25 mg [**Hospital1 **]
9. Lidoderm Topical
10. Nitroglycerin Sublingual
11. Pentoxifylline 400 mg Tablet three times a day: with meals
(pt. reports stopping this
12. Calcium 600 with Vitamin D3 600 mg(1,500mg) -200 unit [**Hospital1 **]
13. Omega-3 Fatty Acids 1,000 mg Capsule once a day
14. Valsartan 80 mg daily
15. Glimepiride 4mg daily
16. Insulin Aspart SS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
10. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO
once a day.
11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob/wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary: acute on chronic systolic heart failure
Secondary: coronary artery disease, diabetes mellitus Type 2,
hypertension, asthma, GERD, osteoarthritis, chronic renal
insufficiency
Discharge Condition:
good, stable, O2 sats in high 90s on 1.5L NC
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2000mL
You were evaluated for respiratory distress due to congestive
heart failure. You improved with diuresis, but because of left
foot pain likely due to gout, you will benefit from rehab.
If you have worsening shortness of breath, chest pain,
lightheadedness, fevers, chills, or any other concerning
symptoms, have the doctors at the facility evaluate you.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-5-11**]
12:10
ICD9 Codes: 5990, 4280, 4439, 5859, 3572, 2724, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3295
} | Medical Text: Admission Date: [**2176-11-14**] Discharge Date: [**2176-11-21**]
Date of Birth: [**2107-11-8**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS:
Mr. [**Known lastname 36803**] is a 69-year-old white male with history of
shortness of breath on exertion. He also visited his primary
care physician who recommended that he undergo a cardiac
stress test evaluation which ultimately revealed a reversible
anterior wall defect. This led to a catheterization and
cardiac arterial dye study with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the
Cardiology staff here at the [**Hospital1 **]. It
revealed significant three vessel coronary artery disease.
Therefore, Dr. [**Last Name (STitle) 1537**] of the Cardiothoracic Surgery service was
consulted for operative management of this patient's
significant disease.
The patient states coronary risk factors include
hypertension, hypercholesterolemia, smoker, and diabetes
mellitus. He has no family history. He has had no prior
history of myocardial infarction.
PAST MEDICAL HISTORY:
His past medical history was as above. He has diabetes. He
is a tobacco user as well as having two hernia repairs
surgically and has had a left nephrectomy and appendectomy in
the past.
ALLERGIES:
None.
MEDICATIONS ON ADMISSION:
Glucotrol 5 mg po bid, Glucophage 850 mg po tid, lisinopril,
Toprol 25 mg po bid, and nitropatch as well as aspirin 325 mg
po q day.
SOCIAL HISTORY:
He is married, currently retired, and has no alcohol history.
He was a [**1-13**] pack per day smoker in the past, but currently
has weaned down to less than a pack a day.
REVIEW OF SYSTEMS:
Otherwise negative. It should be added that the cardiac
catheterization report by Dr. [**First Name (STitle) **] did note a proximal RCA
stenosis of 70% and mid RCA lesion of 90%, mid left anterior
descending artery lesion of 60-70%, diagonal II branch of
70%, and a mid circumflex lesion of 80% stenosis. Ejection
fraction was approximately 49-50%. It was a right dominant
system.
Overall, the impression from Dr. [**First Name (STitle) **] was again mild
diastolic dysfunction the setting of significant three vessel
coronary artery disease. Patient was admitted on [**2176-11-14**]
where he underwent coronary artery bypass graft times four
with Dr. [**Last Name (STitle) 1537**]. He had a LIMA graft to the left anterior
descending artery, saphenous vein graft to the diagonal, and
to the oblique marginal, as well as saphenous vein graft to
the posterior descending. Indications for this operation
were unstable angina.
Dr. [**Last Name (STitle) 1537**] once he has done this procedure, transported the
patient back to the Cardiac Intensive Care Unit where his
postoperative course was relatively stable. He was weaned
off his sedation. No pressors were utilized to maintain his
cardiovascular hemodynamic profiles. His Swan Ganz catheter
was discontinued on postoperative day number one. He was
also extubated on the night of surgery.
He did have postoperative laboratories significant for a
hematocrit of 22.6, preoperative hematocrit was 35.0. His
platelet count was 146,000 postoperatively. His preoperative
numbers were 206. His coagulation panels were normal preop
and postop. His BUN and creatinine on postoperative day
number one was 13 and 0.8. His preoperative BUN and
creatinine were 18 and 0.9 respectively.
On postoperative day number one, he was noted to be
neurologically intact cardiovascular wise. He was started on
Lopressor, aspirin, and Lasix. His chest tubes were
maintained for a small air leak. He was given a cardiac
diabetic diet, and ultimately transferred to the floor.
By postoperative day number two, the patient had a persistent
small air leak. Chest x-ray showed a persistent right apical
pneumothorax despite tube thoracostomy suction. This was
followed serially. The patient was started with physical
therapy and ambulated with portable suction. He remained
stable. His hematocrit on postoperative day number two was
noted to be 23 up from 22 postop. His platelet count was
150,000. His BUN and creatinine is slightly increased to 25
and 1.2 respectively up from 0.8 on postop day number one.
The remainder of his electrolytes were within normal limits.
His sternum was still stable with no erythema or exudate.
It was decided on postoperative day number two that his chest
tube could be removed. Clinically there was no evidence of
air leak at this time. Subsequent to that on the evening of
postoperative day number two going into postoperative day
number three, he had an episode of desaturation into the 88%
with 5 liters nasal cannula. He was given nebulizer
treatments as needed. Subsequently a x-ray on the morning of
postoperative day number three, showed collapse of the right
lung greater than 50%. Therefore, a right chest tube was
re-inserted to allow for re-approximation of the visceral
pleura to the parietal pleura. This was done without any
difficulty. The lung was noted to be re-expanded on the
post-re-insertion chest tube film. However, it was not fully
re-expanded. He did have a persistent right apical
pneumothorax. He was therefore maintained on tube
thoracostomy and low wall suction for a total of four more
days. The patient tolerated this well. He was ambulating at
a level four with physical therapy. His electrolytes and
laboratories are within normal limits. His creatinine
returned to 1.0. He remained afebrile throughout his course
and hemodynamically stable.
Intermittently his Lopressor was titrated up from 12.5 mg
ultimately to a discharge dose of 50 mg po bid. His blood
sugars remained in good control once he started back on his
Glucotrol and Glucophage, and by postoperative day number
seven, after a chest film on the 5th had shown resolution of
his pneumothorax, chest tube was discontinued.
The post-pulled chest film on postoperative day number seven
showed no evidence of pneumothorax. The patient was stable
hemodynamically. His blood pressure and pulse were 126/72
with a pulse of 73 and regular in sinus. His sPO2 was 94% on
room air saturation with a respiratory rate of 20. His
sternum was stable with no evidence of drainage or erythema.
Steri-Strips were in place. His heart was regular with no
murmur. His lungs were clear to auscultation bilaterally
with breath sounds appreciated throughout all lung fields.
Lower extremities were unremarkable. The wound was clean,
dry, and intact on the right lower extremity.
On postoperative day number seven after his chest tubes were
removed and patient was ambulatory without assistance
remaining afebrile, he was deemed stable for discharge to go
home.
CONDITION ON DISCHARGE:
Stable.
DISCHARGE STATUS:
To be sent home without any VNA service. The patient is
completely independent.
DIAGNOSIS:
Unstable angina, significant three-vessel coronary artery
disease, status post coronary artery bypass graft times four.
FOLLOWUP:
The patient's followup will include being seen in the Wound
Care Clinic one week from time of discharge for check of his
sternal wound. He will be instructed not to drive or to lift
anything heavier than 10 pounds for a minimum of one month.
Additionally, he will see his primary care physician or
cardiologist within 2-4 weeks of discharge, and will follow
up with Dr. [**Last Name (STitle) 1537**] in his clinic in approximately one month
from discharge.
DISCHARGE MEDICATIONS:
Protonix 40 mg po q day, aspirin 325 mg po q day, Glucotrol 5
mg po bid, Glucophage 850 mg po bid, K-Dur 20 mEq po q day
times seven days, Lasix 20 mg po q am times seven days,
Lopressor 50 mg po bid, Percocet 5/325 1-2 tablets po q 4-6
hours prn, Colace 100 mg po bid as a stool softener to be
taken while he is on Percocet.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2176-11-21**] 11:18
T: [**2176-11-21**] 11:11
JOB#: [**Job Number 36804**]
ICD9 Codes: 4111, 5180, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3296
} | Medical Text: Admission Date: [**2111-12-11**] Discharge Date: [**2111-12-17**]
Date of Birth: [**2063-4-17**] Sex: F
Service: Medical Intensive Care Unit/Medicine, [**Hospital1 139**] Firm
CHIEF COMPLAINT: Sepsis.
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
female with an extensive past medical history most notable
for a deep venous thrombosis and pulmonary embolism. The
patient was hospitalized in [**2111-11-21**] while on
Coumadin and an inferior vena cava filter was placed.
The patient presented with one to two days of shortness of
breath, malaise, and nonspecific complaints at her nursing
home. Her temperature there was noted to be 101 degrees
Fahrenheit, and her oxygen saturations were noted to be 88%
on 3 liters via nasal cannula. The patient described chills,
nausea, and vomiting (more so than her baseline). Shortness
of breath, but no production of sputum. No diarrhea. No
constipation. No chest pain. She said she has not been
feeling since she was discharged from her prior admission on
[**2111-11-29**] but got much worse over the last two days.
She also notes weight loss of approximately seven pounds and
poor oral intake.
In the Emergency Department, the patient was found to have a
temperature of 102.3 degrees Fahrenheit, her blood pressure
was in the 80s/60s, and a heart rate of 140. A sepsis
protocol was initiated at this point.
PAST MEDICAL HISTORY:
1. Systemic lupus erythematosus with skin involvement.
2. [**Doctor Last Name 15532**] esophagus/dysphagia.
3. Esophageal strictures.
4. Peripheral neuropathy.
5. Anxiety.
6. Eating disorder 12 years ago.
7. Status post gastric bypass surgery.
8. Deep venous thrombosis and pulmonary embolism on [**2111-11-23**].
9. Hypothyroidism.
MEDICATIONS ON ADMISSION: (Medications on admission were as
follows)
1. Multivitamin one tablet by mouth once per day/
2. Protonix 40 mg by mouth once per day.
3. Synthroid 100 mcg by mouth every day.
4. Remeron 30 mg by mouth once per day.
5. Lactulose 15 mL to 30 mL by mouth at hour of sleep.
6. Colace 100 mg by mouth twice per day.
7. Senna.
8. Calcium carbonate 500 mg by mouth three times per day.
9. Vitamin D.
10. MS Contin 30 mg by mouth twice per day.
11. Lorazepam 0.5 mg by mouth twice per day.
12. Verapamil 40 mg by mouth three times per day.
13. Buspirone 15 mg by mouth three times per day.
14. Morphine sulfate immediate release 15 mg up to three
times per day as needed.
15. Tylenol by mouth as needed.
16. Albuterol as needed.
17. Coumadin 3 mg by mouth once per day.
18. Folate.
19. Vitamin B12.
20. Reglan 10 mg by mouth three times per day.
21. Prednisone 7.5 mg by mouth once per day.
ALLERGIES:
1. PENICILLIN (she gets hives).
2. SULFA (she gets a rash).
3. AZITHROMYCIN (she gets anaphylaxis).
4. OFLOXACIN (she gets anaphylaxis).
SOCIAL HISTORY: The patient lives in the [**Hospital6 13941**]
home. She has smoked half a pack of cigarettes per day for
approximately 40 years. She does not drink alcohol. She
does not use drugs. She gets around in a wheelchair.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient's temperature was 99
degrees Fahrenheit, her blood pressure was 103/62, her heart
rate was 93, her respiratory rate was 16, and her oxygen
saturation was 100% on 5 liters via nasal cannula. In
general, the patient appeared older than her stated age. The
patient was comfortable and in no acute distress; fatigued.
Head, eyes, ears, nose, and throat examination revealed the
mucous membranes were very dry. The patient had cracked
lips. The oropharynx was clear. Pupils were equal, round,
and reactive to light. No exudates. No bleeding. The
conjunctivae were pink. The neck was supple. No
thyromegaly. Jugular venous pulsation was flat. Chest
examination revealed breath sounds throughout without wheezes
or crackles. Cardiovascular examination revealed a regular
rate and rhythm; tachycardic. No murmurs were appreciated.
Skin examination revealed no rashes. The skin was severely
dry with tinting with scaling. The abdomen revealed a large
vertical well-healed scar. Very prominent xiphoid. Could
palpate the bowel, but no tenderness. No hepatosplenomegaly.
No guarding or rebound. Extremity examination revealed the
extremities were thin. No splinter hemorrhages. No lesions.
No edema. No clubbing or cyanosis. The extremities were
cool. Strength was [**3-25**] to [**4-25**] throughout. Neurologic
examination revealed no focal deficits. The patient was
alert and oriented times three. The patient followed
commands and answered questions appropriately but slowly.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission revealed the patient's white blood cell count
was 19.9, her hematocrit was 42.6, and her platelets were
252. Her sodium was 142, potassium was 3.5, chloride was
104, bicarbonate was 33, blood urea nitrogen was 9,
creatinine was 0.6, and her blood glucose was 99. Her
calcium was 7, her magnesium was 1.5, and her phosphate was
3.8. Her alanine-aminotransferase was 36, her aspartate
aminotransferase was 51, her alkaline phosphatase was 105,
her amylase was 27, her total bilirubin was 0.6, and her
lipase was 9. Creatine kinase was 16. Troponin was less
than 0.01. Urinalysis showed no nitrites, 21 to 50 red blood
cells, and 6 to 10 white blood cells. Arterial blood gas was
7.3/60/189. Lactate went from 3 to 1.8 to 1. Blood cultures
were no growth to date.
PERTINENT RADIOLOGY/IMAGING: A computed tomography of the
abdomen showed a right lower lobe opacity, possible
aspiration pneumonia, a 2-mm nodule in the left upper lobe, a
right thyroid with low attenuation, loops of small bowel in
the upper abdomen without free air, severe kidney cysts
bilaterally, right hydronephrosis, and hydroureter. No
change from prior study, anasarca.
A chest x-ray showed bile in the left upper quadrant pushing
up the diaphragm.
Electrocardiogram was read as sinus tachycardia.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient is a 48-year-old female with multiple medical
problems who presented to the Emergency Department with a
picture of sepsis. The sepsis protocol was initiated. She
received a great deal of intravenous fluids. She was started
on antibiotics of vancomycin, aztreonam, and Flagyl. She
actually responded quite well to these treatments and did not
require intubation nor did she go into organ/system failure.
None of her blood cultures grew an organism out. She did
have one positive urine culture for Streptococcus bovis;
raising the question of endocarditis, but she had no other
signs, or symptoms, or positive laboratory values pointing in
this direction.
The patient spent five in the Medical Intensive Care Unit
before being transferred to a floor bed.
1. FEVER AND INCREASED WHITE BLOOD CELL COUNT ISSUES: With
negative blood cultures and what appeared to be a pneumonia
on chest x-ray, in the end this was felt due to a pneumonia.
The patient responded quite well to the over 10 liters of
fluid and antibiotics which she received. At the time of
discharge, she had received seven days of vancomycin,
aztreonam, and also a shorter course of Flagyl which had been
stopped. Her white blood cell count had responded nicely.
She had been afebrile for several days. No blood cultures
grew out any organisms. As noted, she did have a urine
culture which grew out Streptococcus bovis; the significance
of which was not entirely clear.
She also did receive one dose of stress-dose steroids which
seemed to improve her course greatly during her time in the
Medical Intensive Care Unit.
A random cortisol was checked and was within normal limits;
although, this was hard to interpret with the patient on
prednisone. A thyroid-stimulating hormone was checked and
found to be quite low, but the T4 was normal. The patient's
levothyroxine was stopped for several days, and then she was
restarted at a lower dose of 75 mcg by mouth every day.
On [**2111-12-16**], the patient was to receive a midline
intravenous line for administration of intravenous
antibiotics once she returned to her extended care facility.
It was also worth noting that the presence of positive
Streptococcus bovis culture was concerning for translocation
of this organism from the gut; in particular, in the presence
of colon cancer. I do not believe the patient has had a
screening colonoscopy, and this is strongly recommended, and
this was discussed with her gastroenterology physician.
2. SHORTNESS OF BREATH ISSUES: The patient responded well
to fluid resuscitation and quickly appeared comfortable on 3
liters nasal cannula in the Medical Intensive Care Unit. An
arterial blood gas did show respiratory acidosis, her lactate
quickly trended down. She did have several episodes of
tachycardia where she was short of breath which was felt
likely secondary to pain and anxiety.
Prior to discharge, the patient was saturating 100% on 2
liters via nasal cannula; although, she did express some
feelings of shortness of breath. She was offered an
albuterol inhaler as needed to treat this shortness of
breath.
3. SYSTEMIC LUPUS ERYTHEMATOSUS AND POSITIVE ANTICARDIOLIPIN
ANTIBODY ISSUES: The patient is known to hypercoagulable,
having had a pulmonary embolism while on anticoagulation. On
the prior admission, an inferior vena cava filter was placed.
On this admission, the patient was continued on her Coumadin;
however, likely its interaction with antibiotics caused her
to be supratherapeutic. Therefore, her Coumadin was held for
several days, but likely to be restarted upon her discharge
at a slightly lower dose.
4. NUTRITIONAL AND DYSPHAGIA ISSUES: The patient was
followed by the Gastroenterology team while in the hospital.
It was clear that the patient was nutritionally deficient at
this point, and consideration was made for placing a
percutaneous endoscopic gastrostomy tube to aid in nutrition.
However, it was decided that the patient would try aggressive
oral feedings; possibly with a liquid diet for the next
several weeks and then would follow up with her
gastroenterologist (Dr. [**Last Name (STitle) 22318**] here at [**Hospital1 190**]. At that time, the decision will be made
whether to place the percutaneous endoscopic gastrostomy
tube. In the meantime, the patient will also continue on
Reglan and Protonix as well as calcium carbonate, folic acid,
and lactulose and Colace as needed for bowel movements.
The patient had a small-bowel follow-through x-ray study
performed during this admission. The results of this test
were not known at the time of this dictation.
5. HYPOTHYROIDISM ISSUES: As noted, the patient's
thyroid-stimulating hormone was suppressed on admission with
a normal T4. Her levothyroxine was initially held and then
restarted at a decreased dose of 75 mcg by mouth once per
day.
6. HEADACHE ISSUES: Headaches are a chronic problem for
this patient; thought to be migraines. The patient has been
resistant to a trial of Imitrex. The patient was continued
on Midrin as well as the pain medications; the MS Contin and
morphine sulfate immediate release. It was recommended that
the patient attempt to optimize these treatments as an
outpatient with consultation with a neurologist.
7. CHRONIC PAIN/PERIPHERAL NEUROPATHY ISSUES: The patient
was maintained on her home regimen of MS Contin and morphine
sulfate immediate release tablets as needed.
8. ANEMIA ISSUES: The patient has anemia of chronic disease
by iron studies and had a stable hematocrit during her stay.
No guaiac-positive stool were noted. Daily complete blood
counts were checked.
9. PSYCHIATRIC ISSUES: The patient was continued on
buspirone 15 mg by mouth three times per day as well as on
lorazepam 0.5 mg by mouth three times per day. The patient
was also continued on her mirtazapine 30 mg by mouth at
bedtime.
DISCHARGE DISPOSITION: The patient was to be discharged to
an extended care facility.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to contact her primary care
doctor with any chest pain, shortness of breath, increased
nausea or vomiting, severe diarrhea, fevers, chills, or
dizziness.
2. The patient was instructed to follow up with her primary
care doctor within one to two weeks.
3. The patient was instructed to follow up with Dr. [**Last Name (STitle) 22318**]
on [**2112-1-5**] at 1 p.m.
4. The patient was instructed to have her INR checked on
[**2111-12-21**]; and her Coumadin dose adjusted accordingly.
5. The patient was instructed to try to increase her
nutritional intake as much as possible.
6. The patient was instructed that she had a magnetic
resonance imaging appointment on [**2111-12-21**] at 8:45
a.m.
7. The patient was instructed that she had a Neurology
appointment on [**2111-12-29**] at 6 p.m.
MEDICATIONS ON DISCHARGE: (Medications on discharge were as
follows)
1. Multivitamin one tablet by mouth once per day/
2. Protonix 40 mg by mouth once per day.
3. Mirtazapine 30 mg by mouth once per day.
4. Lactulose 15 mL to 30 mL by mouth at hour of sleep as
needed.
5. Colace 100 mg by mouth twice per day.
6. Calcium carbonate 500 mg by mouth three times per day
(with meals).
7. Albuterol inhaler 1 to 2 puffs inhaled as needed q.6h.
9. Vitamin D 400 International Units by mouth every day.
10. Folic acid 1 mg by mouth once per day.
11. Lorazepam 0.5 mg by mouth twice per day.
12. Reglan 10 mg by mouth four times per day (before meals
and at bedtime).
13. Buspirone 15 mg by mouth three times per day.
14. Midrin one to two tablets by mouth q.8h. as needed (for
migraines).
15. Prednisone 7.5 mg by mouth once per day.
16. Morphine sulfate 15 mg q.4-6h. as needed (for
breakthrough pain).
17. Morphine sulfate immediate release 30 mg q.12h.
18. Levothyroxine 75 mcg by mouth every day.
19. Cyanocobalamin 1000 mcg once per day.
20. Vancomycin 1000 mg intravenously q.12h. (for seven
days).
21. Aztreonam [**2108**] mg intravenously q.12h. (for seven days).
22. Coumadin 2 mg by mouth at bedtime (adjust this dose
based on monitoring of INR levels). The patient should have
her INR checked on [**2111-12-21**].
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Anemia.
3. Malnutrition.
4. Dysphagia.
5. Systemic lupus erythematosus.
6. Pulmonary embolism/infarction.
CONDITION AT DISCHARGE: Condition on discharge was good but
malnourished.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (NamePattern1) 6006**]
MEDQUIST36
D: [**2111-12-16**] 14:56
T: [**2111-12-16**] 16:36
JOB#: [**Job Number 33533**]
ICD9 Codes: 5070, 5990, 0389, 486, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3297
} | Medical Text: Admission Date: [**2107-4-18**] Discharge Date: [**2107-4-21**]
Date of Birth: [**2060-6-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
patient is a 46 year old female with a PMH of asthma/COPD on
home O2, current smoker, extensive tobacco abuse, HCV,
depression/anxiety, PTSD, learning disability presented to the
ED today complaining of increased SOB. The patient reports that
over the last 2 weeks her breathing has progressively gotten
worse and this morning she felt unable to catch her breath
despite use of her home O2 and inhalers. She denies and recent
cough, fever/chills or chest pain. She denies recent URI or sick
contacts. She reports that her O2 requirement has remained
stable at 2-3L. She denies any recent N/V or abdominal pain.
Denies LE swelling or falls. Of note, the patient was recently
hospitalized at [**Hospital1 18**] with COPD flair and discharged on [**4-11**].
She received a 5 day burst of prednisone, her Advair dose was
increased to 500/50 and she was continued on her home inhalers.
Pulmonary was consulted and felt that her symptoms were [**2-12**]
progression of her disease.
.
In the ED, patient was noted to be somnolent but not tachypneic
with exp. wheezing on exam. VS were T: 97.3 BP: 100/81 HR: 77
RR: 14 O2 sat: 88% RA, 94% 4L. CXR showed ? LLL infiltrate for
which she received levo 750mg x1. ABG notable for 7.33/79/66/44.
She was started on BiPAP and BP dropped to 70s and she was given
1L NS bolus. She remained afebrile with lactate 0.8. She was
also given solumedrol 125mg IV x1.
.
Currently the patient is sleepy, frequently nodding off during
interview but reports that her breathing feels much better. She
continues to deny chest pain, N/V, abdominal pain.
Past Medical History:
HCV
GAD/depression/agoraphobia
Asthma/COPD
Surgical menopause (s/p hysterectomy)
Learning disability
.
Surgery:
s/p hysterectomy x [**2097**]
s/p colostomy x [**2097**]
s/p hernia repair x [**2097**]
Social History:
Cigarettes<[**1-12**] ppd x 28 years (down from max> 3 ppd)
Alcohol=ex
Illicit/intravenous drug use=ex
Education=10th grade (special education)
Lives with boyfriend x 12 years
Family History:
Sister: leukemia
Father: MI in his 50's (patient found her father dead in his
truck)
Denies DM, stroke, aneurysm, cholesterol problems, HTN, asthma,
thyroid problems, bleeding tendencies, anemia, skin/breast/colon
cancer
Physical Exam:
MICU Admission Physical Exam:
T: 96.3 BP: 131/80 HR: 102 RR: 30 O2 87% 4L -> 94% 4L
Gen: Sleepy, nodding off during interview, arousable for short
periods, no accessory muscle use, speaking in full sentences,
NAD
HEENT: No conjunctival pallor. No icterus. MM dry. OP clear.
poor
dentition.
NECK: Supple, No LAD, No JVD.
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: Poor air movement throughout, scattered exp wheezing, no
dullness to percussion.
ABD: NABS. Soft, NT, ND. No HSM
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: No rashes/lesions, ecchymoses.
NEURO: patient having difficulty staying awake, but is arousable
and oriented to person, hospital and year, thought month was
[**Month (only) 958**]. No obvious focal neurologic deficits, moving ext x 4.
Pertinent Results:
[**2107-4-18**] 02:38PM BLOOD Type-ART pO2-66* pCO2-79* pH-7.33*
calTCO2-44* Base XS-11 Intubat-NOT INTUBA
[**2107-4-18**] 07:06PM BLOOD Type-ART pO2-58* pCO2-66* pH-7.32*
calTCO2-36* Base XS-4 Intubat-NOT INTUBA
[**2107-4-19**] 12:06AM BLOOD Type-ART pO2-69* pCO2-59* pH-7.34*
calTCO2-33* Base XS-3
[**2107-4-19**] 04:11AM BLOOD WBC-6.7 RBC-4.01* Hgb-12.5 Hct-37.4
MCV-93 MCH-31.2 MCHC-33.4 RDW-14.0 Plt Ct-266
[**2107-4-19**] 04:11AM BLOOD Glucose-147* UreaN-20 Creat-0.5 Na-142
K-5.1 Cl-106 HCO3-26 AnGap-15
Chest x-ray on [**2107-4-18**]:
FINDINGS: The right costophrenic angle has been excluded. When
compared to
the CT, there is upper lobe lucency and splaying of the
ronchovasculature.
There is no pneumonia. Cardiomediastinal silhouette is normal.
There is no
evidence of effusion or pneumothorax. The bones are normal.
ABG on [**2107-4-20**]: 72* 60* 7.43 41*1 12
Brief Hospital Course:
Hospital course by problem:
# Dyspnea: Secondary to COPD. No evidence of pneumonia on chest
x-ray. Symptoms of lethargy likely the result of CO2 retention
secondary to COPD, multiple sedating psychiatric medications,
and Obstructive sleep apnea. Patient responded to conservative
treatment for COPD, with intravenous corticosteroids,
azithromcyin for 5-day course, - cont. supplemental O2 for goal
sat 88-92%. Viral panel was sent to exclude this as possible
aetiology of COPD flare. Throughout MICU course, patient did
not require intubation, mechanical ventilation, or non-invasive
positive pressure ventilation. Ipratropium was substituted for
tiotropium while in MICU and was changed back prior to
discharge. Intravenous solumedrol was changed to prednisone
taper upon transfer to general medical floor. Patient was
started on nicotine patch and smoking cessation was encouraged.
The patient was stable on HD 2, and likely at her respiratory
baseline on HD 3 and ready for discharge.
.
# GAD/depression/agoraphobia: holding sedating meds in setting
of somnolence
- on mult. meds as outpatient including citalopram, clonazepam,
clonidine, risperdal, divalproex, mirtazepine, holding
risperdal, mirtazepine given somnolence yesterday
- watch for signs of benzo withdrawal
- The patients sedating medications were decreased given her
somnolence and this possible contribution to her hypercarbia,
and the pt was set up with close outpatient follow-up with her
primary care physician, [**Name10 (NameIs) 2447**], and a pulmonologist to
continue to titrate her psych medications given her tenuous
respiratory baseline.
.
# Elevated CK: no obvious culprit meds. Concerning for viral
infection. Trending down after fluids.
- cont. IV hydration
- flu negative
.
# PPX: Hep SQ while in house
.
# Access: PIV
.
# Code: Full
.
# Comm: boyfriend [**Name (NI) **] [**Telephone/Fax (1) 105617**]
.
# Dispo: stable for discharge. Patient cleared by physical
therapy; pt to recieve PT and resp therapy at home, as well as
outpatient pulmonology follow-up.
Medications on Admission:
spiriva daily
advair 500/50 [**Hospital1 **] (inc. dose on last hospitalization)
benztropine 1mg qhs
citalopram 20mg daily
clonazepam 0.5mg QID
clonidine 0.5mg TID
divalproex 500mg [**Hospital1 **]
mirtazapine 30mg qhs - CURRENTLY HELD
risperidone 3mg qhs and 0.5 mg TID - CURRENTLY HELD
Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: [**1-12**]
Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
2. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 doses.
Disp:*2 Tablet(s)* Refills:*0*
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO twice a day:
take [**Hospital1 **], or up to QID ([**1-12**] extra doses) prn anxiety.
7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-12**] Inhalation four times a day as needed for shortness of
breath or wheezing.
Disp:*1 inh* Refills:*0*
13. Prednisone 10 mg Tablet Sig: taper as below Tablet PO once a
day: Take 4 tablets x 2days, then 2 tablets x 3 days, then 1
tablet x 3days, then 0.5 tablets x 3days. When you start 0.5
tablets, call primary physician to discuss if you should
continue.
Disp:*qs Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
1. Chronic Obstructive Pulmonary Disease
2. Asthma
Secondary:
1. Generalized Anxiety Disorder
2. Depression
Discharge Condition:
Good
Discharge Instructions:
Please call your physician or go to the emergency room if you
develop further difficulty breathing or extreme sleepiness,
chest pain, shortness of breath, lightheadedness, fever greater
than 101.5, severe abdominal pain or distention, persistent
nausea or vomiting, diarrhea, inability to eat or drink, or any
other symptoms which are concerning to you.
.
Activity: You may resume your usual activity as tolerated.
.
Diet: You may resume your usual diet.
.
Medications: Resume your usual home medications, including your
usual home oxygen, with the exceptions as noted here: Make sure
you are wearing your home oxygen at 2-3 liters per minute,
especially with activity. Take any new medications as
prescribed, including finishing your antibiotic (azithromycin)
and continuing your prednisone as prescribed. Additionally,
please note that we have decreased your doses of Remeron and
Risperdal, and you should not take your benztropine until
talking with your [**Location (un) 2447**], as these medications may
contribute to over-sedation.
Followup Instructions:
1. It is very important that you follow up with your primary
care physician [**Last Name (NamePattern4) **]. [**Name (NI) **] after your discharge. An
appointment has been scheduled for you: Please see Dr.
[**Name (NI) **] at her office in [**Location (un) **] on next [**Last Name (LF) **], [**4-25**]
at 4:40pm. If you have any questions regarding this appointment,
please call the office at [**Telephone/Fax (1) 1144**]. Please discuss your
lung disease and all of your medications, including your
psychiatric medications, with Dr. [**Name (NI) **].
2. Given that your psychiatric illnesses and medications may be
contributing to your fatigue and sleepiness, it is very
important that you follow-up soon with your outpatient psych
providers. New appointments have been made for you at the
[**Location (un) **] Counselling Center. Please keep the following
appointments at the [**Location (un) **] Counselling Center:
- Therapist [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 105618**] [**5-4**] at 12:30pm at the
[**Location (un) **]
Counseling Center [**Telephone/Fax (1) 105616**]
- [**Telephone/Fax (1) **] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1681**], [**5-9**] at 10am at the
[**Location (un) **]
Counseling Center [**Telephone/Fax (1) 82039**]
- Please call the [**Location (un) **] Counseling Center intake number at
[**Telephone/Fax (1) **] with any questions regarding your appointments.
3. It is also very important to follow-up regarding your lung
disease as an outpatient. We have arranged an appt. with Dr.
[**Last Name (STitle) 2168**] of pulmonology on Tuesday [**5-3**] at 8:30AM. The
pulmonology clinic is in the [**Hospital Ward Name 23**] building on the [**Location (un) 436**].
Please call ([**Telephone/Fax (1) 513**] with any questions regarding the
appointment or to rearrange if you cannot make it.
ICD9 Codes: 2762, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3298
} | Medical Text: Admission Date: [**2143-10-3**] Discharge Date: [**2143-10-4**]
Service: SURGERY
Allergies:
Cephalosporins
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Fall from chair; hit head on chair as she fell.
Major Surgical or Invasive Procedure:
Sling of left arm.
History of Present Illness:
Mrs. [**Known lastname 84700**] is a [**Age over 90 **] y/o F who fell from her chair on 11am
[**2143-10-3**] as she was reaching for the phone. As she was falling,
she hit her head on a table. No loss of consciousness, no
nausea/vomiting. She sustained a 4cm laceration to her left
forehead, which was sutured at [**Hospital6 5016**]. There, a CT
cervical spine was negative for any acute traume or fractures.
Left shoulder films showed a nondispalced fracture of the
proximal left humeral head. Head CT showed a 4mm subdural
hematoma in the left frontoparietal and temporal regions. She
was transferred to [**Hospital1 18**] for further evaluation and care.
Past Medical History:
Arthritis lower back, macular degeneration, pacemaker x 1year,
CHF, hypothyroid, AFib.
Social History:
Lives at Berkeley Retirement Home.
Family History:
Noncontributory.
Physical Exam:
On discharge:
-AO x3
-CTA bilaterally
-RRR, no m/r/g
-Soft, NTND
-Able to ambulate; unable to bear weight on left arm
-Wound c/d/i
Pertinent Results:
[**2143-10-3**] C-spine: Negative for acute trauma/fractures.
[**2143-10-3**] Head CT: +SDH 4mm in L. frontoparietal and temp; soft
tissue hematoma.
[**2143-10-3**] Shoulder film: L. shoulder nondisp fx. of lat
metaphysis of proximal L. humeral head.
[**2143-10-3**] Tib/Fib film: L. mid tibia incomplete fracture.
[**2143-10-4**] Repeat head CT: No change from previous CT.
Brief Hospital Course:
Mrs. [**Known lastname 84700**] was transferred to [**Hospital1 18**] from [**Hospital6 5016**]
after a fall from her chair in which she hit her head. She
sustained a 4cm laceration to her left forehead which was
sutured at [**Hospital3 **]. C-spine of her neck was negative for any
acute trauma. Head CT showed a 4mm subdural hematoma; and
shoulder films showed a left proximal humeral head fracture. At
[**Hospital1 18**], she was followed by the Trauma, Orthopedics, and
Neurosurgery services. She received repeat films of her head,
shoulder, and tibula/fibula; which revealed no acute change in
her subdural hematoma, and revealed a mild incomplete fracture
of her mid tibia on the left in addition to the left humeral
head fracture. She remained in minimal pain through her hospital
course, complaing of [**3-19**] pain at times, well-controlled with
acetaminophen and morphine. Orthopedics felt this injury was
non-operable and would benefit most from a sling. Given her
intact mental status and negative head CTs, Neurosurgery felt
she was stable for discharge. She was evaluated by Physical
Therapy, who also cleared her for discharge, as she is able to
ambulate and needs minimal assistance with her left arm, which
is currently in a sling. She should followup with her PCP to
have her stitches removed, and with the neurosurgery and
orthopedics services.
Medications on Admission:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a
day.
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**2-8**] SPRAY
Nasal once a day.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
2. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a
day.
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**2-8**]
SPRAY Nasal once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Retirement Home
Discharge Diagnosis:
Left proximal humerus fracture and a left non-displaced
incomplete tibia fracture, 4cm laceration to left forehead, 4 mm
subdural hematoma (left frontalparietal, temporal lobe; stable
and cleared by neurosurgery).
Discharge Condition:
Alert and oriented x3, vital signs stable, steady gait. Cleared
by orthopedics, neurosurgery, and PT.
Discharge Instructions:
- You were evaluated in the hospital after you fell from a chair
and hit your head on a table. Your 4cm head laceration was
sutured at [**Hospital6 5016**]. You were found to have a 4mm
subdural hematoma which was followed by neurosurgery and found
to be stable. You also suffered a left proximal humerus fracture
and a left non-displaced incomplete tibia fracture, which was
put into a sling by orthopedics.
- Please continue to take your home medications as prescribed.
Please continue to take your prescribed pain medications as
specified. Pain medications can cause constipation. It is
important that you take stool softeners while on pain
medication.
- Please call your doctor or return to the ED if you experience
any of the following: Any nausea or vomiting. Any signs and
symptoms of infection, including fevers, chills, increased
swelling, discharge from your head laceration wound. Any
shortness of breath or chest pain.
Followup Instructions:
- Please make an appointment with your primary care physician in
the next week to follow up your hospitalization and also to have
the stitches removed from your left forehead. They need to be
removed 7-10 days after they were put in. They should be taken
out on [**2143-10-10**] or [**2143-10-11**]. It is important that they are
removed at this time.
- Please make an appointment in [**4-10**] weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
in the Orthopaedic Trauma Clinic for repeat x-rays of your left
shoulder, by calling [**Telephone/Fax (1) 1228**]. It is important that you make
this follow up appointment.
- Please make an appointment in 4 weeks with the [**Hospital 4695**]
clinic and also for a repeat CT of your head, by calling
[**Telephone/Fax (1) 2359**]. It is important that you make this follow-up
appointment.
- If you have any questions about your hospital course, please
call the Trauma clinic, at [**Telephone/Fax (1) 2359**]. You can also follow up
in the trauma clinic if necessary.
Completed by:[**2143-10-4**]
ICD9 Codes: 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3299
} | Medical Text: Admission Date: [**2188-12-24**] Discharge Date: [**2189-1-1**]
Date of Birth: [**2109-7-19**] Sex: F
Service: NEUROLOGY
Allergies:
Ace Inhibitors / Tamoxifen
Attending:[**First Name3 (LF) 7567**]
Chief Complaint:
Seizures at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname **] [**Known lastname 69797**] is a 79 year-old woman who was transferred from [**Hospital1 **]
[**Location (un) 620**] after she had a prolonged seizure and was found by her
son. [**Name (NI) **] son reports that she was in her usual state of health
on
the prior evening and was not reporting any infectious symptoms
of any kind. Her son came over and found her in her bead with
her
head pushed up against the wall seizing. He described it as
whole
body seizing with foam coming out of her mouth. He is not sure
how long it lasted, but thinks she was probably seizing 10
minutes prior to being found and then another 15 after he found
her. By report she stopped seizing spontaneously, but then had
another seizure en route to [**Location (un) 620**]. She received 6 mg of Ativan
and then 1000 PE of Fosphenytoin. She was then transferred to
[**Hospital1 18**] for additional care.
On arrival there was no evidence of seizure activity, however at
approximately 7:00 pm she had left sided arm and leg rhythmic
jerking witnessed by neurology. She was given an additional 2 mg
of ativan which broke the seizure, and then midazolam was
started.
ROS unobtainable given intubation, but family reports no fevers
and no infectious symptoms.
Past Medical History:
- right posterior frontal stroke ([**2182**]) admitted with left arm
and facial weakness
- left PCA stroke in [**1-/2188**] treated at [**Hospital1 112**] with a R hemianopia
and memory deficits
-Breast ca [**2177**] with lymph node pos; s/p 6 wks chemo then
mastectomy, then xrt + chemo; gets q6mo mammograms
-HTN
-PAF
-S/p appy
Social History:
Former telephone company employee; distant tob (quit 20 yrs
ago);
occ etoh. Lives alone, has 3 children.
Family History:
No strokes, MIs.
Physical Exam:
Physical Exam on Admission:
Vitals: afebrile BP 102/50 P 68 SpO2 100% on 50% FiO2 w/ 5 PEEP
General: intubated and minimally responsive.
HEENT: NC/AT
Neck: in hard cervical collar
Pulmonary: ET tube
Cardiac: irregular rhythm
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: intubated and sedated. Grimaces to sternal rub.
Not following commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: unable to perform Doll's due to cervical collar
V: + corneals
VII: + corneals
VIII: unable to assess due to cervical collar.
IX, X: + gag
[**Doctor First Name 81**]: unable to assess.
XII: unable to assess
-Motor: slightly increased tone in the left upper extremity,
some
spontaneous movements of arms/legs b/l and resistance of the
triceps b/l. *there was rhythmic jerking of the left upper and
lower extremities for approxiamtely 5-10 minutes in ED -
resolved
w/ additional benzodiazepines
-Sensory: withdraws and localizes to pain bilaterally in arms
and
legs.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: unable to obtain given intubation
-Gait: unable to obtain given intubation
Pertinent Results:
ADMISSION LABS:
[**2188-12-24**] 06:10PM BLOOD WBC-10.4 RBC-3.81* Hgb-12.1 Hct-35.5*
MCV-93 MCH-31.7 MCHC-34.0 RDW-12.9 Plt Ct-148*
[**2188-12-24**] 06:10PM BLOOD Neuts-91.3* Lymphs-5.8* Monos-2.6 Eos-0.1
Baso-0.1
[**2188-12-24**] 06:10PM BLOOD PT-24.1* PTT-30.4 INR(PT)-2.3*
[**2188-12-24**] 10:21PM BLOOD Glucose-175* UreaN-18 Creat-0.8 Na-141
K-4.1 Cl-109* HCO3-25 AnGap-11
[**2188-12-24**] 10:21PM BLOOD ALT-60* AST-67* LD(LDH)-210 AlkPhos-111*
TotBili-0.8
[**2188-12-24**] 06:10PM BLOOD Calcium-9.4 Phos-3.0 Mg-1.9
[**2188-12-29**] 05:30AM BLOOD %HbA1c-6.0* eAG-126*
[**2188-12-29**] 05:30AM BLOOD Triglyc-63 HDL-52 CHOL/HD-2.5 LDLcalc-65
[**2188-12-28**] 02:29PM BLOOD Ammonia-60
[**2188-12-25**] 04:25AM BLOOD Phenyto-13.5
[**2188-12-24**] 10:21PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2188-12-24**] 06:21PM BLOOD Type-ART pO2-230* pCO2-44 pH-7.35
calTCO2-25 Base XS--1 Comment-GREEN-TOP
Labs during stay:
[**2189-1-1**] 06:26AM BLOOD freeCa-1.39*
Test Result Reference
Range/Units
LEVETIRACETAM (KEPPRA) 32.5 mcg/mL
EEG [**2188-12-24**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of diffuse background attenuation and slowing indicative of a
moderate
encephalopathy with non-specific etiology. There is diffuse
attenuation
of the left hemispheric activity compared to the right which
reflect
both cortical and subcortical dysfunction, which could be seen
in large
ischemic lesions. There are occasional independent left and
right
frontal sharp waves indicative of potential epileptogenic foci
in these
regions. No electrographic seizures are present.
EEG [**2188-12-25**]: This is an abnormal continuous ICU video EEG because
of
diffuse background attenuation and slowing indicative of a
moderate
encephalopathy. There is diffuse attenuation of the left
hemispheric
activity compared to the right which could be due to diffuse
left
hemispheric cortical and subcortical dysfunction such as is seen
in
large ischemic lesions. There are two pushbutton activations for
tremor of the left upper extremity which have no electrographic
correlate. No epileptiform discharges or electrographic seizures
are
present. Compared to the previous day's recording, this EEG
shows
improvement as there is improvement of background frequencies
and a more
representation of normal sleep potentials without clear
epileptiform
discharges.
EEG [**2188-12-26**]: This is an abnormal continuous ICU video EEG because
of
diffuse attenuation and slowing over the left hemisphere
indicative of
diffuse left hemispheric cortical and subcortical dysfunction.
In
addition, the posterior dominant rhythm on the right side,
although
reached 8 Hz, was low voltage and not well-sustained, indicative
of a
mild encephalopathy. Infrequent sharp wave discharges are
present in the
right frontocentral and rarely in the left frontotemporal
region,
consistent with areas of cortical irritability. Compared to
previous
day's recording, this EEG shows improvement as the background
appears
better organized and reaches 8 Hz.
EEG1/7/12: This is an abnormal video EEG monitoring session
because of
continuous focal slowing, focal attenuation and absent alpha
rhythm over
the left hemisphere. These findings are indicative of a focal
cortical
and subcortical structural lesion in the left hemisphere. There
is also
mild diffuse background slowing and epochs of frontal
intermittent
rhythmic delta activity (FIRDA). These findings indicate more
diffuse
mild cerebral dysfunction which is etiologically non-specific.
No
epileptiform discharges or electrographic seizures are present.
Compared to the prior day's recording, background rhythms have
improved
in frequency, and the left hemisphere focal slowing and
attenuation is
slightly less prominent.
EEG [**2188-12-28**]: This is an abnormal continuous EEG monitoring study
because
of background attenuation and slowing over the left hemispheric
most
consistent with diffuse left hemispheric cortical and
subcortical
dysfunction such as is seen in large ischemic lesions. The
background
activity appears normal over the right hemisphere and reaches 9
Hz
posterior dominant rhythm. Two isolated left temporal
epileptiform
discharges are present in the recording indicative of a
potential
epileptogenic focus in this region. No electrographic seizures
are
present. Compared to previous day's recording, this EEG shows
improvement as there are rare epileptiform discharges, there is
less
attenuation of background with faster frequencies appearing in
the left
hemisphere.
CXR [**2188-12-24**]: Appropriate positioning of ET and NG tubes.
Scattered
subsegmental atelectasis and top normal heart size.
MRI [**2188-12-24**]:
IMPRESSION: Encephalomalacic changes seen in the left occipital
lobe and
right frontal lobe as described above, likely represents
sequelae of prior
infarction.
NCHCT [**2188-12-31**]: No evidence of acute hemorrhage or mass effect.
Left occipital cystic encephalomalacia secondary to old infarct.
EKG [**2188-12-24**]: Atrial Fibrillation
Labs at the Time of Discharge
[**2189-1-1**] 05:20AM BLOOD WBC-5.2 RBC-3.36* Hgb-10.5* Hct-31.4*
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.3 Plt Ct-175
[**2189-1-1**] 05:20AM BLOOD PT-11.0 INR(PT)-1.0
[**2189-1-1**] 05:20AM BLOOD Glucose-91 UreaN-18 Creat-0.7 Na-141
K-3.6 Cl-102 HCO3-34* AnGap-9
[**2188-12-31**] 05:24AM BLOOD ALT-53* AST-41* AlkPhos-95 TotBili-0.5
[**2189-1-1**] 05:20AM BLOOD Calcium-10.5* Phos-2.5* Mg-1.9
[**2188-12-29**] 05:30AM BLOOD %HbA1c-6.0* eAG-126*
[**2188-12-29**] 05:30AM BLOOD Triglyc-63 HDL-52 CHOL/HD-2.5 LDLcalc-65
PTH: Pending
Brief Hospital Course:
This is the case of 79 year-old woman with a hx of a fib and two
prior strokes transferred from [**Location (un) 620**] after being found at home
seizing, with generalized convulsions lasting up to 25 minutes.
Had recurrent seizure activity at [**Location (un) 620**] which was treated with
6 mg of Ativan and 1000mg of Fosphenytoin. She was intubated and
transferred to [**Hospital1 18**] for further care. Here she received an
additional 2mg ativan and 5mg/kg phenytoin for L arm and leg
shaking and was also started on a midazolam drip. She was
admitted to the neuro-ICU.
.
ICU course:
MRI head showed no acute infarct. There were several areas of
FLAIR hyperintensity
in the R posterior frontal lobe as well as periventricular
areas, and a large area of gliosis in L occipital cortex
consistent with her prior strokes. EEG showed significant
attenuation over the L hemisphere and some occasional R
frontocetral sharp waves without any electrographic seizures.
Midazolam drip was weaned off over the night of [**12-24**]. On exam she
was moving all extremities spontaneously with intact brain stem
reflexes but was not opening her eyes spontaneously or following
commands.
.
During the day on [**12-25**] she was noted to have several brief
episodes of low amplitude L arm and leg shaking. EEG again
showed R frontocentral sharp waves and some delta slowing but no
clear electrographic seizures. Clinical picture appeared more
consistent with tremor rather than a true seizure. Dilantin was
stopped, and she was loaded with Keppra 1000mg IV and started on
Keppra 1000mg [**Hospital1 **]. She remained seizure free.
.
On [**12-26**] she was beginning to wake up opening eyes spontaneously
and following commands. She was extubated without difficulty.
She subsequently remained awake and alert but was somewhat
confused and disoriented, saying she was in [**Hospital1 8**] at
"[**Hospital **] Hospital" and thought date was [**7-7**].
.
On [**12-27**] she was transferred to the neurology floor. Upon transfer
she remained confused and also became somewhat agitated and
paranoid, accusing staff of poisoning her. Oriented to hospital
but not date, saying she is here because she is "insane." UA and
CXR were repeated. Her coumadin was held for an INR of 5.2.
.
Floor course:
Ms. [**Known lastname **] was transferred to the floor. She no longer had
periods of active delirium and frank agitation. She remained
afebrile and hemodynamically stable.
- She was originally extubated to nasal cannula. Her
supplemental oxygen requirement was slowly weaned off.
- Her mental status cleared over the course of her stay on the
floor, particularly in terms of her level of orientation. There
were never any real language or speech deficits.
- She likely had several reasons to explain her delirium during
her stay here, including postICU delirium, post ictal changes,
the initiation of an AED, long standing baseline dementia, etc.
There were no major metabolic abnormalities on her routine blood
work, but her UA did appear consistent with a UTI. She was
treated with three days of IV ceftriaxone, and her cultures
ultimately returned back negative.
- Her INR wildly fluctuated during her stay, upto as high as ~6
(at which point warfarin was held), and then as low as 1.5 (at
which point warfarin was restarted, and she was initiated on a
lovenox bridge). She remains on a lovenox bridge to therapeutic
INR on coumadin.
- Two days prior to her discharge, she was noted to have the
development of left deltoid weakness, associated with a patchy
area of sensory loss over the left shoulder. We obtained an MRI
C-spine and MRI Head which showed no acute changes or unstable
spine findings. Her weakness improved on the day of her
discharge, but was still present.
- The patient was noted to have an elevated ionized calcium
level on the days prior to her discharge, with relatively low
phosphate levels. Her PTH levels is pending at this time. This
level does not appear to be high enough to contribute to her
altered mental status, but needs to be followed up in either
case.
- She remained rate controlled in terms of her atrial
fibrillation.
- Code Status/Contact: Full [**Name2 (NI) 7092**], HCP [**First Name8 (NamePattern2) **] [**Name (NI) 69797**],
[**Telephone/Fax (1) 69798**])
TRANSITIONAL ISSUES
- Please ensure that the patient follows up with her PCP and The
Neurology Department at [**Hospital1 18**]
- Please continue [**Hospital1 **] lovenox dosing SQ until the patient's INR
reaches the goal of 2.0 to 3.0. This may require adjustment of
her warfarin daily dose
- The patient was noted to have an elevated ionized calcium
level on the days prior to her discharge, with relatively low
phosphate levels. Her PTH levels is pending at this time. Please
consider a work up for primary hyperparathyroidism
- Please continue keppra 1g [**Hospital1 **] indefinitely. We did attempt to
wean down to 750mg [**Hospital1 **], but this did result in an acute
worsening in the frequency of epileptiform discharges.
- Do not hesitate to contact me with any further questions (Ph:
[**Telephone/Fax (1) 59691**], [**Pager number 69799**])
- Can consider an outpatient EMG to follow up her left deltoid
weakness, to verify findings of a possible C5 radiculopathy.
Medications on Admission:
Warfarin 3 mg daily
Aspirin 81 mg daily
Toprol 50 mg daily
Atorvastatin 10 mg DAILY
Arimidex
Losartan
Lasix 80 mg daily
MVI, B12
Lipitor 80 mg daily
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day): UNTIL INR reaches goal of 2.0-3.0.
4. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
5. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Status epilepticus
Paroxysmal atrial fibrillation
History of ischemic strokes x 2
Hypertension
Hyperlipidemia
Hypercalcemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during this stay. You
were admitted to [**Hospital1 69**] on [**2188-12-24**]
after at least two-three prolonged seizures that occurred at
home. These occur due to abnormal electrical activity in your
brain, which can happen after a history of ischemic strokes. An
MRI of your brain showed no abnormalities other than your two
previous strokes, and did not identify any new tumors, bleeding
or evidence of new strokes. We believe the most likely cause of
your seizure was the scar tissue in the brain from one of these
strokes. We started you on a medication called KEPPRA or
LEVETIRACETAM to reduce the risk of seizures in the future. We
ask that you continue to take this medication indefinitely. We
have been able to arrange follow up for you to see your primary
care physician, [**Name10 (NameIs) 3**] well as one of the doctors at the Department
of Neurology here at [**Hospital1 69**].
- Please take your medications as prescribed below.
- It is important that you follow up with your follow up
appointments.
- We were able to arrange for you to receive a short stint of
rehabilitation at [**Hospital **] REHAB. Here, they will provide you
the rehabilitation that you will need to remain safe at home.
- Do not hesitate to contact us if you have any further
questions.
- Please come to the ED should you experience of the following
below listed unexplained symptoms
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
Please follow up with your primary care physician
[**Name Initial (PRE) 3390**]: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 69800**]
([**Telephone/Fax (1) 69801**]
Friday, [**2189-1-2**] at 9:30a
Please follow up with the Department of Neurology at the [**Hospital1 18**]
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name 10314**]
[**Hospital Ward Name 23**] Building, [**Location (un) 858**]
[**Location (un) 830**], [**Location (un) **], MA: [**Numeric Identifier **]
Phone:[**Telephone/Fax (1) 3506**] Date/Time:[**2189-2-25**] 4:00
Completed by:[**2189-1-2**]
ICD9 Codes: 5990, 4019 |
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