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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3300
} | Medical Text: Admission Date: [**2136-7-24**] Discharge Date: [**2136-7-29**]
Date of Birth: [**2071-11-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Keflex
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
pre-syncope
Major Surgical or Invasive Procedure:
Aortic valve replacement 25mm tissue [**7-25**]
History of Present Illness:
Mr. [**Known lastname 1007**] is a 64 year old with a five year history of aortic
stenosis. He is physically active without symptoms, but he does
describe one episode of pre-syncope 3 years ago while driving
home from work without loss of conciousness.
Past Medical History:
aortic stenosis
hypertension
hyperlipidemia
detached retina and cataracts on left
Past Surgical History:
repair of left retina and cataracts
Left TKR
Right knee surgery for meniscus tear
appendectomy, remotely
Social History:
He lives with his wife and has three grown children. He works
in sales and coaches basketball. He denies smoking and reports
drinking ten to twelve beers per week.
Family History:
Both Mr. [**Known lastname **] mother and sister have aortic stenosis.
Physical Exam:
Pulse: 60 regular Resp: 16 O2 sat:
B/P Right: Left: 144/90
Height: 6'1" Weight: 215lb
General: NAD, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x] right pupil round and reactive to
light, left fixed s/p multiple surgeries
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [**4-15**]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left:
radiation of cardiac murmur, +thrill on left
Discharge:
VS: T: 98.3 HR: 64 SR BP: 126/64 Sats: 94% RA WT: 101.4 kg
General: 64 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: clear breath sounds throughout
GI: benign
Extr: warm no edema
Incision: sternal clean, dry intact
Neuro AA& O MAE
Pertinent Results:
Date/Time: [**2136-7-25**]
Test Type: TEE (Complete)
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: *3.8 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - Peak Gradient: *86 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 54 mm Hg
Aortic Valve - LVOT diam: 2.3 cm
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All
four pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Simple atheroma in ascending aorta. Focal calcifications in
ascending aorta. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. [**Male First Name (un) **] of the mitral chordae (normal
variant). No resting LVOT gradient. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
Conclusions
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person
of the results in the operating room at the time of the study.
POST BYPASS The patient is atrially paced. There is normal
biventricular systolic function, There is a bioprosthesis in the
aortic position. It appears well seated. The leaflets cannot be
well seen. No aortic regurgitation isn appreciated. The maximum
pressure gradient across the aortic valve is 32 mmHg with a mean
of 15 mmHg at a cardiac output near 7 liters/minute. The mitral
regurgitation is improved - now trace to mild. The thoracic
aorta appears intact after decannulation.
CXR:
[**2136-7-28**]: Enlargement of the cardiac silhouette is stable since
recent
postoperative study but somewhat increased from the first
postoperative
radiograph of [**2136-7-25**], suggesting pericardial effusion.
Bibasilar
atelectasis has worsened in the interval and is accompanied by
small bilateral pleural effusions. Retrosternal and subcutaneous
gas on the lateral view near the sternal wires is probably
related to recent sternotomy.
IMPRESSION:
1. Worsening bibasilar atelectasis. Small bilateral pleural
effusions.
2. Widened cardiac silhouette, possibly representing
postoperative
pericardial effusion.
Brief Hospital Course:
On [**7-25**] Mr. [**Known lastname 1007**] [**Last Name (Titles) 1834**] an aortic valve replacement.
Please see the operative note for details. He tolerated the
procedure well and was transferred in critical but stable
condition to the surgical intensive care unit. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable, weaned from inotropic and vasopressor support. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. He did develop atrial fibrillation and
was started on amiodarone converted to sinus rhythm with no
further ectopy. His ACE was restarted on discharge. He was
transfused 1 unit of PRBC for HCT of 22.9 to a HCT of 23.7. By
the time of discharge on POD5 the patient was ambulating
independentanly, the wound was healing and pain well controlled
with oral analgesics. The patient was discharged home with VNA
in good condition with appropriate follow up instructions.
Medications on Admission:
Lipitor 40mg daily Carvedilol 6.25mg [**Hospital1 **] Lisinopril 40mg daily
Omeprazole 20mg daily Aspirin 81mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily): take for 30 days.
Disp:*30 Tablet(s)* Refills:*2*
6. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day for 5 days: take
with lasix.
Disp:*5 Capsule, Extended Release(s)* Refills:*0*
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): take 400mg (2 tabs) x 7 days then 200 mg daily.
Disp:*30 Tablet(s)* Refills:*2*
10. 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*
11. ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for pain: take with food and water.
12. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
13. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
aortic stenosis
hypertension
hyperlipidemia
detached retina and cataracts on left
Past Surgical History:
repair of left retina and cataracts
Left TKR
Right knee surgery for meniscus tear
appendectomy remotely
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema- trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2136-8-7**] 10:15
[**Hospital Unit Name 4081**]
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD:[**Telephone/Fax (1) 170**] Date/Time:[**2136-8-23**]
1:00
[**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) 656**] [**8-30**] at 12:30pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 1112**] R. [**Telephone/Fax (1) 79975**] in [**5-15**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2136-7-29**]
ICD9 Codes: 4241, 9971, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3301
} | Medical Text: Unit No: [**Numeric Identifier 61005**]
Admission Date: [**2173-4-17**]
Discharge Date: [**2173-5-2**]
Date of Birth: [**2173-4-17**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 13950**] is the 2.365
kilogram product of a 33 and [**6-22**] week gestation born to a 28-
year-old G3/P now 2 mom. Prenatal screens of A positive,
antibody negative, RPR nonreactive, rubella immune, hepatitis
surface antigen negative, GBS positive in last pregnancy.
PAST OBSTETRICAL HISTORY: Notable for previous preterm C-
section delivery due to arrest of descent. Current pregnancy
complicated by premature rupture of membranes since [**2173-4-1**]. Mother was beta complete. The decision was made to
proceed with cesarean section today as infant was almost 34
weeks and increasing concern and risk of chorioamnionitis at
this point. Surgery notable for multiple adhesions. Required
only blow-by O2 and routine care in the OR. Apgar's were 8
and 9.
PHYSICAL EXAMINATION ON ADMISSION: 2.365 kilograms (60th
percentile), length 44.5 cm (50th percentile), head
circumference 32.25 cm (75th percentile). Anterior fontanel
soft/flat. Red reflex deferred. Palate intact. Minimal
intercostal retractions. Breath sounds clear and equal.
Regular rate without rhythm. Peripheral pulses of 2+;
including femoral's. Abdomen benign without
hepatosplenomegaly. No masses. Hips deferred. Normal female
external genitalia for gestational age. Skin pink and well
perfused. Normal tone and strength for gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
RESPIRATORY: Cloie has been stable in room air throughout her
hospital course.
CARDIOVASCULAR: Has been stable without issue.
FLUIDS, ELECTROLYTES AND NUTRITION: Was initially started on
60 cc/kg per day of D-10-W. Advanced to full enteral feedings
by day of life #4. Is currently taking ad lib feedings of 150
cc/kg per day of breast milk or Special care similac 24
calories. Her discharge weight is 2515 gms.
HYPERBILIRUBINEMIA: Her peak bilirubin was on day of life #4
at 13.2/0.3. Received phototherapy, and her rebound bilirubin
was within normal limits.
HEMATOLOGY: Hematocrit on admission was 47.3. She did not
require any blood transfusions during this hospital course.
INFECTIOUS DISEASE: CBC and blood culture obtained on
admission. CBC was benign. Blood culture remained negative at
48 hours, at which time ampicillin and gentamicin were
discontinued.
NEUROLOGY: The infant has been appropriate for gestational
age.
AUDIOLOGY: A hearing screen was performed prior to
discharge and passed in both ears.
PSYCHOSOCIAL: A social worker has been involved with the
family and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52383**] (telephone
number [**Telephone/Fax (1) 61006**])
CARE RECOMMENDATIONS:
1. Feedings at discharge: Continue ad lib feedings; breast
milk 24-calorie concentrated with Similac powder or
Similac 24-calorie.
2. Medications: None.
3. Car seat position screening was performed, and the infant
passed.
4. State newborn screen has been sent per protocol and has
been within normal limits.
IMMUNIZATIONS RECEIVED: The infant received the first
hepatitis B vaccine on [**2173-4-27**].
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 gestation; (2) born between 32 and 35 weeks with 2 of
the following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings; or (3) with chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life)
immunization against influenza is recommended for household
contacts and out of home caregivers.
DISCHARGE DIAGNOSES:
1. Premature infant born at 33 and 6/7 weeks.
2. Status post rule out sepsis with antibiotics.
3. Mild hyperbilirubinemia.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2173-5-1**] 01:05:59
T: [**2173-5-1**] 08:46:16
Job#: [**Job Number 61007**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3302
} | Medical Text: Admission Date: [**2128-2-4**] Discharge Date: [**2128-2-7**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 22 year old woman with diabetes type I since [**2120**] who
presents with back pain and chest pain since this morning. She
reports that the pain is like her usual back pain, is mid
thoracic and equal on both sides, and does not radiate. It was
severe this morning but is gradually better now. She also
reports some chest pressure which was associated with shortness
of breath and nausea. She vomited once in the ED waiting room
and once in the ED. She reports that she was able to eat
normally today and took her regular dose of glargine last night.
She is not sure why her sugars are high (it was 183 this
morning), but thinks they get higher when she has pain. She
denies fevers but had some chills. She thinks she may be getting
an upper repiratory infection.
.
In the ED she was found to have an elevated anion gap to 23 and
a blood sugar of 390. She was hydrated with 3L NS (the third
with potassium) and started on an insulin gtt at 5/hour which
was rapidly weaned when her gap closed. She was given 2u regular
insulin SQ and admitted to medicine.
Past Medical History:
- Diabetes Type I diagnosed in [**2120**] after her first pregnancy.
Most recent Hgb A1C 10.4 % ([**7-/2125**])
- Hyperlipidemia
-S/P MVA [**5-3**] - lower back pain since then. + back muscle spasm
treated with tylenol.
- Goiter
- Depression
- Multiple DKA admissions
- G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
shots
- Genital Herpes
Social History:
The patient was born and raised in [**Location (un) 669**], where she lived in
house with siblings, mother, grandmother, and [**Name2 (NI) 12232**] when
growing up. Currently lives in her own apartment. Attended job
corp training following h.s., but presently unemployed feeling
too overwhelmed between diabetes care and caring for three year
old her son. She has a boyfriend. She is close to mother,
sister, and [**Name2 (NI) 12232**] who live nearby. Denies abuse in childhood
or adulthood. She denies tobacco, alcohol or illicit drug use.
Family History:
GM with Type I diabetes. Otherwise non-contributory. Relatives
with "acid in blood" not related to diabetes.
Physical Exam:
PE: V: T97.8 P108 BP 139/87 R20 99% RA
Gen: No acute distress
HEENT: pupils with colored contacts. [**Name (NI) 3899**]. OP clear
Resp: CTA bilaterally
CV: tachy nl s1s2 no MGR
Abd: Soft NTND +BS
Ext: no edema
Neuro: A+Ox3, but not forthcoming with history. Able to move
extremities well.
.
Pertinent Results:
[**2128-2-4**] 01:10PM BLOOD WBC-11.9*# RBC-4.90# Hgb-14.2# Hct-42.5#
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.3 Plt Ct-179
[**2128-2-7**] 03:57AM BLOOD WBC-7.0 RBC-4.07* Hgb-11.9* Hct-34.2*
MCV-84 MCH-29.1 MCHC-34.7 RDW-13.5 Plt Ct-187
[**2128-2-5**] 06:39AM BLOOD Neuts-82.0* Bands-0 Lymphs-14.7*
Monos-2.5 Eos-0.8 Baso-0.1
[**2128-2-4**] 01:10PM BLOOD Glucose-390* UreaN-14 Creat-1.0 Na-138
K-4.0 Cl-98 HCO3-17* AnGap-27*
[**2128-2-7**] 03:57AM BLOOD Glucose-73 UreaN-5* Creat-0.6 Na-135
K-3.7 Cl-104 HCO3-21* AnGap-14
[**2128-2-5**] 12:01AM BLOOD CK(CPK)-69
[**2128-2-4**] 01:10PM BLOOD ALT-28 AST-40 CK(CPK)-89 AlkPhos-86
Amylase-50 TotBili-0.8
[**2128-2-5**] 12:01AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2128-2-4**] 01:10PM BLOOD CK-MB-2 cTropnT-<0.01
[**2128-2-4**] 10:24PM BLOOD %HbA1c-13.4* [Hgb]-DONE [A1c]-DONE
.
CXR [**2-4**]: This examination is normal without cardiomegaly,
vascular
congestion, consolidations, effusions, or hilar/mediastinal
enlargement. No change from more satisfactory study [**2127-12-22**].
.
KUB [**2-6**]: No evidence of obstruction or pneumoperitoneum.
Brief Hospital Course:
A/P: 22F with type I diabetes and DKA, with complaints of
abdominal cramping.
.
#) DKA: Unclear inciting event, but no clear infection source
and by history was taking her usual dose insulin and diet.
However, had son that was sick at home and patient complained of
abdominal cramping. Her anion gap closed while in the ED but
reopened the day after admission to the MICU after having
multiple loose stools and episodes of vomiting. Her insulin drip
was restarted. She had a KUB to rule out obstrucion [**1-2**] to her
episodes of vomiting, which was negative. Afterwards, she was
started on Reglan. Her gap closed again, she was tranisitioned
back to her home regimen of glargine. She will follow-up with
[**Last Name (un) **] as an outpatient. We suspect that she has a viral
gastrointestinal illness.
.
#) chest pain - Initially had complaints of chest discomfort on
presentation but had no EKG changes and her cardiac enzymes were
negative. She was continued on aspirin and her ACEI.
.
#) back pain - Longstanding by her report and by previous notes.
Likley secondary to MVA. She was given dilaudid PRN for pain and
tolerated it well.
.
#) depression - her prozac was held at her request because she
felt it was making her apin worse.
.
#) Hypertension: her lisinopril dose was increased from 10 mg to
20 mg daily for SBPs over 140. She was discharged with a
prescription for 20 mg daily lisinopril.
.
She was discharged home in [**Last Name (un) 2677**] condition with [**Last Name (un) **]
follow-up.
Medications on Admission:
Glargine 29 units QHS
Fluoxetine 20 mg PO DAILY
Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Docusate Sodium 100 mg PO BID
Tamsulosin 0.4 mg PO HS
Novolog 1 unit for every 14 g carbohydrates.
Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO at bedtime.
7. medications
Take your insulin as directed by the [**Last Name (un) **] Diabetes Center
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Diabetes Mellitus
Hypertension
Discharge Condition:
Good. Tolerating regular diet. Blood sugars normalized.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for diabetic ketoacidosis (DKA)
likely secondary to a viral gastrointestinal illness. Your blood
sugars were well controlled on insulin drip and then on your
regular insulin regimen. Your blood acid level also quickly
returned to [**Location 213**].
Your lisinopril was increased from 10 mg daily to 20 mg daily.
Continue taking this dose until seen by your doctor. You should
continue to take all other medications as previously prescribed.
Try to drink lots of fluids and eat full meals.
Contact a physician for fever > 101.5, persistent nausea or
vomiting, increasing abdominal pain, chest pain, shortness of
breath, productive cough, or any other concerns.
Followup Instructions:
Please follow-up with your [**2128-2-9**] at 1:30 PM at [**Last Name (un) **]
Diabetes, Dr. [**First Name (STitle) 4375**] [**Name (STitle) 3617**]. His phone number is [**Telephone/Fax (1) 12068**] for
any concerns or to change your appointment
ICD9 Codes: 2724, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3303
} | Medical Text: Admission Date: [**2158-3-10**] Discharge Date: [**2158-3-15**]
Date of Birth: [**2103-5-7**] Sex: F
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: This is a 54-year-old female
with a history of mild asthma, who has had a recent upper
respiratory infection for three weeks prior to admission who
presented to the Emergency Department with an asthma
exacerbation. The patient reported that her daughter had
been ill with a upper respiratory infection, and she herself
had a runny nose and a cough productive of yellow sputum for
the past 2-3 weeks. The cold had been getting worse and she
was becoming progressively short of breath. Came to the
Emergency Department.
While in the Emergency Department, the patient received
continuous nebulizers, IV Solu-Medrol, and Heliox without
significant improvement in her respiratory status, and
arterial blood gases performed which revealed a pH of 7.27,
pCO2 of 66, and pO2 of 142 on face mask with 70% O2. The
patient was appearing too tired, and was intubated, placed on
assist control 500/12/5 with 100% FIO2 and sedated with
propofol. She was admitted to the MICU for further
management.
PAST MEDICAL HISTORY:
1. Asthma. No prior histories of intubations, no prior
hospitalizations, only on albuterol. Had not used her MDI
for the past 1-2 years.
2. Hypertension.
3. Hypercholesterolemia.
4. Status post hysterectomy.
MEDICATIONS ON ADMISSION:
1. Uniretic 15/25 one tablet po q day.
2. Albuterol prn.
ALLERGIES: Lipitor causes rash.
SOCIAL HISTORY: Lives with her husband and 13-year-old
daughter. Denies history of tobacco use. Occasionally
alcohol use. Exercise capacity: Is able to climb four
flights of stairs without significant shortness of breath.
FAMILY HISTORY: Son died of an asthma exacerbation at age
23. He was incarcerated but sent to the hospital because of
severe asthma. Daughter also with mild persistent asthma.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.7, blood
pressure 250/150, repeated at 140/96, heart rate 148,
repeated at 120s, respiratory rate 26, and 100% on 70% face
mask. In general, middle-aged woman in respiratory distress.
HEENT: Oropharynx is clear, unable to assess jugular venous
pressure. Lungs: Decreased air movement throughout with
diffuse wheezing. Abdomen is soft, obese. Extremities: No
clubbing, cyanosis, or edema.
LABORATORIES ON ADMISSION: White count 15.8, hematocrit 40,
platelets 456. Sodium 136, potassium 8.1, chloride 100,
bicarb 25, BUN 11, creatinine 0.7, glucose 163.
Chest x-ray revealed no infiltrate, no edema. Chest x-ray #2
showed ET tube in place.
HOSPITAL COURSE:
1. Pulmonary: Patient was admitted to the Medical Intensive
Care Unit. Was continued on steroids. Continued with
nebulizers and MDIs. The patient was extubated on the
morning of [**3-12**] at 11 am. The patient was transferred to
the floor and feeling much better and almost to her baseline.
She had persistent mild cough and requiring nebulizers q4-6h.
During her course on the floor, the patient was tapered to 40
mg po q day of prednisone, continued on coffee suppressant
medications, and required less frequent nebulizer treatments
and was using MDIs with a spacer with good technique.
On the day of discharge, the patient was ambulating without
significant shortness of breath. Had an O2 saturation of 96%
on room air, peak flow of 300.
2. Hypertension: The patient was hypertensive during her
MICU and floor stay. Her dose of antihypertensive
medications were increased. She was discharged on Uniretic
at two tablets po q day with a dose of hydrochlorothiazide 25
mg and Univasc 30 mg q day.
3. Endocrine: The patient was maintained on regular
insulin-sliding scale while on steroids in the hospital. On
the day of discharge, she had required no doses of insulin
and this was discontinued at the time of discharge.
DISPOSITION: The patient was discharged home in stable
condition to followup with her primary care provider this
week. She will be started on nebulizers at home. On the day
of discharge, her respiratory therapist worked with her and
showed her how to use the nebulizer machine that she has at
home for her daughter. She was given the telephone number
for the Respiratory Therapy Department at [**Hospital1 **] Hospital to call with any further questions after
she is discharged home.
DISCHARGE MEDICATIONS:
1. Uniretic 12.5/15 two tablets po q day.
2. Prednisone 40 mg po q day x2 days, 20 mg po q day x3 days,
10 mg po q day x3 days, then discontinue.
3. Albuterol and Atrovent MDI 1-2 puffs inhaled q4h prn
shortness of breath.
4. Albuterol nebulizers one vial inhaled q4-6h prn shortness
of breath.
5. Tessalon Perles, one po tid swallow whole prn cough.
6. Robitussin AC [**5-27**] mL po q4-6h prn cough.
DISCHARGE DIAGNOSES:
1. Asthma exacerbation.
2. Hypertension.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4704**], M.D. [**MD Number(1) 4705**]
Dictated By:[**Last Name (NamePattern1) 9422**]
MEDQUIST36
D: [**2158-3-15**] 21:27
T: [**2158-3-16**] 06:17
JOB#: [**Job Number **]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3304
} | Medical Text: Admission Date: [**2166-2-1**] Discharge Date:
Date of Birth: [**2166-2-1**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 62292**], a 32-4/7 week of gestation
twin A admitted with apnea and respiratory distress. Maternal
history: 28-year-old gravida II, para II woman with prenatal
labs noted for O positive, strep antibody test negative, RPR
nonreactive, rubella immune, GBS unknown. Antenatal history:
Estimated date of delivery [**Doctor First Name **] 27, [**2165**] for estimated
gestational age 32-4/7 weeks at delivery. Spontaneous
monochorionic di-amniotic twin gestation. Pregnancy was
notable for elevated nuchal thickness in twin B on early
ultrasound that subsequently normalized. Fetal surveys were
otherwise normal. Mother presented with spontaneous
contraction and positive fetal fibronectin 2 weeks ago and
was treated with betamethasone and terbutaline. She
progressed to spontaneous vaginal delivery under epidural
anesthesia, rupture of membranes 9 hours prior to delivery
and yielded clear amniotic fluid. Intrapartum fever to 99.5
degrees was noted with no other clinical evidence of
chorioamnionitis. Intrapartum antibiotic was started 19 hours
prior to delivery. Neonatal course: Infant was hypotonic and
apneic at delivery. He was orally and nasally bulb suctioned.
Dried and tactile stimulation was provided. She had
persistent hypotonia and intermittent apnea and received
brief bag mask ventilation. Heart rate was well maintained
throughout. Apgars were 5 at one minute, 7 at five minute and
7 at 10 minutes.
PHYSICAL EXAMINATION: A female infant on the warmer, birth
weight 2080 grams. Head circumference 30 cm. Length 43 cm.
Vital signs: Temperature 98.5, heart rate 158, respiratory
rate 60 to 70s, blood pressure 60/30 with a mean blood
pressure of 39, oxygen saturation 94% in room air. HEENT:
Anterior fontanelle open and flat, nondysmorphic, palate
intact. Neck and mouth normal. Normocephalic. Mild nasal
flaring. Nasal CPAP in place. Chest: Mild intercostal
retraction. Good breath sounds bilaterally. No adventitious
sounds. CVS: Well perfused, sated and regular. Femoral pulses
normal. S1, S2 normal. No murmur. Abdomen soft, nondistended,
no organomegaly, no masses. Bowel sounds active. NSHNC
umbilical cord. Genitalia: Normal female genitalia. CNS:
Active, alert, responds to stimuli. Tone slightly decreased
in symmetrical distribution. Moves all extremities
symmetrically, pulses intact. Face is symmetrical. Alimentary
system. Musculoskeletal system: normal spine, limbs, hips,
clavicles. Dextrostix 66.
IMPRESSION: A 32-4/7 week gestational infant who was
admitted due to respiratory distress, hypotonia and apnea.
The possibility of maternal magnesium sulfate toxicity. The
remainder of neurological examination normal.
REVIEW OF HOSPITAL COURSE BY SYSTEMS: Respiratory system:
She was initially placed on nasal CPAP which she continued to
have until day of life #2. On day of life #2 a trial of room
air was given and she was started on caffeine. She continued
to be doing well on room air and caffeine was discontinued on
day of life 6. She continued to have occasional spells with
bradycardia. Some of them were quick self resolved and others
needed stimulation and on day of transfer she still continued
to have these spells.
Cardiovascular system: No issues. Her blood pressures
remained stable. She had normal first and second heart sounds
with no additional sounds, no murmur. Femoral pulses equal
and brachial pulses 2+.
Fluid, electrolytes and nutrition: She was n.p.o. for the
first 2 days of life and was on IV fluids. Feeds were started
with Special Care 20 calories per ounces on the second day of
life and were gradually advanced. She received full feeds at
140 ml per kg per day of Special Care 20 on day of life 7 and
then the calories were advanced. At the time of transfer she
is on Special Care 24 kilocalorie per ounce at 140 cc per kg
per day and she is on p.o. and p.g. feedings. Her last set of
electrolytes were done on day of life 6. Sodium 136,
potassium 5.7, chloride 105, and bicarb 20.
Gastrointestinal: Normal gastrointestinal course. Her maximum
serum bilirubin was total 9, direct 0.4, and she was started
on phototherapy on day of life 3 to 4. Her last bilirubin was
5.7 total and 0.4 direct. At the time of transfer she has
normal abdominal wall, normal umbilical cord. There is no
hepatosplenomegaly, nontender, nondistended and bowel sounds
are present.
Hematology: Her initial CBC showed white count of 13K with 41
polys, 0 bands and 55 lymphocytes. Hematocrit 49.5 and
platelets 257K.
Infectious disease: An initial blood culture was done at the
time of admission and she was started on ampicillin and
gentamycin. The blood culture was negative at 48 hours and
antibiotics were discontinued. She has Desitin which was
applied to the diaper area.
Neurology: She has normal tone. Active and alert. Normal
newborn reflexes.
Sensory: Hearing screen: not performed. Will be conducted at
[**Hospital1 **] SCN.
Ophthalmology: Not examined. Patient is more than 32 weeks of
gestation and no prolonged supplemental oxygen adn clinical
stable.
Psychosocial: The [**Hospital1 69**] social
worker was involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **].
CONDITION AT TIME OF TRANSFER: Stable.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 3765**]. Name of
primary pediatrician:
CARE RECOMMENDATIONS: Feeds at discharge: Similac Special
Care 24 kilocalories per ounce at 140 ml per kg per day.
Medications: None.
Car Seat Position Screening: To be performed at [**Hospital1 **] SCN.
State Newborn Screening Status: The newborn screen was sent
on [**2166-2-3**] which showed increased 17-
hydroxyprogesterone. Repeat newborn screen was sent on
[**2166-2-7**].
Immunizations: She received hepatitis B vaccine on [**2166-2-3**].
Immunizations recommended:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 3 criteria: 1) Born at less than 32 weeks, 2)
Born between 32 and 35 weeks with 2 of the following: Day
care during RSV season, a smoker in the household,
neuromuscular disease, airway abnormality or school age
siblings, or 3) with chronic lung disease.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life immunization against influenza is
recommended for household contact and out of home care-
givers.
Follow up appointment: as per arrangement at time of discharge
from [**Hospital3 3765**] SCN.
DISCHARGE DIAGNOSES:
1. Prematurity at 32-4/7 weeks of gestation, twin A.
2. Initial mild transient respiratory distress.
3. Rule out sepsis.
4. Apnea of prematurity.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Name8 (MD) 67568**]
MEDQUIST36
D: [**2166-2-12**] 16:30:06
T: [**2166-2-12**] 17:33:59
Job#: [**Job Number 71419**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3305
} | Medical Text: Unit No: [**Numeric Identifier 74067**]
Admission Date: [**2137-8-15**]
Discharge Date: [**2137-8-19**]
Date of Birth: [**2137-8-15**]
Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname 74068**] was a 2.33 kg product of a 35
week gestation born to a 38-year-old gravida 3, para 2 now 3
mother. Prenatal [**Name2 (NI) **] were A positive, antibody negative,
hepatitis surface antigen negative, RPR nonreactive, rubella
immune and GBS unknown. Maternal history notable for sinus
tachycardia, treated prior to pregnancy with atenolol.
Maternal obstetric history was notable for 2 prior cesarean
sections. This pregnancy complicated by episodes of preterm
contractions, not requiring intervention. Fetal survey
normal. Amniocentesis declined. Mother presented today with
progressive preterm contractions, early in labor. Due to
advanced gestational age was taken for repeat cesarean
section. Apgars were 8 and 9.
PHYSICAL EXAMINATION ON DISCHARGE: Infant active with good
tone. Anterior fontanelle open and flat, pink, well
perfused. No murmur auscultated. Comfortable in room air
with lungs clear and equal. Abdomen soft. Active bowel
sounds. Voiding and passing meconium. Infant stable in open
crib, appropriate for gestational age. RR present b/l. Hips
stable/symm.
HISTORY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: Infant
has been stable on room air since admission. Mild grunting in
first few hrs of life, resolved w/o intervention.
CARDIOVASCULAR: No issues.
FLUID AND ELECTROLYTES: Birth weight was 2.33 kg., discharge
weight is 4lb 10 oz (2105 gm). Infant was initially ad-lib
feeding,
Isomil 20 calorie with presentation of coffee-ground spit x3,
remained n.p.o. KUB x2 performed; wnl. No further emesis for
over 48 hrs prior to d/c.
HEMATOLOGY: Hematocrit on admission was 49.5. Bili 10.2 on
[**8-18**]. Bili rechecked [**8-19**] (at 52 hrs of life): 12.2 wnl.
INFECTIOUS DISEASE: CBC and blood culture obtained. CBC was
benign. Blood cultures remained negative as of d/c (> 72 hrs)
NEUROLOGIC: Infant has been appropriate for gestational age.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home. D/c wt 4 lb 10 oz (2105 gm)
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5699**], [**Location (un) 1468**], MA.
CARE RECOMMENDATIONS: Continue ad-lib feeding Isomil 20
calorie. Medications: Not applicable. Car seat position
screening: Infant was screened for 90 minute screening. D/c
contingent on baby passing car seat testing on [**8-19**].
State newborn screen sent [**8-18**].
Hep B vaccine given [**8-19**].
Passed BAERS b/l.
Recommend f/u with PMD in one day.
DIAGNOSIS LIST:
1. Prematurity at 35 0/7 GA
2. TTN -- resolved
3. Coffee ground emesis -- resolved.
4. Sepsis eval w/o abx -- resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 71110**], MD [**MD Number(2) **]
Dictated By:[**Last Name (NamePattern1) 73482**]
MEDQUIST36
D: [**2137-8-17**] 23:29:26
T: [**2137-8-18**] 03:55:20
Job#: [**Job Number 74069**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3306
} | Medical Text: Admission Date: [**2184-4-15**] Discharge Date: [**2184-4-17**]
Date of Birth: [**2135-3-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall from ?30ft
Major Surgical or Invasive Procedure:
emergent left craniotomy
History of Present Illness:
Per ER staff pt reportedly working on roof and fell. Unclear
if he was symptomatic prior to fall. Intubated and brought to
OSH
and then transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
unknown
Social History:
has wife and son
Family History:
unknown
Physical Exam:
O: T: BP: / HR: R O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL@3mm sluggishly reactive; no drnge noted from
ears/nose; small laceration to left frontal skull region
Neck: Hard cervical collar in place
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated w/ no eye opening; follows no commands
Cranial Nerves:
I: Not tested
II: PERRL@3mm and sluggish bilat
III, IV, VI: No eye opening; does not blink to threat
V, VII:
VIII: No movement to loud voice.
IX, X: .
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius not tested- hard cervical
collar on
XII: Tongue appears midline.
Motor: Normal bulk and tone bilaterally. Spont moves LUE but
does
not appear purposeful; no commands
Pertinent Results:
Labs:
WBC: 8.2 Na: 141
Hgb: 13.1 K: 3.6
Hct: 38.2 Cl: 104
Plts: 152 CO2:
PT: 12 BUN: 23
PTT: 26.3 Cr: 1.2
INR: 1.0 Gluc: 152
Head CT:
-Large right subdural hematoma and small left subdural hematoma,
which do not cause brain herniation and are associated with 3
mm shift in the midline structures.
-Bilateral frontal contusions are noted.
-Fracture of the right frontal bone is detected.
-Note is made of prior fracture of the left frontal bone with
associated small encephalomalacia.
***[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8745**] bolt was placed urgently after Head CT w/ ICP's
stabilizing 70-80's. A repeat head CT was performed immediately
after [**Last Name (un) 8745**] bolt was placed which showed:
-Unchanged status of bilateral subdural hematoma and bilateral
frontal contusions and interval new development of bilateral
intraparenchymal hemorrhage. It is more obvious on the left
frontal lobe measuring up to 8.2cm.
-There has been interval placement of the ICP shunt in the right
frontal lobe.
-Again fracture of the right frontal bone is noted.
Brief Hospital Course:
On repeat CT, patient's bifrontal bleed increased in size,
particularly on left. Was a rapid progression over only a
period of 2 hours. Showed fluid level suggesting active
hemorrhage. Patient had emergent left crani for decompression.
Overnight, continued to withdraw upper extremities and had
brainstem reflexes but had no purposeful movements.
On [**4-16**] afternoon, family meeting was had where patient's very
poor prognosis was discussed. Family reqeusted DNR status but
wanted to continue care until sunday when they thought they
would want to make him CMO.
On [**4-17**] family requested meeting to discuss making patient care
measures only. Wife, children and multiple other family members
were present and requested that patient be made CMO and
extubated. Dr [**Last Name (NamePattern1) 72723**] RN and social work were also
present. Patient was made CMO at 1545.
Medications on Admission:
unknown
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2184-6-21**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3307
} | Medical Text: Admission Date: [**2183-10-12**] Discharge Date: [**2183-10-13**]
Date of Birth: [**2129-1-14**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Atazanavir / fresh fruit / Cephalosporins /
raltegravir / maraviroc / Hydralazine
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54 yo F with h/o HIV on HAART (CD4=437 [**8-3**]), DM2 (diet
controlled), CKD, R-sided CHF w/severe pulm HTN, with two recent
admissions to [**Hospital1 112**] for hypersensitivity reaction c/b
polymicrobial bacteremia (including VRE/MRSA), iatrogenic
[**Location (un) 3484**], recent C. diff colitis s/p recent hospitalization at
[**Hospital1 18**] from [**9-10**] to [**10-10**] for fluid overload (treated with lasix
gtt and metolazone), MRSA septicemia (requiring MICU stay, IVF,
CVL, and treated with IV vancomycin), skin breakdown (bactroban
cream TID), and hyponatremia. The patient was discharged to
rehab off of diuretics, which were stopped as it was felt she
was intravascularly volume depleted. The patient had just
finished her course of PO vancomycin for C. diff on Friday (two
days before admission).
Earlier today, the patient was found to be acting out and
yelling in pain at her nursing facility. On the ambulance ride
to [**Hospital1 **], the patient's blood glucose was found to be
"low." At [**Hospital1 **], CXR negative. The patient was given
1 amp of D50 and 500mL [**Hospital1 1868**] of saline, after which she stopped
complaining of discomfort. The patient was requiring increasing
oxygen, but otherwise her vital signs were stable. Her blood
pressures were never below 110 systolic, and pulse was generally
in 60s-70s. The patient was hypothermic to 95.8 there. After
discussion with her son [**Name (NI) 2855**], it was decided to bring her to
[**Hospital1 **], where she has received most of her care.
Here she was also found to have a wide-complex, sinusoidal EKG.
Due to concern for hyperkalemia (hemolyzed blood sample),
patient was given 6g calcium gluconate, nebulizer, 10 units of
insulin and an amp of bicarb. She did not receive kayexelate.
She was found to have hypothermia here as well and placed in a
Beir Hugger. She was breathing rapidly and deeply and appeared
to have increasing oxygenation requirement. The patient was
eventually transferred to the ICU on CPAP 10/5 with 50% FiO2.
On my interview, the patient reported that she was much more
comfortable with the CPAP. She confirmed the history above and
reported that she continued to have pain, especially in her
shoulders and legs. When specifically asked, she also endorsed
chest pain.
Past Medical History:
- HIV, diagnosed in [**2158**], on HAART (CD4=437 [**8-3**]),
-Patient recently presented to [**Hospital1 18**] ED on [**7-11**] with severe
desquamating rash and transferred to [**Hospital1 112**] burn unit. Rash was
determined to desquamating lichenoid hypersensitivity reaction
which was treated by stopping ART, avoidance of cephalosporins
and drugs of abuse such as cocaine. Dermatology was consulted on
admission and recommended wrapping patient in saran wrap and
using Vaseline for skin care. No mucosal involvement was noted
on admission. She was given copious IVF, and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Hugger was
utilized given insensible losses and impaired thermoregulation.
Dermatology re-evaluation on [**2183-8-11**] revealed worsening mucosal
involvement and new erythroderma. This raised concern for
progression of her severe drug hypersensitivity eruption. This
was felt to be secondary to ART, specifically abacavir and
lamuvidine, and potentially ceftriaxone to her recent admission
to [**Hospital1 112**]. She is not currently on any related medications. Of
note, her last attempted ART was on [**7-29**] resulting in
maculo-papular rash. s/p Transfer to [**Hospital1 756**] Burn Unit [**8-11**]
- Hepatitis C - no response to PEG-IFN/Ribavirin
- Shingles
- Migraines
- HTN
- DM II
- History of MRSA
- Recurrent UTI
- Recurrent nephrolithiasis
- HSV
- Pancytopenia [**1-23**] HAART medications
- CKD baseline creatinine 2.85-3.0, followed by Dr. [**Last Name (STitle) 118**]
(nephrolithiasis, pyelonephritis & perinephric abscess c/b
perinephric hematoma during stenting [**8-/2182**])
Social History:
Lives at home in [**Location (un) 745**]. Has 3 children: one son [**Name (NI) 2855**] is her
HCP, one daughter with hydrocephalus/seizure disorder is in a
nursing home ([**Location (un) 511**] Pediatric Care), 3rd child (female)
died in childhood from complications of HIV.
- Worked as a counselor (no longer working)
- Former heavy smoker, currently 1 pack q2 weeks.
- Former ETOH abuse, none since [**2174**]
- Former IVDU, none since [**2174**]
- Recent cocaine use ([**2182**])
Family History:
- Father died of MI
- Mother with diabetes
- Sister with lung cancer at age 38 and was a heavy smoker.
- Brother with diabetes
Physical Exam:
Admission physical exam:
Vitals: T: 96.6, BP: 125/66, P: 74, R: 26 on CPAP
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, BiPAP mask in place, MMM, oropharynx
clear, EOMI, PERRL
Neck: supple, no meningismus
CV: S1, S2, systolic mumur heard best at lower sternal border
Lungs: Clear to anterior auscultation only
Abdomen: Soft, non-tender, bowel sounds present, readily
palpable enlarged liver
Ext: Warm, well perfused, 1+/2+ pulses, skin on hands and feet
rough/lichenified, edematous
Neuro: CN III-XII intact, 5/5 strength grip and lower
extremities, grossly normal sensation
Pertinent Results:
[**2183-10-12**] 09:30PM WBC-6.7 RBC-2.66* HGB-7.8* HCT-26.2* MCV-98
MCH-29.2 MCHC-29.8* RDW-17.7*
[**2183-10-12**] 09:30PM HGB-8.1* calcHCT-24
[**2183-10-12**] 09:30PM NEUTS-58 BANDS-0 LYMPHS-31 MONOS-8 EOS-2
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2183-10-12**] 09:30PM PT-17.9* PTT-50.7* INR(PT)-1.6*
[**2183-10-12**] 09:30PM GLUCOSE-95 LACTATE-8.8* NA+-129* K+-5.7*
CL--108
[**2183-10-12**] 09:30PM TYPE-[**Last Name (un) **] PO2-41* PCO2-30* PH-7.15* TOTAL
CO2-11* BASE XS--18 COMMENTS-GREEN TOP
[**2183-10-12**] 09:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2183-10-12**] 09:30PM CORTISOL-19.4
[**2183-10-12**] 09:30PM TSH-95*
[**2183-10-12**] 09:30PM ALBUMIN-2.2* CALCIUM-7.2* PHOSPHATE-7.1*#
MAGNESIUM-2.0
[**2183-10-12**] 09:30PM CK-MB-3 proBNP-5182*
[**2183-10-12**] 09:30PM cTropnT-0.08*
[**2183-10-12**] 09:30PM LIPASE-40
[**2183-10-12**] 09:30PM ALT(SGPT)-39 AST(SGOT)-138* CK(CPK)-52 ALK
PHOS-139* TOT BILI-0.9
[**2183-10-12**] 09:30PM estGFR-Using this
[**2183-10-12**] 09:30PM GLUCOSE-97 UREA N-45* CREAT-3.0* SODIUM-125*
POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-9* ANION GAP-25*
[**2183-10-12**] 09:35PM URINE RBC-1 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-0
[**2183-10-12**] 09:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2183-10-12**] 09:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2183-10-12**] 10:13PM freeCa-1.29
[**2183-10-12**] 10:13PM GLUCOSE-122* LACTATE-9.9* NA+-129* K+-4.7
CL--108
[**2183-10-12**] 10:13PM TYPE-ART TEMP-35 RATES-/30 PO2-172* PCO2-19*
PH-7.26* TOTAL CO2-9* BASE XS--16 INTUBATED-NOT INTUBA
[**2183-10-12**] 11:50PM O2 SAT-38
[**2183-10-12**] 11:50PM LACTATE-8.7* K+-4.7
[**2183-10-12**] 11:50PM TYPE-[**Last Name (un) **]
Imaging:
[**2183-10-12**] CXR:
IMPRESSION: Possible mild pulmonary vascular congestion. No
significant
change from prior.
[**2183-10-13**] CT abdomen:
1. New, moderate-to-large volume ascites as compared to
[**2182-8-22**] exam, which appears to be simple.
2. Increase in heart size compared to prior, consistent with
worsening right heart failure as documented in previous
cardiology notes. Suspect that the ascites may be related to
the right heart failure.
2. Cholelithiasis.
3. Dysmorphic appearance of the right kidney with some capsular
calcifications likely secondary to prior hematoma.
Brief Hospital Course:
The patient is a 54-year-old woman with a complicated medical
history presenting with altered mental status and lactic
acidosis. It was unclear whether her lactic acidosis is Type A
or Type B. The patient was lethargic and agitated earlier, which
suggests hypoperfusion of brain. Creatinine has slowly been
rising over the last week. The patient does not have an obvious
site of infection. She appears to have some cardiac dysfunction,
but chest X-ray suggestive of only mild interstitial edema.
Cortisol level unknown, but patient thought to have iatrogenic
[**Location (un) **] disease in the past. In addition, patient on two HIV
medications that have been implicated in lactic acidosis
(abacavir and lamivudine). She was started on broad coverage
with vancomycin and meropenem for occult infection. She was
started on IV fluids with bicarbonate. She also received stress
dose steroids since she has history of iatrogenic [**Location (un) **]
disease. Her HIV medications were held due to concern for
causing lactic acidosis. The patient was found to have wide QRS
complex, which Cardiology felt was secondary to toxic-metabolic
derangement. The plan was to perform Echo in the morning and
check MB. Troponin was mildly elevated but patient had kidney
injury. At 5:10am on the morning of admission, patient
complained of chest pain and then has seizure-like activity,
followed by bradycardia and loss of blood pressure. A code was
called, and the patient was fund to be in pulseless electrical
activity. After 15 minutes of the pulseless electrical activity
algorithm, the patient had a return of spontaneous circulation.
Despite the presence of two pressors, however, her blood
pressure and heart rate could not be maintained and she went
into pulseless electrical activity again. Another code
commenced. Despite maximal efforts, spontaneous circulation
could not be achieved, and at 5:50 am, the patient was
pronounced dead. The patient's family was notified and decided
against postmortem examination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 300 mg PO BID Start: In am
2. Fosamprenavir 1400 mg PO Q12H Start: In am
3. LaMIVudine 150 mg PO DAILY Start: In am
4. Aquaphor Ointment 1 Appl TP DAILY
5. Aveeno Bath 1 PKG TP [**Hospital1 **] Start: In am
6. BuPROPion (Sustained Release) 150 mg PO QAM
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Start: In am
Hold for SBP < 100.
8. Metoprolol Succinate XL 50 mg PO DAILY Start: In am
Hold for SBP < 100, HR < 60.
9. Omeprazole 40 mg PO DAILY Start: In am
10. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
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: 4271, 2762, 2761, 5849, 4275, 4280, 5859, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3308
} | Medical Text: Admission Date: [**2128-9-25**] Discharge Date: [**2128-10-2**]
Date of Birth: [**2074-9-9**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
intubation
lumbar puncture
bronchoscopy
History of Present Illness:
Mr. [**Known lastname 25996**] is a 54M who presented to [**Hospital1 18**] overnight on [**2128-9-25**]
w/4d of increasing confusion. [**Name (NI) 1094**] mother reported he was seen
by PCP 2d prior to admission for new cough and sore throat and
was given a z-pack (bronchitis vs COPD flare). The following
day he reportedly was found unconsious after hitting his head on
a table and his roommate sent him to [**Hospital3 **]. There, he
was found to have RLL PNA, ARF w/Cr 2.0 from 0.8, hyperkalemia
to 6.9 without EKG changes. Etoh level negative, but tricyclics,
benzos, opiates +. He received levafloxacin, but then left AMA
(no kayexelate given). Roommate and mother thought he was still
very confused at home and he also complained of suprapubic pain
and diarrhea, they and convinced him to come to [**Hospital1 18**] (where he
is seen in the liver center by Dr. [**Last Name (STitle) 497**].
.
Of note, he last saw Dr. [**Last Name (STitle) 497**] about 3 weeks ago. At that time
he was considered to be sufficiently stable as to be under
consideration for HCV eradication therapy with interferon,
ribavirin and a protease inhibitor. He did report some BRBPR but
no hematemesis, melena, abd pain or distension; grade I
esophageal varices on EGD in [**2128-7-7**]. He had a palpable
nontender liver and no ascites, no asterixis. His mental health
counselor reported to Dr. [**Last Name (STitle) 497**] that he was clean, no alcohol or
drug use. However, acording to family, the patient has been
drinking cough syrup and using pills: non-prescription
oxycontin, valium and depakote as well as a "koolaid concoction"
that roommate suspects is methadone bc it "smells like
bubblegum." No alcohol use witnessed heroin use was also
suspected.
.
When he arrived in the [**Hospital1 18**] ED [**9-25**] he was found to be confused
and lethargic with asterixis and icteric sclera. Belly was soft
mildly distended with diffuse pain on palpation. Lungs had
crackles and wheezes throughout. VS were T 98.8 HR 97 BP 126/74
RR 16 O2 98/RA. He had WBC 14.1 with a left shift. AST was 1358
and ALT 527. He was given 1 dose levaquin, 500 cc NS bolus and
nebs. RUQ US showed nephrolithiasis without obstruction, no
ascites, no concerning liver parenchymal changes and a patent
portal vein. Could not assess kidneys [**3-10**] patient's lack of
cooperation. CXR showed "increased interstitial edema-like
pattern, volume overload (noncardiogenic edema) favored,
although atypical infection may result in a similar appearance."
Right hemidiaphragm was elevated compared to prior in [**Month (only) 116**].
Head CT showed unchanged left thalamic lacunar infarct.
.
On the floor, the patient was hydrated and put on CIWA [**Doctor Last Name **] 8
to 23. He was given ativan 0.5 mg IV x 2 and 3 doses of
diazepam 2.5 mg, 3 doses of lactulose, and his rifaximan.
.
The afternoon of [**9-26**], the patient was noted to be more
tachypneic, breathing 24-28 resp per minute, satting 98% on RA,
and he was not oriented. He was minimally able to follow
commands and appeared diaphoretic and tachycardic. ABG was
performed on 2 L nc 7.55/23/59/21. Given his nongap respiratory
alkalosis, Toxicology was called, who did not think he had
aspirin toxicity. MICU was called for eval given tachypnea.
Past Medical History:
1. Hepatitis C (Genotype 1) c/b Cirrhosis
2. Cirrhosis (Alcohol and HCV)
3. COPD (believes he was diagnosed approximately in [**2126**])
4. s/p Right Shoulder Surgery (patient unsure of exact cause)
Family History:
Father died from alcohol cirrhosis. No other family history of
liver disorders.
Physical Exam:
ADMISSION EXAM:
ADMISSION EXAM LIMITED BY PATIENT AGITATION
VS: 97.6 152/79 108 22 96/RA
GEN: thrashing around in bed naked, sitting in feces, in soft
wrist restraints, flushed, does not make eye contact, answers
questions yes or no, ++fetor hepaticus
HEENT: NCAT PERRL EOMI
ABD: soft and nondistended
EXT: no edema
NEURO: nonverbal except yes/no, moves all 4 extremities
spontaneously, EOMI
.
ICU DISCHARGE EXAM:
VS: 97.7 115/64 70 20 96%RA
GENERAL: Chronically ill-appearing man in NAD, comfortable,
tearful at times. No asterixis.
HEENT: NC/AT, R PRRL, L pupil non-reactive, EOMI, mild icterus,
MM dry, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding, no
fluid shift.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions. Multiple tattoos.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-10**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric.
.
DISCHARGE EXAM:
VS: 98.1 114/67 82 20 99/RA
GENERAL: chronically ill-appearing NAD dressed and ready to
leave
HEENT: NC/AT, R PRRL, L pupil non-reactive, EOMI, mild icterus,
MM dry, OP clear. No cervical LAD.
NECK: Supple no JVD
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat no r/r/w.
ABDOMEN: Soft/NT/ND, no HSM, no rebound/guarding, no fluid
shift.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses, R upper arm no
swelling but firm nontender palpable cord
SKIN: Multiple tattoos, spider angiomata
NEURO: Awake, A&Ox3, cannot spell WORLD forward or backward, CNs
II-XII grossly intact, muscle strength 5/5 throughout, gait
normal, no asterixis.
Pertinent Results:
ADMISSION LABS:
[**2128-9-25**] 12:35PM BLOOD WBC-14.1*# RBC-4.08* Hgb-14.2 Hct-39.6*
MCV-97 MCH-34.8* MCHC-35.8* RDW-15.6* Plt Ct-78*
[**2128-9-25**] 12:35PM BLOOD Neuts-81* Bands-0 Lymphs-11* Monos-5
Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2128-9-25**] 12:35PM BLOOD PT-15.8* PTT-34.4 INR(PT)-1.4*
[**2128-9-25**] 12:35PM BLOOD Glucose-108* UreaN-64* Creat-2.0*# Na-135
K-5.1 Cl-103 HCO3-22 AnGap-15
[**2128-9-25**] 12:35PM BLOOD ALT-527* AST-1368* AlkPhos-106
TotBili-4.0* DirBili-2.9* IndBili-1.1
[**2128-9-25**] 12:35PM BLOOD Lipase-45
[**2128-9-25**] 12:35PM BLOOD Albumin-3.4* Calcium-8.9 Phos-2.5* Mg-2.1
[**2128-9-25**] 12:35PM BLOOD Ammonia-27
[**2128-9-26**] 02:50PM BLOOD TSH-3.1
[**2128-9-26**] 02:50PM BLOOD Valproa-<3*
[**2128-9-26**] 02:50PM BLOOD CK-MB-22* MB Indx-0.7 cTropnT-0.05*
proBNP-5217*
[**2128-9-25**] 12:48PM BLOOD Lactate-2.1* K-5.0
.
[**Month/Day/Year **] SCREENS:
[**2128-9-25**] 12:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2128-9-25**] 02:56PM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
SERIAL ABG:
[**2128-9-26**] 01:21PM BLOOD Type-[**Last Name (un) **] pH-7.53* Comment-PERIPHERAL
[**2128-9-26**] 03:09PM BLOOD Type-ART pO2-59* pCO2-23* pH-7.55*
calTCO2-21 Base XS-0
[**2128-9-26**] 07:44PM BLOOD Type-ART pO2-67* pCO2-23* pH-7.54*
calTCO2-20* Base XS-0
[**2128-9-27**] 02:22AM BLOOD Type-ART Rates-14/6 Tidal V-500 PEEP-5
FiO2-50 pO2-119* pCO2-31* pH-7.46* calTCO2-23 Base XS-0
-ASSIST/CON INTUBATED
[**2128-9-26**] 11:07PM BAL FLUID Polys-58* Lymphs-1* Monos-2* Macro-1*
Other-38*
.
URINALYSIS
[**2128-9-25**] 01:45PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2128-9-25**] 01:45PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
[**2128-9-25**] 03:08PM URINE Hours-RANDOM UreaN-1297 Creat-134 Na-<10
K-38 Cl-11
.
CSF ANALYSIS
[**2128-9-27**] 12:34AM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-5240*
Polys-91 Lymphs-9 Monos-0
[**2128-9-27**] 12:34AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-2745*
Polys-55 Lymphs-45 Monos-0
[**2128-9-27**] 12:34AM CEREBROSPINAL FLUID (CSF) TotProt-21 Glucose-76
[**2128-9-27**] 12:34AM CEREBROSPINAL FLUID (CSF) HSV PCR-NEGATIVE
.
DISCHARGE LABS:
[**2128-10-2**] 05:40AM BLOOD WBC-4.5 RBC-3.32* Hgb-12.0* Hct-34.4*
MCV-104* MCH-36.2* MCHC-35.0 RDW-15.2 Plt Ct-57*
[**2128-10-2**] 01:10PM BLOOD PT-15.3* PTT-36.8* INR(PT)-1.3*
[**2128-10-2**] 05:40AM BLOOD Glucose-180* UreaN-19 Creat-1.0 Na-137
K-3.5 Cl-110* HCO3-21* AnGap-10
[**2128-10-2**] 05:40AM BLOOD ALT-136* AST-140* AlkPhos-127
TotBili-1.7*
[**2128-10-2**] 05:40AM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.1 Mg-1.6
[**2128-10-2**] 05:40AM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.1 Mg-1.6
.
MICRO:
CMV IGG NEG IGM NEG
MYCOPLASMA IGG POS IGM NEG
LEGIONELLA NEG
RESPIRATORY VIRAL SCREEN NEG
BAL CULTURE NEG
URINE CULTURE NEG
BLOOD CULTURES:1 OF 8 BOTTLES COAG-NEG STAPH (LIKELY
CONTAMINANT)
CSF CRYPTOCOCCAL ANTIGEN NEG
CSF GRAM STAIN, CULTURES NEG (INCLUDING NEG FUNGAL CX)
STOOL CDIFF NEG
MRSA SWAB NEG
VRE SWAB NEG
.
IMAGING:
ADMISSION CXR:
FINDINGS: There are low lung volumes, and there is elevation of
the right
hemidiaphragm. There is increased opacity in the bilateral lungs
with a
somewhat reticular pattern. The heart size is normal, and the
mediastinal
contours are unremarkable. There is no effusion or pneumothorax.
IMPRESSION: Increased interstitial edema-like pattern. Volume
overload
(noncardiogenic edema) favored, although atypical infection may
result [**Female First Name (un) **]
similar appearance.
.
ADMISSION CT HEAD:
FINDINGS: While somewhat limited by motion artifact, there is no
evidence of hemorrhage. There is no edema or mass effect. The
[**Doctor Last Name 352**]-white matter
differentiation is preserved, although an old left thalamic
lacunar infarct is unchanged from prior study. The ventricles
and sulci appear unremarkable in size. The visualized paranasal
sinuses and mastoid air cells are clear.
IMPRESSION:
1. No acute intracranial process.
2. Unchanged left thalamic lacunar infarct.
.
ADMISSION RUQ US:
FINDINGS: The liver demonstrates no focal lesion or intrahepatic
biliary
dilatation. The portal vein is patent with directionally
appropriate flow.
The gallbladder is distended with layering echogenic material
compatible
sludge but no pericholecystic fluid or wall edema. The common
bile duct
measures 6 mm in caliber.
The right kidney measures 10.5 cm in its long axis and shows no
hydronephrosis.
The aorta is of normal caliber along its course.
Views of the pancreatic head and body show no abnormality, but
the tail is
obscured by overlying bowel gas.
No ascites was seen.
.
ECHO:
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically
ventilated. Cannot assess RA pressure.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC [**Doctor Last Name **]: Normal aortic [**Doctor Last Name **] leaflets (3). No AS. No AR.
MITRAL [**Doctor Last Name **]: Mildly thickened mitral [**Doctor Last Name **] leaflets. No MVP.
Mild mitral annular calcification. Trivial MR.
[**First Name (Titles) 24998**] [**Last Name (Titles) **]: Normal [**Last Name (Titles) **] [**Last Name (Titles) **] leaflets with trivial
TR. Mild PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic [**Last Name (Titles) **]
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral [**Last Name (Titles) **] leaflets are mildly thickened. There is no mitral
[**Last Name (Titles) **] prolapse. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild pulmonary artery systolic hypertension. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function.
.
LUE LENI:
One of the two brachial veins does not compress and no vascular
flow is
identified within this vessel on color Doppler imaging.
Normal flow, compression, and augmentation is seen in the
remainder of the
vessels of the left arm.
IMPRESSION: Deep vein thrombosis seen within one of the two
brachial veins in the left upper arm.
Brief Hospital Course:
54M with ETOH/HCV cirrhosis, recent cough and progressively
declining mental status in setting of suspected hepatic
encephalopathy and toxin/drug ingestion transfered from liver
service to MICU on HD1 for worsening tachypnea after receiving
benzos for presumed ETOH/benzo withdrawal.
.
#Hepatic encephalopathy.
On arrival, the patient was started on standing lactulose 30 mg
QID + rifaximin 550 [**Hospital1 **] for presumed hepatic encephalopathy. On
the floor and in the ICU he received standing lactulose 30 ml
QID and rifaximin 550 [**Hospital1 **] and had frequent BMs with slow
symptomatic improvement. However, hepatic encephalopathy was
thought to be only part of the explanation for his dramatically
altered mental status on presentation, and the underlying reason
for acute HE remained undetermined despite thorough workup. RUQ
ultrasound showed no obstruction or biliary inflammation. Stools
were guaiac negative and Hct was stable. Infection workup was
negative. At time of transfer out of the ICU on HD6, he was
hypoactive but oriented and appropriate. On the floor his mental
status further cleared with additional doses of lactulose. He
was discharged on lactulose (a new medication for him) and
rifaximin (as before).
.
# Suspected drug ingestion:
Pt presented to hospital with significantly altered mental
status. He was non-verbal, naked, and not redirectable. Drug
ingestion was suspected because the patient's roommate reported
recent use of unknown substances; this was later corroborated by
a close friend/neighbor. Initial [**Name2 (NI) **] screen positive for benzos,
opiates, and tricyclics. Patient initially received
benzodiazepines per CIWA for suspected benzodiazepine
withdrawal. On HD2 he became progressively more agitated and
tachypneic, so he was transferred to the ICU. In the ICU his
benzodiazepine regimen was increased in dose and frequency with
acute worsening of his encephalopathy. Benzos were stopped, & pt
was given 5 mg IV haldol with no response followed by 10 mg IV
haldol which caused sedation. Toxicology was consulted because
patient's pre-admission drug history was cryptic, primary
respiratory alkalosis was difficult to explain, and agitated
delirium continued despite lactulose for hepatic encephalopathy.
Patient later denied any ingestions beyond the valium and
seroquel he is prescribed. In addition, it should be noted that
his ETOH level was negative on admission. Patient does have a
history of alcohol and substance abuse but had been clean as
recently as 1 month ago per therapist report to Dr. [**Last Name (STitle) 497**] (see
OMR note). Will require further outpatient follow-up.
.
# Occult infection/intubation:
In the ICU, in the context of unexplained worsening mental
status and respiratory alkalosis, infectious workup was pursued.
The patient did have atypical infiltrates on CXR that could have
been atypical pneumonia versus interstitial edema. He was
intubated in order to perform LP and bronchoscopy with BAL.
Started on Levofloxacin/Ceftriaxone to cover community acquired
atypical pneumonia and acyclovir to cover HSV encephalitis. His
BAL did not grow any organisms and his CSF was negative for HSV
or bacterial infection so antibiotics were narrowed to
levofloxacin. His vent settings remained minimal with good O2
saturations and ventilation. He was started on dexmetomidine and
the following day was successfully extubated and transferred to
the floor. On the floor he completed a 7-day course antibiotics.
Blood cultures sent from the ICU only grew 1 bottle + for staph,
suspected to be a contaminant.
.
# Tachypnea:
Patient became tachypneic prior to ICU transfer. Differential
diagnosis included agitation/withdrawal vs SIRS/infection vs
pain vs splinting. However, the patient became worse with
administration of benzodiazepines, making withdrawal less
likely. CMV serologies, legionella antigen, BAL gram stain and
culture and mycoplasma antibodies were negative. BNP was
elevated and a source of infection was never isolated, making
the pulmonary edema more likely. He was intubated not for
hypoxia, but rather for altered mental status and the need to
obtain studies for infectious workup (LP, BAL). Noted to have a
elevated right hemidiaphragm, but this was not thought to be
contributing to his tachypnea as he was not noted to be
hypercarbic on ABG (decreased ventilation). The presumed reason
for his tachypnea was toxin ingestion, as above. Respiratory
status returned to [**Location 213**] after ICU discharge -- he was
breathing comfortably with O2 sat >95 while walking around the
floor.
.
# Elevated CK:
Elevated on admission, unclear etiology. Pt reportedly had been
complaining of leg pain prior to admission. Also had recent
fall. Cardiac enzymes were slightly elevated with trop 0.05 and
CK MB 22, but the cardiac index was not elevated at 0.7. His
enzymes trended down with IV fluids in the ICU.
.
#Acute-on-chronic liver failure:
The patients LFTs were noted to be elevated from one month
prior. RUQ US showed no obstruction, a patent portal vein & no
ascites. Tylenol and ETOH levels negative. He was continued on
rifaximin and lactulose as above.
.
#Acute renal failure:
On admision, Cr 2.0 from baseline 0.8. FeNa <1%, prerenal. Cr
improved with IVF.
.
# Depression:
Once patient extubated, he noted he did not wish to pursue
treatment for his hepatitis C and wanted to "be with his
daughter" (who had passed away several years earlier from a
genetic disorder). Psychiatry evaluated the patient (in the
context of capacity evaluation, below) and deemed him not to be
depressed but to be suffering from prolonged (non-pathologic)
grief. He does see an outpatient therapist and
psychopharmacologist and should continue to meet with them as an
outpatient.
.
#LUE DVT.
The patient reported L arm pain and swelling ON HD5. LUE US
showed a brachial vein DVT. Anticoagulated on a heparin gtt
while inpatient. At time of discharge, after a careful
evaluation of the risks and benefits of anticoagulation, we felt
that the combination of fall risk, poor adherence to outpatient
care, and concominant drug use given positive urinary opiates on
admission and past indiscretions were contraindications to
continuing outpatient anticoagulation for the patient's brachial
vein DVT with either lovenox or coumadin. This has been
communicated to the patient's primary hepatology team and they
can consider further evaluation with repeat ultrasound or
consider initiating therapy as indicated.
.
# Capacity:
Given the patient's altered mental status throughout this
hospitalization and worsening symptoms with benzodiazepines in
the ICU, benzodiazepimes and opiates were avoided. On HD7 the
patient tried to leave AMA because he did not understand why he
was refused valium, opiates and seroquel, which he takes at
home. He did not agree or understand when explained that these
were held due to concern over very recent,
incompletely-explained mental status changes. He threatened to
leave AMA. Psych eval was obtained. They felt the patient was
still too encephalopathic to understand his medical needs but
felt it was safe to give him seroquel to promote sleep (he
hadn't slept for 72 hours); he agreed to stay one more day for
further treatment of his medical issues as long as he could have
seroquel and sleep. He was discharged the following day with
instructions to stop taking valium at home.
.
# Code status:
The patient's code status was unclear. His recent discharge
paperwork from [**6-16**] documented he was full code but did not
"want to be a vegetable." He had not wanted to identify a
health care proxy at that time, but made explicit instructions
that his mother should not be his HCP. During this admission,
the patient's sister told the team she was his HCP and that pt
was DNI. Per discussions with the sister, she had previously
been the patient's HCP, however this changed multiple times over
the years. She called patient's lawyer who notified ICU team
that the patient in fact did not have a HCP in writing. Per
discussion with the patient's Primary care doctor, the patient
requested his medical information not be shared with the sister.
SW consulted and team instructed to proceed with patient being
full code (per most recent documentation).
.
Medications on Admission:
ALBUTEROL 90 1-2 PUFFS q6H prn sob
DIAZEPAM 2.5 MG QD
FLUTICASONE/SALMETEROL 250-50 inh x1 QD
QUETIAPINE 50 MG QHS
RIFAXIMIN 550 MG [**Hospital1 **]
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): Please take as needed for goal [**4-9**] bowel
movements/day.
Disp:*1 Liter bottle* Refills:*2*
3. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day) as needed for agitation, insomnia.
Disp:*60 Tablet(s)* Refills:*0*
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**2-8**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) inhalation Inhalation once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic Encephalopathy
Discharge Condition:
Mental Status: A&O x 3.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 25996**] it was a pleasure taking care of you.
You were admitted due to concern for confusion and infection.
You were treated with antibiotics as well as medications to
treat your confusion from worsening liver disease.
While hospitalized you were found to have a large blood clot
(DVT) in your left arm. You were treated with heparin, a
medication that stops the clot from spreading. At time of
discharge the clot was stable and it was decided to discontinue
your medications given your risk for falling when leaving the
hospital.
At the time you left the hospital we thought your thinking was
back to baseline - you were no longer confused. We thought you
would be safe to go home, and to make good decisions about
staying away from alcohol and drugs. It is critically important
for you to continue seeing your therapist at [**Hospital1 **] as well as to
continue to abstain from substance use/drugs and alcohol.
.
Changes to your medications:
.
TO TREAT YOUR ANXIETY AND INSOMNIA:
1. STOP TAKING VALIUM - THIS MEDICATION [**Month (only) **] MAKE YOU CONFUSED
2. TAKE SEROQUEL AT A DOSE OF 50 mg UP TO 4 TIMES PER DAY AS
NEEDED FOR ANXIETY AND INSOMNIA.
.
TO TREAT CONFUSION THAT IS CAUSED BY LIVER DISEASE:
1. CONTINUE TAKING Rifaximin 550mg. One tablet twice daily every
day.
2. START TAKING Lactulose 30ml FOUR TIMES PER DAY. CALL YOUR
DOCTOR AND TAKE MORE LACTULOSE IF YOU HAVE < 3 BOWEL MOVEMENTS A
DAY.
.
To treat blood clot:
1. No medications needed, you will follow up with Dr. [**Last Name (STitle) 497**] in
two weeks.
.
Again it was a pleasure taking care of you. Please contact the
liver center or your primary care doctor with any questions or
concerns.
Followup Instructions:
Please follow-up in the Liver Center with Dr [**Last Name (STitle) 497**] in [**3-11**] weeks.
Contact the Liver Clinic to set up an appointment:
.
[**Hospital1 18**] LIVER CENTER
[**Hospital Unit Name **] [**Location (un) **]
[**Doctor First Name **], [**Location (un) **]
[**Telephone/Fax (1) 2422**]
.
Please also see your therapist at [**Hospital1 **] within the next week.
Call him to set up an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
ICD9 Codes: 486, 5849, 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3309
} | Medical Text: Admission Date: [**2136-7-21**] Discharge Date: [**2136-8-1**]
Date of Birth: [**2065-4-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
SOB X 9 days, worsening orthopnea, fatigue with exertion,
nonproductive cough
Major Surgical or Invasive Procedure:
DC cardioversion [**2136-7-24**]
cardiac catheterization with stent placement [**2136-7-26**]
History of Present Illness:
Pt is a 71 y/o man with PMH signficant for inferoposterior MI
[**11/2130**] (cath done at that time insignificant left main ds with
totally occluded LAD, distal circ stenosis and totally occluded
RCA s/p IABP and CABG with L internal mamm art to LAD and vein
graft to post desc artery, vein graft to obtuse marginal-
balloon pump weaned and EF improved to 15-20%), h/o Afib with
RVR and A flutter tx with Coumadin and Amiodarone, lost to
follow up until [**2136-7-17**] when he presented to Dr. [**Last Name (STitle) **]
(PCP)'s office c/o 9 days of worsening SOB, worsening orthopnea,
fatigue with exertion, and non-productive cough with no chest
pain and found to be in Afib with RVR, LBBB, and CHF by clinical
presentation and CXR. He was admitted to [**Hospital 1474**] Hospital with
dx of CHF. Last echo was [**2136-7-17**] showing EF 10-15%, severe
diffuse left ventricular hypokinesis, RV decr fxn, mod MR, mod
TR, PA systolic was 40mmHg.
.
At [**Hospital1 1474**], he was started on Carvedilol 6.25mg po bid, Lasix
40mg IV bid, Lisinopril 2.5mg po qd, hep gtt. He was in
Aflutter with variable conduction, and was started on digoxin
0.125mg po qd. On admission, he had wide complex tachy to 120,
when slowed- was Aflutter. His bp dropped with these meds, to
80s-90s systolic without dizziness. He remained extremely SOB,
however, +orthopnea (cannot sleep from any angle- sleeps sitting
up in bed on tray table.) CXR at OSH c/w pulmonary edema with
b/l pleural effusions.
He ruled out for MI with 2 sets neg CE and 3 sets neg troponins.
Because of his significant orthopnea and failure to diurese
despite IV lasix and hypotension, he was transferred here for
potential IV milrinone, possibly also needed atrial fib ablation
vs. cardioversion to NSR.
Past Medical History:
1. Lasix 40mg IV q12
2. Insulin
3. Coreg 6.25mg po bid
4. Amiodarone 400mg po bid
5. Lisinopril 2.5mg po qd
6. Heparin gtt
7. Digoxin 0.125mg po qd
8. Zocor 20mg po qd
9. ASA 325mg po qd
Social History:
cigarettes 1-2ppd X the past 30 years, cigar tobacco [**1-19**] pipes
per day, no ETOH, no IVDA
Family History:
premature coronary ds, father died of MI at age 51
Physical Exam:
BP: 122/70 HR: 87 RR: 16 Oxygen sat: 98% on 4L NC
General: Pleasant 71 y/o CM, NAD, with occasional dry cough
HEENT: With bilateral glaucoma, no scleral icterus, blind
bilateral eyes
Neck: Supple, with JVD all the way up to the ear
Lungs: With fine crackles at the bases
CV: RRR with occasional PVCs, S1 and S2 audible.
Abd: Soft, NT, ND, Obese, NABS. No masses.
Peripheral Vasc: 1+ edema bilateral lower extremities
Neuro: Blind bilaterally. No focal deficits. Strength 5/5
throughout. Able to ambulate to and from bathroom with a cane.
Sensory intact.
Pertinent Results:
[**2136-7-21**] 07:53PM GLUCOSE-273* UREA N-51* CREAT-1.5*
SODIUM-132* POTASSIUM-5.8* CHLORIDE-99 TOTAL CO2-22 ANION GAP-17
[**2136-7-21**] 07:53PM CALCIUM-9.6 PHOSPHATE-6.0* MAGNESIUM-2.0
[**2136-7-21**] 07:53PM WBC-9.7 RBC-4.96 HGB-14.6 HCT-42.6 MCV-86
MCH-29.3 MCHC-34.2 RDW-13.4
PLT COUNT-239
PT-14.2* PTT-48.4* INR(PT)-1.3
[**11/2130**]
cath done at that time insignificant left main ds with totally
occluded LAD, distal circ stenosis and totally occluded RCA s/p
IABP and CABG with L internal mamm art to LAD and vein graft to
post desc artery, vein graft to obtuse marginal- balloon pump
weaned and EF improved to 15-20%
.
EKG at OSH shows Aflutter with variable conduction
EKG here: Atrial flutter with variable conduction, Rate 75bpm,
wide QRS c/w LBBB, ST elevation in V2, V3, and V4.
.
CXR [**2136-7-21**] here: with slight right pleural effusion, with
cardiomegaly and enlarged pulmonary arteries
.
CTA OSH: Suboptimal but otherwise neg for PE
.
ECHO [**7-20**]: EF:20%
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis (ejection fraction
20 percent). The right ventricular cavity is dilated. Right
ventricular systolic function appears depressed. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension.
.
ECHO [**2136-7-24**]: no thrombus before DC cardioversion from Aflutter
to NSR.
.
Cardiac Cath [**2136-7-25**]:
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease.
2. Patent SVG-RCA. Occluded second SVG-RCA and SVG-OM. Patent
LIMA-LAD.
3. Elevated right and left sided filling pressures.
4. Depressed cardiac output and index.
5. Successful drug-eluting stenting of the LCX.
.
proBNP-3563*
HgbA1C: 11.9, Lipid panel: Tot chol 124, TG 79, HDL 29, LDL 79
[**2136-7-21**] 07:53PM BLOOD CK-MB-2 cTropnT-0.01, CK(CPK)-105
[**2136-7-25**] 03:15PM BLOOD CK-MB-NotDone cTropnT-<0.01, CK(CPK)-40
[**2136-7-25**] 10:00PM BLOOD CK-MB-NotDone, CK(CPK)-42
[**2136-7-26**] 04:40AM BLOOD CK-MB-NotDone, CK(CPK)-36*
Brief Hospital Course:
Impression: 71 y/o man with h/o CAD, s/p 4 vessel CABG in the
past, ischemic cardiomyopathy, with h/o Atrial
fibrillation/flutter, lost to follow up from [**3-/2131**] to [**7-20**],
transferred from OSH in decompensated CHF and Aflutter. He is
now status post DC cardioversion to normal sinus rhythm; s/p
diuresis over 18 L total; s/p cardiac catheterization w/
stenting of his native LCX.
.
1. CHF: His initial decompensation was likely subacute as he
was grossly volume overloaded w/ relatively minor sxs. We felt
this was a combination of dietary non adherance and atrial
flutter. The pt is much improved w/ diuresis, afterload
reduction and restoration of NSR. We diuresed over 18L off of
the pt with IV lasix. His blood pressures tolerated this well.
He will be discharged on CoReg, ACEI. He will receive one more
dose of lasix prior to discharge and will need follow up
labwork.
His echo was done on [**2136-7-23**], showing EF of 20% with severe
global LV hypokinesis.
He has a follow up appointment with Dr. [**Last Name (STitle) **] for potential
ICD placement. His appt is [**8-29**], and he will have an
echocardiogram that same day.
.
2. Coronary Artery Disease: As there was some difficulty
obtaining prior cardiac records, and because his echo
demonstrated an EF of 20% with severe global left ventricular
hypokinesis with depressed systolic function, we pursued workup
of his likely ischemic cardiomyopathy. He went for cardiac
catheterization on [**2136-7-26**], demonstrating 2 of 3 vein grafts
down on cath; patent LIMA to LAD; s/p stent to native left
circumflex. He did well post-cath, and will be discharged on
ASA/statin/BB/plavix, with follow up with his cardiologist, Dr.
[**Last Name (STitle) **]. He was told that he must take his medications. He
will have a repeat echo in [**8-20**]. He has an outpatient follow
up appt with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for potential ICD vs. BiV pacer
placement.
.
3. Aflutter- He initially presented with atrial flutter with
variable conduction w/wide QRS c/w LBBB, ST elevation in V2, V3,
and V4. He is now s/p TEE/DC cardioversion to NSR, without
complications. He remains in NSR. He was given amiodarone
400mg po qd for 10 days, then switched to amiodarone 200mg po
qd. For anticoagulation, we placed him on heparin gtt and
coumadin. He will be discharged on coumadin 7.5mg po qd, with
f/u to his PCP to check INR. His INR is therapeutic at 2.3.
.
4. Hyperlipidemia
His lipid panel was checked: TG 96, HDL 36, LDL 67. We
continued his lipitor. He will continue this medication after
discharge.
.
5. Type II Diabetes Mellitus, new diagnosis:
The pt came in with markedly elevated sugars in the 300s-400s.
His HgbA1C was checked at OSH and found to be 11. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Diabetic consult was obtained, and followed his sugars
throughout his stay. The pt was started on glyburide, titrated
up to 10mg po bid, with lantus titrated to 12u qHS. He was also
on a modified humalog sliding scale. However, nearing
discharge, he was requiring less and less insulin, so he
received lantus 6 units prior to discharge, with follow up the
next day in Dr.[**Name (NI) 8716**] clinic. His wife was instructed on
how to inject him, and is familiar with the care he will need.
.
# Hematuria: He initially had gross blood visible in the foley
bag after the foley was placed, presumably secondary to
traumatic foley insertion. This cleared, and he has not had
blood in the foley for several days. He will f/u with his PCP
for potential cystoscopy as outpatient.
.
7. FULL CODE
Medications on Admission:
Meds on transfer:
1. Lasix 40mg IV q12
2. Insulin
3. Coreg 6.25mg po bid
4. Amiodarone 400mg po bid
5. Lisinopril 2.5mg po qd
6. Heparin gtt
7. Digoxin 0.125mg po qd
8. Zocor 20mg po qd
9. ASA 325mg po qd
.
Meds on admission to OSH (pt reports compliant with meds for
several years):
1. Zocor
2. Digoxin 0.025mg po qd
3. ASA 325mg po qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Warfarin Sodium 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Congestive Heart Failure
2. Atrial fibrillation with rapid ventricular response status
post DC cardioversion
3. Ischemic Cardiomyopathy status post cardiac catheterization
to the native left circumflex artery
4. Diabetes Mellitus type II
5. Blindness
6. Hyperlipidemia
7. Glaucoma
Discharge Condition:
Stable
Discharge Instructions:
If you experience any chest pain, shortness of breath, or
sweating, please come to the emergency room immediately.
If you experience worsening shortness of breath, weight gain, or
fatigue, please come to the ER. Have Dr. [**Last Name (STitle) **] check your
blood chemistries because you are getting a dose of lasix before
you leave.
Please take all of your medications. Please adhere to a low
sodium diet. Weigh yourself every day, if your weight increases
by more than 2kg, notify your physician.
[**Name10 (NameIs) **] up with your doctors (see information below).
Followup Instructions:
You have a follow-up appointment with Dr. [**Last Name (STitle) **] on Thursday,
[**8-2**] at 10 am to discuss referral for your diabetes
treatment.
You have an appointment with Dr. [**Last Name (STitle) **] on [**8-29**] at 2:30 PM in
[**Hospital Ward Name 23**] 7 th Floor, [**Hospital1 **]. Your echocardiogram
is scheduled for the same day, [**2136-8-29**] at 1pm, [**Hospital Ward Name 517**],
[**Hospital Ward Name **] 3, [**Hospital1 **]. Please go to your
echocardiogram before your appointment with Dr. [**Last Name (STitle) **].
Completed by:[**2136-8-1**]
ICD9 Codes: 4280, 4254, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3310
} | Medical Text: Admission Date: [**2137-6-26**] Discharge Date: [**2137-7-7**]
Date of Birth: [**2080-12-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Theophylline / Shellfish Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2137-6-26**] Aortic Valve Replacement(23mm St. [**Male First Name (un) 923**] mechanical) and
Two Vessel Coronary Artery Bypass Grafting(left internal mammary
to left anterior descending with vein graft to diagonal)
History of Present Illness:
This is a 56 year old male with known coronary artery disease
and aortic stenosis. The history of coronary disease dated back
to [**2126**] when he had an Inferior Wall myocardial infarction. At
that time, he received a bare metal stent to the RCA. He
remained stable until [**2134**], when he developed chest pain. Cath
at that time revealed stenosis of the LAD and he received a DES.
In [**2136-11-28**] he was hospitalized and treated for pulmonary
edema. Cardiac cath on [**2137-4-30**] revealed LM and two vessel CAD. He
is also found to have severe AS on echo. He was subsequently
referred for AVR/CABG. Of note, he recently completed a course
of antibiotics for pneumonia. Currently breathing much better.
No fevers, chills, or rigors.
Past Medical History:
-Coronary artery disease s/p IWMI [**2126**] s/p BMS of RCA s/p DES to
LAD [**2134**]
-Hodgkin's Lymphoma, s/p radiation to chest and abdomen [**2113**]
-History of Paroxysmal Atrial Fibrillation dx [**2115**]
-Dyslipidemia
-Diabetes Mellitus Type II
-Hypothyroidism
-Reactive airway syndrome
-s/p Laparotomy, splenectomy
-s/p Biopsy of left clavicular node
-s/p Tonsillectomy
Social History:
Race: Caucasian
Last Dental Exam: [**2136-12-29**], Dr. [**Last Name (STitle) **] in [**Location (un) 1887**]
Lives with: wife, 1 child
Occupation: works in software quality assurance for Tyco Safety
Tobacco: none
ETOH: none
Family History:
No premature coronary artery disease
Physical Exam:
PREOP EXAM
Pulse: 85 regular Resp: 16 O2 sat: 100%
B/P Right: Left: 111/62
Height: 6'2" Weight: 244lb
General: NAD, appears older than stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [] ROM limited [**1-30**] XRT + kyphosis
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 systolic, radiation
markers on chest, pectus excavatum noted
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] - well-healed mid-line abdominal scar
Extremities: Warm [x], well-perfused [x] hair loss laterally
and
distally
Edema: None
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: no bruit noted, no significant murmur noted
Pertinent Results:
[**2137-6-26**] Intraop TEE: Pre Bypass: The left atrium is mildly
dilated. The left atrium is elongated. No spontaneous echo
contrast is seen in the body of the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the ascending aorta. There are complex (>4mm) atheroma in the
aortic arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. The number of aortic valve leaflets cannot be
determined. There is severe aortic valve stenosis (valve area
0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. There
is [**1-31**]+ mitral regurgitation with calcification of the anterior
mitral leaflet. Jet appears central. There is mild valvular
mitral stenosis (area 1.5-2.0cm2). Due to co-existing aortic
regurgitation, the pressure half-time estimate of mitral valve
area [**Known lastname **] be an OVERestimation of true mitral valve area. There
is no pericardial effusion.
Post Bypass: A mechanical prosthesis is seen in the aortic
position (#23 St. [**Male First Name (un) 923**] per surgeons). On initial seperation from
bypass, a significant paravalvular leak is noted between 9 and
12 o'clock position (where the native non coronary cusp would
have been). Surgeons notified immediately and bypass reiniatied.
On second bypass wean, this jet is no longer present; only
symmetric washing type jets are seen. Peak gradients measure
20-30 mm hg, mean 12-21 mm Hg with cardiac output [**6-4**] Lpm and
systemic pressures of 100-120 systolic. Valve leaflets could not
be visualized due to significant artifacts. MR is now [**12-30**]+.
Aortic contours intact. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
[**2137-6-26**] 07:53PM BLOOD WBC-14.1* RBC-3.33*# Hgb-10.2*#
Hct-29.4*# MCV-88 MCH-30.6 MCHC-34.7 RDW-13.8 Plt Ct-169#
[**2137-6-27**] 03:41AM BLOOD WBC-10.5 RBC-3.37* Hgb-10.0* Hct-29.4*
MCV-87 MCH-29.6 MCHC-34.0 RDW-14.0 Plt Ct-153
[**2137-7-5**] 05:48AM BLOOD WBC-20.9* RBC-3.22* Hgb-9.3* Hct-28.7*
MCV-89 MCH-29.0 MCHC-32.6 RDW-14.1 Plt Ct-708*
[**2137-7-6**] 04:45AM BLOOD WBC-17.6* RBC-3.15* Hgb-9.3* Hct-28.1*
MCV-89 MCH-29.4 MCHC-32.9 RDW-14.1 Plt Ct-768*
[**2137-6-26**] 07:53PM BLOOD PT-14.7* PTT-34.9 INR(PT)-1.3*
[**2137-6-26**] 09:00PM BLOOD PT-13.6* PTT-37.8* INR(PT)-1.2*
[**2137-7-3**] 07:46AM BLOOD PT-19.8* PTT-57.5* INR(PT)-1.8*
[**2137-7-3**] 04:07PM BLOOD PT-28.9* PTT-150* INR(PT)-2.8*
[**2137-7-4**] 05:30AM BLOOD PT-28.1* PTT-41.1* INR(PT)-2.7*
[**2137-7-5**] 05:48AM BLOOD PT-30.0* INR(PT)-2.9*
[**2137-7-6**] 04:45AM BLOOD PT-27.3* INR(PT)-2.6*
[**2137-6-26**] 09:00PM BLOOD UreaN-12 Creat-0.7 Na-140 K-3.5 Cl-109*
HCO3-28 AnGap-7*
[**2137-7-6**] 04:45AM BLOOD Glucose-136* UreaN-18 Creat-1.0 Na-137
K-5.2* Cl-101 HCO3-26 AnGap-15
[**2137-7-6**] 04:45AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.1
[**2137-7-7**] 05:40AM BLOOD WBC-16.1* RBC-3.21* Hgb-9.2* Hct-28.7*
MCV-89 MCH-28.8 MCHC-32.2 RDW-14.1 Plt Ct-826*
Brief Hospital Course:
Mr. [**Known lastname 116**] was [**6-26**] admitted and underwent a mechanical aortic
valve replacement and coronary artery bypass grafting surgery by
Dr. [**Last Name (STitle) **]. For surgical details, please see operative note.
Following surgery, he was brought to the CVICU for invasive
monitoring in stable condition. Within 24 hours, he was weaned
from sedation, awoke neurologically intact and was extubated
without incident. He remained in the CVICU receiving aggressive
pulmonary toilet for an additional day and was transferred to
the step-down for on post-op day two. Beta blockers and
diuretics were started and he was diuresed towards his pre-op
weight. Coumadin was initiated for mechanical aortic valve but
INR quickly rose to be supra therapeutic at 5.4. Coumadin was
held, he received vitamin K and INR trended down. Coumadin was
restarted the following day with a gentle titration. On post-op
day four he was transferred back to the CVICU due to rapid
atrial fibrillation with hypotension and no IV access. PICC line
was placed and he was given initially given Cardizem and then
Amiodarone. Rhythm converted back to sinus rhythm and later on
the same day he was transferred back to step-down floor. But he
did continue to have atrial fibrillation/flutter which was
appropriately treated, along with EP consult. Chest tubes and
epicardial pacing wires were removed per protocol. He developed
bilateral arm phlebitis with elevated white count and was
started on IV antibiotics which was eventually changed to oral.
He will continue antibiotics for 10 days. In addition warm
compresses and ace wraps were applied per vascular consult. Over
the next several days he continued to slowly improve while
working with physical therapy for strength and mobility. In
addition his INR slowly trended up and was therapeutic at
discharge, 2.2. On post-op day 11 he was ready for discharge
home with VNA services and the appropriate medications and
follow-up. MWHC will follow INR and adjust Coumadin accordingly.
Medications on Admission:
sotalol 80mg [**Hospital1 **]
digoxin 0.375mg daily
lisinopril 5mg daily
crestor 10mg daily
aspirin 325mg daily
metformin 850 [**Hospital1 **]
glipizide 5mg daily
levothyroxine 150mcg daily
ventolin inhaler prn
Vit C 1000 mg daily
Vit D3 1000 IU daily
Vit B12 1000 mcg daily
MVI daily
SL NTG prn
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
9. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
10. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Take 200mg twice daily for 7 days. Then 200mg daily
until stopped by cardiologist.
Disp:*40 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication: Mechanical aortic valve,
atrial fibrillation
Goal INR 2.5-3
First draw - day after discharge [**2137-7-8**]
Results to [**Hospital 82499**] [**Hospital 197**] clinic phone: [**Telephone/Fax (1) 6256**] fax:
[**Telephone/Fax (1) 31080**]
13. metoprolol tartrate 50 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
14. warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once)
for 1 doses: dose will change daily for goal INR 2.5-3.0.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p Aortic valve
replacement and coronary artery bypass graft x 2
Past medical history:
Hodgkins Lymphoma
Paroxsymal Atrial Fibrillation
Dyslipidemia
Type II Diabetes Mellitus
Hypothyroidism
Reactive airway syndrome
s/p Laparotomy, splenectomy
s/p Biopsy of left clavicular node
s/p Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 2+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2137-7-10**] 10:15
at [**Hospital Unit Name 82500**]
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2137-7-18**] 1:45
Cardiologist: [**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 1295**] [**8-8**] at 3pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) **] in [**4-2**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: Mechanical aortic valve,
atrial fibrillation
Goal INR 2.5-3
First draw - day after discharge [**2137-7-7**]
Results to [**Hospital 82499**] [**Hospital 197**] clinic phone: [**Telephone/Fax (1) 6256**] fax:
[**Telephone/Fax (1) 31080**]
Completed by:[**2137-7-7**]
ICD9 Codes: 4241, 412, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3311
} | Medical Text: Admission Date: [**2124-11-14**] Discharge Date: [**2124-11-18**]
Date of Birth: [**2073-9-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
referred for a stress test after an abnormal EKG at his PCP's
office.
Major Surgical or Invasive Procedure:
status post Coronary artery bypass grafting x
3(LIMA->LAD/SVG->RCA/Diag)
History of Present Illness:
51 yo M with history of hypertension and tobacco use who was
referred for a stress test after an abnormal EKG at his PCP's
office. The patient denies chest pain, dyspnea, PND orthopnea,
syncope,lightheadedness, or edema. Stress test was abnormal and
patient was referred for cardiac catheterization. Now asked to
evaluate for surgical revascularization.
Past Medical History:
-Hypertension
-Past Surgical History:
s/p Right knee surgery
Social History:
Race:Caucasian
Last Dental Exam:>10 yrs ago
Lives with:alone
Occupation:Roofer
Tobacco:+ 2ppd x30 years
ETOH:rare
Illicit drugs: denies
Family History:
Family History:Father died of MI age 62, Mother s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2435**] age 60
Physical Exam:
Physical Exam
Pulse:81 Resp: 18 O2 sat: 99%RA
B/P Right:137/98 Left:128/98
Height: 5'8" Weight:195 lbs
General:
Skin: Dry [x] intact []: possible psoriasis R hand
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: no
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right:drsg [**Name5 (PTitle) 2325**]:palp
DP Right:palp Left:palp
PT [**Name (NI) 167**]: Left:
Radial Right:palp Left:palp
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2124-11-14**] 01:25PM BLOOD WBC-12.5* RBC-4.05* Hgb-12.7* Hct-36.7*
MCV-91 MCH-31.4 MCHC-34.7 RDW-12.2 Plt Ct-210
[**2124-11-16**] 07:05AM BLOOD WBC-9.6 RBC-3.86* Hgb-12.3* Hct-35.0*
MCV-91 MCH-32.0 MCHC-35.3* RDW-12.3 Plt Ct-216
[**2124-11-14**] 12:38PM BLOOD PT-13.9* PTT-28.9 INR(PT)-1.2*
[**2124-11-14**] 01:25PM BLOOD PT-13.1 PTT-32.0 INR(PT)-1.1
[**2124-11-14**] 01:25PM BLOOD UreaN-19 Creat-1.0 Cl-112* HCO3-25
[**2124-11-16**] 07:05AM BLOOD Glucose-92 UreaN-17 Creat-1.0 Na-141
K-4.4 Cl-104 HCO3-28 AnGap-13
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83846**] (Complete)
Done [**2124-11-14**] at 12:30:58 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2073-9-22**]
Age (years): 51 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG
ICD-9 Codes: 786.05, 786.51, 424.1, 424.0
Test Information
Date/Time: [**2124-11-14**] at 12:30 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine: aw1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1)
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40 - 45 %).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened.
The mitral valve leaflets are mildly thickened. Mild (1) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
RV function remains normal
No aortic dissection seen
LV systolic function mildly depressed overall with apical and
anteroseptal hypokinesis, LVEF-40-45%
Valvular function remains same as pre-bypass
Findings communicated to surgical team at time of examination
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2124-11-14**] 12:53
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83847**] M 51 [**2073-9-22**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2124-11-15**] 7:56
AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2124-11-15**] 7:56 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 83848**]
Reason: s/p ct removal ? ptx
[**Hospital 93**] MEDICAL CONDITION:
51 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
s/p ct removal ? ptx
Final Report
HISTORY: Status post CABG, status post catheter removal,
questionable
pneumothorax.
COMPARISON: [**2124-11-14**].
CHEST RADIOGRAPH PORTABLE AP VIEW: Following removal of
endotracheal tube,
chest and mediastinum drains, there are left and right lower
lobes
atelectasis. Otherwise, the lungs are clear. There is no
pneumothorax or
pleural effusion. Mediastinal wires are intact and a slight
decrease of the
mediastinum widening is seen. A right jugular sheath is in the
thoracic
inlet.
IMPRESSION: Bilateral lower lobe atelectasis following removal
of
endotracheal tubes, chest and mediastinal drains. No
pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: [**Doctor First Name **] [**2124-11-16**] 8:29 AM
Imaging Lab
?????? [**2117**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2124-11-14**] Mr.[**Known lastname **] was taken to the operating room and
underwent Coronary artery Bypass Grafting x 3 (Left internal
Mammary Artery grafted to Left Anterior Descending
artery/Saphenous Vein Grafted to Diag/Posterior descending
artery). Cross Clamp time was 44 minutes. Cardiopulmonary Bypass
time was 56 minutes. Please refer to Dr.[**Name (NI) 11272**] operative
report for further details. He tolerated the procedure well and
was transferred to the CVICU in critical but stable condition,
intubated and sedated. Mr.[**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact
and was extubated postoperative night. All lines and drains were
discontinued in a timely fashion. Beta-blocker, statin, aspirin
were initiated. On post-operative day number two he was
transferred to the step down unit for further monitoring.
Physical therapy was consulted for evaluation of strength and
mobility. Mr.[**Known lastname **] continued to progress and on
post-operative day number four he was cleared by Dr. [**Last Name (STitle) 914**] on
Dr.[**Initials (NamePattern4) 11272**] [**Last Name (NamePattern4) 83849**] for discharge to home with VNA. All follow up
appointments were advised.
Medications on Admission:
Medications at home:
Atorvastatin 80mg po daily
Metoprolol Tartrate 50mg po BID
ASA 81mg po 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 50 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 breakthrough pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain.
Disp:*14 Tablet Sustained Release 12 hr(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*2*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): stop this medication after you stop taking pain
medication.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
-Coronary artery disease
-status post Coronary artery bypass grafting x
3(LIMA->LAD/SVG->RCA/Diag)-[**2124-11-14**]
-Hypertension
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 [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) 61898**],[**First Name3 (LF) 278**] T. [**Telephone/Fax (1) 61899**] in [**11-18**] weeks
Cardiologist Dr [**Last Name (STitle) 4469**],[**First Name3 (LF) **] in [**11-18**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2124-11-18**]
ICD9 Codes: 4019, 3051, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3312
} | Medical Text: Admission Date: [**2131-1-17**] Discharge Date: [**2131-1-24**]
Date of Birth: [**2060-8-6**] Sex: F
Service: MEDICINE
Allergies:
Tramadol / Oxycodone / Penicillins
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
History of Present Illness:
70F with COPD on home O2, presented to OSH with shortness of
breath, now admitted to [**Hospital Unit Name 153**] for respiratory failure. Per
family, has shortness of breath particularly with exertion at
baseline, only able to ambulate several feet. This was
significantly worse today. Daughter does not think she used her
CPAP last night due to falling asleep in chair. Had mild
nonproductive cough, no fevers/chills/GI symptoms. Daughter
also notes she has had some falls at home and noted an egg on
the back of her head. Yesterday she complained to daughter of
having difficulty holding things.
.
At [**Hospital3 3583**], O2 sat 81% on RA. Given lasix 40 IV,
solumedrol 125 mg, levaquin 750 mg IV. Also noted to have
minimal STEs inferiorly and heparin thus started, received
SLNTG, 5 mg lopressor, ASA 325 mg PR. Received calcium,
kayexalate, insulin/D50 for hyperkalemia (6.3) with new ARF
(creatinine 4.7). NIPPV trialed but ultimately required
intubation. ABG 7.12/119/181/41 on bipap. WBC 13.4 with 12%
bands. BNP 277. Did have BP drop to 70s at OSH, responded to
250 cc bolus.
.
In the ED, initial vs were: T98.5 P73 BP 93/49, 100% O2 sat on
vent. SBP remained in 90s-110s. Trop 0.04 here; ECG faxed to
cards who did not feel c/w ischemia and recommended d/c heparin
gtt. CXR obtained with ?RUL pneumonia. Patient was given vanc
and aztreonam here.
.
On the floor, patient intubated and sedated.
.
Review of systems: unable to obtain as patient is intubated and
sedated. Positives per family as above. ALso noted
constipation yesterday.
Past Medical History:
- COPD on home O2
- HTN
- Hypothyroidism
- Venous stasis
- Post herpetic neuralgia
- Anxiety/depression
- Osteoporosis
- Obstructive sleep apnea on CPAP
Social History:
Quit smoking 9 years ago after [**12-20**] PPD smoking history. No
EtOH. Lives at home. Daughter is [**Name2 (NI) **] [**Telephone/Fax (1) 86113**]
Family History:
Father had COPD.
Physical Exam:
General: Intubated, sedated, no distress.
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear.
Subcutaneous fluctuant collection on posterior head more on left
side.
Neck: obese, supple, JVD elevation difficult to appreciate,
slightly erythematous ?lymph node at angle of mandible on left
side.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi but prolonged expiratory phase.
CV: Regular rate and rhythm, normal S1 + S2, [**12-23**] SM at RUSB with
some radiation to carotids, and [**12-23**] holosystolic murmur at apex.
Abdomen: soft, appears non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: needs assessment off sedation. Hyperreflexic L patellar
reflex compared to right. Withdraws bilaterally to babinski.
Pertinent Results:
[**2131-1-17**] 05:30PM LACTATE-0.8
[**2131-1-17**] 05:23PM GLUCOSE-130* UREA N-64* CREAT-3.5* SODIUM-141
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-33* ANION GAP-12
[**2131-1-17**] 05:23PM CK-MB-7 cTropnT-0.04*
[**2131-1-17**] 05:23PM WBC-5.7 RBC-2.74* HGB-8.4* HCT-26.1* MCV-95
MCH-30.8 MCHC-32.3 RDW-13.0
[**2131-1-17**] 05:23PM PLT COUNT-145*
[**2131-1-17**] 11:55AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-NEG
[**2131-1-17**] 11:12AM TYPE-ART RATES-/16 TIDAL VOL-550 O2-60
PO2-109* PCO2-53* PH-7.44 TOTAL CO2-37* BASE XS-10 -ASSIST/CON
INTUBATED-INTUBATED
[**2131-1-17**] 10:55AM FIBRINOGE-372
Micro:
Blood cultures 3/3 No growth x2 sets
Urine legionella negative
Sputum [**1-18**]:
GRAM STAIN (Final [**2131-1-18**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2131-1-20**]):
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). RARE GROWTH.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2131-1-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
BAL: [**1-18**]
GRAM STAIN (Final [**2131-1-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2131-1-20**]):
~4000/ML Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. ~[**2120**]/ML.
FURTHER WORKUP ON REQUEST ONLY Isolates are considered
potential
pathogens in amounts >=10,000 cfu/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2131-1-19**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
BAL:
Bronchial lavage:
NEGATIVE FOR MALIGNANT CELLS.
Pulmonary macrophages and bronchial cells.
ECG: [**1-17**]: Sinus rhythm. Low QRS voltage in the limb leads.
Non-diagnostic repolarization
abnormalities. No previous tracing available for comparison.
CXR:[**1-17**]
1. Mild pulmonary vascular congestion.
2. Right upper lobe consolidation, with irregular appearance
that may signify underlying mass. Please correlate with prior
imaging, and/or reimage following treatment and consider CT for
better delineation.
Head CT : [**1-17**]
1. No intracranial hemorrhage or acute intracranial abnormality.
2. 10-mm subgaleal low-attenuation fluid collection, without
underlying bony
abnormality or inflammatory change in the overlying subcutaneous
tissues.
3. Pansinus disease, with fluid in the right maxillary and
sphenoid air cells
and complete opacification of right mastoid air cells.
Chest CT [**1-17**]:
1. Probably right upper lobe pneumonia. **Six-week followup
radiograph to
document resolution is recommended to exclude an underlying
neoplasm**.
2. Bibasilar atelectasis and small nonhemorrhagic pleural
effusions.
3. T8 compression fracture of indeterminate chronicity.
4. Right renal cyst, incompletely characterized. Recommend
correlation with US.
5. Probable pulmonary hypertension.
TTE:
Small, hypertrophied, hyperdynamic left ventricle. No
clinically-significant valvular disease seen.
Brief Hospital Course:
70F with history of COPD on home O2, HTN, presenting with
shortness of breath and hypercarbic respiratory failure.
.
# Hypercarbic respiratory failure. Family gave history of pt
being more tired and lethargic x few days PTA, perhaps due to
hypoventilation. Patient with severe COPD at baseline,
presenting with hypoxia and ABG showing acute on chronic
respiratory acidosis. Thought to be due to worsening
obstructive disease vs. fluid overload vs infection, or
intracranial process causing central respiratory depression, as
patient's family reported pt had recent fall. CT head negative
for intracranial abnormality. Patient was intubated and placed
on a ventilator given her severe CO2 retention. She was
initially treated with vancomycin, levofloxacin and flagyl for
suspected respiratory infection. She was given one dose of
solumedrol 60mg, then started on prednisone 60mg PO daily and
standing albuterol and ipratropium nebulizer treatments for
suspected COPD exacerbation. CT chest showed an irregular
consolidation in the RUL suggestive of infection vs malignancy.
Patient was placed on repiratory isolation in order to rule out
TB. A bronchoscopy was performed and BAL was sent for gram
stain, AFB, culture and cytology; AFB was negative. Sputum gram
stain was positive for gram positive cocci in pairs. Urine
legionella antigen was negative. Patient's antibiotics were
scaled back based on sputum to only levofloxacin on day 2.
(which she completed a 7 day course) The patient was weaned off
the vent and extubated without difficulty on [**2131-1-19**]. Her
prednisone was tapered down to 40 mg po daily and she was
restarted on her home flovent on [**2131-1-20**]. At night the patient
was put on CPAP as she is on BiPAP on home (settings
unknown)--she was asked to have her family bring in her home
BiPAP machine.
She will need to continue her nebulizer treatments, flovent and
prednisone taper. She can be tapered down by 10mg each week, has
been on 40mg since [**1-20**]. She will continue on her oxygen by nasal
cannula at 3 liters
.
# ?Pulmonary Mass: CT and CXR show a ?RUL lung mass concerning
for neoplasm. This lesion appears to have been present
preceeding this hospitalization/infection and warrants REPEAT
IMAGING 6 WEEKS after this infectious process clears. The
patient was made aware of this on [**2131-1-20**] prior to discharge from
the ICU.
This was communicated to [**Doctor Last Name 16901**],who is the assistant for the
patients primary pulmonologist, Dr. [**Last Name (STitle) 58201**] in [**Location (un) 3320**] - ([**Telephone/Fax (1) 86114**]. She will follow-up with him on [**2131-3-9**] at 3:15 pm and
will need to schedule a Chest CT for 6 weeks from now, at [**Telephone/Fax (1) 86115**].
.
# Borderline hypotension. Improved with SBPs >100 consistently.
Concern initially for sepsis/severe pneumonia, but was likely
due to her hypovolemia given history of poor PO intake. Patient
given 500 cc boluses of NS x 2 on admission and her BP improved.
UOP was normal. Blood pressure at the time of discharge was
122/70
.
# Acute Renal Failure: BUN/Cr in ED 69/4.2 (recent past was 1.2
in [**Month (only) **]). Likely prerenal d/t poor forward flow and
hypovolemia. Urine lytes were suggestive of a pre-renal
etiology. Her home ACE-I was held initially then restarted on
[**2131-1-20**]. At time of discharge from the hospital, BUN/Cr improved
at: 25/1.0
.
# ECG changes. Minimal STEs vs. PR depressions on admission.
Troponin was elevated at 0.04 but stable x 3 sets. Serum CK was
mildly elevated at 368 with a CK-MB of 12 on admission and
subsequently trended down to CK of 250s and CK-MB of 6. TTE
demonstrated EF 75%, with mild LVH and mild diastolic
dysfunction, with no regional wall motion abnormalities.
.
# Anemia and thrombocytopenia. Hct last known 29 in [**Month (only) **].
Unclear reason for low plts but these normalized to 195 by time
of discharge from ICU. Iron demonstrated low iron, low TIBC,
consistent with anemia of chronic disease, and HCT remained
stable at 27. TSH was normal.
.
# OSA.
Continued on BiPAP as noted above.
# Osteoporosis
On her Chest CT scan, she was noted to have a compression
fraction at T8 of unknown duration. This is likely related to
her steroids. She was started on calcium and vitamin D and will
need a bisphosphonate started as an outpatient.
# Deconditioning
Given her poor baseline status and intubation, she was evaluated
by physical therapy as an inpatient. Her walking was limited by
her breathing and it was felt that she would benefit from
inpatient pulmonary rehabilitation after discharge.
.
CODE STATUS confirmed as: FULL CODE.
Medications on Admission:
Prednisone 2.5 mg daily
Lisinopril 20 mg daily
Levothyroxine 125 mcg daily
Lasix 20 mg daily
Gabapentin 300 mg TID
Zocor 40 mg daily
KCl 20 meq daily
Paxil 20 mg daily
Flovent 1 puff [**Hospital1 **]
Combivent Q4H prn
Forteo pen 20 mg SC daily
Vitamin D 1000 mg daily
Home O2 at 3LPM
Bipap at nighttime
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): would check finger sticks AC/HS,
prn sliding scale while on steroids.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Albuterol Sulfate 5 mg/mL Solution for Nebulization Sig: One
(1) Inhalation every 4-6 hours as needed for wheezing.
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): taper by 10 mg weekly (started 40mg on [**1-20**]).
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day): please give separated
from levothyroxine by at least one hour.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Hypercarbic respiratory failure
2. Pneumonia
3. Possible lung mass
4. Acute renal failure
5. Osteoporosis
6. Obstructive sleep apnea
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 diagnosed with respiratory failure. This is
predominantly due to your chronic obstructive pulmonary disease
(emphysema) and also in part due to obstructive sleep apnea. You
also had a pneumonia, for which you have completed a course of
antibiotics. You were ill enough to require intubation and
monitoring in the intensive care unit, but have made good
improvement since you have been here. However, given the
severity of your lung disease, you will need pulmonary
rehabilitation prior to returning home.
Followup Instructions:
PCP: [**Name10 (NameIs) **] schedule a follow-up with your pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 26909**]
at [**Telephone/Fax (1) 86116**] after you are released from your rehab facility.
Pulmonary: Dr. [**Last Name (STitle) 58201**] in [**Location (un) 3320**] - ([**Telephone/Fax (1) 86117**] Friday [**3-9**], [**2130**] at 3:15pm; please call [**Telephone/Fax (1) 86118**] to schedule a Chest
CT, which should be done 6 weeks from your discharge (mid [**Month (only) **])
ICD9 Codes: 5849, 486, 2762, 496, 4019, 2449, 4589, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3313
} | Medical Text: Admission Date: [**2127-2-21**] Discharge Date: [**2127-2-24**]
Service: MEDICINE
Allergies:
Celebrex
Attending:[**First Name3 (LF) 1642**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 61977**] is an 89yo woman with dementia, recent Cdiff
infection ([**2126-12-24**]) treated with PO vanco (ended last week,
diarrhea began again 2d ago), recent UTI with coag negative
staph (levo resistant). On [**2-19**] her daughter noticed increased
delirium, although no fever, and called her PCP. [**Name10 (NameIs) **] purchased
an OTC home urine test kit and diagnosed UTI for which her PCP
called in Bactrim x 3d. Despite 2d of antibiotics, she was
febrile today to 101 so her daughter brought her in to the ER
for treatment. She continued to be delirius, not sleeping at
night and instead calling out for her deceased husband. She has
had a decreased appetite. Her daughter noticed a great deal of
stool output in her diaper that was "yellow and smelled like her
C diff again."
Past Medical History:
1. Cholecystitis and choledocholithiasis complicated by bile
duct perforation in '[**24**].
2. DVT, PE treated with IVC filter [**4-29**].
3. GI bleeding secondary to perforated bile duct [**4-29**]
4. Hypertension.
5. Right total knee arthroplasty approximately seven years ago.
6. Either a femur fracture or a suprapatellar fracture of the
right side approximately five years ago.
7. s/p TAH/BSO
8. Glaucoma, s/p cataract surgery b/l.
9. History of hemorrhoids.
10. Dementia --not clear etiology.
11. VRE-bacteremia in urine [**2124**]
12. appendectomy
13. breast lumpectomy
Social History:
Widowed. Lives with son and daughter-in-law. [**Name (NI) **] 5 children. No
tobacco, previously drank red wine (a quart a day per her
daughter-in-law),but not recently; uses a wheelchair to ambulate
however no h/o falls.
Family History:
M died of breast CA at 101. F died of MI in 70s. Pt has
extensive family with 7 siblings.
Physical Exam:
96.7, 111, 129/90, 16, 97% on 3LNC
Gen: NAD, pleasantly confused, follows commands, oriented x 2,
year is [**2066**]
HEENT: MM moist,
Cor: irreg, tachy, no murmur
Pulm: CTA R, mild crackles at L base
Abd: sfot, NT, ND, +bs
Ext: 2+ edema over shins bilaterally, w/w/p
Neuro moves all 4, 5/5 strength LLE, 4.5/5 in RLE, [**3-29**] bilateral
grips
Pertinent Results:
notable for WBC 5.8 but 26% bands, on repeat 37% bands.
creatinine 0.9. hct 33.6. lactate 3.4-->3.6-->1.7 after 1.25L.
.
UA pos nitrites, sm leuk esterase, >50 wbc, 25 epithelials.
repeat shows [**10-14**] WBC, neg nitrities, sm leuk.
.
Bcx pending, stool c diff toxin pending.
.
Studies:
CXR: No evidence for pneumonia. Hiatal hernia.
Brief Hospital Course:
89yo woman with recent c diff infection, h/o VRE UTIs, presents
with UTI, febrile on Bactrim, hypotension, elevated lactate and
26 bands.
In ED, she was found to have a positive UA, lactate
3.4->3.6->1.7->1.1 after 3L IVF, BP 86/50 initially, which
resolved to sbp 96-100s in the ED on its own. A R IJ central
line was placed. She was slated to go to a regular floor bed but
then on recheck SBP was 86 so she was changed to an ICU bed
request. Since then BP has remained in the 100s-110s. CXR was
unremarkable, blood and stool cultures were sent (including for
Cdiff) and she was given levo/flagyl. Unfortunately, urine
culture was not sent prior to antibiotics being given. She was
given potassium repletion. She was admitted to the ICU for
further treatment.
.
On arrival to the ICU the patient denies CP, SOB, dysuria or
pain on urination, abdominal pain. She reports feeling cold and
thirsty. she can state her name and knows we are "in a hospital"
but is otherwise confused. However, this was noted later to be
her usual state (she says she is "in a hospital" when at home
with her daughter).
.
She was called out to the floor as she remained normotensive
without pressors overnight. Her R IJ was accidentally removed
on transfer, and a peripheral line was placed. On arrival to
the floor she was pleasantly confused, and denied any
complaints: No CP, SOB, palp, abdominal pain, GI or GU
complaints.
.
# Sepsis secondary to ?UTI/cdiff: Pt has fever, 26% bands,
infectious source c/w sepsis physiology. Cdiff was found
positive in one of two stool samples sent, and was treated with
flagyl. For suspected UTI, pt was given levo in the ED and was
started on [**Month/Year (2) 11958**] empirically for having a h/o VRE and most
recently in [**12-1**] having levo-resistant coag negative staph UTI.
The urine culture did not grow VRE, and pt was taken off
[**Date Range 11958**] and levo was chaged to cipro.
.
Diarrhea resolved over the course of hospital stay. On day of
discharge pt was tolerating regular diet without loose stools.
Pt was discharged home with po abx regimen of flagyl for
treatment of cdiff that covered her 14d beyond the cipro for
UTI.
.
CXR negative and no respiratory symptoms. Lactate seems to have
responded well to fluid resuscitation, normalizing before
arrival to the ICU.
.
# h/o HTN: Metoprolol was held at the beginning of
hospitalization given hypotension and picture of sepsis with
intention of restarting as needed. Once hypotension resolved,
her BPs remained in good range while hospitalized, thus
metoprolol was held throughout her stay. She was discharged off
of metoprolol with follow up with Dr. [**Last Name (STitle) 713**], her PCP, [**Name10 (NameIs) **] BP
follow up to reinitiate her BP meds as needed.
.
# Anemia: There was a drop in hct from 33->26 which was likely
secondary to dilution given this was after 3L of NS. Morevoer,
all three cell lines were diluted on cbc. There was no obvious
source of blood loss and hct was followed on a daily basis,
which remained stable in the high 20s-low 30s.
Medications on Admission:
* ASA 81mg po qday
* metoprolol 25mg [**Hospital1 **]
* Bactrim DS [**Hospital1 **] x 3 days (took two pills only)
* ativan prn however hasn't taken this in months, then took once
yest
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 19 days.
Disp:*57 Tablet(s)* Refills:*0*
4. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
Cdiff
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor if you have any diarrhea,
nausea/vomiting, fever>101, chills, burning/pain on urination,
mental status change, or any other concerns that worry you.
Please complete your course of anitbiotics as prescribed. Even
if you feel better, please finish all pills. Please continue
with all your medications, EXCEPT METOPROLOL, prior to
admission.
Followup Instructions:
Please call your primary care physician to schedule an
appointment as needed: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 719**]. She
will continue to hold telephone appointments with you.
Completed by:[**2127-3-1**]
ICD9 Codes: 0389, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3314
} | Medical Text: Unit No: [**Numeric Identifier 77833**]
Admission Date: [**2195-3-19**]
Discharge Date: [**2195-3-31**]
Date of Birth: [**2195-3-19**]
Sex: M
Service: NB
HISTORY: This infant was admitted to the NICU for evaluation
of hematochezia. At the time of admission the infant was a 2-
[**2-4**] day old full-term newborn born to a 36-year-old G4P3 now 4
mother. Prenatal screens: blood type 0 positive, antibody
negative, HBsAg negative, RPR nonreactive, Rubella immune, GBS
unknown.
The maternal history was notable for Factor V Leiden
deficiency with a history of DVT, thyroid disease and
thrombocytopenia. Maternal medications included iron, Levoxyl
and Lovenox. Mother had a previous history of 3 cesarean
sections, all children are currently doing well. There is no
history of feeding intolerance or milk protein allergy. There
were no prenatal sepsis risk factors, nor maternal fever.
Rupture of membranes was at the time of delivery which was by
repeat C-section. There was clear amniotic fluid, and
maternal anesthesia was by epidural. The infant emerged
vigorous with Apgars of 9 and 9. The birth weight was 4390
grams.
The infant had been doing well in the newborn nursery for 2
days with normal vital signs, voiding and passing meconium
which was changing to transitional stools on the morning of
admission. The patient had a 10% weight loss at 2 days of
life. Hypoglycemia protocol was started for large for
gestational age status. All measurements were within normal
limits. Family history and social history are otherwise
noncontributory. The review of systems was also otherwise
nonapplicable.
On the day of admission the infant presented with a frankly
bloody stool in the newborn nursery. No rectal fissure was
noted and the infant was admitted to the NICU for further
care and evaluation.
BIRTH MEASURES: Birth weight of 4390 grams which is greater
than 90th percentile. Length of 20 inches. Head circumference
of 36 cm which is greater than 90th percentile.
PHYSICAL EXAM AT DISCHARGE: Showed active, alert male
infant. HEENT: Anterior fontanelle soft and flat, bilateral
red reflex present. Intact palate, supple neck, normal
facies. Respirations: Clear and equal. No increased work of
breathing. Cardiac: No audible murmur, pink and well-
perfused. Normal pulses. Brisk cap refill. GI: Abdomen soft
and round with active bowel sounds. Cord dry and intact. No HS
M/ masses. GU: Normal male with descended testicles.
Well-healed circumcision. Musculoskeletal: Straight spine.
Intact hips and clavicles. Moves all extremities well. Neuro:
Good tone, cry and activity. Normal reflexes.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory - The infant remained stable in room air while
in the NICU with no issues.
2. Cardiovascular- The infant has remained stable
cardiovascularly with no audible murmur. To rule-out a
potential ischemic cause of bowel injury, a cardiac
evaluation was performed to rule out any cardiac anomaly
and/or any clots within the cardiovascular system. The
EKG was within normal limits. An echocardiogram was done
with a cardiology consult. The echocardiogram (performed
[**2195-3-25**]) showed no clots, no PDA, small PFO and good
biventricular function and normal cardiac structure. No
further cardiac follow up is recommended at this time.
Access: PICC line was placed on [**2195-3-25**] and subsequently
discontinued on [**2195-3-29**] when infant reinitiated
feedings.
3. Fluids, electrolytes and nutrition - On admission to the
NICU the infant was made n.p.o.and started on peripheral
IV fluids. The infant remained n.p.o. for a total of 7
days in the NICU while on IV fluids for bowel rest. The
infant was restarted on oral feedings on [**2195-3-28**] and has
since been breast feeding exclusively with no
supplementation given. The infant has stooled since
restarting feedings which have been heme negative.
Discharge weight: 3695 grams.
4. Gastroenterology - The exact etiology of the infant's
hematochezia remains unknown. The infant was treated for
7 days with antibiotics for possible term infant
necrotizing enterocolitis; however he never demonstrated
the salient features of pneumotosis. Infectious
etiologies for an inflammatory enterocolitis were also
ruled out with negative sepsis evaluations and stool
cultures. Although the initial KUBs were abnormal due to
the lack of bowel gas and for what appeared to be
thickened bowel loops, the KUBs did eventually normalize
by the end of day 7 and a KUB after refeeding remained
normal. The abdominal exam had remained benign
throughout the NICU stay from admission to discharge. An
abdominal ultrasound was also performed to assess the
bowel and the vascular structures within the abdomen.
There were no abnormalities seen.
The surgical service at [**Hospital3 1810**] was consulted
and followed with us. The service did not feel the
clinical picture was consistent with an obstructive
process or NEC. Per surgical recommendations, the infant
was treated for 7 days for presumed necrotizing
enterocolitis in the absence of any other cause for the
bloody stool. There is no recommended surgical follow up
needed at this time.
The mother was told to follow the infant's stooling
patterns closely and if blood were to be noticed again to
inform the pediatrician immediately. It is possible that
this could have represented a milk protein allergy
although it would be unusual to present this early and on
a breast milk diet (though possible).
5. Hematology - No blood typing has been done on the
infant. The hematocrit on admission was 44, platelet count
of 445,000. PT and PTT were done on admission to the NICU
with fibrinogen. The PT was 14, PTT 37, fibrinogen of 353
-- all within normal limits. Follow up hematocrits and
platelets have remained stable.
6. Infectious disease - CBC and blood culture were screened
on admission to the NICU. CBC was benign with normal
white blood cell count, and no left shift. Infant was
given 7 days of IV antibiotic treatment with Zosyn.
7. Neurology - The infant has maintained a normal neurologic
exam for gestational age.
8. Sensory - Audiology - hearing screen was performed with
automated auditory brainstem responses and the infant
passed in both ears.
9. Psychosocial - Family is intact. Mother is [**Name (NI) **],
father is [**Name (NI) 10378**]. There are 3 older brothers -- 8 years, 5
years and 3 years old. Family is actively involved.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5656**], M.D., telephone
#[**Telephone/Fax (1) 48440**], address - [**Street Address(2) 77834**], [**Location (un) 31384**], [**Numeric Identifier 77835**].
CARE RECOMMENDATIONS: Ad lib p.o. feedings by breast with
introduction of iron and multivitamin supplementation as
needed per guidance by pediatrician.
MEDICATIONS: None.
IRON AND VITAMIN D SUPPLEMENTATION:
1. Iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age.
2. All infants on predominantly breast milk should receive
vitamin D supplementation at 200 international units
which may be provided as multiple vitamin preparation
daily until 12 months corrected age.
State newborn screen was sent on [**2195-3-21**], results were within
normal limits.
IMMUNIZATIONS RECEIVED: Hepatitis B Vaccine [**2195-3-30**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criteria: Born less than 32 weeks
gestation; born between 32 and 35 weeks with 2 of the
following, either daycare during RSV season, smoker in
the household, neuromuscular disease, airway
abnormalities or school age siblings; chronic lung
disease; hemodynamically significant congenital heart
defect.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, infant immunizations against influenza is
recommended for household contacts and out of home
caregivers.
3. This infant has not received rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following discharge
from the hospital if they are clinically stable and at
least 6 weeks, but fewer than 12 weeks of age.
FOLLOW UP APPOINTMENT: Recommended with pediatrician within
2 days of discharge from the NICU.
DISCHARGE DIAGNOSES:
1. Term male newborn
2. Large for gestational age
3. Hematochezia
4. Sepsis ruled out
5. Presumed enterocolitis status post 7 days of bowel rest and
antibiotics
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 75423**]
MEDQUIST36
D: [**2195-3-30**] 22:40:37
T: [**2195-3-31**] 00:09:45
Job#: [**Job Number 77836**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3315
} | Medical Text: Admission Date: [**2166-12-5**] Discharge Date: [**2167-1-1**]
Date of Birth: [**2099-9-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Metastatic cervical cancer with abdominal carcinomatosis and
obstructive symptoms
Major Surgical or Invasive Procedure:
Exploratory laprotomy
Placement of G-tube
History of Present Illness:
Ms. [**Known lastname 9006**] is a 67-year-old woman
diagnosed with metastatic cervical cancer approximately six
years ago, was treated with radiation and chemotherapy. She
had done well until recently when she developed obstruction
of the third portion of her duodenum. The patient was
referred to Dr. [**Last Name (STitle) 816**] because of concern for a biliary problem.
[**Name (NI) **]
biliary tree proved subsequently to be intact; however, she
had continued problems with emptying her gastrojejunostomy.
As the reasons for this were unclear, as well as a reason to
make a definitive diagnosis of a periaortic mass and
intestinal studding, which had previously come back only as
fibrotic tissue, as well as the possibility of tuberculosis,
she underwent exploration for 1) establish a diagnosis of
peritoneal fibrosis versus tuberculosis versus metastatic
cancer, 2) for palliation of her inability to tolerate p.o.
Past Medical History:
cervical cancer s/p chemo and radiation in [**2159**]
hypertension
acute renal failure
intermittent small bowel obstruction
Social History:
no tobaccono EtOHmarriedmoved to US in [**2158**]
Family History:
non-contributory
Brief Hospital Course:
Admitted [**2166-12-5**] with symptoms of carcinomatosis of the abdomen
and biliary obstruction. She spiked a temperature on [**2166-12-13**] and
was cultured: Klebsiella was isolated from sputum. Over the
next week and a half, her nutrition was optimized for the OR
with TFs and IVF and later TPN, Doboff was removed on [**2166-12-21**].
Pt was taken to the OR on [**2166-12-23**] for an ex-lap, gastrostomy and
staging biopsies for known intestinal and periaortic masses.
The path result return poorly differential carcinoma. She was
transferred to the SICU post-operatively and based on the
intraoperative findings, it was thought that her condition was
not amenable to resection or future radiation and was moreover,
incompatible with life. After a long discussion with the
patient and family, she was transferred to the floor on POD#3
and made DNR. She was placed on a PO regimen of pain
medication, and antibiotics were stopped; she was restarted on
TPN and a Nutrition consult was obtained to aid in her
manangement. TPN was transitioned to TF, and placement in a
Hospice facility was sought. She was discharged to a hospice
facility in Brookeline on POD#9 in stable, but terminal
condition.
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-10 mg PO q2
hour:PRN: For pain relief.
Disp:*qs qs* Refills:*2*
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): hold for SBP<100 and HR<60.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
1) Metastatic cervical cancer
2) Carcinomatosis of the abdomen
3) Obstruction of gastrojejunostomy
Discharge Condition:
DNR, DNI. Vital signs stable, palliative measures only. Pain
controlled with PO regimen.
Discharge Instructions:
Discharge to [**Hospital 7578**] Health Care-Hospice. Medications as
written, continue O2 and IVF as needed. Continue TF as written
10cc/hr. PO as tolerated.
Followup Instructions:
None indicated
ICD9 Codes: 2762, 5845, 2765, 0389, 5185, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3316
} | Medical Text: Admission Date: [**2107-3-29**] Discharge Date: [**2107-4-13**]
Date of Birth: [**2025-8-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81yoM HTN, CHF, Stage III CKD, lung cancer s/p wedge resection,
prostate CA, s/p hormonal tx and XRT presented [**3-29**] with 4 days
RLQ pain, admitted to surgery for ruptured appendix which was
medically managed, transferred to medicine service on night of
transfer after a trigger for tachycardia.
Pt presented [**3-28**] with RLQ abd pain. Per surgery note, pt
reported he was in his usual state of health until 4 days prior
to presentation when he purchased a bottle of wine and drank [**2-5**]
of the bottle, followed by dull pain and tenderness in RLQ
without radiation. Pain persisted over the next four days,
relatively unchanged, until the pt presented to his PCP for an
urgent care visit on [**2107-3-28**]. During this time, he notes
decreased appetite and loose
stools 2-3x/day. He denies fevers, chills. He notes chronic SOB
unchanged recently and denies chest pain.
Pt was admitted to surgery service on [**3-28**], had a CT of abd,
which showed a perforated appendix with possible early abscess
formation. He was started on hep sq, cipro, and flagyl, and
medically managed on surgery service.
Transferred from [**Hospital Ward Name 1950**] 5 at 7pm from surgery service to
medicine service. HR upon transfer 100, sbp ~100, 2l oxygen.
Around 2200, staff noticed pt "not looking good," hr rose to
120-130s, pt diuresed 10mg iv lasix, bp dropped from 110/60 to
96/56 to 92/58, remained on 2L. Also received one albuterol
neb, ipratropium neb, and PO ativan for concern for ethanol
withdrawal. EKG showed rapid rate at 130, likely afib, nl axis.
Past Medical History:
1. COPD
2. HTN
3. CHF EF <35% - inferior scar and LVEF 43% on [**2103**] MIBI
4. PAF
5. Depression
6. Hip Fx
7. Hyperlipidemia
8. Osteoporosis
9. Stage III CKD (baseline Cr 1.3-1.5)
10. Mild Cognitive Impairment
11. Lung Cancer T1 Adenocarcinoma - wedge resection [**2105**]
12. s/p RUL wedge resection [**7-10**] ([**Doctor Last Name 952**]) - unable to perform
complete lobar resection [**3-7**] poor respiratory reserve. c/b
persistent mediastinal lymph node followed by yearly CT
13. Prostate CA - high grade, s/p Lupron tx, XRT - in [**12-11**]
14. s/p left intertrochanteric nail '[**97**]
15. pancreatic head mass -- likely IPMT
Social History:
He lives alone in [**Location (un) **] apartment. He was divorced 25 yrs
ago. (+) tobacco 69 pack yrs quit 3 yrs ago. has been drinking
since his divorce 25 yrs ago 1/2-1 liter wine qd. no hard
liquor. He lost his job at [**University/College **] because
Family History:
noncontributory
Physical Exam:
On Transfer to the [**Hospital Unit Name 153**]
T=98 BP83/61 HR110 (after 10mg iv lopressor) RR 16 99%2l
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing ..... in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: 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: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**2-4**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ECHO [**3-30**]: prior myocardial infarction without inducible
ischemia to achieved low workload. Blunted heart rate response
to physiologic stress. Moderate regional left ventricular
systolic dysfunction. Moderate mitral regurgitation at rest. At
least moderate pulmonary artery systolic hypertension. EF 35%.
.
CT abd [**3-28**]:
1. Findings are consistent with perforated appendicitis with
surrounding phlegmonous or early abscess collection. Small
locules of extraluminal air are noted within the pelvic cavity
with free fluid and air also noted to track into the right
inguinal ring. Edema of the terminal ileum is presumed to be
reactive.
2. Known underlying emphysema and extensive atherosclerotic
disease.
3. Stable hypoattenuating pancreatic head lesions likely
representing side branch IPMT.
CT abd/pelvis [**2107-4-12**]:
Final Report
INDICATION: Perforated appendicitis being conservatively managed
with
antibiotics, please evaluate for fluid collections or
pseudocyst.
COMPARISON: [**2107-4-2**].
TECHNIQUE: Axial MDCT images were obtained from the lung bases
to the pubic
symphysis with oral contrast only but no intravenous contrast.
Coronal and
sagittal reformatted images are provided.
CONTRAST: Oral contrast only.
CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Large bilateral
pleural
effusions of low density are slightly increased from the CT of
[**4-2**].
There is adjacent atelectasis in the lower lobes bilaterally,
also more
marked. Focal calcifications along the left hemidiaphragm
(2A:11) are
unchanged and could represent sequelae of prior asbestos
exposure. The
aerated portions of the lungs appear unremarkable. Heart and
pericardium
appear unchanged.
Allowing for non-contrast technique, the liver, spleen, adrenal
glands, and
pancreas appear unremarkable, although it is noted that
hypodense pancreatic
lesions were seen on previous contrast examination that are not
evident on
today's study. Bilateral renal calcifications are most likely
vascular in
nature, and there is no evidence of hydronephrosis. Abdominal
aorta is normal
in caliber with mural calcification consistent with atheromatous
disease.
Since the previous examination of [**4-2**], the degree of
distention of the
proximal small bowel has decreased somewhat, and there is now
passage of
contrast into the colon without definite evidence of small bowel
obstruction.
Note is made of a filling defect in the distal esophagus, which
is hyperdense
and most likely represents a pill. Numerous additional similar
structures are
seen in the ascending colon and cecum, also most likely
representing pills.
Again seen is a distended appendix containing contrast and air
at its base
with periappendiceal stranding and inflammation as well as
extraluminal gas,
consistent with the patient's known appendiceal perforation. A
couple of very
small adjacent organized fluid collections are seen, the largest
in the right
lower quadrant measuring 1.8 x 2.3 cm (2A:61), probably
minimally decreased
from the previous examination and no longer containing gas as it
had at the
time of the prior scan. No new developing fluid collections are
identified.
Hyperdense material again seen within the non-distended
gallbladder possibly
representing stones or sludge.
CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: A left-sided fat-
and fluid-
containing inguinal hernia is again noted, slightly larger than
at the time of the previous study. Smaller right-sided fat- and
fluid-containing inguinal hernia is seen with the fluid
component decreased in size and no longer containing gas. A
Foley catheter is in place within the bladder which appears
otherwise unremarkable. Prostate and seminal vesicles, and
hyperdense prosthetic structures possibly representing
brachytherapy seeds, are unchanged. Rectum and sigmoid colon
appear unremarkable. A small collection in the right upper
pelvis is probably slightly decreased as previously described.
There is diffuse stranding throughout the subcutaneous tissues.
Bilateral femoral neck compression screws in unchanged
orientation.
BONE WINDOWS: Degenerative change of the lumbar spine again
noted.
IMPRESSION:
1. Slight decrease in size of small fluid collections adjacent
to the
patient's known perforated appendicitis, without evidence of
drainable
collections or new collections.
2. Decrease in previously present small bowel obstruction with
only mild
residual small bowel dilation, possibly reflecting ileus.
3. Increase in large bilateral pleural effusions and adjacent
bilateral lower lobe atelectasis.
4. CT appearance of pills located in distal esophagus and in the
colon and
cecum.
[**2107-4-10**] RUE U/S:
Final Report
HISTORY: 81-year-old male with asymmetric right extremity
swelling, with PICC
line. Evaluate for DVT.
COMPARISON: None available in the [**Hospital1 18**] PACS.
RIGHT UPPER EXTREMITY ULTRASOUND: The right arm is erythematous
and
edematous, with multiple blisters on the medial aspect several
centimeters
proximal to the elbow. Grayscale, color, and pulse wave Doppler
ultrasound of
the right upper extremity were performed to evaluate for deep
venous
thrombosis.
A right PICC line enters the basilic vein, and courses beyond
the subclavian vein into the superior vena cava. The subclavian
vein demonstrates thrombus on grayscale images, with minimal
flow distally. Except for where instrumented by PICC, the right
basilic and axillary veins are compressible and demonstrate
color flow with appropriate waveforms. No augmentation maneuvers
were performed due to thrombus in the subclavian vein, and the
patient was unable to perform Valsalva maneuvers. However, flow
in the basilic, axillary, internal jugular, and brachial veins
demonstrate respiratory phasicity. Although compression of the
brachial veins was somewhat difficult, they were somewhat
compressible and demonstrated normal flow with appropriate
waveforms and respiratory variation, and likely do not contain
thrombus. The left subclavian vein was evaluated for comparison,
and demonstrate wall-to-wall flow and collapsibility during the
respiratory cycle.
IMPRESSION: Thrombus in the right subclavian vein, with minimal
if any distal flow.
PCXR [**2107-4-13**]:
Final Report
HISTORY: Left PICC line placement.
FINDINGS: In comparison with study of [**4-6**], there has been
placement of a left subclavian PICC line that extends to the
upper portion of the SVC. Persistent prominent bilateral pleural
effusions. The pulmonary vascular congestion appears to have
substantially reduced.
Brief Hospital Course:
81 yo male with PMH of HTN, CHF, Stage III CKD, lung cancer s/p
wedge resection, prostate CA, s/p hormonal tx and XRT presented
[**3-29**] with 4 days RLQ pain, admitted to surgery for ruptured
appendix which was medically managed, transferred to medicine
service on night of transfer after a trigger for tachycardia,
transferred to micu for 5 day course for management of
tachycardia, called out to medical floor with stable vital
signs.
#Atrial Tachcyardia: Patient was initially in 150's-160's with
SBP in 80's though denying light-headedness, SOB, chest pain, or
any other issues. His heart rate was initially controlled with
iv lopressor with uptitration to po lopressor. The rhythm
transitioned from sinus tachycardia with apbs, with some EKGs
which could not rule out atrial fibrillation. Cardiac enzymes
were checked and were not consistent with an ACS. CTA ruled out
PE. Cardiology was consulted (thought tachycardia was sinus
tach with APBS and MAT) and was due to intra-abdominal appendix
rupture and inflammation, recommended watching clinically, with
consideration of digoxin therapy, which was not initiated.
#Anemia, Guiac positive stool: On the day of presentation to the
[**Hospital Unit Name 153**] the patient had guiac positive stools and a Hct drop from
27-24, with no signs of hemodynamic instability; there was no
melena or hematochezia. GI was consulted, thought no indication
for immediate scope and that this could be dangerous given
ruptured appendicitis. Over the following days, patient showed
no signs of bleed and had a stable hematocrit. His aspirin and
heparin sq was held in ICU and upon transfer to medical floor.
#Ruptured appendicitis: The patient was conservatively managed
by surgery with antibiotics and this was continued with
ciprofloxacin and metronidazole, initiating date was [**3-29**], with
continuation until [**4-2**], then changed to vanco/zosyn for broader
coverage until [**4-6**], then transitioned back to cipro/flagyl, with
plan to complete full course of abx until [**4-23**]. Bladder
pressures and lactates were monitored while in ICU, which both
remained normal, in addition to stable abdominal exam. The
patient's abdominal exam improved and the patient was advanced
to a regular diet per surgery on day of discharge.
-Antibitics can likely be changed to oral if he is tolerating
regular diet well (CT scan had demonstarted retained meds in
esophagaus and stomach).
-Patient to have outpatient surgery f/u.
#Renal failure: pt noted to have rising creatinine from 1.0 to
1.4, 1.8, and 1.9 while in [**Hospital Unit Name 153**]. Urine electrolytes suggested
pre-renal physiology, but clinical suspicion for
contrast-induced nephropathy was high, given dye load on [**4-2**].
Pt was not diuresed in this setting (o2 requirements at 4L
thought [**3-7**] chf, copd) and allowed to run positive. The renal
failure was non-oliguric throughout this course and remained
stable with discharge creatinine of 2.1.
#Right Subclavian Vein thrombus: The patient had RUE swelling in
the arm he initially had a PICC line in. RUE U/S revealed a
thrombus in the right subclavian vein, with minimal if any
distal flow. Given recent hct drop in ICU with concern for GI
bleed, the patient was started on a heparin ggt. If patient
continues to tolerate heparin ggt well, can transition to
lovenox and coumadin for a three month course.
Medications on Admission:
1. ALENDRONATE 70 mg weekly
2. ATENOLOL 100 mg daily
3. PRAVASTATIN 40 mg daily
4. TIOTROPIUM BROMIDE 18 mcg Capsule 1 puff inhalation daily
5. TRAZODONE 75 mg qHS
6. ASPIRIN 325 daily
7. CALCIUM CARBONATE 500 mg TID
8. Vit D3 400 U [**Hospital1 **]
9. Daily MVI
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q
8H (Every 8 Hours).
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO Q 12H (Every 12 Hours).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
11. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation q2h () as needed for SOB.
12. Heparin, Porcine (PF) 10,000 unit/5 mL Solution Sig: One (1)
dose Intravenous continuos: Heparin ggt per DVT protocol.
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
15. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 10
days.
16. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four
Hundred (400) mg Intravenous Q12H (every 12 hours) for 10 days.
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Perforated Appendicitis
Ileus/Partial SBO
Anemia from acute GI bleed
Acute Renal Failure
Multi-atrial Tachycardia
Right Subclavian DVT
COPD Exacerbation
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to the ED if you are having very high fevers, severe
abdominal pain, confusion.
You had a perforated appendicitis which was treated
conservatively with antibiotics.
Followup Instructions:
Tuesday. [**4-26**] at 10am [**Hospital1 18**] Surgery clinic with Dr. [**Last Name (STitle) 1924**]
[**Telephone/Fax (1) 7508**]
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2107-6-3**] 1:10
Provider: [**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2107-6-13**]
2:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD,PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2107-6-23**] 9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule
appointment
ICD9 Codes: 5849, 2851, 5789, 4280, 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3317
} | Medical Text: Admission Date: [**2201-4-12**] Discharge Date: [**2201-4-20**]
Date of Birth: [**2129-2-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Fever and Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname **] is a patient well-known to our service who has had a
long and complicated history originating with his pancreatic
pseudocyst, gallstone pancreatitis, and a challenging
post-operative course therein. After an arduous recovery, Mr
[**Known lastname **] was discharged to the [**Hospital6 **]
under the expert care of Uri [**Doctor Last Name **]. He was eventually weaned
from ventilatory support and his tracheostomy was removed. He
complained on [**4-9**] of Fever to 103 and hypotension. He
subsequently developed respiratory distress and had to be
re-trached and placed on a ventilator. He denies
nausea/vomiting, or other constitutional signs. He presents for
evaluation and management of fever and respiratory distress.
Past Medical History:
HTN
CAD, s/p angioplasty
s/p AVR [**7-6**]
Respiratory failure
tracheostomy
Failure to thrive
s/p R knee surgery
ventilator associated pneumonia
pancreatic pseudocyst
Atrial fibrilation
galstone pancreatitis
picc line placement
cholelithiasis
COPD
CHF
sepsisq
Social History:
lives with his wifeformer tobacco use
Physical Exam:
Physical exam on discharge:
Lungs CTA B bs
Herat rrr nm ng
Abd soft nt nd
Cns awake, alet MAE FC
ext + edema pos pulses
Pertinent Results:
[**2201-4-12**] 05:15PM BLOOD WBC-13.1* RBC-3.08* Hgb-9.7* Hct-29.6*
[**2201-4-19**] 04:29AM BLOOD WBC-8.1 RBC-3.13* Hgb-9.2* Hct-29.1*
Brief Hospital Course:
Pt admitted through ER for fever and hypotension. Admitted to
SICU for ventilatory management. His indwelling PICC line was
removed. Cultures drawn and pt continued on meropenem and zyvox
as [**First Name8 (NamePattern2) **] [**Hospital1 **].
Resp: He was placed on assist-control mode ventilation with a
PEEP of 10. A speech and swallow eval was reluctant to advance
his po's as at that high of PEEP his ability to swallow would be
impaired. Throughout his hospital course his PEEP was gradually
reduced. This was not pursued aggressively, as it was felt that
[**Hospital1 **] was well-suited to do a long, gradual [**Hospital1 **] wean that
would be ideal for this patient, and the acute hospital issue
was the infection. He was discharged on the [**Hospital1 **] with a PEEP of
5 on assist-control, with the understanding that [**Hospital1 **] would
resume his [**Hospital1 **] wean.
GI: As he had no active GI issues, his tubefeeds were rapidly
increased to his goal rate. He tolerated this well, as would be
expected. No other acute GI issues.
ID: Although pt arrived with high fevers and likely infection,
his cultures were negative except for a positive MRSA screen,
which was unsurprising as the pt is known to be MRSA-positive.
Pt continued to be afebrile throughout hospital course on
meropenem and linezolid.
Neuro: Pt has been on long-term [**Last Name (LF) **], [**First Name3 (LF) **] no significant sedation
was needed for [**First Name3 (LF) **] tolerance. No other active issues.
GU: Although a UTI was suspected as an infectious source, urine
culture was negative.
Medications on Admission:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
mL Injection TID (3 times a day).
2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours)
10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) susp PO DAILY (Daily).
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
12. Meropenem 1 g Recon Soln Sig: One (1) gram Intravenous every
eight (8) hours
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
mL Injection TID (3 times a day).
2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) susp PO DAILY (Daily).
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
12. Meropenem 1 g Recon Soln Sig: One (1) gram Intravenous
every eight (8) hours for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Fever of likely respiratory origin
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed. [**Location (un) 5442**] wean as per Sapulding
protocols. If pt experiences return of fevers, chills, rigors,
respiratory difficulty, or other concerning symptoms, please
contact our office or the [**Hospital1 18**] Emergency dept.
Followup Instructions:
Please contact [**Name (NI) 20112**] office to arrange follow up.
Completed by:[**2201-4-20**]
ICD9 Codes: 0389, 5070, 496, 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3318
} | Medical Text: Admission Date: [**2183-6-26**] Discharge Date: [**2183-7-14**]
Date of Birth: [**2135-3-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**2183-7-2**]
PROCEDURES:
1. Open reduction internal fixation of bilateral maxillary
Lefort
I fracture with multiple approaches
2. Open reduction internal fixation of right orbital floor blow
out fracture with titanium plate.
3. Open reduction internal fixation of nasoorbitoethmoid
fracture
4. Open reduction internal fixation of nasal fracture
5. Open reduction internal fixation of nasomaxillary complex
fracture, Lefort II, right with multiple approaches.
6. Complex layerered closure laceration, nasal dorsum
[**2183-7-2**]
Tracheostomy
[**2183-7-8**]
1. Posterior cervicothoracic arthrodesis, C5 to T1.
2. Instrumentation, posterior, C5 to T1.
3. C7 and C6 laminectomy.
4. T1 laminotomy.
5. Open reduction of fracture-dislocation.
6. Application of local autograft.
7. Application of allograft for fusion augmentation.
History of Present Illness:
48 F s/p fall down 13 stairs at home sustaining significant
facial trauma; +EtOH. Intubated for airway protection because
due to combativeness. Transported to [**Hospital1 18**] for further care.
Past Medical History:
HTN, psoriasis
Social History:
Alcoholism
Family History:
Noncontributory
Physical Exam:
PE: (in ICU)
On exam, the patient is intubated and sedated. She reveals a 4
x
3 cm stellate laceration over her nasal bridge with exposed bone
and muscle. She has a 4 cm transverse subciliary laceration
down
to muscle. The patient has a full thickness partial avulsion of
[**12-28**] to [**12-27**] of her right upper lip. The patient demonstrates
bilateral peri-orbital ecchymosis. No facial step offs. Bony
instability at nasal bridge. No nasal septal hematoma.
Significant intra-oral lesions associated with partial avulsion
of upper lip. Edentulous. Midface instability noted.
Pertinent Results:
[**2183-6-26**] 11:37PM TYPE-ART PO2-149* PCO2-47* PH-7.40 TOTAL
CO2-30 BASE XS-3
[**2183-6-26**] 11:37PM LACTATE-0.7 K+-3.4*
[**2183-6-26**] 07:34AM GLUCOSE-113* UREA N-8 CREAT-0.6 SODIUM-141
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-23 ANION GAP-14
[**2183-6-26**] 07:34AM ALT(SGPT)-35 AST(SGOT)-58* ALK PHOS-61 TOT
BILI-0.3
[**2183-6-26**] 07:34AM LIPASE-107*
[**2183-6-26**] 07:34AM PT-11.4 PTT-26.2 INR(PT)-0.9
[**2183-6-26**] 04:56AM WBC-18.2* RBC-3.50* HGB-12.3 HCT-35.7*
MCV-102* MCH-35.2* MCHC-34.5 RDW-12.2
[**2183-6-26**] 04:56AM PLT COUNT-276
CT Head [**2183-6-26**]
IMPRESSION:
1. No intracranial hemorrhage.
2. Extensive midface trauma detailed in the separately reported
CT of the
facial bones and paranasal sinuses.
CT c-spine [**2183-6-26**]
IMPRESSION: Fracture of the posterior elements of C6. No acute
cervical
spine malalignment.
CT Sinus/Mandible [**2183-7-3**]
IMPRESSION: Status post repair of bilateral Le Fort I fractures
and right Le [**Location 56204**] fracture. High-density fluid within all the
paranasal sinuses
consistent with blood. Proptosis of the right eye when compared
to the left with no evidence of retrobulbar hemorrhage, and
intact globe and lens.
Repeat CT Sinus/Mandible [**2183-7-9**]
IMPRESSION: Essentially stable appearance status post repair of
bilateral Le Fort I and right Le [**Location 56204**] fractures, with
high-density fluid within
paranasal sinuses representing blood. Proptosis of the right eye
when
compared to the left continues, although there is slight
diminution of the
low-density fluid anterior to the right eye. No signs of an
infection are
demonstrated, though this (non-enhanced) study is certainly not
the most
sensitive method.
T-spine [**2183-7-12**]
FINDINGS: On the current study, there is some anterior
displacement of C4
with respect to C5 with slight angulation at this intervertebral
disc space. Minimal residual prominence of the anterior soft
tissues are seen. Posterior fusion device is again noted at C5
and T1.
Brief Hospital Course:
She was admitted to the Trauma service. Orthopedic Spine and
Plastic surgery were initially consulted. she was taken to the
operating room on [**7-2**] for repair of her multiple facial
fractures; a tracheostomy was also performed at that time by
Trauma Surgery. Postoperatively she was taken to the Trauma ICU
where she remained sedated and vented. On [**7-8**] she was taken to
the operating room by orthopedic spine surgery for stabilization
of her spine fractures. There were no intraoperative
complications. Postoperatively she remained in the Trauma ICU
and was eventually weaned from sedation and extubated. A
Dobbhoff was placed early on and tube feedings were initiated.
During her ICU stay she intermittently had high fever spikes and
was pan cultured. Infectious disease was consulted given the
leukocytosis and elevated lipase and amylase levels. It was felt
the fever spikes were secondary to acute pancreatitis which did
resolve and also because of sputum came back positive for
Klebsiella and she was started on a 10 day course of
Levofloxacin.
She was eventually transferred to the regular nursing unit where
her mental status slowly showed improvement. A Swallow
evaluation was done for which she initially failed. The Dobbhoff
remained and tube feeding continued until patient self removed
the Dobbhoff. A trial with oral diet was done for which she was
able to eat without any overt signs of aspirating. Her diet was
then upgraded t regular with supervision for all meals.
Her tracheostomy was downsized to a 6 french, fenestrated,
cuffless. She tolerated this without difficult.
She was evaluated by Physical and Occupational is being
recommended or acute rehab after her hospital stay.
Medications on Admission:
atenolol 50', lisinopril 10', HCTZ 12.5', hydroxizinge [**10-14**]
QHS
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-27**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
2. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units
Injection TID (3 times a day).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**3-31**]
hours as needed for fever or pain.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML
PO Q6H (every 6 hours) as needed for constipation.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. FoLIC Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
13. Bisacodyl 10 mg Suppository Sig: One (1) supp Rectal DAILY
(Daily) as needed for constipation.
14. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
s/p Fall
Multiple facial fractures - LeForte fracture
Right orbital fracture
Avulsion laceration right lip
T7 compression fracture
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
Call your doctor or go to the ER if you experience any high
fevers, increased pain, or purulent drainage from your wounds.
Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma surgery for
evaluation of tracheostomy removal. Call [**Telephone/Fax (1) 6429**] for an
appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 1007**], Orthoepdic Spine; call
[**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks in Plastics surgery, call [**Telephone/Fax (1) 5343**] for
an appointment.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3319
} | Medical Text: Admission Date: [**2125-12-3**] Discharge Date: [**2125-12-14**]
Service: VSU
CHIEF COMPLAINT: Right carotid stenosis.
HISTORY OF PRESENT ILLNESS: This is an 86-year-old gentleman
who gives a history of a left TIA 1 year ago. Symptoms
manifested as left upper extremity weakness. He was admitted
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital. He was found to have an 80% stenosis
of the right coronary artery. The patient consulted Dr.
[**Last Name (STitle) 1391**]. The patient denies a history of stroke or further
transient ischemic attacks. The patient denies dizziness,
memory loss, facial droop, speech changes, history of
myocardial infarction. The patient is also known to have
renal insufficiency, and is status post renal artery stenting
in the past. The patient also has a history of gout, for
which he is on allopurinol for. The patient now presents for
elective right carotid endarterectomy and a renal angiogram
with potential renal artery stenting. The patient also admits
to claudication. He cannot walk further than 100 feet, with
improvement in his symptoms with rest. He denies any rest
pain.
PAST MEDICAL HISTORY: Illnesses include hypertension,
hyperlipidemia, gout, renal artery stenosis, status post
angioplasty with stenting, peripheral vascular disease with
claudication.
PAST SURGICAL HISTORY: Right herniorrhaphy, remote.
ALLERGIES: No known allergies. IBUPROFEN causes GI upset.
MEDICATIONS: Include nifedipine 70 mg daily, Lipitor 40 mg
daily, multivitamin daily, allopurinol 100 mg daily,
metoprolol 50 mg b.i.d., Nexium 40 mg daily, Detrol long
acting 4 mg daily, aspirin 81 mg daily, Catapres-2-TTS 1
q.72h..
SOCIAL HISTORY: The patient denies tobacco, alcohol or drug
use. He has been a widow for the last 5 years. He lives
alone.
FAMILY HISTORY: Positive for coronary artery disease and
diabetes.
REVIEW OF SYSTEMS: Positive for claudication and difficulty
with urination.
PHYSICAL EXAMINATION: Vital signs are stable. General
appearance is an alert, white male in no acute distress.
HEENT exam is unremarkable. There is a carotid bruit on the
right. Chest is clear to auscultation with old sternotomy
scar incision. Heart is a regular rate and rhythm with a 2/6
systolic ejection murmur at the base. Abdomen is
unremarkable. Extremities are without edema, ulcers or nail
changes. Pulse exam shows radial pulses are palpable
bilaterally. Femoral pulses are palpable bilaterally.
Dorsalis pedis are absent bilaterally, and the posterior
tibials are dopplerable signals bilaterally. Neurological
exam reveals he is oriented. It is a nonfocal exam. Cranial
nerves are intact. EOMs are intact. Pupils are equal, round
and reactive to light and accommodation. Motor/sensory is
intact. Strength is [**4-6**] upper and lower. There is no drift.
HOSPITAL COURSE: The patient was admitted the night prior to
anticipated surgery. He underwent a right carotid
endarterectomy with Dacron patch angioplasty on [**2125-12-4**]. He tolerated the procedure well. He was extubated in
the OR. He was neurologically intact. He was hemodynamically
stable and was transferred to the PACU for continued
monitoring and care.
On the day of surgery, in the PACU, the patient was confused.
He had a low urine output. He was fluid resuscitated with
excellent results. His FENA was consistent with prerenal
changes. The patient remained in the PACU until urine output
improved.
On postoperative day #1, his home medications were restarted.
He diet was advanced. The arterial line was discontinued. He
was weaned off the nitroglycerin for systolic hypertension.
He was hydrated and given Mucomyst pre angio, and underwent
an angio on [**2125-12-5**]. He had a renal artery stent
stenosis angioplasty. He developed hypertension, requiring
nitroglycerin. Cardiac enzymes were sent, which were
negative. The day after angio, the patient desaturated to the
low 90s. He required a 50% face mask. His chest x-ray showed
congestive failure. His ABG on 4 liters nasal cannula showed
an 86% saturation. His blood gas was 7.42/33/40. A Foley was
placed. IV fluids were hep-locked. Placed on a nonrebreather.
He was given Lasix 20 mg IV. The blood gases were repeated
with improvement. Continued to monitor him during this period
of time. He remained in the VICU.
He required continued face mask on postoperative day #3 and
continued diuresis. His BUN did bump during this period.
Peaked at 2.1 from 1.6 with return to baseline. The patient
was transferred to the ICU on [**2125-12-8**] because of
persistent hypoxia. His white count went from 14 to 16. His
hematocrit remained stable at 30. BUN was 97. Creatinine was
2.0. Diuresis was continued. He remained in the SICU.
Neurologically, he remained intact.
On postoperative day #5, enzymes demonstrated a peak CPK was
45, MBs were not done, troponins were 0.61 and 0.78.
Cardiology was requested to see the patient in regards to the
elevated troponins, in the setting of chronic renal
insufficiency. Recommendations were that this was related to
his myocardial demand and slow clearance of the troponin. An
echo was obtained. Echo findings demonstrated moderate left
atrial enlargement and a dilated right atrium. The left
ventricle showed symmetric left ventricular hypertrophy with
normal cavity size and systolic function with an EF of 55%.
There was normal regional left ventricular systolic function.
There was no resting LVOT gradient. The right ventricle was
normal in chamber size and free wall motion. The aortic
valve, there was a bioprosthetic aortic prosthesis. The AVR
was well seeded. The leaflet disk motion and transvalvular
gradients were within range. There was no aortic
insufficiency. The mitral valve was mildly thickened. Mitral
valve leaflets with moderate mitral valvular calcification
with calcified tips of papillary muscles with mild-to-
moderate mitral insufficiency. This could be worse. It is
difficult to tell because of acoustic shadowing, and could be
under estimated. The tricuspid valve was normal with mild
regurgitation. Moderate pulmonary systolic hypertension.
There was a trivial physiologic pericardial effusion.
The patient was transferred to the VICU for continued
monitoring and care on [**2125-12-9**] after obtaining the
echo results. Gentle diuresis was continued with continued
improvement in the patient's oxygenation. The patient was
evaluated by physical therapy. The patient will require rehab
to safely return to previous functional status, since he
lives alone.
On postoperative day #7, the patient remains in the VICU with
intermittent episodes of confusion as to time and place. We
will feel this is related to his prolonged hospitalization.
Electrolytes and hematocrit are unremarkable.
DISCHARGE DISPOSITION: The patient will be discharged to
rehab once medically stable and bed is available.
DISCHARGE DIAGNOSES: Include right carotid stenosis,
symptomatic; restenosis of the renal artery stenting; status
post angioplasty with a stent on [**2125-12-3**]; history of
hypertension; history of gout; history of renal artery
stenosis; status post angioplasty with stenting, remote;
history of peripheral vascular disease with claudication;
status post right inguinal hernia repair, remote; history of
hyperlipidemia, on a statin; history of chronic renal
insufficiency, baseline creatinine of 1.6; history of
postoperative confusion; postoperative congestive heart
failure, compensated.
DISCHARGE MEDICATIONS: Include clonidine 0.2 mg per 24-hour
patch weekly, q. Wednesday; tolterodine 2-mg tablets twice a
day; allopurinol 100 mg daily; nifedipine 90 mg sustained
release daily; Protonix 40 mg daily; atorvastatin 40 mg
daily; aspirin 325 mg daily; Plavix 75 mg daily; hydralazine
25 mg q.6h.; Colace 100 mg b.i.d.; bisacodyl suppository 10
mg p.r.n.; metoprolol tartrate 50 mg b.i.d..
DISCHARGE INSTRUCTIONS: The patient should follow up with
Dr. [**Last Name (STitle) 1391**] as directed once discharged from rehab.
MAJOR SURGICAL OR INVASIVE PROCEDURES: Carotid
endarterectomy with Dacron patch; angioplasty on [**2125-12-4**]; renal artery stent angioplasty on [**2125-12-5**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2125-12-11**] 11:58:05
T: [**2125-12-11**] 13:18:17
Job#: [**Job Number 69882**]
ICD9 Codes: 4280, 5859, 2749, 4019, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3320
} | Medical Text: Admission Date: [**2105-9-1**] Discharge Date: [**2105-9-8**]
Date of Birth: [**2066-11-1**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 93880**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation [**Date range (1) 32272**]
History of Present Illness:
38 yo female G8 P5 and post-operative day #8 from uncomplicated
Cesarean section was admitted from the ED with shortness of
breath and increasing lower extremity edema.
Patient underwent uncomplicated Cesarean section on [**2105-8-24**] (8
days prior to admission) and was discharged to home 4 days prior
to admission on [**2105-8-28**]. Since discharge, patient reports
shortness of breath which was significantly worse on the day of
admission. Additional symptoms include the following:
- increasing lower extremity edema
- increased frequency of urination with nocturia
- orthopnea
- dyspnea on exertion
- abdominal pain s/p Cesarean section; pain well-controlled with
oxycodone and ibuprofen
- dysuria
She denies cough, fevers, chills, night sweats, sick contacts,
unilateral leg swelling, diarrhea, constipation, or recent
travel.
Upon admission to the ED, temp 101.8, HR 118, BP 173/110, and
pulse ox 97% on NRB. Her ED exam was notable for significant
distress, difficulty completing sentences, and inability to
tolerate BiPap. She received 40mg IV lasix, ceftriaxone 1gm IV x
1, Nitro gtt, Albuterol Neb x 3, Ipratropium Neb x 3. She
diuresed 800mL urine upon arrival to the floor and her shortness
of breath had subjectively improved.
Past Medical History:
- Positive PPD in the past - reportedly received treatment with
subsequent negative CXR
- Uncomplicated previous pregnancies - G8 P6
Social History:
Home: lives with husband and four kids, born in [**Name (NI) **] and then
grew up in [**State 2748**] Occupation: works as a nursing assistant
in a nursing home
Tobacco: denies EtOH: denies Drugs: denies
Family History:
No family history of heart disease or clotting disorders
Physical Exam:
T 100.7 / HR 110 / BP 165/96 / RR 42 / Pulse ox 96% on NRB
Gen: moderate distress, not speaking in full sentences but able
to answer questions appropriately
HEENT: Clear OP, MMM
NECK: Supple, No LAD, JVP elevated to earlobe
CV: tachycardic but regular rhythm. NL S1, S2. No murmurs, rubs
or gallops
LUNGS: crackles scattered bilaterally to mid lung fields; no
egophony
ABD: +BS, Soft, mild tenderness to soft/deep palpation
surrounding Csxn scar. ND. Well-healing Csxn scar in lower
abdomen without purulence, discharge, erythema, swelling.
EXT: [**12-9**]+ lower extremity edema to knees, 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 intact. 5/5 strength
throughout. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
LABS:
[**2105-9-1**] 07:02PM BLOOD WBC-11.4* RBC-3.83* Hgb-9.5* Hct-28.9*
MCV-75* MCH-24.8* MCHC-32.8 RDW-15.8* Plt Ct-540*#
[**2105-9-7**] 07:00AM BLOOD WBC-6.5 RBC-4.01* Hgb-10.0* Hct-30.1*
MCV-75* MCH-25.0* MCHC-33.3 RDW-16.1* Plt Ct-536*
[**2105-9-1**] 07:02PM BLOOD PT-14.3* PTT-29.0 INR(PT)-1.3*
[**2105-9-7**] 07:00AM BLOOD Plt Ct-536*
[**2105-9-1**] 07:02PM BLOOD Fibrino-626* D-Dimer-1566*
[**2105-9-1**] 07:02PM BLOOD Glucose-107* UreaN-11 Creat-0.6 Na-140
K-3.1* Cl-102 HCO3-26 AnGap-15
[**2105-9-7**] 07:00AM BLOOD UreaN-10 Creat-0.5 Na-140 K-3.8 Cl-100
HCO3-28 AnGap-16
[**2105-9-2**] 04:02AM BLOOD ALT-16 AST-16 AlkPhos-93 TotBili-0.3
[**2105-9-2**] 04:02AM BLOOD TotProt-5.7* Albumin-3.0* Globuln-2.7
Calcium-8.3* Phos-4.6* Mg-1.9 UricAcd-3.8
[**2105-9-6**] 02:40AM BLOOD Calcium-9.3 Phos-4.5 Mg-2.0
[**2105-9-1**] 07:02PM BLOOD TSH-0.40
[**2105-9-1**] 09:01PM BLOOD Type-ART pO2-79* pCO2-34* pH-7.52*
calTCO2-29 Base XS-4 Intubat-NOT INTUBA
[**2105-9-4**] 07:48PM BLOOD Type-ART Temp-36.7 Rates-/27 PEEP-10
FiO2-40 pO2-109* pCO2-41 pH-7.45 calTCO2-29 Base XS-3
Intubat-INTUBATED
STUDIES:
- [**9-1**] CTA Neg for PE
- [**9-1**] CXR New, diffuse bilateral alveolar airspace opacities
concerning for ARDS, or possibly CHF secondary to a
cardiomyopathy. Diffuse, multifocal infection is not excluded.
[**9-2**] CXR - same as prev CXR with increased opacities
- [**9-1**] Echo: preserved systolic function EF 60-65% with no
significant valvular abnormalities
- [**9-2**] CXR Mild cardiomegaly. Small bilateral pleural effusions
are R>L. Mild interval increase in diffuse bilateral alveolar
space opacities in perihilar regions and in the upper lobes
greater in the right side.
- [**9-3**] CXR AM: interval partial resolution in bilateral
parenchymal opacities, bibasal retrocardiac atelectasis is
unchanged.
- [**9-4**] CXR: interval worsening in bilateral parenchymal
opacities consistent with patient's known ARDS
-[**9-6**] CXR: improvement in airspace opacities at right base, left
retrocardiac region
CULTURES
[**2105-9-1**] - Urine culture negative
[**2105-9-1**] - Blood culture x 2 pending
[**2105-9-1**] - Urinary Legionalla antigen negative
[**2105-9-2**] - Rapid Resp Viral Test neg, culture pending
[**2105-9-2**] - Blood culture x 2 pending
Brief Hospital Course:
The patient is a 38 yo female G8 P5 s/p recent Cesarean section
admitted with respiratory failure, hypertension, and proteinuria
of unclear etiology.
# Respiratory failure. Etiology of her respiratory distress is
unclear but includes most likely pneumonia (viral or bacterial)
given fever, ARDS with unclear precipitant, or noncardiogenic
pulmonary edema secondary to severe pre-eclampsia.
The patient was originally admitted to the ICU on BiPAP. Soon
after admission, the patient began to tire and was intubated.
She was treated with levofloxacin and flagyl for 7 days and
diuresed. She was extubated on [**2105-9-5**] and was oxygenating well
on 3L NC at the time of transfer out of the ICU. At the time of
discharge on HD#8, she had been oxygenating @ 96-99% on room air
x 36 hrs.
# Hypertension. Unclear etiology for patient's sudden onset of
hypertension. Etiology includes post-partum pre-eclampsia or
increased sympathetic tone in the setting of infection and
respiratory distress. Her pressures were originaly up to the
SBP's >220. She was started on metoprolol TID and hydralazine
as needed. Lisinopril was then added and hydralazine was
discontinued. The patient was discharged with blood pressure
under good control on metoprolol.
# Proteinuria. Etiology of proteinuria is unclear although
possible etiologies include post-partum pre-eclampsia or
transient proteinuria in the setting of elevated BPs. Renal was
consulted and determined that proteinuria was indeed most likely
secondary to severe preeclampsia. Pt will f/u with PCP [**Last Name (NamePattern4) **] 6
weeks and 3 months to ensure resolution of the proteinuria.
# Post-operative C section. Stable with clean wound site. Pain
was controlled with oxycodone.
# Social. Pt coping well. Seen by social work and support
offered. Partner is coping adequately at home with 6 children
including newborn
HOSPITAL COURSE:
38 yo G8P6 s/p repeat LTCS [**8-24**] with new onset respiratory
distress, HTN and fever. In the ED, temp 101.9, HR 118, BP
173/110, and pulse ox 97% on NRB. She received antibiotics, nebs
and diuretic. In the MICU, she was initially managed with NRB,
gentle diuresis, broad spectrum antibiotics and metoprolol. On
HD#2, she was intubated due to worsening pulmonary function.
Over the course of the day, her resp status and HTN improved but
her UOP was minimal. On HD#4, she is intubated with improved
respiratory function but persistent HTN. Renal consult was
requested. They felt that preeclampsia was the most likely
etiology of this non-cardiogenic pulmonary edema with HTN
secondary to volume overload. On HD #5, she was extubated and
transferred out of ICU on HD#6. Pt continued to recover on HD#7
and was discharged in good condition on HD#8.
STUDIES:
- [**9-1**] CTA Neg for PE
- [**9-1**] CXR New, diffuse bilateral alveolar airspace opacities
concerning for ARDS, or possibly CHF secondary to a
cardiomyopathy. Diffuse, multifocal infection is not excluded.
[**9-2**] CXR - same as prev CXR with increased opacities
- [**9-1**] Echo: preserved systolic function EF 60-65% with no
significant valvular abnormalities
- [**9-2**] CXR Mild cardiomegaly. Small bilateral pleural effusions
are R>L. Mild interval increase in diffuse bilateral alveolar
space opacities in perihilar regions and in the upper lobes
greater in the right side.
- [**9-3**] CXR AM: interval partial resolution in bilateral
parenchymal opacities, bibasal retrocardiac atelectasis is
unchanged.
- [**9-4**] CXR: interval worsening in bilateral parenchymal
opacities consistent with patient's known ARDS
-[**9-6**] CXR: improvement in airspace opacities at right base, left
retrocardiac region
CULTURES
[**2105-9-1**] - Urine culture negative
[**2105-9-1**] - Blood culture x 2 pending
[**2105-9-1**] - Urinary Legionalla antigen negative
[**2105-9-2**] - Rapid Resp Viral Test neg, culture pending
[**2105-9-2**] - Blood culture x 2 pending
Pt was discharged on HD#8 in good condition. Will follow up with
Dr. [**Last Name (STitle) **] [**9-11**] and [**9-16**] and with her PCP at [**Name9 (PRE) **] [**Name9 (PRE) **] in 6
weeks.
Medications on Admission:
Oxycodone
Ibuprofen
Discharge Medications:
1. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
severe preeclampsia
respiratory distress
pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please call or return to the hospital if you have shortness of
breath, chest pain, fevers, chills, increased pain, nausea,
vomiting, inability to tolerate food or drink.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2105-9-11**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2105-9-16**] 10:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Hospital1 **]in 6 weeks
ICD9 Codes: 486, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3321
} | Medical Text: Admission Date: [**2112-4-5**] Discharge Date: [**2112-4-11**]
Date of Birth: [**2043-2-28**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Transfer from [**Hospital 882**] Hospital for Respiratory Distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
(History obtained from chart)
69 year old male with CHF (EF 20%), COPD, HTN, who presented to
[**Hospital 882**] Hospital ED today via EMS with shortness of breath. He
was noted to be diaphoretic, with a BP of 180/110. He was given
Lasix 100mg IV, NTG x 6, CPAP en route. Upon arrival to the ED,
he was reportedly agitated and hypoxic (no O2sat recorded). An
ABG done immediately after intubation was 7.23/86/87. He was
transiently in atrial fibrillation with RVR to 160s with LBBB.
He was transferred to the [**Hospital1 18**] ED because there were no ICU
beds at [**Hospital 882**] Hospital. Upon arrival to the [**Hospital1 18**] ED, VS
were HR 68, BP 143/70, O2sat 100% (FiO2 100%). Telemetry showed
NSR. He was admitted to the CCU for further management.
Currently, he is intubated and sedated, and unable to answer
questions or follow commands. Recent medical history notable
for admission to [**Hospital1 1516**] [**Date range (1) 8769**] for CHF exacerbation suspected
[**12-19**] medication nonadherence. He was ruled out for an acute MI
and was diuresed with IV Lasix. He was also diagnosed with RLE
cellulitis and was treated with Augmentin (regimen completed
today).
Past Medical History:
PAST MEDICAL HISTORY:
1) CHF- TTE 20-25%, dry weight 198 lbs.
2) CAD-Most recent cath in [**2-23**] showed single vessel LCx disease
3) Ventricular Fibrillation- s/p VF arrest [**2102**], AICD placed at
that time
4) Paroxysmal atrial fibrillation- started on amiodarone [**2-23**],
also on BB, anticoagulated with Coumadin
4) [**Name (NI) 3672**] pt uses inhalers, steroids during [**1-23**] admission, PFTs
showing both mod. restrictive and marked obstructive component
5) DM Type 2- Lantus + Humalog ISS, Hgb A1C 10.3 in [**2-/2112**] at
[**Last Name (un) **]
6) Hypertension
7) Barrett's esophagus
8) Hypercholesterolemia
9) s/p GI bleed- UGIB from a gastric ulcer [**12/2102**]
10) s/p Appendectomy [**2063**]
11) s/p Bone tumor excision from shoulder [**2057**]
12) ? portal vein thrombosis
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Cardiac History: no h/o CABG
Pacemaker/ICD placed: [**Company 1543**] [**Last Name (un) 24119**] VR 7232Cx [**12/2102**]
Social History:
Pt is retired from the [**Location (un) 86**] police force and security service
at [**Location (un) 745**] [**Hospital 3678**] hospital. He lives independently at [**Doctor Last Name 406**]
Estates senior center, a retirement community. Closest family is
his cousin who lives down the street from him. He was adopted,
never married, and has no children. He smoked for 45 yrs, [**11-18**]
ppd, quit 8 yrs ago. He denies any alcohol intake or other drug
use.
Family History:
The patient was adopted and does not know family history.
Physical Exam:
VS: T 96.9, BP 122/69, HR 70, O2 100% on AC 550/16/5/100%
Gen: Intubated and sedated, obese. Not responsive to name,
minimal response to noxious stimuli.
HEENT: NCAT. Sclerae anicteric. Pupils 3mm-->1mm. Conjunctiva
pink. ETT/OGT.
Neck: Supple with JVP of cm.
CV: RR, normal S1, S2. No S4, no S3. No murmur/rub.
Chest: Coarse breath sounds throughout. No wheeze. No focal
abnormalities auscultated.
Abd: Obese, soft, no response to palpation. No abdominal
bruits.
Ext: 2+ pitting edema to knees bilaterally. Venous stasis
changes. No femoral bruits.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+; 1+ DP
Pertinent Results:
[**2112-4-5**] 04:40PM BLOOD WBC-11.4*# RBC-4.63 Hgb-11.0* Hct-36.7*
MCV-79* MCH-23.8* MCHC-30.0* RDW-14.3 Plt Ct-386
[**2112-4-11**] 07:05AM BLOOD WBC-7.4 RBC-4.88 Hgb-12.2* Hct-37.6*
MCV-77* MCH-25.1* MCHC-32.5 RDW-14.6 Plt Ct-365
[**2112-4-5**] 04:40PM BLOOD PT-78.5* PTT-33.6 INR(PT)-9.9*
[**2112-4-6**] 05:25AM BLOOD PT-103.2* PTT-39.2* INR(PT)-13.8*
[**2112-4-11**] 07:05AM BLOOD PT-16.9* PTT-30.9 INR(PT)-1.5*
[**2112-4-5**] 04:40PM BLOOD Glucose-392* UreaN-17 Creat-0.7 Na-141
K-4.0 Cl-101 HCO3-29 AnGap-15
[**2112-4-11**] 07:05AM BLOOD Glucose-150* UreaN-22* Creat-0.6 Na-140
K-4.0 Cl-97 HCO3-35* AnGap-12
[**2112-4-5**] 04:40PM BLOOD CK(CPK)-86
[**2112-4-5**] 09:00PM BLOOD CK(CPK)-76
[**2112-4-6**] 05:25AM BLOOD CK(CPK)-57
[**2112-4-5**] 04:40PM BLOOD cTropnT-<0.01
[**2112-4-5**] 09:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2112-4-6**] 05:25AM BLOOD CK-MB-NotDone cTropnT-<0.01
STUDIES:
2D-ECHOCARDIOGRAM performed on [**2112-3-30**] demonstrated:
The left atrial volume is markedly increased (>32ml/m2). There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis (LVEF = 20-25 %). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
with borderline normal free wall function. The ascending aorta
is moderately dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
CARDIAC CATH performed in [**2112-2-25**] demonstrated:
1- Selective coronary angiography of this right-dominant system
showed single vessel CAD. The LMCA, LAD, and RCA were free from
obstructive disease. The LCX had 70% distally and the OM branch
had 90% at mid vessel.
2- Limited resting hemodynamic assessment revealed normal
systemic
arterial pressure (119/62 mmHg) and moderate pulmonary
hypertension
(59/31/43 mmHg). The right and left-sided filling pressures were
markedly elevated with PCWP 31 mmHg and RVEDP 16 mmHg. The
cardiac
output and cardiac index were preserved at 5.0 l/min and 2.3
l/min/m2.
[**2112-4-5**] CXR:
IMPRESSION:
1. ET tube and OG tube in standard positions.
2. Mild CHF with worsening left retrocardiac opacity, likely
combination of small left pleural effusion and left basilar
atelectasis.
[**2112-4-5**] ECG:
Sinus rhythm
Left atrial abnormality
Nonspecific T wave abnormalities
Q-Tc interval appears prolonged but is difficult to measure
Clinical correlation is suggested
Since previous tracing of [**2112-3-30**], left bundle branch block
absent
[**2112-4-8**] ECG:
Sinus bradycardia. Q-T interval prolongation. Anterior T wave
inversions
extend all the way to the lateral leads which may be due to
myocardial
ischemia. Compared to tracing #1 the T waves are completely
inverted
now from anteriorly to laterally.
Brief Hospital Course:
This is a 69 year old male with history of Chronic Systolic
Heart failure, Chronic Obstructive Pulmonary disease,
Hypertension, who transferred from [**Hospital 882**] Hospital with
respiratory failure.
.
# Respiratory failure/Acute on Chronic Systolic Heart Failure:
Patient arrived from [**Hospital 882**] hospital intubated for respiratory
distress. Initial exam and CXR consistent with congestive heart
failure. Patient was treated with IV Lasix with good effect.
He was extubated successfully and was transitioned back to Lasix
PO. While in the hospital he overdiuresed on his home Lasix
regimen, so it was decreased from 120mg [**Hospital1 **] to 80mg daily. Mr.
[**Known lastname **] reports missing doses of medications from time to time
and it is unclear how compliant he is at home. He was also very
uneducated about the concept of a low sodium diet stating "I did
not know that cheese had salt in it, next time I go to
McDonald's I will ask for a hamburger without cheese."
Nutrition was consulted and he was educated on Low Sodium diet
and that he should not be eating hamburgers and other salty
foods. Home VNA was ordered to evaluate the patients home
environment and to obtain daily weights. Carvedilol was changed
to Toprol XL to allow for once daily dosing and improve
compliance. Lisinopril was decreased to 10mg daily due to
hypotension in the hospital. He is to restart his home
aldactone on discharge.
# Coagulopathy: Patient presented with elevated INR of 12.
This was likely secondary to excessive anticoagulation with
warfarin. It appears the dose was increased on his last
admission. He was also started on Amiodarone at that time which
likely contributed to the increased INR. Mr. [**Known lastname **] was treated
with 7.5mg of Vitamin K with goog effect. Coumadin was
restarted and he is to go home on a dose of 3mg daily. He will
have outpatient labwork on [**2112-4-13**] and will have the results
faxed to his PCP.
.
# Pump: Last Echo showed EF of 20%. He has been in and out of
the hospital 3 times in the last month for CHF exacerbations.
Mr. [**Known lastname **] was educated on diet and medications. He is to go
home with VNA for added education. He will follow up in [**Hospital 1902**]
clinic with his new cardiologist Dr. [**First Name (STitle) 437**]
# CAD/Ischemia: EKG initially with nonspecific ST-T changes,
which then converted to T wave inversions. Cardiac biomarkers
were negative x 3 on arrival and he was asymptomatic throughout
his hospital stay. Cath in [**2-23**] showed stable LCx disease.
Plan is for medical management. He is to continue on his home
ASA, statin/ezetimibe. He going home on Toprol as above.
.
# Rhythm: Mr. [**Known lastname **] has history of paroxsmal atrial
fibrillation, with rate-related LBBB. He arrived to [**Hospital1 18**] in
NSR with no LBBB. He also carries a history of VF arrest, and
has an ICD in place. He is to continue on beta-blocker and
amiodarone for rate and rhythm control. He is on coumadin for
anticoagulation. INR subthearapeutic on discharge secondary to
Vitamin K administration as above. He will have INR follow up
with his PCP.
# HTN: Patient had an episode of hypotension while in the
hospital. Medications were adjusted as above. He will go home
on Toprol 25mg daily and Lisinopril 10mg daily.
.
# Diabetes Mellitus: Patient is to continue his home Lantus and
Insulin Sliding scale.
# Anemia: Hematocrit has been stable during this
hospitalization. Iron, Ferritin and TIBC were normal in [**2106**].
Colonoscopy in [**2109**] showed diverticulosis, no masses seen. This
should be followed up by his PCP as an outpatient.
Medications on Admission:
CURRENT MEDICATIONS:
Amiodarone 200 mg DAILY
Carvedilol 3.125 mg [**Hospital1 **]
Spironolactone 25 mg DAILY
Lasix 120 mg twice a day.
Lisinopril 20 mg DAILY
Aspirin 81 mg DAILY
Ezetimibe 10 mg DAILY
Atorvastatin 40 mg DAILY
Prilosec 20 mg once a day.
Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **]
Tiotropium 18 mcg One Cap DAILY
Coumadin 7.5 mg once a day
Lantus 76 Units at bedtime
Augmentin 875-125 mg twice a day x 5 days (RLE cellulitis)
Insulin Regular sliding scale
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) INH Inhalation [**Hospital1 **] (2 times a day).
8. Insulin Sliding Scale
as instructed
9. Lantus 100 unit/mL Solution Sig: Seventy Six (76) units
Subcutaneous at bedtime.
10. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
15. Outpatient Lab Work
INR check [**2112-4-13**]. Please fax results to PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) 25160**] [**Name Initial (NameIs) **].
Ph: [**Telephone/Fax (1) 25161**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute on Chronic Systolic Heart Failure
Discharge Condition:
Hemodynamically stable, breathing well
Discharge Instructions:
You were transferred to [**Hospital1 69**]
from [**Hospital 882**] hospital for treatment of your congestive heart
failure. You were intubated at [**Hospital 882**] hospital for
respiratory distress. You were on a breathing machine for two
days and the breathing tube was taken out successfully. You
were treated with intravenous diuretics for removal of your
excess fluid. Please adhere to a low sodium diet for prevention
of future exacerbations.
Please stop taking your carvedilol
Your Coumadin was decreased to 3mg daily
Your Furosemide was decreased to 80mg once per day.
You have been started on Toprol XL 25mg daily
Your Lisinopril was decreased to 10mg per day
Please continue with your remaining medications as instructed
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L
Followup Instructions:
Please call your Primary Care Physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] to
schedule a follow up appointment within 1 to 2 weeks from your
discharge. [**Telephone/Fax (1) 25161**]
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2112-4-18**]
11:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2112-4-18**]
2:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2112-4-22**]
8:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 4280, 496, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3322
} | Medical Text: Admission Date: [**2146-4-17**] Discharge Date: [**2146-4-23**]
Date of Birth: [**2095-12-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Variceal bleed stabilized at OSH, TIPS occluded and transferred
for TIPS revision
Major Surgical or Invasive Procedure:
Central line placement
TIPS revision
History of Present Illness:
Mr. [**Known lastname 52412**] is a 50yo man with HCV cirrhosis s/p TIPS in
[**1-31**], TIPS redo by IR in [**6-1**] at OSH and again [**1-1**] here.
Presented to OSH with hematemesis. Intubated for airway
protection. EGD showed gastric bleeding most likely secondary
to gastric varices. He was xferred to [**Hospital1 **] for further mgmt. He
was admitted to the SICU. He was found have TIPS blocked. The
TIPS was revised on [**4-17**]. Pt was started on cotreotide. His HCT
remained stable at 25-26.
.
On ROS, he c/o diarrhea. he says usually he has [**3-29**] BM/day. he
denies N/V/abd pain. he [**Last Name (un) 52413**] CP, SOb, dizziness, palpitations,
dysuria, F/C/C.
Past Medical History:
- HepC w/ cirrhosis - complicated by variceal bleeds s/p
banding.
- TIPS placement [**1-31**] with redo [**6-1**], another balloon dilation
[**1-1**]
- hepatic encephalopathy
- carpel tunnel syndrome
- h/o recurrent cellulitis
- obesity
- mild COPD by PFTs
- diverticulosis
- chronic low back pain [**2-26**] disk protrusion
- depression
- h/o substance abuse
Social History:
Lives with his sister. Previously used to work in bakery but
quit in [**Month (only) **] as was too tired to work (was lifting 50lb
bags of flour, etc). Smokes [**1-26**] ppd of cigarettes, no EtOH,
prior heroin use but reports being sober since [**1-31**].
Attempting to quit tobacco and feels like this hospitalization
may prompt change.
Family History:
No history of liver problems. Otherwise noncontributory.
Physical Exam:
99.2 130/71 80 16 96/3L
HEENT: EOMI, PERRL, MMM, no LAD
Neck: supple, mo thyromegaly
Heart: RRR, no M/R/G, nl S1 S2
Lungs: CTAB
Abd: soft, obese, NT/ND, no HSM, BS +, no ascites
Extr: 2+ pitting edema b/l, right arm with swelling in hand,
forearm and arm TTP, no erythema or warmth
Neuro: AAO x 3. no asterixis. no focal neuro deficit
Pertinent Results:
[**4-17**] TIPS revision
IMPRESSION:
1. Moderate new intimal hyperplasia and stenosis at the hepatic
venous end of the TIPS, clearly flow limiting, with a post
balloon angioplasty persitent portosystemic gradient of 14 mmHg.
Given the persistently elevated gradient and the presence of
large varices as well as the moderate but clearly flow-limting
proximal stenosis, an additional 10 mm Wallstent was deployed,
with subsequent balloon angioplasty of the stent and good
angiographic results. The portosystemic gradient was reduced to
10 mmHg post stent deployment.
Plan: The bleeding risk should be eliminated at the current
time. Careful ultrasonogrphic imaging is recommended, the TIPS
is at risk of failure given the presence of multiple stents
[**4-18**] u/s
IMPRESSION:
1. In comparison to the last study, there is a marked increase
in velocity from 120 to 212 cm/sec with no flow in the left
portal. This represents a new baseline with markedly increased
TIPS velocity. This study cannot exclude an element of stenosis.
2. Thready flow within the stent, which may be technical.
[**4-19**] u/s
IMPRESSION: Limited examination due to body habitus. Patent TIPS
with velocities ranging from 132-140 cm/sec
d/c labs
[**2146-4-23**] 04:10AM BLOOD WBC-3.2* RBC-2.82* Hgb-8.3* Hct-24.9*
MCV-89 MCH-29.4 MCHC-33.2 RDW-15.9* Plt Ct-39*
Brief Hospital Course:
A/P: 50yo man with HCV cirrhosis s/p TIPS p/w GIB to OSH.
Intubated for airway protection. Found to have TIPS occluded.
TIPS revised. started on octreotide. HCT stable.
.
# Variceal bleed due to TIPS occlusion
As per OSH d/c summary, most likely from variceal bleed. TIPS
was fund to be occluded. TIPS revised on [**4-17**] with good flow on
US. HCT stable for several days, patient discharged with stable
hematocrit and no signs of further bleeding.
.
# HCV Cirrhosis
HCV cirrhosis. recent VL [**2146-3-24**] was 755,000 IU/mL. s/p rx w/
interferon and ribavirin in [**2139**]. relapsed after that. recent
note from Dr [**Name (NI) 32282**] talks about starting rx w/ pegylated
inteferon and ribavirin. COntinued lactulose and rifaximin for
encephalopathy. Refractory ascites s/p TIPS with multiple
revisions and at high risk for further occlussion given multiple
stents placed. Continued lasix and aldactone to manage ascites
and peripheral edema. S/p band ligation of varices, h/o
recurrent variceal bleeding, restarted nadolol. Will follow up
in next 2 weeks with Dr. [**Last Name (STitle) 497**].
.
# Depression: Continued his outpatient Wellbutrin and trazodone
at home doses.
Medications on Admission:
Bupropion 100 mg 1 p.o. b.i.d.
Lasix 20 mg once a day
lactulose 3 tablespoons by mouth daily
Prilosec 40 mg once a day
Aldactone 100 mg once a day
trazodone 50 mg once a day
Discharge Medications:
1. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Variceal bleed
Secondary:
Hep C
Cirrhosis
COPD
Hepatic encephalopathy
Discharge Condition:
Stable. ambulating well, cleared by PT
Discharge Instructions:
You were admitted with a variceal bleed requiring TIPS revision
for narrowing of the stent. You need to complete 1 more day of
antibiotics and you were started on nadolol 20mg daily to help
prevent any further episodes of variceal bleeding. You should
follow up with Dr. [**Last Name (STitle) 497**] in [**2-28**] weeks for follow up, the
[**Date Range **] coordinator.
.
If you have any bloody vomit, blood in stool, fainting,
shortness of breath, abdominal pain or any worrisome symptoms
present to the ER immediately for evaluation.
Followup Instructions:
Call Dr.[**Name (NI) 948**] office at ([**Telephone/Fax (1) 3618**] to schedule an
appointment in the next 2-4 weeks, [**Telephone/Fax (1) **] coordinator aware
.
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-6-22**]
10:30
.
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2146-6-22**] 1:00
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2146-6-22**]
2:00
ICD9 Codes: 5715, 496, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3323
} | Medical Text: Admission Date: [**2111-8-29**] Discharge Date: [**2111-9-2**]
Date of Birth: [**2059-1-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Dizziness, nausea/vomiting coffee grounds
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
52yoM [**Location 7972**] speaking with hypertension and dyslipidemia
presenting for nausea/bloody emesis, black stool, and dizziness.
The patient reports he was experience abdominal pain for the
past two days and noted black tarry stool the day prior to
presentation. Tonight, he woke up tonight at midnight with
abdominal pain, nausea felt he had to have a bowel movement. He
then had two episodes of dark bloody emesis with subsequent
lightheadedness. He has no prior history of bleeding, denies
significant alcohol use, denies history of liver disease, and
reports minimal NSAID use occasionally for pain. He denies
fevers, chills, chest pain, but does report epigastric pain.
In the ED, initial VS were: 98.5 93 126/76 16 100%
He was noted to have coffee ground emesis with dark blood x1 and
an NGT was placed. NG lavage showed coffee grounds which did
not clear, and his hct was found to be 29, down from a baseline
of 42-45 most recently on [**2111-2-28**]. He had guiac positive black,
tarry stool on rectal. The patient was noted to be pale, cool,
diaphoretic, with epigastric pain and leukocytosis, and sugery
was consulted for concern for perforation. CXR showed no
evidence of free air under the diaphragm and surgery will follow
along but recommended CT abdomen/pelvis which was ordered to be
obtained en route to the ICU. GI was consulted and recommended
initiation of a PPI gtt which was started, and will perform an
EGD on arrival to the ICU. The patient was given a dose of
Cipro/Flagyl given his leukocytosis but remained afebrile in the
ED. He was type and crossed 2 units and x2 [**17**] gauge PIV's were
placed. His HR was in the 80's with BP's sustaining in the
130's, and he received a total of 2L NS. EKG showed no acute ST
changes per ED read. On transfer, VS were: 81 136/89 20
100%RA afebrile. He arrived with 2 units PRBC which were
ordered in the ED but not yet hung.
On arrival to the MICU, the patient denied any symptoms
including abdominal pain, chest pain, shortness of breath,
dizziness, or lightheadedness. He did have nausea with the NGT
in place.
Past Medical History:
- Hypertension
- Dyslipidemia
Social History:
- Tobacco: Active smoker, 1PPD x at least 30 years
- Alcohol: Reported initially EtOH use once weekly, but later
reported drinking 3-4 beers weekly.
- Illicits: Denies
He is married with four children and lives with wife and
children in [**Name (NI) 86**]. He worked in the past as a forklift driver,
now works various jobs.
Family History:
NC
Physical Exam:
Admission Exam:
Vitals: 96.3 88 139/87 28 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, NGT in place
Neck: Supple
CV: Regular rate and rhythm, normal S1 + S2, GII holosystolic
murmer at apex, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or
edema
.
Discharge PE:
Vitals: 98.2 132/82 74 18 98%RA
General: NAD. speaking full sentences, smiling, mentating
properly
HEENT: Sclera anicteric, MMM
CV: Regular rate, no m/r/g.
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: Soft NT, ND, no HSM
Ext: warm, well perfused, 2+ DP pulses, no cce
Pertinent Results:
Adm labs:
[**2111-8-29**] 01:40AM WBC-18.8* RBC-3.29*# HGB-10.8*# HCT-29.5*#
MCV-90 MCH-32.9* MCHC-36.7* RDW-13.8
[**2111-8-29**] 01:40AM NEUTS-65.7 LYMPHS-27.8 MONOS-3.2 EOS-2.8
BASOS-0.5
[**2111-8-29**] 01:40AM PLT COUNT-399
[**2111-8-29**] 01:40AM PT-12.5 PTT-18.9* INR(PT)-1.1
[**2111-8-29**] 01:40AM ALBUMIN-3.7
[**2111-8-29**] 01:40AM cTropnT-<0.01
[**2111-8-29**] 01:40AM LIPASE-25
[**2111-8-29**] 01:40AM ALT(SGPT)-18 AST(SGOT)-8 LD(LDH)-109 ALK
PHOS-78 TOT BILI-0.2
[**2111-8-29**] 01:40AM GLUCOSE-149* UREA N-39* CREAT-0.6 SODIUM-140
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP
Reports:
CXR [**2111-8-29**]: Low lung volumes with bibasilar atelectasis.
CT abd/pelvis [**2111-8-29**]: 1. No acute abnormalities in the abdomen
or pelvis to explain patient's symptoms. Nasogastric tube in a
stomach which still remains somewhat fluid-filled. 2. Left L5
pars defect. 3. Age indeterminate minimal T11 anterior wedging.
EGD [**2111-8-29**]: Medium hiatal hernia, Blood in the fundus,
[**Doctor First Name **]-[**Doctor Last Name **] tear
No esophageal varices, Otherwise normal EGD to third part of the
duodenum
.
CXR [**2111-8-31**]: Again seen is an area of volume loss or infiltrate
in the right lower lobe.There is improved aeration in the left
lower lobe. The right hemidiaphragm is mildly elevated. Cardiac
and mediastinal silhouettes are normal. The upperlungs are
clear.
.
EGD [**2111-8-31**]: Normal mucosa in the stomach. Clip in place at GE
junction at site of previously reported [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear
bleed. No stigmata of continued bleeding found. Erythema in the
duodenal bulb compatible with duodenitis. Otherwise normal EGD
to third part of the duodenum. Recommendations: Avoid all nsaid
usage. Continue protonix 40mg [**Hospital1 **] indefinitely.
.
Discharge labs:
[**2111-9-2**] 05:40AM BLOOD WBC-11.8* RBC-2.73* Hgb-8.6* Hct-24.7*
MCV-90 MCH-31.4 MCHC-34.8 RDW-15.5 Plt Ct-411
[**2111-8-29**] 01:40AM BLOOD PT-12.5 PTT-18.9* INR(PT)-1.1
[**2111-9-2**] 05:40AM BLOOD Glucose-100 UreaN-14 Creat-0.6 Na-141
K-4.1 Cl-109* HCO3-25 AnGap-11
[**2111-9-2**] 05:40AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
Brief Hospital Course:
52yoM with hypertension and dyslipidemia presenting for coffee
ground emesis, black tarry stool consistent with upper GI bleed.
#. Upper GI bleed: He had a Hct on admission of 29 down from his
baseline of 42-45 in the past year. He was given 3 units PRBCs
over the first 24 hours of hospitalization and then his Hct
remained stable. He had NG tube placed which initially drained
dark bloody stomach fluid. He was started on octreotide and IV
PPI drip. He had EGD the morning after admission which showed a
[**Doctor First Name 329**] [**Doctor Last Name **] tear and lots of old blood with difficulty
visualizing the whole stomach. Repeat EGD was initially planned
for HD #2, but his hemoglobin and hematocrit remained stable and
GI felt that repeat EGD was not necessary. He was switched to
PPI IV BID and octreotide was discontinued. NG tube was pulled
and he was called out to the floor. On the floor, his
hematocrit remained stable. GI did not recommend repeat
inpatient endoscopy. His diet was slowly advanced, and he was
tolerating a regular diet at discharge. It remains unclear as
to the inciting event, as the patient reports that his first
vomiting was bloody. A repeat EGD did not reveal any other
areas of concern. The patient was started on pantoprazole 40mg
[**Hospital1 **], and was instructed not to take NSAIDs.
.
#. Leukocytosis: Initially felt to most likely be a stress
response from his GI bleed. He was given a dose of cipro/flagyl
in the ED which was not continued. On further evaluation, it
was noted that his leukocytosis was chronic and had been seen on
labs as far back as [**2101**]. Unclear etiology. This will need to
be trended. His PCP was [**Name9 (PRE) 31142**] prior to transfer out of the
unit.
.
# Night sweats, cough, weight loss, smoking history: Was
concerning for malignancy. A PA/Lateral CXR did not reveal any
suspicious lesions. An abdominal/pelvic CT scan did not reveal
anything suggestive of cancer. His wife states he has frequent
night sweats when the patient is not ill, that he has not done
any exercising that would lead to weight loss, and that he is
cough more than he used to. However, per a different provider
seeing the patient in-house, when asking the patient through his
son, he states his sweats are when he has a cold, his wt loss is
intentional, and is cough isn't that bad. It is unclear whether
he is downplaying his symptoms, or if his wife is exaggerating.
This may warrant very close monitoring, and may consider a chest
CT as an outpatient.
#. Hypertension: His home Lisinopril was held given acute GI
bleed.
.
.
TRANSITIONAL ISSUES:
- Encourage pt to quit smoking! This was done in-house as well
- Unclear what precipitated his vomiting, his first episode was
bloody. [**Doctor First Name **]-[**Doctor Last Name **] tear was seen and clipped, but it is a bit
strange for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear to not be precipitated by any
vomiting or retching. However, repeat EGD did not reveal any
other areas of concern in the stomach, esophagus, or duodenum.
In the setting of a hiatal hernia, this makes it a bit more
likely to have occured. Perhaps he also was retching before
vomiting and has not been telling us.
- Had some subjective complaints suspicious for malignancy.
However pt tells a different story than his wife, and no
suspicious lesions seen on CXR or CT ab/pelvis. See above -
should be closely followed and may need an outpatient CT scan of
chest if concerned.
- Follow up of persistent leukocytosis
- [**Month (only) 116**] need to restart lisinopril at PCP [**Name9 (PRE) 702**] appointment.
Medications on Admission:
LISINOPRIL - 40 mg Tablet daily
Discharge Medications:
1. 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:*0*
2. Outpatient Lab Work
Please check a CBC prior to your visit with Dr. [**Last Name (STitle) **] on
[**2111-9-8**] and fax the results to ([**Telephone/Fax (1) 22298**].
Discharge Disposition:
Home
Discharge Diagnosis:
[**Doctor First Name **]-[**Doctor Last Name **] Tear
Tobacco Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for blood in your vomit. You were initially
admitted to the intensive care unit for close monitoring. You
were given blood transfusions given the amount of blood that you
lost. Your blood counts were followed very closely, and when
they remained stable you were transferred to the medical floor.
.
You were evaluated by the gastroenterologists, and you had an
endoscopy (a procedure that allows your doctors to [**Name5 (PTitle) 788**] the
inside of your throat and your stomach). This revealed a small
tear in your esophagus (the tube that connects your mouth to
your stomach). This tear is likely the reason for your bleeding.
Your blood counts dropped slightly, and you were taken back for
a repeat endoscopy. The repeat endoscopy did not reveal any
other sources of bleeding. It did reveal an inflammation of a
part of the gut that comes just after the stomach. You should
take a new medication for this, called pantoprazole.
.
It is also VERY important that you STOP smoking. Smoking is
incredibly dangerous, and is associated with many, many health
problems, including cancer and heart disease. Please try to
quit, it is one of the most important things that you can do for
your health.
.
Please note the following medication changes:
.
Please START:
Pantoprazole 40mg twice daily
.
Please STOP:
Lisinopril - this is a blood pressure medication. Your blood
pressures were in the normal range without this medication. You
should stop taking it until you see your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]c next week.
.
Please DO NOT take any NSAIDs for pain (these are medications
that include drugs like ibuprofin, aleeve, etc). If you need to
take medications for pain, please take TYLENOL.
.
We have written you for a prescription to have your blood counts
checked prior to your follow-up appointment with your primary
doctor next week.
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: TUESDAY [**2111-9-8**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2111-9-22**] at 1 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2111-9-2**]
ICD9 Codes: 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3324
} | Medical Text: Admission Date: [**2196-8-4**] Discharge Date: [**2196-8-13**]
Service: MEDICINE
Allergies:
Penicillins / Fosamax
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
shortness of breath, cough, fatigue, lightheadedness for 3 weeks
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 93940**] is an 83 y/o M w/PMH significant for lung CA who
presents w/gradually progressing SOB, cough, fatigue and
lightheadedness over the past 3weeks. Per daughter & patient: Pt
was in his usual state of health and able to perform ADLs until
3 wks ago when he suddenly became SOB though pt cannot recall
exact moment he became SOB. Pt describes feeling as not being
able to breathe in enough air/oxygen. SOB is persistent, occurs
w/slightest movement. SOB only relieved when pt is sitting up
and not moving. SOB is worse at night and pt has been sleeping
w/three large pillows to elevate himself to almost a seating
position. Pt can no longer lie flat on back w/o becoming SOB.
Around this time, pt also has been experiencing lightheadedness,
dizziness and worsening cough w/yellow-whitish sputum. Pt has
been unable to perform ADLs and his 4 children have been
assisting him with activities he would normally do on his own
such as bathing and eating. His daughter also states he has has
had a depressed mood, decreased motivation and has also been
confused, not able to recall the date or what he ate for
breakfast. He has had one episode of syncope during these three
weeks, though he cannot recall when and how long he was
unconscious. Episode of syncope occurred while he was sitting,
he did not fall or hit his head. Pt also admits to cold
intolerance, LOA and constipation but denies CP, fevers/chills,
diaphoresis, n/v, diarrhea, incontinence, dysuria, urinary
frequency, black or dark stools, blood in stool and hematuria.
.
This AM, pt went for scheduled appointment w/Dr. [**Last Name (STitle) **] at
[**Hospital1 18**] for his lung CA. Dr. [**Last Name (STitle) **] was concerned when he saw
pt and sent him to [**Hospital1 18**] ED.
Past Medical History:
PMH:
1. Squamous cell lung cancer
1. NIDDM: diet controlled ?????? in records but daughter denies
2. RCC: diagnosed [**2183**]; s/p partial R nephrectomy [**2-/2184**]
3. Prostate CA: s/p XRT [**2182**]
4. CAD: s/p catheterization & stent??????2; other blockages said to
be seen in [**1-/2195**]
5. HTN
6. GERD
7. Basal cell CA of skin: on maxilla bilat; not excised
8. Asthma
9. Arthritis
Social History:
Mr. [**Known lastname 93940**] was born in [**Country 532**] and immigrated to the Unites
States in [**2179**]. He has four children. His daughter who lives
nearby accompanies him today. He is a widow and currently lives
in a [**Location (un) 448**] apartment alone. His family visits very often.
He is a former smoker, smoking one pack a day for at least 40
years. He quit approximately 20 years ago. He is a retired
engineer but denies any occupational or environmental exposures.
Family History:
Mr. [**Known lastname 93941**] mother died at the age of 68 from complications
of hypertension. His father died in his 70s from a blood
infection. He has two brothers, one of whom has diabetes.
Physical Exam:
T: 96.8 HR: 68 BP: 118/68 RR: 22 O2Sat: 99%2L
General: elderly man of avg wt; slightly cachectic; appears
fatigued; NAD
Skin: nml temp & consistency; +seborrhaic keratoses & cherry
angiomata on abdomen
HEENT: MMM; no supraclavicular or cervical LAD; no thyromegaly;
no JV elevation
Chest: +diffuse coarse breath sounds/rhonchi; intermittent
crackles in LL & ML bilat; no wheezes; +use of accessory muscles
Cardiac: distant HS; RRR
Abd: difficult to appreciate BS; soft; nontender; nondistended;
no splenomegaly or hepatomegaly
Ext: no LE edema; +good DP pulses bilat
Neuro: CNII-XII intact; no asterixis; no pronator drift;
strength 5/5 in major muscle groups of arms & legs
Pertinent Results:
[**2196-8-4**] 11:45AM GLUCOSE-79 UREA N-36* CREAT-1.9* SODIUM-142
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16
[**2196-8-4**] 11:45AM CK(CPK)-29*
[**2196-8-4**] 11:45AM CK-MB-NotDone
[**2196-8-4**] 11:45AM WBC-6.9 RBC-4.83 HGB-13.1* HCT-41.0 MCV-85
MCH-27.1 MCHC-31.9 RDW-15.9*
[**2196-8-4**] 11:45AM NEUTS-67.5 LYMPHS-23.7 MONOS-7.5 EOS-1.1
BASOS-0.2
[**2196-8-4**] 11:45AM HYPOCHROM-1+ MICROCYT-1+
[**2196-8-4**] 11:45AM PLT COUNT-430
[**2196-8-4**] 11:45AM PT-12.9 PTT-28.9 INR(PT)-1.1
.
.
Radiology:
[**2196-8-4**] CHEST (PA & LAT)
1) Right perihilar opacity/mass; it is unclear per given
history, whether this represents the site of the patient's
primary lung cancer. If not, this may represent a pneumonic
infiltrate; correlate clinically.
2) Multiple small nodules and cavitary lesions seen on the prior
chest CT are not appreciated on the current chest x-ray.
.
[**2196-8-4**] CTA CHEST W&W/O C
1. No evidence of pulmonary embolism. 2. Increased right-sided
effusion.
3. Diffuse bronchial wall thickening. 4. Increase in size of
multiple lung lesions, some of which again demonstrate cavitary
transformation and peripheral wedge-shaped appearance. The
overall appearance is most concerning for progression of
metastatic disease with differential diagnosis again including
typical and atypical infectious processes.
Brief Hospital Course:
Patient is an 83 y/o M w/PMH significant for lung CA who
presented w/gradually progressing SOB, cough, fatigue and
lightheadedness over the past 3weeks w/CXR concerning for PNA or
worsening lung CA. CT performed for further eval also revealed
unilateral pleural effusion and increased pulmonary lesions
concerning for worsening CA or infection. Differential
diagonisis on presentation included advancing malignancy, CHF,
pneumonia. The patient after admission became hypotensive and
additionally was requiring increasing oxygen support. The
patient was transferred to the [**Hospital Unit Name 153**] for ongoing care. In the
[**Hospital Unit Name 153**] he was started on Levofloxacin and Flagyl for possible
pneuominia, with ceftriaxone additionally added as well later.
The patient had large O2 requirements, requiring a
non-rebreather to maintain O2 sats > 90. However, as the patient
was DNR/DNI without presssors, therapies offered in the [**Hospital Unit Name 153**]
were limited. The patient was tried on a trial of CPAP to held
decrease the associated work of breathing but found the CPAP too
uncomfortable and preferred not to use it. The patient therefore
was trasnferred back to the floor for ongoing care. The
patient's prognosis was known to be poor which the patient and
his family were aware of. Therefore, priority was shifted
towards comfort which was guided by the patient's family. As the
patient was lucid and interactive, although markedly tachypnic,
he and his family preferred not to use any narcotics for comfort
initially. However, as the patient's course progressed over a
course of days and he became more tired and confused, the
patient's family guided the use of morphine until a point when
the patient was on a morphine drip titrated to comfort. All
supportive measures including medications, fluids, and lab
checks were discontinued and the patient was allowed to pass
away with his family present. The patient passed away from
respiratory arrest on [**2196-8-13**].
Medications on Admission:
Atenolol 25mg po QD
Ambien 5mg po QHS
Robitussin A-C 2tsp po QHS
Lipitor 10mg po QD
Imdur 30mg po QD
Albuterol Sulfate 17gm IH 2puffs QID
Protonix 40mg po QD
Advair Diskus 500-50mcg IH 1puff [**Hospital1 **]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Squamous Cell Lung Cancer
Secondary:
Squamous cell lung cancer
Diabetes Mellitus: diet controlled ?????? in records but daughter
denies
Renal Cell Carcinoma: diagnosed [**2183**]; s/p partial R nephrectomy
[**2-/2184**]
Prostate cancer: s/p XRT [**2182**]
Coronary artery disease: s/p catheterization & stent??????2; other
blockages said to be seen in [**1-/2195**]
Hypertension
Gastro-esophageal Reflux disease
Basal cell Cancer of skin: on maxilla bilat; not excised
Asthma
Arthritis
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 4280, 2765, 486, 5070, 4019, 2720, 2859, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3325
} | Medical Text: Admission Date: [**2153-9-4**] Discharge Date: [**2153-9-23**]
Date of Birth: [**2153-9-4**] Sex: M
Service: NICU
HISTORY OF PRESENT ILLNESS: Boy [**Known lastname 13144**] was [**Known lastname **] to a 32
year old gravida 2, para 2 to 3 mother at 34 4/7 weeks
gestation secondary to premature rupture of membranes. Fetal
lung maturity score was 18 with absent PE. The baby was [**Name2 (NI) **]
via repeat cesarean section in the breech position.
Mother prenatal laboratory values were blood type A positive,
direct antibody test negative, RPR nonreactive, rubella
immune, hepatitis B surface antigen negative, gonorrhea and
Chlamydia negative and group B streptococcus status unknown.
PHYSICAL EXAMINATION: On physical examination, the baby's
birth weight was 2,765 grams (75th to 90th percentile), head
cm (75th to 90th percentile). Heart rate was 138, regular
rhythm, respiratory rate 48, temperature 97.3, blood pressure
64/45 with a mean arterial pressure of 57, and pulse oximetry
99% on C-PAP of 6 cm of water in room air. Head, eyes, ears,
nose and throat: Anterior fontanelle soft and flat,
nondysmorphic, palate intact, neck and mouth normal, mild
nasal flaring prior to C-PAP tube placement. Chest:
Moderate retractions, fair breath sounds bilaterally, few
scattered coarse crackles. Cardiovascular: Well perfused,
regular rate and rhythm, femoral pulses normal, S1 and S2
normal, no murmur. Abdomen: Soft, nondistended, no
organomegaly, three vessel cord, anus patent. Neurologic:
Active, alert, responsive to stimulation, tone appropriate
for gestational age, moving all limbs symmetrically, suck,
root, gag, grasp and Moro reflexes all intact. Skin:
Normal. Musculoskeletal: Normal for spine, limbs, hips and
clavicles.
LABORATORY DATA: Initial Dextrostix was 31, white blood cell
count 16.2, hematocrit 45.7 and platelet count 311,000.
Initial arterial blood gases were 7.32, PaCO2 51, PaO2 67 and
total carbon dioxide 27.
HOSPITAL COURSE: 1. Respiratory: Initially, [**Known lastname **] had
some respiratory distress but was stabilized on C-PAP. He
did not require surfactant until day of life number two,
[**2153-9-6**], when his respiratory status had
deteriorated slightly overnight with increased oxygen
requirement and increased pressure requirement. He was
intubated and surfactant was delivered via endotracheal tube
times two. He was easily extubated on the following day, day
of life number three, [**2153-9-7**], and put into a nasal
cannula, from which he also easily weaned and, by day of life
number five, he was in room air with no subsequent
respiratory distress. [**Known lastname **] did experience infrequent
bradycardic episodes thought to be secondary to respiratory
immaturity. He was monitored and had been asymptomatic for a
period of five days prior to discharge home. Car seat testing was
normal.
2. Cardiovascular: On day of life number six, [**Known lastname **] was noted
to have increased blood pressures. He had systolic blood
pressures equal in all four extremities, with the systolic
blood pressure in the low 100s and diastolic in the 50s and
60s, with means as high as 70. His resting pulse was in the
low 100s. He also had an abdominal
ultrasound on day of life number seven, [**2153-9-11**],
which was also normal. Urinalysis was also within normal limits.
Although his systolic blood pressure remains intermittently in
the high-normal range of 85-90 mmHg, he has had no further
systolic peaks above 100, and it was not felt that the finding
was pathologic. Blood pressure should be monitored at each
pediatric visit, with further evaluation undertaken if it
increases inappropriately.
3. Fluids, electrolytes and nutrition: [**Known lastname **] had initial
mild hypoglycemia but, after day of life number
one, he has been feeding regularly and is drinking breast
milk on an ad lib basis, with good weight gain. Weight at the
time of discharge is 2860 grams.
4. Gastrointestinal: The patient has been stable. His
bilirubin on day of life number five had been 14.7 and 0.4
and, on day of life number six, dropped to 14.5 and 0.4. He
has never required phototherapy.
5. Hematologic: The patient's blood type is A positive. He
required no transfusions and his most recent hematocrit was
47.1 on day of life number one.
6. Infectious disease: The patient had blood cultures drawn
at birth and was treated with ampicillin and gentamicin until
his cultures were 48 hours negative. The culture was final
with no growth on [**2153-9-10**], day of life number six.
7. Neurologic: [**Known lastname **] has had no abnormal findings.
8. Sensory: Hearing screening was performed with automated
auditory brain stem responses and the patient passed his
hearing screen.
9. Ophthalmology: The patient was not examined as he was
not premature enough to require any examinations for
retinopathy of prematurity.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To home.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 5279**] [**Last Name (NamePattern1) 43699**], [**Location (un) 43700**], [**Location (un) 86**], [**State 350**], telephone number [**Telephone/Fax (1) 43701**],
fax number [**Telephone/Fax (1) 43702**].
CARE RECOMMENDATION: The patient is going to be sent home
breast feeding, on ferinsol. The newborn
screening test is pending.
IMMUNIZATIONS RECOMMENDED: As protocol.
DISCHARGE DIAGNOSES:
1. Surfactant deficiency and respiratory distress syndrome,
resolved.
2. High normal blood pressure, without apparent pathology
3. Apnea/bradycardia of prematurity
4. Mild physiologic hyperbilirubinemia, resolved without
treatment.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (NamePattern1) 43703**]
MEDQUIST36
D: [**2153-9-11**] 14:23
T: [**2153-9-11**] 14:47
Edited: [**2153-9-23**] 13:55
JOB#: [**Job Number 43704**]
ICD9 Codes: 769 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3326
} | Medical Text: Admission Date: [**2104-3-18**] Discharge Date: [**2104-5-1**]
Date of Birth: [**2035-7-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
fatigue, malaise, APML
Major Surgical or Invasive Procedure:
Endotracheal intubation
Tracheostomy
CVL placement
Pericardial drain
Bone marrow biopsy
History of Present Illness:
Pt is a 68 Y M with Hx of HTN who is transferred from
[**Hospital3 **] with DVT, PE, and a new diagnosis of
APML. History is obtained from the patient without the current
availability of all previous records. On [**2104-1-25**], he
went to see his PCP for [**Name Initial (PRE) **] routine visit and because he had
conjunctivitis. There he was found to have Hgb of 10 and WBC
2.2 whose values were the same a week later. His PCP referred
him to a hematologist who sent him for a CXR because he had a
chronic, dry cough. The CXR showed bilateral patchy infiltrate,
but he had a chest CT to characterize it further. He was
started on Avelox for PNA, and referred to a pulmonologist. His
pulmonologist noted peripheral eosinophilia and started him on a
course of prednisone 80mg PO daily x 3 days with a 20mg taper
every 3 days which ended about a week ago. The prednisone
improved his breathing and dry cough somewhat. Repeat CBC
approximately one week prior to admission showed WBC of 22K with
immature cells in the periphery. He underwent a BMBx and
afterwards complained of right leg pain and swelling. His
pulmonologist referred him for LE ultrasound which showed a RLE
DVT; he was admitted to [**Hospital1 **] where CTPA also
revealed PE. He was started on IV heparin. His BMBx and
peripheral flow cytometry returned which was consistent with
APML. He was transferred to [**Hospital1 18**] for further evaluation. On
arrival, he states that he has had fatigue, anorexia, insomnia,
and 25 lb weight loss for the past 1-2 months. He also has a
mild global HA and RLE swelling and soreness but no other acute
concerns.
.
Review of Systems:
(+) Per HPI; Tmax 100.7 this past week; + night sweats for 2
weeks, DOE for the past week
(-) Denies chills Denies blurry vision, diplopia, loss of
vision, photophobia. Denies sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, melena, hematemesis,
hematochezia. Denies dysuria. Denies arthralgias or myalgias.
Denies rashes or skin breakdown. No numbness/tingling in
extremities. All other systems negative.
.
Past Medical History:
.
PMH:
HTN
s/p T&A at age 4
.
Social History:
Lives alone and is a widower; has 1 son, 4 daughters, and 10
grandchildren. He is retired from working in Telecom at [**University/College **],
quit smoking 40 years ago, occasional EtOH but quit for Lent, no
illegal drugs
Family History:
Mother had breast CA in her 40s, father's side of family had
Alcoholism; no other blood or oncologic disorders
Physical Exam:
VS: T 100.7 bp 118/60 HR 114 RR 17 SaO2 96 RA Wt 176.3 lbs
GEN: Elderly man in NAD, awake, alert, making jokes
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD
CV: Reg tachycardia, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, 2+ DP/PT bilaterally; RLE has ankle swelling and
red, non-puritic rash on anterior shin. Bilateral sock-line
edema
SKIN: warm skin
NEURO: oriented x 3, normal attention, CN II-XII intact, [**4-12**]
strength throughout, intact sensation to light touch
PSYCH: appropriate
.
Pertinent Results:
[**2104-3-18**] 07:39PM GLUCOSE-96 UREA N-21* CREAT-0.8 SODIUM-132*
POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-27 ANION GAP-11
[**2104-3-18**] 07:39PM ALT(SGPT)-16 AST(SGOT)-18 LD(LDH)-210 ALK
PHOS-52 TOT BILI-0.3
[**2104-3-18**] 07:39PM CALCIUM-7.8* PHOSPHATE-2.6* MAGNESIUM-2.1
URIC ACID-4.3
[**2104-3-18**] 07:39PM WBC-28.9* RBC-2.15* HGB-7.7* HCT-22.6*
MCV-105* MCH-35.6* MCHC-33.9 RDW-15.8*
[**2104-3-18**] 07:39PM NEUTS-1* BANDS-0 LYMPHS-19 MONOS-15* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* OTHER-65*
[**2104-3-18**] 07:39PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
TEARDROP-OCCASIONAL
[**2104-3-18**] 07:39PM PLT COUNT-119*
[**2104-3-18**] 07:39PM PT-16.4* PTT-28.6 INR(PT)-1.5*
[**2104-3-18**] 07:39PM FIBRINOGE-429*
Portable TTE ([**2104-3-20**]) - Post STEMI
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 5-10 mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. Mild tricuspid regurgitation. Mild pulmonary
artery systolic hypertension.
Portable TTE ([**2104-3-21**]) - Acute onset of pulmonary edema
Overall left ventricular systolic function is probably
moderately depressed (LVEF= 30-35 %). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. No mitral regurgitation is seen. There is no
pericardial effusion.
Portable TTE ([**2104-3-22**]) - Hypotensive episode
The estimated right atrial pressure is 5-10 mmHg. Overall left
ventricular systolic function is moderately depressed (LVEF=
30-35 %) secondary to hypo- to akinesis of the mid-distal
anterior septum, apex, and distal lateral wall
(anterior/inferior walls not well visualized). Right ventricular
chamber size is normal. with ? focal hypokinesis of the apical
free wall (clip [**Clip Number (Radiology) **]). The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a trivial pericardial effusion.
IMPRESSION: Poor image quality. Moderate regional and global
left ventricular systolic dysfunction. Possible focal
hypokinesis of the RV apex. Mild mitral regurgitation. Moderate
tricuspid regurgitation with mild pulmonary artery systolic
hypertension.
Compared with the prior study dated [**2104-3-21**] (images reviewed),
regional and global biventricular systolic function are similar.
Mitral regurgitation is slightly worse but still in the mild
range. Pulmonary pressures were measured but not reported on the
prior echo (also mildly elevated then).
Portable TTE ([**2104-3-26**]) - Persistently tachycardic
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate to severe regional left ventricular systolic
dysfunction with hypokinesis of the anterior septum and anterior
walls, distal inferior wall, and apex. The remaining segments
contract normally (LVEF = 30-35%). 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 (?#). No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is a very small pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD (LAD distribution). Compared with
the prior study (images reviewed) of [**2104-3-22**], left ventricular
systolic function is similar.
Cardiac catheterization ([**2104-3-19**])-
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated single vessel coronary disease. The LMCA was
patent. The LAD had a 70% proximal lesion with extensive
thrombosis. The LCX and RCA were patent.
2. Limited resting hemodynamics revealed normotension.
3. Successful Export thrombectomy and PTCA only of proximal LAD
thrombotic lesion.
4. Successful hemostasis of right radial arteriotomy with TR
band.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Anterior STEMI
3. Successful export thrombectomy and PTCA only of proximal LAD.
3. ASA while ok with heme/onc; integrilin for 12 hours; restart
heparin per CCU team.
ECHO POST-DRAINAGE [**4-25**]: There is a very small pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
Mr. [**Known lastname **] is a 68M with a h/o HTN who was admittedon [**3-18**] to
the BMT service with newly diagnosed AML and DVT/PE on heparin.
He was transferred to the CCU after patient developed an acute
STEMI; cath demonstrated an acute thrombous in the LAD and he
underwent PTCA and thrombectomy; no stents were deployed. His
CCU course was notable for tachycardia, volume overload
(requiring IV lasix prn), several fevers with an episode of
hypotension prompting the initiation of Abx in the setting of
neutropenia, and initiation of chemo with etoposide and
cytarabine for his AML. He was called out to the BMT floor on
4/18pm. He was later admitted to the MICU because of hypotension
and tachypnea in the setting of diuresis. His course was c/b
ARDS and hypoxic respiratory failure, renal failure and volume
overload requiring CVVH, and pericardial tamponade. After the pt
had been intubated for several weeks, he was transitioned to
tracheostomy. His respiratory status waxed and waned but then
progressively declined; he also had a persistent pressor
requirement to maintain his pressures while on CVVH. After
multiple discussions with the family, the pt was transitioned to
CMO status, and he passed away o/n on [**2104-5-1**].
.
ACTIVE HOSPITALIZATION ISSUES:
.
#AML: pt was transferred from OSH with labs initially concerning
for AML vs APML, was briefly treated with ATRA prior to Dx of
AML. No e/o TLS. We d/c'd Allopurinol 300mg PO daily given uric
acid levels <4 for about 2 days. Pt was treated with etoposide
and cytarabine given cardiotoxicity from anthracyclines
(Etoposide 100 [**12-13**]/cytarabine 200 [**12-15**]). Due to complicated ICU
course, further chemo was not undertaken.
.
#s/p STEMI: On BMT floor on day after admission, pt developed an
acute STEMI. In the cath lab he was found to have an acute
thrombous in the LAD and underwent PTCA and thrombectomy; no
stents were deployed. Currently has depressed EF ~30-35%. Had
intermittent episodes of being volume-up in CCU, has been
intermittently diuresed. Has o/w been asymptomatic. A small
pericardial effusion seen on [**3-26**] TTE; no tamponade or
physiologic changes; thought by cards to be clinically
insignificant. He had tachycardia to 120-130s for several days
in the CCU, but after call-out had a HR in the 80-90s. On BMT,
we stopped atorvastatin on [**3-27**] given possibility of drug-drug
interaction with chemo drugs after consulting with cards. Pt was
not given heparin and ASA given falling PLTs.
.
#Pericardial tamponade: The patient was transferred to the CCU
on [**2104-4-24**] in the setting of decreased blood pressures and
echocardiographic evidence of pericardial effusion with
tamponade physiology. A pericardial drain was placed on [**4-24**]
and 500cc of bloody fluid was removed and drain left in place.
Opening pressure was 28. No right heart cath was done. Drain put
out 150mL bloody fluid overnight and then stopped draining the
morning after it was placed. Repeat echo on [**4-25**] AM showed very
small pericardial effusion. Drain was pulled and pt was
transferred back to [**Hospital Unit Name 153**]. Pt tolerated procedure well with no
complications. He remained stable on 2 pressors, which were not
able to be weaned while in the CCU.
.
# Hypoxic respiratory failure: Secondary to multifocal
PNA/ARDS. Mini- BAL from [**4-19**] showed Pseudomonas fluorescens
resistant to cefepime, sensitive to zosyn, intermediate to
meropenem. CT chest [**4-16**] showed worsening of bilateral diffuse
opacifications compared to prior, possibly due to further volume
overload. Pt received tracheostomy. Prior to CMO status, the pt
was being treated with amikacin, ambisome, Zosyn, linezolid.
.
# Hypotension, persistent pressor requirement: likely related
to prolonged shock/sepsis. Pt required pressors especially
during CVVH volume removal.
.
# [**Last Name (un) **]. Creatinine was up to 3.6 from baseline 0.8 in the context
of ATN from hypotension; it improved down to the 1??????s with CVVH.
Although CVVH was able to remove volume occasionally, volume
removal was limited due to tenuous BP's.
.
# Apical hypokinesis and PAF: He was s/p DCCV x3 on [**4-9**] for
atrial tachyarrhythmia. He was maintained on a heparin drip.
.
#DVT and PE: Dx'd at OSH, initially was on heparin upon
admission, until PLT's started to drop.
.
Medications on Admission:
HCTZ 25mg PO daily
ASA 81 mg PO daily
Discharge Medications:
Pt passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
AML
PNA
[**Last Name (un) **]
STEMI
Pericardial tamponade
PE/DVT
Discharge Condition:
Pt passed away
Discharge Instructions:
Pt passed away
Followup Instructions:
Pt passed away
Completed by:[**2104-5-3**]
ICD9 Codes: 0389, 486, 5845, 2760, 2761, 4280, 4019, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3327
} | Medical Text: Admission Date: [**2153-5-29**] Discharge Date: [**2153-6-7**]
Date of Birth: [**2097-1-18**] Sex: M
Service:
ADMISSION DIAGNOSIS: Esophageal cancer.
DISCHARGE DIAGNOSES:
1. Esophageal and proximal gastric cancer.
2. Status post [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] esophagectomy.
3. Gastroesophageal Reflux
HISTORY OF PRESENT ILLNESS: The patient is a 56 year old
gentleman with a known diagnosis of esophageal cancer
involving the proximal stomach. The patient had previously
received feeding jejunostomy and new adjuvant treatment. He
now presents for resection of his cancer.
PAST MEDICAL HISTORY:
1. Esophageal cancer.
2. Gastroesophageal reflux disease.
PAST SURGICAL HISTORY:
1. Laminectomy in [**2120**].
2. Pilonidal cyst times two.
3. Right knee arthroscopy [**2136**].
4. Laparoscopic jejunostomy and port-a-cath placement in
12/92.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg once daily.
2. Lorazepam 1 mg p.r.n.
ALLERGIES: Penicillin causes joint swelling. Erythromycin
also causes joint swelling.
HOSPITAL COURSE: The patient was admitted for resection of
his esophageal cancer after having received feeding
jejunostomy and neo-adjuvant treatment beginning in [**2153-1-7**]. The patient tolerated the procedure well without
complication. In the immediate postoperative period, the
patient was transferred to the Intensive Care Unit for closer
monitoring. He was found to have tachycardic and the
postoperative hematocrit was 39.0. He was given volume
resuscitation of one liter on the evening of postoperative
day zero. The patient was otherwise maintained NPO and
seemed to be doing well. He remained slightly tachycardic.
The patient was transferred to the floor on the evening of
postoperative day number two. On postoperative day number
three, the patient had trophic tube feeds begun. Lopressor
was increased in order to control heart rate. The patient
was making good urine. The patient was maintained NPO and
tube feeds were increased. An upper gastrointestinal swallow
study was obtained on postoperative day number five which
showed no evidence of an anastomotic leak. There was delayed
gastric emptying with no contrast visualized in the small
bowel after approximately twenty minutes. On postoperative
day number seven, the patient was advanced to clear liquid
diet and chest tube was discontinued. Subsequent to this,
the patient seemed to do well and diet was advanced as
tolerated. The jejunostomy tube was capped. Ultimately, the
patient was discharged on postoperative day number nine
tolerating a regular and adequate pain control with p.o. pain
medications and having normal bowel movements.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DIET: Ad lib.
MEDICATIONS ON DISCHARGE:
1. Percocet p.r.n.
2. Protonix 40 mg once daily.
3. Lorazepam 1 mg p.r.n.
INSTRUCTIONS: The patient is to follow-up with Dr. [**Last Name (STitle) **]
in one to two weeks time. He should also follow-up with his
regular oncologist for continued protocol therapy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2153-7-20**] 12:35
T: [**2153-7-25**] 19:57
JOB#: [**Job Number 47533**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3328
} | Medical Text: Admission Date: [**2159-5-10**] Discharge Date: [**2159-5-17**]
Date of Birth: [**2102-11-7**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
progressive decline in vision
Major Surgical or Invasive Procedure:
1. Bifrontal bicoronal craniotomy with left sided pterional
extension for resection of meningioma.
2. Intraoperative image guidance.
3. Microscopic dissection.
4. Exenteration of frontal sinus with pericranial pedicle
flap.
5. Duraplasty.
History of Present Illness:
The patient is a 56-year-old Chinese female who presents to
brain tumor clinics. She had noticed a progressive decline in
vision over the last 3 years. The patient presents with a blind
right eye and a left eye that only has a superior quadrant left.
Imaging workup revealed a large suprasellar mass consistent with
tuberculum sellae meningioma. Incidental findings made of right
side high frontal meningioma. The meningioma displaces the optic
track and splays the optic nerves. The patient presented with
SIADH.
It is negative for skin, HEENT, neck, cardiovascular, pulmonary,
gastrointestinal, genitourinary, musculoskeletal, hematological,
allergy/immunology, endocrine, and psychiatric systems. Her
neurological review of system is listed above.
Past Medical History:
diabetes,
hypertension,
COPD
Positive PPD and she was treated with 6
months of INH.
Past Surgical History: She had a biopsy of a cyst in the right
breast. She also has a thyroid nodule with normal TSH.
Social History:
She does not smoke cigarettes or drink alcohol.
Family History:
Her father died of a motor vehicle accident while her mother is
healthy. She has 7 siblings and 2 children and they are all
healthy.
Physical Exam:
Weighs:132lbs Height:62inches.
T:97.8 F BP:132/68 HR:78 RR:16
GEN:
SKIN: full turgor.
HEENT: Neck is supple.
Cardiac: Regular rate and rhythms.
Lungs: clear.
Abdomen is soft.
Extremities:No show clubbing, cyanosis, or edema.
Neurological Examination:
She is awake, alert, and oriented times 3. Her language is
fluent with good comprehension, naming, and repetition (there is
a Chinese interpreter present). Her recent recall is good.
Cranial Nerve Examination: Her pupils are equal and reactive to
light, 4 mm to 2 mm bilaterally. There is an afferent papillary
defect in OD. Extraocular movements are full; there is no
nystagmus. Visual fields are full to confrontation in OS but she
is barely able to detect light in OD. Her face is symmetric.
Facial sensation is intact bilaterally. Her hearing is intact
bilaterally. Her tongue is midline. Palate goes up in the
midline. Sternocleidomastoids and upper trapezius are strong.
Motor Examination: She does not have a drift. Her muscle
strengths are [**6-15**] at all muscle groups. Her muscle tone is
normal. Her reflexes are 2- and symmetric
bilaterally. Her ankle jerks are absent. Her toes are down
going. Sensory examination is intact to touch and
proprioception. Coordination examination does not reveal
dysmetria. Her gait is normal. She does not have a Romberg.
Brief Hospital Course:
This 56 y/o female presented to the brain tumor clinic after she
had outisde imageing that revealed a suprasellar meningioma.
Her initial complaint was for progressive visual loss over a
three yr period. Her visual loss was significant for right eye
blindness as well as VF cut to temporal [**Last Name (un) 8491**] in left eye. She
was admitted to the hospital [**2159-5-10**] through the same day
surgery department after informed consent with an interpreter
was obtained. She underwent the procedure without complication.
She also had a lumbar drain placed intraopertively for cerebral
decompression for improved access for tumor resection. This was
clamped postoperatively until the MRI of the Brain was
completed. She remained intubated postoperatively for airway
protection. Her post operative exam was stable and she was MAE.
POD#1 pt was transfused one unit PRBC for HCT of 27.8. She was
started on mannitol, decadron and dilantin immediatley
post-operatively. POD# 2 her HCT had dropped to 23.0 and she
was transfused 2 additional units of PRBC's. She was started on
Heparin sq as well. The Neuro-oncology service was called to
evaluate the patient postoperatively. She is known to their
service and at this time they recommmend repeat formal ophtho
eval after d/c. Her lumbar drain was d/c'd on POD#3 as well as
her foley. She was extubated this day as well. Her exam
remained stable however her VF testing remains difficult [**3-15**]
periorbital edema and language barrier. She is MAE with full
strength. Her HCT is 24.7 this day. Her decadron was tapered 1
mg QD. POD# 4 HCT 27.7. Dilantin 11.6. Her incision remains
CDI and is approximating well.
Her evaluation by PT and OT reveals that she is safe to go home
with use of a walker.
Her post hospitalization office visits have been arranged. Her
husband has concerns that she is not completely pain free in the
scalp area but this is normal for the postoperative phase. This
was explained to him through and interpreter. He also had
concerns that she was not sleeping well at night and requests a
sedative. It was explained in detail to the husband with and
interpreter and the son that the pt is NOT to go home and lay on
the couch or in bed. She has needed a lot of encouragement to
remain mobile during the hospitalization. Side effect of DVT
and postoperative PNA and the danger associated with them were
also discussed in detail. The son verbalizes understanding of
this.
Upon d/c on [**2159-5-16**], pt had 1 episode of emesis 100cc, patient
kept inhouse for one more night, no futher nausea/vomiting
noted.
Patient dicharged home on [**2159-5-17**] with discharge and follow up
instructions in stable condition.
Medications on Admission:
NONE
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a
day.
Disp:*90 Capsule(s)* Refills:*2*
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain: do not drive while you are on this
medication.
Disp:*60 Tablet(s)* Refills:*1*
4. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 days: On [**5-18**] only then stop.
Disp:*4 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
5 days.
Disp:*5 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Benadryl 25 mg Capsule Sig: One (1) Capsule PO at bedtime as
needed for insomnia for 10 days.
7. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: may stop when off
the percocet or loose stool.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p bifrontal craniotomy for meningioma
Discharge Condition:
neurologically stable
Discharge Instructions:
Please do not get your incision wet/wash your hair for five
days. Do not pick at your incision. Please call the office at
[**Telephone/Fax (1) **] for any concerns, fever, drainage or redness at or
from your incision.
Followup Instructions:
1: Follow up in the Brain tumor clinic at [**Telephone/Fax (1) **] [**Location (un) **]
of the [**Hospital Ward Name **] center on the [**Hospital Ward Name **] on Monday [**2159-5-21**] at
2pm with Dr. [**Last Name (STitle) 724**] - You will have your sutures removed there.
It is very important that you attend this appointment - if you
cannot, you must call ahead to notify the staff.
You are to have formal visual field testing- please call
[**Telephone/Fax (1) **] for an appointment to be seen within the next 2
weeks.
Please keep the following appointments:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. SURGICAL SPECIALTIES CC-3 (NHB)
Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2159-5-22**] 11:15
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2159-6-26**] 9:00
Completed by:[**2159-5-17**]
ICD9 Codes: 5990, 496, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3329
} | Medical Text: Admission Date: [**2188-5-14**] Discharge Date: [**2188-5-25**]
Date of Birth: [**2118-3-27**] Sex: M
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 70-year-old
gentleman who was evaluated by Dr. [**First Name (STitle) 4667**] [**Doctor Last Name **] after being
referred by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] for possible treatment of
invasive distal esophageal carcinoma. This is a patient who
has had longstanding gastroesophageal reflux disease and
underwent upper GI endoscopy in [**2187-12-30**] due to this
complaint and new anemia. This confirmed Barrett's esophagus
with high grade dysplasia, squamous to columnar cells. He
then received endoscopy again for biopsy and was found to be
cancerous on pathology and showed adenocarcinoma and showed
invasion of the submucosa with deep positive margins. The
patient did not report any dysphagia at this time or
odynophagia. He did not report any weight loss and had no
other constitutional signs or symptoms such as fever, chills,
night sweats.
PAST MEDICAL HISTORY: Diabetes type 2, hypertension, and
history of hemorrhoidectomy.
MEDICATIONS:
1. Hydrochlorothiazide.
2. Mavik.
3. Omeprazole.
4. Vytorin.
5. Reglan.
SOCIAL HISTORY: He was 1.5 pack per day smoker for 33 years.
He quit smoking approximately 20 years ago and occasionally
has an alcoholic beverage up to 3 drinks per week and is
employed by the UPS delivery company.
FAMILY HISTORY: He reports a strong family history of
gastric carcinoma.
ALLERGIES: He has no medical allergies.
PHYSICAL EXAMINATION: Vital signs: He weighed 164 pounds and
was afebrile with a pulse in the 80s, blood pressure 136/84,
respiratory rate 18, and room air saturation of 94%. HEENT:
He had no scleral icterus. There is no adenopathy in the neck
region anteriorly, posteriorly, or in the supraclavicular
fossa. There is no axillary lymphadenopathy. Chest: Breath
sounds are clear to auscultation bilaterally. Cardiovascular:
Heart in regular rate and rhythm with no murmurs, rubs or
gallops. Abdomen: Nondistended with normal active bowel
sounds. It was nontender throughout.
HOSPITAL COURSE: At this time the patient was admitted for
operative intervention for scheduled likely trans-hiatal
esophagectomy and feeding jejunostomy. The patient was
brought to the operating room on the day of admission and
underwent the following procedures: Bronchoscopy, left video
assisted resection of the lower lobe nodule with biopsy of
the left upper lobe, transhiatal esophagectomy and feeding
jejunostomy. This was done under general endotracheal
anesthesia. The patient tolerated the procedure well and was
brought to the post anesthesia care unit afterwards and then
intubated to the surgical intensive care unit in satisfactory
condition. The patient in his postoperative course remained
intubated and on postoperative day 2 underwent diagnostic
flexible bronchoscopy for likely right lower lobe infiltrate
found on chest x-ray.
Bronchoscopy revealed a clot in the bronchus intermedius that
was evacuated and some residual blood in the bilateral lungs
which was aspirated therapeutically. There was noted to be no
active bleeding from many segments of the left or right lung
and the patient tolerated the procedure well. The patient at
this point had a nasogastric tube or right internal jugular
venous catheter and left sided chest tube in place. He was
progressing well. He was still having some difficulty at this
time regaining his respiratory status however, and was kept
strict NPO with the back end of the esophagectomy and was
then placed on tube feeds at this time through his
jejunostomy tube that was placed in the operating room. He
was receiving ProMod with fiber half strength at this time at
atrophic level that was not advanced past 10 ml per hour.
It was noted at this point that the patient had a somewhat
persistent ileus, likely as in the postoperative period. His
abdomen became somewhat distended until postoperative day 8
when he noted the passing of flatus and small bowel
movements. At this point he was given sips and to have no
more than 30 ml per hour. He faired well with this actually
and was able to be advanced to clear liquids at 1.5 days
later and also tolerated this well. As his ileus resolved we
also increased his tube feeds up to goal rate of 70 ml per
hour and then the day before discharge advanced them to a
full strength formulation from the half strength formulation
from the half strength formulation, so now at this point he
was completely meeting his nutritional goals through the tube
feeds. Also of note he was started on all of his oral
medications and he was started on full liquids at this time.
The patient's chest tube had been discharged and followup
chest x-rays revealed there to be slight increase in this
effusion on the right side. This actually seemed to gradually
resolve and the patient has had no trouble with his
respiratory status during this time.
On the day prior to discharge his staples were removed from
his left neck and from his abdomen and Steri-Strips were
placed. Also of note his [**Location (un) 1661**]-[**Location (un) 1662**] drain had been
discharged 4 days before discharge without difficulty and he
had been noted to have minimal output in the days leading up
to its removal.
On postoperative day 11, the patient was deemed fit for
discharge, was tolerating full strength tube feeds at goal
rate and was tolerating full liquids without difficulty, was
walking around and having no significant difficulties and was
restarted on all of his home medications at this time. His
wound had had mild redness, notably the abdominal pain that
had gradually resolved during this time. He was watched
carefully with serial exams and did not ever require
antibiotic treatment.
On the morning of [**5-25**], the patient was discharged to home.
DISCHARGE INSTRUCTIONS: The patient to call Dr. [**First Name4 (NamePattern1) 4667**]
[**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 65511**] if developing chest pain,
shortness of breath, inability to swallow, fever, chills,
nausea, vomiting, diarrhea, redness or drainage from the
incisions or problems with the feeding tube. If the feeding
tube stitches break or the feeding tube falls out, call the
thoracic surgery office immediately. If you are unable to
reach the thoracic service, please go to the emergency room
and have the tube replaced.
FINAL DIAGNOSIS:
1. Transhiatal esophagectomy.
2. Left video assisted thoracoscopy for nodule biopsy and
jejunostomy tube placement.
3. Hypertension.
4. Hypercholesterolemia.
5. Diabetes type 2.
RECOMMENDATIONS: The patient to follow up in Dr. [**First Name4 (NamePattern1) 4667**]
[**Last Name (NamePattern1) **] office in 7 to 14 days and to call [**Telephone/Fax (1) 65511**] for
follow up appointment. The patient arrived 45 minutes prior
to report to the [**Hospital Ward Name 23**] Clinical Center for follow up chest
x-ray.
MAJOR SURGICAL INVASIVE PROCEDURES:
1. Transhiatal esophagectomy.
2. Jejunostomy tube placement.
3. Left lower lobe video assisted thoracoscopy.
CONDITION ON DISCHARGE: Good.
MEDICATIONS:
1. Percocet 5/325 in the elixir form 5 to 10 ml PO q4 to 6
hours as needed for pain.
2. Lansoprazole 30 mg PO once daily in the elixir format.
3. Tube feeds Impact with fiber at a rate of 70 ml per hour
at full strength.
4. Hydrochlorothiazide 25 mg PO once daily.
5. Trandolapril 4 mg PO once daily.
6. Atorvastatin 80 mg PO once daily.
7. Ezetimibe 10 mg PO once daily.
8. Metoprolol 37.5 mg PO b.i.d. with parameters for systolic
blood pressure less than 100 and heart rate less than 60.
9. Dulcolax p.r.n.
10. Regular insulin sliding scale as needed.
He likely can go home on just his oral glucose agents.
DISPOSITION: The patient will be discharged to home and
follow up with Dr. [**First Name (STitle) 4667**] [**Doctor Last Name **].
[**Name6 (MD) 4667**] [**Name8 (MD) **], M.D. [**MD Number(2) 39921**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2188-5-24**] 23:53:00
T: [**2188-5-25**] 10:32:31
Job#: [**Job Number 65512**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3330
} | Medical Text: Admission Date: [**2117-1-24**] Discharge Date: [**2117-2-1**]
Date of Birth: [**2047-4-15**] Sex: F
Service: NEUROLOGY
HISTORY OF THE PRESENT ILLNESS: This is a 69-year-old
right- handed woman who presented with a new onset of
right-side weakness and aphasia on the day of admission. The
CT of the head, four hours after the onset of the symptoms,
was negative for early signs of infarction, as well as
seizure with paralysis considered. She was loaded with
Dilantin and started on daily dose. She became bradycardiac,
hypotensive, and she had difficulty protecting her airway.
She was intubated and sent to the neurological ICU. Repeat
CT the following day showed evolving left posterior temporal
area infarct with patent vessels on CT angiogram. She was
taken off sedation on [**2117-1-27**] and extubated on [**2117-1-28**].
However, despite this, the mental status has varied between
opening eyes and purposeful movement to pain, but otherwise,
she has been unresponsive. Repeat CT scan showed evolution
of the prior stroke and it was noted to involve both the
cerebrum peduncle on the left large portion of the temporal
lobe on the left, as well as the thalamus and the mid brain.
PAST MEDICAL HISTORY: History is significant for left
occipital stroke approximately one year ago; seizure disorder
since [**2109**], for which she had been taking Klonopin for
several years; hypertension; atrial fibrillation; history of
DVT; bilateral carpal-tunnel surgery; familial tremor and
glaucoma.
ALLERGIES: The patient is allergic to DILANTIN, DARVON, and
COUMADIN.
MEDICATIONS ON ADMISSION:
1. Naprosyn.
2. Klonopin.
3. Celexa.
4. Aspirin.
5. Zantac.
6. Insulin.
7. Metoprolol.
SOCIAL HISTORY: History is significant for no alcohol,
tobacco or drug use. She lives with her daughter, son and
20-year-old grandson.
FAMILY HISTORY: History is significant for father who had a
brain tumor, brother who had [**Name (NI) **] disease.
PHYSICAL EXAMINATION: On examination, vital signs revealed
blood pressure 140/58, heart rate 60, respiratory rate 15,
temperature 99.6. GENERAL: The patient is an obese,
elderly, woman. HEAD AND NECK: Examination revealed supple
neck with no carotid bruits. CARDIAC: Examination revealed
regular rate and rhythm. LUNGS: Lungs were clear. ABDOMEN:
Abdomen was soft and nontender. EXTREMITIES: Extremities
showed no edema. NEUROLOGICAL: On neurological examination,
she did not open eyes to sternal rub or voice. She moved
the left arm purposefully to pain and would withdraw the left
leg to pain. The right leg showed triple flexion and the
right arm showed minimal finger flexion to pain. There was
no speech output. She did not follow command. Oculocephalic
reflexes were intact. Pupils were equal, round, and reactive
to light. Reflexes in the arms were symmetrical and absent
at the knees and ankles. The right toe was up and the left
toe was downgoing.
HOSPITAL COURSE: The patient was felt to be hemodynamically
stable and transferred out of the unit on [**2117-1-29**]. At
that point in time, she was still only minimally responsive.
It appeared that she had aspirated at some point and began to
show clinical indications of a pneumonia. Extensive
consultation was undertaken with the family, who indicated to
the team that this was not what the patient would have wished
and given the very poor prognosis of a brain stem stroke and
low likelihood of her recovering meaningful function, that
they did not with to pursue any heroic measures. For this
reason, she was treated for her comfort only. No further
invasive testing, blood draws, etc, was performed. She was
only kept on minimal IV fluids, which was discontinued on the
final hospital day. She continued to spike fevers, for
which she was given Tylenol for symptomatic relief. Her
respiratory rate gradually increased over the course of
[**2117-1-31**] and was in the 50s. However, she appeared
comfortable, in no pain medication was required.
She was seen by hospice services, who recommended inpatient
hospice care under their supervision. At that point in time,
the NG tube was discontinued. The IV fluids were
discontinued. Medications were given pr where possible, but
only consisted of Tylenol and Dilantin.
Her condition continued to deteriorate. She died on the
morning of [**2117-2-1**]. Family was present at bedside and
discussion was held with them by a member of the Neurology
Team.
CAUSE OF DEATH: Acute stroke.
ASSOCIATED MEDICAL PROBLEMS:
1. Acute stroke.
2. Aspiration pneumonia.
3. Hypertension.
4. Atrial fibrillation.
5. Status post DVT in [**2097**].
[**Last Name (LF) **],[**First Name3 (LF) **] J.S. M.D. [**MD Number(1) 8347**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2117-2-1**] 16:25
T: [**2117-2-1**] 16:24
JOB#: [**Job Number 18897**]
ICD9 Codes: 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3331
} | Medical Text: Admission Date: [**2111-5-30**] Discharge Date: [**2111-8-5**]
Date of Birth: [**2069-5-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
post pneumonectomy syndrome
Major Surgical or Invasive Procedure:
[**6-2**]-airway stents removed by IP
[**6-3**]- trach placed
History of Present Illness:
42 yr old woman with hx of right pneumonectomy in [**2107**] for stage
IIb adenocarcinoma c/b post op chronic dyspnea with multiple
acute L PNA episodes (post pneumonectomy syndrome) transferred
to [**Hospital1 18**] from [**Hospital **] Hospital, GA for IP evaluation s/p failure
of L sided stenting procedure.
In [**Month (only) 956**] of this year, the patient was taken to the OR for
postpneumonectomy syndrome, where she underwent repeat R
thoracotomy, LOA, pericardial implantation , breast
implantation. Postoperatively, she was unable to wean from the
vent and underwent tracheostomy after one week. She had
continued difficulty weaning of the trach, and bronchoscopy
revealed severe tracheomalacia, with almost complete obstruction
throughout the airway due to anterior movement of the posterior
membrane and collapse of root of trachea. She was also noted to
have L mainstem with severe malacia. An custom made14x6mm L
stent was planned, but this broke, and in [**2111-4-6**] a 14x5mm L
stent was placed under rigid bronchoscopy. She was extubated
successfuly. Prior to discharge, a flexible bronchoscoy noted
significant granulation tissue at the distal portion of the
stent, but this was noted not to be obstructive. Upon discharge
she did well for ~ 1 month, whern she had repeat episode of
respiratory distress. At this time, the [**Last Name (un) 2435**] was removed, and a
dual lumen L sided ETT placed in the OR. On [**2111-5-21**], the patient
returned to the OR for replacement of the orginial L sided
stent. This was overlapped with a 14X5cm polyflex (distal
overlap 3cm). ON POD#4, she developed heavy secretions requiring
intubation of stent. She had been weaned to a successful SBT
(600-700cc Vt), but was transferred to [**Hospital1 18**] for further IP
evaluation.
Past Medical History:
Adenosquamous lung cancer dx [**2107**]
-s/p total R pneumonectomy [**10-16**]
-Bronchomalacia of L mainstem s/p stent [**3-/2111**]
HTN
GERD
Anxiety
Klebsiella UTI [**4-18**]
NASH dx [**2106**]
Migraine
S/P Appendectomy [**2092**]
s/p CCY [**2089**]
TAHBSO [**2106**]
H/O Endometriosis
Social History:
Lives in GA. Has 2 children.
Family History:
Non-contributory
Physical Exam:
VS - Wt 78.3 T 98.4 BP 120/80 HR 90-100 RR 16
GEN - intubated, sedated, NAD
HEENT - pupils small but minimally reactive
COR - RRR, clear S1/S2, no murmurs/rubs/gallops
PULM- absent R breath sounds, clear L
ABD - obese, soft, hypoactive BS, s/p G tube
EXT- WWP, no edema
Neuro - Responds to tactile stimuli, sedated
Pertinent Results:
[**2111-5-30**] Urine - Klebsiella
[**2111-6-8**] Blood - [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **]
[**2111-6-19**] BAL - Pseudomonas/Proteus
[**2111-6-20**] Urine - Klebsiella/Proteus
Imaging:
[**2111-5-30**] CXR - Right hemithorax is nearly uniformly opacified
except for air at the base. This could represent an expander in
the right hemithorax. Tracheobronchial stent extends from the
subglottic trachea to left main bronchus, approximately 15 mm
beyond the carina. Left lung is well expanded. Mediastinum is
shifted mildly to the right of midline.
CT airways: Tracheal and bronchial stents are patent and free of
complications, aside from minimal ingrowth in the bronchial
portion. Stented central airway is normal calibre.
Post-pneumonectomy mediastinum midline. Right intrathoracic
spacers. Mild left lung aspiration and/or pneumonia. Lower lobe
lesion should be followed to confirm that it is inflammatory
[**2111-5-31**] CT Abd:
1. Marked pneumoperitoneum with extensive loculations. This
likely is consistent with recent surgical intervention (J-tube)
as well as peritoneal adhesions.
2. Pericolonic fat stranding in the region of the ascending and
proximal transverse colon. This is nonspecific but could be
related to an inflammatory process though diverticuli are not
visualized. Perforation cannot be excluded.
3. Peripancreatic lymphadenopathy. Further evaluation is limited
on this non-contrast scan.
4. Cystic structure in the pelvisd ma represent hydrosalpinx
versus peritoneal inclusion cyst within the pelvis.
[**2111-5-31**] Abd U/S:
1. Patient is status post cholecystectomy. No intrahepatic
biliary ductal dilatation.
2. Diffusely echogenic liver consistent with fatty infiltration.
Other forms of liver disease, and more advanced liver disease
including hepatic fibrosis/cirrhosis cannot be excluded on this
study.
3. No ascites.
[**2111-6-3**] CT Abd:
1. Interval decrease in the amount of loculated intraabdominal
free air, consistent with recent jejunal tube placement.
2. Interval decrease in the degree of inflammatory fat stranding
surrounding the hepatic flexure of the colon.
3. Unchanged fullness within the region of the pancreatic head.
Unchanged low- density structure anterior to the uncinate of the
pancreas. Evaluation of these structures is limited due to the
lack of intravenous contrast enhancement.
4. Bilateral cystic structures within the pelvis which may
represent bilateral hydrosalpinx versus loculated pelvic free
fluid.
5. Status post right pneumonectomy with fluid filled cavity at
the right lung base and subsegmental airspace opacification at
the left lung base, which may represent atelectasis versus
consolidation.
6. Left lung base nodular density and atelectasis, stable.
[**2111-6-10**] ECHO - Suboptimal views. There is probably a small
pericardial effusion. Left ventricular systolic function appears
grossly preserved. Valves could not be adequately assessed.
[**2111-6-17**] CXR - No change in mediastinal position since [**6-9**],
lower mediastinum midline, trachea deviated to the right. No air
in the right pneumonectomy space. Left lung fully expanded and
clear. Tracheostomy tube in standard placement. Tip of the left
subclavian line projects over the SVC. Redundant lucencies
projecting over the trachea and the right paramedian lower chest
could be small gas collections in the mediastinum. If there is
clinical concern about mediastinal infection, CT scanning
employing esophageal contrast [**Doctor Last Name 360**], would be required.
[**2111-6-25**] ECHO - Left ventricular wall thickness, cavity size,
and systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. No evidence of endocarditis
seen.
CTA CHEST W&W/O C &RECONS [**2111-7-3**] 2:01 PM
[**Hospital 93**] MEDICAL CONDITION:
42 year old woman with s/p pneumectomy now tachycardia,
tachypnea
REASON FOR THIS EXAMINATION:
r/o PE
INDICATION: Status post pneumonectomy, now tachycardia and
tachypnea, rule out PE.
COMPARISON: [**2111-5-31**].
TECHNIQUE: Non-contrast and contrast-enhanced axial CT imaging
of the chest with multiplanar reformats was reviewed.
CT CHEST WITH CONTRAST: The patient is status post right
pneumonectomy with two saline implant devices in the right
thorax. There is unchanged elevation of the right hemidiaphragm.
The pulmonary arteries opacify without filling defects. The
heart and great vessels in the mediastinum are unremarkable.
Multiple small and non-pathologically enlarged mediastinal lymph
nodes are identified.
There is near total collapse of the distal trachea,
approximately 4 cm distal to the tip of the endotracheal tube.
At its most narrow margin, there is only a 4-mm patency of the
left main stem bronchus. The left lung is inflated adequately,
and a patchy ill-defined opacity at the left base is unchanged.
There is a small left pleural effusion and associated
atelectasis. Central venous catheter terminates in the
cavoatrial junction. The visualized portions of the abdomen are
unremarkable. The patient is status post cholecystectomy.
IMPRESSION: Near total collapse of the distal trachea and left
main stem bronchus with only 4-mm patency at its most narrow
margin. The left lung is currently still well aerated
VIDEO OROPHARYNGEAL SWALLOW [**2111-7-29**] 9:49 AM
[**Hospital 93**] MEDICAL CONDITION:
42 year old woman s/p tracheoplasty
REASON FOR THIS EXAMINATION:
please evalaute
INDICATION: 42-year-old female status post tracheoplasty.
VIDEO OROPHARYNGEAL SWALLOW EXAMINATION: An oral and pharyngeal
swallowing video fluoroscopy study was performed in
collaboration with the speech and language pathology division.
Various consistencies of barium including thin liquid, nectar
thickened liquid, puree and a half cookie coated with barium
were administered.
FINDINGS: Normal bolus formation and mastication were identified
during the oral phase. There was no significant premature
spillover. The pharyngeal phase demonstrates normal swallow
initiation, palatal elevation, laryngeal elevation, laryngeal
valve closure, and epiglottic deflection. There is intermittent
trace penetration during the swallow when the tracheostomy valve
was removed. No aspiration or penetration were identified with
the valve in place.
IMPRESSION: Functional pharyngeal swallow without evidence of
aspiration. Mild penetration which resolved with placement of
the tracheostomy valve.
CT HEAD W/O CONTRAST [**2111-7-24**] 3:09 PM
Reason: please evaluate for cause of rising white count, please
scan
[**Hospital 93**] MEDICAL CONDITION:
42 year old woman with h/o of pneumonectomy, s/p tracheoplasty
for tracheomalacia POD 16, now with rising WBC.
REASON FOR THIS EXAMINATION:
please evaluate for cause of rising white count, please scan
head, sinuses, chest, and abd.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 42-year-old woman with history of pneumonectomy,
status post tracheoplasty, now with rising WBC count. Evaluate
for source of increasing count.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT.
CT HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage or mass
effect is identified. The ventricles are symmetric, and there is
no shift of normally midline structures. The [**Doctor Last Name 352**]-white
differentiation preserved. The density of the brain parenchyma
is within normal limits. The soft tissue structures are normal.
The visualized portion of the paranasal sinuses are within
normal limits. The osseous structures are normal.
IMPRESSION: No intracranial hemorrhage or mass effect is
identified.
CT CHEST W/CONTRAST [**2111-7-24**] 3:10 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: please evaluate for fluid collections, cause for rising
whit
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
42 year old woman with h/o of pneumonectomy, s/p tracheoplasty
for tracheomalacia POD 16, now with rising WBC.
REASON FOR THIS EXAMINATION:
please evaluate for fluid collections, cause for rising white
count, please scan head, sinuses, chest, and abd.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 42-year-old female with history of pneumonectomy
status post tracheoplasty and tracheomalacia, postop day #16,
now with rising white blood cell count. Please evaluate for
fluid collection cause of rising white count.
COMPARISON: [**2111-7-3**], CTA chest.
TECHNIQUE: MDCT acquired axial images of the chest, abdomen, and
pelvis were performed without IV contrast. Multiplanar
reformations were obtained.
CT CHEST WITH IV CONTRAST: The patient is status post
tracheotomy with endotracheal tube extending into the distal
aspect of the left main stem bronchus. The patient is status
post right pneumonectomy with a stable appearing fluid
collection. There are no signs of infection within or around
this fluid collection. The mediastinum, hila, and axilla
demonstrate no pathologically enlarged lymph nodes.
CT ABDOMEN WITHOUT IV CONTRAST: There is a focal well
circumscribed hypodensity along the diaphragm that is unchanged
in size. The unopacified liver, pancreas, spleen, adrenal
glands, kidneys are unremarkable. The patient is status post
cholecystectomy. The small and large bowel are unremarkable.
There is no free fluid or free air within the abdomen.
CT PELVIS WITHOUT IV CONTRAST: The urinary bladder is
catheterized. The rectum contains fluid and stool. Again seen is
a hypodense tubular well- circumscribed lesion within the right
pelvis seen on prior study and unchanged either representing a
hydrosalpinx or peritoneal inclusion cyst. There is no evidence
of inflammatory changes surrounding this collection to suggest
infection. There are no suspicious lytic or sclerotic bony
lesions.
IMPRESSION:
1. Status post right pneumonectomy with no evidence of pneumonia
or infection within the right pneumonectomy bed.
2. No evidence of intraabdominal source for infection.
3. Unchanged right pelvic fluid collection. Possible etiologies
include a hydrosalpinx or a peritoneal inclusion cyst.
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **]
**NOT REVIEWED BY ATTENDING**
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 67990**]
Service: Date: [**2111-7-20**]
Date of Birth: [**2069-5-20**] Sex: F
Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**]
ASSISTANT: [**Name6 (MD) **] [**Name8 (MD) 67991**], MD
PROCEDURE: Flexible bronchoscopy for airway survey.
INDICATION: Mrs. [**Known firstname **] [**Known lastname **] is a 42-year-old woman status
post tracheoplasty and flexible bronchoscopy is undertaken to
assess airway patency, presence of granulation tissue, and
tracheostomy tube location.
PROCEDURE: The patient has a 7.5 endotracheal tube through a
tracheostomy. The mechanical ventilator was set to 100% and 2
cc of 1% topical lidocaine was instilled through the
endotracheal tube. The flexible bronchoscope was gently
introduced into the endotracheal tube and advanced to the
distal end of the endotracheal tube. The endotracheal tube
was found to be in excellent position and all airways were
widely patent. There was a small rim of granulation tissue in
the dorsal aspect of the tip of the endotracheal tube but the
lumen of the tube was widely patent. There were no
significant secretions noted. The flexible bronchoscope was
then withdrawn from the patient without difficulty. The
patient tolerated the procedure extremely well with no
oxyhemoglobin desaturations or coughing. At the endo forceps
the procedure, the endotracheal tube was reconfirmed to be in
satisfactory position.
SPECIMENS: None.
COMPLICATIONS: None.
IMPRESSION: Small non obstructing rim of granulation tissue
to the dorsal aspect of the endotracheal tube with excellent
position of the endotracheal tube.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) **]
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **]
**NOT REVIEWED BY ATTENDING**
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 67990**]
Service: Date: [**2111-8-3**]
Date of Birth: Sex:
Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**]
ASSISTANT: Dr. [**First Name8 (NamePattern2) 32954**] [**Last Name (NamePattern1) **].
PREOPERATIVE DIAGNOSIS: Post pneumonectomy syndrome,
complicated with a tracheal bronchomalacia status post
plasty.
POSTOPERATIVE DIAGNOSIS: Post pneumonectomy syndrome,
complicated with a tracheal bronchomalacia status post
plasty.
PROCEDURE: Flexible bronchoscopy.
INDICATIONS FOR PROCEDURE: Assessment of airway patency.
DESCRIPTION OF PROCEDURE: After informed consent was
obtained, the patient was prepped in the bronchoscope suite
with 1% lidocaine applied through the tracheostomy tube. We
proceeded to remove the tracheostomy tube, and through the
ostomy site we introduced a flexible bronchoscope into the
trachea. We could appreciate moderate tracheomalacia at mid
and proximal trachea, but at distal trachea and distal
trachea and left mainstem bronchus, there was no evidence of
malacia.
IMPRESSION: Post pneumonectomy syndrome, complicated with
tracheal bronchomalacia, status post plasty, now with wide
patent airways.
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on FRI [**2111-7-17**] 6:27 PM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 67990**]
Service: Date: [**2111-7-8**]
Date of Birth: [**2069-5-20**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], MD 2367
PREOPERATIVE DIAGNOSIS: Post pneumonectomy syndrome with
tracheobronchomalacia.
POSTOPERATIVE DIAGNOSIS: Post pneumonectomy syndrome with
tracheobronchomalacia with stenosis of the left main.
PROCEDURE PERFORMED:
1. Flexible bronchoscopy.
2. Redo right thoracotomy with extraction of intrathoracic
implants and posterior membranous wall tracheoplasty.
3. Left mainstem bronchoplasty with rib graft augmentation.
4. Pedicled intercostal muscle flap.
ASSISTANT SURGEON: [**Name6 (MD) 67548**] [**Name8 (MD) 67549**], M.D.
ANESTHESIA: General endotracheal.
INDICATION FOR OPERATION: The patient is a delightful 42-
year-old woman who is status post a right pneumonectomy for
stage IIb adenocarcinoma of the lung. The original surgery
was [**2107**], and she subsequently developed a post pneumonectomy
syndrome requiring mediastinal repositioning which was
performed in [**2111-1-14**]. She was unextubatable at the end
of the case due to severe tracheobronchomalacia and required
endobronchial stenting. This allowed for extubation. For the
subsequent 4 months, she was carefully managed with
endobronchial and endotracheal stents but had several
complications ultimately requiring extraction and replacement
of the stents. The main complication was granulation tissue
obstructing the distal end of the stents. She ultimately was
transported via Med Flight to the [**Hospital1 190**] for continued care. As part of our initial
evaluation, we removed the left main and tracheal stents and
maintained her with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 295**]. An initial bronchoscopy
demonstrated superior tracheomalacia as well as left mainstem
bronchial malacia, and a question of fixed stenotic lesion in
the left main. There is also a distal left mainstem tear. She
subsequently developed multiple episodes of sepsis including
candidal sepsis. She was treated for all these successfully.
Multiple scheduled surgeries were cancelled due to continued
fevers and relative instability. Ultimately, we were able to
find a window of relative stability with low airway
pressures, and a falling white count, and a reasonable
without fevers to take her forward for operation. Our plan is
to enter the right chest, remove the intrathoracic implants,
perform a tracheoplasty and a left main bronchoplasty.
Therefore, the following procedure was performed.
DESCRIPTION OF PROCEDURE: The patient was transported from
the ICU by the anesthesia service to the operating room. In
the operating room, we removed her [**Last Name (un) 295**] tracheostomy tube
and placed a #8 endotracheal tube into the tracheostomy
stoma. I then performed a flexible bronchoscopy and examined
the entire airway. There was severe malacia of the trachea
extending down to the carina and the proximal left main.
Within 1-cm of the entrance way to the left main, there was
an area of either malacic cartilaginous wall with complete
absence of cartilage versus granulation tissue, or stenosis
on the superior cartilaginous-membranous wall junction,
commencing approximately 1-cm distal to the orifice to the
left main and extending for several centimeters. The distal
left main at the level of the lobar bronchial orifices and
extending proximally about 1-1.5 cm was widely patent without
evidence of malacia or stenosis.
We then guided the endotracheal tube into the left main and
then positioned the patient carefully in a left lateral
decubitus. We took great care to avoid pressure points or
hyperextension of extremities. Both ulnar nerves were
appropriately supported. Her head was maintained in a midline
position and appropriately supported. We prepped and draped
her right chest in the usual sterile fashion. All antibiotics
were continued. We entered the chest through the fourth
intercostal space and shingled the fifth rib posteriorly. The
chest spreader was placed. We immediately encountered the
saline implants which were easily removed, as they were
nonadherent to the surrounding tissue. We then examined the
pleural space on the right and were pleased to see that there
was less inflammatory fibrosis than I had predicted. There
was, however, a significant amount of inflammation and scar
tissue in the area of the right mainstem bronchus and right
paratracheal region.
We commenced the operation by incising the pleura and scar
tissue posterior to the trachea and right main bronchial
stump, incising from high in the thoracic inlet all the way
down to below the carina. We carefully dissected the
esophagus off of the posterior membranous wall of the trachea
and right main bronchus. The right main bronchial stump was
visible, as it had Prolene suture material on it. The stump
was relatively short. Of note, the trachea had been pulled
high into the thoracic inlet, and the right main bronchus was
only several centimeters below the apex of the chest.
We again proceeded to dissect out the posterior membranous
wall of the trachea from high in the thoracic inlet all the
way down to the carina from cartilaginous membranous wall
junction to cartilaginous membranous wall junction. This was
quite difficult, as there was extensive scarring in the area.
Great care was taken to avoid injury to the recurrent
laryngeal nerve on the right, as well as the left. We divided
the azygos vein which was caught up in scar tissue and suture
ligated it with 2-0 silk sutures and doubly tied it.
We then proceeded to dissect out the left main bronchus all
the way down to the lobar takeoffs from cartilaginous
membranous wall junction to cartilaginous membranous wall
junction. We then withdrew the endotracheal tube high into
the cervical trachea and examined the airways. The posterior
membranous wall of the trachea was redundant measuring 3-cm
in width with a floppy posterior membranous wall. The left
main measured approximately 1.7-1.8 cm in width, but was
disfigured by scar tissue. Midway down the left main, there
was an obvious indentation in the cartilaginous membranous
wall junction with complete loss of cartilage at the superior
junction. The membranous wall in this area had been scarred
and contracted and had become fibrotic and was, in fact not
redundant as all, but spanned the distance from one side of
the cartilage to the other remaining portion of cartilage,
creating a mound of protruding posterior membranous wall
which was fixed in position. It was obvious to me at this
point that we could not perform a posterior membranous wall
bronchoplasty as it would result in further obstruction of
the left main creating an even worse fixed obstruction. It
was obvious that the airway had to be augmented. Simple
augmentation would leave the airway malacic and; therefore, a
rigid augmentation was required. In considering materials, it
was obvious that a foreign body could not be used to provide
rigidity since we would have to open the airways, and it
would be a contaminated field. We would have to use rigid
body tissues. In addition, it was obvious that we would have
to provide immediate sealing of the airway since the patient
is under positive pressure ventilation and the location of
this repair would be near the distal tip of the left main
where the endotracheal tube would be positioned with its
cuff. Given the patient's high airway pressures on positive
pressure ventilation, it was absolutely essential that the
airway was completely sealed with autologous tissue and any
rigid structural tissue augmented this sealed airway.
After much consideration, I decided to use a pedicled
intercostal muscle flap with periosteum intact to augment the
airway such that with time bony ossification from the intact
and viable periosteum would provide structural support. The
softness of the muscle flap with the firm periosteum would
provide an immediate seal to the airway and would hold
sutures well. Finally, I decided to further support this
repair with the rigidity of a carved bone graft. Therefore,
we proceeded to open the posterior membranous wall of the
left main over the area of fixed obstruction longitudinally
near the cartilaginous membranous wall junction where the
malacia existed.
A 3-cm longitudinal incision was made, and the airway opened-
up widely posteriorly to then accommodate the #8 endotracheal
tube. Unfortunately, the endotracheal tube lost its cuff
during all these maneuvers and had to be replaced, and we
chose to replace it with a 7.5 endotracheal tube. We then
guided the endotracheal tube into the left main and
positioned the tip just a few millimeters above the lobar
takeoffs of the left lower and left upper lobe bronchus. The
balloon of the endotracheal tube was immediately over our
bronchotomy.
We then turned our attention at an intercostal muscle flap.
We resected the fourth rib and developed a healthy third
intercostal muscle flap based on the posterior pedicle. The
periosteum was elevated and maintained nicely intact along
the entire length of the pedicle. We then proceeded to suture
the periosteal surface of the distal intercostal muscle
pedicle to the airway with interrupted 4-0 Vicryl sutures
such that it completely sealed off the 3-cm longitudinal
opening which now created an elliptical opening measuring 3-
cm long and 1-cm wide in the mid portion.
Once the pedicle was satisfactorily sealing the airway, we
then fashioned a piece of resected intercostal rib to 3.5-cm
in length. We resected 1 side of the flattened rib and cored
out the periosteum, creating a cupped 3.5-cm long rib graft.
The cup portion was then turned in toward the membranous wall
repair and carefully positioned. The redundant extra
intercostal muscle flap, as well as the fourth intercostal
muscle and fibrotic tissue which came with the graft was used
to wrap the rib graft and secure it in position. The rib
graft was positioned from just below the takeoff of the left
main all the way down to about 1-cm above the distal left
main.
We then irrigated the chest with copious volumes of saline
and closed the mediastinal dissection site. Therefore, the
tracheobronchoplasty was sealed off from the pleural space. I
should note that I would have ideally resected the mid
portion of the left main. However, due to the severe fibrosis
and retraction of the trachea high into the thoracic inlet
and rigidity of the mediastinum from prior fibrosis, I was
unable to achieve any mobility to either the left main or the
carina on testing, and therefore decided not to pursue a left
main resection. It was obvious to me that there would be no
way that the 2 ends of the airway could come together without
excessive tension.
We then proceeded to irrigate the chest with copious volumes
of saline over-and-over until we were satisfied that we had
diluted any contamination. We then replaced the previous
implants with 2 new 550-cc saline implants. We then placed 1
gram of Ancef solution into the right chest and closed the
chest in layers. No chest tube was placed. The patient was
then transported back to the ICU in stable condition. Dr.
[**Last Name (STitle) 952**] was present the entire case. Sponge, instrument and
needle counts correct x2.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Brief Hospital Course:
A/P - 42 yo F s/p R pneumonectomy, w/ post pneumonectomy
syndrome and complicated course including Left sided stent w/
stent failure, persistent resp distress, transferred from [**Hospital **]
Hospital for further IP evaluation @ [**Hospital1 18**].
.
#Resp failure/post-pneumonectomy syndrome - Patient was
transferred from [**Male First Name (un) **] on [**2112-5-29**]. She had passed a spontaneous
breathing trial prior to arrival, but was intubated when she
arrived here. Her ABG shortly after arrival was 7.00/112/300.
She was taken to have a bronch and found to have severe
tracheomalacia and also mucous/granulation tissue obstruction of
her stents (? improved after removal of tissue). Her
respiratory status improved after intervention. Bronchocscopy
by IP and CT airway to evaluate her airways prior to surgical
intervention (she has a contrast allergy and required
premedication with methylprednisone prior to imaging). She was
stable on the vent and tolerate PSV. She was taken to the OR by
IP on [**6-2**]. She was found to have a full thickness mucosal
defect in the L mainstem bronchus with communication to the
mediastinum, thought to be potentially caused by her stents. The
stents were removed at that time. [**6-3**] she was taken to the OR
for trach placement. After the procedure she had a significant
cuff leak, b/c the walls of her trachea were not rigid enough to
keep the trach in place. She was intervened on by IP and
remained stable o/n. QOD bronchoscopies for secretion clearancea
nd airway observation. Bronch as of [**6-19**] showed minimal
secretions and healing tear. Plan for Thoracic Surgery for
tracheal reconstruction when afebrile x5-7 days and WBC WNL. See
below- for Thoracic Surgery post op course summary.
TEE was performed on [**6-25**] and was negative.
#Hypotension - Patient presented with hypotension and was on
pressors initially. Her hypotension was thought to be [**1-15**] to
dehydration vs. increased propofol vs. sepsis from PNA/UTI. This
quickly resolved and she was weaned off pressors during her
first day here. She was started empirically on antibiotics
(zosyn,vanc) which were discontinued once she completed her
course for her UTI as below.
#UTI - Pt had a UTI at the OSH. UA grew klebsiella that was
zosyn resistant--results returned on [**6-3**] and changed to
meropenem for 10 days.
.
# [**Female First Name (un) 564**] Fungemia: Pt had several urine and sputum cultures
growing yeast. On [**6-8**], pt noted to have yeast growing in a bld
cx bottle. She was started on Caspofungin 50mg IV qD. Her
yeast eventually grew out [**Female First Name (un) 564**] [**Female First Name (un) 29361**], however, the lab
lost the blood sample prior to obtaining sensitivities. After
d/w ID, felt fluconazole 400mg po qD for 3 weeks was adequate
treatment. ID wanted a negative TEE prior to surgery and to
decided definitively on a course for the fluconazole. Multiple
attempts were made bedside to do the TEE but she repeatedly had
complete collapse of her trachea and desaturations to the 20's.
On [**6-25**] she was eventually taken to the OR and a TEE was
performed while IP kept her airways patent. The TEE was
negative and fluconazole was completed on [**6-26**].
.
# Pneumonia: A BAL from [**6-19**] grew pseudomonas and proteus both of
which were sensitive to cefepime- treated with a 14 day course.
.
# Pneumoperitoneum: Pt was discovered to have pneumoperitoneum
on CXR. She initially had no abdominal pain and was clinically
stable. Possible sources for the pneumoperitoneum included J
tube placement (unclear when placed), air tracking down from
mediastinum [**1-15**] to increased pressure or abdominal perforation.
It appeared that the pneumoperitoneum was noted at [**Hospital **]
hospital prior to admission, but no information about w/u was
noted. She had an abdominal CT to further evaluate this here
and it showed stranding of the ascending and transverse colon.
Perforation could not be ruled out. Surgery was consulted and
recommended stopping the pt's tube feeds. Repeat abd ct was done
on [**6-2**] and showed stable pneumoperitoneum. The mucosal defect
of the trachea found on [**6-2**], suggested that was the site of the
pneumomediastinum. She was re-started on tube feeds and her abd
exam was followed. Surgery was consulted and had no further
recommendations.
.
#Anemia - Pt has unknown baseline but hct was stable during her
stay.
.
#NASH - Pt presented with RUQ tenderness on exam and slightly
elevated LFTs. Her imaging studies showed pneumoperitoneum and
colonic stranding. RUQ u/s showed fatty liver but no
choledocholithiasis. LFTs remained stable and pneumoperitoneum
was unlikely from abdominal source.
.
#Agitation: Pt noted to be frequently tearful and agitated. She
was started on ativan and haldol and Paxil for depression.
Psychiatric evaluation done and medications adjusted
appropriately. Current meds listed. Psych notes attached.
.
[**7-8**]- THORACIC SURGERY
Patient take to OR for operative intervention of repair of
trachea defect and trachealmalacia via Redo right thoracotomy
with extraction of intrathoracic
implants and posterior membranous wall tracheoplasty, Left
mainstem bronchoplasty with rib graft augmentation, Pedicled
intercostal muscle flap.
Patient tolerated procedure well, tranferred to ICU post op w/
ETT in place of LMSB, on ventilator- ACmode. T-103 post-op-
levofloxacin and vancomycin added to cefapime and bactrim.
POD#1- [**E-mail address 67992**]/350/20/5 peep; TF restarted; Hemodyn stable.
Post-op ICU course ([**Date range (1) 67993**]) significant for:
1.Mechanical ventilation via ETT via tracheostomy- placed
strategically to assist w/ surgical site healing. ETT
transitioned to Trach Portex 6 w/ CPAP wean over 2 weeks to
eventual trach collar trials of increasing duration to
independent breathing on trach collar. Secretions moderate,
thick and suctioned prn. Regular bronchoscopies for repair
monitoring and secretion clearance.
2. Hemodynamic management- diuresis w/ lasix gtt transitioned to
dialy dosing.
3.ID- persistant low grade fevers on antibiotics- ID consult
[**2111-7-26**] w/ + Cdiff result in setting of multiple antibiotic use
over 3 months w/ recs of start flagyl and tapering other
antibiotic done. Current rx as listed in d/c meds
4.Psychiatry- Hx depression on lexapro as outpt. Depression
worsened over hospital course. Evaluation and followup by Psych.
NOtes attached. Meds as listed
5. Nutrition w/ tube feeding support via j-tube, with transition
to pureed diet while trach in place.
6. REconditioning/Physical Therapy- ongoing- refer to note.
Transfer to floor/step down unit [**2111-7-29**].
Resp- Trach collar w/ Passey-Muir valve use tolerated well. CPT
and pulmonary toilet as needed for secretion management.
Tracheostomy tube ddecannulation [**8-3**] w/o complication. Stoma
w/o erythema, tr tenderness, min clear secretions. Healing well.
DSD change QD. Some intermittent exp wheezes cont. Nebs given w/
improvement. Decreasing frequency.
Nutrition- TF cont, transitioned to pureed diet w/ thick liquids
as swallow eval dictated. Increasing po intake encouraged.
Present diet as listed in d/c instructions as tube feeding,
pureed, thick. Advance as tolerated.
Psych- Continues to follow- last note attached.
ID- antibiotic weaned to off, WBC normalizing. Flagyl po until
[**2111-8-13**] for Cdiff treatment course. PICC line d/c [**2111-8-5**]
Physical Therapy- ongoing per notes.
Supports- Parents have remained in [**Location (un) 86**] throughout
hospitalization. Tremendous support to patient. Extremely
appropriate and gracious.
Medications on Admission:
Xopenex
Atrovent
Lexapro
Toprol XL 50 mg QD
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Acetaminophen 160 mg/5 mL Solution Sig: 10-15 cc PO Q4-6H
(every 4 to 6 hours) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection [**Hospital1 **] (2 times a day).
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q6H (every 6 hours).
9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Discharge Disposition:
Extended Care
Facility:
South [**Hospital 3908**] Medical Center
Discharge Diagnosis:
Right lung cancer, Left bronchomalacia, Hypertension, Gastric
esophogeal reflux disease, anxiety, NASH, migraine,
endometriosis
PSH: Right pneumonectomy [**10-16**], Left main stem brochial MB stent
[**3-19**], appendectomy, cholycystectomy, TAH/BSO
Discharge Condition:
fair, improving steadily
Discharge Instructions:
Call [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**], MD/ Thoracic Surgery at [**Hospital1 18**] for any post
surgical managment issues- [**Telephone/Fax (1) 170**]
Followup Instructions:
Follow- w/ Primary Pulmonologist- [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12667**], MD [**Telephone/Fax (1) 67994**]
Completed by:[**2111-8-5**]
ICD9 Codes: 2762, 5990, 311, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3332
} | Medical Text: Admission Date: [**2143-8-16**] Discharge Date: [**2143-8-23**]
Date of Birth: [**2143-8-16**] Sex: M
HISTORY: Baby [**Name (NI) **] [**Known lastname 43521**], [**Name2 (NI) 37336**] number three, was the [**2095**]
gram product of a 35-5/7 week gestation born to a 32 year old
Gravida 3, Para 0, now 3, mother.
[**2141**], six week [**Doctor Last Name **] and 8 weeks IVI triplets. This
pregnancy is also IVI conceived.
The pregnancy was relatively uncomplicated, admitted at
31-3/7 weeks for preterm labor, received magnesium sulfate
and betamethasone complete. She was later discharged home.
Fetal growth has been followed closely and all have been
decided to deliver on [**8-16**].
The infant delivered by cesarean section and admitted to the
Newborn Intensive Care Unit for further management of
prematurity, hypoglycemia and temperature instability.
PHYSICAL EXAMINATION: On admission, birth weight was [**2095**]
grams, 10 to 25th percentile; length of 42 centimeters, 10th
percentile; head circumference 31.5 centimeters, 25th
percentile. Physical examination was unremarkable. Anterior
fontanel open and flat. Pink and well perfused. Palate
intact. Positive red reflex bilaterally. Clear breath
sounds. Heart rate within normal limits; S1, S2 audible; no
murmur. Pulses two plus, pink, well perfused. Abdomen
benign, no hepatosplenomegaly, three-vessel cord. Normal
external male genitalia. Testes descended bilaterally. Hips
stable; no sacral defects. Neurological appropriate for
gestational age.
HISTORY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Has been stable on room air throughout his
hospital course with no issues. Had a few dusky episodes
with enteral feedings, but has resolved with no further
issues.
2. Cardiovascular: No issues during this hospital course.
3. Fluids, Electrolytes and Nutrition: Birth weight was
[**2095**] grams, discharge weight was 1850 grams. Infant is
currently ad lib feeding Neosure 24 calorie, taking in
adequate amounts, demonstrating good weight gain. D-sticks
have been stable.
4. Gastrointestinal: Peak bilirubin was 11.2/0.2 on day of
life number four. Received phototherapy for a total of three
days; rebound bilirubin was 5.4; issue has been resolved.
5. Hematology: No issues. The infant has not required any
blood transfusion.
6. Infectious Disease: No issues.
7. Neurologic: No issues.
8. Audiology: Hearing screen was performed by Automated
Auditory Brain Stem responses and the infant passed both
ears.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] from [**Location (un) 620**],
telephone number of [**Telephone/Fax (1) 37814**].
CARE RECOMMENDATIONS:
1. Continue Neosure 24 calories to support nutritional needs
and growth.
2. Medications: No medications at this time.
3. Car Seat Position Screening Test was performed under 90
minutes in car seat and infant passed car seat position
screening.
4. Immunizations: The infant has not received any
immunizations as his birth weight was less than two kilos.
Will need to have his hepatitis B vaccine at two kilos or two
months, whichever comes first.
5. Follow-up with pediatrician within three days.
DISCHARGE DIAGNOSES:
1. Premature triple number three at 35-5/7 weeks.
2. Transient hypoglycemia, resolved.
3. Hyperbilirubinemia, resolved.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (NamePattern1) 38444**]
MEDQUIST36
D: [**2143-8-23**] 21:02
T: [**2143-8-23**] 22:50
JOB#: [**Job Number 43525**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3333
} | Medical Text: Admission Date: [**2195-5-29**] Discharge Date: [**2195-6-8**]
Service: MICU
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: This is an 87 year old woman
with an extensive past medical history including coronary
artery disease, status post coronary artery bypass graft,
diabetes mellitus, chronic renal failure, status post
hemodialysis, congestive heart failure, who presents from
[**Hospital1 13199**] rehabilitation with complaints of abdominal pain.
The patient was discharged one month ago following a [**Hospital1 1444**] admission status post a fall
with a right Colles fracture. Course was complicated by
worsening renal failure requiring hemodialysis, non ST
elevation myocardial infarction, change of mental status, and
new onset stridor of unclear etiology. She was discharged to
rehabilitation on [**2195-5-16**], and at that time had mild
intermittent crampy abdominal pain mainly in the bilateral
lower quadrants. The patient also had decreased p.o. intake.
These symptoms progressed gradually over the two weeks prior
to admission, and then over the 36 hours prior to admission
became much more acute. The patient was initially treated
with Oxycodone with temporary relief of the pain. The pain
prior to admission was ten out of ten which prompted her
transfer to the Emergency Department.
The patient denies any exacerbating or alleviating factors
and does not feel that food changes her abdominal pain. She
denies fever, chills, nausea, vomiting and is passing flatus
and belching. She is unable to move her bowels without
laxatives but with laxatives is having fairly loose stools.
She denies hematochezia and melena. Also, she notes a twenty
pound weight loss over one month. No night sweats. She also
admits to a sore throat over the past two weeks which she
attributes to a nasogastric tube on her last admission.
In the Emergency Department, the patient was given a
Morphine, Nitroglycerin, Aspirin, and Lopressor, intravenous
fluids and was seen by surgery who felt that the patient did
not have any acute surgical issues. She was then transferred
to the floor.
PAST MEDICAL HISTORY:
1. Coronary artery disease, coronary artery bypass graft in
[**2184**].
2. Diabetes mellitus.
3. Chronic renal failure, status post hemodialysis in [**5-16**].
4. Pacemaker.
5. Congestive heart failure with echocardiogram in [**2195-4-14**], with ejection fraction of 55%.
6. Trigeminal neuralgia.
7. Hypertension.
8. Hyperthyroidism.
9. Hypercholesterolemia.
10. Status post total abdominal hysterectomy bilateral
salpingo-oophorectomy.
11. Status post cholecystectomy.
12. Status post right Colles' fracture.
13. Status post open reduction and internal fixation [**5-16**].
14. Dizziness/gait disorder.
15. Gout.
16. Status post appendectomy.
17. Chronic hemorrhoids with symptomatic bleeding.
ALLERGIES: Sulfonamides, unclear reaction. Benzodiazepines
and Haldol, she is very sensitive to these.
MEDICATIONS ON TRANSFER:
1. Allopurinol 100 mg p.o. once daily.
2. Norvasc 10 mg p.o. once daily after hemodialysis.
3. Aspirin 81 mg p.o. once daily.
4. Lipitor 20 mg p.o. q.h.s.
5. TUMS two tablets p.o. three times a day.
6. Epogen 10,000 units with hemodialysis.
7. Lasix 60 mg p.o. twice a day.
8. Amphojel 10 mg p.o. three times a day.
9. Trileptal 150 mg p.o. q.a.m. and noon with 300 mg p.o.
q.h.s.
10. Potassium Chloride 10 meq p.o. once daily.
11. Tylenol 650 mg p.o. q4hours.
12. Simethicone 80 mg p.o. four times a day.
13. Pericolace one tablet p.o. twice a day.
14. Senna two tablets p.o. q.h.s.
15. Mycelex one tablets five times a day.
16. Hydralazine 25 mg p.o. three times a day.
17. Oxycodone 5 mg p.o. q4hours p.r.n.
18. InFed 100 mg intravenous with hemodialysis.
19. Imdur 30 mg p.o. once daily.
20. Keppra 250 mg p.o. twice a day.
21. Cozaar 50 mg p.o. twice a day, hold until after
hemodialysis.
22. Antivert 12.5 mg p.o. twice a day.
23. Pred Forte one drop O.S. three times a day.
24. Tapazole 2.5 mg q.Monday and Thursday.
25. Nephrocaps one tablet p.o. once daily.
SOCIAL HISTORY: The patient quit smoking approximately forty
years ago but had significant smoking history up to that
point. She denies any history of alcohol or drug use. She
is currently at [**Hospital1 13199**] Rehabilitation following her
Colles' fracture. She has a family who is very involved in
her care. Her daughter, [**Name (NI) 17122**] [**Name (NI) **], at [**Telephone/Fax (1) 99886**], is
her healthcare proxy.
PHYSICAL EXAMINATION: Vital signs revealed temperature 98.4,
heart rate 75, blood pressure 107/23, respiratory rate 16,
oxygen saturation 100% on two liters. In general, she is
awake and in no acute distress. Head, eyes, ears, nose and
throat examination is normocephalic and atraumatic, sclera
anicteric. The pupils are restricted surgical. Extraocular
movements are intact bilaterally. Mucous membranes are dry.
The oropharynx is clear. Positive exophthalmus. The neck is
supple with no bruits. Jugular venous distention is seven
centimeters at 45 degrees. Cardiovascular is regular rate
and rhythm, normal S1 and S2, II to III/VI systolic ejection
murmur at the apex and upper sternal border. Chest -
occasional bibasilar rhonchi; otherwise clear to auscultation
bilaterally with moderate aeration. The abdomen is obese,
soft, slightly distended with diffuse bilateral lower
quadrant tenderness without rebound or guarding, tympanitic,
no hepatosplenomegaly or pulsatile mass. Extremities are
warm, dry with 1+ pedal pulses bilaterally. Rectal -
positive external hemorrhoids, brown stool, guaiac positive
per Emergency Department and surgery. Neurologically, she is
alert and oriented times three. Speech is normal. Cranial
nerves II through XII are intact bilaterally. No focal
deficits.
LABORATORY DATA: Arterial blood gases revealed pH 7.46, pCO2
41, pO2 81 with a lactate of 0.8. White blood cell count
9.9, hematocrit 37.0, blood urea nitrogen 9, creatinine 1.1.
CK 28, MB 3.0, troponin less than 0.3.
Chest x-ray without acute infiltrates or congestive heart
failure. Abdomen supine and upright with nonspecific bowel
gas pattern, prominent loops of large and small bowel. CT of
the abdomen with intravenous contrast, no evidence of
intestinal ischemia, no acute intra-abdominal process to
account for the patient's symptoms.
Electrocardiogram - question of atrial paced, 85 beats per
minute, with possible worsening of ST segment depressions in
V3 through V5. The patient was in sinus on [**2195-5-9**].
HOSPITAL COURSE:
1. Abdominal pain - The patient continues to note abdominal
pain on admission in bilateral lower quadrants and was no
different in nature. The pain transiently was in epigastric
area. The patient had normal liver function tests.
Gastroenterology was consulted who recommended vigorous bowel
regimen as well as possible colonoscopy if her cardiac issues
were stable. The patient was planning to have this performed
until she showed respiratory distress. At this time, her
gastrointestinal workup was delayed. At the time of this
dictation, the patient will be reseen by Gastroenterology for
consideration of colonoscopy to assess for ischemic colitis
or other etiology. She is also having Clostridium difficile
toxins for possible Clostridium difficile. Laxatives and
bowel preparation did not appear to improve the patient's
abdominal pain.
2. Laryngeal edema - On the patient's episode, she had acute
episode of stridor which was thought possibly secondary to
nasogastric tube placement or less likely due to chronic
gastroesophageal reflux disease. ENT was reconsulted on the
floor and then they found supraglottic swelling. The patient
was restarted on steroids, H2 blocker, as well as proton pump
inhibitor. H1 blocker was not used due to possible change in
mental status with these medications. The patient's stridor
did become worse. On hospital day number three, the patient
had a blood gas drawn to check for a repeat lactate to assess
for ischemic colitis. At the time, the gas showed a pH of
7.27, pCO2 51 and pO2 66. It was felt the patient was having
a metabolic acidosis from her renal failure as well as a
respiratory acidosis from respiratory distress. It was felt
that the laryngeal edema was causing significant impairment
in her workload and she could not compensate for this. She
was brought to the Medical Intensive Care Unit for further
monitoring. On hospital day number four, the patient had
desaturation to 70% and anesthesia was called for stat
intubation. Due to the patient's narrow swallowing,
intubation was performed with a 6-O2. The patient was placed
on mechanical ventilation. Over the course of a week, the
patient was attempted to wean off the ventilator. Initially,
she did not tolerate pressure support due to apneic episodes,
but throughout her course, she became more responsive and was
able to tolerate some pressure support.
After a long discussion with the patient's family regarding
possible extubation, consideration was brought up whether or
not a tracheostomy would be beneficial as tube removal could
result in acute closure of her vocal cords in which case the
patient would need an emergent tracheostomy. After a two
hour meeting with the family, the family and the patient
decided she would want to undergo said procedure and the
patient was seen by interventional pulmonology. Percutaneous
tracheostomy was performed on [**2195-6-5**], without complication.
The patient was then weaned off the ventilator and is
currently tolerating a trach mask. She will continue to wean
down her oxygen as tolerated.
3. Urinary tract infection - The patient had urinalysis
drawn on admission which grew out pansensitive pseudomonas
aeruginosa. The patient completed a seven day course of
Ciprofloxacin.
4. Fever - The patient spiked a fever in the Medical
Intensive Care Unit. She had Staphylococcus aureus grow out
of the sputum as well as gram positive cocci in her blood.
She received one dose of Vancomycin until final cultures were
drawn. Final cultures grew out coagulase negative
Staphylococcus which was thought to be contamination.
Antibiotics were discontinued and she remains afebrile at
this time.
5. Acute on chronic renal failure - The patient came in on
dialysis, however, it was thought that the patient may be
able to discontinue dialysis in the future. The patient
received a CT of the abdomen with contrast during her time in
the Emergency Department to further evaluate her belly. The
patient likely developed a dye nephropathy with worsening
renal failure. The patient required dialysis as an
inpatient. At this time, the patient's renal status is
improving. Her phosphate binders were discontinued. She was
still requiring dialysis two to three times per week and is
being followed by the renal team.
6. Coronary artery disease - The patient was ruled out for a
myocardial infarction on presentation with normal CK and
troponin. During the patient's episode of respiratory
distress, the patient had her enzymes recycled which revealed
a troponin leak of 219 with normal CKs. This is likely due
to demand ischemia. She was continued on her Aspirin and
beta blocker.
7. Fluid, electrolytes and nutrition - While intubated, the
patient was fed through an OG and then nasogastric tube. The
patient did have episode of ileus which responded to
nasogastric tube suction. The patient was started tolerating
OG and is going to be seen by Speech and Swallow for more
formal evaluation as well as for evaluation to allow to
speak.
8. Colles' fracture - The patient was seen by orthopedics by
Dr. [**Last Name (STitle) 9694**]. The patient had repeat films of her wrist done
which were showing improvement in her wrist. The patient may
take off splint p.r.n. and to have it discontinued in
approximately one month around [**2195-7-3**].
The rest of this dictation will be completed by the following
intern.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 17420**]
MEDQUIST36
D: [**2195-6-8**] 13:00
T: [**2195-6-8**] 13:26
JOB#: [**Job Number **]
ICD9 Codes: 5789, 5849, 5990, 2762, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3334
} | Medical Text: Admission Date: [**2167-11-23**] Discharge Date: [**2167-12-9**]
Date of Birth: [**2105-6-4**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Haldol / Darvon / Keppra
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Bright Red Blood Per Rectum
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
TIPS
Endotracheal Intubation and Mechanical Ventilation
History of Present Illness:
Ms. [**Known lastname **] is a 62 year-old woman with a history of HCV
cirrhosis, polysubstance abuse, and history of hemorrhoidal
bleeding presented [**2167-11-24**] with 1-2 wks BRBPR and discovery of
Hct 18 at PCP's office. Her creatinine was 1.1. In the ED, she
was found to have a hct of 10% and acute renal failure with
creatinine of 1.6. She had a femoral cordis placed. She was
given IVF and had emergency released blood transfused. Her BP
was as low as 80/40, but stabilized with IVF to 100/60. She
refused NG lavage.
Past Medical History:
1) iron deficiency anemia
2) GI bleed - presumed secondary to hemorrhoids
3) Sigmoid diverticulosis
4) Schatzki's ring
5) Duoenal polyps and duodenitis
6) MGUS
7) ?etoh/ HCV cirrhosis followed by Dr. [**Last Name (STitle) 497**] (vl 9k in [**5-15**])
8) psychotic disorder
9) remote polysubstance abuse - etoh, cocaine, marijuana
10) COPD
11) compex partial seizures
Social History:
She lives alone, 10 blocks from her daughter. She smokes several
cigaretts per day, and occasionally uses EtOH, marijuana, and
cocaine. She is originally from [**State 3908**], and changed her name
when she became a practicing Muslim, which she says she
currently still practices. She worked as an administrative
assistant when she was younger, but is now on SSDI (for
schizophrenia and seizure disorder, per pt, both now quiescent).
Family History:
Mother: asthma, grandmother with diabetes, HTN. No family
history of liver disease or bleeding disorders. Great aunt with
epilepsy
Physical Exam:
Physical Exam on Discharge
Gen: Awake and alert. Oriented to month, year, person.
Tangential speech. Easily re-directed.
HEENT: Mucous membranes moist. EOMI. Pupils equal and reactive.
Marked scleral icterus.
Neck: Bandage in place.
Heart: Regular Rate and Rhythm. Normal S1, S2. No murmurs.
Chest: Diffuse crackles bilaterally
abd: Soft. Nt/ND.
Extremities: 1+ peripheral edema
Neuro: CN II-XII intact. Moving all extremities. Tangential
speech but easily directed.
Pertinent Results:
Echo [**2167-11-28**]-The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is 10-20mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60-70%) There is no ventricular septal defect. The
right ventricular cavity is dilated. Right ventricular systolic
function appears depressed. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Impression: moderate pulmonary hypertension; dilated
hypocontractile right ventricle
.
Chest X-ray [**2167-12-8**]:Severe infiltrative pulmonary abnormality
has worsened radiographically but this may be a function of
extubation and the end of positive pressure ventilatory support
which has produced slightly lower lung volumes. Small bilateral
pleural effusions may be present. Heart size is normal.
Mediastinal vascular engorgement is moderate and unchanged. No
pneumothorax. Tip of the right supraclavicular central venous
line projects over the upper SVC.
Brief Hospital Course:
# Gastrointestinal bleed: Pt admitted with significant lower GI
bleed at hemorrhoids likely thought secondary hepatitis C
associated cirrhosis. She underwent EGD with two cords of Grade
I varices identified, no stigmata of bleeding. Colonoscopy led
to rectal prolapse and bleeding thought likely from rectal
varices. A TIPS by interventional radiology was performed with
the intention of relieving portal hypertension and rectal
variceal bleeding. Rectal bleed recurred on [**11-27**], with rectal
foley placed by surgery later expelled with Valsalva.
Hepatology placed a rectal [**Last Name (un) **] to tension, which
controlled bleeding. Ultrasound revealed patents TIPS and it
was thought that bleeding may be secondary to hemorrhoids versus
varices. Patient was transfused intermittely to maintain stable
hematocrit. [**Last Name (un) **] subsequently discontinued with no
significant bleeding since. Hematocrit is stable at discharge at
30.8.
.
# Respiratory distress: On [**11-27**] in the setting of acute
re-bleed, Ms. [**Known lastname **] was intubated secondary to wheezing, severe
shortness of breath, and increasing rales. Vancomycin,
cefepime, flagyl started [**11-27**] to cover for nosocomial PNA.
Metronidazole later discontinued. Endotracheal suction removed
particulate matter consistent with aspiration. She also
demonstrated fluid overload and pulmonary edema. She has
received intermittent furosemide to relieve pulmonary vascular
congestion. To maximize respiratory capacity, she was started on
standing ipratropium MDI 6 puff IH Q4H, albuterol 6 puff IH Q4H,
fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]. On [**12-3**], pt noted
to have respiratory distress likely [**2-13**] flash pulmonary edema
after administration of D5W 250ml over 2 hours for
hypernatremia; stat CXR demonstrated increased opacities. She
was extubated on [**12-7**] and was saturating well on nasal cannula.
Vancomycin and cefepime were discontinued on [**2167-12-8**] after a
12 day course.
.
# Hypernatremia: On [**2167-12-3**], Ms. [**Known lastname **] was noted to have
increasing sodium (147), and therefore free water boluses were
begun and IV D5W administered. Because of pulmonary vascular
congestion, IV fluids were discontinued were and free water
boluses titrated to maintain stable sodium. Once patient was
extubated, IV fluid boluses were discontinued in favor of oral
free water repletion. Sodium is 148 on the day of discharge.
.
# Acute renal failure: Creatinine was noted to be gradually
increasing, with consideration of acute interstitial
nephritis/acute tubular necrosis in setting of hypotension or,
given positive rare eosinophils in urine, of new drug.
Creatinine gradually improved as overall condition improved.
Creatinine is 1.7 on the day of discharge. Electrolytes and
renal function should be monitored daily for the next several
days given new oral diuretic regimen.
.
# Tachycardia: Pt demonstrated episodic tachycardia to 160s-170s
during suctioning, but persistent tachycardia as well into 100s
even without stimulation. In addition, pt developed concomitant
hypertension into the 190s-220s. Pt received Haldol for
agitation, hydralazine 10 mg IV x2, Dilt 10 mg IV x1. She was
started on metoprolol which was discontinued in favor of the
non-selective blockade with labetalol 100mg PO BID given
patient's recent cocaine use.
.
# Coagulopathy: Ms. [**Known lastname **] has had persistently abnormal
coagulation factors. This was thought likely secondary to poor
synthetic function in the setting of hepatic failure. Vitamin K
was initially given to correct any component of nutritional
deficiency with little effect. She was transfused with FFP in
times of acute bleeding with a goal of INR < 2.5. At the time
of discharge, Ms. [**Known lastname **] INR was stable at 2.4.
.
# HCV cirrhosis: Pt not on medical therapy for HCV cirrhosis.
Paracentesis results during hospitalization demonstrated no
evidence of spontaenous bacterial peritonitis. Pt is s/p TIPs
and there is concern that TIPS may have worsened encephalopathy
noted during admission. Lactulose continued for encephalopathy
prevention. Total bilirubin reached a peak of 11 on [**2167-12-1**]
and has been trending downward to 8.2 at time of discharge. She
should continue lactulose and rifaximin. and follow-up with Dr.
[**Last Name (STitle) 497**] of hepatology [**2167-11-18**].
.
# Altered Mental Status- Following extubation, Ms. [**Known lastname **] has
had intermittent delirium which is likely a combination of
hepatic encephalopathy and delirium associated with prolonged
hospital stay. If needed, recommend low dose Haldol for
behavioral control with attention to QT interval on
electrocardiogram. QT interval 438 on day of discharge.
.
# Substance abuse: Pt continued using cocaine, marijuana, and
EtOH. SW consult pending. HIV was tested given risk factors
and was negative.
.
# Full code
.
# Communication: Daughter [**Name (NI) 4850**] [**Telephone/Fax (1) 99373**] (HCP), Son [**Name (NI) **]
[**Name (NI) 5857**]) [**Telephone/Fax (1) 99374**]
Medications on Admission:
None
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution [**Telephone/Fax (1) **]: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for Agitation.
4. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Last Name (STitle) **]: One
(1) Inhalation 2 puffs [**Hospital1 **] () as needed for SOB.
5. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
TID (3 times a day) as needed for itching.
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
Inhalation Q6H (every 6 hours).
7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: [**1-13**]
Inhalation Q2H (every 2 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: [**1-13**] Inhalation Q6H
(every 6 hours).
9. Lactulose 10 gram/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO QID (4
times a day).
10. Rifaximin 200 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3 times
a day).
11. Labetalol 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times
a day).
12. Haloperidol Lactate 5 mg/mL Solution [**Month/Day (2) **]: One (1) Injection
(0.5mg) TID (3 times a day) as needed for agitation.
13. Lasix 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
Tablet(s)
14. Spironolactone 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a
day. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Lower Gastrointestinal Bleed
Cirrhosis
Hepatic Encephalopathy
Respiratory Distress/ Aspiration Pneumonia
Acute Renal Failure
Hypernatremia
Coagulopathy secondary to liver failure
Hepatitis C
Hepatic Cirrhosis
Discharge Condition:
Good
Discharge Instructions:
Per hepatology recommendations, Ms. [**Known lastname **] should begin Lasix
40mg PO daily and spironolactone 50mg PO daily, and electrolytes
and creatinine should be checked daily for the next several
days. These medications may be titrated up as tolerated by
electrolytes, renal function and blood pressure. She should
follow-up with Dr. [**Last Name (STitle) 497**] in hepatology clinic on Friday,
[**12-18**] as described below.
She should continue on lactulose and rifaximin for hepatic
encephalopathy. Haldol at low dose as needed for agitation.
Please take all medications as prescribed. Return to the
hospital for:
.
* Bleeding
* Frank blood in stools
* Tarry black stools
* Bloody emesis
* Fevers, chills
* Abdominal pain
* Nausea, vomiting
* Worsening cough
* Decline in mental status
Followup Instructions:
[**2167-12-18**], morning- Appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]
of hepatology [**Location (un) 858**] of the [**Hospital Unit Name **] at [**Last Name (NamePattern1) **].
Call ([**Telephone/Fax (1) 1582**] with questions.
Primary Care Dr. [**Last Name (STitle) **] on [**2167-12-31**] at 1:45 pm at [**Hospital **]
Community Health Center. Phone ([**Telephone/Fax (1) 10975**]
ICD9 Codes: 2851, 5849, 2760, 5070, 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3335
} | Medical Text: Admission Date: [**2103-9-4**] Discharge Date: [**2103-9-11**]
Date of Birth: [**2027-6-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Vytorin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
+ETT during preop w/u for TKR
Major Surgical or Invasive Procedure:
[**2103-9-4**] Coronary Artery Bypass x 3 (LIMA to LAD, SVG to OM1, SVG
to OM2/lPLB)
History of Present Illness:
76 yo female was undergoing pre-op evaluation for R TKR and was
found to have positive stress test. Cardiac catheterization and
coronary angiography revealed 3 vessel disease. The patient has
experienced dyspnea on exertion for several years. She was
referred for consideration of cabg.
Past Medical History:
CAD, DM, CVA, htn, hypothyroidism, pancreatic cyst, s/p R CEA,
s/p parathyroidectomy
Social History:
retired
lives with husband
[**Name (NI) **]: quit 30 yrs ago, 20 pack year hx
occasional etoh
Family History:
mother with RHD
Physical Exam:
Elderly WF in NAD
VSS
HEENT: NC/AT, EOMI, oropharynx benign, R CEA scar
Neck: supple, FROM, no lymphadeopathy or thyromgaly
Lungs: Clear to A+P
CV: RRR without R/G/M
Abd: +BS, soft, nontender, without masses or tenderness, obese
Ext: +bil. edema, without varicosities, pulses Fem 1+ bilat, all
others 2+ bilat.
Neuro: mild L facial droop
Pertinent Results:
Iintra-op TEE [**2103-9-4**]:
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Simple atheroma in aortic arch. Normal descending
aorta diameter. Complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Severe mitral annular
calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
severe mitral annular calcification. Mild (1+) mitral
regurgitation is seen. There is a 1 x1 cm echogenic density in
the posterior mitral annulus near the P3 region consistent with
calcium deposit and MAC. This was conveyed to the surgeon and
cross read with Dr.[**Last Name (STitle) **]. Clinical correlation suggested to
rule out endocarditis.
There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results on [**Known lastname **], [**Known firstname **] at11:!5 AM before
CPB.
Post_Bypass:.
Preserved biventricular sytolic function.
LVEF 55%.
Normal RV systolic function.
Trivial MR.
Intact thoracic aorta
[**2103-9-10**] 04:50PM BLOOD WBC-11.8* RBC-3.23* Hgb-10.0* Hct-28.8*
MCV-89 MCH-31.0 MCHC-34.7 RDW-14.1 Plt Ct-343
[**2103-9-4**] 02:21PM BLOOD PT-14.2* PTT-41.6* INR(PT)-1.2*
[**2103-9-10**] 04:50PM BLOOD Glucose-89 UreaN-20 Creat-1.1 Na-140
K-4.6 Cl-99 HCO3-32 AnGap-14
[**Known lastname **],[**Known firstname 8207**] [**Medical Record Number 79632**] F 76 [**2027-6-24**]
Radiology Report CHEST (PA & LAT) Study Date of [**2103-9-8**] 12:23
PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2103-9-8**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 79633**]
Reason: r/o effusion
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with
REASON FOR THIS EXAMINATION:
r/o effusion
Provisional Findings Impression: NR SAT [**2103-9-8**] 2:38 PM
Bilateral effusions left greater than right, improved right
basilar
atelectasis, no new consolidations. No PTX.
Final Report
PA AND LATERAL CHEST ON [**2103-9-8**] AT 12:43
INDICATION: Prior pneumothoraces and chest tubes.
COMPARISON: [**2103-9-6**]
FINDINGS:
There is no PTX visualized. There are bilateral effusions, left
greater than
right with slightly more blunting at the left CP angle compared
to the most
recent prior study. There is better aeration at the right base
with
improvement in previously seen atelectasis. Again noted is some
right
paratracheal density presumably related to distended or tortuous
brachiocephalic vessels. There are no new focal consolidations.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: SAT [**2103-9-8**] 3:34 PM
Brief Hospital Course:
Following a discussion of risks, benefits and alternatives to
CABG, the pt was admitted to [**Hospital1 18**] and taken to the operating
room on [**2103-9-4**] for CABGx3 with LIMA>LAD, and SVG>OM1, OM2.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU for observation
and recovery. POD #1 found the pt extubated, alert and oriented
and breathing comfortably. She was neurologically intact and
hemodynamics were maintained with epinephrine. The patient was
transfered to the floor on POD #1. Chest tubes were
discontinued on POD #2 without complication. Her wires were
removed on the following day. With pulmonary toilet, lasix,
incentive spirometry, and ambulation her breathing improved.
She was transferred to the floor on POD 3 after she achieved
blood pressure control. She continued to improve and had her BP
meds further adjusted. She was discharged to rehab in stable
condition on POD #7.
Medications on Admission:
atenolol 25', norvasc 5', diovan 160', lasix 40', levothyroxine
25', metformin 500''', asa 81', novalin 58am/30pm, vit b 12
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
CAD, DM, CVA, htn, hypothyroidism, pancreatic cyst,
parathyroidectomy
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
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) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 9751**] in 1 week, [**Telephone/Fax (1) 9752**], please call for appointment
Dr [**Last Name (STitle) **],[**First Name3 (LF) **] J. in [**2-25**] weeks ([**Telephone/Fax (1) 16335**]) please call
for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2103-9-11**]
ICD9 Codes: 4111, 5119, 5180, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3336
} | Medical Text: Admission Date: [**2108-12-7**] Discharge Date: [**2109-1-10**]
Service: MICU
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF THE PRESENT ILLNESS: The patient is an
81-year-old female with a history of coronary artery disease,
peripheral vascular disease, COPD, and CHF, who presented to
[**Hospital3 1443**] Hospital on [**2108-11-29**] with roughly one week
of shortness of breath, weight gain, fatigue. There, she was
found to be in new onset atrial fibrillation and congestive
heart failure. An aggressive rate control and diuresis were
attempted; however, her condition with regards to her oxygen
requirement continued to worsen.
A transthoracic echocardiogram was performed which revealed
no clot, aortic stenosis, with a valve area of 0.65 cm
squared and a valve gradient of approximately 15 mm.
Cardioversion was then attempted which required the patient
to be intubated due to worsening respiratory distress. She
was transferred to [**Hospital1 18**] for valvuloplasty and further
evaluation and management.
Per outside hospital records, the patient also was febrile
with an increased leukocytosis with possible pulmonary
infiltrates. She was treated with ceftriaxone, Zosyn,
Flagyl, moxifloxacin, with persistent fever. Apparently, all
cultures there including sputum, blood, and urine cultures
were negative.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post CABG times two, last
one performed in [**2103**].
2. COPD, on home oxygen, 2 liters nasal cannula.
3. CHF, EF of approximately 45-50%.
4. Peripheral vascular disease.
5. Chronic anemia.
6. Depression.
7. Status post cholecystectomy.
ALLERGIES: The patient is allergic to morphine.
TRANSFER MEDICATIONS:
1. Combivent.
2. Protonix.
3. Amiodarone.
4. Lasix.
5. Vancomycin.
6. Moxifloxacin.
7. Flagyl.
PHYSICAL EXAMINATION ON TRANSFER: Vital signs: Temperature
102.0 rectally, blood pressure 133/42, heart rate 70, normal
sinus rhythm. Ventilatory settings: Assist control, tidal
volume 650, respiratory rate 16, 100% FI02, PEEP 18.
General: The patient is intubated, sedated, and
unresponsive. HEENT: The pupils were equal, round, and
reactive to light, anicteric sclerae. Cardiovascular:
Regular rate and rhythm, [**Year (4 digits) 1105**]/VI systolic murmur,
crescendo/decrescendo, loudest at the right upper sternal
border, no rubs or gallops. Lungs: Crackles bilaterally to
the midlung fields. No wheezes. Abdomen: Obese,
nondistended, hypoactive bowel sounds. Extremities: Right
groin without hematoma, trace pitting edema bilaterally.
Lower extremities: Feet cool to the touch, 1+ dorsalis pedis
pulses bilaterally. Neurological: Toes upgoing.
LABORATORY STUDIES: White count 14.2, hematocrit 23.9,
platelets 244,000. Sodium 149, potassium 3.1, chloride 110,
C02 26, BUN 52, creatinine 1.4, glucose 138, calcium 8,
magnesium 2.0, phosphorus 4.1. ALT 68, AST 43, CK 93,
troponin 1.4, albumin 2.7. ABGs 7.36, PC02 50, P02 155.
EKG revealed a normal sinus rhythm at a rate of 75, normal
axis, PR slightly prolonged at 0.24, QRS, QT within normal
limits. Q in [**Last Name (LF) 1105**], [**First Name3 (LF) **] depressions in V4 through V6.
Microbiology studies from the outside hospital include
sputum, urine, and blood cultures all negative.
Chest x-ray revealed bilateral infiltrates.
HOSPITAL COURSE: 1. AORTOVALVULOPLASTY: The patient was
brought emergency to the Catheterization Laboratory with
successful valvuloplasty.
2. ACUTE RESPIRATORY DISTRESS SYNDROME: The patient had
difficulty with her respiratory requirements and difficulty
coming off the ventilator requiring high amounts of oxygen
content as well as difficulty coming off pressors for her low
blood pressure.
It was felt that this combination of respiratory distress was
from a cardiac as well as a pulmonary etiology. A pulmonary
artery catheter was placed for further monitoring of her
hemodynamics which revealed a wedge pressure of 30 as well as
elevated right atrial and right ventricular pressures, right
atrial pressure being 23/18, right ventricular pressure being
55/12, pulmonary artery pressure being 60/29/
On hospital day number ten, she was transferred from the CCU
Service to the Medical Intensive Care Unit Service for
management of her acute respiratory distress syndrome despite
having a capillary wedge pressure of 20.
She was placed on Ardonette protocol and throughout her
hospital course, attempts were made to decrease the oxygen
content as well as the end-expiratory pressures without
success. Tracheostomy was deferred secondary to her
critically ill state and it was felt that she would not
survive the procedure.
Serial chest x-rays revealed clearing of her acute
respiratory distress syndrome; however, given her
comorbidities and requiring aggressive fluid hydration, she
progressed to congestive heart failure, again requiring high
levels of ventilatory support, and was never successfully
taken off of mechanical ventilation.
3. HYPOTENSION: It was felt that the etiology of her
hypotension was again multifactorial with a decreased cardiac
output requiring multiple pressors as well as a distributive
shock picture from an infectious cause of an unknown source.
Throughout her CCU stay, she required Levophed,
Neo-Synephrine, and dobutamine. Throughout her hospital
course trending into the Medical Intensive Care Unit course
she never was successfully weaned off of pressors, requiring
quadruple pressors at her time of expiration.
It was also felt that these pressors were causing an
exacerbation of her ischemic colitis; however, given her
extremely low hypotension she was unable to successfully wean
and remained on quadruple pressors at the time of expiration.
4. FEVERS: Since prior to admission, the patient was noted
to have fevers of unknown etiology despite multiple cultures
drawn. She continued to experience multiple episodes of
fevers despite an unknown etiology despite an exhaustive
amount of cultures including her blood, urine, sputum, and
stool.
She was placed empirically on antibiotics despite a known
source. During which time, she seemingly responded and her
fevers dropped. However, approximately two weeks after
initiation of antibiotics, she continued to have fevers up to
103.0 Fahrenheit, despite broadening her antibiotic coverage
to include antifungals. Multiple drugs were withdrawn for a
suspected drug fever, but she continued to experience fevers.
However, with the comorbid diagnosis of ischemic colitis, it
was felt that she was having translocation of bacteria from
her colon that may have been causing her fevers and was
continued to be covered broadly up to the time of her
expiration.
5. ISCHEMIC COLITIS: It was noted on hospital day number 21
that the patient had a significant increase in the amount of
her stool. Her stool was Guaiac positive throughout her
hospital course but the appearance of her stool turned bright
red.
A Gastrointestinal consult was obtained for further
evaluation, at which time a CT of the abdomen was obtained
which revealed edema throughout her transverse, descending,
and sigmoid colon. A flexible sigmoidoscopy was performed
which revealed changes that are consistent with ischemia. At
this time, she was aggressively hydrated to maintain her
blood pressures above a mean of 60 for adequate perfusion.
Despite this strategy, however, she continued to have massive
amounts of stool output, approaching 4 liters per day, and
became increasingly acidotic despite aggressive bicarbonate
repletement. Surgery was declined by both the patient's
family as well as the Surgery Team secondary to an extremely
high operative risk.
She continued to have high volumes of stool output up to the
time of her expiration.
6. ANEMIA: The patient was noted to have blood loss through
her GI tract and was supported with multiple units of packed
cells for blood transfusions to maintain a hematocrit above
30.
7. ADRENAL INSUFFICIENCY: Random cortisol levels were drawn
throughout her hospital course; with a value of 12 it was
felt that she was adrenally insufficient and was started on
an empiric course of steroid replacement. However, this had
no effect on her blood pressures and after approximately
seven days her steroids were discontinued.
8. VENTILATOR-ASSOCIATED PNEUMONIA: The patient was noted
to have an acute increase in secretions while on the
ventilator and required increased suctioning as well as an
antibiotic course for adequate treatment.
9. NUTRITION: Because of her ischemic colitis, she was
placed on total parental nutrition for the remainder of her
hospital course up until her date of expiration.
10. HYPERNATREMIA: On admission, the patient was noted to
be hypernatremic. Free water deficit was repleted over the
time course of her hospital stay and her sodium was
maintained with TPN.
Of note, the patient was made comfort measures only two days
prior to her expiration after a long family meeting with her
husband and three daughters present as well as her son. The
husband stated that he wished to make her comfort measures
only and was moved to this directive by the husband's wishes.
The patient expired on [**2109-1-10**] at 4:30 p.m. An
autopsy was declined at this time.
CONDITION: Expired.
DIAGNOSIS:
1. Aortic stenosis, status post valvuloplasty.
2. Acute respiratory distress syndrome.
3. Cardiogenic and distributive shock requiring multiple
pressors.
4. Ischemic colitis.
5. Anemia.
6. Adrenal insufficiency.
7. Ventilator-associated pneumonia.
8. Hypernatremia.
9. Total parenteral nutrition.
10. Coronary artery disease.
11. Chronic obstructive pulmonary disease.
12. Congestive heart failure.
13. Peripheral vascular disease.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-685
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2109-1-22**] 03:34
T: [**2109-1-22**] 20:38
JOB#: [**Job Number 29074**]
ICD9 Codes: 4280, 0389, 486, 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3337
} | Medical Text: Admission Date: [**2188-6-6**] Discharge Date: [**2188-6-13**]
Date of Birth: [**2103-9-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
abdominal pain, hypotension
Major Surgical or Invasive Procedure:
Esophago-gastro-duodenoscopy
History of Present Illness:
Pt is an 84 yo man with history of chronic CHF (EF 40%),
pulmonary HTN, severe TR, diabetes type 2 now controlled off
meds, afib on warfarin and congestive cirrhosis, who presents
with abdominal pain and hypotension. Pt is currently residing at
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], where he had complaints of abdominal pain. Pt says
that a day and a half ago he had some right sided sharp,
fleeting pain [**9-15**], non-radiating, lasting for a few seconds.
He says he has never had this pain before and denies any nausea
and vomiting. He last had a small, loose, non-bloody, non-black
bowel movement yesterday. Says he has been passing gas. He says
he has been quite hungry, and hasn't really eaten anything for
the last 3-4 days since "no one gave me food." He has only been
drinking 1 cup of water and maybe [**12-9**] cup of gingerale daily. He
noticed that his urination has decreased over the last day. He
says he last 10 lbs over the last week. He feels cold, but
denies fever or chills.
.
In the ED, initial vital signs were trigger for hypotension
84/61 - per EMS, BPs labile on route. Exam was notable for pt
was able to answer questions, no somnolent, did not assess for
asterixis, irregular heart rate, significant bruising and
petechiae across the chest wall, no chest tenderess; no
back/flank bruising; guiaic positive, light brown stool. EKG was
vpaced 80. Cards was consulted for elevated trop, but not
concerned in setting of elevated Cr, and pt with no chest pain.
CXR showed a decrease in pulmonary vascular engorgement,
otherwise stable from prior. CT torso prelim read showed no
acute abnormalities to explain pain, and only small ascites.
Bedside u/s showed no pericardial effusion, and only minimal
ascites. Labs were notable for hyponatremia (125 from 135 most
recently), mildly decreased Hct from baseline 31-32 to 29.
Lactate 1.0. Cr was notable for elevation of 2.0 from 1.4, AST,
AP and lipase all mildly elevated. Tox screen not sent. He was
given 1L NS. Concern for infection, though WBC normal with
normal diff, and given one dose of Zosyn, and Vanc ordered, but
not yet given. UA and Urine cultures not yet sent. For access he
has 2, 18g.
.
Vital signs prior to transfer T96.8, 81, 94/51, 16, 100% 2L NC.
.
On the floors, he currently feels weak, and hungry, but does not
have any abdominal pain right now except for when he presses on
his right side.
.
He had a recent admission [**5-27**] for similar presentation of
abdominal pain, ileus, volume overload. He had acute on chronic
systolic heart failure, at which point his diuresis was
uptitrated. He was given a 3 day course of acetazolamide for
contraction alkalosis. He also had hyponatremia and [**Last Name (un) **]
attributed to heart failure and poor forward flow that improved
with diuresis. Then his Cr was 2.2, and decreased to 1.4 on the
day of discharge. Had upgrade to pacemaker at that time ([**Hospital1 **]-v
pacemaker placed [**5-28**]).
His abdominal pain then was attributed to ascites. He had a
diagnostic para that was negative for SBP.
.
He was seen 2 days ago in heart failure clinic, where he
appeared dry, weight 113 from 115 on discharge (was 135 on last
admission), and metolazone dose was decreased from 5mg daily to
2.5mg MWF.
.
ROS:
Positive as above. Also notable for some SOB when he coughs, but
this is unchanged from prior. Also endorses knee pain from
chronic arthritis.
He currently denies any fevers, night sweats, chest pain,
palpitations, nausea, vomiting, constipation, bloody or black
stools, hematuria, pain with urination though occasional
"burning" at the end of his penis.
Past Medical History:
1. Diabetes type 2 now on no medication
2. Dyslipidemia.
3. Hypertension.
4. Atrial fibrillation on coumadin
5. Hyperthyroidism, on methimazole.
6. Anemia.
7. Dysphagia.
8. Arthritis.
9. Chronic kidney disease.
10. Moderate-to-severe tricuspid regurgitation.
12. Systolic heart failure.
13. Sick sinus syndrome with complete heart block s/p pacemaker,
now with revision [**5-/2188**]
14. Pulmonary hypertension.
15. Mild diabetic retinopathy.
16. PVD, lower extremity venostasis.
17. Cirrhosis from chronic congestive hepatopathy - though
unclear how pt received this diagnosis
Social History:
He previously lived alone in [**Location 1268**]. His daughter and
grandchildren live nearby and would like him to move in with
them but he refuses. He is currently at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42905**] skilled
nursing and would not like to return there. He denies alcohol,
tobacco, and IVDU.
Family History:
He has no known family history of premature coronary artery
disease or sudden death. His mother died of a CVA. His father
died of cancer. His son survived lymphoma.
Physical Exam:
On admission in ICU:
VS: Temp: 97 BP: 115/54 HR: 81 RR: 16 O2sat 100% 2LNC Wt 49.6kgs
GEN: elderly gentleman, pleasant, lying down in bed, very thin,
comfortable, NAD
HEENT: PERRL, EOMI, anicteric, very dry MM, op without lesions,
NECK: thin, no supraclavicular or cervical lymphadenopathy,
elevated JVP to just above clavicle
CVS: irregular, 3/6 systolic murmur loudest at RUSB without
apparent radiation, S1 and S2 wnl
CHEST: left-sided pacer with steri-strips in place, ecchymoses
across entire chest, extending to left side of rib cage
RESP: no use of access mm, decreased at right base 1/3 up with
faint crackles, no wheezes
ABD: +NABS, soft, mild tenderness to palpation in right flank,
no epigastric tenderness, no masses or hepatosplenomegaly, neg
[**Doctor Last Name **] sign
EXT: warm, very thin, muscle wasting, no edema, no cyanosis
SKIN: no jaundice, right medial ulcer on shin ~ 3cm, ~ 2cm
healing ulcer on left medial leg below knee, with some erythema
of buttocks but no frank skin breakdown
NEURO: AAOx2, states [**2187**], but says [**5-15**], Cn II-XII intact.
5/5 strength throughout. gait deferred
On day of discharge:
VS: Tmax:98.6, Tcurrent:98.6, BP:98/40, HR: 80, RR:20
General: NAD, generally weak
HEENT: PERRL, EOMI, slightly dry mucous membranes
Neck: no JVD
CHEST: left-sided pacer with steri-strips in place, swelling and
ecchymoses over pacer pocket, echhymoses over chest, left and
right
RESP: lungs CTAB, but for decreased breath sounds at right lung
base
Abdomen: bowel sounds active, nontender, soft, voluntary
guarding, no rebound
EXT: cachectic, no edema, cyanosis, or clubbing, ulcers over
heels, healing venous ulcers on lower legs
Pertinent Results:
ADMISSION LABS:
[**2188-6-6**] 04:40PM BLOOD WBC-7.5 RBC-4.20* Hgb-9.3* Hct-29.6*
MCV-71* MCH-22.2* MCHC-31.5 RDW-18.4* Plt Ct-228
[**2188-6-6**] 04:40PM BLOOD Neuts-72* Bands-0 Lymphs-12* Monos-14*
Eos-2 Baso-0
[**2188-6-6**] 04:40PM BLOOD PT-15.0* PTT-34.3 INR(PT)-1.3*
[**2188-6-6**] 04:40PM BLOOD Ret Aut-2.1
[**2188-6-6**] 04:40PM BLOOD Glucose-153* UreaN-101* Creat-2.0*
Na-123* K-7.5* Cl-79* HCO3-36* AnGap-16
[**2188-6-6**] 04:40PM BLOOD ALT-27 AST-120* CK(CPK)-115 AlkPhos-189*
TotBili-0.7
[**2188-6-6**] 04:40PM BLOOD cTropnT-0.25*
[**2188-6-6**] 11:21PM BLOOD Calcium-8.2* Phos-4.4 Mg-2.6 Iron-52
[**2188-6-6**] 11:21PM BLOOD calTIBC-307 Ferritn-131 TRF-236
[**2188-6-6**] 11:50PM BLOOD %HbA1c-6.7* eAG-146*
[**2188-6-6**] 04:40PM BLOOD Lipase-188*
DISCHARGE LABS:
[**2188-6-13**] 07:15AM BLOOD WBC-11.0 RBC-3.85* Hgb-8.2* Hct-28.4*
MCV-74* MCH-21.2* MCHC-28.8* RDW-19.0* Plt Ct-221
[**2188-6-13**] 07:15AM BLOOD PT-16.4* PTT-30.3 INR(PT)-1.4*
[**2188-6-12**] 06:40AM BLOOD Ret Aut-2.9
[**2188-6-13**] 07:15AM BLOOD Glucose-147* UreaN-67* Creat-1.2 Na-135
K-4.4 Cl-95* HCO3-33* AnGap-11
[**2188-6-11**] 06:25AM BLOOD ALT-25 AST-32 LD(LDH)-214 AlkPhos-201*
TotBili-0.8
[**2188-6-11**] 06:25AM BLOOD Lipase-113*
[**2188-6-13**] 07:15AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.1
[**2188-6-12**] 06:40AM BLOOD Hapto-19*
[**2188-6-6**] 11:50PM BLOOD %HbA1c-6.7* eAG-146*
URINE:
[**2188-6-6**] 11:21PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2188-6-6**] 11:21PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2188-6-6**] 11:21PM URINE Hours-RANDOM UreaN-383 Creat-24 Na-63
K-35 Cl-35
[**2188-6-6**] 11:21PM URINE Osmolal-311
MICRO:
BLOOD CX x2 [**2188-6-6**]: FINAL NEGATIVE
URINE CX [**2188-6-6**]: FINAL NEGATIVE
MRSA SCREEN [**2188-6-6**]: NO MRSA ISOLATED
STUDIES:
CT TORSO [**2188-6-6**]:
IMPRESSION:
1. No retroperitoneal hematoma or intrathoracic hemorrhage.
2. Moderate right pleural effusion with resolution of previously
visualized left pleural effusion. Interval improvement in
aeration of the superior segment right lower lobe patchy
opacity, which may be an area of improving infection or
atelectasis.
3. Stable cardiomegaly.
4. Cirrhosis with small amount of ascites.
5. Right renal cysts, better characterized on prior renal
ultrasound.
CXR [**2188-6-6**]: IMPRESSION: Stable appearance of chest radiograph in
comparison to prior study from [**2188-5-29**] with minimal
improvement in previously visualized vascular engorgement.
CT ABD & PELVIS W/O CONTRAST [**2188-6-6**]:
CT OF THE CHEST WITHOUT IV CONTRAST: Again visualized is a
moderate right
pleural effusion with adjacent airspace atelectasis which has
remained stable in comparison to prior study from [**2188-5-16**].
Previously visualized left pleural effusion has, however, since
resolved. Previously visualized area of patchy opacity within
the superior segment of the right lobe is again seen, but
appears less confluent. Bronchiectasis changes are again
visualized throughout the right lower lobe. Sub-4mm
pleural-based nodules are again visualized within the right
upper lobe and lingula, stable in comparison to prior studies
(2:18 and 36). The lungs are without any new consolidations.
The heart remains massively enlarged as seen previously, with
extensive
atherosclerotic calcifications of the coronary arteries.
Pacemaker leads
appear stable. Note is again made of gynecomastia. There is
stable mediastinal lymphadenopathy, with the largest node in the
precarinal region measuring up to 12 mm, likely reactive.
CT OF THE ABDOMEN WITHOUT ORAL OR IV CONTRAST: Evaluation of the
abdominal
structures is again limited by the lack of intravenous contrast.
The liver
appears to be shrunken with a nodular contour. Stable
calcification is again visualized in segment VI. There is a
small amount of abdominal ascites, decreased in comparison to
prior study from [**2188-5-16**]. The pancreas is atrophic but
stable. The kidneys are also atrophic bilaterally, but stable
with no evidence of hydronephrosis or stones. Two stable
hypodensities again visualized within the interpolar region of
the right kidney (2:72 and 75), compatible with cysts and better
characterized on the renal ultrasound from [**2188-3-28**]. The patient
remains status post splenectomy with a small amount of splenosis
in the left upper quadrant, which remains unchanged. The
stomach, visualized loops of small and large bowel, and
bilateral adrenal glands are within normal limits. The abdominal
aorta has extensive atherosclerotic changes, but normal in
caliber and contour. Pathologic lymphadenopathy through the
abdomen.No retroperitoneal hematoma is present and there is no
free air.
CT OF THE PELVIS WITHOUT ORAL OR IV CONTRAST: The bladder,
rectum, and
visualized portions of sigmoid colon are within normal limits.
There is a
small amount of free fluid in the pelvis. No retroperitoneal
hematoma is
present. No pelvic lymphadenopathy by CT size criteria.
OSSEOUS STRUCTURES: Multilevel degenerative changes are again
visualized
throughout the thoracolumbar spine with anterior and posterior
osteophytes and uncovertebral hypertrophy. A stable focus of
calcification is again
visualized at L5-S1 disc space. No suspicious lytic or blastic
osseous
lesions.
IMPRESSION:
1. No retroperitoneal hematoma or intrathoracic hemorrhage.
2. Moderate right pleural effusion with resolution of previously
visualized left pleural effusion. Interval improvement in
aeration of the superior segment right lower lobe patchy
opacity, which may be an area of improving infection or
atelectasis.
3. Stable cardiomegaly.
4. Cirrhosis with small amount of ascites.
5. Right renal cysts, better characterized on prior renal
ultrasound.
DUPLEX DOPP ABD/PEL [**2188-6-7**]: IMPRESSION:
1. Coarse echotexture of the liver, with lobulated contour
compatible with
cirrhosis. No distinct hepatic lesions. Hepatic vasculature is
patent.
2. Small amount of ascites.
3. Small right pleural effusion.
4. Cholelithiasis without evidence of cholecystitis.
[**2188-6-13**] EGD
Birth Date: [**2103-9-22**] (84 years) Instrument: GIF-H180 ([**Numeric Identifier 101235**])
ID#: 054 20 81
Medications: MAC Anesthesia
Indications: cirrhosis rule out varices
Dysphagia
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
moderate sedation. Supplemental oxygen was used. The patient was
placed in the left lateral decubitus position and an endoscope
was introduced through the mouth and advanced under direct
visualization until the third part of the duodenum was reached.
Careful visualization of the upper GI tract was performed. The
procedure was not difficult. The patient tolerated the procedure
well. There were no complications.
Findings: Esophagus:
Other No varices
Stomach:
Mucosa: Two erosions of the mucosa was noted in the body on the
greater curve. Patchy erythema of the mucosa was noted in the
antrum. These findings are compatible with gastritis.
Duodenum:
Flat Lesions A single medium angioectasia was seen in the
distal bulb.
Impression: No varices
Erosion in the [**Last Name (un) 67230**] greater curve
Erythema in the antrum compatible with gastritis
Angioectasia in the distal bulb
Otherwise normal EGD to third part of the duodenum
Recommendations: If any questions or you need to schedule an
[**Telephone/Fax (1) 682**] or email at [**University/College 21854**]
Additional notes: FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology
Brief Hospital Course:
Pt is an 84 yo man with history of chronic systolic CHF (last EF
40%), pulmonary HTN, severe TR, diabetes type 2 now controlled
off meds, afib on warfarin and congestive cirrhosis, who
presents with abdominal pain and hypotension, and found to have
acute on chronic renal insufficiency, hyponatremia and
alkalosis. Pt was initially admitted to the MICU given
hypotension. He was given IVF's and his SBP improved into the
100s.
.
#. Hypotension: Likely [**1-9**] hypovolemic etiology given clinically
dry, elevated BUN/Cr, recent increased diuresis and poor po
intake. Patient in clinic recently noted to have weight of 115
lbs down from 135 lbs between [**5-30**] and [**6-4**]. Pt had no s/s
infection and no leukocytosis to suggest infectious etiology or
sepsis. He was given IVF's and his BP improved. He was given one
dose of Zosyn in the ED, though this was not continued on
admission. Cultures were sent. UA was unremarkable, and CXR
without infiltrate. He was not continued on antibotics, and was
given fluid resuscitation with IVF boluses. His SBP was in the
100s on discharge. His hypotension was felt most likely to
overdiuresis, and thus his spironolactone and furosemide dosages
were decreased as per medication reconcillation. We also lowered
his dose of Metoprolol given his borderline hypotension in
house; this can be uptitrated in the future as needed. We also
discontinued the patient's metolazone.
.
#. Acute on Chronic systolic CHF: With volume status restored,
patient had slight volume overload and diuretics were slowly
re-introduced. This was evidenced by right pleural effusion and
increased requirement for oxygen at rest. Physical exam of right
lung base and symptoms of dyspnea improved over a few days when
diuretics were re-introduced at lower dose. ACE-i/[**Last Name (un) **] was held
because of hypotenstion.
.
#. Abdominal pain: Unclear etiology, but seemed to have resolved
prior to admission. DDx includes constipation vs. SBP vs.
cholelithiasis vs. pancreatitis vs. ileus vs. gastritis. Lipase
is elevated, though clinically pt has no epigastric pain, and
clinical story of location of pain and duration is not c/w
pancreatitis. Pt is passing gas and had BM so ileus less likely,
in addition to no obstruction seen on CT. Cholelithiasis
certainly possible given brief intermittent pain, that has now
since resolved. Elevated alk phos and AST could be explained by
intermittent cholelithiasis. Given guaiac positive stools,
gastritis also possible, though intermittent nature makes this
less likely. LFTs were within normal limits, and RUQ u/s showed
no evidence of infection, although it did show coarse
echotexture of the liver, with lobulated contour compatible with
cirrhosis, a small amount of ascites, a small right pleural
effusion, and cholelithiasis without evidence of cholecystitis.
#. Dysphagia: Patient was seen in hospital for a speeh and
swallow evaluation. They recommend a diet of soft moist solids
and thin liquids, as well as further evaluation by speech and
swallow at his facility.
#. GI bleed: Patient's Hct trended down in house and stool was
confirmed to be guiac positive. Upper endoscopy showed no
varices, but erosions in the stomach and vascular ectasia of the
duodenum. No varices were seen. His coumadin was held for this
procedure and re-started afterwards. On discharge, his Hct was
trending upwards to 28.4 from 25 two days prior, and there was
no frank blood or melena ever observed in his stool. This is
likely a slow, chronic GI bleed and felt to be stable. Iron
supplements continued.
# Acute on chronic renal insufficiency: Likely pre-renal in
setting of poor po intake, and diuresis as discussed above. ATN
also possible given BP slightly lower than baseline.
Post-obstructive etiologies much less likely on the
differential. FeUrea 31%, suggestive of pre-renal etiology. He
was given IVF's as discussed above and Cr was trended down to
1.2 on discharge, which is his baseline.
# Metabolic Alkalosis with resp compensation: Pt has significant
alkalosis with HCO3 of 36 on admission, has been higher up to
39. Suspect that this is contraction alkalosis [**1-9**] overdiuresis.
ABG obtained showed 7.44/55/79/39, suggestive of respiratory
compensation. Lytes were trended with correction of bicarb to 33
on day of discharge.
# Elevated troponin: Trop was elevated to 0.25 from prior 0.11.
However, in the setting of elevated Cr, this is the most likely
etiology. Reassuring that EKG unchanged, and pt has no chest
pain. CK, MB were stable upon a recheck during admission.
#. Hyponatremia: Hypovolemic hyponatremia as evidenced by
picture of dehydration as discussed above. Na much lower from
baseline by ~ 10pts. Diuretics were held and he was given IVF's.
Na was trended up to 135 on discharge secondary to IVF, good PO
intake, and the holding of his diuretics.
#. Anemia: Microcytic, suspect iron deficiency. Possible
etiologies include upper slow bleed given brown stools, such
erosions and duodenal ectasia. No reported bloody or black
stools, which is reassuring. Hct on admission is 29, and
baseline is closer to 31-33. However, suspect that this is
hemoconcentrated given picture of dehydration as discussed
above. Volume status was restored and Hct recovered to 28 on
d/c. Fe studies and retic count were sent, which showed no
evidence of hemolysis, and without reticulocytosis to suggest
bleeding. Iron studies were wnl. Patient was discharged back on
his home dose of 20 mg daily of omeprazole.
# Atrial fibrillation: Chronically on Warfarin, for CHADS 4
(CHF, HTN, Age and Diabetes). However, INR subtherapeutic on
admission to 1.3. Listed on dc summary and in some nursing notes
per rehab, but not on primary list. Held Toprol XL initially
given hypotension. Placed on heparin gtt briefly, but on
discharge was therapeutic on Coumadin at 5.5 mg Daily at 2.1.
Metoprolol was re-started at 25mg PO daily before d/c.
# Lower extremity wounds: Exam c/w venous stasis ulcers with no
evidence of superinfection. Wound was consulted for care.
# Diabetes: last A1c from [**12/2187**] 6.6. Not currently on any
medications for diabetes. Suspect that he no longer requires
meds given his weight loss. Placed on QID FS and ISS, and was
discharged on diet control for diabetes.
# Hyperthyroidism: TSH 3.7 on [**2188-5-17**]. Besides weight loss,
likely [**1-9**] issues of poor po intake & diuresis, no other s/s
hyperthyroidism. Continued on methimazole 5mg daily.
Transitional Issues:
- Please monitor weights daily for change greater than 3 lbs in
weight gain
- Please have the patient follow-up with his CHF clnic, whom has
been managing his medications.
- Please follow-up 7/1 Blood cultures for any signs of
microorganism growth (NGTD)
- Please monitor fluid status daily, with low threshold to
uptitrate spironolactone back to prior dosing.
Medications on Admission:
-aldactone 50mg 9pm, 25mg qam
-K-dur 10meq daily
-metolazone 2.5mg MWF
-ASA 81mg daily
-Docusate 100 [**Hospital1 **]
-Methimazole 5mg daily
-Torsemide 20mg 3 tabs [**Hospital1 **]
-oxygen 2L NC
-toprol XL 50mg daily
-prilosec 20mg daily
-MVI
-calcium carb 500 tid
-ferrous suldate 325mg q8pm
-VitD 400u 2 tabs daily.
-warfarin 5.5mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO three times a day.
8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. warfarin 5 mg Tablet Sig: ASDIR Tablet PO Once Daily at 4
PM: Please take warfarin 5.5 mg Daily at 4 PM.
11. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day: hold for SBP<100.
12. Aldactone 25 mg Tablet Sig: One (1) Tablet PO twice a day.
13. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
14. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for fever or pain.
15. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Palm [**Hospital 731**] Nursing Home - [**Location (un) 15749**]
Discharge Diagnosis:
Primary: Volume depletion, Slow gastrointestinal bleed
Secondary: dysphagia, chronic systolic CHF (EF 40%), Diabetes,
Dyslipidemia, HTN, atrial fibrillation, sick sinus syndrome s/p
pacemaker placment, hyperthyroidism, liver cirrhosis, anemia,
CKD, pulmonary hypertension, venous peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 101236**],
You were admitted to the hospital because you had an episode of
abdominal pain and your blood pressure was very low. In the
hospital, you were given IV fluids and your blood pressure
increased. We held your usual diuretics and you were able to eat
soft foods well. Your level of red blood cells dropped for a few
days and we were worried about you losing blood into your GI
tract because we found evidence of a slow blood loss in your
stool. An upper endoscopy showed an abnormal blood vessel in the
stomach that may be leading to slow blood loss. There were no
rapidly bleeding vessels seen in this study. In the hospital
your red blood cell level stabilized and began to rise. You were
discharged from the hospital with a plan to decrease some of
your diuretics and follow up with your doctor about the slow
bleeding in your stomach.
Please make the following changes in your medications:
- STOP taking Metolazone
- STOP taking Potassium Chloride 10meq daily
- CHANGE your dose of Torsemide to two 20mg tabs twice daily
(previously you had been taking 60 mg twice a day)
- CHANGE aldactone to 25mg twice daily (previously you were
taking 50mg in the night and 25mg in the morning)
- DECREASE your dose of Toprol XL to 25 mg Daily (previously you
had been taking 50 mg Daily)
- START senna 8.6 mg Tablet: Take 2 tablets at night as needed
for constipation
- START acetaminophen 325 mg Tablet: Take 1-2 Tablets PO every
six (6) hours as needed for fever or pain.
- START Miralax 17 gram Powder in Packet: Take One (1) packet
PO once a day as needed for constipation
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 251**] D.
Location: [**Hospital3 249**] [**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 250**]
**Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge**
Department: CARDIAC SERVICES
When: FRIDAY [**2188-6-20**] at 2:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2188-8-7**] at 3:00 PM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], 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
ICD9 Codes: 5849, 2761, 4168, 5715, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3338
} | Medical Text: Unit No: [**Numeric Identifier 64228**]
Admission Date: [**2174-8-8**]
Discharge Date: [**2174-9-22**]
Date of Birth: [**2174-8-8**]
Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 64229**] was [**Known lastname **] at 30-4/7 week
premature infant [**Known lastname **] to a 30-year-old, G1, para 0
mother with an estimated date of confinement of [**2174-10-14**]. The
baby weighed 1700 [**Name2 (NI) **] at birth.
Maternal history is notable for a prior LEEP procedure and
placement of a cerclage early in pregnancy. Pregnancy was
complicated by PPROM on [**2174-8-1**] at which time the
mother was admitted and treated with betamethasone which was
completed by [**2174-8-3**]. Also had cerclage removal and
ampicillin and erythromycin started. Mother began to have
contractions and gradually worsening abdominal pain and
tenderness prompting induction of labor on the day of birth
for concerns of chorioamnionitis. Maximum maternal fever was
99.2.
PRENATAL LABS: Mother was O negative, antibody negative,
Hepatitis B surface antigen negative. RPR nonreactive, rubella
immune and GBS unknown.
Baby girl was [**Name2 (NI) **] vaginally, vigorous with Apgars 8 and 9
and needing only blow-by oxygen in the delivery room. The
baby developed moderate retractions and work of breathing and
was brought to the NICU. In the NICU work of breathing
improved rapidly and the infant did not require supplemental
oxygen.
ADMISSION PHYSICAL EXAMINATION: Vital signs: T 98, heart
rate 160, respiratory rate 70, blood pressure 158/28 with a
mean arterial pressure of 39, oxygen saturation was 97% on
room air.
Weight was 1700 [**Name2 (NI) **] (75 to 90 percentile), length 43 cm,
75th percentile and head circumference 29 cm which was 50 to
75 percentile.
General: This is a premature infant with mild tachypnea and
contractions are rest but overall comfortable without
significant work of breathing. Dubowitz shows approximately
31 weeks gestation.
Head and neck: Fontanel is soft and flat, palate is intact.
Red reflex was deferred. There was caput and molding and eyes
and ears are patent. Some facial bruising.
Neck: Supple, no lesions.
Chest: Moderate to mild retractions, clear lungs bilaterally,
some asymmetry with left side elevated compared to right.
Cardiac: Regular rate and rhythm, no murmur.
Abdomen: Soft, 3 vessel cord. No masses, no
hepatosplenomegaly and baby's abdomen is not distended.
GU: Normal female, patent anus.
EXTREMITIES: Warm, no edema. Back is normal.
NEUROLOGY: Good tone, good reflex, weak grasp. Moving
extremities equally bilaterally.
PE ON DISCHARGE: Baby has a hemangioma present on the right
side of her neck just beneath the mandible. No cardiac murmur
present. Tone within normal limits for her age. Symmetrical
exam.
LABORATORY FINDINGS: Dextrose on admission was 59. Chest
x-ray showed no pneumothorax, symmetric lungs and evidence of
mild respiratory distress syndrome or retained fetal lung
fluid.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory. The baby was [**Name2 (NI) **], required blow by oxygen
but quickly was weaned to room air. The patient has never
required intubation or supplementary oxygen during her stay in
the hospital. Respiratory rate remains anywhere from 30 to
60's and saturation remains greater than 95%.
[**Known lastname **] had a history of having some occasional episodes of
apnea and bradycardia but did not require caffeine during
her admission here. She was noted to have problems with
desaturation during feedings. She had a severe episode of
bradycardia and desaturation on [**9-14**] for which she
required stimulation and blow by oxygen. This spell was
clearly related to feeding dyscoordination. There was a
normal CBC at that time. She had another episode on [**9-17**] that
was milder. The patient has been free of significant
episodes of desaturation and bradycardia since then. The baby
does very well with breastfeeding and when paced and observed
carefully during bottle feedings.
2. Cardiovascular. The patient has remained cardiovascularly
stable throughout her entire stay here. No episodes of
hypotension. Heart rate ranges from 130 to 170's and her
latest blood pressure was 61/44 with a mean arterial
pressure of 49. Feeding related episodes of apnea and
bradycardia as described above have resolved.
3. Fluids, Electrolytes and Nutrition: Her electrolytes since
birth have been stable. Bilirubin rose to 9.3 requiring
phototherapy on day of life 2 through 5. A rebound was 10.4
and phototherapy was reinitiated from day of life 8 to 11.
Another rebound showed a bili of 9.6 and again received
phototherapy from day of life 12 through 14 after which it
was discontinued with a rebound of 9.1 noted on day of life
23.
4. GI: Feeds were begun via NG tube from day of life 2.
Breast milk was given and calories were accelerated to 28
calories per ounce over time. Breast feeding began on day
of life 20 and her feeds were all p.o. by day of life 35
so for the past 11 days she has been taking her feeds all
p.o. Her current formula
is breast milk 24 calorie. She has been taking over 130-140
ml per kilo per day of breast milk by bottle and breast
feeding in addition.
[**Known lastname **] has a history of having an anal rectal fissure which
has on occasion produced trace positive heme results which
were managed with emollients and Desitin. She has been
stooling well since that time and constipation has not been
an issue.
Hematology: The patient has not been transfused during this
admission. Her latest CBC was on [**2174-9-14**] with a white
count of 8.8, hemoglobin 9.8, hematocrit 28.2%, platelets 300,
neutrophils 18, bands 0, lymphocytes 79, reticulocyte count
3.3%. She has been on iron supplements since day of life 8.
Infectious disease: The patient received ampicillin and
gentamicin for the first three days of life. Cultures
were negative.
Placental pathology results did reveal the presence of acute
chorioamniotis and acute funisitis.
Neurology: Cranial ultrasound findings are as follows.
[**2174-8-16**] ultrasound day of life #8 normal.
[**9-7**] day of life 30 Grade 1 IVH on the right.
[**9-14**] day of life 37 showed bilateral germinal matrix
hemorrhages, right greater than left. There was also a tiny
new echolucency or cyst (3x2x2mm) lateral to the frontal [**Doctor Last Name 534**]
of the left lateral ventricle of questionable significance.
Follow-up with the Infant Follow-up Program is being scheduled
A follow-up head ultrasound has been scheduled for [**10-6**]
at 2:50PM at CH.
Audiology: The patient passed her hearing screen with
automated auditory brainstem responses on [**2174-9-13**].
Ophthalmology: An eye examination was performed on [**2174-9-5**] which showed no retinopathy of prematurity and mature
retinas and follow-up in 9 months was recommended by Dr.[**Name (NI) **]
[**Name (STitle) 56687**], Ophthalmology.
Psychosocial: [**First Name4 (NamePattern1) 3460**] [**Last Name (NamePattern1) 36244**], LICSW Social work was involved
with the family during their NICU stay. She can be reached at
[**Telephone/Fax (1) 8717**]. Parents are wonderful and have been very involv
ed with [**Known lastname 64230**] care. Mother is a Cardiac Physician's
Assistant at [**Hospital1 112**].
CONDITION ON DISCHARGE: Good.
DISPOSITION: Home.
Primary pediatrician is Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] in [**Location (un) 745**],
[**Telephone/Fax (1) 38714**].
Follow-up appointment with Dr. [**First Name (STitle) **] is scheduled for
[**Last Name (LF) 2974**], [**2174-9-23**]. [**Hospital6 **] will
visit the family on Saturday or Sunday the 13th or [**9-25**].
DISCHARGE RECOMMENDATIONS: Feedings were to continue with
breatsfeeding and bottle feedings of mother's milk
supplemented with Enfamil powder to provide 24kcal/oz. With
good weight gain over the next few weeks, baby will hopefully
be able to transition to complete breastfeeding.
FU HUS scheduled for [**10-6**] at 2:50PM at CH [**Telephone/Fax (1) 47462**].
Infant Follow Up Program - at 3 months of age - referral made
from NICU and family will be contact[**Name (NI) **] - [**Telephone/Fax (1) 37126**].
Appointment will be scheduled on day when Neurology attends
clinic.
FU eye exam Dr.[**Name (NI) **] [**Name (STitle) 56687**] at 9 months of age.
FU hearing assessment at one year of age.
DISCHARGE MEDICATIONS:
1. Iron supplements.
2. Tri-Vi-[**Male First Name (un) **] daily
Car seat test was passed yesterday on [**2174-9-21**].
Newborn screen was normal on [**2174-8-31**]. The patient
received hepatitis B vaccine on [**2174-8-29**].
Immunizations recommended are as follows:
1. Synagis RSV prophylaxis is recommended from [**Month (only) **]
through [**Month (only) 958**] as [**Known lastname **] was [**Known lastname **] at less than 32
weeks gestation. Influenza immunization is recommended
annually in the Fall for infants once they reach 6 months
of age. In addition, it is recommended that all care
providers receive the influenza vaccine.
DISCHARGE DIAGNOSIS:
1. Prematurity
2. Sepsis ruled out
3. Right neck - submandibular capillary hemangioma
4. Status post hyperbilirubinemia requiring phototherapy.
5. Apnea of prematurity
6. Abnormal head ultrasound, Grade 1 IVH and periventricular
white matter echolucency.
Discharge weight was 3.040 kilos at a corrected gestational
age of 37 weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern4) 55751**]
MEDQUIST36
D: [**2174-9-22**] 11:20:13
T: [**2174-9-22**] 12:49:17
Job#: [**Job Number 64231**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3339
} | Medical Text: Admission Date: [**2176-6-13**] Discharge Date: [**2176-6-15**]
Date of Birth: [**2111-5-9**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization s/p drug-eluting stent to LAD
History of Present Illness:
65 F with pmh of DL p/w chest pain.
patient was in USOH until ~ 945pm on the day of admission. She
even walked the streets of [**Location (un) **] the prior week. Never any
history of chest pain, pressure, nausea, indigestion. Watching
TV, had burning, non-radiating, stuttering SS CP. Called 911,
went upstairs, took 81mg of ASA and 20 mg of Atorvastatin.
En route, at 2146, mild STE in [**Last Name (LF) 1291**], [**First Name3 (LF) **] STE in V1-V3, STD in
II. At 2200, only marginal STE in V2. At 2215, original pattern
reccurred.
In the ED, p/w HR80 BP 160/80. Received 600 mg Plavix, Heparin
gtt, Nitro gtt, morphine, zofran. Presenting trop is 0.02. In
the lab at 1058, maintained on IV heparin (1100/hr), NTG
(20mcg/hr), Bivalrudin. Received bolus Nicardipine (200mcg), NTG
(200mch) and Fent (25 mcg) received PROMUS DES to 90% LAD
lesion. Also had several discrete tight LCX lesions with 30%
lesions in RCA. No integrillin. Post-cath EKG with TWFlattening
in III, aVF and V2.
In the CCU, patient is pleasant and symptom free.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. 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:
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
- Chronic Cough with spirometry WNL as of [**11/2174**]
- Postnasal drip
- possibly treated for HTN in
Social History:
She is a widow. Her husband died approximately 20 years ago.
She
lives alone. She works as a travel [**Doctor Last Name 360**]. She does not have
any
animals in her home. She quit smoking 32 years ago. She rarely
drinks alcohol. She knows of no asbestos or TB exposure.
Family History:
Her family history is notable for a mother dying at age 85 of
heart disease. Her father died of myocardial infarction when he
was 52. Her brother had coronary artery disease status post 4
vessel CABG
Physical Exam:
Admission Exam
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. No obvious hematoma
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2176-6-13**] 10:14PM BLOOD WBC-8.6 RBC-4.33 Hgb-13.9 Hct-38.0 MCV-88
MCH-32.1* MCHC-36.5* RDW-13.5 Plt Ct-198
[**2176-6-15**] 06:30AM BLOOD WBC-6.7 RBC-4.17* Hgb-12.7 Hct-37.0
MCV-89 MCH-30.6 MCHC-34.4 RDW-13.7 Plt Ct-167
[**2176-6-13**] 10:14PM BLOOD Glucose-124* UreaN-24* Creat-0.8 Na-140
K-4.2 Cl-103 HCO3-22 AnGap-19
[**2176-6-15**] 06:30AM BLOOD Glucose-105* UreaN-20 Creat-1.0 Na-143
K-4.4 Cl-105 HCO3-27 AnGap-15
[**2176-6-13**] 10:14PM BLOOD cTropnT-0.02*
[**2176-6-14**] 11:14PM BLOOD CK-MB-9 cTropnT-0.24*
[**2176-6-15**] 06:30AM BLOOD CK-MB-7 cTropnT-0.17*
[**2176-6-14**] 12:16AM BLOOD %HbA1c-5.6 eAG-114
Cardiac Cath ([**2176-6-13**])
95% Prox LAD lesion, significant LCx and 30% RCA's. s/p DES to
LAD
TTE ([**2176-6-14**])
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with fcal
hypokinesis of the mid septum and distal inferior walls. The
remaining segments contract normally (LVEF = 55 %). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction c/w CAD. Mild mitral
regurgitation.
Brief Hospital Course:
65 female with Anterior STEMI
1. CAD: Patient with proximal LAD thrombus, 50% LMCA, and
significant LCx disease. She received DES to the culprit LAD
lesion and plan to medically manage the remaining lesions. Her
aspirin was increased to 325 mg po qdaily. She was started on
plavix 150 mg PO daily for 7 days followed by 75 mg daily for at
least one year thereafter. She was also started on lisinopril 5
mg po qdaily, metoprolol succinate 25 mg po qdaily and
atorvastatin 80 mg po qdaily. She was given phone numbers to
set up appointment with her future cardiologist.
2. questionable history of HTN: She is currently on
cardioprotective antihypertensives which can be adjusted per her
cardiologist or PCP
3. Dyslipidemia: Atorvastatin 80 mg po qdaily per PROVE IT
trial. Can be adjusted per her cardiologist or PCP in the
future.
4. Chronic cough: Continued on home omeprazole, mucinex and
fluticasone.
Medications on Admission:
Aspirin 81 mg daily
ATORVASTATIN [LIPITOR] - 20 mg Tablet qd
GUAIFENESIN [MUCINEX] - 600 mg x 2 [**Hospital1 **]
.
Historical meds
FLUTICASONE - 50 mcg Spray IN [**Hospital1 **]
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE - 20 mg Capsule
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
2. clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 5 days.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): 2 tablets per day for 5 days, then 1 tablet per day for
at least 1 year.
Disp:*90 Tablet(s)* Refills:*2*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
7. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain.
Disp:*30 tablets* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ST elevation myocardial infarction
.
Secondary:
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for a heart attack (an
ST-elevation MI) and went directly to the catheterization lab
where a stent was placed in one of your coronary arteries - your
left anterior descending artery. Your EKG and cardiac enzymes
after the cath procedure were all improved. We changed several
of your medications to help improve your heart health. The most
important medications are aspirin and Plavix - these medications
will help keep your stent patent. Take Plavix every day and do
not stop the medication unless directed by your cardiologist. It
will be important for you to watch your diet and to exercise to
prevent a second heart attack.
.
We made the following changes to your medications:
We INCREASED Aspirin to 325 mg per day
We INCREASED Atorvastatin to 80 mg per day
We STARTED Plavix - 150 mg for the next 5 days, then 75 mg per
day for at least 1 year
We STARTED Lisinopril 5 mg per day
We STARTED Metoprolol Succinate 25 mg per day
Sublingual nitroglycerin 0.4 mg as needed for chest pain. Please
call your cardiologist office as well.
.
The information for follow-up is listed below.
Followup Instructions:
It will be important for you to have a cardiologist. The
cardiologist who performed your catheterization was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. To set up an appointment with him, please call
[**Telephone/Fax (1) 1942**]. If you choose to see a cardiologist closer to
home, one recommendation is Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital1 **]- [**Location (un) 620**]. Her
office # is [**Telephone/Fax (1) 4105**].
.
You should also call Dr.[**Name (NI) 41811**] office to make an appointment
to see her this week so that she is up to date about your recent
hospitalization and medication changes.
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3340
} | Medical Text: Admission Date: [**2110-3-29**] Discharge Date: [**2110-4-8**]
Service: NEUROLOGY
Allergies:
Benadryl
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
84 year-old right-handed man with a history of hypertension,
long-standing diabetes, and atrial fibrillation (not on
anti-coagulation or anti-platelet therapy due to a history of
gastrointestinal bleeding), and chronic kidney disease
(creatinine baseline ~[**1-14**]) who presented earlier today after a
fall with left hip pain; a code stroke was called at 8:13 pm,
after concern for a right MCA infarction on CT of the head.
According to the patient's daughter, with whom I discussed the
case over the phone, the patient was in his usual state of
health until awakening this morning. At that time, he reported
difficulty seeing multiple objects in the kitchen, including a
kettle on the stove as well as a cup. He did not further
describe the character of the vision loss. His daughter thought
that this was unusual in a well-lit room, but attributed the
difficulties from recently awakening, transitioning from the
dark to light. He did not have any clear weakness, difficulty
with speaking or comprehension. He has chronic tingling in his
fingers related to diabetes, though no new sensory changes.
At approximately 2 pm, he tripped over a cord as he walked from
the kitchen, and fell forward. He was able to break his fall
with his hands on a nearby table before landing on the floor of
the study. There was no observed head trauma nor loss of
consciousness. He reported pain in the left hip and was taken
to [**Hospital1 18**] for further evaluation. Once at [**Hospital1 18**], the patient
underwent a trauma evaluation for his fall. He was reporting
pain and given 4 mg of morphine at 5:55 pm for his discomfort,
then 50 mg bendadryl at 6:04 pm for subsequent itchiness. An
attempt to perform CT scan was made around this time (~6 pm),
but the patient was sent back as he was becoming increasingly
confused and unable to sit still. He subsequently received 1 mg
of lorazepam at 6:42 pm, then developed apneic periods for
~10-15 seconds at a time over a period of 20 minutes, by ED
report. He received the CT of the head at 7:45 pm and a code
stroke was called at 8:13 pm after a preliminary read of a right
middle cerebral artery stroke.
Review of Systems:
Unable to obtain at this time due to confusional state.
Past Medical History:
Chronic Systolic CHF - Echo [**3-20**] with EF 25%
Hypertension
Dyslipidemia
Afib not on Coumadin
CKD IV, baseline 2.1-2.5, sees Dr. [**Last Name (STitle) 4883**]
Anemia - likely mixed, CKD and Iron Deficiency, baseline 35-39
DM, on insulin, hgb A1c 9.2 [**3-20**]
Gastritis
- hematemesis [**2109-7-12**]. EGD with antral erosions, small AVM in
duodenum
- colonoscopy [**12/2108**] with single sessile 2 mm polyp of benign
appearance in the proximal transverse colon (not removed [**1-13**]
bleeding risk)
Prior Tobacco use
Osteoarthritis
Prostate Cancer s/p prostatectomy
Urinary incontinence
Social History:
Widowed and lives with his daughter [**Name (NI) 12469**], who is his health
care proxy. Former [**Name2 (NI) 1818**], smoked 1-2 packs daily for ~40 years.
Previously drank one shot of whiskey daily. No known history of
illicit drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T 98.6 F BP 133/75 P 84 RR 14 SaO2 100 RA
General: Thin, elderly gentleman - mildly deshevelved appearing.
[**Name2 (NI) 4459**]: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Lungs: clear to auscultation
CV: irregularly irregular, no MMRG
Abdomen: soft, non-tender, non-distended
Ext: dry, no edema, pedal pulses appreciated
An NIHSS could not be performed due to the patient's confusional
state
Neurologic Examination:
Mental Status:
Alert and oriented to place and self. Mildly dysarthric speech
but fluent. Follows commands.
Cranial Nerves:
Fundi difficult to visualize bilaterally; inconsistent blink to
threat on either side. Pupils equally round and reactive to
light, 3 to 2.5 mm bilaterally. Eyes move to the left and
right, but no gaze deviation. Corneals intact bilaterally, and
face appears grossly symmetric. Tongue midline and palate
elevated evenly.
Sensorimotor:
Normal bulk throughout, though tone is difficult to assess given
active movement. No tremor. He had mild L pronator drift but
full strength otherwise.
Reflexes: B T Br Pa Pl
Right 2 2 2 2 0
Left 2 2 2 2 0
Left toe upgoing, right toe downgoing.
Coordination and gait: Mild dysmetria with FTF more on L likely
reflecting weakness. Ambulatory with minimal assistance.
Pertinent Results:
[**2110-4-8**] 06:00AM BLOOD WBC-5.5 RBC-4.39* Hgb-12.1* Hct-37.6*
MCV-86 MCH-27.5 MCHC-32.1 RDW-17.3* Plt Ct-163
[**2110-4-8**] 06:00AM BLOOD PT-18.3* PTT-36.1* INR(PT)-1.7*
[**2110-4-8**] 06:00AM BLOOD Glucose-107* UreaN-32* Creat-2.2* Na-141
K-3.9 Cl-102 HCO3-26 AnGap-17
[**2110-3-29**] 05:55PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2110-3-30**] 07:45AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2110-4-8**] 06:00AM BLOOD Calcium-9.4 Phos-2.6* Mg-2.0
[**2110-3-29**] 05:55PM BLOOD calTIBC-399 Ferritn-55 TRF-307
[**2110-3-30**] 07:45AM BLOOD %HbA1c-9.7*
[**2110-3-30**] 07:45AM BLOOD Triglyc-49 HDL-52 CHOL/HD-2.0 LDLcalc-40
[**2110-4-1**] 04:40AM BLOOD Ammonia-73*
[**2110-3-29**] 05:55PM BLOOD TSH-1.5
[**2110-4-4**] 05:20PM BLOOD PEP-POLYCLONAL IgG-1334 IgA-385 IgM-252*
HEAD CT [**3-29**]:
1. Acute infarct of the distal right MCA (M3) distribution.
Regional sulcal effacement without midline shift. No
intracranial hemorrhage at this time.
2. Left frontal arachnoid cyst, unchanged.
Carotid US [**3-31**]:
No evidence of internal carotid artery stenosis in their
extracranial portion.
Renal US [**3-31**]:
1. No evidence of hydronephrosis.
2. Small amount of ascites.
MRI HEAD [**3-31**]:
1. Right MCA, superior division, acute infarct.
2. Chronic small vessel ischemic disease.
3. No evidence of intracranial hemorrhage.
Echocardiogram [**4-2**]:
The left atrium is elongated. The estimated right atrial
pressure is 10-20mmHg.There is moderate symmetric left
ventricular hypertrophy with normal cavity size and severe
global hypokinesis (LVEF = 20-25 %). No masses or thrombi are
seen in the left ventricle. The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. The
ascending and descending thoracic aorta are 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 structurally normal. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2109-7-16**],
left ventricular systolic function is less vigorous. In the
absence of a history of marked hypertension, the findings are
suggestive of an infiltrative process (e.g., amyloid, Fabry's
etc.)
Brief Hospital Course:
84 year-old right-handed man with a history of hypertension,
long-standing diabetes, and atrial fibrillation (not on
anti-coagulation or anti-platelet therapy due to a history of
gastrointestinal bleeding), presented to ED after a fall and
left hip pain. Code stroke was called after a head CT
concerning for R MCA infarct and his
examination was limited, given an acute confusional state with
left upgoing toe is the only clear localizing finding at the
time. He was out of the window for intervention and vessel
imaging and contrast studies were risky given his degree of
renal failure.
Patient was admitted to neurology service and he underwent
pelvis study to rule out hip fracture and renal US to rule out
renal obstruction. His left lower back pain most likely spasm
s/p fall since he responded very well to small dose Valium and
analgesics.
Although, he initially was quite confused, he improved
significantly with near full strength on his left side except
for mild left facial, left pronator drift and some dysarthria.
He was evaluted per PT/OT who recommended home PT/OT and VNA
services plus speech recommended regular diet if he has his
dentures.
Given that patient has Afib and this is most likely
cardioembolic stroke given the risk factors, GI was consulted
about his hx of gastritis and possible duodenal AVM. GI
recommended colonoscopy for risk stratification - bowel prep was
extremely difficult. He has hx of several failed colonoscopies
in the past due to poor prep. After several days of clear diet
and several rounds of golytely, he underwent colonoscopy on [**4-7**]
which showed a few polyps but no contra-indication for
anticoagulation hence he was started on Coumadin with [**Month/Year (2) **]
bridging ([**Month/Year (2) **] to be stopped once INR therapeutic between 2~3).
His INR will be followed up per Dr. [**Last Name (STitle) 8499**], PCP.
Also, given his CHF hx and Afib, cardiology was also consulted
who recommended changing Coreg to Metoprolol since it is less
hypotensive and he was instructed to restart low dose ACEI per
PCP as outpatient. He had repeat echocardiogram that showed
even more reduced EF of 20~25% and signs of infiltrative disease
hence SPEP and UPEP were checked that appeared within normal
range. He will be following up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] at the
heart failure clinic.
Patient was discharged home with home PT/OT and VNA services
plus follow-up appointments with his healthcare providers
including Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] for neurology.
Medications on Admission:
-Lipitor 10 mg daily
-Calcitriol 0.25 mcg daily
-Colchicine 0.6 mg Tablet daily
-Aranesp 40 mcg/0.4 mL Syringe SQ weekly
-Fluticasone 50 mcg spray, 1 puff each nostril daily
-Lasix 120 mg [**Hospital1 **]
-Insulin aspart: Take 8 units when blood sugar over 150 before
supper once a day
-Insulin detemir: Take 50 units SC once a day at supper
-Metalozone 2.5 mg daily in am if weight 165 and over as needed
for for swelling
-Nitroglycerin 0.1 mg/hour Patch 24 hr apply at night, remove
in once daily in am
-Protonix 40 mg daily
-Potassium chloride 20 mEq daily
-Diovan 40 mg daily
-Acetaminophen 325 mg TID as needed for fever, pain
-Ferrous sulfate 325 mg [**Hospital1 **]
-Artificial tears one drop QID, bilaterally
-Senna/colace [**Hospital1 **], as needed for constipation
Discharge Medications:
1. Outpatient Lab Work
Please draw an INR this every Monday, Wednesday and [**Hospital1 2974**] until
told otherwise per Dr. [**Last Name (STitle) 8499**]. Fax results to [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) 8499**] [**Location **]Health Ctr, [**Hospital1 7977**],
[**Location (un) 686**], [**Numeric Identifier 12477**]
Phone: ([**Telephone/Fax (1) 2535**]
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
6. Nitroglycerin 0.1 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Telephone/Fax (1) **]:*60 Capsule(s)* Refills:*2*
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please stop once INR therapeutic (2~3).
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*2*
9. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-[**Telephone/Fax (1) 2974**]).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
[**Telephone/Fax (1) **]:*60 Tablet(s)* Refills:*2*
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily) as
needed for hold if SBP < 100 or HR < 55.
[**Telephone/Fax (1) **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Insulin Glargine 100 unit/mL Cartridge Sig: One (1)
Subcutaneous at bedtime: Please take 25 units at bedtime.
[**Telephone/Fax (1) **]:*8 cartridge* Refills:*2*
13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust the dose per Dr. [**Last Name (STitle) 8499**] with goal INR 2~3 and
please take Coumadin between 4~6pm every day. You will need
frequent INR checks while on Coumadin.
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
primary diagnoses:
right middle cerebral artery cardioembolic stroke
uncontrolled diabetes mellitus (A1C 9.7)
systolic congestive heart failure (EF 20-25%)
left lower back strain
secondary diagnoses:
atrial fibrillation
chronic renal insufficiency
mildly elevated ammonia
hypertension
anemia, secondary to iron deficiency and chronic kidney disease
Discharge Condition:
mild left sided neglect with mild left facial droop
Discharge Instructions:
You were admitted with a right middle cerebral artery territory
stroke that was likely cardioembolic. On echocardiogram, you
were found to be in worsened congestive heart failure (EF
20-25%) and were seen by cardiology who recommended that you
follow-up in heart failure clinic as an outpatient. Because of
atrial fibrillation, stroke and heart failutre, you were started
on a blood thinning medication called Warfarin which will need
close blood checks after undergoing colonoscopy to assess for
gastro-intestinal bleeding risk.
You have been evaluated and treated per occupational and
physical therapy during this admission who recommend discharge
to home under the care of your daughter with home PT/OT and VNA
services.
You will need to follow-up with your primary care physician this
coming Tuesday, [**4-8**] at 12:15pm where he will check your INR
(goal [**1-14**]) and adjust your Warfarin dose accordingly. You will
likely need your INR blood level checked at least twice or
thrice weekly until your PCP instructs you otherwise.
Please take medications as prescribed.
Please keep follow-up appointments with all your health care
providers.
Given your heart failure and low ejection fraction, please weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Also please
adhere to 2 gm sodium diet and fluid restriction: 1.5 liters
Please call your PCP [**Last Name (NamePattern4) **] 911 if you have new weakness/numbness,
visual problems including transient blindness and/or speech
problems including slurring of speech.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2110-4-9**] 3:00 PM
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2110-4-9**] 9:30
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2110-4-15**] 2:00
[**First Name8 (NamePattern2) **] [**Doctor Last Name **] (neurology) [**2110-5-14**] 2:30 PM [**Hospital Ward Name 23**] Clinical Center
[**Location (un) 858**]
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] (cardiology - heart failure clinic) [**2110-5-19**] 1:00 PM
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2110-4-13**]
ICD9 Codes: 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3341
} | Medical Text: Admission Date: [**2169-1-30**] Discharge Date: [**2169-2-13**]
Date of Birth: [**2102-5-21**] Sex: F
Service: Vascular
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: The patient underwent an
abdominal computed tomography for anticipation for
intravascular abdominal aortic repair and determined she was
not a candidate. She is now admitted for open abdominal
aortic iliac aneurysm repair.
An outside cardiac workup included a cardiac catheterization
for a positive stress test. She underwent cardiac
catheterization and a angioplasty with stent placement of the
circumflex artery on [**2168-12-30**]. She now returns for
elective revascularization.
PAST MEDICAL HISTORY:
1. History of cerebrovascular accident in [**2167-11-5**];
which presented with left-sided weakness (from which she has
recovered).
2. Abdominal aortic aneurysm since [**2167-11-5**].
3. History of coronary artery disease; status post silent
myocardial infarction by electrocardiogram.
4. Atrophic left kidney.
5. Echocardiogram on [**2168-10-10**] demonstrated a left
ventricular hypertrophy with infrabasilar hypokinesis and an
ejection fraction of 45%, with moderate mitral regurgitation,
left atrial enlargement, and inferobasilar aneurysm.
6. Type III aortic dissection; treated medically.
7. Questionable renal artery stenosis.
8. Chronic obstructive pulmonary disease; on home oxygen as
needed.
9. Hypertension.
10. Diverticulosis.
11. Rectal polyps.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Sublingual nitroglycerin as needed.
3. Imdur 60 mg p.o. b.i.d.
4. Prilosec 20 mg p.o. q.d.
5. Lipitor 20 mg p.o. q.d.
6. Verapamil-SR 240 mg p.o. q.d.
7. Hydralazine 150 mg p.o. b.i.d.
8. Potassium chloride 20 mEq p.o. q.d.
9. Albuterol inhaler 2 puffs q.i.d.
10. Celexa 10 mg p.o. q.d.
SOCIAL HISTORY: The patient is a widow. She lives in [**Location 11269**]
with her three sons.
RADIOLOGY/IMAGING: A Duplex of the carotids showed moderate
plaque in both carotids bilaterally, but no hemodynamically
significant lesions.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area on [**2169-1-30**]. She underwent
aortobifemoral bypass surgery with [**Hospital1 **]-iliac artery ligation.
The patient tolerated the procedure well. She required 4
units of packed red blood cells intraoperatively with 200 cc
of cellsaver. An epidural catheter was placed
intraoperatively for postoperative analgesic control.
The patient was transferred to the Postanesthesia Care Unit
in stable condition. She was transferred to the Vascular
Intensive Care Unit for continued monitoring and care.
On postoperative day one, there were low oxygen saturations
with blood gas results of 7.31/43/56/23/-4. X-ray results
congestive failure. The patient's hematocrit was 30.6.
Blood urea nitrogen was 26. Creatinine was 1.7.
The Renal Service was consulted on postoperative day two
because of increasing creatinine. It was felt this patient's
oliguria was prerenal in origin secondary to hypertension
intraoperative and a singular functioning kidney. Their
recommendations were to check eosinophils, C3-C4 compliments.
A renal ultrasound with Doppler to rule out obstructive
disease. Keep systolic blood pressure between 120s and 130s.
Keep hematocrit greater than 30. No nonsteroidals, ACE
inhibitors, or angiotensin receptor blockers until resolution
of elevated creatinine and return of normal urine volume.
Medicines for creatinine clearance of 20 to 30. The
patient's oxygen saturation continued to remain in the 80s
and 90s with albuterol nebulizers and nonrebreather at 6
liters. Questionable congestive heart failure. The
peripheral arterial line was discontinued. An oxygen wean
was begun, and she was diuresed. She remained in the
Vascular Intensive Care Unit for continued pulmonary care and
monitoring. The epidural was discontinued, and oral
analgesics were begun.
By postoperative day four, the patient was passing flatus.
her diet was advanced to clear liquids. Her hematocrit
drifted to 27.8 (down from 29). Her creatinine showed
improvement from 2 to 1.9 with a blood urea nitrogen of 35.
There was improvement in her oxygenation. Intravenous Lasix
dosing was decreased from 100 mg intravenously q.6h. to 100
mg intravenously q.12h with a fluid restriction to one liter
per day. Her free water deficit equaled two liters allow the
patient to drink to thirst. Replace potassium and magnesium.
Physical Therapy saw the patient and felt that she would
require rehabilitation status post discharge.
By postoperative day four, her creatinine was back to
baseline of 1.6. Her hematocrit remained stable at 29.2.
She was tolerating oral intake. Her lines were discontinued
and was transferred to the regular nursing floor. The
[**Hospital 228**] transfer to the floor was delayed because of
respiratory status. Arterial blood gas results were
7.54/33/125/29 and 6. Aggressive diuresis continued and
aggressive pulmonary care was continued. Her Lasix dosing
was decreased to 80 mg intravenously, and this was converted
to 40 mg p.o. b.i.d. Recommendations from the Renal Service
were to keep her on -500,000 cc daily. The Renal Service
signed off. The patient continued to show excellent
diuresis. Her hematocrit was 32.6. Blood urea nitrogen was
26. Creatinine was 1.1.
The patient was transferred to the Trauma Surgical Intensive
Care Unit on [**2169-2-8**] for continued poor oxygenation.
Aggressive pulmonary care was continued. The patient was
nothing by mouth. She was continued on Levaquin and Flagyl.
An arterial line was placed.
Over the next 48 hours, the patient remained in the Surgical
Intensive Care Unit for continued pulmonary monitoring, and
she was transferred to the regular nursing floor on [**2169-2-9**]. Her creatinine was 1.7. Blood urea nitrogen was
37. Hematocrit was 29.6.
The patient's creatine phosphokinases and troponin levels
were flat. Electrocardiogram was without changes. She was
continued on Unasyn for questionable pneumonia.
The Renal Service was consulted again on [**2169-2-9**].
Their recommendations were to continue to hold her diuretics
for prerenal azotemia. The nephropathy secondary to contrast
had resolved, and treat her hyponatremia secondary to free
water loss and diuretics with D-5-W at 100 cc per hour times
24 hours.
The Pulmonary Service was consulted regarding the patient's
pulmonary status. Their recommendations were to begin
ambulation to chair with Physical Therapy and Occupational
Therapy. Consider studies for rule out pulmonary embolus.
Keep her oxygen saturations at no greater than 93%.
The patient was returned to the Vascular Intensive Care Unit
from the Surgical Intensive Care Unit on postoperative day 11
(which was [**2169-2-10**]) for pulmonary embolism. A
computed tomography of the chest was obtained which showed
thoracic aortic dissection and aneurysmal dilatation which
extended to the MH portion of the intra-abdominal aorta.
This was consistent with the patient's known of aortic
aneurysm. The left lobe was noted to be collapsed. This
could be related to mucous plug or other obstructive process
correlating with the patient's clinical examination. It
should be noted that patchy peripheral opacities were noted;
mostly in the left upper lobe which were secondary to an
acute inflammatory process.
The patient continued to show slow progressive improvement in
her pulmonary status. She was transferred to the regular
nursing floor on [**2169-2-12**].
The computed tomography, per the Pulmonary Service,
determined the etiology of her hypoxia were related to both
her underlying chronic obstructive pulmonary disease and her
lower lobe changes, and it was most imperative that the
patient do incentive spirometry and aggressive physical
therapy. If the left lower lobe does not open up with these
measures, then would have to consider a bronchoscopy.
DISCHARGE DISPOSITION: By postoperative day fourteen, the
patient continued to show improvement and stabilization of
her respiratory function. Her skin clips were removed, and
the patient was discharged to home. The patient was to
follow up with Dr. [**Last Name (STitle) 1391**] in his clinic in [**Location (un) **].
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Verapamil-SR 240 mg p.o. q.d.
2. Protonix 40 mg p.o. q.d. (times one month).
3. Acetaminophen 325 mg to 650 mg p.o. q.4-6h. as needed
(for pain).
4. Metoprolol 50 mg p.o. t.i.d.
DISCHARGE DIAGNOSES:
1. Abdominal aortic aneurysm with extension to iliac.
2. Status post aortobifemoral bilateral iliac ligation.
3. Respiratory failure secondary to atelectasis and
underlying chronic obstructive pulmonary disease; corrected.
4. Coronary artery disease; stable.
5. Chronic renal insufficiency compounded by secondarily
contrast-induced acute tubular necrosis; resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2169-2-13**] 09:52
T: [**2169-2-13**] 09:55
JOB#: [**Job Number 47275**]
ICD9 Codes: 5845, 5185, 4280, 5180, 2760, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3342
} | Medical Text: Unit No: [**Numeric Identifier 70902**]
Admission Date: [**2134-3-4**]
Discharge Date: [**2134-4-4**]
Date of Birth: [**2134-3-4**]
Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 70899**] is a 34 and [**2-14**]
week, 2520 gram female newborn who was admitted to the
neonatal intensive care unit for management of prematurity.
The infant was born to a 37-year-old gravida [**Month/Day (4) 1105**], para II,
now [**Name (NI) 1105**] mother with prenatal screens blood type O positive,
antibody negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, group B strep status unknown.
[**Hospital 37544**] medical history of asthma maintained on albuterol
and Flovent. Other maternal medications include prenatal
vitamins. Previous pregnancies resulted in 2 full term
infants in [**2125**], and [**2126**]. This pregnancy was complicated by
pregnancy induced hypertension beginning around 28 weeks
gestation. Preeclampsia laboratory monitoring without
concerns. Maternal fetal medicine involved in care and mother
underwent close monitoring with a nonstress test and
biophysical profiles. About 1 week history of nonreactive
nonstress test but this would be followed by reactivity. A
betamethasone was complete on [**2-26**]. Today's monitoring
revealed a biophysical profile of 8 out of 8 and AFI of 29
(polyhydramnios), and MCA Doppler flow of 1.5. There was
increased MCA flow that prompted decision for delivery. Of
additional note, father reported a viral like illness in mom
approximately 3 weeks prior to delivery. Dr. [**Last Name (STitle) **] informed
the neonatal intensive care unit team at delivery that CMV,
toxo and Parvovirus titers were all negative. The remainder
of the family history is noncontributory. Delivery of this
infant was by cesarean section for nonreassuring fetal heart
tracing. Mother received spinal anesthesia. Positive meconium
stained amniotic fluid. Apgar scores were 8 at one and 9 at
five minutes of age, respectively.
PHYSICAL EXAMINATION: Birth weight was 2520 grams greater
than 75th percentile, length 46 cm, 50th to 75th percentile,
head circumference 31.5 cm, 50th percentile. Pink well
appearing infant in no acute distress. Anterior fontanelle
soft and flat. Difficulty with keeping eyes open to assess
red reflex. Ears normal set, dull slightly edematous. Intact
palate. Good suck. Neck supple. Intact clavicles. Lungs
slightly coarse bilaterally but good and equal aeration.
Heart regular rate and rhythm, no murmurs, +2 femoral pulses.
Abdomen soft, positive bowel sounds, no hepatosplenomegaly, 3
vessel cord, meconium stained. GU: Normal preterm female.
Patent anus. No sacral anomalies. Hips stable. Extremities
pink and well perfused. At delivery, extremities felt
slightly taunt and edematous though currently appear
improved.
HOSPITAL COURSE: Respiratory: The infant has been in room
air for her entire newborn intensive care unit admission. She
has not required any supplemental oxygen and has not had any
notable apnea of prematurity.
Cardiovascular: The infant's blood pressure has been stable
throughout her hospitalization. No murmurs have been
auscultated. Heart rate has been consistently in the 120 to
160 range.
Fluid, electrolytes and nutrition: At the time of admission
to the newborn intensive care unit, the infant was started on
IV fluids of D10W at 80 cc/kilo/day by way of peripheral IV.
Her initial D-sticks were 20 and 36 and she did receive 2 D10
boluses for these hypoglycemic events. The infant remained
NPO and it was noted on day of life 2 that her stools
contained frank blood. KUB was done at this time and found to
be nonspecific. She continued to have KUBs every 4-6 hours
which continued to be nonspecific in appearance. On day of
life 3, her repogle tube was placed and put to low continuous
suction. She has remained NPO receiving PN and Intralipid
well at peripheral IV. Of note, from day of life 5 to day of
life 7, it was noted that her repogle tube output had
increased from 5 to 12 cc of very dark green bilious drainage
and an abdominal ultrasound was obtained on [**3-11**], which
showed normal placement of mesenteric arteries with no
malrotation. On [**3-12**], the infant was transferred to
[**Hospital3 1810**] for Broviac placement and upper GI and a
small bowel follow through which were read as normal. The
infant was medically treated for necrotizing enterocolitis.
She completed her 14 days of bowel rest with 14 days of Zosyn.
On day of life 17, enteral feeds began of Nutramigen 20
calories and, on day of life 22, full enteral feeds of 150
kilo/day of breast milk. She is currently feeding adlib
amounts of expressed breastmilk made up to 24 calories with
Neosure powder. Calories were added for poor weight gain on 20
cal breastmilk.
Gastrointestinal: Peak bilirubin on day of life 3 was
5.4/0.3. She has not required any phototherapy.
Hematology: This infant's blood type is not known at this
time. She has not received any blood products during her stay
in the newborn intensive care unit.
Infectious disease: Upon admission to the newborn intensive
care unit, CBC with differential and blood cultures were
drawn. White blood cell initially 36.3 with a hematocrit of
40.4 with 49 polys, 2% bands, and a platelet count of
483,000. She was placed on ampicillin and gentamicin upon
admission to the newborn intensive care unit. A repeat white
count on day of life 2 was 33 with 50% polys and 3% bands.
Given her presentation of bloody stool on day of life 2, it
was decided to treat her with a course of antibiotics. On day
of life 4, she was switched from ampicillin and gentamicin to
Zosyn and the infant completed her 14 day course. Stool
cultures were also sent on day of life 4 for salmonella,
shigella, C. Difficile and all those cultures are negative.
Neurology: Head ultrasound is not indicated for this 34 and
[**2-14**] weeker.
Sensory: Audiology screening pending.
Ophthalmology examination is not indicated at this
gestational age.
Immunizations: Hepatitis B on [**2134-3-26**].
State newborn screening: The first State newborn
screening was sent at 72 hours of age. Results came back
on [**3-18**], of slightly elevated for PKU and this was
thought to be secondary to the TPN. Repeat
State newborn screen status sent on [**3-29**], and
results were normal.
F/U at [**Location (un) 2274**]/CAM, Dr. [**Last Name (STitle) 21615**] within in 5
days of discharge.
VNA to come to home day post discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and [**2-14**] week gestation.
2. Rule out sepsis.
3. Rule out necrotizing colitis.
4. Rule out gastrointestinal obstruction.
F/U at [**Location (un) 2274**]/CAM, Dr. [**Last Name (STitle) 70903**] within 5 days of discharge. VNA
to go to home day post discharge.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) 67981**]
MEDQUIST36
D: [**2134-4-1**] 16:17:05
T: [**2134-4-1**] 19:17:16
Job#: [**Job Number 70904**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3343
} | Medical Text: Admission Date: [**2109-1-2**] Discharge Date: [**2109-1-5**]
Date of Birth: [**2077-9-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
31 year old previously healthy male was seen at the office of
his PCP today for complaint of melena (black stools),
lightheadedness and mild ?coffee ground emesis. Patient states
he woke up on Sunday at 3am and had an episode of dark brown
emesis; given that he had just had BBQ for dinner, he was unsure
of the significance. The following morning, he had a solid
black, foul smelling, formed but slightly soft bowel movement.
He did not have any abdominal cramping but did have some
discomfort, so he started taking Pepto Bismo. The patient
proceeded to have two more episodes of tarry black stools on
Tuesday morning prior to going to his PCP's office. Throughout
Tuesday, he felt light headed and short of breath with mild
chest pressure when exerting himself (ex: walking up stairs to
his apartment). Labs at his PCP's office showed hemoglobin 7.6
and hematocrit 22.6. Patient was advised to come to the ER for
further work-up and management. Of note, patient denies
significant alcohol, NSAID, coffee consumption; also denies
significant retching with episode of emesis on Sunday or
significant history of GERD.
.
In the ED, patient was tachycardic to 110 although abdominal
exam was benign; patient was complaining of exertional chest
pressure/shortness of breath but cardiac enzymes were negative
X1. On rectal exam, no bright red blood or tarry stools were
found in the rectal vault but patient was guaiac positive. NG
lavage was performed which yielded coffee ground emesis that
would not clear after 400cc, no bright red emesis was noted.
Patient was given 1L intravenous fluid boluses and transfused 2
units of pRBC, type and crossed for 4 units. Two 18 gauge
peripheral IVs were placed and intravenous PPI started. GI was
informed of the patient and plans to do EGD in the morning
unless the patient is still tachycardic. VS upon transfer: were
afebrile, heart rate 102, BP126/65, RR20, 100%RA.
.
Upon arrival to the ICU, patient was resting comfortably in bed.
He denies current light headedness, chest pressure or shortness
of breath.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denies coughor
wheezing. Denies chest pain, palpitations, or weakness. Denies
nausea, diarrhea, constipation, abdominal pain. Denies dysuria,
frequency, or urgency.
Past Medical History:
Bilateral ankle fractures
Social History:
Social History: Third year law student at [**University/College 86617**]T - Denies
A - [**1-24**] drinks every other weekend
D - Denies illicit drug use
Family History:
Diabetes Mellitus, no history of Peptic Ulcer Disease or
malignancies
.
Physical Exam:
Vitals: T: Afebrile BP: 156/84 P: 109 R: 18 O2: 98% RA
General: Alert, oriented, no acute distress, well-nourished
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2109-1-1**] 10:05PM BLOOD WBC-11.4* RBC-2.21* Hgb-6.2* Hct-18.5*
MCV-84 MCH-27.6 MCHC-33.0 RDW-15.9* Plt Ct-235
[**2109-1-1**] 10:05PM BLOOD Neuts-76* Bands-0 Lymphs-17* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-4*
[**2109-1-1**] 10:05PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2109-1-1**] 10:05PM BLOOD PT-13.5* PTT-25.0 INR(PT)-1.2*
[**2109-1-1**] 10:05PM BLOOD Ret Man-4.7*
[**2109-1-1**] 10:05PM BLOOD Glucose-109* UreaN-24* Creat-1.0 Na-137
K-4.2 Cl-105 HCO3-26 AnGap-10
[**2109-1-1**] 10:05PM BLOOD ALT-22 AST-24 LD(LDH)-176 CK(CPK)-92
AlkPhos-28* TotBili-0.2
[**2109-1-1**] 10:05PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2109-1-1**] 10:05PM BLOOD Lipase-47
[**2109-1-1**] 10:05PM BLOOD Albumin-3.4* [**Year/Month/Day **]-135
[**2109-1-1**] 10:05PM BLOOD calTIBC-289 VitB12-262 Folate-13.1
Hapto-105 Ferritn-98 TRF-222
[**2109-1-1**] 10:24PM BLOOD Glucose-108* Na-138 K-3.9 Cl-104
calHCO3-25
[**2109-1-1**] 11:12PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.019
[**2109-1-1**] 11:12PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**1-2**] HELICOBACTER PYLORI ANTIBODY TEST (Final [**2109-1-4**]):
POSITIVE BY EIA.
(Reference Range-Negative).
[**1-1**] ECG: Sinus tachycardia. Slight ST-T wave changes are
non-specific and may be within normal limits. No previous
tracing available for comparison.
[**1-2**] EGD: Old hematin was seen in the stomach. There was a very
small ulcer noted in her antrum with small clot overlying it.
This was likely the source of GI bleeding. There were also
several small erosions noted in the antrum as well as gastritis.
Erythema in the duodenal bulb compatible with duodenitis
Otherwise normal EGD to third part of the duodenum
[**2109-1-5**] 02:13AM BLOOD WBC-6.7 RBC-3.66* Hgb-10.4* Hct-31.0*
MCV-85 MCH-28.3 MCHC-33.5 RDW-17.8* Plt Ct-211
[**2109-1-5**] 02:13AM BLOOD Glucose-92 UreaN-12 Creat-1.2 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
[**2109-1-4**] 05:10AM BLOOD ALT-18 AST-20 AlkPhos-32* TotBili-1.2
[**2109-1-5**] 02:13AM BLOOD Calcium-8.9 Phos-4.8*# Mg-2.2
[**2109-1-1**] 10:05PM BLOOD calTIBC-289 VitB12-262 Folate-13.1
Hapto-105 Ferritn-98 TRF-222
[**2109-1-1**] 10:05PM BLOOD Albumin-3.4* [**Year/Month/Day **]-135
[**2109-1-2**] 09:25AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2109-1-1**] 10:05PM BLOOD Ret Man-4.7*
[**2109-1-3**] 09:47AM BLOOD Hgb A-PENDING Hgb S-PND Hgb C-PND
Brief Hospital Course:
# Melena - Patient presented with melena and Hct of 18. He
received IVF and blood transfusions support as was admitted to
the MICU. An emergent EGD was performed and this revealed an
antral ulcer, as above. The patient denied alcohol or recent
NSAID use. Adequate type and screen and IV access were
maintained. He was also started on IV PPI boluses/gtt.
Overnight, the patient's Hct had decreased to 22.6, and the GI
fellow was paged. Urgent EGD was not felt to be necessary, as
the patient's NG lavage was negative for gross hemorrhage. Once
the patient was stable and Hct was also stable he was started on
a clear diet and advanced to regular. IV PPI was changed to PO
after 3 days of therapy. H Pylori serology was sent and resulted
in a positive test. He was started on clarithromycin and
metronidazole (allergic to penicillin) and given a prescription
to finish a 2 week course of triple therapy. He received a total
of 6 PRBC transfusions.
.
# Anemia - The patient had an active GI bleed as above, but it
was unclear what his baseline hematocrit is. Hemoglobin
electropheresis was sent, but these are still pending and should
be followed up by his PCP. [**Name10 (NameIs) **] panel and hemolysis labs were
WNL and this was all felt to be secondary to GI bleed.
.
# Substernal chest pressure - Believed to be mild demand
ischemia in setting of GI bleed. EKG and cardiac enzymes within
normal limits. The patient was followed on telemetry.
.
# Leukocytosis - Mild, likely demargination in the setting of
recent GI bleeding, this resolved after treatement for acute
GIB.
.
# Code: The patient was full code for the duration of the
admission
Medications on Admission:
Occasional Centrum, Advil ~1X/week (up to 4 tabs
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 13 days.
Disp:*26 Tablet(s)* Refills:*0*
2. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 13 days.
Disp:*52 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI ulcer bleed
H. pylori
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted because you were having blood in your stool
and found to be severe anemia due to blood loss. We transfused a
total of 6 units of blood. We did an upper endoscopy and found
you had an ulcer that looked like it had recently bled. You were
started on medications to decrease the acid in your stomach. You
were also found to have a bacteria in you stomach called H.
Pylori that can cause ulcers. You were started on antibiotics
for this and should finish a 2 week course of these.
Medication changes:
START: Pantoprazole 40 mg twice a day
START: Metronidazole 500 mg twice a day for 13 days
START: Clarithromycing 500 mg twice a day for 13 days
Followup Instructions:
Appointment #1
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Internal Medicine-Primary Care
Date/ Time:
Location: [**Street Address(2) 75332**], [**Location (un) 86**] Ma
Phone number: [**Telephone/Fax (1) 644**]
Special instructions for patient: The office will call you with
an appointment for your hospitalization. If you do not here from
the office in 2 business days please call them. Thanks.
Appointment #2
MD: Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 26390**]
Specialty: Gastroenterology
Date/ Time: [**2109-1-10**] 12:40pm
Location: [**Location (un) 4363**], [**Location (un) 86**] MA
Phone number: [**Telephone/Fax (1) 2296**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3344
} | Medical Text: Admission Date: [**2123-1-27**] Discharge Date: [**2123-2-9**]
Date of Birth: [**2057-8-13**] Sex: F
Service: MEDICINE
Allergies:
Augmentin / Avelox / Plendil / metoprolol / Cefzil / clindamycin
/ lisinopril / Felodipine
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Headache, fever
Major Surgical or Invasive Procedure:
PICC line placement
Arterial Line for BP monitoring
Foley Catheter Placement
History of Present Illness:
BRIEF CLINICAL HISTORY: 65yo woman with history of CKDIII,
gastric bypass and strep endocarditis (>12 years ago) presented
with headache and fever to 103. Found to have SAH, MSSA
bacteremia, and native mitral valve endocarditis with septic
emboli to brain. SAH thought to have developed in setting of
mycotic aneurysm, although patient also has polycystic kidney
disease with puts her at higher risk of [**Doctor Last Name **] aneurysm. The
patient was initially stabilized in the neuro ICU with BP
control and serial imaging showing stability of the bleed. The
patient was placed on Cefazolin.
.
On the floor, the patient is feeling well. She only complains of
a waxing and [**Doctor Last Name 688**] headache that has improved. The patient
denies any focal deficits. She is having some diarrhea, C diff
negative, with some Guaic positivity due to irritated
hemorrhoids. The patient's kidney function is improving, and she
is not oliguric.
Past Medical History:
HTN
Rheumatic fever (age of 13)
MR (annual ECHO)
Recurrent UTIs ,some with drug resistent organisms
Gastric bypass (c/b duodenal ulcer at anastomotic site)
strep endocarditis (SBE) (12+ yrs ago), treated with ceftriaxone
CKD III
c.difficile diarrhea (after having been treated with abx for
UTI)
Social History:
Lives with husband. [**Name (NI) 1403**] as COO of health care agency. Denies
Tobacco use
Family History:
no family history of immunosuppression, kidney disease, or SAH
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 3 GCS E:4 V:5 M:6
O: T: 100.5 BP: 147/59 HR: 95 R 18 O2Sats 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm EOMs intact
Neck: Supple.
Lungs: CTA bilaterally
Cardiac: RRR
Abd: Soft, NT
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-1**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Handedness Right
DISCHARGE EXAM:
Gen: NAD, AOx3
HEENT: scaling, healing vesicles on mouth, nose, forehead
Heart: 3/6 systolic murmur with radiation into axilla
Lungs: scattered basilar crackles
Abd: obese, soft, NT, ND
Ext: 3+ nonpitting edema, good pulses
Skin: tender Osler nodes on foot, improved
Pertinent Results:
DISCAHRGE LABS
[**2123-2-5**] 05:54AM BLOOD WBC-11.2* RBC-3.22* Hgb-9.3* Hct-29.1*
MCV-91 MCH-28.9 MCHC-32.0 RDW-16.0* Plt Ct-405
[**2123-2-4**] 05:51AM BLOOD Neuts-73.4* Lymphs-11.9* Monos-9.1
Eos-5.1* Baso-0.4
[**2123-1-29**] 02:03AM BLOOD PT-12.2 PTT-26.2 INR(PT)-1.1
[**2123-2-5**] 05:54AM BLOOD Glucose-111* UreaN-76* Creat-3.9* Na-136
K-3.7 Cl-102 HCO3-20* AnGap-18
[**2123-1-29**] 02:03AM BLOOD ALT-35 AST-39 AlkPhos-100 TotBili-0.3
[**2123-2-5**] 05:54AM BLOOD Calcium-8.6 Phos-6.4* Mg-2.3
[**2123-2-2**] 12:30PM BLOOD HIV Ab-NEGATIVE
[**2123-1-31**] 06:10AM BLOOD C3-106 C4-26
[**1-26**] NCHCT: left diffuse SAH, no extension into ventricles, no
midline shift
[**1-27**] NCHCT - stable
[**1-27**] MRI/MRA - No evidence of intracranial aneurysm. No apparent
increase in hemorrhage since CT of [**1-27**]. Apparent atherosclerotic
plaque, dissection, or both in distal cervical L ICA --> on
further review this was just due to tortuosity of carotid
arteries. Also on this scan were some diffusion weighted areas
of possible septic emboli, not picked up on first read.
[**1-27**] CXR - Mild cardiomegaly. Mild vasc. congestion. Nodular
opacity in R base & between 5th-6th R posterior ribs, likely
calcified granulomas. No evidence of PNA.
[**1-28**] renal u/s: several simple cysts, no hydro, enlarged GB with
dilated intra and extrahepatic ducts of unknown significance
[**1-28**] TTE: possible mitral valve vegetation
[**1-29**] TEE: Small posterior mitral valve vegetation. Moderate to
severe mitral regurgitation.
[**1-30**] Head MRI: Two small infarctions in the left posterior
parietal lobe and left cerebellum seen on the previous mr may be
secondary to septic emboli
[**1-30**] CXR: PICC in good position. R and ? L basilar consolidation
MICRO:
- [**1-27**] UCx: Group B strep
- [**1-27**] Blood Cx: coag + staph --> MSSA
- [**2-4**] Head CT: 1. Interval decrease in the amount of left
frontoparietal subarachnoid hemorrhage, now minimal.
2. No new intra- or extra-axial hemorrhage.
3. No mass effect or evidence of herniation.
Brief Hospital Course:
This is a 65 yo F with PMH of HTN, CKD, rheumatic fever, and
subacute bacterial endocarditis of native mitral valve in the
past who presented with headache and fevers, found to have MSSA
bacteremia, mitral valve endocarditis, subarachnoid hemorrhage,
and acute kidney injury.
.
1. Subarachnoid Hemorrhage: Ms. [**Known lastname 6105**] was admitted to the
Intensive care unit after initial evaluation for workup of her
Subarachnoid hemorrhage. Patient underwent an MRI/MRA given her
renal insufficiency. MRA findings did not reveal an underlying
aneurysm. Repeat imaging showed a stable bleed and the patient
did not have any focal neuro deficits nor fluctuations in
consciousness. She had aggressive BP control and close
monitoring. The patient had repeat imaging that showed
reabsorption of the bleeding and no new findings. The patient
will be followed by neurosurgery. When her renal function
improves, she will need a cerebral angiogram to definitively
rule out a small [**Doctor Last Name **] aneurysm. In the meantime, the patient
will have BP control with Labetalol 600mg TID, Hydralazine 25mg
Q6hrs, and HCTZ 25mg Daily. If her BP improves, the patient's
hydralazine can be decreased.
.
2. MSSA Endocarditis: The patient has a h/o mitral valve disease
[**1-28**] rheumatic fever as a child. She has previous SBE of the
mitral valve in the past. The patient presented with fever and
was found to have a MSSA bacteremia with vegetations of her
mitral valve consistent with endocarditis. The patient also has
a loud systolic murmur. The patient was treated initially with
Nafcillin, but this was switched to Cafazolin due to
eosinophilia and diarrhea side effects. The patient will
complete a 6 week course of treatment. She will be followed by
ID as outpatient. After resolution of this acute episode, she
may benefit from cardiac surgery consultation for possible MVR
in the future if complications ensue.
.
3. Acute on Chronic Kidney Disease: The patient had chronic
renal insufficiency that was known, although, the etiology was
unclear. Here, the patient had imaging that was consistent with
polycystic kidney disease. The patient also had nausea,
vomiting, dehydration prior to admission leading to ATN that
caused an acute decline in her GFR. Her Cr rose to a max of 3.9.
Her urine had muddy brown casts. With supportive care, her Cr
came down slightly, although her GFR is still much lower than
her baseline. The patient was never oliguric. Her electrolytes
were never altered, except for slightly low bicarb. The patient
has nephrology follow-up. They will follow her PCKD, for which
she may require dialysis in the future.
.
4. Urinary retention: The patient had trouble voiding after
Foley removal. With time, the patient spontaneously voided,
although a PVR showed 350cc of retained urine. The patient has a
history of chronic UTIs which are likely from her urinary
retention. Her urinary retention has never been worked up, but
she will be seen as an outpatient to determine possible causes
and interventions to prevent chronic UTIs and worsening kidney
function.
.
5. E coli UTI: The patient had an E coli UTI. We are treating
this with a 7 day course of Trimethoprim. Last day of treatment
is [**2-11**].
.
6. Diarrhea: The patient had multiple episodes of loose stool
per day. She had C diff toxin negative x 2. She has a PCR which
was also negative for C. diff. Her diarrhea improved after
coming off of the Nafcillin. Still, she has a slight
leukocytosis and some loose stools. Repeat C diff testing should
be done for concerning symptoms.
.
7. Anemia: The patient came in with a Hct of 30. She has a h/o
iron deficient anemia, for which she is on [**Hospital1 **] iron
supplementation. The patient had some BRBPR with an active
source of bleeding from external hemorrhoids. The patient also
has a h/o marginal ulcer near Roux-and-Y site, so we were
concerned for upper GIB, given dark stools. Her stools were
green, however, and Guaiac negative. She was given 1 unit of
blood for a Hct 24. Her hemodynamics were otherwise stable. Iron
was continued. She is on Protonix. The patient should continue
to be monitored for occult GI bleeding. There may also be a
component of anemia due to poor production from her kidney
disease.
.
TRANITIONAL ISSUES:
1. Repeat Hct within 1 week.
2. Have low threshold to obtain CT scan if she has worsening
headaches or focal neurologic signs/symptoms.
3. She should continue aggressive physical therapy at rehab.
Medications on Admission:
Multivitamin, allopurinol, Calcium, fluticasone, Zyrtec
albuterol sulfate, Pataday 0.2 % Eye Drops , Lasix, Fioricet,
ferrous sulfate, omeprazole, labetalol 300 mg [**Hospital1 **], hydroxyzine
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. Eucerin Cream Sig: One (1) application Topical every four
(4) hours as needed for itching.
5. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day): Will need to be redosed as kidney
function changes.
6. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3
times a day) as needed for hemorrhoids.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six (6)
hours: Hold for SBP<100.
9. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day): Hold for SBP < 100, HR < 55.
11. trimethoprim 100 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours): Last Day [**2-11**].
12. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO every eight (8) hours as needed for headaches.
13. psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for loose stools.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. cefazolin 10 gram Recon Soln Sig: Two (2) grams Injection
Q12H (every 12 hours): This will be a 6 week course. ID will
determine when to stop. Renally dosed.
16. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Subarachnoid Hemorrhage
MSSA mitral valve endocarditis
Acute Kidney Injury
Polycystic Kidney Disease
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a subarachnoid
hemorrhage. While you were here, we determined that you also had
bacteria in your blood that attached to your mitral valve. You
also developed worsening kidney function that our renal
colleagues thought was due to dehydration on top of polycystic
kidney disease. We performed multiple images of your head that
showed stability of the bleeding. We treated your infection with
antibiotics, which you will continue as an outpatient. We
monitored your kidney function, which we will continue to work
up as an outpatient with the urologist and nephrologist. Below
are some general recommendations from the neurosurgery
colleagues.
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
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:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2123-2-22**] at 10:00 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: THURSDAY [**2123-2-25**] at 1:30 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: THURSDAY [**2123-2-25**] at 2:45 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital 9380**] CLINIC
When: TUESDAY [**2123-3-9**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
ICD9 Codes: 5845, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3345
} | Medical Text: Admission Date: [**2118-12-13**] Discharge Date: [**2118-12-27**]
Date of Birth: [**2033-2-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10682**]
Chief Complaint:
Acute blood loss anemia
Major Surgical or Invasive Procedure:
- ERCP [**12-14**]
- Selective mesenteric arteriography and coil and gelfoam
embolization of distal GDA branches [**12-15**]
- Intubation peri-ERCP [**Date range (1) 63832**]
- Trauma RIJ [**Date range (1) 63833**]
- Right radial arterial line [**Date range (1) 24019**]
History of Present Illness:
85M with DM, AFib on coumadin, and recent diagnosis (on [**12-10**])
of cholangitis and cholecystitis s/p ERCP, sphincterotomy, and
distal CBD stone extraction at [**Hospital1 18**] on [**12-11**] transferred from
[**Hospital3 3583**] for acute blood loss anemia. Periampullary
diverticulum was also noted during ERCP. Initially returned to
[**Hospital3 3583**] post-procedure and did well for the first 24
hours. Treated with zosyn. The plan was to proceed with
cholecystectomy but Hct dropped 28%->22% overnight into [**12-13**].
He denies feeling fever, chills, sweats, dizziness,
lightheadedness, chest pain, shortness of breath, abdominal
pain, nausea, vomiting, melena, or hematochezia. Underwent EGD
[**12-13**] showing active bleeding at the base of the sphincterotomy
site with blood in the stomach and the duodenum. Treated with SC
epi injection and gold probe BICAP for hemostasis. Tranfused a
total of 3U pRBC prior to transfer.
Upon arrival, patient is without complaints.
Past Medical History:
DM
CAD
AFib
s/p PPM
Chronic diastolic CHF
Cerebral aneurysm repair
CKD
Social History:
Former employee at Proctor & Gamble. No tobacco or ETOH.
Family History:
Mother died at 93 of CAD.
Physical Exam:
Physical Exam on [**Hospital Unit Name 153**] Admission
VS: T 97.2 HR 72 BP 128/54 RR 15 92%2L
GEN: Appears comfortable, resp nonlabored
HEENT: icteric sclera, OP clear, dry MM
RESP: R>L bibasilar rales no wheeze/rhonchi
CV: reg rate nl S1S2 no m/r/g
ABD: soft obese NTND normoactive BS
EXT: warm, dry no edema
NEURO: AAOx3
Pertinent Results:
Admission labs:
[**2118-12-13**] 08:44PM WBC-6.0 RBC-3.13* HGB-9.6* HCT-27.5* MCV-88
MCH-30.8 MCHC-35.1* RDW-15.3
[**2118-12-13**] 08:44PM NEUTS-78.8* LYMPHS-13.4* MONOS-5.3 EOS-2.2
BASOS-0.3
[**2118-12-13**] 08:44PM PLT COUNT-154
[**2118-12-13**] 08:44PM GLUCOSE-119* UREA N-49* CREAT-1.8* SODIUM-141
POTASSIUM-5.1 CHLORIDE-109* TOTAL CO2-24 ANION GAP-13
[**2118-12-13**] 08:44PM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-1.8
[**2118-12-13**] 08:44PM ALT(SGPT)-91* AST(SGOT)-61* ALK PHOS-193* TOT
BILI-2.9*
[**2118-12-13**] 08:44PM LIPASE-74*
[**2118-12-13**] 08:44PM PT-13.9* PTT-30.9 INR(PT)-1.2*
Discharge labs:
[**2118-12-27**] 6:15AM WBC 6.8, Hgb 9.6, HCT 29.4, Plt ct 338
[**2118-12-27**] 6:15AM INR 1.3, PTT 77.7
[**2118-12-26**] Glu 125, BUN11, Cr 1.2, Na 140, K 3.9, Cl 109, HCO3 25
[**2118-12-23**] ALT 26, AST 26, LDH 246, Alk phos 130, TB 0.9
MRSA SCREEN (Final [**2118-12-18**]):
STAPH AUREUS COAG +.
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
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
============
IMAGING
============
[**2118-12-13**]
- CXR: There is enlargement of the cardiac silhouette. Left
transvenous pacemaker leads terminate in standard position,
although the tip of the one that goes to the right ventricle is
not visualized. There is mild interstitial pulmonary edema. The
left lateral CP angle was not included on the film. There is no
evidence of large pleural effusions. There are no focal
consolidations.
[**2118-12-14**]
- Echo: The left atrium is moderately dilated. The right atrium
is moderately dilated. The estimated right atrial pressure is
0-5 mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
right ventricular free wall is hypertrophied. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is moderately dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
normal biventricular systolic function. Moderate aortic
regurgitaiton
============
INTERVENTION
============
[**2118-12-14**]
- ERCP: Evidence of a previous sphincterotomy was noted in the
major papilla and active bleeding was noted at the apex on the
left side of the sphincterotomy. Previous cautery marks were
visible at the base of the sphincterotomy. The area was
thoroughly irrigated. Cannulation of the biliary duct was
performed with a sphincterotome using a free-hand technique. The
common bile duct, common hepatic duct appeared unremarkable. In
order to keep patency of the CBD, A 7cm by 10FR Cotton-[**Doctor Last Name **]
biliary stent was placed successfully. After insertion of a CBD
stent, approximately 20mL of 1:10,000 epinephrine was injected
at the apex of the sphincterotomy with significant slowing of
the bleeding. Bipolar cautery using a Gold probe was applied at
26Watts with successful complete hemostasis.
[**2118-12-15**]
- IR: The common hepatic arteriogram showed brisk reflux of
contrast into the large splenic artery. There was some
resistance to antegrade flow in the hepatic arteries noted and
intrahepatic arteries were attenuated and irregular consistent
with either edema or possibly changes related to infection
and/or ischemia. A plastic stent was seen in the right upper
quadrant and arterial phase of the gastroduodenal opacification
shows active extravasation from the distal branches of the
pancreaticoduodenal arcade. This corresponds with the expected
site of the ampulla and corresponds to findings at the ERCP.
With the microcatheter out distally, active extravasation was
not seen, but Gelfoam and coil embolization were performed and
final images shows coils proximal and distal to the site of
extravasation. The initial post-embolization showed antegrade
flow at the level of the extravasation though no active bleeding
was seen at that time, however therefore additional embolization
was performed and the final post-embolization arteriogram taken
from the level of the proximal GDA showed no further antegrade
flow in anterior and posterior branches. In addition,
post-embolization study of the superior mesenteric arteries
showed no anterograde flow or extravasation at the area
embolized. More detailed study of the SMA was not performed.
Incidental note is made of pacer wires and tortuosity of the
lower abdominal aorta and iliac arteries.
CONCLUSION:
1. Mesenteric arteriography is showing active contrast
extravasation (bleeding) from the distal branches of the
gastroduodenal artery corresponding to the site of the ampulla.
2. Successful microcoil and Gelfoam embolization proximal and
distal to the site of extravasation with post-embolization
imaging showing no further anterograde flow in this region.
3. Note made of of abnormal hepatic arterial supply the branches
of which are attenuated and mildly tortuous distally suggesting
some combination of edema, possible underlying cirrhosis and/or
changes related to known recent infection/ischemia.
4. Aortoiliac atherosclerosis.
CXR [**2118-12-17**]-IMPRESSION: AP chest compared to [**12-13**]
through 19:
Severe cardiomegaly and vascular congestion suggests cardiac
decompensation is responsible for mild interstitial edema. A
right supraclavicular introducer ends in the right
brachiocephalic vein. Right atrial and left ventricular pacer
and right ventricular pacer defibrillator leads are in standard
placements. Pleural effusion is small, if any. No pneumothorax.
ECG Study Date of [**2118-12-16**] 7:15:44 AM
Atrial fibrillation. Left bundle-branch block. No previous
tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
96 0 158 374/437 0 -34 178
Brief Hospital Course:
85M with DM, AFib on coumadin, and recent diagnosis (on [**12-10**])
of cholangitis and cholecystitis s/p ERCP, sphincterotomy, and
distal CBD stone extraction [**12-11**] transferred for further
evaluation and management of acute blood loss anemia, s/p ERCP
and IR embolization.
# GIB/Acute blood loss anemia. During the [**Hospital Unit Name 153**] course, patient
required IVF boluses for hypotension and a total of 10 units of
pRBC. He initially underwent repeat ERCP with cauterization of
the bleeding site. However, his hematocrit continued to drop
requiring blood transfusion as well as an IR embolization
procedure. His last unit of pRBC was received on [**2118-12-18**].
He continued to pass dark black, dark maroon colored stool at
times during the ICU stay although his Hct has remained stable.
His pantoprazole was increased to 40 mg [**Hospital1 **] for a short period
for concern of also PUD, but was later decreased back to 40 mg
daily as his symptoms improved and gastritis was not found on
EGD. Pt's aspirin and coumadin were restarted with a heparin
bridge as he has a CHADS2 score of 4. Risk of stroke is high
enough in this patient to warrant retrial of anticoagulation.
Pt's HCT remained stable and there were no signs of active
bleeding. HCT upon discharge was 29.4.
# Cholangitis/cholecystitis. Given the recent diagnosis of
cholangitis/ cholecystitis s/p initial ERCP, he was placed on
ciprofloxacin and flagyl (D1, [**2118-12-13**]) for medical management
given that he was not a surgical candidate in the setting of
acute GIB. His AST, ALT, Alk phos normalized toward the end of
his ICU stay. Surgery was following patient and planning to
have an ultimate cholecystectomy for prevention of futuer
gallstones and cholangitis, pending stabilization of the
bleeding. Called over to [**Hospital3 3583**] as pt stated that he
had a surgery schedule at [**Hospital3 **] this week. Spoke to
Dr. [**Last Name (STitle) 63834**] there, who stated that given pt's recent course of
bleeding and ICU stay, he should follow up in clinic with Dr. [**Name (NI) 63835**] at [**Hospital3 3583**] to determine further care and when/if
cholecystectomy can be performed. In addition, pt will need his
biliary stent removed 4 weeks from placement on [**2118-12-14**]. This
has been scheduled.
# Acute on Chronic Kidney Disease. Likely [**3-1**] pre-renal and
renal hypotension induced ATN initially. His Cr improved over
time. His medications were renally dosed and nephrotoxins were
avoided. Creatinine remained stable. CR at discharge was 1.2.
# Chronic systolic/diastolic CHF. No acute CHF while in the
ICU. Patient received multiple fluid boluses as well as pRBC
transfusions with the addition of Lasix. His weight actually
came down from admission weight of 107.9 kg to 94.5 kg upon call
out to the floor. He was restarted on sotalol 40 mg [**Hospital1 **] and
nifedipine on [**12-16**] after extubation as he was hypertensive. His
Coreg 6.25mg [**Hospital1 **] was restarted on [**2118-12-22**]. His home dose of
Lasix 40 mg was restarted on [**2118-12-27**].
# Atrial fibrillation. He was restarted on sotalol and Coreg as
mentioned above as his hemodynamics improved. Digoxin and
anticoagulation were held as his HR was mostly in the 70s and
SBP mostly 100-130s. Anticoagulation therapy was held initially
given GIB. Given CHADS2 score of 4, risk of stroke was
considered high enough that anticoagulation was resumed-coumadin
with heparin gtt and aspirin. INR at discharge was 1.3. He will
resume heparin bridge at LTAC.
# History of CAD. Patient was restarted on sotolol and
nifedipine (see above) on [**12-16**] post extubation. Lipitor was
initially held given LFT elevation. Lipitor, coreg, and aspirin
were restarted.
# Delirium: This was thought to be likely secondary to delirium
with disrupted sleep-wake cycle. Patient's mental status was
noted to be waxing and [**Doctor Last Name 688**], worse than his baseline per
family (son) while in the ICU. His CXR did not show
consolidation suspicious for pneumonia and has been afebrile
without respiratory symptoms. He responded to Zyprexa in the
evening when he had agitation. Of note, he was initially
transferred to the floor on [**2118-12-20**] but later returned to the
[**Hospital Unit Name 153**] for increased somnolence and hypotension SBP 80s requiring
bolus fluid. Hct on the floor was 14.3 but upon quickly
repeating Hct was 29.6, likely a falsely low value. He
responded well to the fluid bolus with improved mentation. His
neurological exam was also without focal deficits. Toxic
metabolic encephalopathy much improved. Pt was continued home
home dose risperdol. This did not reoccur on the medical floor.
#Benign hypertension: Coreg, nifedipine, and Lasix were
restarted.
# Diabeties mellitus. Pt continued on insulin sliding scale.
# Hypothyroidism. Pt continued on home levothyroxine.
# Code status: Full
Medications on Admission:
Medications at home (per OSH records, patient cannot recall)
Warfarin
Sotatol 40 mg [**Hospital1 **]
Levothyroxine 25 mcg daily
Allopurinol 200 mg daily
Lasix 40 mg daily
Protonix 40 mg daily
Coreg 6.25 mg [**Hospital1 **]
Nifedipine CR 90 mg daily
Celexa 20 mg daily
Digoxin 125 mcg daily
Combivent 2 puffs QID
Risperdal 1 mg daily
Lipitor 80 mg daily
ASA 81 mg daily
MVI
Discharge Medications:
1. sotalol 80 mg Tablet Sig: 0.5 Tablet PO twice a day.
2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours.
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
11. meds
asa/coumadin
12. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
17. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
18. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 1 days.
19. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days.
20. insulin lispro 100 unit/mL Solution Sig: 0-12 units
Subcutaneous ASDIR (AS DIRECTED): pls see attached sliding
scale.
21. heparin (porcine) in NS Intravenous
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Major:
Acute blood loss anemia related to gastrointestional bleed
Cholangitis
Minor:
Type 2 diabetes with complication
Coronary artery disease
Atrial fibrillation
Chronic diastolic heart failure
Chronic kidney disease, stage 3
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 63836**],
It was a pleasure taking care of you. You were admitted with
cholangitis (infection of the bile ducts) and a large bleed
related to your ERCP procedure. You were transferred from
another hospital. You received blood transfusions an
interventional radiology procedure to stop the bleeding and your
blood counts are now stable with no signs of current bleeding.
For your cholangitis that had already been known, you were
continued on antibiotics (Cipro and flagyl).
You will need your biliary stent removed 4 weeks from the date
it was placed ([**2118-12-14**]), around [**2119-1-11**]. Your will need
another ERCP for this. Please call the number below to schedule
this follow up appointment.
Your aspirin and coumadin were resumed. You will need close
monitoring of your INR level and blood counts.
You should be evaluated by general surgery for consideration of
gallbladder removal. Please see the contact number below.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 25821**] to
schedule a follow up within 1 week of discharge from the
facility.
Name: NP [**First Name5 (NamePattern1) 63837**] [**Last Name (NamePattern1) 63838**]
Address: [**Apartment Address(1) 63839**], [**Location (un) **],[**Numeric Identifier 40624**]
Phone: [**Telephone/Fax (1) 25821**]
Appointment: Monday [**2119-1-2**] 1:30pm
Name: [**Last Name (un) 63840**],[**Name6 (MD) 63841**] F MD
Address: [**Street Address(2) 63842**], [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 63843**]
Appointment: Wednesday [**2119-1-4**] 3:30pm
Department: DIGESTIVE DISEASE CENTER
When: THURSDAY [**2119-1-12**] at 11:00 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Department: ENDO SUITES
When: THURSDAY [**2119-1-12**] at 11:00 AM
*** YOU MUST ARRIVE FOR THIS APPOINTMENT AT 9:30am ***
ICD9 Codes: 5845, 5789, 2851, 2760, 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3346
} | Medical Text: Admission Date: [**2180-4-18**] Discharge Date: [**2180-4-21**]
Date of Birth: [**2131-3-21**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 36695**]
Chief Complaint:
Lightheadedness, heavy vaginal bleeding
Major Surgical or Invasive Procedure:
uterine artery embolization
History of Present Illness:
This is a 49 year old female with a history of menorrhagia and
likey posterior cervical fibroid who presents with worsening
vaginal bleeding. The patient has had irregular vaginal
bleeding since [**Month (only) 1096**]. Her hemoglobin was noted to be 8 mg/dl
in [**Month (only) 958**] and she started on iron supplements with improvement in
her hemoglobin to 10 in [**Month (only) 547**]. On [**2180-4-12**] she started what she
thought was her normal menstrual period. The bleeding was
intially heavy but not alarming, however, since [**2180-4-16**] she has
been having extremely heavy bleeding, soaking 3 super tampons
and 1 pad every 5 to 60 minutes. She also developed
lightheadedness, dizziness and dyspnea on exertion without chest
pressure. She contact[**Name (NI) **] her primary care physician who
performed [**Name Initial (PRE) **] stat hematocrit on [**2180-4-17**] which was 23.6 (from 26.8
in [**2180-2-14**]). In response to this hematocrit she was
prescribed Provera by her primary care physician and took 20 mg
on [**2180-4-17**] and 10 mg on [**2180-4-18**]. She typically takes propranolol
240 mg [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] for migraine headache prophylaxis. She took 120
mg on the day prior to presentation and held her dose on the day
of presentation. Her bleeding persisted and she presented to
the emergency room.
In the ED, initial vs were: T: 99.0 BP: 92/54 P: 78 R: 16 O2:
100% on RA. Her initial hematocrit was 20.1. Patient was given
three units of PRBCs and 2 liters of normal saline. Her blood
pressures in the emergency room ranged from the 80s to 100s
systolic with heart rates in the 60s to 70s. She made 800 cc of
urine. She was admitted to the [**Hospital Unit Name 153**] for further management.
On the floor she endorses migraine headache. She denies current
lightheadedness, dizziness, chest pain, shortness of breath,
nausea, vomiting, abdominal pain, diarrhea, constipation,
dysuria, hematuria, leg pain or swelling. Vaginal bleeding as
above. All other review of systems negative in detail.
Past Medical History:
Menorrhagia with evidence of posterior fibroid
Migraine headaches
Fibronodular breasts
Rosacea
Atypical melanocytic proliferation
Past Gynecologic History: G5P4. One spontaneous abortion. Last
vaginal delivery complicated by post-partum hemorrhage. No
history of sexually transmitted diseases. No history of
abnormal PAP smears.
Social History:
She is a physician at [**Name Initial (PRE) **] local student health center. She denies
history of smoking. Drinks alcohol socially. No history of
illicit drug use. She is married with four children.
Family History:
No family history of bleeding disorders or vaginal bleeding.
Physical Exam:
Vitals: T: 98.5 BP: 98/60 P: 79 R: 14 O2: 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pelvic (per gynecology exam): Gross vaginal bleeding with clots
in vaginal vault
Pertinent Results:
Hematology:
[**2180-4-17**] 01:49PM BLOOD WBC-7.3 RBC-2.62* Hgb-8.0* Hct-23.6*
MCV-90 MCH-30.5 MCHC-33.9 RDW-13.8 Plt Ct-215
[**2180-4-19**] 03:12AM BLOOD WBC-7.0 RBC-2.73* Hgb-8.5* Hct-23.8*
MCV-87 MCH-31.0 MCHC-35.7* RDW-15.9* Plt Ct-138*
[**2180-4-18**] 01:15PM BLOOD Neuts-87.7* Lymphs-10.3* Monos-1.6*
Eos-0.3 Baso-0
[**2180-4-18**] 01:15PM BLOOD PT-12.4 PTT-23.8 INR(PT)-1.0
[**2180-4-19**] 04:23AM BLOOD PT-13.0 PTT-26.1 INR(PT)-1.1
Chemistries:
[**2180-4-18**] 01:15PM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-133
K-4.0 Cl-100 HCO3-27 AnGap-10
[**2180-4-19**] 03:12AM BLOOD Glucose-97 UreaN-8 Creat-0.7 Na-134 K-3.8
Cl-109* HCO3-21* AnGap-8
[**2180-4-19**] 03:12AM BLOOD TotBili-0.8
[**2180-4-19**] 03:12AM BLOOD Calcium-7.2* Phos-2.7 Mg-1.9
[**2180-4-18**] 01:32PM BLOOD Hgb-7.2* calcHCT-22
Urinalysis:
[**2180-4-18**] 04:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.002
[**2180-4-18**] 04:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2180-4-18**] 06:00PM URINE UCG-NEGATIVE
Microbiology:
Urine culture: pending
Brief Hospital Course:
Dr. [**Known lastname **] was initially admitted from the emergency department
with heavy vaginal bleeding, acute on chronic anemia, and
hypotension. She was admitted from the ED to the [**Hospital Unit Name 153**] for
initial management. She required a total of 7 u PRBC's and 3 u
FFP and her vaginal bleeding stabized immediately after
successful uterine artery embolization. She had mild
thrombocytopenia and hypofibrinogenemia which was likely [**1-18**]
acute blood loss and dilution with PRBC's. She was monitored
post procedure in the [**Hospital Unit Name 153**] and transfered to the floor once
stable. She was continued on provera. She was discharged on HD
4 with a HCT of 27 which was stable > 24 hours, as well as
rising plts/ fibrinogen.
Medications on Admission:
Provera (20 mg [**2180-4-17**], 10 mg [**2180-4-18**])
Iron 325 mg daily
Azelaic Acid 15 % Gel daily
Fluticasone 50 mcg Spray, Suspension
Metronidazole 1 % Cream QHS
Propranolol LA 240 mg daily
Sumatriptan Succinate PRN
Calcium Carbonate 1,250 mg [**Hospital1 **]
Diphenhydramine HCl PRN
Loratadine PRN
Multivitamin daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical fibroid
menorrhagia
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take medications as prescribed
Call for:
- heavy vaginal bleeding, passing large clots
- increased pain
- fevers/ chills
- redness/ swelling/ warmth on R groin
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 23**] as planned on [**2180-5-1**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2180-5-1**] 12:50
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2180-5-1**] 2:15
Provider: [**Name10 (NameIs) 3833**] Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2180-10-4**] 4:00
Completed by:[**2180-4-22**]
ICD9 Codes: 2851, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3347
} | Medical Text: Admission Date: [**2148-3-16**] Discharge Date: [**2148-3-22**]
Date of Birth: [**2077-4-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6029**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
Pt presented to ED on [**2148-3-15**] with fever to 102.5 at [**Hospital 4382**] 2 days after vaporization of prostate by Dr. [**Last Name (STitle) 43569**] at
[**Doctor Last Name 1263**]. Pt states that he has had mild dysuria, denies
hematuria. He was discharged from [**Doctor Last Name 1263**] with a foley and
Bactrim.
.
Pt states that he had no significant symptoms other than the
fever. Did start feeling "woozy" the night prior to transfer,
describes lightheadedness but no vertigo. Has dull suprapubic
abdominal pain, does not radiate. Denies recent cough, denies
SOB or CP/pressure. Has had muscle aches. No recent travel, no
known sick contacts. Denies recent diarrhea; had BM on AM of
transfer, no blood.
.
On arrival to the ED, T was 102.7, satting 92% on RA, HR 102.
Blood cultures sent, pt given 2L NS, levo, vanco, azithromycin,
admitted to floor. Urology has been following in hospital, feel
that ABX for the PNA will cover UTI, feel no acute urological
issues. On the AM of transfer, pt became hypotesnive to 80s,
responded to 2L IVF, BP up to 110s. Pt was noted to be
tachypneic but was not complaining of SOB. ABG on RA was
7.44/26/62 with lactate 2.4 (up from 1.9 earlier), ABG on 5L was
7.46/26/55. Pt was transferred to [**Hospital Unit Name 153**] for further management.
Past Medical History:
- h/o prostate Ca, s/p external beam RT years ago, now treated
with Lupron
- h/o urinary retention s/p laser vaporization of prostate 2d
PTA
- hypertension
- anxiety
- depression
Social History:
Lives in [**Hospital3 **] since the death of his mother. [**Name (NI) 4084**]
married, no children. Has a cat. Denies present or past
tobacco, drinks 1 glass wine/week, no IVDU. Used to work as a
security guard and car salesperson.
Family History:
noncontributory; has one sister, poor relationship with her; no
children or other siblings, both parents deceased
Physical Exam:
Admission exam:
VS: Tm 102.2 Tc 102.2 112/71 102 30 93% 5L NC
Gen: appears tachypneic
HEENT: MM dry, EOMI, PERRL
Neck: JVP flat, no LAD
CV: tachycardic, regular, nl S1/S2, no m/r/g
Pulm: occasional end-expiratory wheezes, breathing shallowly,
bibasilar crackles, E->A change at L base
Abd: soft, suprapubic tenderness, no rebound or guarding, +BS
Ext: well-healed scars over knees; 1+ pitting pretibial edema,
2+ distal pulses
Neuro: 5/5 strength bilaterally, CN II-XII intact
Pertinent Results:
Admission labs:
[**2148-3-15**] 06:16PM BLOOD WBC-17.5* RBC-4.66 Hgb-13.0* Hct-38.9*
MCV-83 MCH-27.8 MCHC-33.3 RDW-15.4 Plt Ct-299
[**2148-3-19**] 03:48AM BLOOD PT-12.8 PTT-30.8 INR(PT)-1.1
[**2148-3-15**] 06:16PM BLOOD Glucose-136* UreaN-22* Creat-1.5* Na-138
K-3.8 Cl-105 HCO3-20* AnGap-17
[**2148-3-15**] 06:16PM BLOOD Calcium-9.3 Phos-2.8 Mg-1.8
[**2148-3-20**] 06:20AM BLOOD calTIBC-146* VitB12-446 Folate-10.6
Ferritn-629* TRF-112*
[**2148-3-16**] 04:45PM BLOOD Hapto-227*
[**2148-3-16**] 03:59AM BLOOD Type-ART pO2-71* pCO2-27* pH-7.47*
calHCO3-20* Base XS--1
[**2148-3-15**] 06:15PM BLOOD Lactate-2.0
[**2148-3-16**] 03:59AM BLOOD Lactate-1.9
[**2148-3-16**] 11:54AM BLOOD Lactate-2.4*
Discharge labs:
Cultures:[**2148-3-15**] 6:16 pm BLOOD CULTURE
**FINAL REPORT [**2148-3-18**]**
AEROBIC BOTTLE (Final [**2148-3-18**]):
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
IMIPENEM-------------- 2 S
MEROPENEM------------- 1 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
[**2148-3-15**] 7:30 pm URINE Site: CATHETER
**FINAL REPORT [**2148-3-18**]**
URINE CULTURE (Final [**2148-3-18**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 2 S
MEROPENEM------------- 4 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
Radiology:
CHEST, TWO VIEWS: There are no comparisons. The cardiac
contour appears
enlarged. There are low lung volumes. No definite pulmonary
vascular
congestion, pleural effusion, or pneumothorax. On the lateral
view, there
appears to be an opacity posteriorly, most likely in the left
lower lobe.
IMPRESSION: Findings likely represent a left lower lobe
pneumonia
INDICATION: Left lower lobe pneumonia, hypoxic, tachypneic,
tachycardic.
Please evaluate pulmonary embolus.
COMPARISONS: None.
MDCT acquired axial images of the chest were acquired with and
without IV
contrast. CT PE protocol.
CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There is no
evidence of
pulmonary embolism. Evaluation beyond second order vessels is
limited by
atelectasis. Bilateral pleural effusions are seen, with
associated
atelectasis/consolidation, worse on the left.
No pathologically enlarged mediastinal lymphadenopathy is
identified. There
is evidence of atherosclerotic disease with calcification seen
within the
aorta as well as coronary vessels.
BONE WINDOWS: No suspicious lytic or blastic lesions are
identified.
Degenerative changes, including loose body, seen in the right
shoulder.
Multiplanar reformatted images confirm the axial findings.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Lower lobe atelectasis and consolidation with effusions,
worse on the left
side. Findings consistent with pneumonia.
3. Atherosclerotic disease with marked calcifications seen
within the aorta
and coronary vessels.
.
CT Abd/Pelvis [**2148-3-22**]: per report by radiology, bilateral renal
cysts; no evidence of renal abscess on CT scan.
Brief Hospital Course:
The patient was admitted for hypotension, hypoxia, and fevers.
He was initialyl admitted to the floor but was then shortly
transferred to the ICU for sepsis. He was found to have
urosepsis with pseudomonoas and was treated with Zosyn. He was
then transferred back to the floor and was gently diuresed.
.
# Hypoxia: The patient was initially admitted with mild hypoxia
which quickly worsened with from fluid boluses for his
hypotension resulting in pulmonary edema. He was also thought to
have an pneumonia, though this was later thought to be
atlectasis. There was concern given his recent surgery and
hypoxia that he could have a PE, therefore a CT angio was
preformed which showed no evidence of PE. His flu DFA negative,
Legionella neg. ABG showed worsening respiratory alakalosis. At
his worst, he required 10 L NC to maintain his O2 Sats. He was
gently diuresed and on discharge, was no longer hypoxic. He may
need an echo as an outpaitent to evaluate for cardiomyopathy.
# Sepsis: The patient had pseuodomonal urosepsis likely related
to his recent prostate insturmentation. He was fluid recucxiteec
in the [**Hospital Unit Name 153**] and responded well to antibiotics. He will continue
a course of Zosyn for a total of 14 days ending on [**3-29**].
# Continued fevers: The patient continued to have low grade
temps after DC from the ICU. A fever workup ensued. He had
diarrhea which was cdiff neg x2 witn the 3rd pending, though he
was started on flagyl for emperic treatment. Ultrasound of his
kidneys showed a cyst vs. abscess, therefore a CTU was done. The
CT showed no evidence of abscess.
# s/p prostate vaporization for urinary retention: Initially
urology was consulted who felt that there was no acute urologic
issue. His foley was changed on admission once his UA was foind
to be positive. I spoke with Dr. [**Last Name (STitle) 43569**] about this and he
suggested that the Foley be removed and the patient try to void.
He underwent a voiding trial here. He was able to pass urine,
though was incontinent. His PVR was 300. This needs to be
checked daily. He will follow up with Dr. [**Last Name (STitle) 43569**], his urologist
within 1 week.
# Acute renal failure: The paitent does not have a history of
renal failure. His Cr was 1.5 on admission and he was felt to be
prerenal with a FENA <1%. His Cr initially decreased then
increased, likely [**3-7**] to contrast induced nephropathy. He
recieved another dye load on [**3-22**], thereore needs his Chem 7
checked on Monday ro follow his Cr.
Medications on Admission:
ambien 5mg qHS
celexa 10mg daily
imipramine 25mg daily
terazosin 2mg qHS
verapamil SR 240mg daily
protonix 40mg daily
Ancef/Bactrim/diflucan x 1 day peri-procedure
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for SOB, wheezing.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): [**Month (only) 116**] DC when paitent is more
active.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal [**Hospital1 **] (2 times a day).
9. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38**] Landing
Discharge Diagnosis:
urosepsis
Discharge Condition:
good, foley in place.
Discharge Instructions:
Continue all your medications
call your PCP with any fevers
Followup Instructions:
urology: You have an appointment with Dr. [**Last Name (STitle) 43569**] on Feburary
Tuesday 21 at 11:00, [**Street Address(2) **] [**Hospital1 **] MA, phone
[**Telephone/Fax (1) 64585**] for directions. Fax: [**Telephone/Fax (1) 65549**]
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] will see you in the rehab.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 6035**]
Completed by:[**2148-3-26**]
ICD9 Codes: 5990, 5849, 4280, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3348
} | Medical Text: Admission Date: [**2153-3-6**] Discharge Date: [**2153-3-12**]
Service: CCU
CHIEF COMPLAINT: Hypotension
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female
with a history of coronary artery disease status post
myocardial infarction in [**2150**], hypertension and
hypercholesterolemia, recently admitted for evaluation of a
right ankle ulcer/cellulitis. She was discharged to home
with Keflex on [**2-24**] with a 7 to 10 day course of antibiotic
scheduled. She was brought in today by her daughter after
being found down in her apartment. The daughter was out of
town for the last five days, returned today and found the
patient down on the afternoon of admission. She had seen the
patient the night before and the two had had dinner and there
were no problems at that time. There was no loss of
consciousness. By the patient's report, there was no chest
pain, shortness of breath, nausea, vomiting, no head trauma.
By the daughter's report, the patient had not been taking any
of her medications for the last five days.
PAST MEDICAL HISTORY:
1. Hypertension
2. Hypercholesterolemia
3. Coronary artery disease, status post myocardial
infarction in [**2150-12-12**]. ETT with inferolateral
reproduced perfusion defect, moderate mitral regurgitation,
mild to moderate AS. Ejection fraction greater than 55% on
[**2150-12-12**].
4. Hypothyroidism on chronic replacement
5. Diverticulosis, last colonoscopy in [**Month (only) 404**] of '[**49**]
6. External hemorrhoids
7. Status post fall with a pubic ramus fracture
8. History of pyuria with AFB x3
9. Dementia
ADMISSION MEDICATIONS:
1. Levoxyl 75 mcg po qd
2. Celexa 30 mg po qd
3. Cozaar 25 mg po qd
4. Anusol HC
5. Imdur 30 mg po qd
6. Iron sulfate
7. Lasix 20 mg po qd
8. Lipitor 10 mg po qd
9. MVI 1 tablet po qd
10. Lopressor 25 mg po bid
11. Aspirin 325 mg po qd
12. Keflex 250 mg po qid
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives alone. Her daughter is
her healthcare proxy and the telephone number ([**Telephone/Fax (1) 2651**].
There is no tobacco or alcohol history.
PRIMARY CARE PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2184**] [**Last Name (NamePattern1) **]
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Temperature 97.3??????, blood pressure 113/68, pulse
83.
GENERAL: Alert and oriented to person only in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT: Dry mucous membranes,
bilateral surgical pupils, no jugular venous distention.
NECK: Supple.
PULMONARY: Bibasilar rales, no wheezes.
CARDIOVASCULAR: 2/6 systolic murmur at the left upper
sternal border with 1/6 regurgitant murmur, holosystolic
murmur at the left lower sternal border radiating to the
apex. The PMI is nondisplaced and is a normal size.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds. No hepatosplenomegaly.
EXTREMITIES: Large 10 x 5 cm medial right malleolus ulcer
with scattered areas of necrosis and surrounding erythema.
There is no swelling.
ADMISSION LABS: White count 10.9, hematocrit 31.5, platelets
416. SMA-7 143, 5.7, 104, 23, 43, 1.7 and 106. Urinalysis
showed trace ketones, small bilirubin, nitrite negative, no
leukocyte esterase, no red blood cells.
IMAGING: Chest x-ray showed a small right pleural effusion,
but no cardiomegaly. A head CT was negative and hip films
were also negative.
In the Emergency Department, the patient was initially
normotensive. She was started on intravenous cefazolin and
developed hypotension with a systolic blood pressure in the
80s. She was then started on low dose dopamine and admitted
to the Medical Intensive Care Unit for further management.
Admission electrocardiogram shows ST depressions in 1, 2, F,
V5 and V6. T-wave inversions present diffusely.
BRIEF HOSPITAL COURSE: The patient was admitted to the CCU
with a strong concern of evolving non Q-wave myocardial
infarction. Indeed, the patient's peak CK was 335 with an MB
of 28 and an MB index of 8.4. The associated troponin was
16.1. After discussion with the family, the patient was
conservatively managed and cardiac catheterization was not
pursued.
With volume resuscitation, the patient's hematocrit dropped
to 26.3. Iron studies revealed the following: an iron of
287, TIBC of 398, ferritin of 49 and transferrin of 306. It
was felt that the patient had anemia of chronic disease on
the low hematocrit reflected hemodilution. Her dose of
Niferex was increased to [**Hospital1 **] and her hematocrit remained
stable after receiving 2 units of packed red blood cells.
In terms of the patient's elevated creatinine, this also
responded quickly to volume resuscitation.
The patient had recently been in house with a concern of a
right lower extremity cellulitis versus pyoderma gangrenosum.
The patient was seen by dermatology and it was felt that the
lesion was most consistent with partially treated ulcerated
cellulitis. The patient was initially started on cefazolin
and clindamycin. She developed diarrhea in the setting of
clindamycin therapy. Stool toxin assays did reveal the
presence of the Clostridium difficile toxin A and the
patient's clindamycin was discontinued and she was started on
metronidazole. On the day of discharge, the patient was
switched over from intravenous cefazolin to oral cephalexin
with no difficulties.
The patient was evaluated by physical therapy and it was felt
that she was unsteady on her foot and would need 24 hour
supervision.
An echocardiogram was obtained which revealed a normal
ejection fraction, normal valves and no resting wall motion
abnormalities.
On [**2153-3-12**], the patient was felt to be medically stable for
discharge. Given the setting in which the patient was
discovered and the physical therapy evaluation, it was felt
that she would benefit from a course of short term
rehabilitation.
DISCHARGE CONDITION: Discharged to short term
rehabilitation.
DISCHARGE STATUS: Stable
DISCHARGE MEDICATIONS:
1. Levoxyl 75 mcg po qd
2. Celexa 30 mg po qd
3. Anusol HC prn
4. Calcium carbonate 600 mg po bid
5. MVI 1 tablet po qd
6. Enteric coated aspirin 325 mg po qd
7. Lipitor 20 mg po qd
8. Flagyl 500 mg po tid x10 days
9. Cephalexin 250 mg po qid x10 days
10. Niferex 150 mg po bid
11. Toprol XL 25 mg po qd
12. Zestril 10 mg po qd
DISCHARGE DIAGNOSES:
1. Status post non Q-wave myocardial infarction, peak CK of
355
2. Resolving Clostridium difficile colitis
3. Preserved cardiac pump function
4. Anemia of chronic disease
5. Right lower extremity cellulitis complicated by
ulceration
DISCHARGE FOLLOW UP: The patient will follow up in
[**Hospital 2652**] Clinic at [**Hospital6 256**] in
one week's time. The patient will follow up with her
cardiologist, Dr. [**Last Name (STitle) **], at [**Hospital6 2018**] in two weeks' time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 2653**]
MEDQUIST36
D: [**2153-3-12**] 13:46
T: [**2153-3-12**] 13:55
JOB#: [**Job Number 2654**]
ICD9 Codes: 4280, 2765, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3349
} | Medical Text: Admission Date: [**2188-2-24**] Discharge Date: [**2188-2-25**]
Date of Birth: [**2153-4-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
Ingestion of ice-pack contents
Major Surgical or Invasive Procedure:
None
History of Present Illness:
34 yo F with PMH of catatonic schizophrenia who ingested the
contents of an ice pack today at [**Hospital1 **] where she is an
inpatient. Shortly after the ingestion, the patient vomited a
large amount of fluid that contained bright red blood. It was
noted that it was not dark nor chocolate covered. Pt was then
transferred to [**Hospital1 **].
Pt had been admitted to [**Hospital1 **] on [**2-22**] for acute
psychotic decompensation.
In the ED, initial vs were: T 98 P 144 BP 1348/81 R 33 O2 100%
RA. Patient was given 5L NS and seen by toxicology. Despite
adequate fluid resuscitation the patient remained tachycardic.
Because ammonia nitrate can be an irritant, there was some
concern for gastritis and a possible need for GI to scope. The
patient was then transferred to the ICU.
On arrival to the ICU, vital 97.5 112 132/76 12 99%RA. Pt calm
but would not repond to questions. Cooperative with exam but
would not allow labs to be drawn. Talking quietly to herself
about religion and God.
Past Medical History:
Catatonic Schizophrenia s/p 9 psychiatric hospitalizations
? Bulimia
Social History:
Lives with sister who also has schizophrenia. Per report, Pt has
a B.A. from [**Location (un) **] [**Location (un) **]. She is currently unemployed and
disabled.
Family History:
Mother stroke
Sister schizophrenia
Physical Exam:
Vitals: 97.5 112 132/76 12 99%RA
General: Alert, no acute distress, Oriented x 0, speaks softly
to heerself about God, does not respond to questions
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses
Pertinent Results:
[**2188-2-24**] 12:33PM BLOOD WBC-12.7* RBC-4.92 Hgb-14.2 Hct-42.7
MCV-87 MCH-28.9 MCHC-33.4 RDW-13.3 Plt Ct-296
[**2188-2-25**] 03:58AM BLOOD WBC-10.2 RBC-3.96* Hgb-12.0 Hct-33.8*
MCV-85 MCH-30.3 MCHC-35.6* RDW-13.0 Plt Ct-260
[**2188-2-24**] 12:33PM BLOOD Neuts-80.7* Lymphs-15.9* Monos-2.0
Eos-1.3 Baso-0.1
[**2188-2-24**] 12:33PM BLOOD Glucose-135* UreaN-17 Creat-1.0 Na-137
K-4.3 Cl-106 HCO3-18* AnGap-17
[**2188-2-25**] 03:58AM BLOOD Glucose-83 UreaN-7 Creat-0.7 Na-137 K-3.8
Cl-108 HCO3-16* AnGap-17
[**2188-2-24**] 09:48PM BLOOD Calcium-8.1* Phos-2.9 Mg-1.9
[**2188-2-25**] 03:58AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9
[**2188-2-24**] 01:42PM BLOOD pO2-113* pCO2-30* pH-7.33* calTCO2-17*
Base XS--8
[**2188-2-24**] 01:42PM BLOOD Lactate-0.8
[**2188-2-25**] 12:31AM BLOOD Lactate-0.6
[**2188-2-24**] 12:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CHEST (PORTABLE AP) Study Date of [**2188-2-24**] 12:49 PM
Lungs volumes are low. There is no airspace consolidation to
suggest pneumonia or pneumonitis. Cardiac silhouette,
mediastinal and hilar contours are within normal limits. Osseous
structures appear intact.
IMPRESSION: No acute cardiopulmonary process, including no
evidence of
pneumonia.
Brief Hospital Course:
34 yo F with schizophrenia transferred from [**Hospital1 **] after
ammonium nitrate ingestion. Per toxicology, it is a slightly
caustic [**Doctor Last Name 360**] which can cause gastritis. Per toxicology, no
nasogastric tube and no intervention but should monitor for
pain.
# Ammonium Nitrate Ingestion: Patient admitted for observation.
Per Toxicology, neede to observed for 6 hours. Plan was to
obtain an EGD if HCT drop or continued hematemesis, but these
did not occur. She did recieve 5L NS in ED, and was continue on
gentle fluids with Lactated Ringers while inpatient. Her diet
was advanced as toleratd.
# Metabolic Acidosis - likely [**1-14**] to aggressive fluid
resuscitation with normal saline while in the Emergency
department. NS stopped upon arrival to ICU. She was continued
on LR.
# Psychiatric issues: Schizophrenic, s/p mutliple
hospitalizations, currently at [**Hospital1 **]. Psychiatry consult
was obtained on admission. Per their recommendations, she was
started on scheduled Haldol and Ativan. Upon arrival the ICU,
patient attempted to strangle herself with her restraint. She
was subdued and remained in 2-point restraints while inpatient
for her safety.
# Tachycardia: Patient was noted to have intermittent sinus
tachycardia up to 170 beats per minute. This was in the setting
of agitation. When the patient was not stimulated or after her
Haldol/Ativan, her tachycardia would resolve to high 80s.
Patient was a FULL CODE while inpatient per confirmation with
her mother, [**Name (NI) **] [**Name (NI) 15824**] ([**Telephone/Fax (1) 81281**]).
Medications on Admission:
Abilify 15mg po bid
Zoloft 25mg po qd
Ativan 1mg po TID
Thorazine 50mg po q4h prn
Discharge Medications:
1. Aripiprazole 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
2. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day.
4. Chlorpromazine 50 mg Tablet Sig: One (1) Tablet PO four times
a day as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8063**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Toxic ingestions
Secondary: Schizophrenia
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted after eating the contents of an ice pack. You
were seen by Toxicology. Once medically stable, you were
discharged back to [**Hospital1 **].
Please take all medications as prescribed.
Followup Instructions:
Please follow-up with your regular [**Hospital1 **] providers for
on-going psychiatric care.
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3350
} | Medical Text: Admission Date: [**2181-2-12**] Discharge Date: [**2181-2-28**]
Date of Birth: [**2117-7-25**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
1. Status post fall
2. Left renal fracture
Major Surgical or Invasive Procedure:
Status post gelfoam renal embolization x3 on [**2181-2-13**]
History of Present Illness:
69-year-old male status post fall on car door; transferred from
referring facility with large perinephric, subcapsular hematoma.
+ ETOH. CT [**Last Name (un) 103**] revealed active extravasation. Tx to BIBMC for
management. On arrival, vitals stable, tachycardic, INR 4.3, on
coumadin for DVT ppx. Given 2u FFP, 2u PRBC, 5L NS, Proplex.
Taken to interventional radiology for embolization. Admitted to
the TSICU.
Past Medical History:
1. Gastroesophageal reflux
2. Gout
3. History of left lower extremity DVT
4. Left kidney stone
5. Low back pain
Social History:
1. EtOH abuse
Family History:
NC
Physical Exam:
On arrival:
VS: 97.8 175/85 147 20 96% FM
GEN: A&Ox3, NAD
HEENT: L forehead lac, OP clear, c-collar
CARDIO: S1S2, RRR
PULM: CTAB
[**Last Name (un) **]: L flank tenderness, rectal tone nl, no gross blood
ORTHO: warm, no deformities
NEURO: moves all extremities
Pertinent Results:
[**2181-2-12**] 04:47PM WBC-14.9* RBC-2.82* HGB-9.9* HCT-28.6*
MCV-102* MCH-35.2* MCHC-34.7 RDW-12.7
[**2181-2-12**] 04:47PM PLT COUNT-181
[**2181-2-12**] 04:47PM PT-26.1* PTT-29.9 INR(PT)-4.3
[**2181-2-12**] 05:01PM GLUCOSE-140* LACTATE-4.7* NA+-141 K+-5.0
CL--108 TCO2-26
[**2181-2-12**] 04:47PM UREA N-25* CREAT-1.9*
[**2181-2-12**] 04:47PM AMYLASE-47
[**2181-2-12**] 04:47PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2181-2-12**] 05:06PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2181-2-12**] 05:06PM URINE RBC-[**2-10**]* WBC-[**2-10**] BACTERIA-FEW YEAST-NONE
EPI-0
[**2181-2-12**] 08:10PM HCT-22.4*
[**2181-2-12**] 10:45PM HCT-29.1*#
[**2181-2-13**] 05:12PM BLOOD Hct-25.4*
[**2181-2-14**] 05:22AM BLOOD WBC-7.3 RBC-3.24* Hgb-10.0* Hct-28.2*
MCV-87 MCH-30.9 MCHC-35.4* RDW-16.4* Plt Ct-53*
[**2181-2-14**] 09:55AM BLOOD Hct-27.6*
[**2181-2-14**] 01:55PM BLOOD Hct-24.3*
[**2181-2-16**] 01:14AM BLOOD WBC-7.5 RBC-3.14* Hgb-9.7* Hct-28.2*
MCV-90 MCH-31.0 MCHC-34.5 RDW-15.9* Plt Ct-81*
[**2181-2-23**] 01:30AM BLOOD WBC-8.5 RBC-2.96* Hgb-9.0* Hct-27.8*
MCV-94 MCH-30.5 MCHC-32.5 RDW-15.1 Plt Ct-463*
[**2181-2-27**] 05:43AM BLOOD WBC-7.1 RBC-3.50* Hgb-10.5* Hct-31.9*
MCV-91 MCH-29.9 MCHC-32.9 RDW-14.8 Plt Ct-761*
##
CT [**Last Name (un) 103**] [**2181-2-12**]:
1. Large left perinephric and subcapsular hematoma which
displaces and compresses the left kidney medially. Multiple foci
of active extravasation are demonstrated within the left
perinephric space. The hematoma extends to the retroperitoneum
bilaterally.
2. The left renal vein at the left hilum is not well visualized,
and this may be due to compression of the vein by the left
perinephric hematoma or formation of thrombus within this
region.
3. Both kidneys enhance symmetrically. Bilateral renal cysts and
renal calculi are demonstrated without evidence of
hydronephrosis.
4. Small amount of hemoperitoneum noted within the perihepatic
space likely related to the large retroperitonal hematoma.
5. Bibasilar atelectasis with small left pleural effusion.
##
Angio [**2181-2-12**]:
1. Selective left renal arteriography revealed active contrast
extravasation from two areas arising from the cortical surface
of the lower half of the left kidney.
2. Successful superselective gelfoam embolization of three left
renal artery branches where the extravasation was identified,
with good immediate angiographic results.
3. Selective left L1, L2, and L3 lumbar arteriography without
evidence of extravasation or vascular abnormality.
4. Left iliac arteriography was performed and showed no evidence
of extravasation or vascular abnormality from the branches of
the hypogastric, external iliac, or common femoral arteries.
##
CXR [**2181-2-28**]:
Decrease of bilateral pleural effusion with bibasilar
atelectasis. Left lower lobe opacity, probably representing
atelectasis, however, pneumonia cannot be totally excluded.
Brief Hospital Course:
NEURO: Mr. [**Known lastname **] was admitted to the TSICU after undergoing an
angiogram with embolization for his left kidney fracture. He was
placed on a CIWA scale, ativan as needed and dilaudid for the
pain. The patient developed delirium tremens with severe
tremors, agitation and was tachycardic to 140s on HD#2
refractory to ativan, metoprolol, IVF boluses. The patient was
sedated and intubated until HD#13. Once extubated, the patient
was placed on oral pain medications with good results.
##
RENAL: The patient's angiogram revealed bleeding cortical
vessels. This was embolized with gelfoam. Repeat hematocrit
levels showed moderate drops corrected with a series of blood
transfusions. A repeat angiogram did not reveal further
bleeding. An IVC filter was placed for his history of DVT.
##
CV: The patient was placed on metoprolol with good control on
his hypertension. An echocardiogram revealed a normal ejection
fraction. He was also placed in lasix for diureses as his fluid
balance remained positive in the initial phase of his
hospitalization. A clonidine patch was also added to his
regimen. A lower extremity ultrasound did not reveal any DVT.
##
PULM: The patient developed atelectasis and consolidation in the
left lower lobe during his ICU stay requiring a course of
antibiotics. He was weaned off the ventilator on HD#13 with no
complications after failed prior attempts at extubation due to
episodes of hypoxemia and tachypnea.
##
ID: The patient grew Gram positive cocci from his arterial line
after her spiked a fever at 101.7 on HD#3. He was started on
vancomycin and later on levofloxacin due to a possible
infiltrate of the left lower lobe and staph coagulase negative
growth in the urine. The vancomycin was discontinued on HD#8 and
replaced by clindamycin. Levofloxacin was discontinued on HD#10
and oxacillin was started once sputum culture sensitivities
returned. On HD#9, the patient developed herpetic lesions on his
lips and was started on acyclovir. All antibiotics were
discontinued on HD#11. On [**2-27**], the patient developed a fever of
101.2. His right subclavian line was removed and sent for
culture. Urine and blood cultures remained negative. He
developed a flare of his gout prior to discharge and treated
with colchicine.
##
ORTHO: The patient's forehead laceration was sutured in the
emergency department and his sutures were removed on HD#6. No
other issues were uncovered.
##
EtOH: The patient was under prophylaxis with ativan and, despite
that, developed DTs in the ICU requiring intubation and
sedation. This resolved after the initial few days of ICU care.
He remained stable in that aspect throughout his hospital stay
thereafter. The patient discussed his drinking problem with
[**Name (NI) **] [**Name (NI) 54184**], our social worker, and agreed to seek for help
to overcome this problem.
##
DISPO: The patient was discharged in stable condition to a
rehabilitation facility.
Medications on Admission:
1. Coumadin 4 mg once daily
2. Protonix 40 mg once daily
3. Prilosec 20 mg once daily
4. Toprol XL 50 mg once daily
5. Probenecid 500
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
Disp:*1 1* Refills:*2*
2. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
Disp:*5 Patch Weekly(s)* Refills:*2*
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 26478**] - [**Location (un) 1157**]
Discharge Diagnosis:
1. Status post fall
2. Left renal fracture
Discharge Condition:
Stable
Discharge Instructions:
you were hospitalized in the trauma service for injuries you
sustained after your fall. you injured your left kidney and our
radiologists placed a catheter to stop the bleeding. you spent a
few days in the intensive care unit to monitor your blood count
closely. you have been sent to a rehabilitation facility to help
you regain your strength prior to returning home.
1. Notify MD if you develop fever, chills, increased abdominal
pain nausea, vomitting or diarrhea.
2. Avoid any heavy lifting until follow up with trauma clinic.
3. Avoid alcohol consumption.
Followup Instructions:
1. Follow up w/ PCP [**Last Name (NamePattern4) **] [**12-10**] weeks after discharge; Dr. [**First Name (STitle) **].
2. Follow up with trauma clinic in 2 weeks [**Telephone/Fax (1) 600**], call
[**Doctor First Name **] for appt.
3. Follow up with Dr. [**Last Name (STitle) 261**] at urology clinic as needed
[**Telephone/Fax (1) 277**]
Completed by:[**2181-2-28**]
ICD9 Codes: 486, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3351
} | Medical Text: Admission Date: [**2156-4-13**] Discharge Date: [**2156-4-14**]
Date of Birth: [**2083-10-18**] Sex: M
Service: MEDICINE
Allergies:
Ceftriaxone
Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
[**First Name3 (LF) **] meningitis, ceftriaxone desensitization
Major Surgical or Invasive Procedure:
PICC line
History of Present Illness:
72-year-old male with history of [**First Name3 (LF) **] disease ([**2149**] and [**2154**])
and glaucoma who developed Bell's palsy after a trip to [**Hospital3 **] two weeks ago presents to the [**Hospital3 12145**] for ceftriaxone
desensitization for presumed [**Hospital3 **] meningitis.
.
His symptoms started on [**2156-3-29**] when he developed a left sided
headache. He also had low-grade fever of 100.5 around this time.
He saw Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] on [**2156-4-1**] who ordered an MRI head, which
came back negative. His symptoms continued to worsen and he
developed left sided numbness and difficulty closing his left
eye. He was concerned for closed angle glaucoma, which he has a
history of and presented to [**Hospital 13128**], where he was ruled
out for this and told to see an opthalmologist for the
difficulty closing his left eye. He continued to worsen and was
seen in the ED on [**4-4**] and blood taken in the ED returned
positive for [**Month/Year (2) **]. He was seen by neurology who thought that he
should be discharged with prednisone and seen by neuro urgent
care. They decided not to take the prednisone because his wife
read on the internet that you are not supposed to take steroids
during an infection. He was referred to a neurologist who saw
him yesterday on [**2156-4-12**] and did an LP which showed 53 WBC in
4th bottle, 94% lymphs (2RBC, protein 50, glucose 59) and was
sent for VZV, HSV and Borriella PCR which are pending. Given his
clinical course and lab results he was presumed to have [**Date Range **]
meningitis requiring Ceftriaxone. However, he has a hisory of
rash immediately following Ceftriaxone in the past so he is
being directly admitted to the ICU for Ceftriaxone
desensitization.
.
On arrival, the patient complains of mild left sided headache
with retroorbital pain, which is the same as his prior pain for
the past 2 weeks. He denies any other symptoms including chest
pain, shortness of breath, cough, chills, sweats, nausea,
vomitting, diarrhea, abdominal pain, calf pain, focal weakness,
numbness or tingling, seizures, or any other neurologic
symptoms. Positive neck soreness but no stiffness.
Past Medical History:
#. Hyperlipidemia, diet controlled.
#. Ventricular ectopy on stress test.
#. History of glaucoma, controlled.
#. Lipoma removed left hip
#. [**Date Range **] disease twice ([**2145**], [**2149**] both treated with
Doxycycline. In [**2154**] he had a tick bite and was treated with 1
dose of doxycycline)
Social History:
Retired editor of a sailing magazine. Never smoker and drinks
[**12-21**] glasses of wine weekly. No drugs. Lives with his wife in
[**Location (un) 2030**] and exercises 3-4 times per week.
Family History:
Father: CVA age 38 lived till 93, mother CVA age
76 lived to 84. Brother: melanoma and CAD
Physical Exam:
GEN: pleasant, comfortable, NAD, obvious left sided facial droop
HEENT: PERRLA, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact except for complete left sided
facial droop with inability to close left eye lid, left sided
facial numbness in all 3 dermatomes, an inability to smile with
left side of face. 5/5 strength throughout upper and lower
extremities. No sensory deficits to light touch appreciated. No
pass-pointing on finger to nose. 2+DTR's-patellar and biceps. No
nuchal rigidity.
Pertinent Results:
Labs on admission:
[**2156-4-13**] 03:58PM BLOOD WBC-4.7 RBC-4.40* Hgb-14.5 Hct-41.2
MCV-94 MCH-33.0* MCHC-35.2* RDW-12.6 Plt Ct-233
[**2156-4-13**] 03:58PM BLOOD Neuts-67.9 Lymphs-25.9 Monos-4.1 Eos-1.6
Baso-0.5
[**2156-4-13**] 03:58PM BLOOD Plt Ct-233
[**2156-4-13**] 03:58PM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-140
K-4.3 Cl-104 HCO3-28 AnGap-12
[**2156-4-13**] 03:58PM BLOOD Calcium-8.9 Phos-3.1 Mg-2.2
[**2156-4-12**] 03:40PM CEREBROSPINAL FLUID ([**Month/Day/Year **]) PROTEIN-50*
GLUCOSE-59
[**2156-4-12**] 03:40PM CEREBROSPINAL FLUID ([**Month/Day/Year **]) WBC-53 RBC-2*
POLYS-0 LYMPHS-94 MONOS-6
[**2156-4-12**] 03:40PM CEREBROSPINAL FLUID ([**Month/Day/Year **]) WBC-44 RBC-7*
POLYS-0 LYMPHS-94 MONOS-6
.
Labs on discharge:
[**2156-4-14**] 03:26AM BLOOD WBC-4.5 RBC-4.17* Hgb-13.5* Hct-38.6*
MCV-93 MCH-32.4* MCHC-35.0 RDW-12.7 Plt Ct-217
[**2156-4-14**] 03:26AM BLOOD Glucose-118* UreaN-12 Creat-0.9 Na-139
K-3.9 Cl-107 HCO3-26 AnGap-10
.
Pending labs:
- To follow up [**Month/Day/Year **] [**Month/Day/Year **] IGM/IGG results call [**Company 5620**]
at [**Telephone/Fax (1) 40616**]
- To follow up blood [**Telephone/Fax (1) **] IGM/IGG results call [**Hospital **] Medical Labs
at [**Telephone/Fax (1) 40617**], be sure to have [**Hospital1 18**] account # if necessary
([**Numeric Identifier 40618**])
Brief Hospital Course:
72-year-old male with history of [**Numeric Identifier **] disease ([**2149**] and [**2154**])
and glaucoma who developed Bell's palsy after a trip to [**Location (un) 7453**] two weeks ago presents to the [**Location (un) 12145**] for ceftriaxone
desensitization for presumed [**Location (un) **] meningitis.
.
#. Subacute meningitis: Presumed [**Location (un) **] meningitis given recent
exposure, positive [**Location (un) **], Bell's Palsy and [**Location (un) **] done as an
outpatient with normal glucose, lymphocytic predominence, and
negative gram stain. Patient's PCP arranged for him to be
admitted to the hospital for Ceftriaxone desensitizaton given
his history of immediate allergy to Ceftriaxone. HSV
encephalitis is unlikely given the lack of confusion or altered
mental status and lack of associated changes on recent MRI brain
imaging. HSV titer is pending. Plan was discussed with
infectious disease, neurology (Dr. [**Last Name (STitle) **], PCP, [**Name10 (NameIs) 12145**], and
allergy attendings on call.
-Patient tolerated ceftriaxone desensitization on [**4-13**]
-he received his first dose of ceftriaxone 2 grams on [**4-14**]
-per discussion with neurology (Dr. [**Last Name (STitle) **], will proceed
with 2 gram IV ceftriaxone for 28 days
-PICC line was placed on [**4-14**] for 28 days of Abx
-HSV, VZV, [**Month/Year (2) **] culture, [**Month/Year (2) **] IgM and IgG serologies, and
B.Burgdorferi PCR in [**Month/Year (2) **] are pending and will be followed by
PCP, [**Name10 (NameIs) **] [**Last Name (STitle) 1007**]
.
#. Ceftriaxone Allergy:
-Ceftriaxone Desensitization per protocol completed without
adverse reaction
.
#. Hyperlipidemia
-diet controlled
-fish oil as an outpatient
.
F/U on discharge:
- routine PICC line care
- ceftriaxone 2 gram IV x 28 days with PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]
- HSV, VZV, [**Last Name (NamePattern1) **] culture, [**Last Name (NamePattern1) **] IgM and IgG serologies, and
B.Burgdorferi PCR in [**Last Name (NamePattern1) **] are pending and will be followed by PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] [**Name11 (NameIs) **] IGM/IGG results [call [**Company 5620**] at
[**Telephone/Fax (1) 40616**]]
- [**Telephone/Fax (1) **] IGM/IGG results [call [**Hospital **] Medical Labs at [**Telephone/Fax (1) 40617**],
be sure to have [**Hospital1 18**] account # if necessary ([**Numeric Identifier 40618**])]
Medications on Admission:
1) Aspirin 81 mg
2) Fish Oil
Discharge Medications:
1. ceftriaxone 2 gram Recon Soln Sig: Two (2) grams Intravenous
once a day for 28 days.
2. 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.
3. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
Capsule(s)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. [**Numeric Identifier **] meningitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because you have [**Numeric Identifier **] meningitis and
you needed Ceftriaxone desensitization. You tolerated this
well. It is very important that you continue to take your
Ceftriaxone on time every day or else you are at risk of an
allergic reaction. It is also important to know that once your
course of antbiotics is finished you will still be allergic to
Ceftriazone. If you need this medication again you will have to
come to the hospital again.
.
We made the following changes to your medications:
Ceftriaxone 2g IV q24 hours for 28 days
Please continue to take all your medications as tolerated.
Followup Instructions:
You will follow-up with neurology, Dr. [**First Name8 (NamePattern2) 5464**] [**Last Name (NamePattern1) **], on
[**5-21**] at 11:30 AM. If there are any concerns, please call her
at [**Telephone/Fax (1) 31415**].
.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], your PCP, [**Name10 (NameIs) **] arrange for you to come in to his
office for daily IV antibiotics and weekly blood tests during
the four weeks of ceftriaxone.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3352
} | Medical Text: Admission Date: [**2124-3-16**] Discharge Date: [**2124-3-22**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
male with past medical history significant for CHF, atrial
fibrillation, and cardiomyopathy who presents with left lower
extremity cellulitis and hematoma. The patient bumped his
left shin with a suitcase approximately 6 days prior to
admission. He then developed a focal hematoma, which
progressively increased in size over the next few days. He
saw his PCP 4 days prior to admission, he was concerned for
concurrent cellulitis. He was started on Keflex to cover for
cellulitis and also Vicodin for pain. The patient
subsequently noted a decrease in his hematoma size. Today,
he went to see his cardiologist, who was concerned given the
significant hematoma size and concurrent cellulitis and
referred him to the Emergency Department to be admitted for
IV antibiotics. The patient does complain of shin pain
localizing to the hematoma site. He denies any distal
weakness or any sensory deficits. No fevers or chills. He
does note his INR was noted to be supratherapeutic this week,
at which point his Coumadin dose was decreased. At the time
of presentation in the Emergency Department, the patient was
afebrile with vital signs stable. He was started on IV Ancef
following attainment of blood cultures.
REVIEW OF SYSTEMS: Negative except as per HPI.
PAST MEDICAL HISTORY: Coronary artery disease, status post
CABG in [**2102**] and [**2106**] with LIMA to LAD, SVG to diagonal 1,
SVG to PDA.
Ischemic valvular cardiomyopathy.
Pulmonary hypertension.
Paroxysmal atrial fibrillation, on Coumadin.
Basal cell carcinoma.
Obstructive sleep apnea, on BiPAP.
Status post aortic valve replacement in [**2116**].
Hypercholesterolemia.
CHF with EF 35 percent.
Moderate mitral regurgitation.
Bradycardia, status post pacemaker and ICD placement in [**2120**].
Gynecomastia.
HOME MEDICATIONS:
1. Coumadin.
2. Digoxin.
3. Toprol XL.
4. Diovan.
5. Bumex.
6. Aspirin.
7. Zoloft.
8. [**Doctor First Name **].
9. Flonase.
10. Astelin.
11. Keflex.
12. P.r.n. Vicodin.
ALLERGIES: PENICILLIN CAUSES RASH. MORPHINE CAUSES
PARANOIA.
SOCIAL HISTORY: Married. Lives at home with wife. [**Name (NI) **]
alcohol, tobacco or IV drug use at present.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAM ON ADMISSION: VITAL SIGNS: Afebrile,
temperature 97.3 degrees, blood pressure 116/50, pulse 62,
and respirations 20. GENERAL: An elder male sitting in bed
in no acute distress. HEENT: Pupils equal, round and
reactive to light. Extraocular movements intact. Oropharynx
clear. Two punctate lesions on roof of mouth. No vesicles
or focal bleeding. NECK: Soft and supple, no JVD.
CARDIOVASCULAR: Irregular rate and rhythm. No murmurs.
LUNGS: Clear to auscultation, equal bilaterally. ABDOMEN:
Soft and nontender. EXTREMITIES: Left shin with an
approximately 4 cm circumferential hematoma with surrounding
erythema and 2 plus pitting edema. NEUROLOGIC: Strength 5/5
in bilateral lower extremities, although left lower extremity
exam limited secondary to pain. Sensation intact. Nonfocal
neurologic exam.
LABORATORY DATA: White count 9.6, hematocrit 35.2, platelets
337, with a differential of 70 neutrophils, 20 lymphs, 5
monocytes, and 4 eosinophils. PT 25.8, PTT 36.7 with an INR
of 4.4.
HOSPITAL COURSE: Cellulitis: The patient with left lower
extremity hematoma occurring in the setting of
supratherapeutic INR. He then developed a secondary
cellulitis. At the time of admission, he had been on 4 days
of oral antibiotics as an outpatient with failure to clear
his infection. He was started on IV Ancef at the time of
admission. Blood cultures were obtained, which remained
negative. He was continued on IV antibiotics throughout the
admission as his hematoma issues were treated and addressed.
The surrounding erythema did resolve, and his edema markedly
improved. On the day of discharge, he was then converted
over to oral antibiotics to complete a 7-day course of
Keflex.
Hematoma: The patient with left shin hematoma, which did
occur in the setting of a supratherapeutic INR.
Anticoagulation was held at the time of admission. Given the
lack of resolution of hematoma and concern for a concurrent
cellulitis, in addition to functional deficits due to
immobility due to pain, a Vascular Surgery consult was
obtained to evaluate the hematoma. He was taken to the OR
for evacuation. He tolerated this procedure well without any
complications. However, several hours after the procedure,
he did have extensive bleeding from the hematoma site. The
wound was compressed and pressure dressings were applied with
subsequent control of bleeding. He remained in-house several
days after this to ensure hemodynamic stability. He was then
discharged to home with plan to follow up in [**Hospital **] Clinic
in the next week. He also will have VNA for continued
dressing changes and wound care.
Atrial fibrillation/AVR: The patient was admitted with
diagnosis of atrial fibrillation and a recent AVR, for which
he takes Coumadin. His INR was noted to be supratherapeutic
at the time of admission. This was thought to be due to a
recent dose adjustment in his Coumadin with over aggressive
titration of his Coumadin dose. Coumadin was initially held
as per above. He was then restarted on this the day of
admission. He was on VNA at home to monitor his INR.
CHF: The patient with ischemic cardiomyopathy, CHF with an
EF of 35 percent. He had no clinical evidence of failure
during this hospitalization. He was maintained on beta-
blocker, ACE, Bumex and digoxin as per his home regimen. His
inputs, outputs, and weights were followed, and he was
maintained on a cardiac diet with fluid restriction. CHF
Service did see him while he was in-house and felt he was
doing well on his current regimen.
SVT: The patient with AICD defibrillator in place. He did
have a short run of an SVT, an approximately 6-beat run, for
which he was asymptomatic while in-house. The EP team did
come by and interrogate his pacemaker and felt that it was
functioning well. He will follow up as an outpatient in [**Hospital **]
Clinic.
DISCHARGE DIAGNOSES: Left lower extremity hematoma.
Left leg cellulitis.
Congestive heart failure.
Atrial fibrillation, on Coumadin.
Status post aortic valve replacement.
Coronary artery disease.
DISCHARGE MEDICATIONS:
1. Digoxin 0.125 mg daily.
2. Sertraline 50 mg daily.
3. Colace 100 mg b.i.d.
4. Valsartan 80 mg b.i.d.
5. Toprol XL 100 mg q.d.
6. Coumadin 6 mg at q.h.s.
7. Bumex 2 mg b.i.d.
8. Keflex 500 mg b.i.d. x 7 days.
9. Percocet p.r.n. x 7 days.
DISCHARGE FOLLOW-UP: Follow up with primary care doctor Dr.
[**First Name (STitle) **] on Wednesday, [**2124-3-29**]. Follow up with Surgery Dr.
[**Last Name (STitle) **] on Friday, [**2124-3-31**]. Follow up with Dr. [**First Name (STitle) **] in [**12-24**]
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16638**], [**MD Number(1) 16639**]
Dictated By:[**Last Name (NamePattern1) 14186**]
MEDQUIST36
D: [**2124-5-29**] 09:32:39
T: [**2124-5-29**] 22:51:59
Job#: [**Job Number 16640**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3353
} | Medical Text: Admission Date: [**2129-6-8**] Discharge Date: [**2129-6-11**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Meropenem / Penicillins / Carbapenem
Attending:[**Doctor First Name 3290**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
85M hypotensive to SBP 60s prior to HD today. Did not get
[**Doctor First Name 2286**]. Overall tells me that he was feeling well, had
breakfast this morning. Specifically he denied any fevers,
chills, nausea, vomiting ,diarrhea (had a normal BM this
morning). He is using a wheelchair at baseline and has been
using it today to get around his apartment without any
difficulty. He has not noticed any rashes. Of note, he had
fractured his left foot recently, but this has healing. He still
wears a brace when trying to walk with a walker.
ED Course:
- Initial Vitals: 97.4 78 80/46 20 98% 4L Nasal Cannula
- EKG: afib @ 67, LAD, QRS 114, TWI III, TW flattening v2-5
- WBC up from b/l
- 70s/30s, improved with bolus ~ 800 cc total
[x] bld cx
[x] CXR - low lung volumes, streaky basilar opacities, more in
left retrocardiac region, likely atelectasis, pleural
effusion/PNA not excluded
[x] UA --> doesn't make urine
[x] abx for ? PNA on CXR --> written for levo, vanc
.
On arrival to the MICU, patient told me that he was feeling much
better. His BP was 113/71, HR 68.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- ESRD on HD (MWF)
- CAD s/p MI
- Afib, not anticoagulated
- CVAs x2, residual R sided weakness, from 12 [**Doctor First Name 1686**] then 5 [**Doctor First Name 1686**] ago
- Hx of GI Bleed
- Nephrolithiasis
- OSA, not using CPAP
- Iron Deficiency Anemia
- Depression
- Hx of C.diff
- Restrictive Ventalatory Pulmonary Defect
- Pelvic and wrist fractures [**1-29**]
- Recurrent UTIs, including VRE and klebsiella
- Multiple episodes of line related bacteremia:
- MRSA in [**2125-9-6**] treated for 6 weeks of vanc given possible
clot in fistula. Line removed. TTE negative for vegetation. TEE
not performed.
- ESBL E.coli bacteremia in [**2125-9-26**] thought to be line related.
- ESBL E.coli bacteremia in [**2125-11-26**]. Thought to be line
related. s/p total 4-week course of meropenem/ertapenem.
([**Date range (1) 12915**]) for likely endovascular infection in setting of R
IJ clot.
- ESBL E.coli x 2 types, E. faecium [**Name (NI) 12916**] unclear source despite
extensive work-up ([**2126-6-27**]). s/p 4 weeks of Vancomycin and
Meropenem.
- ESBL E. coli and E. faecium [**Month/Day/Year 12916**] ([**2126-7-28**]) thought to be line
related s/p 2 weeks Vancomycin/Meropenem.
- Pansusceptible Klebsiella pneumoniae [**Month/Day/Year 12916**] thought [**1-20**] 7mm CBD
stone. s/p ERCP and stenting. Due for repeat ERCP
Social History:
Lives with wife [**Name (NI) **], wife of 62 [**Name2 (NI) 1686**]; she is his primary
caregiver. [**Name (NI) **] is wheelchair bound but has a nurse to help with
showering, daughter lives downstairs
-h/o smoking [**12-20**] PPD for 50 years, quit 20 years ago, occasional
beer, no drugs.
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, neck collar in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no CVA
tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, CN II-XII w/out decrement, PERRL, [**2-21**] RLE strength,
[**3-24**] RUE strength
Pertinent Results:
ADMISSION LABS
[**2129-6-8**] 01:05PM BLOOD WBC-9.5# RBC-3.61* Hgb-11.6* Hct-35.0*
MCV-97 MCH-32.1* MCHC-33.2 RDW-15.3 Plt Ct-137*
[**2129-6-8**] 01:05PM BLOOD Neuts-73.5* Lymphs-20.4 Monos-4.2 Eos-1.6
Baso-0.3
[**2129-6-8**] 01:05PM BLOOD PT-11.4 PTT-48.2* INR(PT)-1.1
[**2129-6-8**] 01:05PM BLOOD Glucose-97 UreaN-61* Creat-6.7*# Na-137
K-4.8 Cl-98 HCO3-22 AnGap-22*
[**2129-6-8**] 01:05PM BLOOD ALT-13 AST-15 AlkPhos-133* TotBili-0.2
[**2129-6-8**] 02:12PM BLOOD Lactate-1.7
[**2129-6-8**] 02:19PM BLOOD Lactate-0.9
.
[**2129-6-8**] CXR Portable AP
IMPRESSION: Low lung volumes with patchy basilar opacities,
greater on the left than right, probably attributable to
atelectasis, but not entirely specific.
If pulmonary symptoms are present or other concern for
pneumonia, than when clinically appropriate, short-term followup
chest radiographs, preferably with standard PA and lateral
technique if possible, could be considered
[**2129-6-11**] CXR PA and lateral
PENDING
Brief Hospital Course:
85 M w/ hx of ESRD on HD, CAD, afib, CVA w/ residual R sided
weakness who presented from [**Month/Day/Year 2286**] with hypotension.
#Hypotension: The patient was initially hypotensive in the ED
however BP normalized with one liter of IVF. BP normal upon
presentation to ICU (last admission BP normalized to approx
100-110 systolic). Hypotension was felt to most likely be
secondary to hypovolemia as the patient had no clear e/o
infection (WBC normal, no fevers). He was continued on
vancomycin and levofloxacin initially. The patients blood
pressure remained stable and he remained afebrile and was
transferred to the general medical service. Thereafter, BP were
normal with the exception of one event during hemodialysis; this
episode of hypotension was attributed to not taking midodrine
prior to hemodialysis as the patient normally does. The patient
declined further labs and ECHO and requested discharge to home.
As the patient remained afebrile and hemodynamically stable, the
antibiotics were discontinued and the patient was discharged
home.
STABLE ISSUES
#ESRD on HD: Patient is dialyzed on a MWF schedule. He had
missed [**Month/Day/Year 2286**] on the day of admission. As above blood pressure
stabilized and he was dialyzed on HD 1 and 3. He was also
continued on his home phosphate binder.
#Hx of CAD: no e/o active ischemia. No EKG changes. A cardiac
evaluation for heart failure was attempted; troponin 0.05 but
the patient declined further cardiac biomarkers and ECHO.
Patient was continued on his home statin and ASA.
# Atrial Fibrillation- Patient has a known hx of a fib in the
past. He is not currently anti-coagulated due to frequent falls.
His was intermittently in atrial fib throughout this admission.
However HR remained stable in the 80s-90s.
#Pulm Htn: noted TTE from [**2128-1-20**]. Has OSA but is not currently
on CPAP. No e/o heart failure on exam.
Medications on Admission:
1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for SOB.
4. midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous HD
protocol for 2 weeks.
Disp:*6 * Refills:*0*
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Gabapentin 300 mg PO HS
3. Ipratropium Bromide MDI 1 PUFF IH QID shortness of breath
4. Midodrine 5 mg PO BID
Please give dose before HD session.
5. Omeprazole 20 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. Acetaminophen 650 mg PO Q 8H
9. Ascorbic Acid 1000 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Cyanocobalamin 100 mcg PO DAILY
12. Calcium Acetate 1334 mg PO TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 12731**],
You were admitted to [**Hospital1 18**] for evaluation of low blood pressure
during hemodialysis. It is unclear what caused these low blood
pressures. We do not think you have an infection, and we could
not complete our tests of your heart function. We recommended
further tests, but you elected to defer these studies. Please
continue to take your medications as you had been taking them.
It was a pleasure taking care of you and we wish you a speedy
recovery!
Followup Instructions:
Please call your PCP on [**Name9 (PRE) 766**] to move up your appointment with
Dr. [**Last Name (STitle) **] to an earlier date.
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: TUESDAY [**2129-7-12**] at 1:30 PM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2129-6-13**]
ICD9 Codes: 4589, 5856, 4168, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3354
} | Medical Text: Admission Date: [**2194-9-1**] Discharge Date: [**2194-9-13**]
Date of Birth: [**2141-9-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
increasing DOE and angina
Major Surgical or Invasive Procedure:
s/p R thoracotomy/redo sternotomy/redo Bentall(23mm St. [**Male First Name (un) 923**]
mechanical AV graft composite)/closure of PA w/ pericardial
patch/coronary artery jump graft [**2194-9-2**]
History of Present Illness:
52 yo male with five prior aortic valve replacements, including
homograft Bentall procedure in [**2181**]. He had an aborted [**Last Name (un) 73756**]
procedure via left thoracotomy in [**2193-4-29**]. He has severe
homograft prosthetic AI associated with symptoms for the past
year and CHF hospitalization [**7-26**]- [**2194-8-7**]. Preoperative workup
for surgery started during that hospitalization. Echo [**2194-7-28**]
showed EF >55%, [**12-31**]+ AI, and reversal of diastolic flow.
Past Medical History:
Congential aortic valve anomaly s/p 5 AVR including Homograft
Bentall procedure [**2181**]
endocarditis
Possible prior MI
CHF
Atrial flutter s/p ablation
Hep B&C
History of IV drug use
Childs Class A Cirrhosis
HTN
s/p adenoidectomy
s/p remote gunshot wound
Peptic ulcer disease
CVA s/p surgery [**2181**]
Social History:
Social history is significant for the presence of current
tobacco use. There is no history of alcohol abuse. Prior IVDU.
The patient lives in [**Hospital1 189**]. He previously worked as a mechanic.
Family History:
Mother - aortic valve disease and died from CHF at 55. There is
no family history of premature coronary artery disease or sudden
death.
Physical Exam:
T 98.1 HR 76 `150/60 RR 22 99% RA sat.
alert and oriented x3, NAD
RRR with SEM
CTAB with decreased BS at bases
multiple scars on abd healed, soft, NT, ND, +BS
+ peripheral pulses
66 " 56.7 kg
Pertinent Results:
[**2194-9-13**] 05:40AM BLOOD WBC-6.5 RBC-3.36* Hgb-9.5* Hct-29.4*
MCV-88 MCH-28.2 MCHC-32.2 RDW-17.7* Plt Ct-357#
[**2194-9-13**] 05:40AM BLOOD PT-21.2* PTT-47.9* INR(PT)-2.1*
[**2194-9-13**] 05:40AM BLOOD Plt Ct-357#
[**2194-9-13**] 05:40AM BLOOD Glucose-95 UreaN-17 Creat-1.1 Na-137
K-3.8 Cl-99 HCO3-30 AnGap-12
[**2194-9-8**] 06:20AM BLOOD ALT-96* AST-81* AlkPhos-71 Amylase-60
TotBili-0.8
[**2194-9-1**] 07:20PM BLOOD %HbA1c-4.9
Cardiology Report ECHO Study Date of [**2194-9-2**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: Abnormal ECG. Aortic valve disease. Congestive heart
failure. Coronary artery disease. Left ventricular function.
Mitral valve disease. Mitral valve prolapse. Prosthetic valve
function. Right ventricular function. Valvular heart disease.
Status: Inpatient
Date/Time: [**2194-9-2**] at 16:58
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW05-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *7.0 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 5.9 cm
Left Ventricle - Fractional Shortening: *0.16 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%)
INTERPRETATION:
Findings:
LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast
or thrombus
in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins
identified and enter
the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing
wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity.
Moderately depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal
inferior -
hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo; basal anterolateral - hypo; mid anterolateral - hypo;
anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex -
hypo;
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Normal descending aorta diameter. Complex (>4mm)
atheroma in the
descending thoracic aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Thickened AVR
leaflets. No AS. Severe (4+) AR. Eccentric AR jet directed
toward the anterior
mitral leaflet.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
MVP. Moderate
mitral annular calcification. Moderate thickening of mitral
valve chordae.
Moderate (2+) 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. The TEE probe
was passed
with assistance from the anesthesioology staff using a
laryngoscope. No TEE
related complications.
Conclusions:
PRE-BYPASS: The left atrium is markedly dilated. No spontaneous
echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage.
The right atrium is moderately dilated. No atrial septal defect
is seen by 2D
or color Doppler. Left ventricular wall thicknesses are normal.
The left
ventricular cavity is severely dilated. Overall left ventricular
systolic
function is moderately depressed (LVEF= XX %). There is moderate
global right
ventricular free wall hypokinesis. There are complex (>4mm)
atheroma in the
descending thoracic aorta. A bioprosthetic aortic valve
prosthesis is present.
The prosthetic aortic valve leaflets are thickened. There is no
aortic valve
stenosis. Severe (4+) aortic regurgitation is seen. The aortic
regurgitation
jet is eccentric, directed toward the anterior mitral leaflet.
The mitral
valve leaflets are moderately thickened. There is mild mitral
valve prolapse.
There is moderate thickening of the mitral valve chordae.
Moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 73757**])
RADIOLOGY Final Report
CHEST (PA & LAT) [**2194-9-13**] 8:49 AM
CHEST (PA & LAT)
Reason: check hydroptx
[**Hospital 93**] MEDICAL CONDITION:
52 year old man s/p right thoracotomy/redo .
REASON FOR THIS EXAMINATION:
check hydroptx
EXAMINATION: PA and lateral chest.
INDICATION: Right hydropneumothorax.
PA and lateral views of the chest are obtained on [**2194-9-13**] and
compared with the most recent study performed on [**2194-9-10**]. There
has been a decrease in the size of the loculated effusion on the
right side, both in the retrosternal area and in the major
fissure. The pneumothorax has decreased in size with only a tiny
apical amount remaining. Air-fluid level seen in the
retrosternal area consistent with small loculated
hydropneumothorax has resolved. Small amount of fluid is seen at
the right costophrenic angle and a small left pleural effusion
is also present. The patient is status post recent cardiac
surgery with multiple skin staples present.
IMPRESSION:
Decrease in right-sided loculated hydropneumothorax. Persistent
small left pleural effusion.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: SAT [**2194-9-13**] 8:38 PM
Brief Hospital Course:
Admitted [**2194-9-1**] to complete dental workup . Surgery done on [**9-2**]
with Dr. [**Last Name (STitle) 1290**]. Transferred to the CSRU in stable condition
on neosynephrine, epinephrine, epinephrine and propofol drips.
Extubated on POD #2. Followed by the hepatology service.
Transferred to the floor on POD #3. Coumadin started for
mechanical valve. Chest tubes removed sequentially over the next
week and pacing wires removed without incident. Seen by vascular
surgery for right groin cannulation site swelling on POD #7.
Right CFA hematoma /pseudoaneursym diagnosed by US. Repeat fem.
US done [**9-10**] showed no flow into hematoma and no pseudoaneursym
present. Coumadin therapeutic for discharge on [**9-13**] and cleared
to go home with services. Coumadin/INR followup with Dr.
[**Last Name (STitle) 52855**]. First blood draw Monday [**9-15**]. Pt. to make all follow
up appts. as per discharge instructions.
Medications on Admission:
ASA 81 mg daily
Fe SO4 325 mg [**Hospital1 **]
lasix 80 mg [**Hospital1 **]
lisinopril 2.5 mg daily
lopressor 12.5 mg [**Hospital1 **]
methadone 20 mg daily
protonix 40 mg daily
senna one tab [**Hospital1 **]
zocor 20 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day.
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 2
days: Take as directed by Dr. [**Last Name (STitle) 52855**] for INR goal of
2.5-3.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
Aortic insufficiency
Mitral regurgitation
MVP
s/p multiple cardiac surgeries
s/p endocarditis
s/p CVA
COPD
a flutter
s/p GI bleed
hepatitis B
hepatitis C
cirrhosis
HTN
diastolic CHF-chronic
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds.
Call our office with sternal drainage, temp>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 52855**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Completed by:[**2194-9-15**]
ICD9 Codes: 4241, 4240, 4280, 9971, 496, 5715, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3355
} | Medical Text: Admission Date: [**2132-3-28**] Discharge Date: [**2132-4-3**]
Date of Birth: [**2132-3-28**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname 65737**] [**Known lastname 1191**] is the former 3.050
kg product of a 38 and 2/7 weeks gestation pregnancy, born to
a 34-year-old, Gravida V, Para 1 now 2 woman. Prenatal
screens: Blood type 0 positive, antibody negative, RPR
nonreactive. Rubella immune. Hepatitis B surface antigen
negative. Group beta strep status negative.
[**Hospital **] MEDICAL HISTORY: Notable for Grave's disease that
was treated with a thyroidectomy in the year [**2129**] and is on
subsequent Levo-thyroxine replacement.
PAST OBSTETRICAL HISTORY: Notable for a 42 week gestational
age infant, delivered by Cesarean section for fetal distress.
Spontaneous abortions x3; dilation and curettage x3 with no
fetal abnormalities. This was a planned, repeat Cesarean
section. Pregnancy was complicated by an anterior placenta
for which several ultrasounds were normal. Elective Cesarean
section was performed under spinal anesthesia. Rupture of
membranes occurred at delivery, yielding clear amniotic
fluid. Infant had Apgars of 8 at 1 minute and 8 at 5
minutes. She developed respiratory distress in the first
hour of life and was transferred to the NICU for further
evaluation.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, weight was 3,050 kg; length 44 cm, head
circumference 35 cm. Oxygen saturation 94% in 100% oxygen.
Head, eyes, ears, nose and throat: Anterior fontanel soft
and flat, non dysmorphic facies, palate intact. No nasal
flaring. Chest: Mild to moderate intercostal retractions.
Breath sounds fair bilaterally. Scattered, coarse crackles.
Cardiovascular: Well perfused, regular rate and rhythm, no
murmur. Femoral pulses normal. Abdomen: Soft, nontender, no
organomegaly, no masses. Bowel sounds active. Anus patent.
Genitourinary: Normal female. Central nervous system:
Active, alert, reactive to stimuli. Tone slightly decreased
in symmetric distribution, moving all extremities. Suck, gag
intact. Grasp symmetric. Musculoskeletal: Normal spine,
limbs, hips and clavicles and skin normal pink, without
lesions.
HOSPITAL COURSE:
1. Respiratory: [**Known lastname 65737**] was intubated shortly after admission
to the NICU for respiratory distress. Her chest x-ray
was 8 to 9 ribs expanded with diffuse moderate alveolar
opacification. She was treated with 2 doses of
Surfactant. She was able to wean rapidly to room air and
low settings and was extubated to continuous positive
airway pressure on day of life #2. She transitioned to
nasal cannula oxygen by day of life #3 and weaned to room
air by day of life #4. At the time of discharge, she is
breathing comfortably with a respiratory rate of 50 to 70
breaths per minute, oxygen saturations greater than 95%
in room air.
1. Cardiovascular: Due to the respiratory distress and
hypoxemia, there was concern for possible congenital
heart disease. An echocardiogram was obtained on the day
of birth and showed a structurally normal heart with
pulmonary hypertension with right to left shunting across
the PDA and left to right shunting across the PFO. An
electrocardiogram was within normal limits. She received
one initial normal saline bolus for some borderline
hypotension. A murmur was heard on day of life #3 and
remained audible at the time of discharge. Baseline
heart rate is 120 to 150 beats per minute with a recent
blood pressure of 73/46 with a mean of 52.
1. Fluids, electrolytes and nutrition: [**Known lastname 65737**] was initially
n.p.o. and given intravenous fluids. She had an
umbilical arterial catheter that was discontinued on day
of life #2. Enteral feeds were started on day of life #3
and were well tolerated. At the time of discharge, she is
ad lib feeding Enfamil 20 calories per ounce formula.
Weight on the day of discharge is 3.040 kg.
1. Infectious disease: Due to the unknown etiology of the
respiratory distress, a sepsis evaluation was done upon
admission to the Neonatal Intensive Care Unit. A
complete blood count was within normal limits. A blood
culture was obtained prior to starting intravenous
Ampicillin and Gentamycin. Blood culture was no growth
at 48 hours and the antibiotics were discontinued.
1. Gastrointestinal: [**Known lastname 65737**] was treated for unconjugated
hyperbilirubinemia with phototherapy. Her peak serum
bilirubin was 12.8, total over 0.4 mg/dl direct. Her
most recent rebound bili on the day of discharge is 10.7
total over 0.3 mg/dl direct.
1. Hematologic: Hematocrit at birth was 46%. [**Known lastname 65737**] did not
receive any transfusions of blood products.
1. Neurology: [**Known lastname 65737**] has maintained a normal neurologic exam
during admission. There are no concerns at the time of
discharge.
1. Sensory: Audiology: Hearing screening was performed
with automated auditory brain stem responses. [**Known lastname 65737**]
passed in both ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, [**Hospital 1426**]
Pediatrics, [**Hospital1 **]., [**Location (un) 86**], [**Numeric Identifier **]. Phone
number [**Telephone/Fax (1) 37802**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding ad lib Enfamil 20.
2. No medications.
3. Car seat position screening not indicated.
4. State newborn screen was sent on [**2132-3-31**] with no
notification of abnormal results to date.
5. Hepatitis B vaccine was administered on [**2132-4-1**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: (1) Born at less than
32 weeks; (2) Born between 32 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.
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.
FOLLOW UP: Appointment with Dr. [**Last Name (STitle) **] within 5 days of
discharge.
DISCHARGE DIAGNOSES:
1. Respiratory distress syndrome secondary to Surfactant
deficiency.
2. Pulmonary hypertension.
3. Suspicion for sepsis ruled out.
4. Unconjugated hyperbilirubinemia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2132-4-3**] 01:47:28
T: [**2132-4-3**] 05:13:40
Job#: [**Job Number 65738**]
ICD9 Codes: 769, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3356
} | Medical Text: Admission Date: [**2151-3-31**] Discharge Date: [**2151-4-3**]
Date of Birth: [**2086-10-5**] Sex: F
Service: MEDICINE
Allergies:
Imdur
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Less than 24 hour intubation in the medical intensive care unit.
History of Present Illness:
64 F w/ hx CABG (LIMA-LAD, SVG-RCA, jump SVG-RI-OM occluded),
occasional angina, DM, htn, hypercholesterolemia p/w SOB X [**1-30**]
days culminating in calling EMS tonight [**3-31**]. On arrival, patient
was hypoxemic (unclear to what degree), hypertensive to SBP 200,
agitated and was intubated in ambulance.
In ED, found to have RMS intubation, pulled back w/ atypical ETT
position, but normal pressures on vent and good blood gas. CXR
reveals CHF. BP 200/140Also w/ metabolic acidosis and DKA on
labs. Insulin gtt started. Afebrile. Given levoquin in ED.
Past Medical History:
CAD, s/p CABG [**1-/2143**] (LIMA-LAD, SVG-RCA, and SVG to RI to OM1) now
occluded. Persantine MIBI showed EF 46% with severe reversible
defects of inferolateral walls (worse than [**1-31**])
HTN
Hypercholesterolemia
DM recently diagosed in setting of DKA
s/p hemithyroidectomy
Social History:
smoked 1 ppdX 20 years, quit 10 years ago; denies etoh/illicits,
lives with husband
Family History:
NC
Physical Exam:
AF 100 151/83 14 98% AC 500X15, peep 10 and Fi 0.5
Gen: int/sedated
HEENT: EOMI, PERRL
CV: Tachy, regular, no nrg
Resp: Crackles B
Abd: distended, tympanic, hypactive BS, not tense
Ext: 2+ pitting edema to knees
Neuro/Psych: downgoing toes
Pertinent Results:
[**2151-3-31**] 07:59PM GLUCOSE-143* UREA N-8 CREAT-1.0 SODIUM-146*
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-22 ANION GAP-20
[**2151-3-31**] 07:59PM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-2.8*
[**2151-3-31**] 07:59PM PTT-42.8*
[**2151-3-31**] 05:16PM TYPE-ART TEMP-36.5 RATES-/35 O2-95 PO2-55*
PCO2-40 PH-7.40 TOTAL CO2-26 BASE XS-0 AADO2-599 REQ O2-96
INTUBATED-NOT INTUBA VENT-SPONTANEOU COMMENTS-HIGH [**Last Name (un) **] N
[**2151-3-31**] 05:16PM LACTATE-3.0*
[**2151-3-31**] 05:16PM O2 SAT-87
[**2151-3-31**] 03:19PM GLUCOSE-183* UREA N-8 CREAT-1.0 SODIUM-145
POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-21* ANION GAP-18
[**2151-3-31**] 03:19PM CK-MB-14* cTropnT-0.07*
[**2151-3-31**] 03:19PM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-1.8
[**2151-3-31**] 07:45AM GLUCOSE-74 UREA N-9 CREAT-0.9 SODIUM-147*
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-24 ANION GAP-17
[**2151-3-31**] 07:45AM CK(CPK)-335*
[**2151-3-31**] 07:45AM CK-MB-12* MB INDX-3.6 cTropnT-0.08*
[**2151-3-31**] 07:45AM CALCIUM-8.5 PHOSPHATE-2.7# MAGNESIUM-1.8
[**2151-3-31**] 07:45AM WBC-5.2 RBC-3.53* HGB-10.0* HCT-31.9* MCV-91
MCH-28.4 MCHC-31.4 RDW-16.1*
[**2151-3-31**] 07:45AM PLT COUNT-299
[**2151-3-31**] 07:45AM PT-12.4 PTT-20.1* INR(PT)-1.1
[**2151-3-31**] 05:54AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2151-3-31**] 05:54AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2151-3-31**] 05:54AM URINE RBC-[**3-1**]* WBC-[**3-1**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2151-3-31**] 04:24AM TYPE-ART RATES-14/0 TIDAL VOL-500 PEEP-10
O2-60 PO2-112* PCO2-42 PH-7.36 TOTAL CO2-25 BASE XS--1
-ASSIST/CON INTUBATED-INTUBATED
[**2151-3-31**] 04:19AM COMMENTS-GREEN TOP
[**2151-3-31**] 04:19AM GLUCOSE-171* K+-2.6*
[**2151-3-31**] 03:57AM GLUCOSE-189* UREA N-10 CREAT-0.9 SODIUM-146*
POTASSIUM-2.6* CHLORIDE-112* TOTAL CO2-18* ANION GAP-19
[**2151-3-31**] 02:20AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2151-3-31**] 02:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
[**2151-3-31**] 02:20AM URINE RBC-21-50* WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-[**6-6**] TRANS EPI-[**3-1**] RENAL EPI-[**3-1**]
[**2151-3-31**] 02:20AM URINE HYALINE-0-2
[**2151-3-31**] 02:05AM LACTATE-5.1*
[**2151-3-31**] 01:33AM TYPE-ART RATES-14/ TIDAL VOL-500 PEEP-8 O2-60
PO2-71* PCO2-41 PH-7.28* TOTAL CO2-20* BASE XS--6 -ASSIST/CON
INTUBATED-INTUBATED
[**2151-3-31**] 12:30AM GLUCOSE-324* UREA N-10 CREAT-1.2* SODIUM-140
POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-15* ANION GAP-25*
[**2151-3-31**] 12:30AM estGFR-Using this
[**2151-3-31**] 12:30AM CK(CPK)-179*, cTropnT-0.04*, CK-MB-5
proBNP-7201*
[**2151-3-31**] 12:30AM CALCIUM-9.5 PHOSPHATE-6.4*# MAGNESIUM-2.0
[**2151-3-31**] 12:30AM WBC-7.6# RBC-3.97* HGB-11.4* HCT-38.4 MCV-97#
MCH-28.7 MCHC-29.7*# RDW-15.8*
[**2151-3-31**] 12:30AM NEUTS-40* BANDS-1 LYMPHS-49* MONOS-7 EOS-3
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2151-3-31**] 12:30AM PLT SMR-NORMAL PLT COUNT-368#
[**2151-3-31**] 12:30AM PT-12.5 PTT-24.7 INR(PT)-1.1
.
2D-ECHOCARDIOGRAM performed on [**2151-3-31**] demonstrated:
Conclusions: EF 30-35%
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. Left ventricular wall thicknesses
are normal. Overall left ventricular systolic function is
moderately depressed with global hypokinesis. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. There is
mild global right ventricular free wall hypokinesis. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse.
Moderate (2+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is at least mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
.
[**2151-3-31**]
Admission CXR
IMPRESSION:
1) Right mainstem bronchus intubation; this has been corrected
on the
subsequent chest radiograph.
2) Complete opacification of the left hemithorax with volume
loss from
collapse due to the malpositioned endotracheal tube.
3) Evidence of congestive heart failure/volume overload with a
moderate right pleural effusion.
Brief Hospital Course:
This is a 64 y/o with CHF, hx CABG (LIMA-LAD, SVG-RCA, jump
SVG-RI-OM occluded), DM, htn, hypercholesterolemia, presented
with hypertensive urgency, pulmonary edema, s/p intubation and
successful extubation, as well as metabolic acidosis, likely DKA
versus lactic acidosis
.
MICU course significant for rapid extubation in < 24 hours with
diuresis. Patient's blood pressure was controlled with ACE-I,
HCTZ and metoprolol.
.
1. Cardiac: Patient with history of CAD including CABG, most
stents occluded, presented with progressive dyspnea, pulmonary
edema and DKA. Her troponins were slightly elevated on
admission, likely secondary to demand from CHF exacerbation and
pulmonary edema. She was evaluated by cardiology in the unit
who recommended medical management including optimization of her
blood pressure medications. She remained chest pain free and
shortness of breath much improved after diuresis. She was
maintained on ASA, BB, ACE-I, Statin and plavix, and her blood
pressure medications were titrated upwards as tolerated. LVEF
depressed to 30%, likely in setting of acute pulm edema versus
new onset CHF from acute event. She was started on lasix for
improved diuresis and was weaned off oxygen prior to discahrge.
Repeat CXR showed improvement of pulmonary edema.
.
2. Respiratory failure: Now resolved, likely secondary to
pulmonary edema. Acute episodes of shortness of breath may have
been secondary to elevated BP, DKA, difficult to tell what was
inciting factor. Not likely to be secondary to acute ischemic
event, as above. Repeat CXR showed improvement of pulmonary
edema. She was weaned off oxygen.
.
3. DM: [**3-3**], Hb A1C 16.5%. DKA on admission, gap has now closed.
[**Last Name (un) **] following during hospital course, recs appreciated.
.
4. Dispo: In good condition to home, ambulating without an
oxygen requirement
Medications on Admission:
Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times a
day.
Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Humalog 100 unit/mL Solution Sig: 0-16 units Subcutaneous
QAC/HS: Per sliding scale. Disp:*QS 1 month* Refills:*2*
Lantus 100 unit/mL Solution Sig: Thirty Three (33) units
Subcutaneous at bedtime. Disp:*QS 1 month* Refills:*2*
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Disp:*qs qs* Refills:*2*
10. Humalog 100 unit/mL Solution Sig: Per sliding scale units
Subcutaneous qachs: Please find attached sliding scale with your
discharge paperwork. .
Disp:*qs qs* Refills:*2*
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Emergency
Pulmonary Edema
Diabetic Ketoacidosis
Discharge Condition:
Vital signs stable. No shortness of breath or chest pain. No
peripheral edema.
Discharge Instructions:
Please return to the hospital if you feel short of breath, have
chest pain, or have blood sugars over 400. If you have vision
changes, headahces or blood in your urine you should return to
the hospital.
.
Please follow up with your primary care doctor's appointment and
all of your other appointments.
.
Please take all of your medications as prescribed. If we have
given you a prescription for a medication that you were already
on, then the dose may be different. For example we are giving
you a prescription for metoprolol Tartrate 50mg twice a day.
This is a greater dose than you were taking when you came in.
Please dispose of your old prescription and start on the new
one.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2151-4-15**] 9:00
Provider: [**Name Initial (NameIs) 703**] (C4) TCC RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2151-4-21**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2151-4-21**] 3:30
ICD9 Codes: 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3357
} | Medical Text: Admission Date: [**2178-9-8**] Discharge Date: [**2178-9-15**]
Service: ORTHOPAEDICS
Allergies:
Oxycontin
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Right hip fracture
Major Surgical or Invasive Procedure:
ORIF right hip.
History of Present Illness:
86 F w/ Alzheimer's dementia s/p fall from chair onto R hip w/
pain/deformity. No syncope or LOC.
Past Medical History:
1. Aortic aneurysm - details unclear, per daughter pt was told
she had no surgical options
2. Alzheimer's Dementia - lives in dementia unit/ALF. At
baseline does not always know place/time and prone to agitation
in a new environment
3. Osteoporosis
4. Hx of multiple fractures
5. Hx of falls
6. Hx of recurrent UTIs
7. ?Hx of Crohn's disease
8. Hypothyroidism
9. HTN
10. Depression
11. Hx of K antigen in blood - should get K antigen neg blood
transfusion if needed
Social History:
lives in dementia unit, an ALF, at [**Last Name (un) **]. Walks w walker at
baseline. No significant smoking, alcohol, drug use
Family History:
Noncontributory
Physical Exam:
Upon Discharge:
AVSS
NAD
AAO x 3
NCAT
RRR, S1S2
CTAB
Soft, NTND
RLE - wound c/d/i. Soft compartments. NVI. SILT. palpable DP
pulse.
Pertinent Results:
[**2178-9-7**] 10:55PM BLOOD WBC-10.7# RBC-3.43* Hgb-10.9* Hct-32.5*
MCV-95 MCH-31.6 MCHC-33.4 RDW-14.5 Plt Ct-273
[**2178-9-8**] 06:40AM BLOOD WBC-8.2 RBC-3.04* Hgb-9.5* Hct-28.7*
MCV-94 MCH-31.3 MCHC-33.2 RDW-14.1 Plt Ct-303
[**2178-9-8**] 05:05PM BLOOD WBC-14.6*# RBC-2.95* Hgb-9.2* Hct-27.1*
MCV-92 MCH-31.3 MCHC-34.0 RDW-15.4 Plt Ct-327
[**2178-9-9**] 01:14AM BLOOD WBC-9.7 RBC-3.07* Hgb-9.5* Hct-27.6*
MCV-90 MCH-30.8 MCHC-34.3 RDW-16.8* Plt Ct-223
[**2178-9-9**] 06:15AM BLOOD Hct-30.7*
[**2178-9-10**] 06:45AM BLOOD WBC-7.6 RBC-2.69* Hgb-8.4* Hct-24.0*
MCV-89 MCH-31.3 MCHC-35.1* RDW-16.2* Plt Ct-180
[**2178-9-10**] 11:50PM BLOOD WBC-9.7 RBC-3.42*# Hgb-10.4* Hct-30.0*
MCV-88 MCH-30.6 MCHC-34.8 RDW-16.1* Plt Ct-173
[**2178-9-11**] 06:50AM BLOOD WBC-9.6 RBC-3.31* Hgb-10.2* Hct-29.2*
MCV-88 MCH-30.8 MCHC-35.0 RDW-16.4* Plt Ct-185
[**2178-9-11**] 09:00AM BLOOD WBC-9.5 RBC-3.35* Hgb-10.5* Hct-29.6*
MCV-88 MCH-31.2 MCHC-35.3* RDW-16.5* Plt Ct-193
[**2178-9-12**] 06:40AM BLOOD WBC-8.4 RBC-3.08* Hgb-9.5* Hct-27.5*
MCV-89 MCH-30.8 MCHC-34.5 RDW-16.6* Plt Ct-227
[**2178-9-12**] 09:35PM BLOOD Hct-27.9*
[**2178-9-13**] 10:45AM BLOOD Hct-29.0*
[**2178-9-14**] 09:25PM BLOOD Hct-31.9*
[**2178-9-15**] 06:25AM BLOOD WBC-8.0 RBC-3.45* Hgb-10.6* Hct-31.2*
MCV-90 MCH-30.7 MCHC-34.0 RDW-16.6* Plt Ct-284
[**2178-9-7**] 10:55PM BLOOD PT-13.0 PTT-24.9 INR(PT)-1.1
[**2178-9-10**] 06:45AM BLOOD PT-12.6 PTT-26.4 INR(PT)-1.1
[**2178-9-11**] 09:00AM BLOOD PT-12.1 PTT-26.5 INR(PT)-1.0
[**2178-9-7**] 10:55PM BLOOD Glucose-125* UreaN-20 Creat-0.9 Na-137
K-4.8 Cl-104 HCO3-25 AnGap-13
[**2178-9-8**] 06:40AM BLOOD Glucose-131* UreaN-19 Creat-0.7 Na-136
K-4.9 Cl-104 HCO3-24 AnGap-13
[**2178-9-8**] 05:05PM BLOOD Glucose-161* UreaN-18 Creat-0.7 Na-133
K-4.5 Cl-102 HCO3-22 AnGap-14
[**2178-9-9**] 01:14AM BLOOD Glucose-171* UreaN-19 Creat-0.9 Na-133
K-4.1 Cl-104 HCO3-21* AnGap-12
[**2178-9-10**] 06:45AM BLOOD Glucose-118* UreaN-15 Creat-0.6 Na-131*
K-4.1 Cl-103 HCO3-23 AnGap-9
[**2178-9-10**] 11:50PM BLOOD Glucose-90 UreaN-17 Creat-0.7 Na-133
K-4.0 Cl-102 HCO3-25 AnGap-10
[**2178-9-11**] 06:50AM BLOOD Glucose-102 UreaN-18 Creat-0.7 Na-134
K-3.9 Cl-102 HCO3-23 AnGap-13
[**2178-9-11**] 09:00AM BLOOD Glucose-134* UreaN-17 Creat-0.8 Na-134
K-3.9 Cl-103 HCO3-22 AnGap-13
[**2178-9-12**] 06:40AM BLOOD Glucose-100 UreaN-17 Creat-0.6 Na-139
K-4.1 Cl-107 HCO3-24 AnGap-12
[**2178-9-15**] 06:25AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
[**2178-9-8**] 05:05PM BLOOD CK-MB-3 cTropnT-<0.01
[**2178-9-9**] 01:14AM BLOOD CK-MB-6 cTropnT-<0.01
[**2178-9-8**] 05:05PM BLOOD Calcium-8.8 Phos-3.7 Mg-1.7
[**2178-9-10**] 06:45AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.9
[**2178-9-10**] 11:50PM BLOOD Calcium-7.9* Phos-2.6* Mg-2.0
[**2178-9-11**] 06:50AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.9
[**2178-9-11**] 09:00AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9
[**2178-9-12**] 06:40AM BLOOD Calcium-7.6* Phos-2.0* Mg-2.2
Xrays of R hip [**9-8**]:
IMPRESSION:
1. Comminuted, displaced right femoral intertrochanteric
fracture. No
dislocation.
2. Osteoarthritis of bilateral hips.
CXR:
IMPRESSION:
1. Mild cardiomegaly, with mild CHF.
2. Slight cortical step-off and irregularity of the right
humeral neck.
Correlate with site of symptoms, and if clinically indicated,
dedicated right shoulder radiographs can be obtained to exclude
an acute fracture.
TTE:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Diastolic function could not be assessed because
of aortic regurgitation. Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is markedly dilated. No
dissection flap is seen (best excluded by [**Last Name (LF) **], [**First Name3 (LF) **] MR/CT).
The aortic valve leaflets (3) are thickened but with good
leaflet excursion. There is no aortic valve stenosis. Moderate
to severe (3+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is a physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Moderate to
severe aortic regurgitation. Markedly dilated ascending aorta.
CT Head:
IMPRESSION: No acute intracranial process.
CT Chest:
IMPRESSION:
1. Limited study with no evidence of pneumonia. Mild changes of
both lung
bases may represent atelectasis versus mild chronic interstitial
changes due to CHF.
2. Stable cardiomegaly. Based on the radiographic appearance,
pulmonary
edema seen on [**9-7**] has resolved today.
3. Ascending aortic aneurysm, unchanged.
4. Interval increase in diameter of aberrant right subclavian
artery, with
resultant proximal dilatation of the esophagus.
Brief Hospital Course:
Mrs. [**Known lastname 34586**] was seen in the ED and found to have a right
subtrochanteric femur fracture. She undwerwent ORIF on [**2178-9-8**].
She tolerated the procedure well, but had an epidose of SVT
intra-op that was quickly controlled with an esmolol drip. She
was sent to the ICU overnight for observation. She then
transferred to the general floor in stable condition the next
day.
Post op anemia: She was transfused a total of 6 units of prbcs
post op for acute blood loss anemia. On discharge, her blood
volume was stable.
Hypoxia: On POD 2 she desaturated down into the 70s. A CT of her
chest showed atelectasis and was otherwise benign. She improved
with supplemental oxygen and remained stable thereafter.
Her foley came out POD 4.
Her pain was well controlled with IV and then PO pain meds.
She tolerated a regular diet throughout her stay
She was seen and evaluated by PT.
She is being discharged today in stable condition with her
staples still in place.
Medications on Admission:
Synthroid 25', ASA 81', Omeprazole 20', Wellbutrin 75'',
Donepezil 10qhs, Vit D, Fosamax 70qfriday, Mirtazapine 15qhs
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily) for 4 weeks.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for crackles/wheezing.
13. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for crackles/wheezes.
17. Insulin
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-50 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
51-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Right hip fracture
Discharge Condition:
Stable, improved.
Discharge Instructions:
WBAT on your leg.
continue to ambulate daily and work with PT as planned.
Continue to take your blood thinning medication as planned.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications. * If you have shaking chills, or a fever greater
than 101.5 (F) degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Physical Therapy:
WBAT
Treatments Frequency:
Reinforce dressing as needed for drainage
Lovenox 40mg SC q24 hrs x 4 weeks
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in 2 weeks. Call
[**Telephone/Fax (1) 1228**] to make that appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2178-9-15**]
ICD9 Codes: 9971, 2851, 2761, 4019, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3358
} | Medical Text: Admission Date: [**2130-11-9**] Discharge Date: [**2130-11-11**]
Service: NEUROSURGERY
Allergies:
Neosporin
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Left subdural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 M on Coumadin for afib s/p fall on [**2130-10-4**] and presented to
the [**Hospital1 18**]. His head CT revealed bilateral SDH. He was admitted
for observation and discharged without surgical intervention. He
was readmitted on [**2130-10-14**] for failure to
thrive and was again discharged without surgical intervention.
His head CT revealed resolution of the R SDH but with a
persistent L SDH.
Since discharge, the patient had re-initiated his Coumadin. He
complains of intermittent pressure his head and continued
difficulty ambulating (baseline).
Past Medical History:
Subdural Hematoma [**10-4**]
Atrial Fibrillation
Hypertension
Hypothyroidism
Vertigo
BPH
Social History:
Social History: The patient lives alone at home and is very high
functioning, is the CEO of his own business. Denies tobacco,
alcohol or illicit drug use.
Family History:
Non-contributory
Physical Exam:
Office exam: the patient is sitting comfortably in a wheel
chair. He is awake, alert, and appropriate. Ox3. PERRL at 2 mm
and 1.5 mm. VFF. FS. hearing and shoulder shrug symmetric.
Tongue and uvula midline. His motor strength is notable for a
mild right pronator drift.
Pertinent Results:
[**2130-11-10**] 02:43AM BLOOD WBC-4.9 RBC-3.02* Hgb-9.8* Hct-28.5*
MCV-94 MCH-32.6* MCHC-34.6 RDW-14.5 Plt Ct-177
[**2130-11-10**] 02:43AM BLOOD Plt Ct-177
[**2130-11-10**] 02:43AM BLOOD Glucose-75 UreaN-18 Creat-1.3* Na-143
K-3.9 Cl-108 HCO3-25 AnGap-14
[**2130-11-10**] 02:43AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.0
Brief Hospital Course:
Mr [**Known lastname 634**] was admitted to the ICU his coagulopathy was
reversed with FFP and Vitamin K. He was observed overnight and
had a head CT on his second hospital day which was unchanged
from admission. The patient was offered surgery for which he
refused. He was transferred to the neurosurgery floor where his
neurological remained stable. He was discharged back to his
skilled nursing facility with instructions to resume his prior
physical therapy. He was instructed to make a follow-up
appointment to see Dr. [**First Name (STitle) **] in four weeks with a CT scan to be
obtained prior to the office visit.
Medications on Admission:
Levothyroxine 75 mcg daily
Amiodraone 200 mg PO daily
Diltiazem 180 mg SR daily
Trazodone 12.5 mg QHS:PRN
Tylenol 325 mg PRN
Metoprolol Tartrate 75 mg PO TID
Lasix 60 mg daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day for 4
weeks.
6. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Left sided subdural hematoma
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:
?????? 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) 88**] to schedule an appointment with Dr.
[**First 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: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3359
} | Medical Text: Admission Date: [**2119-2-14**] Discharge Date: [**2119-2-20**]
Date of Birth: [**2040-10-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Meperidine / Ace Inhibitors / Hydrocodone / Sulfa
(Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
epistaxis
Major Surgical or Invasive Procedure:
Placement of epistat
PICC line placement and removal
History of Present Illness:
78 F with ESRD, CAD, h/o CVA, COPD admitted from NH to [**Hospital 7912**] with epistaxis in the setting of ASA, Plavix,
Coumadin. She was admitted on Friday with INR 3.2 has required 3
units PRBC and 4 units FFP. Was seen by ENT and Epistat packing
with resolution of bleeding until this AM when she rebled during
HD. ENT replaced the Epistat packing with control of the
bleeding and labs from this morning HCT 30, plt 221, INR 1.2 and
she did not receive any further blood products. Patient was
transferred to [**Hospital1 18**] for ENT and possible embolization by
neuro-interventional radiology.
Upon arrival to the ICU ENT arrived and confirmed no active
bleeding.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
ESRD- patient on TTS schedule
CAD- stents last in [**1-/2118**]
Candidemia- on 4 wks
CVA
COPD
DM
Heart failure- unknown EF (diastolic per report)
Depression
h/o epistaxis
HTN
Aortic valve mass seen on TTE [**5-/2118**]
PVD
Patent foramen ovale
Dementia
Glaucoma
Atrial fibrillation
Childhood seizures
s/p hysterectomy
s/p cholecystectomy
s/p appendectomy
s/p exploratory laparotomy -age 18
Social History:
Lives in [**Hospital **] Nursing Home.
- Tobacco: none currently prior 45 pack year
- Alcohol: none
- Illicits: none
Family History:
CAD, DM, unknown cancer
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2119-2-14**] 08:42PM BLOOD WBC-13.6*# RBC-3.74* Hgb-11.2* Hct-34.5*
MCV-92 MCH-30.0 MCHC-32.5 RDW-17.9* Plt Ct-251
[**2119-2-14**] 08:42PM BLOOD Neuts-88.9* Lymphs-6.9* Monos-3.5 Eos-0.4
Baso-0.3
[**2119-2-14**] 08:42PM BLOOD PT-13.7* PTT-23.9 INR(PT)-1.2*
[**2119-2-14**] 08:42PM BLOOD Glucose-126* UreaN-21* Creat-4.1*# Na-144
K-4.0 Cl-103 HCO3-27 AnGap-18
[**2119-2-14**] 08:42PM BLOOD Calcium-9.6 Phos-3.1 Mg-1.8
.
DISCHARGE LABS:
[**2119-2-15**] 05:19AM BLOOD Triglyc-98
[**2119-2-20**] 06:29AM BLOOD WBC-9.7 RBC-3.14* Hgb-9.3* Hct-28.9*
MCV-92 MCH-29.6 MCHC-32.0 RDW-20.7* Plt Ct-226
[**2119-2-18**] 05:47AM BLOOD PT-12.1 INR(PT)-1.0
[**2119-2-20**] 06:29AM BLOOD Glucose-120* UreaN-34* Creat-5.1*#
Na-128* K-4.0 Cl-88* HCO3-25 AnGap-19
[**2119-2-19**] 06:41AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.9
.
Micro:
Blood Cx [**2-15**]: No growth to date (not finalized)
.
Imaging/Studies:
CXR [**2119-2-14**]: Mild cardiomegaly may be smaller. No pulmonary
edema, pulmonary vascular engorgement. A flame-shaped opacity
projecting over the right first rib anteriorly is probably
calcification, better appreciated on the [**2117-3-26**]
radiograph. Lungs are otherwise clear. There is no pleural
effusion. Mediastinal and hilar silhouettes are unremarkable.
Vascular stent and clips project over the left axilla.
.
TTE [**2119-2-15**]: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: No aortic valve mass seen. If indicated, a TEE would
be better to assess aortic valve structure.
Brief Hospital Course:
78 yo F with PAF on coumadin, dementia, ESRD on HD, CAD who
presents with posterior nasal bleed. Pt was initially admitted
to OSH last Friday for epistaxis in the setting of elevated INR
3.2 and taking ASA, Plavix and coumadin. She received 3 units
PRBC and 4 units FFP. She was stable until rebleeding on [**2-14**] at
dialysis and transferred to [**Hospital1 18**].
.
# Epistaxis: Patient was transferred to [**Hospital1 18**] for epistaxis
requiring multiple transfusions. She was initially admitted to
the MICU, where ENT placed balloon in left nostril for posterior
bleed. Her hematocrit remained stable while in MICU and she did
not require further transfusion. She remained hemodynamically
stable and the nasal balloon was removed from her left nostril
on [**2-19**] without complication. Per ENT, if the patient has any
additional epistaxis, use afrin in each nostril, lean head
forward, pinch nostrils closed for 20 minutes. Patient should
return to the hospital for any bleeding that does not resolve
with these measures. Coumadin should continue to be held for
two weeks, and restarted thereafter. ASA should be held for an
additionally week, and restarted at 81 mg daily thereafter.
Plavix should be discontinued permanently.
.
# ESRD: Pt on TTS schedule, last HD [**2-18**]. Next dialysis planned
for Tuesday, [**2119-2-21**]. She should continue nephrocaps and
sevelamer. She will also continue to receive epogen with
dialysis. Additionally, patient should continue to receive
fluconazole with dialysis for a total four week course.
.
# HTN: Antihypertensive medications were additionally, held and
gradually restarted for goal systolic BP of 110. She should
continue home anti-hypertensive regimen with amlodipine,
metoprolol, hydralazine and Imdur at discharge.
.
# Dementia/ Hx of embolic CVA: Coumadin and antiplatelet agents
were held during this admission, given significant nasal bleed.
The patient should resume anticoagulation with coumadin 2 weeks
after discharge, and should restart ASA 81 mg 1 week after
discharge.
.
# CAD: S/p PCI with stent placement [**1-14**]. All antiplatelet
agents were held on this admission. She was continued on statin
and antihypertensive regimen. Given that last PCI was greater
than one year ago, the patient may discontinue plavix completely
at discharge. She should restart ASA 81 mg one week after
discharge for coronary artery protection.
.
# Hx COPD: Continued on inhalers prn.
.
# Hx childhood seizures: The patient was continued on home dose
keppra for seizure prophylaxis.
.
# COMM: [**Name (NI) **] and Daughter [**First Name4 (NamePattern1) 1453**] [**Known lastname 174**], MD and son are HCP.
Daughter's phone numbers: [**Telephone/Fax (3) 78112**]
# CODE: DNR/DNI during this admission (but per HCP would consent
for elective intubation for procedure or airway protection)
Medications on Admission:
Coumadin 2mg daily
Norvasc 10mg daily
Aspirin 81mg daily
Keppra 500mg daily
Paxil 40mg daily
Plavix 75mg daily
MiraLax daily
Hydralazine 25mg three times daily
Lopressor 25mg three times daily
Lipitor 80mg at bedtime
Senokot at bedtime
Travatan eye drops both eyes at bedtime
Trazodone 75mg at bedtime
Dalyvite vitamin daily
Imdur 60mg daily
Renvela 80mg three times daily with meals
Nitroglycerin 1/150 for chest discomfort
Ativan as needed
Lactulose as needed
Fluconazole 200mg after dialysis for 4 weeks. Once positive
blood cultures are negative, can be stopped after 4 weeks
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Renvela 0.8 gram Powder in Packet Sig: One (1) PO three
times a day: with meals.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
14. Travatan 0.004 % Drops Sig: One (1) drop Ophthalmic at
bedtime: both eyes.
15. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO QHD (each
hemodialysis) for 4 weeks: 4 weeks once blood cultures negative.
16. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO once a
day.
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
18. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis
Posterior Nasal Epistaxis
Discharge Condition:
alert and oriented
ambulating on discharge
Discharge Instructions:
You were admitted with a posterior nasal bleed. You were seen by
our ENT doctors who stopped the bleeding with a balloon
tamponade packing. That packing has since been removed. The
following changes were made to your medications.
1. STOP Plavix
2. HOLD Aspirin and coumadin. It is fine to restart your aspirin
one week after discharge and your coumadin two weeks after
discharge.
Followup Instructions:
Follow-up with your primary care physician [**Name Initial (PRE) 176**] 1-2 weeks of
discharge.
ICD9 Codes: 5856, 2761, 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3360
} | Medical Text: Admission Date: [**2154-8-6**] Discharge Date: [**2154-9-17**]
Date of Birth: [**2081-10-8**] Sex: F
Service: Vascular
CHIEF COMPLAINT: Mesenteric ischemia.
HISTORY OF PRESENT ILLNESS: (Information was obtained from
the transfer records for [**Hospital **] Hospital and interview of
the patient)
This is a 72-year-old nondiabetic white female with a history
of hypertension, hypercholesterolemia, and history of
migraines headaches with complaints of postprandial
epigastric pain since [**Month (only) 404**]. She eats a regular diet with
good appetite, but pain starts about one and a half hours
after eating anything and last from two to two and a half
hours. She has lost 25 pounds since [**Month (only) 404**] and has been
admitted to [**Hospital **] Hospital several times.
A gastrointestinal workup with an esophagogastroduodenoscopy
and colonoscopy showed mild gastritis, diverticulosis, and
was negative for Helicobacter pylori biopsy. An abdominal CT
with ultrasound were negative. A magnetic resonance
angiography was done on [**2154-6-28**] which showed superior
mesenteric artery and internal mammary artery stenosis. The
patient was treated with Plavix and nitrates without
improvement. She is now transferred here for further
evaluation and treatment.
PAST MEDICAL HISTORY: (Illnesses include)
1. Aortic insufficiency.
2. Hypertension.
3. Gastritis.
4. History of migraines.
5. History of hypercholesterolemia.
PAST SURGICAL HISTORY: Tonsillectomy.
MEDICATIONS ON ADMISSION: Medications included aspirin 81 mg
p.o. q.d., nitroglycerin paste one-half inch q.6h.,
atenolol 25 mg p.o. q.d., Pepcid 20 mg intravenously b.i.d.,
Senokot tablets one p.o. b.i.d., Darvocet-N 100 one p.o.
q.i.d. as needed. At home, she took
hydrochlorothiazide 25 mg q.48h. and Plavix 75 mg p.o. q.d.
ALLERGIES: Drug allergies are PENICILLIN (which causes
erythema and swelling), ERYTHROMYCIN (reaction unknown).
SOCIAL HISTORY: She lives with a roommate. She is single.
She is a former smoker of one pack per day. She denies
alcohol.
FAMILY HISTORY: There is a family history of neurologic
disease, heart disease, and cancer.
REVIEW OF SYSTEMS: Except for the postprandial abdominal
pain, there were no other remarkable review of systems.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
temperature was 98.5, blood pressure was 170/86, pulse
was 60, respiratory rate was 18, oxygen saturation was 97% on
room air. General appearance revealed an alert and cooperate
white female in no acute distress. Skin was warm and dry.
There were no rashes. There were multiple actinic keratosis
on the back. Head, eyes, ears, nose, and throat examination
was unremarkable. There was no lymphadenopathy. There was
no thyromegaly or carotid bruits. She had intact carotid,
radial, and femoral pulses bilaterally. She had a palpable
abdominal aorta without bruits. The pedal pulses were a
dopplerable signal only. Neurologic examination was grossly
intact. The chest was clear to auscultation. Heart had a
regular rate and rhythm. A 1/6 systolic ejection murmur at
the base. Abdominal examination was unremarkable. The
rectal examination was deferred. Bone and joint examination
were essentially warm and pink in color without ulceration.
HOSPITAL COURSE: The patient was evaluated by our
Cardiology Department prior to surgery for risk assessment.
She felt she was at a low risk for a high-risk procedure.
Their recommendations were an echocardiogram to determine the
degree of aortic insufficiency and that postoperatively she
should be started on an ACE inhibitor with captopril 12.5 mg
t.i.d. and titrate up to a dose as blood pressure tolerates.
She needed no further imaging or stress studies. Change the
atenolol to metoprolol 37.5 mg p.o. b.i.d. and watch for
bradycardia.
Echocardiogram results revealed transesophageal
echocardiogram demonstrated left ventricular wall thickness,
cavity size, and systolic function were normal with an
ejection fraction of greater than 55%, regional left
ventricular motion was normal. There was simple atheroma in
the descending aorta. The aortic valves were moderately
thickened. There was mild-to-moderate aortic insufficiency.
The mitral valves were mildly thickened with mild mitral
regurgitation. The aorta and mesenteric bypass graft was not
visualized. There was no significant change from previous
echocardiogram done on [**2154-7-19**].
The patient was admitted to the preoperative holding area.
On [**2154-10-7**] she underwent two bisiliac aorta to
celiac artery and a superior mesenteric artery bypass with
12 X 6 bifurcated graft. She tolerated the procedure well
and was transferred to the Postanesthesia Care Unit in stable
condition.
On immediate postoperative check, she was hemodynamically
stable and afebrile. Cardiac index was 3.07, systemic
vascular resistance was 1233, pulmonary artery was 38/13,
central venous pressure was 6. Blood gas was
7.28/42/134/21/-6. She did well and was transferred the
Medical Intensive Care Unit for continued monitoring and
care.
On postoperative day two, the patient developed respiratory
failure and required reintubation and was transferred to
Intensive Care Unit for continued respiratory support.
Nutrition saw the patient. She was assessed for total
parenteral nutrition.
Serial creatine kinase, MB, and troponin levels were drawn.
Her peak creatine kinase was 370, MB fraction was flat, and
troponin levels were less than 0.3. ALT and AST were
elevated at 335 and 716 with an elevated white count.
Levofloxacin and Flagyl were begun. A transesophageal
echocardiogram was obtained which was negative for
vegetations. She required one unit of packed red blood cells
for her hematocrit. Venous Doppler studies were [**Female First Name (un) **] which
were negative for deep venous thrombosis. She had an episode
of hypotension requiring Levophed for blood pressure support.
Levofloxacin and Flagyl were discontinued, and vancomycin
and Bactrim were begun. Tube feeds were considered, but
these were deferred. A left pleural tap was done on [**8-15**]
for a total of 1.6 liters. The patient had a repeat tap 48
hours later. An ultrasound of her gallbladder was obtained
with questionable cholecystitis. She remained intubated.
On [**8-27**], General Surgery was consulted and a
cholecystotomy tube was placed percutaneously. This was to
remain in for a total of three weeks.
The patient underwent studies at that time. A chest CT
showed no bowel ischemia. There was a simple liver cyst.
The cholecystectomy tube had decompressed the gallbladder.
The superior mesenteric artery, internal mammary artery, and
celiac arteries were patent. A chest x-ray showed
diminished pleural effusion. Multiple sputum, urine, and
blood cultures were obtained, and cultures of the pleural
fluid. All of these were no growth and finalized.
The patient had a peripherally inserted central catheter line
placed on [**8-29**] for further intravenous access.
Gastroenterology saw her on [**9-3**] because of persistent
inability to eat solids or liquids. An
esophagogastroduodenoscopy was done which demonstrated an
esophagus with a grade 1 candidiasis. The stomach was
atrophic gastritis changes, and the duodenum showed an
intrinsic stenosis at the distal duodenal bulb which the
scope could pass through. Fluconazole was begun at this
time. She was continued on total parenteral nutrition and
then converted to tube feeds, and these were discontinued,
and caloric assessments were made. The patient did not meet
necessary caloric requirements.
Gastroenterology was consulted again on [**9-17**] and
repeated the endoscopy which demonstrated a normal esophagus
with mild gastritis. The duodenum was normal. A #20 French
percutaneous endoscopic gastrostomy tube was placed in the
stomach for anticipated tube feeds. Nutrition would make
their appropriate recommendations regarding tube feeds, and
this would be initiated 24 hours after the tube insertion.
The patient also had a swallow done prior to have the
percutaneous endoscopic gastrostomy tube placed, and there
was no aspiration; although, she had a delayed
aorticopulmonary bolus transit time with premature spillage
into the funiculi with delayed swallowing, but there was no
aspiration.
At the time of discharge, the patient was stable. She was
ambulating and working with Physical Therapy. Tube feeds
will be dictated as an addendum.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Reglan 10 mg p.o. a.c. and q.h.s.
2. Fluconazole 100 mg p.o. q.24h. (this was started on
[**2154-9-9**] and will continue through [**2154-9-23**] and then be discontinued).
3. Lopressor 75 mg p.o. b.i.d. (hold for a systolic blood
pressure of less than 100 and heart rate of less than 50).
4. Lasix 20 mg p.o. q.d.
5. Enteric-coated aspirin 81 mg p.o. q.d.
6. Tube feeds with Empac with fiber starting at 10 cc per
hour; this will be advanced for a goal rate to be determined.
Residuals should be checked q.4h., and tube feeds should be
held if residual is greater than 100 cc.
DISCHARGE FOLLOWUP: Follow up with Dr. [**Last Name (STitle) **] in two to
three weeks.
DISCHARGE INSTRUCTIONS: The patient may ambulate, full
weightbearing, ad lib distances.
DISCHARGE DIAGNOSES:
1. Mesenteric ischemia; status post celiac superior
mesenteric artery bypass graft.
2. Pleural effusion, status post thoracentesis times two.
3. Respiratory failure requiring reintubation.
4. Esophageal candidiasis; treated.
5. Gallbladder disease; status post percutaneous
cholecystotomy with gallbladder decompression; this has
continued anorexia and difficulty in feeding; the etiology is
undetermined. Status post esophagogastroduodenoscopy times
two and barium swallow which were unremarkable.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2154-9-17**] 14:56
T: [**2154-9-17**] 15:02
JOB#: [**Job Number 42959**]
ICD9 Codes: 5185, 5119, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3361
} | Medical Text: Admission Date: [**2148-1-11**] Discharge Date: [**2148-1-16**]
Service: NEUROLOGY
Allergies:
Penicillins / Amoxicillin / Banana
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
code stroke
Major Surgical or Invasive Procedure:
- IV-tPA given for stroke, with minimal improvement
- Right thigh fasciotomy for hematoma / compartment syndrome
- Made CMO
- Deceased
History of Present Illness:
Ms. [**Known lastname **] is a 86 yo W with h/o AF not on coumadin, MVR and
recent hip fracture s/p ORIF [**2147-12-20**] who presents with acute
onset L sided weakness and facial droop at rehab.
The patient was noticed by rehab staff to acutely develop left
facial droop and left arm and leg weakness at 13:45 today. There
is no other collateral history available.
Per patient's daugther, she has been declining since [**2147-9-13**] with more confusion, falls and finally the hip fracture for
which she remained hospitalized for 3 weeks with complications
including delirium. She is intermitently confused, but usually
oriented x 2, she is able to feed herself. She has not walked
since the surgery, but was previously using a walker. Before
[**Month (only) **], she was living alone and independent.
On arrival in [**Hospital1 18**] ED, NIHSS 8 for L facial droop, L
hemiparesis, answers name but not age correctly, dysarthria.
Head CT showed hypodensity of the R MCA territory, no cut-off
seen, no ICH. Patient was deemed candidate for t-PA with no
absolute contraindications (surgery was >14 days ago). She was
given t-PA with no immediate improvement. After 30 minutes, L
arm
was antigravity, she was opening eyes more and answering yes/no
questions with nodding head. Denies pain or headache.
Upon completion of t-PA (1 hour), patient was lifting L hand
antigravity to command, proximal strength better than distal
strength (still not squeezing hand). She was indicating she had
pain in the right lower back and right thigh. Inspection of the
right thigh revealed swollen, hard area c/w hematoma. Ortho was
consulted for possible compartment syndrome. CT scan of the
thigh
was ordered.
Past Medical History:
- MVR for prolapse
- chronic Afib
- HTN
- hyperlipidemia
- hypothyroidism
- UTIs
Social History:
Had been @Rehab Facility. Had been living alone until [**9-/2147**],
then went to rehab due to falls, then [**Hospital3 **] ([**Hospital **]), and then fell again prompting recent hospitalization and
discharge to rehab.
Family History:
Non-contributory
Physical Exam:
<<on admission>>
VS: T AF HR 84 BP 123/65 RR 19 02 100/face mask
GEN: cachectic elderly woman, moderate distress
HEENT: sclera anicteric
CV: irregular
PULM: CTAB
AB: ND/NT
EXT: no edema
NEURO:
MS: Eyes closed, do not open to command, open slightly to
noxious
stimuli. Answers name, says age is 61. Speech dysarthria, also
moaning, difficult to assess language further.
CN: PERRL 2.5 to 2mm. EOMI. Blinks to threat bilaterally. L
facial droop at rest. Tongue midline
MOTOR: moving R side spontaneously and to command (cannot lift
RLE to command s/p hip surgery), moving LLE to command
antigravity for 8 seconds, no movement of LUE to command.
Withdraws and localizes pain in all 4 extremities.
SENSATION: withdraws to pain in all 4 extremities.
COORDINATION: intact finger to nose on RUE
Pertinent Results:
[**2148-1-12**] 04:52AM BLOOD WBC-10.9 RBC-2.95* Hgb-9.2* Hct-26.9*
MCV-91 MCH-31.2 MCHC-34.3 RDW-19.9* Plt Ct-243
[**2148-1-11**] 09:34PM BLOOD WBC-15.1* RBC-2.44* Hgb-7.8* Hct-23.6*
MCV-96 MCH-32.1* MCHC-33.3 RDW-19.5* Plt Ct-285
[**2148-1-11**] 02:44PM BLOOD WBC-10.1 RBC-2.60* Hgb-8.8* Hct-26.3*
MCV-101* MCH-33.9* MCHC-33.5 RDW-16.9* Plt Ct-359
[**2148-1-11**] 09:34PM BLOOD PT-14.4* PTT-27.3 INR(PT)-1.3*
[**2148-1-11**] 02:44PM BLOOD PT-13.2 PTT-24.9 INR(PT)-1.1
[**2148-1-12**] 04:52AM BLOOD Glucose-99 UreaN-28* Creat-0.6 Na-138
K-4.8 Cl-105 HCO3-26 AnGap-12
[**2148-1-11**] 09:34PM BLOOD Glucose-101* UreaN-28* Creat-0.6 Na-135
K-5.0 Cl-106 HCO3-24 AnGap-10
[**2148-1-11**] 02:44PM BLOOD Glucose-91 UreaN-29* Creat-0.7 Na-138
K-4.7 Cl-104 HCO3-27 AnGap-12
[**2148-1-11**] 09:34PM BLOOD CK(CPK)-42
[**2148-1-11**] 09:34PM BLOOD CK-MB-4 cTropnT-0.04*
[**2148-1-11**] 02:44PM BLOOD CK-MB-5
[**2148-1-11**] 02:44PM BLOOD cTropnT-0.04*
[**2148-1-12**] 04:52AM BLOOD Calcium-7.9* Phos-4.1 Mg-2.4
[**2148-1-11**] 09:34PM BLOOD Calcium-7.9* Phos-4.3# Mg-1.8
[**2148-1-11**] ECG:
<<a.flutter>>
Cardiology Report ECG Study Date of [**2148-1-11**] 2:35:06 PM
Possible atrial flutter with multiple premature ventricular
complexes. Right axis deviation. Left ventricular hypertrophy
with secondary repolarization abnormalities. Inferolateral ST
segment changes secondary to left ventricular hypertrophy versus
myocardial ischemia. Clinical correlation is suggested.
Extensive baseline artifact. Compared to the previous tracing of
[**2148-1-3**] the rhythm now appears to be more consistent with
atrial flutter versus atrial fibrillation and multiple premature
ventricular complexes are now seen.
TRACING #1
Read by: FISH,[**Doctor First Name **] E.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
87 0 122 364/411 0 69 35
[**2148-1-11**] HCT/CTA/CT-perfusion (@presentation to our ED):
FINDINGS:
HEAD CT: An extensive region of the right MCA distribution
demonstrates loss of the [**Doctor Last Name 352**]-white matter differentiation and
is diffusely hypodense. There is minimal sulcal effacement.
There is no associated intracranial hemorrhage. Elsewhere in
the brain, there is no edema, hemorrhage, mass effect, or
evidence of infarction. Ventricles and sulci are otherwise
normal in size and configuration for the patient's age. No
fractures are identified. The right maxillary sinus is again
atelectatic and completely opacified. Remaining paranasal
sinuses and mastoid air cells are well aerated. The
configuration of the calvarium is again unusual, with thinning
of the posterior calvarium bilaterally, with a congenital
appearance.
CT PERFUSION: The perfusion maps demonstrate an extensive region
of prolonged transit time and reduced blood flow and blood
volume throughout the right MCA distribution, compatible with
infarct. There is no mismatch to indicate a penumbra.
HEAD AND NECK CTA: There is an abrupt cutoff of the superior
division of the right M2 segment of the right middle cerebral
artery. The inferior division arises early from the M1 segment
on the right. There is a relative paucity of distal
opacification within the MCA territory on the right. However, a
few opacified vessels are present, the result of collateral
flow. The remainder of the circle of [**Location (un) 431**] is patent without
other area of occlusion. The anterior communicating artery has a
slightly bulbous appearance. The cervical carotid and vertebral
arteries and major branches are patent with no high-grade
stenoses. However, the entire right cervical ICA is slightly
diminutive in caliber relative to the left, and slightly
irregular suggesting a long segment of atherosclerosis. Both
carotid bulbs demonstrate atheromatous irregularity without
high-grade stenosis. There is atherosclerotic calcification of
the cavernous carotids bilaterally as well.
Lung apices demonstrate scarring and high-density material
bilaterally, with bronchiectasis at the right lung apex. The
aortic arch and origin of the major vessels demonstrate dense
atherosclerotic calcification.
The right internal carotid artery measures 8.3 mm at the bulb, 3
mm just above the bulb, and 3 mm at its upper portion. The left
internal carotid artery measures 9 mm at the bulb, 5 mm just
above the bulb, and 3.3 mm along the upper segment.
IMPRESSIONS:
1. Large acute infarct in the right MCA distribution, with no
perfusion
mismatch.
2. Abrupt occlusion of the superior division of the right M2
segment of the right middle cerebral artery, with decreased
filling of distal branches. Otherwise, patent circle of [**Location (un) 431**].
3. Atheromatous irregularity at the carotid bulb bilaterally,
with slightly diminutive right cervical ICA along its entire
length, suggesting long segment atherosclerosis versus
vasculitis. However, no high-grade stenosis of either side.
4. Slightly bulbous appearance of the anterior communicating
artery. Please correlate with angiography.
5. Complete opacification and atelectasis of the right maxillary
sinus as seen previously.
[**2148-1-11**] NCHCT:
FINDINGS: Again noted is loss of the [**Doctor Last Name 352**]-white matter
differentiation in the right insula. Sulcal effacement and loss
of [**Doctor Last Name 352**]-white differentiation extends to the right frontal and
parietal lobes in a right MCA distribution. No evidence of acute
hemorrhage is seen. There is some compression of the right
lateral ventricle, not significantly changed from the prior
examination. General prominence of the ventricles and sulci is
compatible with generalized atrophy, age related. Areas of
periventricular and subcortical white matter hypodensity likely
reflect sequela of chronic small vessel ischemic disease.
No concerning osseous lesion is seen. There are vascular
calcifications of the bilateral carotid siphons. Complete
opacification of the right maxillary sinus is unchanged.
IMPRESSION:
1. No evidence of acute hemorrhage.
2. Infarction in right MCA distribution as previously seen. No
shift of
midline structures.
[**2148-1-12**] NCHCT:
FINDINGS: Again seen is a large right MCA territory infarct with
expected
evolution. There is no evidence of hemorrhage within the
infarct. No
significant mass effect or shift of midline structures is seen.
The
ventricles and sulci are mildly dilated, consistent with
age-related
involutional changes. The basal cisterns are normal.
Calcification of the
cavernous portion of bilateral carotid arteries is present.
The mastoid air cells and imaged paranasal sinuses are clear.
IMPRESSION:
1. Expected evolution of the large right MCA territory infarct.
No
significant mass effect or shift of midline structures is seen.
2. No evidence of hemorrhage within the infarct.
Brief Hospital Course:
86y F with atrial flutter and recently worsening dementia
(undiagnosed), who was not taking anti-coagulation for her afib,
recently s/p right Femur repair [**2147-12-20**]. Returned from Rehab
to our ED as a code stroke due to Left-sided weakness, and was
found to have a Right-M2 (superior division) occlusion,
presumably due to cardioembolic clot given her aflutter without
A/C. Given IV-tPA in the ED, with some improvement in her LUE
(anti-gravity strength), but this was c/b a large and painful
hematoma in the region of her recent surgery, which required
that she go to OR urgently with Orthopedics for fasciotomy to
relieve pressure from compartment syndrome (70mmHg pressure
measured by Ortho). Her H&H dropped, but improved appopriately
after transfusion of 2U PRBCs. Her family decided to stop
pursuing aggressive care measures; fasciotomy and transfusion
were performed due to their palliative value (pt. in severe pain
from pressure/compartment syndrome). Pt was made CMO by family
and transferred to the floor, with removal of tubes, lines, and
invasive interventions and testing measures. She remained
comfortable, but minimally responsive, with PRN sublingual
morphine and with scopolamine patch. She died [**2147-1-16**].
Medications on Admission:
1. docusate sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO HS (at bedtime).
3. aspirin 81 mg Tablet, Chewable [**Year (4 digits) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. levothyroxine 100 mcg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
5. lisinopril 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
6. [**Year (4 digits) **] 0.03 % Drops [**Year (4 digits) **]: One (1) drop Ophthalmic at bedtime.
7. megestrol 400 mg/10 mL (40 mg/mL) Suspension [**Year (4 digits) **]: One (1)
pill PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet [**Year (4 digits) **]: Two (2)
Tablet PO DAILY (Daily).
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Year (4 digits) **]: One
(1) Tablet, Chewable PO TID (3 times a day).
10. sertraline 50 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO DAILY
(Daily).
11. digoxin 125 mcg Tablet [**Year (4 digits) **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
12. polyethylene glycol 3350 17 gram/dose Powder [**Year (4 digits) **]: One (1)
packet PO DAILY (Daily) as needed for constipation.
13. bisacodyl 10 mg Suppository [**Year (4 digits) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. olanzapine 5 mg Tablet, Rapid Dissolve [**Year (4 digits) **]: 0.5 Tablet,
Rapid Dissolve PO BID (2 times a day).
15. cyanocobalamin (vitamin B-12) 250 mcg Tablet [**Year (4 digits) **]: One (1)
Tablet PO DAILY (Daily).
16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain fever.
18. enoxaparin 30 mg/0.3 mL Syringe [**Last Name (STitle) **]: One (1) syringe
Subcutaneous QHS (once a day (at bedtime)) for 10 days: Last day
= [**1-20**].
19. mirtazapine 15 mg Tablet [**Month (only) **]: One (1) Tablet PO at bedtime.
20. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
[**Month (only) **]: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2148-1-23**]
ICD9 Codes: 4254, 2449, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3362
} | Medical Text: Admission Date: [**2166-10-16**] Discharge Date: [**2166-10-31**]
Date of Birth: [**2088-2-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Shellfish Derived
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Shortness of breath, weight gain, decreased O2 sats
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78yo F with h/o severe AS (area 1.0-1.2cm2), CAD s/p PCI,
diastolic dysfunction with EF on last TTE >55% admitted with
dyspnea. Patient was recently admitted in [**9-8**] for similar
symptoms and was found to be volume overloaded on exam. She
received lasix and her Imdur was stopped as well and she
improved clinically. At that time she also had some atrial
tachycardia that was treated with a beta blocker and increased
dose of diltiazem. She was discharged to a [**Hospital1 1501**] where she was
progressing with physical therapy. She then developed abdominal
pain and diarrhea and was re-admitted. She had negative CDiff
toxins X 3 and was sent home on an empiric course of
cipro/flagyl and plan for o/p colonoscopy after CT showed
colitis. While admitted she had an episode of hypotension as
well as AV-Junctional rhythm on telemetry. Because of this her
beta blocker was discontinued and her diltiazem dose was
decreased. She was then seen by her cardiologist on [**10-10**] and
was restarted on her metoprolol at 25mg [**Hospital1 **]. She was continued
on her diltiazem at 60mg TID. She was recently discharged from
the [**Hospital1 1501**] and was at home, not on oxygen, with VNA services.
.
On the DOA the VNA came to visit and noted the patient had
gained 4.5 pounds in one day. She was satting 82-84% on RA and
so she was brought to the ED. In the ED her vitals were: T:97.4
HR 74 BP 144/65 RR 20 O2sat 92% on RA and came up to 98% on 2L.
She was given 40mg of IV lasix and diuresed 1Liter. Prior to
transferring to the floor her vitals were: BP 138/61 AR 72 O2
sat 96% on 1.5 L.
Per her son she has been living in the apartment upstairs from
him and has had VNA a few times per week since being discharged
from the rehab facility recently. Her medications are spread
throughout the apartment and of the ones he could find I have
listed them below. He is not sure that she takes them all every
day or as directed.
.
On presentation to the floor the patient notes that she normally
has shortness of breath while walking and can never sleep flat.
However, over the last week she has had increased shortness of
breath when walking and has had to sit in her arm chair to
sleep. She has also woken up at night very short of breath. She
denies chest pain and says that her legs are actually smaller
than they were a few months ago.
Past Medical History:
-CHF: diastolic dysfunction, EF 55%
-CAD, s/p placement of 2 [**Hospital1 **]: In [**2-7**] found to have 90% lesion
of RCA. She was evaluated by cardiothoracic surgery, and she
was felt to not be a candidate for CABG given her co-morbidities
and morbid obesity. On [**2166-9-3**] she was admitted for SOB and
subsequently had placement of 2 drug eluting stents, one for an
ostial lesion for the
right coronary and one for a distal left circumflex lesion.
-Aortic stenosis (moderate-severe): valve area 0.8cm2 on echo,
1.1cm2 on cath
-Diabetes: controlled on oral meds, last HbA1c=6.1% in [**2-7**].
-s/p ventral hernia repair
-History of cholecystitis
-Hypertension
-Obesity
-Hypercholesterolemia: Controlled on atorvastatin, lipids last
checked [**1-/2166**]: Total cholesterol 161, HDL 45, LDL 93.
-Low back pain s/p motor vehicle accident in [**2159**] with
diffuse degenerative joint disease, pain tolerable without pain
meds
-Hypothyroidism
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Social History:
Was living independently in apartment below son's apartment. Was
at [**Hospital 100**] Rehab since stent placement and is currently living at
home with VNA a few times per week. Walks with a walker, no
problems bathing/dressing. Denies smoking/ETOH use. Worked at
[**Hospital1 **] for 26 years as supervisor coordinator. Son works at [**Hospital1 **] as
materials supervisor, daughter-in-law works as phlebotomist.
Family History:
Father passed away at age 67 from heart attack, mother passed at
82 from heart attack. Has one brother age 65, lives in [**Location **]
[**Country **]. Has two sisters, 83 and 80. No history of cancer in
family.
Physical Exam:
VS - T: 97.9 HR:74 BP: 106/54 RR: 18 O2sat: 98% on 2L Wt
113.4kg (249.5 lbs)
Gen: Obese elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP to earlobe.
CV: Irregular rhythm at normal rate. Blurred S1, S2. [**3-6**] SM RUSB
Chest: Speaking in short sentences, no accessory muscle use.
Decreased lung fields bilaterally. Wet crackles bilaterally [**3-4**]
of the way up. No wheezing appreciated.
Abd: Obese with central scar well-healed. Soft, NTND.
Ext: 2+ pitting edema bilaterally to knees. Erythema bilaterally
from ankles to knees without streaking, discharge, blisters,
lascerations, excoriations. No ulcers on feet.
Pulses: Right: DP 1+ Left: DP 1+
Pertinent Results:
[**2166-10-16**] 04:50PM CK(CPK)-45
[**2166-10-16**] 04:50PM cTropnT-<0.01
[**2166-10-16**] 04:50PM WBC-8.3 RBC-3.80* HGB-10.2* HCT-31.8* MCV-84#
MCH-26.9* MCHC-32.1 RDW-15.1
[**2166-10-16**] 04:50PM NEUTS-80.0* LYMPHS-14.5* MONOS-4.3 EOS-1.1
BASOS-0.1
[**2166-10-16**] 04:50PM PLT COUNT-319
[**2166-10-16**] 04:50PM PT-14.0* PTT-26.8 INR(PT)-1.2*
[**2166-10-16**] 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
[**2166-10-16**] CXR (AP): There is stable cardiomegaly. There is
blunting of the costophrenic angles, likely representing small
pleural effusions. There is added density at the right lung base
suggestive of pneumonic consolidation
.
[**2166-10-16**] EKG: Rate 77, Sinus rhythm with atrial premature
depolarizations. Non-diagnostic repolarization abnormalities.
.
[**2166-9-3**] CARDIAC CATH:
1. Selective coronary angiography of this right dominant system
revealed
2 vessel CAD. The LMCA had no angiographically flow limiting
lesions. The LAD had mild diffuse disease. The LCX had an 80%
distal stenosis after the takeoff of the OM2. The RCA was a
dominant vessel with an 80% ostial
stenosis with marked pressure dampening with engagement. 2.
Limited resting hemodynamics revealed severely elevated left and
right sided filling pressures with a mean RA pressure of 23, an
LVEDP and a PCWP of 36. The cardiac index was preserved at 4.3
L/min/cm2. 3. Moderate aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.9 cm2
and a peak to peak gradient of 60 mmHg. Left ventriculography
was deferred. 4. Successful PTCA and stenting of the ostial RCA
with a 3.0 x 15 mm XIENCE [**Location (un) **]. Final angiography revealed no
residual stenosis in the stent, no dissection and TIMI III flow
5. [**Name (NI) 9927**] PTCA and stenting of the distal LCX with a 2.5 x 18
mm [**Name (NI) **]. Final angiography revealed no residual stenosis in the
stent, no dissection and TIMI III flow (See PTCA comments)
6. Right femoral arteriotomy site was closed with a 6 French
ANgioseal
device.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Moderate aortic stenosis.
3. Elevated left and right sided filling pressures.
4. Successful stenting of the ostial RCA.
5. Successful stenting of the distal LCX.
.
[**2166-8-19**] ECHO (TTE) :
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging
are consistent with Grade III/IV (severe) LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
There is moderate to severe aortic valve stenosis (area
0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. Compared with the prior study (images
reviewed) of [**2166-1-21**], the findings are similar with moderate
to severe aortic stenosis.
Brief Hospital Course:
78 year old F with h/o moderate AS, CAD s/p [**Year (4 digits) **] in [**9-8**] and
diastolic CHF admitted with 4lb weight gain, dyspnea and CHF
exacerbation.
.
1. Diastolic CHF acute and chronic: Combination of acute
exacerbation of diastolic CHF and moderate/severe Aortic
Stenosis. On exam was fluid overloaded and described symptoms
classic of acute CHF exacerbation. She was 4.5 pounds heavier
than her last weight on [**2166-10-10**] at cardiology clinic (245lbs).
Her BNP was over 2X the last measured in our system. Acute CHF
most likely relating to med non-compliance. She was ruled out
for an acute ischemic event with negative cardiac enzymes and
unchanged EKG. Patient aggressively diuresised on Lasix drip.
Goal -3 L reached daily with improvement on physical exam.
Patient discharged on 120 mg Lasix daily. HER DRY WEIGHT IS 103
KG.
.
# Severe Aortic Stenosis: Patient with multiple recent
admissions for heart failure. Once stable and recovered from
acute CHF episode needs C-Surgery consult for possible valve
replacement. Echocardiogram showed valve area of 0.8-1.
.
#. Hypotension: After being re-started on her home
anti-hypertensives including diltiazem, metoprolol, and
lisinopril as well as IV lasix for diuresis she developed
asymptomatic hypotension with BPs ~70s/40s that was unresponsive
to 2 X 500mL NS. There was concern about giving her more fluids
in the setting of her CHF and overloaded volume status, so she
was sent to the CCU for better titration of her medications and
possible initiation of pressors. Dopamine was started however
she developed acute respiratory distress and it was consequently
discontinued. Respiratory distress secondary to acute pulmonary
edema in the setting of hypertension and inotropic effects off
dopamine. Patient's blood pressure was stable with no pressors.
.
#. CAD: s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 10157**] in ostial RCA and distal LCx. She was
ruled out for ACS. Continued on plavix, aspirin, statin. Beta
blocker and ACE-I held in setting of hypotension and
bradycardia. BB restarted temporarily but pt developed a
junctional escape rhythm at rate of 40s, otherwise asymptomatic
and was taken off, while on Amiodarone.
.
#. Rhythm: Patient had episode of A Flutter on [**2166-10-19**] during
acute CHF episode. Patient spontaneously converted. Started
Amiodarone 200 mg [**Hospital1 **] for 2 weeks (Day 1: [**2166-10-21**]).
Anti-coagulation was started, however patient developed
hematuria, guaiac + stool, epitaxsis even on low goal ptt.
Anti-coagulation was stopped due to short duration of A Fib
episode, high fall risk and bleeding. Patient demonstrated
multiple ventricular and atrial ectopy over course of admission.
She was started on daily amiodorone on discharge and outpatient
PFTs were scheduled.
.
#. Hypothyroidism: TSH on this admission was elevated at 6.1. It
is possible she was not taking her home dose of levoxyl, however
a repeat TSH was 7.7 prior to discharge.
These results were communicated to her PCP.
.
#. COPD: Questionable COPD diagnosis with no PFTs and no smoking
history, but is on inhalers at home. Inhalers were discontinued
as it was felt COPD was unlikely with patient's non-smoking
history.
.
#. Glaucoma: Continued home regimen.
#. Iron-Deficiency Anemia: At baseline hematocrit 26-28 during
stay. Colonoscopy [**2163**] with no CA, diverticulosis, and polyp in
T-colon. She is due for a colonoscopy this year and this was set
up on her last admission but she has not been yet. Iron studies
showed iron deficiency anemia. Will have further workup as
outpatient and already has colonoscopy scheduled and will likely
need to be discharged on iron supplements.
#. Diabetes mellitus Type II: Actos discontinued due to history
of heart failure. Glyburide discontinued due to episodes of
hypoglycemia. Patient had several increases in her daily ISS
while hospitalized for tighter glucose control. Started Glargine
QHS dosing as well. Transitioned patient to oral regimen [**First Name8 (NamePattern2) **]
[**Last Name (un) **] recommendations (Glipizide [**Hospital1 **]) prior to discharge with
additional 70/30 insulin regimen.
Medications on Admission:
From Discharge Medications from [**9-8**] and Cardiology note
[**2166-10-10**]:
1. Aspirin 81 mg Tablet PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Fluticasone 110 mcg/Actuation Aerosol Sig: One Puff [**Hospital1 **]
5. Lansoprazole 30 mg Tablet Rapid Dissolve PO DAILY
6. Latanoprost 0.005 % Drops Sig: One Drop Ophthalmic HS
7. Levothyroxine 100 mcg 1 Tablet PO DAILY
8. Multivitamin 1 Tablet PO DAILY
9. Calcium Carbonate 500 mg Tablet PO QID as needed.
10. Cyanocobalamin 100 mcg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Diltiazem HCl 60 mg PO TID
13. Metoprolol Tartrate 25 mg PO BID
14. Albuterol Sulfate PRN
15. Glyburide 10 mg b.i.d.
16. Lasix 100mg PO BID
17. Imdur 100mg PO daily
18. Actos 30mg PO QAM 15mg QPM
.
Per Son patient is taking the following at home:
Glyburide 10mg by mouth [**Hospital1 **]
Actos 15mg QAM 30mg QPM
Prevacid 30mg PO daily
Lipitor 40mg PO daily
Levoxyl 100mcg PO daily
Vitamin b12
Ocuphite drops
Xalatan drops
Nitro SL PRN
Albuterol INH 1-2 puffs Q6H PRN
Flovent PRN
Metoprolol 25mg PO BID
Zolpidem 2.5mg PO QHS
Lasix 100mg PO BID
Diltiazem 60mg PO TID
Omeprazole 40mg PO daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**].
Disp:*30 Tablet(s)* Refills:*11*
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
11. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen
Sig: Eight (8) units Subcutaneous twice a day.
Disp:*3 pens* Refills:*2*
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
13. Flovent Diskus 50 mcg/Actuation Disk with Device Sig: One
(1) puff Inhalation once a day.
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day.
16. Ocuvite Tablet Sig: One (1) Tablet PO once a day.
17. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. NitroQuick 0.3 mg Tablet, Sublingual Sig: One (1) tabs
Sublingual every 5 minutes for three [**Last Name (Titles) 4319**] as needed for chest
pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic stenosis
Acute on chronic diastolic heart failure
Hypertension
Secondary
Diabetes type 2 non-insulin dependent
Acute Blood loss anemia
Discharge Condition:
The patient was afebrile, hemodynamically stable, with O2 sats
>92% on RA at rest and >88% on RA while ambulating.
The patient's dry weight is 103 kg.
Creat 1.1.
Discharge Instructions:
You were admitted to the hospital with acute worsening of your
baseline shortness of breath. You were found to have heart
failure. We have given you fluid pills to clear the fluid out of
your lungs and legs and you are now feeling better. To prevent
this from happening in the future you need to take your
medications exactly as prescribed every day, including your
lasix once a day. Weigh yourself every morning, [**Name8 (MD) 138**] MD if
weight > 3 lbs. Adhere to 2 gm sodium diet
Your Lisinopril has been discontinued while we are waiting for
your kidney function to return to nomal. This medication needs
to be restarted once you speak with your outpatient physician.
[**Name10 (NameIs) **] should not take your metoprolol while on amiodorone as this
could cause your heart rate to be too low.
Medication Changes:
STOP: Diltiazem and metoprolol,glyburide, and actos.
CHANGE: Lasix to 120mg by mouth daily, start taking insulin
twice daily and amiodarone. You were on 2 medicines for
heartburn, stop taking Lansoprazole but continue omeprazole. You
were started on iron for anemia.
Please call your doctor or come back to the emergency room if
you have light-headedness, dizziness, fainting, worsening
shortness of breath, more than 3 pounds of weight gain,
worsening leg swelling, or any concerning symptoms.
Take your Plavix every day, do not stop taking unless your
cardiologist tells you to.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 608**],
on [**2166-11-4**] at 1:50pm.
Please follow up with your cardiologist, Dr. [**First Name (STitle) **], and
[**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 3100**] NP([**Telephone/Fax (1) 62**]), on [**2166-11-13**] at 3:00pm.
.
Please follow up at [**Last Name (un) **] with Dr [**Last Name (STitle) 99905**] on [**11-19**]
at 2:30pm
.
In addition you have a follow up appointment with a nurse
educator to learn how to use the Insulin Pen- this appointment
is for Monday, [**11-3**] at 10 a.m. at the [**Hospital **] Clinic.
Your nurse educator is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
.
PFT's needed ASAP as outpt. Pt will need LFT's/TFT's q6 months
and yearly CXR.
Completed by:[**2166-11-1**]
ICD9 Codes: 5849, 2851, 4280, 4241, 4019, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3363
} | Medical Text: Admission Date: [**2154-8-26**] Discharge Date: [**2154-9-13**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
female who is status post colonoscopy and sigmoid polyp
biopsy approximately 10 days prior to presentation. She is a
resident of [**Hospital3 **]. At
the [**Hospital3 **] Center the patient was noted to be
complaining of diffuse abdominal pain over the past three
days. She was taken to the Emergency Room at the [**Hospital1 346**] where she was noted to be febrile,
diffusely tender. White count was 18,000. Chest x-ray
revealed free air under the diaphragm. She was resuscitated
in the Emergency Room and given antibiotics. She was
subsequently taken to the operating room for exploratory
laparotomy.
HOSPITAL COURSE: The patient was taken to the operating room
emergently and underwent an exploratory laparotomy which
revealed rupture of sigmoid colon. A sigmoid colectomy with
a diverting colostomy was performed. The patient was stable,
intubated, to the surgical Intensive Care Unit. Over the
next several days the patient did well and support was
weaned. She was subsequently extubated and transferred to
the floor in stable condition. On the floor it appears that
the patient had an episode of possible aspiration, was found
in respiratory distress and was transported back to surgical
Intensive Care Unit in fair condition. Of note, her
abdominal incision was opened for drainage. The course was
[**Male First Name (un) 3928**] over the next several days and after extensive
discussions with the family, the patient was made comfort
measures only. She expired shortly thereafter.
DISCHARGE DIAGNOSIS:
1. Ruptured sigmoid colon.
2. Feculent peritonitis.
3. Aspiration pneumonia.
4. Sepsis.
5. Respiratory failure.
6. Refractory sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 13197**]
MEDQUIST36
D: [**2154-11-14**] 18:20
T: [**2154-11-14**] 18:49
JOB#: [**Job Number 31955**]
ICD9 Codes: 5070, 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3364
} | Medical Text: Admission Date: [**2156-6-22**] Discharge Date: [**2156-6-26**]
Date of Birth: [**2102-3-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
s/p Minimal Invasive Mitral Valve Replacement on [**2156-6-22**]
History of Present Illness:
54 y/o female with heart murmur since age 14. Known h/o MR [**First Name (Titles) **] [**Last Name (Titles) **]S from prior Echo's over the past [**5-11**] yrs. Now with increasing
SOB, even at rest, along with palpitations.
Past Medical History:
Mitral Regurgitation/Stenosis
Diabetes Mellitus
Hypertension
Rheumatic Heart Disease
Diverticulosis
Pulm Hypertension
Basal cell CA s/p removal
Lumbar disc dz
Obesity
Rosacea
s/p Lap chole 98
s/p tubal Ligation 82
s/p Urethral Dilation 84
Social History:
Lives alone. Rare tobacco (quit 20 yrs ago). Rare ETOH. -IVDA
Family History:
Father MI @ 58, Grandmother died from MI ?age
Physical Exam:
VS: 84 16 152/78 5'3" 175#
General: NAD, WN, slightly obese
Skin: Warm, Dry
HEENT: EOMI, PERRLA, nl buccal mucosa, non-icteric
Neck: Supple, From, -JVD, heart murmur radiates to bilat
carotids
Heart: RRR, 3/6 SEM
Lungs: CTAB, -w/r/r
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -c/c/e, -varicosities, BFA 2+, BRA 2+,
BDP 2+, BPT 2+
Neuro: CN2-12 intact, grossly intact
Pertinent Results:
[**2156-6-22**] 06:50PM BLOOD WBC-14.0*# RBC-2.92*# Hgb-8.9*#
Hct-26.0*# MCV-89 MCH-30.7 MCHC-34.3 RDW-13.1 Plt Ct-106*
[**2156-6-25**] 06:00AM BLOOD WBC-14.2* RBC-3.11* Hgb-9.2* Hct-27.6*
MCV-89 MCH-29.4 MCHC-33.2 RDW-14.3 Plt Ct-108*
[**2156-6-22**] 06:50PM BLOOD PT-15.9* PTT-36.5* INR(PT)-1.7
[**2156-6-22**] 07:51PM BLOOD PT-14.4* PTT-32.2 INR(PT)-1.4
[**2156-6-24**] 12:31AM BLOOD PT-13.0 PTT-25.6 INR(PT)-1.1
[**2156-6-22**] 07:51PM BLOOD Glucose-118* UreaN-13 Creat-0.5 Na-142
K-4.0 Cl-112* HCO3-24 AnGap-10
[**2156-6-25**] 06:00AM BLOOD Glucose-141* UreaN-10 Creat-0.6 Na-140
K-4.5 Cl-104 HCO3-26 AnGap-15
[**2156-6-24**] 12:31AM BLOOD Calcium-8.5 Phos-2.1* Mg-1.9
Brief Hospital Course:
Pt was a same day admit and on [**6-20**] she was brought to the
operating room where she underwent a Min. Inv. MVR. Please see
op note for surgical details. Pt. Tolerated the procedure well
and was transferred to the CSRU in stable condition being
titrated on Neo and Propofol. Early POD #2, pt was weaned from
mechanical ventilation and propofol and was extubated without
incident. Pt. remained in the CSRU until POD #2, requiring Neo
for hemodynamic support. On that day she was transferred to the
telemetry floor. Diuretics and b-blockers started per protocol.
Chest tubes also removed on POD #2. The rest of her hospital
course was very uneventful. She recovered well and was at level
5 on POD #4. She was discharged in good condition to home with
VNA services on POD #4 with 1+ edema and decreased BS bilat.
Medications on Admission:
1. Diltiazem XR 120mg qd
2. HCTZ 25mg qd
3. ASA 325mg qd
4. Cultrate 600mg [**Hospital1 **]
5. Nuphase qd
6. [**Doctor Last Name **] cream
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 2 weeks.
Disp:*14 Packet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. 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*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): x 2 weeks then Q6hours/PRN.
Disp:*120 Tablet(s)* Refills:*0*
7. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO four times
a day.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
home care services
Discharge Diagnosis:
Mitral Regurgitation/Stenosis s/p Minimal Invasive Mitral Valve
Replacement
Diabetes Mellitus
Hypertension
Rheumatic Heart Disease
Diverticulosis
Pulm Hypertension
Basal cell CA
Lumbar disc dz
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr [**Last Name (STitle) 61678**] in [**5-12**] weeks
Dr [**Last Name (STitle) **] in [**4-9**] weeks
Completed by:[**2156-9-1**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3365
} | Medical Text: Admission Date: [**2133-4-9**] Discharge Date: [**2133-4-29**]
Date of Birth: [**2068-8-29**] Sex: M
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Aortic stenosis and aortic insufficiency as
well as right coronary artery stenosis.
HISTORY OF PRESENT ILLNESS: Patient is a 64-year-old
dialysis-dependent male without any history of angina, who
experienced increasing shortness of breath for about one year
prior to [**2133-3-15**]. Patient had been noted to have
noncritical aortic stenosis about five years ago during a
routine cardiac evaluation. During routine followup
transthoracic echocardiogram performed in [**2133-2-12**],
the patient was noted to have critical aortic stenosis and
aortic insufficiency.
The patient then underwent a cardiac catheterization, which
revealed right coronary artery stenosis. The patient did
complain of some lightheadedness over the prior 1-3 months.
The patient denied having any symptoms suspicious for
transient ischemic attacks or cerebrovascular accident.
PAST MEDICAL HISTORY: End-stage renal disease secondary to
polycystic kidney disease (on dialysis via a Permacath on
Mondays, Wednesdays, and Fridays).
PAST SURGICAL HISTORY:
1. Multiple access procedures including A-V fistulas and A-V
grafts.
2. Status post right nephrectomy in [**2108**].
3. Abdominal hernia repair.
4. Partial colon resection in [**2120**] for diverticulosis.
5. Status post failed kidney transplant in [**2109**] at [**University/College 18328**]Medical Center.
6. Status post parathyroidectomy.
ALLERGIES: Patient has a severe contrast allergy and is also
allergic to penicillin, gentamicin, and Keflex as well as
cephalosporins.
MEDICATIONS ON ADMISSION:
1. PhosLo 638 mg to take five tablets 3x a day.
2. Renagel 1600 mg t.i.d.
3. Nephrocaps one tablet q.d.
4. Colace 100 mg p.o. q.d.
5. Prilosec 20 mg p.o. q.d.
PHYSICAL EXAM ([**2133-3-26**]): Patient's physical exam was
notable for carotid bruits worse on the right than on the
left. His heart rate was regular with a systolic rumble.
Lungs were clear. Abdomen was soft and nontender with some
well-healed surgical scars at the midline, right lower
quadrant, and subcostally. There were no palpable masses.
Patient had left groin Permacath. Patient had some venous
stasis changes of both lower extremities, but with palpable
dorsalis pedis pulses bilaterally. The patient also had a
right arm A-V graft in place.
HOSPITAL COURSE: Patient was admitted to the [**Hospital1 18**] on
[**2133-4-9**], and underwent an aortic valve replacement with #25
[**Last Name (un) 41101**] valve. The patient also underwent coronary artery
bypass grafting from the saphenous vein graft to the right
coronary artery. The procedure was performed without
complications, and the patient was as is routine, transferred
to the Cardiac Surgery Intensive Care Unit while intubated.
The patient was extubated awhile after arriving to the
Intensive Care Unit. At the time, the patient was alert and
moving all extremities. His blood gases were good and
appeared in no distress. Within a few minutes after being
extubated, however, the patient decompensated and became
apneic with a decrease in his oxygen saturations. The
patient required reintubation and was evaluated by the
Neurology service.
Following evaluation, the patient's event was believed to be
secondary to respiratory arrest contributed by the need to be
supine with his groin line as well as his previously
undiagnosed history of sleep apnea. Patient showed no
neurological deficits after the reintubation and quickly
returned to baseline neurologic function. No immediate
imaging was deemed necessary.
A bronchoscopy was performed revealing minimal mucus and
essentially clear airways. Patient underwent hemodialysis on
postoperative day #1. Patient was ultimately extubated on
postoperative day #2 without event.
On postoperative day two, the patient underwent another
session of hemodialysis, and was noted to have frequent
premature atrial contractions subsequently changing to atrial
fibrillation at a rate of 140. The patient was bolused with
amiodarone and started on a drip. The patient returned to
sinus rhythm shortly after. The patient remained on Levophed
drip. The patient had been empirically started on
levofloxacin antibiotic regiment for possible pneumonia given
some thick copious mucus. This patient was afebrile and had
a normal white count.
Over the following few days, the patient had brief episodes
of atrial fibrillation, though revert to sinus rhythm with
amiodarone boluses. A Heparin drip was started and plans
were made for anticoagulation with Coumadin. The patient
remained on a Levophed drip to support his blood pressure
with goal systolic blood pressures in the 90s-100s.
Patient was ultimately weaned off of his Levophed on
postoperative day #7. His systolic blood pressure remained
low mainly in the 90s, but the patient seemed to tolerate
this well. The patient was transferred out of the ICU on
postoperative day #8. The patient remained on hemodialysis
and ultrafiltration to try and offload some of the volume the
patient had gained intraoperatively.
Patient was ultimately started on Coumadin on [**2133-4-17**].
Within three days, the patient's INR was 2.5 following doses
of 2 mg, 2 mg, and 1 mg. Patient completed a 14-day course
of levofloxacin and was started on clindamycin for some lower
extremity erythema. Patient was noted to have small Stage II
decubitus ulcer on [**2133-4-23**], and wound care consult was
requested with the recommendation made for Duoderm gel and
thin Duoderm wafer dressings to the wound as well as frequent
positioning changes.
Patient had remained in normal sinus rhythm with no further
episodes of atrial fibrillation since transferred from the
Intensive Care Unit. He was on amiodarone by mouth.
By postoperative day 20, the patient was deemed ready for
discharge to rehab facility. But by the time of discharge,
the patient's pain was well controlled and his respiratory
status was stable. His estimated dry weight was 87 kg, and
on the day prior to discharge, had a predialysis weight of
94.1 kg. Four kg of fluid was taken off that day.
Patient had been seen by Physical Therapy while in house and
on ambulation remained somewhat unsteady and weak, requiring
the assist of two people for safe ambulation. The patient's
sternal incision was healing well with Steri-Strips in place.
Patient also had some left lower extremity incisions, which
appeared to be healing well with a few small blisters.
A transthoracic echocardiogram had been performed on
approximately [**2133-4-29**] to confirm the absence of thrombus in
the patient's heart. The transthoracic echocardiogram
revealed no such thrombus, and the decision was made to cease
further anticoagulation on the patient and his Coumadin was
discontinued. The benefits and risks of further Coumadin
therapy had been reviewed, and further treatment was deemed
unnecessary given that the patient had been in normal sinus
rhythm for much of his hospitalization and that his atrial
fibrillation could have been attributed to his significant
fluid overload immediately after the surgery.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Aortic stenosis.
2. Aortic insufficiency.
3. End-stage renal disease.
4. Coronary artery disease.
5. Atrial fibrillation.
6. Sacral decubitus ulcer.
7. Lower extremity cellulitis.
8. Respiratory arrest.
9. Sleep apnea.
FOLLOWUP: Patient is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]
within 1-2 weeks following discharge. The patient is also to
followup with his primary care physician [**Name Initial (PRE) 176**] 1-2 weeks
following discharge. The patient will need to setup an
appointment with his outpatient cardiologist in [**2-13**] weeks
following discharge. The patient will also need to setup an
appointment with a Sleep Clinic for further evaluation of his
sleep apnea.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg p.o. q.d.
2. Aspirin 81 mg p.o. q.d.
3. Dulcolax 10 mg p.r. q.d. prn.
4. Calcium acetate 1334 mg p.o. t.i.d. with meals.
5. Colace 100 mg p.o. b.i.d.
6. Milk of magnesia 30 mL p.o. q.h.s. prn.
7. Percocet 1-2 tablets p.o. q.4h. prn.
8. Protonix 40 mg p.o. q.24h.
9. Sevelamer 1600 mg p.o. t.i.d.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2133-4-29**] 11:32
T: [**2133-4-29**] 12:17
JOB#: [**Job Number 41102**]
(cclist)
ICD9 Codes: 4241, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3366
} | Medical Text: Admission Date: [**2198-2-11**] Discharge Date: [**2198-2-20**]
Date of Birth: [**2132-6-5**] Sex: F
Service: MEDICINE
Allergies:
Nsaids / Lovenox / Pravastatin / Zetia
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Mesenteric angiography
Transfusion of PRBC's
Colonscopy
Femoral line placement
PICC line placement
Flexible sigmoidoscopy
History of Present Illness:
Ms. [**Known lastname 6330**] is a 65 yo woman with DM2, CHF, diverticulosis, and
recent hospitalization at [**Hospital 8**] Hospital for aspiration
pneumonia c/b C diff colitis and LGIB, and several
hosptalizations/rehab stays for last 4 months. She was sent to
[**Hospital 8**] Hospital ED this a.m. from [**Hospital1 **] with hematochezia
and LLQ tenderness x 4 days. Pt did not see hematochezia herself
but was told by nursing staff that this was present. Hct there
was 26 and she was transfused 2uPRBC ([**1-14**] 35). Transferred to
[**Hospital1 18**] for further management d/t no capacity for embolization or
surgery. NG lavage in the ER revealed bile only, no evidence of
blood. The GI team saw pt in the ER and recommended tagged RBC
scan. In the ER the pt had stable vital signs except tachycardia
to 120s. She received 4 units PRBC's in ED (although 2 of these
may have included [**Name (NI) 8**] [**Name (NI) **] - unclear), 3.5 L of NS.
.
Pt recently in [**Hospital 8**] hospital [**1-27**] with pneumonia treated
with Zosyn and developed Cfdiff, treated with PO flagyl. Had
some GI bleeding at that time and did not perform c-scope given
her infection. Also had some CP during that stay with negative
cardiac w/u including persantine mibi, and was started on dilt
and asa at that time. Has been in rehab for 5 days since
discharge from [**Hospital1 8**].
.
The patient presented to the MICU after tagged red cell scan was
completed. She complains of her usual back pain in the setting
of known spinal stenosis and rectal pain in setting of loose
stools/hematochezia. She has occasional abdominal pain, crampy,
that has been present since her last admission to [**Hospital 8**]
hospital and is no better or worse. Not exacerbated by food. No
recent NSAID use (allergic to ibuprofen). No fevers, chills,
nausea, vomiting. Last colonoscopy 5 yrs ago with
diverticulosis.
.
ROS: no fevers, chills, + cough with greenish sputum, improving,
no sore throat, congestion, HA, diploplia, chest pain, SOB. +
whole body pain and fatigue. occ. dysuria with foley catheter
chronically in place.
Past Medical History:
Pneumonia
Recent LGIB at OSH
DM 2 - followed by [**Last Name (un) **]
Diabetic neuropathy
CRI
Hypercholesterolemia
COPD
HTN
CHF - PMIBI by report at OSH was normal with EF 70%
Hypothyroidism
Diverticulosis
Glaucoma
Spinal stenosis
? Dermatomyositis
UTIs with indwelling foley for bladder atony
Sleep apnea on bipap overnight
Ectopic pregnancy
Social History:
40 pack yr history, quit 26 yrs ago, 2 glasses of wine with
dinner, no IVDU, lives with husband who takes care of her, sits
in chair all day long
Family History:
Father died of CVA at 50
Mother with gastric cancer
Brother with MI at 50
No GI disorders
Physical Exam:
PE: 97.7, 117, 102/50, 15, 97% on RA
Gen: Obese, lying in bed, moaning d/t back pain, sleepy from
dilaudid
HEENT: PERRL, EOMI, MM dry, OP clear, neck full and unable to
assess JVP
Cor: RRR, NL S1 and S2, no MRG
Pulm: CTAB ant
Abd: obese, +BS, nontender (just recieved pain meds), no
rebound, no guarding
Ext: 3+ LE edema and anasarce, LE cool, dopplerable pulses
Neuro: CN III-XII intact, [**6-16**] UE strength, [**5-17**] left LE, [**4-16**]
right LE, toes downgoing
Skin: no obvious sores anteriorly, but known sacral decub (will
examine when nursing turns patient)
Pertinent Results:
[**2198-2-11**] 07:03AM BLOOD WBC-15.4* RBC-3.07* Hgb-9.4* Hct-27.9*
MCV-91 MCH-30.5 MCHC-33.6 RDW-16.3* Plt Ct-463*
LABS:
.
[**2198-2-19**] 05:52AM BLOOD WBC-10.5 RBC-3.85* Hgb-11.7* Hct-34.1*
MCV-89 MCH-30.3 MCHC-34.2 RDW-16.2* Plt Ct-302
[**2198-2-11**] 07:03AM BLOOD Neuts-86* Bands-0 Lymphs-7* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2198-2-17**] 05:43AM BLOOD Neuts-67.5 Lymphs-24.1 Monos-4.9 Eos-3.2
Baso-0.3
[**2198-2-11**] 07:03AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2198-2-11**] 07:03AM BLOOD PT-13.4* PTT-25.5 INR(PT)-1.1
[**2198-2-18**] 05:22AM BLOOD PT-11.8 PTT-24.6 INR(PT)-1.0
[**2198-2-11**] 07:03AM BLOOD Glucose-262* UreaN-9 Creat-1.0 Na-134
K-4.6 Cl-97 HCO3-26 AnGap-16
[**2198-2-19**] 05:52AM BLOOD Glucose-203* UreaN-12 Creat-1.4* Na-133
K-3.7 Cl-95* HCO3-29 AnGap-13
[**2198-2-13**] 03:57PM BLOOD ALT-13 AST-16 AlkPhos-65 TotBili-0.3
[**2198-2-12**] 02:30AM BLOOD Lipase-13
[**2198-2-14**] 12:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2198-2-11**] 01:51PM BLOOD Calcium-7.9* Phos-4.3 Mg-1.6
[**2198-2-18**] 05:22AM BLOOD Calcium-8.5 Phos-4.7* Mg-1.5*
[**2198-2-12**] 09:00PM BLOOD Type-ART pO2-78* pCO2-61* pH-7.34*
calTCO2-34* Base XS-4 Intubat-NOT INTUBA
[**2198-2-11**] 09:05AM BLOOD Lactate-1.8
[**2198-2-12**] 09:00PM BLOOD O2 Sat-94
.
DIAGNOSTICS:
.
TAGGED RBC'S [**2198-2-11**]: Passage of blood clots with tagged RBCs
confirms active GI bleeding; localization is difficult but
appears likely in the sigmoid colon (first focus appears in the
first 5 minutes of the scan).
.
Emergency mesenteric angiography via left transfemoral approach
[**2198-2-11**]:
1. No active bleeding demonstrated angiographically.
2. Nonvisualization of the inferior mesenteric artery.
3. Unremarkable celiac axis and superior mesenteric artery
branches.
.
CT ABDOMEN/PELVIS [**2198-2-14**]:
1. Markedly limited examination due to patient's body habitus.
No definite CT evidence of colitis.
2. Small bilateral pleural effusions and bibasilar airspace
disease.
.
UNILAT UP EXT VEINS US LEFT [**2198-2-15**] 6:34 PM
No evidence of left upper extremity deep venous thrombosis. Left
brachial vein PICC line.
.
FLEX SIGMOIDOSCOPY:
Ulceration, friability and erythema in the rectum compatible
with ulcerative colitis, although Crohn's colitis possible
(biopsy). Otherwise normal sigmoidoscopy to rectum
Brief Hospital Course:
65yo woman with MMP including DM, recent pneumonia with Cdiff,
presents with hematochezia and tachycardia, transferred from
MICU to general medicine floor on [**2-16**], Hct and hemodynamics
stable.
.
#. GI Bleed:
Hematochezia with stable BP/tachycardia suggestive of likely
lower GI source. Differential includes diverticular bleed, AVM,
Cdiff colitis, ischemic colitis. Appreciate GI seeing pt in ER.
Normal lactate not suggestive of ischemia, unlikely to have this
degree of hematochezia from Cdiff, although possible, pt with
known diverticulosis making this leading differential. Last
scope 5 years ago was reportedly clean so malignancy less likely
but possible. Stool cultures for hemorrhagic bacterial
infections were negative. Tagged red cell scan positive. Patient
transfused total of 4 units in MICU and 1 unit platelets with
eventual stabilization of Hct. Angio could not localize
bleeding. Colonospcopy [**2198-2-13**] showed large blood and clots up to
20 cm from anus and therefore limited study. Repeat CTA of
abdomen/pelvis performed at request of GI for evaluation of
colon wall and source of bleed. CTA limited secondary to body
habitus but no contrast extravasation or frank colitis. Femoral
line discontinued [**2-14**], tip culture no growth. Due to limited
studies and uncertainty regarding location of bleeding, patient
had a flex sigmoidoscopy on [**2198-2-19**]. It revealed ulceration,
friability and erythema in the rectum compatible with ulcerative
colitis, although Crohn's colitis possible (biopsy). Pt remained
hemodynamically stable on general medicine floor.
- mesalamine enema qHS, suppository qAM
- await biopsy results
- Hct stable, monitor daily
- on PPI
- hold anticoagulation, including ASA
.
#. Pneumonia at OSH, now resolved:
LLL infiltrate with GNR in sputum diagnosed on [**1-27**] at OSH.
Patient was s/p 10 day course of zosyn (ended [**2-6**]). Upond
arrival to MICU, patient continued to have leukocytosis and
sputum production. CXR without infiltrate. Sputum culture
ordered but patient without productive cough in MICU and unable
to produce expectorate. Remained afebrile, sats stable on
baseline supplemental oxygen, without increased requirement.
.
#. C. diff dx'd at OSH:
Completed full course flagyl, not having loose stools. Toxin
assay negative. Afebrile without leukocytosis at during hospital
course.
.
#. COPD:
No evidence of COPD flare. Continued pt's outpatient regimen.
Unclear if this is why pt was on prednisone from OSH. Lung exam
unremarkable. Steroid taper discontinued [**2197-2-13**]. Sats stable in
mid-90s on 2L at discharge.
- albuteral nebs, spireva
- humidified oxygen
.
# CHF:
Patient has hx of diastolic heart failure, EF 70% on recent
persantine MIBI from OSH. She takes lasix at home and did not
come in with dyspnea but does have severe peripheral edema
secondary to heart failure. Lasix was continued at home dose.
.
#. CRI:
Pt with admission Cr 1.8, normalized after volume, now 0.9.
Received bicarb and mucomyst prior to angio embolization.
Remained stable with adequate urine output. Cr increased to 1.4
on [**2-19**]. Unclear etiology as there have been no change in meds,
pt not dry on exam, BP normotensive. Last contrast study was on
[**2-15**] for CT abd, decreasing chance for contrast-induce
nephropathy which tends to occur in 48hrs. Fractional excretion
of urea was 45% indicating pre-renal etiology due to hypovolemia
as patient appeared dry on exam.
- avoid nephrotoxins
- cont lasix 80 IV BID for diuresis
- monitor UOP via foley
.
#. Cardiac:
Pt apparently had CP at OSH 2w ago and had a negative persantine
mibi by report. At that time she was started on asa and dilt by
cardiology. BP stable throughout MICU stay. EKG without changes
and cardiac enzymes negative.
- continue to hold ASA in setting of recent lower GI bleed
.
#. Back pain control:
Pt has history of spinal stenosis. Continued pt's usual pain
regimen of morphine SR and dilaudid initially. Patient became
over-sedated on initial regime and was switched to dilaudid prn.
Avoiding standing doses of morphine [**3-16**] sedation.
- dilaudid prn
- followup with outpatient neurologist
.
# UTI/indwelling foley:
Patient has hx of recurrent UTIs due to chronic indwelling foley
catheter, which has been changed intermittently. She was found
to have a UTI prior to discharge and placed on antibiotics. She
has had a foley for urinary frequency and urgency, had
cystoscopy last year by urologist in [**Hospital1 2436**] and found to
have scarring in bladder. Urologist at [**Hospital1 18**] recommended against
suprapubic catheter placement as it does not reduce the risk of
frequent infections and thus not indicated in this patient.
- cipro 500mg x 5 days
.
#. Skin breakdown:
Stage II ulcer on R buttock and ?cellulitis on L thigh at recent
bx site.
- continue ketoconacole topically to buttock wound
- daily wound care
- applying antibiotic ointment to L thigh at bx site
- rectal tube in place
.
#. LUE swelling:
Pt had Power PICC, changed over wire [**2198-2-15**] b/c occluded; UE
ultrasound performed. No evidence of left upper extremity deep
venous thrombosis.
- keep arms raised on pillows to prevent orthostatic edema
.
#. Hypothyroidism:
- continue levoxyl
.
#. DM2:
[**Last Name (un) **] followed patient during hospital stay, modifying insulin
coverage. Patient's FSBG were well-controlled on following
regimen.
- continue insulin with FS checks qachs
- 36 units lantus standing dose with dinner, humalog sliding
scale
- neurontin for peripheral neuropathy
.
#. Glaucoma:
- continue eye drops
.
#. PPX:
- hep SQ, pneumoboots
.
#. Code status: FULL
.
#. DISPO:
DC to rehab. Follow up with GI outpatient. Consider making an
appointment with [**Hospital 511**] [**Hospital **] [**Hospital 36418**] Obesity Consult
Center at [**Telephone/Fax (1) 97026**] for physical fitness and weight loss
management.
Medications on Admission:
Flagyl 500mg po tid
lantus 128 units
lispro 8units sc with meals
albuterol 1-2 puffs [**Hospital1 **]
asa 81mg po qday
diltiazem 120 q6h
baclofen 5mg po bid
timolol 1 drop tid
dorzolamide 1 drop tid
cymbalta 60mg po qday
advair 500/50 1 puff [**Hospital1 **]
lasix 80mg po bid
neurontin 30 qam?/600qhs
heparin 5000u tid SQ (due to prolonged hospitalizations she has
been on this)
levoxyl 100mg po qday
MS contin 60 PO tid
Morphine IR 5 mg PO Q6prn
spiriva 18mcg qday
protonix 40mg po qday
prednisone 5mg po qday
ketoconazole cream
Kdur 20meq po qday
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
10. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day).
11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)).
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY ().
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Albuterol Sulfate 0.083 % Solution Sig: [**2-13**] Inhalation Q6H
(every 6 hours) as needed.
16. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal QDAY ().
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
18. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. Insulin Glargine 100 unit/mL Solution Sig: Sliding Scale
Subcutaneous QAHS.
20. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
21. 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.
22. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
23. Mesalamine 4 g/60 mL Enema Sig: One (1) Rectal HS (at
bedtime).
24. Mesalamine 1,000 mg Suppository Sig: One (1) Suppository
Rectal QAM (once a day (in the morning)).
25. Sodium Chloride 0.65 % Aerosol, Spray Sig: One (1) Spray
Nasal PRN (as needed).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses:
Lower GI bleeding
Ulcerative colitis
Urinary tract infection
.
Secondary diagnoses:
Recent pna hospitalization
recent LGIB at OSH, no intervention d/t c. diff and PNA
DM 2- pt at [**Last Name (un) **]. c/b neuropathy
CRI - Cr 1.6 in past, however 1.0 today nephrologist Dr. [**Last Name (STitle) 97027**]
at OSH
hypercholesterolemia
COPD
HTN
CHF - PMIBI by report at OSH was normal with EF 70%
hypothyroidism
diverticulosis
glaucoma
spinal stenosis
?dermatomyositis
UTIs with indwelling foley for bladder atony
sleep apnea on bipap overnight
ectopic pregnancy
Discharge Condition:
Stable, BP normotensive, no GI bleeding
Discharge Instructions:
You were admitted for bleeding per rectum and found to have a
very low blood count. You were stabilized in the Medicine
intensive care unit. You underwent several studies to determine
cause of bleeding and were found to have ulcerative colitis and
started on treatment.
.
You were also found to have a urinary tract infection and were
placed on short course of antibiotic treatment.
.
Please take all your medications as prescribed. You are being
discharged to [**Hospital **] Rehab.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD [**First Name (Titles) **] [**Last Name (Titles) 18**] GI
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2198-3-13**] 3:00
ICD9 Codes: 5789, 5859, 496, 2851, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3367
} | Medical Text: Admission Date: [**2179-6-13**] Discharge Date: [**2179-6-23**]
Date of Birth: [**2109-9-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
R PICC inserted [**2179-6-12**], A-line [**2179-6-14**]
History of Present Illness:
69 M with COPD on 3L NC at home, obstructive sleep apnea on
CPAP, type 2 diabetes mellitus, and chronic renal insufficiency
(baseline 1.8-2.0) and several recent admissions with SOB (most
recently in [**2179-6-7**]) who presents with SOB, after finishing a
steroid taper yesterday. Was at [**Hospital1 **] and noted to have
increasing respiratory distress low o2 sats to the 80s on 3L and
had an abg with co2 of 89, was given ceftriaxone and vancomycin.
He was recently noted with increasing edema and was being
diuresed. at OSH.
.
In the ED, 99.9 93 145/58 29 100%bipap was noted 7.15/118/113
was placed on bipap for 30min, with continued hypercarbia, and
was intubated, given solumedrol, nebulizers and lasix 100mg IV.
Past Medical History:
1) Chronic obstructive pulmonary disease, no pulmonary function
test on record, on 3L NC at home (only with exertion).
2) Obstructive sleep apnea on BIPAP (settings = 12&6 on 8 L
oxygen.)
3) Type 2 diabetes c/b biopsy-proven diabetic nephrosclerosis.
4) Paroxysmal atrial fibrillation on aspirin/coumadin
5) Chronic renal insufficiency from diabetic nephropathy:
- diagnosed by renal biopsy
- baseline Cr 1.8-2.2
- Followed by Dr. [**Last Name (STitle) **].
- [**3-/2178**] Renal U/S: Mildly echogenic kidneys consistent with
chronic parenchymal disease. No evidence of cortical thinning or
hydronephrosis
6) Gout
7) Anemia
8) Hypertension
9) Anxiety
10) CHF (EF > 75%, mild ventricular outflow tract obstruction)
Social History:
Lives with daughter. +[**Year (4 digits) **] 100 pack year hx; quit in [**2-/2179**]; has
not had EtOH in >1 year; prior to that had 3 beers/day. no
illicits
Family History:
Non-contributory
Physical Exam:
Vitals - 100.0 95 158/50 18 100% AC 500x18
General - obese, NAD, sedated.
HEENT - PERRL, JVD flat
CV - rrr, distant heart sounds, no m/r/g heard
Chest - ant xm, coarse bs b/l
Abdomen - obese, soft, NTND, nl BS, no HSM
Extremities -no c/c 1+ edema, erythema/warmth noted on RUE, 1+
b/l DP pulses
Neuro - sedated, intubated,
Pertinent Results:
Labs on admission:
[**2179-6-13**] 08:37PM BLOOD WBC-10.3 RBC-3.77* Hgb-9.2* Hct-30.2*
MCV-80* MCH-24.3* MCHC-30.3* RDW-16.7* Plt Ct-224
[**2179-6-13**] 08:37PM BLOOD Neuts-76.1* Lymphs-15.7* Monos-6.6
Eos-1.1 Baso-0.5
[**2179-6-14**] 04:05AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2179-6-13**] 08:37PM BLOOD PT-19.9* PTT-29.5 INR(PT)-1.9*
[**2179-6-13**] 08:37PM BLOOD Glucose-51* UreaN-52* Creat-2.1* Na-147*
K-5.5* Cl-106 HCO3-37* AnGap-10
[**2179-6-13**] 08:37PM BLOOD CK(CPK)-64
[**2179-6-21**] 02:51AM BLOOD ALT-31 AST-25 AlkPhos-35* TotBili-0.2
[**2179-6-13**] 08:37PM BLOOD CK-MB-NotDone proBNP-4271*
[**2179-6-13**] 08:37PM BLOOD cTropnT-0.08*
[**2179-6-13**] 08:37PM BLOOD Calcium-8.5 Mg-2.4
[**2179-6-21**] 02:51AM BLOOD TSH-0.82
[**2179-6-14**] 04:05AM BLOOD Vanco-20.5*
[**2179-6-13**] 08:43PM BLOOD Type-ART pO2-113* pCO2-118* pH-7.15*
calTCO2-43* Base XS-7
[**2179-6-13**] 08:43PM BLOOD Lactate-0.5
[**2179-6-16**] 12:30PM BLOOD Glucose-69*
.
[**6-17**] Renal U/S
TECHNIQUE: Son[**Name (NI) 493**] ultrasound was performed at the bedside.
Limited imaging, two images, were obtained due to patient
combative state.
FINDINGS: Only two transverse views of the right kidney were
obtained due to patient's combative state. The submitted views
demonstrate no evidence for hydronephrosis in the right kidney.
.
[**6-13**] CXR
CHEST, SUPINE AP: Comparison made to earlier on the same day.
There is a new endotracheal tube, terminating 4 cm above the
carina, beyond the thoracic inlet. A PICC line is unchanged. A
nasogastric tube has also been introduced. Its distal course is
not well delineated, but it appears to terminate near the
gastroesophageal junction. Advancement of the tube further into
the stomach is recommended.
The heart is enlarged. There is persistent congestive heart
failure and right basilar effusion. There are bibasilar
opacities, which may reflect atelectasis. The left costophrenic
angle is excluded.
IMPRESSION:
1. Satisfactory positioning of endotracheal tube.
2. Nasogastric tube appearing to terminate near the
gastroesophageal junction. Advancement into the stomach is
recommended.
3. Persistent congestive heart failure, right effusion and
non-specific bibasilar opacities.
.
[**6-22**] CXR
Since most recent film, there is improved aeration at both lung
bases with persistent left-sided pleural effusion. The right
costophrenic angle is not included on current radiograph.
Additionally, right infrahilar density appears stable and may
represent either superior segment atelectasis versus aspiration
in supine patient. Mild interstitial pulmonary edema persists.
There is no evidence of pneumothorax, and tip of endotracheal
tube terminates approximately 7.5 cm from the carina in a
chin-up position. A right central venous catheter and orogastric
tube remain in stable position.
IMPRESSION:
1. Decreasing lower lobe atelectasis with persistent left-sided
pleural effusion and right infrahilar opacity that likely
represents atelectasis versus aspiration.
2. Mild interstitial pulmonary edema.
.
Labs prior to death:
[**2179-6-23**] 03:06AM BLOOD WBC-24.5* RBC-4.12* Hgb-9.8* Hct-31.1*
MCV-75* MCH-23.9* MCHC-31.7 RDW-18.2* Plt Ct-156
[**2179-6-23**] 03:06AM BLOOD Plt Ct-156
[**2179-6-23**] 03:06AM BLOOD PT-18.5* PTT-39.3* INR(PT)-1.7*
[**2179-6-23**] 03:06AM BLOOD Glucose-188* UreaN-144* Creat-7.7* Na-135
K-7.6* Cl-95* HCO3-27 AnGap-21*
[**2179-6-23**] 03:06AM BLOOD Calcium-8.8 Phos-9.6* Mg-2.6
[**2179-6-22**] 03:37AM BLOOD Vanco-17.9
[**2179-6-23**] 03:16AM BLOOD Type-ART Temp-37.9 Rates-16/0 Tidal V-550
PEEP-10 FiO2-60 O2 Flow-8.6 pO2-75* pCO2-65* pH-7.25* calTCO2-30
Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2179-6-21**] 09:57PM BLOOD K-6.2*
[**2179-6-21**] 12:24AM BLOOD Lactate-2.5*
Brief Hospital Course:
A/P: Patient is a 69 yo m with COPD, CRI, DM, pAfib, who
presented from rehab w/ SOB. Hospital course complicated by:
.
# Toxic megacolon: Stool cx positive for cdiff. Initially
treated with IV flagyl but it continued to get worse so po vanc
was added but this progressed to toxic megacolon. Abd XR c/w
very dilated loops of lg intestine. Per surgery, would need
surgery for colectom/ostomy but per family mtg, he would not
want surgery.
.
# Hypercarbic respiratory failure: He was intubated for
hypercarbic resp failure after admission. Likely
multifactorial, including COPD flare [**3-12**] ? PNA. Started on abx
at [**Hospital1 **] for presumptive nosocomial PNA and CAP. Also
recently finished a steroid taper on the day PTA. SOB may also
be complicated by element of CHF, given increased BNP. Baseline
O2 requirement 3L NC. Extubated on [**2179-6-16**] and tolerateding BiPAP
w/ CO2 in 80's which may be close to baseline but then was
re-intubated given rising CO2. Continued on
nebs/solumedrol/vanc/zosyn/ but continued on vent until his
death with unsuccessful weaning, likely [**3-12**] volume overload from
renal failure.
.
# ARF on CKD: He progressed to ARF during his hospital course
and was anuric prior to his death. Bladder pressure 28
indicating abd compartment syndrome. Likely a combination of
pre-renal azotemia +/- septic ATN +/- compartment syndrome. He
progressed to hyperkalemia but per family wishes CVVHD was not
initiated. Hyperkalemia likely was ultimately the proximal
cause of his death.
.
# Afib: Developed a-fib w/ RVR on [**6-16**] s/p extubation. Rate
controlled with diltiazem drip initially but continued to flip
in and out of RVR. EP followed and amio load and amio gtt
started. Pt unable to take PO beta-blocker. Per EP, held off on
starting dilt. Also, has been shocked several times when
hypotensive in afib/RVR and only briefly stays in sinus rhythm.
.
# CHF: With increased BNP from previous values around 1500, also
discontinued from lasix while on recent admission. Patient
appeared intravascularly dry by clinical exam and BUN:Cr,
although total body overloaded.
.
# Hypernatremia: Now resolved. Was likely [**3-12**] volume depletion.
Poor PO intake. Repleted volume with free H2O via NGT.
.
# DM2: insulin gtt.
.
# RUE Erythema: initially concerned for cellulitis vs DVT. U/S
negative and clinically improving. IV RN called, but not
concerned about cellulitis.
- ? remove PICC, not indicated now but would need alternate
access
.
# Microcytic anemia: likely [**3-12**] CKD, stable.
- Continue iron repletion and erythropoeitin per home regimen
.
# Access: R PICC inserted [**2179-6-12**], A-line [**2179-6-14**], PIVs x 2
.
# Contact: [**Name (NI) **] [**Name (NI) 5110**], daughter: [**Telephone/Fax (1) 96937**] (H),
[**Telephone/Fax (1) 96940**] (C)
.
# DNR
Medications on Admission:
Tiotropium Bromide 18 mcg Capsule, QD
Ipratropium Bromide Q6HRS
Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **]
Aspirin 325 mg QD
Lasix 40mg QD
Ferrous Sulfate 325 QD
Quetiapine 25 mg TID
Multivitamin QD
Terazosin 2 mg QHS
Sevelamer 800 mg TID with meals
Warfarin 7.5 mg QD
Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) ml Injection
QMOWEFR (Monday -Wednesday-Friday).
Diltiazem HCl 300 mg Capsule, SR QD
Metoprolol Tartrate 50 mg TID
Prilosec OTC 20 mg Tablet, QD
Docusate Sodium 100 mg [**Hospital1 **]
Fexofenadine 60 mg Tablet [**Hospital1 **]
Senna 8.6 mg Tablet [**Hospital1 **]
Albuterol PRN
Vancomycin 1gm ([**6-7**])
Ceftrixaone [**6-7**]
Azithromycin
RISS
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 496, 4280, 486, 5849, 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3368
} | Medical Text: Admission Date: [**2165-11-21**] Discharge Date: [**2165-11-28**]
Date of Birth: [**2122-12-25**] Sex: F
Service: Neurology
HISTORY OF PRESENT ILLNESS: This is a 42 year old woman with
history of metastatic melanoma diagnosed in [**2159**], status post
chemotherapy here at [**Hospital6 256**] who
presents with acute onset of right hemiparesis and expressive
aphasia since earlier this evening. History is provided by
her fiance and husband who are at the bedside. At 7:35 PM
tonight she lost motor movement of her right arm without
sensory loss. Over the next 15 to 20 minutes she noted that
her right leg was also weak. Emergency medical services was
called and as she was on her way here she began to lose her
speech. She was unable to talk but was able to understand
and follow commands. Her symptoms progressively got worse
over time and have stabilized over the last two hours and
there have been no significant changes since. The family
denies any seizure activity or shaking movements. She denies
any headache, sensory loss or other complaints. There was no
loss of bowel or bladder control or candlelighting. There
were no similar episodes in the past. Review of systems is
essentially negative per family except for longstanding left
hip pain due to metaphysis.
PAST MEDICAL HISTORY: 1. Metastatic melanoma on maintenance
IL2 with Dr. [**Last Name (STitle) **]; 2. Left groin metaphysis in the
gluteal region, status post surgery.
MEDICATIONS: MS Contin 60 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives in her fiance and is from [**Location (un) **],
Mass.
FAMILY HISTORY: Multiple relatives with cancer and paternal
grandmother with coronary artery disease.
PHYSICAL EXAMINATION: Afebrile, blood pressure 142/71, pulse
100, respiratory rate 18. Generally, lucid woman in general
discomfort holding her fiance's hand. Neck, limited range of
motion with no pain. The patient resists movements. Lungs
are clear to auscultation bilaterally. Cardiovascular,
regular rate and rhythm. On neurological examination, she is
awake and for the most part alert, mostly cooperative with
examination. Language no verbal output. She can follow
simple commands like closing her eyes and protruding her
tongue. She can also follow more complex commands, crossing
midline, showing two fingers. On cranial nerve examination,
she blinks to visual threat bilaterally. Funduscopic not
well visualized due to lack of cooperation. Pupils equal,
round and reactive to light, 42 mm bilaterally. Extraocular
eye movements are intact with sticcottic eye movements and no
nystagmus. Facial sensation can not be assessed. Facial
movement has marked right facial droop as well as some slight
right upper face weakness. Hearing is intact to finger rub
bilaterally. Tongue is midline without fasciculation.
Sternocleidomastoid and trapezius is normal only on the left.
On motor examination, she has normal bulk and tone
bilaterally. There is no tremor. There is dense right
hemiparesis 0 out of 5 with the right arm flexed upward in
upper motor neuron pattern. Muscle strength on the left was
suboptimal effort but no focal weakness besides that limited
by pain, especially on the left lower extremity. Sensory
examination, it is difficult to assess but she denies any
changes to light touch, pinprick, temperature or vibration.
She withdraws to pain in the left lower extremity and upper
extremity. Her reflexes are brisk throughout 3 out of 4 and
symmetric. Her grasp reflex is absent. Toes are upgoing
bilaterally. On coordination examination, she is intact to
finger-to-nose test on the left with slow rapid alternating
movements. Gait was not assessed.
LABORATORY DATA: Laboratory data and radiology upon
admission revealed sodium 142, chloride 105, BUN 10, glucose
123, potassium 3.2, bicarbonate 27, creatinine 0.6, calcium
9.8, magnesium 1.8, phosphate 2.9. White count 6.7,
hemoglobin 11.3, hematocrit 34.1, platelets 227. PT 12.6,
PTT 27.1, INR 1.1. Noncontrast head computerized tomography
scan shows a left frontal 3.5 by 3.4 cm hemorrhagic
metastatic lesion and a left posterior parietal hemorrhagic
lesion. The patient was started on Dilantin for seizure
prophylaxis.
HOSPITAL COURSE: She was initially admitted to the Intensive
Care Unit for blood pressure monitoring. A magnetic
resonance imaging scan of the brain was done showing a left
frontal, left posterior parietal and left superior parietal
hemorrhagic metastatic lesion. The patient remained stable
and was called out to the floor. While on the floor, she
continued to have a dense right hemiplegia but her verbal
output did return. The Neurosurgery Service was consulted
and they recommended that the left frontal metastatic lesion
be excised and the patient was accepting of this offer.
Radiation Oncology and Neuro-Oncology was consulted and both
felt that the patient should have stereotactic radiation
after the surgical resection of her left frontal metastatic
lesion. In addition, her Dilantin was switched over to
Keppra given that the Dilantin will give her a higher
threshold of seizures during the radiation. The patient was
seen by physical therapy and found to be able to move around
with minimal assistance. She was discharged and set up for
surgery one day next week. Given the edema around the
hemorrhagic metastatic lesion, the patient was started on
Decadron.
DISCHARGE DIAGNOSIS:
1. Hemorrhagic brain metastases
2. Metastatic melanoma
DISCHARGE MEDICATIONS:
1. Tylenol 325 mg p.o. q. 4-6 hours prn pain
2. Morphine Sulfate sustained release 16 mg p.o. q.d.
3. Percocet 5/325 one tablet p.o. q 4-6 hours prn pain
4. Famotidine 20 mg p.o. b.i.d.
5. Dilantin 150 mg p.o. b.i.d. times three days and then 100
mg p.o. b.i.d. for three days and then discontinue
6. Keppra 1000 mg p.o. b.i.d. times three days and then 1500
mg p.o. b.i.d.
7. Decadron 4 mg p.o. t.i.d. times five days
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5930**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6125**]
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2165-12-1**] 14:30
T: [**2165-12-1**] 16:28
JOB#: [**Job Number 48461**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3369
} | Medical Text: Admission Date: [**2154-9-22**] Discharge Date: [**2154-9-27**]
Date of Birth: [**2096-8-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Penicillins
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
CVL placement
History of Present Illness:
History of Present Illness: This is a 58 y/o M with HTN on
diltiazem presenting with GI bleeding. He had been admitted to
[**Hospital6 33**] 1 week ago with GI bleeding, with EGD
revealing healed gastritis and colonoscopy showing polyposis. CT
angio was non diagnostic. He received 4U of PRBC and underwent
upper endoscopy revealing non erosive gastritis and healing
esophagitis. Colonoscopy did not show acute bleeding and 4
polyps were removed. He was readmitted on [**2154-9-18**] with crampy
abdominal pain, 2 episodes GI bleeding prior to admission, with
900cc blood loss per rectum inhouse with ICU admission. He
received 7U of PRBC with cessation of bleeding for 36 hours, and
then a drop in his crit again. He was also briefly hypotensive.
Most recent HCT was 26.2. He was restarted on [**1-7**] dose of home
antihypertensives today.
He is being transferred to [**Hospital1 18**] for angiography and potential
coiling.
On arrival to the MICU pt was hypotensive to 64/49 with
sensation of light headedness. He immediately had bright red
blood per rectum with clots to 1L. He was given a 1L IVF bolus
and started on neosynephrine and the massive transfusion
protocol was activated.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
OSA
BPH
Hypertension
Nasal Surgery
Vasectomy
Social History:
He is married, has 2 children, 1 is living, 1 is deceased. Works
in computers. No tobacco for 2 and 1/2 months. Alcohol intake is
[**2-8**] drinks per day, last drink 9 days ago
Family History:
He has 2 brothers. [**Name (NI) **] family history of diabetes mellitus.
Father with family history of cancer. Uncle with leukemia.
Physical Exam:
Admission exam:
T:98.1 BP:122/46 P:79 R:23 18 O2: 100% 2L CVP 11
General: Alert, oriented, endorsing light headedness, mentating
well
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge exam:
VS- 98.3 126-187/83-105 67-75 18 98%RA
Gen- NAD, AAOx3
HEENT- MMM, no JVD
CV- S1S2 RRR no m/g/c/r
PULM- CTAB
ABD- Soft, BS+, nt/nd
EXT- No c/c/e
Pertinent Results:
Admission Labs:
[**2154-9-22**] 08:28PM PT-12.3 PTT-27.2 INR(PT)-1.1
[**2154-9-22**] 08:28PM PLT COUNT-371
[**2154-9-22**] 08:28PM WBC-6.8 RBC-3.08* HGB-9.7* HCT-28.0* MCV-91
MCH-31.6 MCHC-34.7 RDW-16.3*
[**2154-9-22**] 08:28PM CALCIUM-7.9* PHOSPHATE-3.1 MAGNESIUM-1.8
[**2154-9-22**] 08:28PM GLUCOSE-87 UREA N-9 CREAT-1.0 SODIUM-146*
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-21* ANION GAP-18
[**2154-9-22**] 10:07PM HCT-33.6*
[**2154-9-23**] 03:52AM BLOOD ALT-20 AST-21 LD(LDH)-182 AlkPhos-29*
TotBili-0.7
[**2154-9-23**] 08:12AM BLOOD CK-MB-2 cTropnT-<0.01
[**2154-9-22**] 08:28PM BLOOD CK-MB-2 cTropnT-<0.01
Discharge Labs:
[**2154-9-27**] 08:40AM BLOOD WBC-6.6 RBC-3.78* Hgb-12.0* Hct-34.7*
MCV-92 MCH-31.7 MCHC-34.5 RDW-14.8 Plt Ct-424
[**2154-9-27**] 08:40AM BLOOD Plt Ct-424
[**2154-9-25**] 08:15AM BLOOD PT-12.4 PTT-31.1 INR(PT)-1.1
[**2154-9-26**] 08:15AM BLOOD Glucose-116* UreaN-8 Creat-0.9 Na-145
K-3.4 Cl-108 HCO3-28 AnGap-12
[**2154-9-26**] 08:15AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.7
Imaging:
CTA Abdomen
IMPRESSION:
1. No source of GI bleed identified.
2. Left descending colonic diverticulosis without
diverticulitis.
3. Extensive atherosclerotic disease with areas of soft plaque
ulceration in
the abdominal aorta. No aneurysmal change or dissection.
4. Incidental note of a left sided inferior vena cava.
5. Left nephrolithiasis.
CXR
FINDINGS: Heart size remains normal, and lungs and pleural
surfaces are
clear.
Micro:
Negative MRSA screen
Brief Hospital Course:
58 y/o M with history of HTN, with readmission to OSH for GI
rebleed, transferred to [**Hospital1 18**] for angiography and IR
intervention.
# GI bleed: He had presented to [**Hospital6 **] twice in
the last week with crampy abdominal pain and bright red blood
per rectum. Notably, colonoscopy showed multiple non bleeding
diverticulae as well as non bleeding polyps with biopsies taken.
Endoscopy showed only non erosive gastritis and healed
esophagitis. He had two CTAs performed over the two admissions
showing diverticulitis. The second CTA did not capture the
arterial phase and was thus suboptimal. A diverticula bleed was
felt to be most likely although a source of bleeding within the
small bowel lumen would not have been evaluated with endoscopy,
colonoscopy or CTA. A repeat CTA was performed at [**Hospital1 **] which was
non revealing. On admission he had an acute episode of massive
lower GI bleed for which he received 4U PRBC with stabilization
of his HCT. He was transferred to the floor with no recent
bloody BM. On the medicine floor, he had one episode of darker
red BM with clots. CTA was ordered but there was a delay in
communicating with the floor for transfer and thus cancelled
since it was unlikely to revel the site of the bleed. A repeat
hematocrit later that day was stable. Over the next 2 days he
did not have another BM, likely indicating that the bleeding had
stopped since blood is cathartic. On the day of his planned
discharged, he had a BM which showed really dark blood but not a
significant amount. He was kept over night, and the next
morning, he had a normal looking BM. His H/H remained stable
during his entire time on the medicine floor ~3-4 days (no need
for transfusion). He was seen by GI who thought that a pill
endoscopy was not necessary since the bleed was likely
diverticulosis. We scheduled a f/u appt with GI at [**Hospital1 2292**]. He was also instructed to return to the ER if he
begins to have bloody BM again. He may need a colectomy in the
future iof he has recurrent bleeds. It was also mentioned to him
to ask his GI doctor at his f/u visit if he needed a pill
endoscopy. His asprin was stopped and he was sent with a PPI, as
per GI.
# Hypotension: He was hypotensive on admission in the setting of
active GI bleed and initially required pressor support. He was
symptomatic with lightheadedness. He received rapid
resuscitation with fluids and blood products with normalization
of his BP. His home cozaar, diltiazem, hctz, terazosin and
aspirin were held. An EKG showed new T wave inversions. His
troponins remained flat x2. He quickly came off pressors and was
stable. He was transferred to the medicine floor. He began to
become hypertensive on the floor and his BP meds were gradually
restarted. He was discharged on his home regimen.
# Alcohol abuse: He endorsed drinking [**2-8**] drinks per day with
last drink 9 days prior to admission. No history of seizures,
blackouts, withdrawal symptoms. Outside of window for withdrawal
but received a banana bag on admission and was monitored for
evidence of withdrawal. Did not develop sxs of withdrawal during
his stay. Stressed to cut down the drinking to 1-2 drinks/day.
# Depression: Continued Wellbutrin.
# Obstructive sleep apnea: Continued CPAP.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Terazosin 10 mg PO HS
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Simvastatin 20 mg PO QHS
6. Aspirin 81 mg PO DAILY
7. BuPROPion 150 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Simvastatin 20 mg PO QHS
6. Terazosin 10 mg PO HS
7. BuPROPion 150 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
Give if pt has not received IV pantoprazole today
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diverticulosis, Gastrointestinal Bleed
Secondary: OSA, HTN
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 admitted with a GI bleed likely due to
diverticulosis. We were unable to find a definite source for the
bleed, but you were stable for several days prior to discharge.
The following changes were made to your medications:
STOP Aspirin, it is an anticoagulant and your relative risk of
serious bleed outweighs the positive heart attack prevention
aspirin would cause.
START protonix to help prevent bleeds
Followup Instructions:
Name: [**Last Name (LF) 17466**], [**Name8 (MD) **] MD
Location: [**Hospital1 641**]
Department: Gastroenterology
Address: [**Location (un) 17467**], [**Hospital1 **],[**Numeric Identifier 10727**]
Phone: [**Telephone/Fax (1) 17468**]
Appointment: Monday [**2154-9-30**] 10:00am
Name: POST,[**Location (un) **] A.
Location: [**Location (un) 2274**] [**Hospital1 **]
Address: [**Location (un) 17467**], [**Hospital1 **],[**Numeric Identifier 20089**]
Phone: [**Telephone/Fax (1) 68410**]
Appointment: Friday [**2154-10-4**] 1:30pm
*You did have an appointment scheduled for tomorrow [**2154-9-27**] but
it has been cancelled. If you have any questions or concerns
please call the office.
ICD9 Codes: 2851, 4589, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3370
} | Medical Text: Admission Date: [**2101-8-13**] Discharge Date: [**2101-8-20**]
Date of Birth: [**2039-8-28**] Sex: F
Service: [**Hospital1 **] Medicine, [**Hospital Ward Name 517**]
CHIEF COMPLAINT: Hypoglycemia.
HISTORY OF PRESENT ILLNESS: This is a 61 year old woman with
a history of hypoglycemic episodes in the past of unknown
etiology and she was found unresponsive at home by her
family. Emergency medical technician notes indicate a
fingerstick glucose in the field of 28. The patient was
given 1 amp of D10 in the field with some improvement in her
mental status. The patient arrived in the Emergency
Department and was hypotensive with a systolic [**Hospital Ward Name **] pressure
of 74 and fingerstick going as low as 47. The patient
required Dopamine drip to maintain a [**Hospital Ward Name **] pressure despite
repeated normal saline boluses, necessitating a Medicine
Intensive Care Unit admission on [**2101-8-13**]. On
arrival to the floor the patient had been off of pressors for
24 hours. The patient had been transferred to the floor on
[**8-16**] and the patient had received a hemodialysis
session on [**8-15**]. The patient also had been on four
days of Vancomycin upon transfer to the floor. This was for
one out of four bottles of gram positive cocci which were
subsequently believed to be contaminate. Upon transfer to
the floor, the patient's fingersticks over night ranged from
85 to 150. Upon transfer the patient denied any pain, nausea
or shortness of breath. She started to report poor appetite
secondary to "bad cooking" of the hospital cafeteria.
PAST MEDICAL HISTORY: Notable for upper gastrointestinal
bleed secondary to esophagitis as well as gastritis in [**2101-5-31**]. The patient has been on end stage renal disease since
approximately seven years ago and has a history of Type 2
diabetes, going back 20 to 30 years and is status post
adenoma resection approximately 13 years ago with resulting
panhypopituitarism and is currently on Prednisone at the
current dose of 10 mg daily as well as Synthroid dependent.
History of hypertension. History of congestive heart
failure. Ejection fraction less than 20%. History of
coronary artery disease. History of gastroesophageal reflux
disease. History of secondary arteriovenous block, Type 1.
History of hemosiderosis and history of recurrent
hypoglycemics noted above. Also status post ovarian mass
resection in [**2087**].
ALLERGIES: No known drug allergies.
OUTPATIENT MEDICATIONS: Prednisone, outpatient dose 5 mg
daily; Colace 100 mg b.i.d.; Folate 1 mg daily; Synthroid 75
mcg daily; Thiamine 100 mg daily; Lisinopril 5 mg daily;
Epogen given with each for hemodialysis session.
On transfer to the floor her medications were Vancomycin 1 gm
intravenously q. day Day #4, Protonix 40 mg intravenously
daily, Synthroid 75 mcg daily, Prednisone 10 mg daily and
..................2 to 4 mg intravenously q. 8 hours prn
nausea.
SOCIAL HISTORY: The patient was living with her sister and
has no known drug, tobacco or ethyl alcohol history. She has
no children and is separated. She is a retired packer for
[**Company 22916**] Razor Company.
FAMILY HISTORY: Pertinent for diabetes in her mother.
HOSPITAL COURSE: As noted above the one out of four bottle
turned out to be a most likely contaminate. The patient
remained afebrile without any evidence of leukocytosis. The
Vancomycin was subsequently discontinued. Her hemodialysis
was continued for end stage renal disease, continuing
sessions of Monday, Wednesday, and Friday hemodialysis
sessions. In terms of her hypoglycemia in consultation with
the underconservative, the decision was of an insulinoma,
therefore after her dialysis session on [**8-17**], the
patient was put on an overnight fast with the only p.o.
permitted to be her medications, water and diet soda.
Fingersticks were checked q. 6 hours during this episode and
then when her fingersticks fell below 60 q. 1 hour
fingersticks were checked with a goal being less than 45. On
the morning of [**8-18**], the fingerstick was 42 and the
following protocol was initiated - Given her lack of
peripheral intravenous access, all [**Month (only) **] draws to this point
were done by arterial sticks in the left radial artery, the
right arm being off limits as her hemodialysis port was cited
in that arm. Initial arterial stick was drawn, being divided
to be sent off for a serum glucose with additional tubes sent
off in the Tiger top tube for analysis for termination of
total insulin, pro-insulin, C-peptide and Beta hydroxy
butyrate levels. After this [**Month (only) **] sample was obtained, the
patient was given intravenous injection peripherally of 1 mg
of Glucagon and, then at set time points after the
administration of Glucagon, repeat arterial sticks were done
to determine the serum glucose. The initial plan was for
[**Month (only) **] to be drawn at 10, 20 and 30 minutes after the
administration of Glucagon, however, given her terribly poor
access, the actual timepoints obtained were at 15 minutes
after the administration of Glucagon and then at 45 minutes
after the administration of Glucagon. The final results of
this study are still pending as of this dictation. The
patient's course was also notable for thrombocytopenia during
her time in the Intensive Care Unit, of note when the patient
was not intubated, she had a HITT antibody which was sent out
and report indicated as negative. The etiology of her
thrombocytopenia is unknown but it was checked daily and was
found to be stable. In terms of her panhypopituitarism she
was continued on her dose of Synthroid 75 mcg daily and dose
of 10 mg of Prednisone p.o. daily. In terms of her
gastroesophageal reflux disease, she was continued on
Protonix 40 p.o. q. day. In terms of her diet she was
continued on a diabetic house diet with t.i.d. Nutrashakes
with snacks in between as per nutritional recommendations for
episodes of hypoglycemia. In terms of her prophylaxis she
was continued on pneuma boots when in bed. Given her low
platelet counts subcutaneous heparin was avoided.
CODE STATUS: Her code status at this time remained
questionable. The patient herself refused to discuss the
issue and discussion with her primary care physician, [**Last Name (NamePattern4) **].
[**First Name (STitle) 1022**], revealed that he had met with similar result when he
discussed this issue with the patient in the past. The
patient said refer such discussions to her sister. A family
meeting was therefore finally called on [**8-19**].
Present were the attending, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] as well as Case
Management and the patient's family. The patient was
agreeable at that point to send the patient to rehabilitation
with planned date of discharge to rehabilitation on [**2101-8-20**].
DISCHARGE MEDICATIONS:
1. Prednisone 10 mg p.o. daily
2. Protonix 40 p.o. q. day
3. Synthroid 75 mg p.o. q. day
4. Vitamin D 400 units p.o. q. day
5. Daily multivitamin
6. Senna prn
FOLLOW UP: The patient will have follow up set up with her
primary care physician in one to two weeks prior to discharge
to rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**MD Number(1) 20316**]
Dictated By:[**Last Name (NamePattern1) 8442**]
MEDQUIST36
D: [**2101-8-19**] 15:32
T: [**2101-8-19**] 16:39
JOB#: [**Job Number 26867**]
ICD9 Codes: 2875, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3371
} | Medical Text: Admission Date: [**2111-6-14**] Discharge Date: [**2111-6-25**]
Date of Birth: [**2036-12-27**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This 74-year-old female with a
history of coronary artery disease and aortic stenosis, as
well as known three-vessel disease presented with mid chest
pain occasionally that radiated to her back. She had been
worked up with cardiac catheterization and was awaiting
surgical options prior to be examined by the Cardiothoracic
Surgery team. She had been told to go to the Emergency Room
in the event of pain. On examination, her review of systems
was negative with no shortness of breath, nausea, vomiting,
diarrhea and some dry cough.
PAST MEDICAL HISTORY: Hypercholesterolemia.
Hypertension.
Coronary artery disease.
Severe aortic stenosis.
PAST SURGICAL HISTORY: Status post left cataract extraction.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lopressor 50 mg p.o. b.i.d.
2. Lisinopril 2.5 mg p.o. q d.
3. Lipitor 20 mg p.o. q d.
4. Iron supplements.
5. Aspirin 325 mg p.o. q d.
PHYSICAL EXAMINATION: On examination, she is an elderly
woman who spoke with broken English. She was in no acute
distress. Her heart was a regular rate and rhythm. Her lungs
were clear bilaterally. Her abdominal examination was benign.
Her extremities were warm and well perfused.
LABORATORY DATA: Her cardiac catheterization from [**5-/2111**]
showed the following: An ejection fraction of 84 percent, 80
percent OM-1 lesion, 90 percent distal right coronary artery
lesion, 30 percent distal left main lesion, as well as
lesions of the left anterior descending coronary artery and
first diagonal. It also showed moderate to severe aortic
stenosis with 0.9 cm sq aortic valve area and a 40 mm
gradient. Ejection fraction was approximately 42 percent on
the Persantine scan. Her chest x-ray showed no active
cardiopulmonary issues.
Preoperative laboratories on admission were as follows:
White blood cell count 5.9, hematocrit 30.2, platelet count
195,000, PT 13, PTT 24.6, INR 1.2, sodium 143, potassium 3.7,
chloride 107, CO2 of 24, BUN 11, creatinine 0.9, blood sugar
165. Unremarkable cardiac enzymes.
HOSPITAL COURSE: The assessment was that her anatomical and
her symptoms both led to consistency with a probable
operative need for cardiac surgical intervention. The patient
was placed on low-dose intravenous nitroglycerin, heparin, to
rule out for myocardial infarction and the plan was discussed
with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], M.D. The patient was initially seen
by Dr. [**Last Name (STitle) **] with the Cardiac Surgery team. The patient was
also seen by Cardiology who agreed to keep her on intravenous
heparin at that time and to also address her anemia by guaiac
stools and persuing possible workup of that diagnosis also.
The patient did rule out for a myocardial infarction. No
Plavix was given at the time given the possibility of going
to cardiac surgical intervention. The patient was examined
again by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], M.D. for evaluation of aortic
valve replacement and coronary artery bypass grafting.
Additional labs were drawn including repeat chest x-ray and
liver function tests. The patient was also started on an
Integrelin drip in addition to the heparin drip.
On [**2111-6-7**], the patient underwent aortic valve replacement
with a 21 mm mosaic porcine valve and a coronary artery
bypass grafting times two with the left internal mammary
artery to the left anterior descending coronary artery and a
vein graft to the right coronary artery/posterior descending
artery. The patient was transferred to the Cardiothoracic
Intensive Care Unit in stable condition on titrated propofol
and phenylephrine drips.
On the day of the operation in the evening, the patient was
also started on a nitroprusside drip for better blood
pressure control. The first set of postoperative labs showed
potassium of 4.7, BUN 11, creatinine 0.7. The patient
remained on insulin drip, Nipride drip. The plan to wean the
patient was started with the patient being extubated shortly
after midnight in the early hours of [**2111-6-17**].
On postoperative day one, the patient had been extubated, was
started on aspirin and Plavix, as well as continued
perioperative vancomycin. T-max was 100.4 with a T-current of
99.1, CVP 18, PA pressures of 33/16 with a cardiac index of
3.28, blood pressure 135/67 in sinus rhythm at 96 with a
reasonable blood gas. The patient was on 50 percent face
mask.
Postoperatively, white blood cell count was 10, hematocrit
32.4, platelet count 152,000, INR 1.4, sodium 140, potassium
5.3 which declined to 4.8 during the day, BUN 13, creatinine
0.9 with a blood sugar of 111. The patient was alert and
oriented. The heart was regular rate and rhythm. The patient
had some bilateral rhonchi. The abdomen was soft, nontender
and nondistended. The sternum was stable. Incisions were
clean, dry and intact with no edema. Upper full extremities
were warm. Diet was advanced. The Foley remained in place.
On postoperative day two, the patient was started on beta
blockade and Lasix for diuresis with a blood pressure of
140/66. The patient's saturation was 96 percent on three
liters nasal cannula with a creatinine of 1.0 and a
hematocrit of 29.8. The patient's examination was
unremarkable other than slightly hypoactive bowel sounds. The
patient also received some albuterol nebulizers for the
rhonchi and continued on Lasix diuresis. The patient was also
seen by Case Management on [**6-18**]/1004.
On postoperative day three, the patient had some low urine
output and received a bolus. The patient also complained of
some abdominal and back pain. The patient was on a Neo-
Synephrine drip at 0.5 mcg/kg/minute at the time with the
heart rate in sinus rhythm at 90 and a blood pressure of
110/60 with saturation of 98 percent on two liters nasal
cannula. The liver function tests were as follows: AST 23,
ALT 15, alkaline phosphatase 54. The patient's T-max was
100.0. The examination was unremarkable. The patient was
started empirically on levofloxacin 500 mg every day. The
patient received one unit of packed red blood cells for the
low hematocrit. Blood cultures, urine cultures, urinalysis,
as well as sputum cultures were sent. The Lasix was
discontinued and the Foley was discontinued.
On postoperative day four, the patient had a ten-beat run of
ventricular tachycardia. The patient was on Neo-Synephrine
with a heart rate in sinus rhythm at 75. Laboratory work was
relatively stable with a potassium of 4.2, BUN 13, creatinine
0.7. The patient had a T-max of 99.5. The examination was
unremarkable with the heart in regular rate and rhythm. The
incisions were looking good. The lungs were clear bilaterally
with one plus edema in bilateral lower extremities, but
appeared to be well perfused. The patient was on day two of
levofloxacin for the sputum that she had produced awaiting
all culture results.
On postoperative day five, the patient weaned off Neo-
Synephrine. Urine culture and sputum culture were both no
growth to date. Blood culture and Clostridium difficile were
both still pending from [**2111-6-19**]. Hematocrit rose to 31.8.
T-max was only 98.2. The Foley had remained in place pending
results of the urine culture. The Foley was then discontinued
and the patient was transferred out to the floor. The patient
continued on aspirin and Plavix and also received Dulcolax.
On postoperative day six, there were no events overnight. The
patient remained in sinus rhythm with a blood pressure of
125/54 with a stable hematocrit at 29.9, creatinine 0.9. The
patient had some decreased breath sounds. The heart was
regular rate and rhythm. The sternum was stable with no
erythema. Abdominal examination was benign with positive
bowel sounds. She still had one plus edema in the peripheral
lower extremities. The patient was on day four of a five day
levofloxacin course. The patient was stable. Cardiac diet was
advanced. The patient was transferred out to the floor on
[**2111-6-22**].
The patient was seen again on [**2111-6-23**] by Case Management
on postoperative day seven. The patient remained on the floor
and had some rhonchi throughout her chest. Her laboratory
work was stable. Her saturation was 93 percent on room air
with a T-max of 99.6 in sinus rhythm with a good blood
pressure of 134/77. Her sternum was stable. Her cardiac
examination was benign. Her incisions looked good. Her
extremities were warm with one plus pedal edema. She was
progressing with physical therapy very slowly but continued
to make some progress. Her Lopressor was increased to 50 mg
p.o. twice a day. Physical Therapy was re-consulted about the
decision for the patient to be discharged home versus
rehabilitation. The Foley was removed. The patient was
evaluated by Physical Therapy on [**2111-6-23**] and continued to
work with them and have more aggressive pulmonary toilet for
the bilateral rhonchi.
On postoperative day eight, the patient had no events over
the 24 hours other than the Foley being discontinued. She
still had some coarse rhonchi throughout. She continued with
adding vitamin C and iron to her medications. Her physical
therapy continued to help her advance her physical activity.
The plan was for her to be discharged within the next 1-2
days depending on her progress and her pulmonary status. She
completed her levofloxacin antibiotic coverage.
On [**2111-6-25**], the day of discharge, the patient's
examination was as follows: Her lungs were clear
bilaterally. Her heart was in regular rate and rhythm without
a murmur. Her vital signs were stable. Her abdomen was soft
with positive bowel sounds. Her incisions were clean, dry and
intact. Her sternum was stable. Laboratory results were as
follows: White blood cell count 12.6, hematocrit 37.4,
platelet count 331,000, sodium 139, potassium 4.6, chloride
109, CO2 of 27, BUN 14, creatinine 1.0 with a blood sugar of
112.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. once a day.
2. Plavix 75 mg p.o. once a day times three months.
3. Colace 100 mg p.o. twice a day.
4. Percocet 1-2 tablets p.o. p.r.n. q 4-6 hours for pain.
5. FeSO4, 325 mg p.o. once a day.
6. Vitamin C 500 mg p.o. twice a day.
7. Multivitamin, one p.o. once a day.
8. Lipitor 10 mg p.o. once a day.
9. Lopressor 75 mg p.o. three times a day.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES: Status post aortic valve replacement
with porcine valve and coronary artery bypass grafting times
two.
Coronary artery disease.
Hypertension.
Hypercholesterolemia.
Anemia.
Status post left cataract extraction.
FOLLOW UP: The patient was discharged to home in stable
condition with the following discharge instructions: To
follow-up with an appointment with Dr. [**Last Name (STitle) **], her primary
care physician, [**Name10 (NameIs) **] approximately 1-2 weeks and to follow-up
with a postoperative surgical visit to her [**Last Name (LF) 5059**], [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 40324**], M.D., in approximately six weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2111-7-20**] 10:52:48
T: [**2111-7-20**] 11:43:29
Job#: [**Job Number 55502**]
ICD9 Codes: 4241, 4111, 4280, 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3372
} | Medical Text: Admission Date: [**2110-2-6**] Discharge Date: [**2110-2-11**]
Date of Birth: [**2033-7-20**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 76-year-old with
severe pulmonary hypertension with congestive obstructive
pulmonary disease on 4 liters of home oxygen here with
altered mental status. Over the last few months she had been
doing steadily worse, more dyspneic with exertion, and
limited activity. Was seen by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**1-24**] for
worsening and put on seven days of levofloxacin and a steroid
taper, as well as having her oxygen increased.
She reports feeling better, though not quite back to feeling
well. She had never been on oral steroids before. In the
past few days, her symptoms have been stable. She was seen
by her doctor two days ago and she was brought to Pulmonary
Rehabilitation appointment and was okay. On that
appointment, her oxygen was increased to 5 liters. The next
day she was more sleepy. The doctor did not call her because
she was supposed to go out to lunch in the afternoon. When
she called in the evening, she was very sleepy.
The patient reports feeling confused without remembering much
of what was happening in the past few days, unsure if she was
taking the right number of pills, and not eating. On
baseline, she self disimpacts her rectum and last did this a
few days ago noting some fecal incontinence. She also
reports worsening shortness of breath. She had a cough that
has been dry. Her weight has been fluctuating a great deal
from 107 to 117, though on a higher side recently 6 pound
weight gain to 124 and worsened lower extremity edema. The
left side is greater than the right which always decays when
she has more edema.
She denies chest pain, sinus symptoms, hemoptysis, no
weakness, nausea, vomiting, abdominal pain, although she has
been uncomfortable from constipation. In the Emergency
Department, she had a respiratory rate of 4 and oxygen
saturation of 85% on 5 liters. Narcan 0.3 mg was given with
immediate awakening, and then confusion, dry mouth, and
dysarthria which resolved. A total of 0.5 mg of Narcan was
given, and the initial chest x-ray showed cardiomegaly,
bilateral pleural effusions. Blood pressure dropped until 5
pm it was 69 systolic. She was given 500 cc of normal saline
and responded to 80-95 systolic.
She was started on a stress dose of steroids, right lower
lobe pneumonia on chest x-ray. Was treated with Levaquin.
PAST MEDICAL HISTORY:
1. Severe pulmonary hypertension by catheterization in [**2108**].
2. Systemic hypotension, two vasodilators presumed secondary
to congestive obstructive pulmonary disease.
3. Congestive obstructive pulmonary disease with a FVC of
2.2, FEV1 of 0.81, this was 52% of predicted, FEV1/FVC ratio
of 55%.
4. Congestive heart failure secondary to diastolic
dysfunction in [**2106**], to have normal coronary arteries on
catheterization followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
5. Hypertension.
6. Carcinosarcoma of the uterus status post total abdominal
hysterectomy/bilateral salpingo-oophorectomy.
7. Diverticular disease.
8. Anxiety on Valium.
9. Cauda equina syndrome status post laminectomy in [**2105**]
continued.
10. Urinary retention resolved after pessary placement,
baseline decrease in lower extremity sensation left greater
than right. Perianal sensation, abnormal bowel movements
requiring disimpaction.
11. Left cataract.
12. Osteoporosis.
ALLERGIES: Penicillin, gives her hives, but she tolerates
cephalosporins. Shellfish give her abdominal pain.
MEDICATIONS ON ADMISSION:
1. Lasix 60 mg po q day.
2. Flovent 110 two puffs [**Hospital1 **].
3. Combivent two puffs qid.
4. Serevent two puffs [**Hospital1 **].
5. Prednisone taper completed two days ago.
6. Coreg 6.25/3.125.
7. Norvasc 5 mg po q day.
8. Neurontin 900 mg po qid.
9. Colace prn.
10. K-Dur 30 mEq po q day.
11. Valium 2 mg po q am, 1 mg po q hs.
12. Remeron 45 mg po q day.
13. Prilosec 20 mg po q day.
14. Calcium carbonate po tid.
15. Zestril 20 mg po q day.
16. Morphine IR 15 one tablet q6h.
17. MS Contin 30 mg [**11-21**] [**Hospital1 **].
18. Macrobid 100 mg po q day.
19. Fosamax 70 mg weekly.
20. Temazepam 30 mg po q hs.
SOCIAL HISTORY: She lives alone. Daughter and son live
nearby. Thirty pack year history, quit 12 years ago. Used
to drink a few glasses of alcohol, cut has cut back recently.
FAMILY HISTORY: Her mother had a history of lymphoma. Her
father with a myocardial infarction at an unknown age.
Sister with [**Name2 (NI) 499**] cancer at age 66.
PHYSICAL EXAM ON ADMISSION: Temperature is 96.5, pulse is
75, blood pressure 106/68, respiratory rate of 24, sat 85
which decreased to the 70s and increased to 90's with deep
breathes on a Ventimask at 5 liters. In general, she is
fatigued appearing, thin-elderly woman in no apparent
distress. Her pupils were reactive bilaterally. Irregular
and small on the left. Extraocular muscles are intact. The
neck was supple. There was jugular venous distention sitting
at 60 degrees. Heart: Regular, rate, and rhythm, normal S1,
S2 prominent, P2 [**12-26**] blowing systolic murmur at the left
upper sternal border. Decreased breath sounds throughout, no
wheezes. Abdomen had positive bowel sounds with diffusely
mildly tender and distended. Rectal was guaiac negative in
the Emergency Department. Extremity examination showed 3+
left and 3+ right lower extremity pitting edema up to the
thighs. Neurologic examination: She was alert and oriented
times three. She could give the days of the week forwards
and backwards. Cranial nerves II through XII are intact.
Reflexes were 2+ and symmetric throughout with downgoing
toes. Strength was [**3-24**] in the upper extremities bilaterally.
Some decreased sensation in the left lower extremity to light
touch, positive asterixis.
LABORATORIES: On admission, white count 9.4, hemoglobin of
12.7, hematocrit of 38.2, platelets of 272. Urinalysis was
negative. Glucose 125, BUN 46, creatinine 2.1, which is
significantly up from her baseline normal creatinine. Sodium
of 126, potassium of 6.5, chloride 88, and bicarbonate of 28.
ALT of 84, AST 78, CK of 512, alkaline phosphatase of 251,
amylase 38, lipase 4. Troponin 0.3. MB index 4.1. Albumin
3.9, phosphorus 5.6, magnesium 2.4. An arterial blood gas in
the Emergency Room showed a pO2 of 76, pCO2 of 71, pH of
7.25, and a total CO2 of 33.
She was admitted to the Intensive Care Unit.
HOSPITAL COURSE BY SYSTEMS:
1. Pulmonary: Patient's initial hypercarbic respiratory
failure was likely due to Narcan overdose of narcotics.
There was a question of infiltrate on her initial chest x-ray
consistent with pneumonia, and in addition her history of
congestive obstructive pulmonary disease along with new
abdominal distention and oxygen retention from her increased
O2 likely cause of altered mental status and worsened
pulmonary status.
She was continued on oxygen, given a stress dose of steroids
at that time.
2. Cardiology: She was ruled out for myocardial infarction.
3. Renal: Acute renal failure improved rapidly during her
stay, etiology unknown.
4. Gastrointestinal: Abdominal CT scan was obtained given
the history and increased LFTs. CT scan of the abdomen
showed a significant ascites, multiple hepatic lesions
consistent with metastatic cancer, a right adrenal mass
thought to be an adenoma, retroperitoneal lymphadenopathy,
and bilateral pleural effusions. Patient is thought to have
metastatic disease from an unknown primary, however, her
uterine cancer was the most likely source.
She had a paracentesis while in-house, which 1 liter of fluid
was removed, however, it was difficult to continue removal of
fluid given that it was in multiple pockets in the abdomen.
5. FEN: The patient had hyponatremia likely secondary to
ascites and heart failure. She was continued on salt
restriction and diuresed.
Code status was discussed. The patient is DNR/DNI, wants
comfort only. Her pain was controlled with Morphine as
needed by a drip and then converted to IV boluses of Morphine
and a Duragesic patch.
DISCHARGE MEDICATIONS:
1. Lasix 60 mg po q day.
2. Flovent 110 two puffs [**Hospital1 **].
3. Combivent two puffs qid.
4. Serevent two puffs [**Hospital1 **].
5. Prednisone taper completed two days ago.
6. Coreg 6.25/3.125.
7. Norvasc 5 mg po q day.
8. Neurontin 900 mg po qid.
9. Colace prn.
10. K-Dur 30 mEq po q day.
11. Valium 2 mg po q am, 1 mg po q hs.
12. Remeron 45 mg po q day.
13. Prilosec 20 mg po q day.
14. Calcium carbonate po tid.
15. Zestril 20 mg po q day.
16. Morphine IR 15 one tablet q6h.
17. MS Contin 30 mg [**11-21**] [**Hospital1 **].
18. Macrobid 100 mg po q day.
19. Fosamax 70 mg weekly.
20. Temazepam 30 mg po q hs.
21. Morphine IR sublingual x20 mg po q1h prn.
22. Duragesic 100 mcg patch td q72h.
DISCHARGE STATUS: She is being screened for hospice.
DISCHARGE CONDITION: Fair.
DISCHARGE DIAGNOSIS: Metastatic cancer of unknown primary
source.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 251**] 12-988
Dictated By:[**Last Name (NamePattern1) 9128**]
MEDQUIST36
D: [**2110-2-10**] 22:58
T: [**2110-2-11**] 04:09
JOB#: [**Job Number 108710**]
ICD9 Codes: 486, 496, 4280, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3373
} | Medical Text: Admission Date: [**2173-12-16**] Discharge Date: [**2173-12-18**]
Date of Birth: [**2108-5-10**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
hypotension, melena, hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 65 year old male with PMH of coronary artery disease
s/p MI with PCI and stent placed in [**2167**], type 2 diabetes
mellitus c/b diabetic retinopathy, hypertension,
hypercholesterolemia, and recently diagnosed unresectable 3.6cm
x 3.2cm pancreatic adenocarcinoma s/p metallic biliary stent
placement [**12-15**] and fiducial placement for Cyberknife earlier
this AM now presenting with hematemesis and melena hours s/p the
procedure. The patient tolerated his fiducial placement well
earlier today, but on the way home in his car, he developed
frank hematemesis. He says that he had about a cupful of blood
at that time. He was them transported directly to the ED.
At triage, his BP was measured to be in the 60s systolic and his
HR was in the 100s. In the ED, he received 2 units of pRBCs and
his Hct and vitals subsequently stabilized despite an anomalous
hct of 15 and witnessed episodes of hematemesis and melena.
Vitals upon transfer was SBP in the 120s, HR in the 80s, and
satting 100% RA.
GI performed an EGD upon admission to the ICU and did not see
any active bleeding or stigmata of recent bleeding despite
witnessed hematemesis and an NG lavage in the ED which was
positive for bright red blood which did not clear. He has since
had 2 episodes of melena in the setting of stable vitals and
hct.
Past Medical History:
CAD, NIDDM, HTN, hypercholesterolemia, diabetic retinopathy,
cataracts
Social History:
Works as dispatcher. Lives with wife. Smokes 1.5 ppd. No EtOH
Family History:
noncontributory
Physical Exam:
VS: As above
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**]
sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN,
HTS). gait WNL.
Pertinent Results:
Admission Labs:
[**2173-12-15**] 11:15AM BLOOD WBC-6.9 RBC-3.45* Hgb-11.5* Hct-34.0*
MCV-99* MCH-33.4* MCHC-33.8 RDW-16.4* Plt Ct-140*
[**2173-12-16**] 09:45AM BLOOD WBC-9.2 RBC-3.63* Hgb-11.9* Hct-35.5*
MCV-98 MCH-32.8* MCHC-33.6 RDW-16.5* Plt Ct-152
[**2173-12-16**] 02:45PM BLOOD WBC-10.6 RBC-3.05* Hgb-9.9* Hct-29.6*
MCV-97 MCH-32.6* MCHC-33.6 RDW-16.6* Plt Ct-203
[**2173-12-16**] 03:00PM BLOOD Hgb-5.3*# Hct-15.7*#
[**2173-12-16**] 06:29PM BLOOD Hct-33.1*#
[**2173-12-17**] 03:51AM BLOOD WBC-8.5 RBC-3.53* Hgb-11.2*# Hct-32.0*
MCV-91 MCH-31.8 MCHC-35.0 RDW-16.6* Plt Ct-114*
[**2173-12-15**] 11:15AM BLOOD ALT-132* AST-96* AlkPhos-435* Amylase-41
TotBili-12.2* DirBili-7.9* IndBili-4.3
[**2173-12-16**] 09:45AM BLOOD ALT-122* AST-99* AlkPhos-400* Amylase-45
TotBili-12.0*
[**2173-12-16**] 02:45PM BLOOD ALT-99* AST-80* AlkPhos-319* TotBili-9.9*
[**2173-12-17**] 03:51AM BLOOD ALT-93* AST-76* LD(LDH)-182 AlkPhos-272*
TotBili-9.9*
[**2173-12-16**] 02:45PM BLOOD Albumin-2.5* Calcium-8.2* Phos-3.7 Mg-1.6
[**2173-12-17**] 03:51AM BLOOD Glucose-211* UreaN-14 Creat-0.7 Na-135
K-3.9 Cl-105 HCO3-24 AnGap-10
[**2173-12-15**] 11:15AM BLOOD PT-11.4 PTT-23.4 INR(PT)-0.9
[**2173-12-17**] 03:51AM BLOOD PT-14.0* PTT-24.6 INR(PT)-1.2*
.
Imaging:
[**12-15**] ERCP: IMPRESSION: Stricture of mid common bile duct with
replacement of a plastic stent with metal stent. Gallstones.
Filling defects in cystic and common bile duct, likely air
bubbles, though stones cannot be excluded.
[**12-16**] CTA Ab-Pelvis: IMPRESSION:
1. Stable pancreatic mass as described.
2. Increase in size and number of liver metastases consistent
with rapid
disease progression from CT 1 month ago.There is also new
ascites.
3. No evidence of retroperitoneal hematoma.
[**12-18**] CT Chest: 1. No evidence of metastatic disease in the
chest.
2. Linear atelectasis in the right lower lobe which is similar
to the prior study.
3. Mild irregularity of the pleural surface bilaterally which is
new as
compared to the prior studies. Attention on followup is
recommended.
4. Suspicion for focal liver lesion in segment VI of the liver
measuring 1.2 cm. Further evaluation is recommended by CT of the
abdomen or MRI.
5. Pneumobilia with stent in place.
6. Diffuse mild enlargement of the left adrenal gland, without
evidence of
focal lesion.
[**12-15**] EGD
A plastic stent previously placed in the biliary duct was found
in the major papilla.
A small sphincterotomy was successfully performed in the 12
o'clock position using a needle-knife over the existing plastic
biliary stent.
The plastic stent was then removed with a snare.
Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique
A single irregular stricture of malignant appearance that was 2
cm long was again seen at the mid-CBD.
A 60mm by 10mm [**Company 2267**] Wallfex fully covered metal
biliary stent was placed successfully with excellent drainage of
bile and contrast
[**12-16**] EGD
Erythema in the stomach body c/w NG trauma. No fresh or old
blood was noted.
Stent in the second part of the duodenum. No fresh or old blood
was noted.
Otherwise normal EGD to second part of the duodenum
[**12-16**] EUS
EUS was performed using a linear echoendoscope at 7.5 MHz
frequency
An approximately 2.5cm ill-defined mass was again noted in the
head of the pancreas.
Four fiducials were placed into the pancreas mass
[**2173-12-18**] 01:30PM BLOOD WBC-8.0 RBC-3.48* Hgb-11.3* Hct-32.2*
MCV-93 MCH-32.6* MCHC-35.1* RDW-16.1* Plt Ct-130*
[**2173-12-16**] 02:45PM BLOOD Neuts-83.1* Lymphs-10.6* Monos-5.4
Eos-0.4 Baso-0.4
[**2173-12-18**] 01:30PM BLOOD Plt Ct-130*
[**2173-12-18**] 01:51PM BLOOD Type-ART pO2-89 pCO2-38 pH-7.45
calTCO2-27 Base XS-2
[**2173-12-18**] 01:51PM BLOOD Hgb-11.2* calcHCT-34
Brief Hospital Course:
65 year old male with PMH of coronary artery disease s/p MI with
PCI and stent placed in [**2167**], type 2 diabetes mellitus c/b
diabetic retinopathy, hypertension, hypercholesterolemia, and
recently diagnosed unresectable 3.6cm x 3.2cm pancreatic
adenocarcinoma s/p metallic biliary stent placement [**12-15**] and
fiducial placement for Cyberknife earlier this AM now presenting
with hematemesis and melena hours s/p the procedure.
.
# Upper GI bleed: EGD performed in the ICU showed no evidence of
ongoing bleeding or stigmata of chronic bleed. It was felt that
the bleed was likely secondary to the EUS with fiduciary
placement. The patient was transfued 4 units of pRBCs and his
Hct stabilized. All anticoagulants were held and patient
remained hemodynamically stable. He was transferred to the floor
and monitored after restarting Aspirin 81mg without any evidence
of recurrent bleeding. Pt was restarted on all his home
anti-hypertensives but plavix was not restarted given that this
stents were placed >5 yrs prior to this presentation with life
threatening bleed. Pt was encouraged to discuss this further
with his PCP/cardiologist after discharge.
.
# Fiducial placement: Continued on augmentin per GI and was
discharged on this medication for a total course of 5 days.
.
# Pancreatic adenocarcinoma. The patient has unresectable
adenocarcinoma and plans to undergo Cyberknife with fiducials
placed on [**2173-12-16**]. Per the patient's request and in conjunction
with his oncologist, he underwent CT-Chest the day of discharge.
Dr. [**Last Name (STitle) 1852**] has agreed to follow the results of this imaging
with the patient at his follow up appopintment schedule for
[**2173-12-20**].
.
# CAD / DM2: As discussed above, anti-hypertensives were held in
the acute setting and restarted prior to discharge. No changes
were made to the patient's DM regimen. Aspirin was restarted
though we continued to hold plavix which should be discussed
with his PCP/cardiologist.
Medications on Admission:
-AMLODIPINE-BENAZEPRIL 10mg-20 mg Capsule by mouth once a day
-CLOPIDOGREL 75 mg by mouth once a day
-FUROSEMIDE 20mg QD
-GLYBURIDE-METFORMIN 5 mg-500mg Tablet by mouth twice a day
-METOPROLOL TARTRATE 100mg by mouth twice a day
-OMEPRAZOLE 20 mg by mouth
-PIOGLITAZONE 30 mg by mouth once a day
-PROCHLORPERAZINE MALEATE 10 mg by mouth Q6 hour as needed for
nausea/vomiting
-ASPIRIN 81 mg by mouth once a day
-MULTIVITAMIN Daily
Discharge Medications:
1. amlodipine-benazepril 10-20 mg Capsule Sig: One (1) Capsule
PO once a day.
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. glyburide-metformin 5-500 mg Tablet Sig: One (1) Tablet PO
twice a day.
4. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
5. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. multivitamin Capsule Sig: One (1) Capsule PO once a day.
10. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
-Endoscopy related bleed
-Pancreatic Cancer
Secondary Diagnoses:
-Coronary artery disease
-Diabetes type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It has been a privilege to take care of you in the hospital.
You were hospitalized because you were vomiting blood after your
endoscopic ultrasound procedure. You were transfused blood
because of your bleeding and monitored in the ICU. Your blood
levels stabilized after these transfusions. In the ICU, the
gastrointestinal doctors saw [**Name5 (PTitle) **] and performed an endoscopic
grastroduodenscopy to look for active bleeding in your stomach -
they found no active bleeding and no signs of old bleeding,
which led them to believe that your blood loss was due to the
endoscopic ultrasound procedure you had happened several hours
before the bleeding started. You will need to continue your
antibiotics as prescribed by the gastrointestinal doctors.
.
Your cancer doctors have asked that you undergo an outpatient
CT-Scan after you are discharged. Please attend the appointment
scheduled below.
.
We temporarily held some of your blood thinners and
anti-hypertensive medications when you were losing blood, but we
are restarting MOST - but not ALL - upon discharge. Please take
all of your other medications as previously prescribed.
.
# STOP Plavix - It is very important that you follow-up with
your PCP regarding whether to restart this medication for your
heart
# START Augmentin for post-endoscopy antibiotic treatment
# START Senna for constipation
# START Colace for constipation
Followup Instructions:
Department: RADIOLOGY
When: MONDAY [**2173-12-20**] at 7:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2173-12-20**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2173-12-27**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2851, 412, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3374
} | Medical Text: Admission Date: [**2165-6-9**] Discharge Date: [**2165-6-22**]
Date of Birth: [**2086-5-7**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
woman with past medical history significant for hypertension
and hypercholesterolemia who was in her usual state of health
until 1-1/2 weeks prior to admission. She states that she
was shopping when she felt the onset of chest pressure
radiating to her left arm. It was accompanied by dyspnea,
nausea, and diaphoresis. The pressure was relieved by rest.
However, this intermittent pain continued throughout the week
until she began to feel chest pain while lying in bed. The
patient arrived at emergency room where her EKG showed ST
depressions in the precordial leads. Patient was given
aspirin, sublingual nitroglycerin x2, morphine, metoprolol 5
mg IV x2, and potassium. She became pain free and her EKG
went back to baseline.
PAST MEDICAL HISTORY: Hypertension.
Hypercholesterolemia.
CLL, status post chemotherapy.
Idiopathic pulmonary fibrosis.
Esophageal dilatation.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Advair.
2. Nitrofurantoin for frequent UTIs.
3. Pravachol.
4. Actonel 35 mg every week on Thursdays.
PHYSICAL EXAMINATION: Temperature is 97.5 degrees, blood
pressure is 123/61, heart rate is 65, oxygen saturation is 99
percent on room air. General: Pleasant, in no acute
distress, appropriate, alert and oriented x3. HEENT: No
JVD, no carotid bruits. Oropharynx is benign.
Cardiovascular: Distinct but regular rate and rhythm.
Pulmonary: Crackles bilaterally throughout. Abdomen:
Positive bowel sounds, nontender, nondistended, no masses.
Guaiac-negative stool. Extremities: Warm, no cyanosis;
trace edema, right more than left.
RADIOGRAPHIC STUDIES: EKG with ST-segment depressions in
precordial leads, resolving with medical management.
Hematocrit 22, white blood cells 30.5. Chest x-ray, PA and
lateral, with reticular pattern consistent with IPF, right
costophrenic angle blunted. Troponin 0.06. Cardiac
catheterization performed on [**2165-6-12**] revealed three-vessel
coronary artery disease with normal ventricular function and
atrial fibrillation. The patient was admitted to the Medical
Service and was also followed by Hematology Service for her
CLL.
HOSPITAL COURSE: Based on the results of the cardiac
catheterization, a decision was made between the cardiac
surgery team as well as the medicine team to pursue
definitive surgical management of her three-vessel disease.
She was taken to the operating room on [**2165-6-14**] and underwent
a CABG x3; number 1, LIMA to LAD; number 2, SVG to DRCA; and
number 3, SVG to OM. She tolerated the procedure well and
was transferred to the CSRU. She was extubated the following
day and was transferred to the floor on [**2165-6-17**]. Over the
next four days, she was able to ambulate and void
appropriately. She continued to be seen by hematology and
the medicine team. On [**2165-6-20**], the patient was cardioverted
out of atrial fibrillation. She was placed on heparin and
Coumadin until her INR was therapeutic, at which time her
heparin was discontinued. She was discharged in good
condition on [**2165-6-22**].
DISCHARGE DIAGNOSES: Status post myocardial infarction.
Chronic lymphocytic leukemia.
Status post coronary artery bypass graft x3.
Hypertension.
Hypercholesterolemia.
Idiopathic pulmonary fibrosis.
Esophageal dilatation.
DISCHARGE MEDICATIONS:
1. Pravastatin 40 mg p.o. q.d.
2. Multivitamin p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Docusate sodium 100 mg p.o. b.i.d.
5. Nitroglycerin 0.3 mg tablet sublingual, 1 tablet
sublingually p.r.n.
6. Folic acid 1 mg tablet 5 tablets p.o. q.d.
7. Toprol XL 25 mg tablet, sustained release, 24 hours, 1
tablet p.o. q.d.
8. Prednisone 20 mg tablet, take 3 tablets p.o. q.d. for 7
days through [**2165-6-24**].
RE[**Last Name (STitle) **]DED FOLLOWUP: The patient was instructed to make
appointments with her cardiologist as well as her
hematologist. She was asked to make a follow-up appointment
with Dr. [**Last Name (Prefixes) **] in four to six weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 32536**]
MEDQUIST36
D: [**2165-6-21**] 22:21:49
T: [**2165-6-22**] 11:12:47
Job#: [**Job Number 11094**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3375
} | Medical Text: Admission Date: [**2121-12-18**] Discharge Date: [**2121-12-22**]
Date of Birth: [**2052-9-16**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
woman with a 13-year history of right-sided facial pain. Was
initially stabbing and jabbing in nature, located in the
right upper lip, right upper gum, right lower teeth as well
as the lateral part of the right nose, right middle maxillary
region, lower eyelid, eye, and eyebrow, and occasionally
ended up towards the right vertex. Over the last year and a
half there has been a mixture of burning quality to the pain.
The pain can last up to one minute to a minute and a half
but still comes in an attack-like fashion with no interval
pain. Touching the middle maxillary skin can provoke pain.
Talking and chewing can equally provoke the pain. She has
been on Tegretol for the last 13 years, and Neurontin, and
methadone. About 10 years ago she had what sounds like a
peripheral procedure done with some injection into the right
cheek without lasting effect. The MRI scan from this past
Summer of the brain showed there was mild white matter
changes, but no specific pathology related to the trigeminal
system.
The patient was admitted for a microvascular decompression
and gamma treatment of the trigeminal nerve.
HOSPITAL COURSE: On [**2121-12-19**], the patient
underwent a suboccipital craniotomy for trigeminal neuralgia
with partial rhizotomy. The patient tolerated the procedure
well. Vital signs have been stable postoperatively. She was
monitored in the Surgical Intensive Care Unit
postoperatively. She did spike a temperature to 101
immediately postoperatively. She had difficulty with nausea
and vomiting postoperatively. Fever was thought to be
related to postoperative status. She had a chest x-ray that
was within normal limits.
DISCHARGE DISPOSITION: She was seen by Physical Therapy and
Occupational Therapy and found to be safe for discharge to
home with home services.
DISCHARGE FOLLOWUP: Will follow up with Dr. [**Last Name (STitle) 6910**] in
three to four weeks, and the patient will have her staples
removed in 10 to 14 days at home in [**State 3914**].
CONDITION AT DISCHARGE: She was stable at the time of
discharge.
MEDICATIONS ON DISCHARGE:
1. Dilaudid 2 mg to 4 mg p.o. q.4h. p.r.n.
2. Atenolol 100 mg p.o. q.d.
3. Lasix 10 mg p.o. q.d.
4. Glyburide 1.25 mg p.o. q.d.
5. Evista 60 mg p.o. q.d.
6. Zantac 150 mg p.o. b.i.d.
7. Methadone was discontinued.
8. Neurontin was discontinued.
9. Mevacor 20 mg p.o. q.d.
10. Reglan 10 mg p.o. t.i.d.
The patient will wean off Tegretol over 10 days. Neurontin
was discontinued. The patient was in stable condition at the
time of discharge and will follow up with Dr. [**Last Name (STitle) 6910**] in
three to four weeks' time.
[**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2121-12-22**] 11:02
T: [**2121-12-27**] 02:51
JOB#: [**Job Number 36353**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3376
} | Medical Text: Admission Date: [**2168-8-7**] Discharge Date: [**2168-8-14**]
Date of Birth: [**2126-3-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
42 yo man who fell [**9-21**] feet and struck occiput with LOC for 5
minutes. Reportedly landed on concrete. Amnestic to event and
mildly confused. Was initially taken to [**Hospital6 5016**]
where he was found to have SAD, SDH and T12-L3 transverse
process fractures as well as L2 compression fracture.
Past Medical History:
None
Social History:
Lives at home with his wife, 4 children, and mother in law
Family History:
non-contributory
Physical Exam:
On the day of discharge
Gen: NAD alert and oriented x4
CV: Regular rate and rhythm
Pulm: Lungs clear to auscultation bilaterally
abdomen: soft NT, ND
extremities: no clubbing/cyanosis/edema
Neuro: equal strength bilaterally upper and lower extremities,
equal sensation.
Pertinent Results:
[**2168-8-7**] 07:40PM PLT COUNT-210
[**2168-8-7**] 07:40PM WBC-20.3* RBC-4.73 HGB-14.2 HCT-43.1 MCV-91
MCH-30.1 MCHC-33.0 RDW-12.7
[**2168-8-7**] 07:42PM ASA-NEG ETHANOL-30* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-8-7**] 07:42PM AMYLASE-49
[**2168-8-7**] 07:42PM estGFR-Using this
[**2168-8-7**] 07:42PM GLUCOSE-125* UREA N-15 CREAT-1.0 SODIUM-138
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-21* ANION GAP-19
[**2168-8-7**] 07:43PM PT-12.6 PTT-27.6 INR(PT)-1.1
[**2168-8-7**] 07:57PM GLUCOSE-110* LACTATE-4.3* NA+-142 K+-3.9
CL--101 TCO2-22
CT HEAD [**8-7**]
1. Extensive bilateral subarachnoid hemorrhage, left greater
than right with
mild rightward subfalcine herniation and slight increase in
edema in the
temporal lobes bilaterally. Partial effacement of the
suprasellar and
quadrigeminal cisterns. Recommend close followup.
2. Small subdural hematomas along the left frontal and temporal
lobes as well
as the falx.
3. Non-displaced right occipital bone fracture extending to the
foramen
magnum.
CT L-spine [**8-7**]
Comminuted compression fracture of L2 vertebral body. Right
transverse process fractures of T11 through L3, with T11 and T12
transverse processes oblique and L1 to L3; complete transverse
process fractures with lateral displacement.
CTA Head/Neck [**8-8**]
Stable appearance of subarachnoid hemorrhage and subdural
hemorrhage. Suboptimal vascular study. No definite sign for the
presence of an aneurysm.
MR [**Name13 (STitle) **] [**8-8**]
No evidence of neural compressive changes secondary to L2
fracture. Please see above report. No spinal cord compression
identified elswhere in the spine as well.
CT HEAD [**8-11**]
IMPRESSION:
1. Increasing left frontotemporal edema, which may be due to
progressive
infarction in the MCA territory versus contusion. The normal
appearance of
the left MCA on CTA of the head [**2168-8-8**] makes contusions
slightly more
likely. If clinical management will change based on
differentiation of these entities, an MRI/MRA of the brain could
be obtained.
2. Slightly increased mass effect and rightward subfalcine
herniation with no evidence of uncal herniation. Also no
evidence of hemorrhage.
Brief Hospital Course:
42 yo man who fell [**9-21**] feet and struck occiput with LOC for 5
minutes. Reportedly landed on concrete. Amnestic to event and
mildly confused. Was initially taken to [**Hospital6 5016**]
where he was found to have SAD, SDH and T12-L3 transverse
process fractures.
CTA of Head/Neck were performed on presentation to r/o any
vascular malformations or injuries secondary to the pt's right
occipital bone fracture extending to the foramen magnum. There
were no documented abnormalities.
Neurosurgery evaluated the pt for multiple intracranial
hemorrhages which were stable other than contusion/edema.
Repeat CT scans of the head documented stability of the
hemorrhage. Pt was initially loaded with Dilantin and was
transitioned to Keppra for seizure prophylaxis.
Spine evaluated the pt and he was fitted for a TLSO brace for
multiple thoracic and lumbar fractures. Pt worked with PT and
was eventually cleared.
Pt's pain control was transitioned from IV Dilaudid to PO pain
meds before discharge. Pt was tolerating PO intake, passing
bowel movements and functioning with TLSO brace. Pt has
scheduled follow-up with both Neurosurgery and Spine.
Medications on Admission:
none
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*1*
2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-13**]
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while using dilaudid for pain control to
prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: take as needed for constipation
associated with Pain medications.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left Subdural hemorrhage, bilateral subarachnoid hemorrhage,
mild cistern loss
Basilar skull fracture extending into foramen magnumn
Comminuted compression fracture of L2 vertebral body
right transverse process fracture of T11-L3 with t11-12 having
oblique fractures. L1-L3 complete transverse process fractures
with displacement
Right psoas hematoma
Discharge Condition:
hemodynamically stable, tolerating oral intake, voiding without
difficulty, pain is well controlled with an oral regimen.
Discharge Instructions:
Please return to the emergency room if you experience:
increasing shortness of breath, new chest pain, uncontrollable
nausea/vomiting, have acute mental status change/confusion, or
experience new weakness or loss of sensation in your
extremities.
Spine:
You have been fitted with a TLSO brace. This should be worn at
all times when you are out of bed. You may take it off when
laying flat in bed.
Medications:
you have been prescribed anti-seizure medications. These should
be taken for the next month until you have followup with the
Neurosurgeons. At that appointment they will tell you whether
you should continue taking the medication.
You are also being prescribed pain medications. please be aware
that these can cause sedation/confusion and you should NOT
operate heavy machinery or consume alcohol while taking these
drugs.
Take all medications as ordered
Followup Instructions:
Neurosurgery: Please follow-up with Dr. [**Last Name (STitle) 23813**] in 4 weeks.
You will need a repeat CT scan of the head without contrast.
Please call [**Telephone/Fax (1) 1669**] to set up the appointment and the CT
scan.
Ortho spine: Please follow-up with Dr. [**Last Name (STitle) 363**] in 1.5 weeks. Call
([**Telephone/Fax (1) 11061**] for a f/u appointment. You will need xrays prior
to your appointment. The scheduler will help you set this up.
Completed by:[**2168-10-27**]
ICD9 Codes: 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3377
} | Medical Text: Admission Date: [**2143-3-20**] Discharge Date: [**2143-3-26**]
Date of Birth: [**2073-7-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lasix / Zaroxolyn
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
69 yo female w/ PMHXx significant for tracheoplasty via right
thoracotomy [**1-16**] presents on [**2143-3-20**] w/ cough and SOB x 1 week.
Denies fever, chills, abd pain, or N/V/D.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69 year old female s/p tracheoplasty via right thoracotomy [**1-16**]
now presents with cough x1 week and worsening SOB.
Past Medical History:
Tracheomalacia with baseline shortness of breath, s/p
bronchoscopy and stent [**12-28**]
DM type II, insulin dependent
CHF EF > 55%, LVH, restrictive cardiomyopathy
Hypertension
COPD based on history of smoking
GERD, s/p Stretta procedure [**Hospital1 2025**] [**2140-11-18**]
vocal cord dysfunction (?reflux laryngitis)
IBS
OA
cecal AVM
rheumatic fever as child
Social History:
The patient is widowed and she used to work as a medical
secretary. She drinks alcohol occasionally and socially. She is
not a current smoker. She stopped smoking 7 years ago and she
smoked for almost 40 years 1.5 - 2 packs a day and she denies
any history of any asbestos exposure.
Family History:
CAD in grandparents, but no lung disease
Physical Exam:
General appearance: Tacypneic in mild distress.
HEENT: atraumatic, PERRL, MMM.
Heart: tacycardic but regular rhythm.
Chest: wheezes bilaterally. Right thoracotomy site well healed.
Abd: Soft, NT, ND, +BS.
Extrem: No C/C/E
Neuro: A+Ox3. no focal deficits.
Pertinent Results:
[**2143-3-20**] 09:32PM TYPE-ART RATES-/25 PO2-82* PCO2-36 PH-7.40
TOTAL CO2-23 BASE XS--1 INTUBATED-NOT INTUBA
[**2143-3-20**] 09:03PM GLUCOSE-274* UREA N-24* CREAT-1.2* SODIUM-141
POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-22 ANION GAP-21*
[**2143-3-20**] 09:03PM WBC-6.1 RBC-4.83# HGB-13.5# HCT-39.7 MCV-82
MCH-28.0 MCHC-34.1 RDW-13.4
CT CHEST W/CONTRAST [**2143-3-21**] 2:02 PM: IMPRESSION:
1) Airway wall thickening at the level of the thyroid gland,
suggestive of subglottic edema.
2) Overinflation of the endotracheal tube cuff.
3) Dependent right basilar atelectasis, but no findings in the
lung to explain respiratory distress.
CHEST (PORTABLE AP) [**2143-3-20**] 8:28 PM: IMPRESSION:
1) No evidence for pneumonia.
2) Emphysema.
3) Basilar atelectasis improving.
CHEST (PORTABLE AP) [**2143-3-23**] 8:55 AM:IMPRESSION: Right base
atelectasis.
Brief Hospital Course:
Pt was transfered from [**Hospital **] Hosp to [**Hospital1 18**] Thoracic service
on [**2143-3-20**] for c/o cough x 1 week and worsening SOB.
PMHx significant for COPD, tracheomalacia w/ Tracheoplasty [**1-16**].
Was admiited to the trauma SICU for progessively worsening SOB.
Placed on CPAP, IV steriods and azithromax for prophylaxis w/
some improvement.
[**2143-3-21**]- pt w/ increased resp fatigue- was intubated for
support. Bronch w/ BAL for viral culture (negative results) and
airway CT was done -stent in good position.
Extubated on [**2143-3-23**] w/o incident.
Episode appears to be COPD exacerbation.
Iv steriods changed tp po and to continue taper as out patient.
H2 blocker also increased to [**Hospital1 **]. Diabetes control managed with
NPH and regular insulin. Pt to return to see Dr. [**Last Name (STitle) 952**] for
follow up in 2 weeks.
Medications on Admission:
[**Last Name (un) 1724**]: nexium 40', lipitor 40', aldactone 25', evista 60',
allopurinol 300', NPH 20/30, HISS, advair, [**Doctor First Name 130**], ativan,
omnicef, robitussin, salmetol, ventolin
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
COPD exacerabation
Discharge Condition:
good
Discharge Instructions:
Call interventional pulmonology [**Telephone/Fax (1) 3020**] if you experienced
increased shortness of breath, productive cough of yellow, green
or tan sputum, or chest pain.
Resume all medications that you were taking prior to this
hospitalization and take all new medications as directed.
Followup Instructions:
Call and schedule a floow up appointment with Dr. [**Last Name (STitle) **] or Dr.
[**Name (NI) **] in one week.
Completed by:[**2143-3-28**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3378
} | Medical Text: Admission Date: [**2149-11-15**] Discharge Date: [**2149-12-5**]
Date of Birth: [**2080-11-2**] Sex: M
Service:
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 68 year old gentleman
with a history of coronary artery disease, previous coronary
artery bypass graft with severe known aortic stenosis who had
been scheduled for an aortic valve replacement on [**2149-11-17**] with Dr. [**Last Name (Prefixes) **]. The patient presented to the
Emergency Department on [**2149-11-15**] with increasing
shortness of breath. The patient had previously been
admitted to Dr. [**Last Name (Prefixes) **] for apical aortic conization.
The procedure was aborted in the Operating Room due to
evidence of a significant amount of aortic insufficiency.
The patient was subsequently discharged to home and scheduled
for
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2149-12-4**] 17:02
T: [**2149-12-4**] 21:37
JOB#: [**Job Number 3871**]
ICD9 Codes: 4241, 4280, 5119, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3379
} | Medical Text: Admission Date: [**2200-2-27**] Discharge Date: [**2200-2-28**]
Date of Birth: [**2143-10-11**] Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING ADMISSION AND TRIGGER NOTE .
Date: [**2200-2-27**]
Time: 2100
_
________________________________________________________________
PCP: [**Name10 (NameIs) **] info(fax and phone), confirmed with patient, last
saw PCP [**Last Name (NamePattern4) **]
.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17474**] [**Location (un) 796**]
_
________________________________________________________________
HPI:
56 y/o M with tobacco and ETOH abuse who presets with stage 4
pancreatic cancer diagnosed in [**2200-1-31**] when he presented with
abdominal pain and weight loss. He presented with biliary
obstruction and is transferred from an OSH after a failed ERCP
attempt with Dr. [**First Name (STitle) **]. Pt underwent PTC in [**2200-1-31**]. The wire
traversed the gallbladder and reached the duodenum. The wire
could be seen in the duodenum fluroscopically but could not be
reached by endoscope due to diffuse duodenal edema and tumor
growth.
He was transferred her for palliative stent placement to relieve
his biliary obstruction as without this, he will not be a
candidtate for chemotherapy.
He has been having nausea and vomiting non-bilious, non bloody.
Upon arrival to floor he had an episode of diarrhea.
Of note the patient reports that he was diagnosed with a blood
clot in his L leg but the left leg "blew up" overnight and is
worse.
He reports a cold R foot with increasing pain and numbness,
worse over the past 24 hours which he attributes to the
ambulance ride.
.
PAIN SCALE: [**7-20**] RUQ
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ ] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[X ] ____30_ lbs. weight loss/gain over __6___ weeks
Eyes
[] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [] All Normal
[+] Shortness of breath [+ ] Dyspnea on exertion which I
witnessed but he does not report this [ ] Can't walk 2 flights
[ ] Cough [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis
[ ]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [- ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ +] Nausea [+] Vomiting [+] Abd pain [] Abdominal swelling
[ ] Diarrhea [ ] Constipation [ ] Hematemesis
[- ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [] All Normal
[ ] Rash [ ] Pruritus [+] jaundice
MS: [x] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [x] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
[ +] jaundice
HEME/LYMPH: [] All Normal
[+ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [X] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
ALLERGY:
[ x]Medication allergies [ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
Metastatic pancreatic cancer with liver mets and regional
adenopathy- s/p percutaneous drain on [**2200-1-31**]. He has had 4
attempted ERCPs.
Rectal abscess and L hirdradenitis incision and drainage.
Per report LLE DVT but no imaging report available
HTN
Colonic polyps
Gout
Folic acid deficiency
Alcohol abuse
Lyme disease
Tobacco
PVD
-----------
Social History:
He lives with his wife. [**Name (NI) **] smokes 2.5 packs per day for ? 30
years. He denied alcohol abuse to me but per the d/c summary he
has a history of alcohol abuse. Social history is very limited
because he does not want to talk as he is tired.
Wife: [**Name (NI) **]: [**Telephone/Fax (1) 77883**]
Family History:
Father died at age 60 with cirrhosis, HTN, CAD. Mother died at
age 53 with a CVA. [**3-15**] sisters with HTN.
Physical Exam:
1. VS Tm T P 90 BP RR 18 O2Sat on _95 RA___ liters O2 Wt,
ht, BMI
GENERAL: thin, ill appearing male sitting on the toilet.
Nourishment : at risk
Grooming : ok
Mentation
2. Eyes: [] WNL
+ jaundice
PERRL, EOMI without nystagmus, Conjunctiva:
clear/injection/exudates/icteric Ears/Nose/Mouth/Throat: MMM, no
lesions noted in OP
3. ENT [x] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[X] Regular [] Tachy [x] S1 [x] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[] Edema RLE None, Neither DPP nor PT pulse could be
appreciated by doppler.
L DPP and L PT could be appreciated by doppler [] Bruit(s),
Location:
[] LLE None 3+ up to the middle of the thigh
[] Vascular access [x] Peripheral [] Central site:
5. Respiratory [ ]
[x] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ ] WNL
[x] Soft
PTC drain site C/D/I
[] Rebound [] No hepatomegaly [x] Non-tender [] Tender [] No
splenomegaly
[] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [x ]Upper extremity strength 5/5 and symmetrical
[ ]Other:
[ ] Bulk WNL [X] Lower extremity strength 5/5 and symmetrica
[ ] Other:
[x] Normal gait - able to walk to BR unassisted []No cyanosis
[ ] No clubbing [] No joint swelling
8. Neurological [] WNL
[x ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
jaundiced
R foot
10. Psychiatric [] WNL
[] Appropriate [x] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
[**Doctor First Name **] [] No inguinal [**Doctor First Name **] [] Thyroid WNL [] Other:
12. Genitourinary [X] WNL
[ ] Catheter present [] Normal genitalia [ ] Other:
TRACH: []present [x]none
PEG:[]present [X]none [ ]site C/D/I
COLOSTOMY: :[]present [X]none [ ]site C/D/I
.
Discharge Physical:
VS - Afebrile, HR108, BP95/68, RR17, 91% on 5L NC.
General: Alert, oriented, no acute distress, jaundiced,
chronically ill appearing
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: Soft, supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
mild discomfort to deep palpation in RUQ, perc drain site
clean/intact - covered, with significant serous drainage. Green
bile, no blood or pus in drain.
GU: Foley in place
Ext: Warm, well perfused bilateral upper extremities, no
clubbing of bilateral lower extremities, [**2-10**]+ pitting edema
bilaterally with L>R, dopplerable pulses, warm bilaterally with
good capillary refill on left but purplish, mottled right toes
(big, second/third toes especially) with significant TTP
Pertinent Results:
[**2200-2-27**] 10:30PM WBC-18.8* RBC-3.42* HGB-11.8* HCT-37.0*
MCV-108* MCH-34.4* MCHC-31.8 RDW-15.6*
[**2200-2-27**] 10:30PM PLT COUNT-131*
.
SR: 95 bpm. No acute changes.
.
[**2200-2-27**] 11:42PM ALT(SGPT)-35 AST(SGOT)-57* CK(CPK)-43* ALK
PHOS-252* TOT BILI-5.0*
[**2200-2-27**] 11:42PM CK-MB-2 cTropnT-<0.01
[**2200-2-27**] 11:42PM CALCIUM-6.9* PHOSPHATE-1.9* MAGNESIUM-1.6
[**2200-2-27**] 11:42PM PT-18.3* PTT-29.0 INR(PT)-1.7*
[**2200-2-27**] 10:30PM NEUTS-86.4* LYMPHS-6.9* MONOS-5.8 EOS-0.6
BASOS-0.4
[**2200-2-27**] 10:30PM NEUTS-86.4* LYMPHS-6.9* MONOS-5.8 EOS-0.6
BASOS-0.4
.
CT [**2200-1-31**]
Locally advanced pancreatic malignancy with obstruction of the
CBD, liver metastases and regional adneopathy.
Tumor abuts the proximal superior mesenteric artery, superior
mesenteric vein and the portal vein.
ERCP [**2200-1-31**]
Friable mass in the second portion of the duodenum. Stricture
with conscioius villing. Pancreatic duct accesses but the CBD
could not be accessed.
.
Path from bx demonstrated pancreatic adenocarcinoma.
.
CT torso [**2200-2-28**]:
IMPRESSION:
Preliminary Report1. Extensive pulmonary embolism involving the
right main, lobar and segmental
Preliminary Reportarteries of the right lower lobe and segmental
arteries of the left lower
Preliminary Reportlobe. No right heart strain.
Preliminary Report2. Multifocal consolidation in both lungs,
predominantly involving both upper
Preliminary Reportlobes and the right middle lobe, concerning
for multifocal pneumonia.
Preliminary ReportBilateral small pleural effusions.
Preliminary Report3. Known pancreatic malignancy, is not well
assessed in this study. Bulky
Preliminary Reportpancreatic head may represent the known mass.
Metastatic disease in the
Preliminary Reportabdomen including multifocal liver metastasis,
enlarged
Preliminary Reportgastrohepatic/retroperitoneal adenopathy, and
thickened left adrenal gland.
Preliminary Report4. Diffuse thickening of the gastric and
colonic walls could be reactive
Preliminary Reportchanges versus third spacing. Moderate amount
of abdominal ascites.
Preliminary Report5. Percutaneous cholecystostomy tube and
duodenal stent are in place.
Preliminary Report6. Extensive atherosclerotic disease of the
iliac arteries.
Preliminary ReportRIGHT: Long segment occlusion of the right
external iliac and the common
Preliminary Reportfemoral artery, with reconstitution at the
level of distal CFA. Multifocal
Preliminary Reportstenosis of the right SFA and popliteal
arteries, with absent flow in the
Preliminary Reportright anterior tibial and peroneal at the
distal third of the leg.
Preliminary ReportLEFT: Multiple areas of high-grade stenosis
and short segment near-complete
Preliminary Reportocclusion of the left external iliac artery,
with multiple areas of high-grade
Preliminary Reportstenosis in the femoral, popliteal arteries of
the left lower extremity.
Preliminary ReportAbsent flow in the anterior tibial and
peroneal distal to the ankle.
Preliminary ReportPatent posterior tibials bilaterally.
Preliminary ReportThe above findings were discussed via
telephone with Dr.[**Last Name (STitle) **] at 8:30 A.M on
Preliminary Report1/20/12.
.
TTE:
Conclusions
Poor image quality. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size is
normal with normal free wall contractility. Interventricular
septal motion is normal. There is no pericardial effusion.
IMPRESSION: No clear evidence of RV strain.
Brief Hospital Course:
Brief Course:
Pt is a 56 year old male with history of hypertension,
peripheral vascular disease, tobacco abuse, previous alcohol
abuse, LLE DVT, and recently diagnosed metastatic stage 4
pancreatic cancer with gastric outlet/biliary obstruction who
presented s/p ERCP at [**Hospital1 18**] for duodenal/biliary stent
placement, found to have bilateral PE's, now transferred to the
medical ICU with acute hypotension and dyspnea on
exertion/hypoxemia. After arrival of his family in the ICU,
decision was made to make patient CMO. He was discharged to
hospice.
.
# Goals of care: On arrival to the ICU, pt's family, including
his Wife, [**Name (NI) **] (HCP), arrived. Per discussion with the patient
and his wife, pt desired comfort and no more aggressive
treatment. Decision was made for comfort measures only. Heparin
gtt for PE's, and antibiotics were discontinued. He was
continued on pain medications. He was discharged to hospice on
[**2200-2-28**].
.
# Hypotension: Likely multifactorial from bilateral PE's,
possible hypovolemia, and concern for developing sepsis. Pt had
CTA torso on the medical floors prior to transfer to the ICU,
and was found to have bilateral PE's. TTE showed no evidence of
right heart strain. He had a mild drop in hematocrit, but no
obvious signs of bleeding, and the Hct on recheck was stable.
Infiltrates were seen on CT, with concern for developing
infection, though he remained afebrile. Given goals of care as
discussed above, pt was made CMO and antibiotics in addition to
heparin gtt were discontinued.
.
# Right foot/toe ischemia and peripheral vascular disease:
Currently no plans for intervention. Improved overnight. CTA
suggests chronic problem with intermittent ischemia. As above,
heparin gtt was discontinued. He was given pain medication as
needed for vomfort.
.
# LLE DVT: Per report and patient was previously on lovenox
which was stopped ~ 7 days prior to admission to [**Hospital 794**] Hospital
on [**2200-2-24**] for planned ERCP with stenting. As above, heparin
gtt was stopped.
.
# Non-anion gap metabolic acidosis: Differential includes
hyperalimentation (TPN was started previously?) vs. diarrhea vs.
pancreatic fisuli (alkali lossfrom pancreas). Most likely due to
his pancreatic cancer and known fisultas/obstructions. No more
labs were checked given goals of care.
.
# Metastatic Pancreatic Cancer: Complicated by biliary/duodenal
obstruction with difficult to intervent anatomy. The patient is
s/p PTC drain and was transferred for another attempt at biliary
stent placement vs. new PTC drain placement via EUS. ?role of
chemotherapy and what the plans were for this. As above, given
goals of care discussion, he was given morphine for pain
control.
.
Transitional care:
1. CODE: comfort measures only
2. Contact: wife
3. Discharged to hospice care
Medications on Admission:
Allopurinol 300 mg po qd
Polyethylene Glycol 17 gm
Morphine sulfate 15 mg ER [**Hospital1 **]
Morphine 15 mg po q 4 hours
Discharge Medications:
1. morphine 30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
3. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
1. metastatic pancreatic cancer
2. pulmonary emboli
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 35962**],
You were admitted to the hospital for ERCP. However, your blood
pressure was low, and you were admitted to the ICU. You were
found to have pulmonary emboli, and possible infection in your
lungs. After discussion with you further, you and your family
decided that you would like to pursue comfort. You were
discharged to hospice.
Please stop all medications you were taking at home prior to
this.
Please start the following medications:
- Morphine IR 30mg orally every 4 hours as needed for pain
- Tylenol as needed for pain or fevers
- Ondansetron 4mg IV or ODT as needed for nausea every 8 hours
Followup Instructions:
Please follow-up with the hospice care team.
Completed by:[**2200-3-1**]
ICD9 Codes: 0389, 486, 2762, 4019, 2749, 2859, 4589, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3380
} | Medical Text: Admission Date: [**2144-11-12**] Discharge Date: [**2144-11-16**]
Service: MEDICINE
Allergies:
Cefuroxime / Cephalosporins
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
inferior STEMI
Major Surgical or Invasive Procedure:
cardiac catheterization and right coronary artery balloon
angioplasty [**2144-11-12**]
cardiac catheterization and placement of right coronary artery
stent [**2144-11-13**]
History of Present Illness:
The patient is an 81 y.o F with no prior documented h/o heart
disease who presented to OSH c/o 1 day h/o chest pain radiating
to left arm & jaw. As per patient, her chest pain started one
day ago while attending funeral services. The pain radiated to
her left arm & jaw and was accompanied by diaphoresis. There
was no SOB or nausea. Ms. [**Known lastname **] also denies fevers, chills,
palpitations, syncope, PND or orthopnea.
.
Ms. [**Known lastname **] reports an Exercise MIBI 3-4 years ago at [**Hospital1 392**], that
was negative. And another ET MIBI on [**4-9**] w/ an Echo, both
were negative for heart disease.
.
Although her pain was [**10-13**], the patient attributed her symptoms
to indigestion. She took Nexium that evening, with minimal
relief. The pain was intermittent through the night, awakening
the patient at times from sleep.
.
On the morning of admission, Ms. [**Known lastname **] [**Last Name (Titles) 46101**] her PCP for an
EMG and reported her symptoms. At the time, it was still
believed to be symptoms of indigestion. However, subsequent to
the appointment, the patient's symptoms became worse and her
husband drove her to [**Hospital3 **] [**Name (NI) **]. On admission, patient
had elevated troponin I. EKG show ST elevation with tombstoning
in II, III &aVF, and ST depression in I, L, V1 & V2, with left
axis deviation, anterior inferior ST depression. Ms. [**Known lastname **] was
treated with 0.4mg nitro X2 and morphine sulfate. Her blood
pressure dropped significantly when nitro was administered.
Patient was transfered to [**Hospital1 18**] for cardiac cath.
.
At [**Hospital1 18**], patient was urgently admitted to cath lab where and
RCA balloon angioplasty was performed. Procedure was well
tolerated with no complications. Findings showed elevated
filling pressures, mild disease in LMCA, 70% distal LAD disease,
90% occulusion of OM1 & 80%LPL, RCA was occluded prior to
balloon angioplasty. Patient was placed on [**Last Name (LF) 70451**], [**First Name3 (LF) **] &
plavix. Plan to stent RCA & OM on [**11-13**].
.
ROS:
In addition to symptoms noted in HPI, Ms. [**Known lastname **] reports 5lb
weight loss in last 1 month, secondary to decreased appetite.
She denies headache, fever, chills, vomiting, diarrhea,
constipation, hematuria, dysuria, melena or dyschezia.
Past Medical History:
1)Left knee operation 3/4 years ago for arthritis
2)Tonsillectomy
3)Spinal stenosis
4)Asthma
5)GERD
6)Gout
7)HTN
8)bursitis
Social History:
retired receptionist. married. lives in [**Location 70452**]
social tobacco use in past
occ ETOH
Family History:
brother and grandson with nephritis
Physical Exam:
VS: bp: 118/83 SpO2: 00% on NC RR: 18 HR: 61 T:97
Gen: A&O*4, WNWD
HEENT: PERRLA, EOMI, Anicteric sclera, no scleral injection, no
lacrimation or rhinorrhea
Neck: JVP @ 8cm, no JVD, soft & supple
CV: RRR, S1 & S2 heard, no murmurs, rubs or gallops appreciated.
Lungs: CTABL, no wheezes, rales or rhonchi appreciated.
Abd: benign, soft, NT, ND, catheter insertion site - bloody &
oozing, no bruits heard, BS*4
Ext: cool to touch, 2+ tp & dp pulses.
Pertinent Results:
[**2144-11-12**] 09:07PM PT-14.4* PTT->150* INR(PT)-1.3*
[**2144-11-12**] 09:07PM PLT COUNT-194
[**2144-11-12**] 09:07PM WBC-11.2* RBC-3.52* HGB-11.4* HCT-31.8*
MCV-90 MCH-32.4* MCHC-35.9* RDW-13.2
[**2144-11-12**] 09:07PM CALCIUM-8.4 PHOSPHATE-3.1 MAGNESIUM-1.8
[**2144-11-12**] 09:07PM CK-MB-74* MB INDX-15.1* cTropnT-0.76*
[**2144-11-12**] 09:07PM CK(CPK)-489*
[**2144-11-12**] 09:07PM GLUCOSE-129* UREA N-15 CREAT-0.6 SODIUM-133
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-23 ANION GAP-11
.
[**2144-11-14**] 07:03AM CKMB 42* CK 703
[**2144-11-13**] 11:45PM CKMB71* * CK 939
[**2144-11-13**] 07:04AM CKMB229* CK 1711
[**2144-11-12**] 09:07PM CKMB74* CK 489
.
[**11-12**] ccath:
COMMENTS:
1) Selective coronary angiography of this right dominant system
demonstrated two vessel coronary artery disease. The LMCA had
mild
disease. The LAD had 70% stenosis distally. The LCX had system
had 90%
ostial OM1 and 80% stenosis at LPL. The RCA was totally
occluded.
2) Mildly elevated right-sided pressure.
3) Left ventriculograpy was deferred.
4) RCA POBA performed with residual severe stenosis and no
reflow.
Intracoronary Diltiazem, Nitroglycerin, and Adenosin used with
marked
improvement in flow.
5) Successful PTCA of the RCA as described in the procedure
portion of this report.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Totally occluded RCA
3. Mildly elevated right-sided pressure
4. Acute inferior myocardial infarction managed by PTCA of the
RCA as
described in this report.
.
[**11-13**]: report pending, 3 stents to PDA, OM unrevascularized.
Brief Hospital Course:
This is an 81 yo F with no h/o heart disease who presented with
an inferior STEMI s/p POBA RCA [**2144-11-12**] and 3 stents to the PDA
[**11-13**] w/no revascularization to OM1 (90% occluded).
.
1. CAD: This patient had a POBA to the RCA on [**11-12**]. The day
following the procedure, the patient had recurrent chest pain
and was taken back to the cath lab. She had a total of 3 bare
metal stents to the PDA which was complicated by PDA dissection.
There was no intervention to OM which was 90% occluded.
Additional PCI to address the OM lesion was deferred secondary
to the large CK release from the MI and the significant contrast
load and flouroscopic exposure. The patient will follow up with
Dr. [**Last Name (STitle) 911**] on [**2144-12-25**] for follow up and to discuss management of
her OM lesion. She will likely have either an outpatient stress
test or repeat PCI to address this lesion after optimum medical
management has been achieved. The patient received post cath
hydration for renal protection. She was started on [**Date Range **] & Plavix,
lipitor, metoprolol 25 [**Hospital1 **], and lisinopril 5 QD.
.
2. Pump: The patient had an inferior STEMI with peak CKs of
1711. An echo showed an EF 50% with hypokinesis of basal and mid
infero-lateral wall. The patient appeared euvolemic upon
discharge. She was started on a BB and ACEI for their
cardioprotective/remodelling effects. They may be titrated up as
BP allows as an outpatient.
.
3. Rhythm: The patient experienced bradycardia post MI which had
resolved upon discharge. She remained in NSR with a pulse in the
70s on metoprolol 25 [**Hospital1 **].
.
4. GERD: The patient was given protonix for GERD during her
hospitalization.
.
5. GOUT: The patient's allopurinol and colchicine were stopped
for three days secondary to the large dye load she recieved
during her two cardiac catheterizations. However, her cr was
stable throughout her stay and the allopurinol and colchicine
were restarted prior to discharge.
.
6. Anemia: The patient came in with a Hct 31.9 which dipped to a
low of 27. This was attributed to her two intravascular
procedures, blood draws, and post cath hydration. The patient
was guiac negative. Her Hct was stable at 27 upon discharge.
Iron studies were added on to the am labs on the morning of
admission and may be followed up by her PCP as an outpatient.
Her PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was contact[**Name (NI) **] concerning her anemia
and the patient was advised to f/u with her within 1-2 weeks of
discharge.
Medications on Admission:
Norvasc 10 mg QD
Atenolol 25 mg QD
Colchicine 0.6 mg QD
allopurinol 300 mg QD
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*12*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] vna
Discharge Diagnosis:
Inferior ST elevation myocardial infarction
Right coronary artery dissection with resulting bare metal stent
Discharge Condition:
Good
Discharge Instructions:
You must take your plavix and aspirin every day. Failure to do
so may result in a heart attack or even death.
Please call 911 or return to the emergency room should you
develop any recurrence of chest pain, shortness of breath, or
left arm pain.
Followup Instructions:
1)Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
to schedule follow up in [**1-6**] weeks.
2)Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**], Cardiology: Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2144-12-25**] 11:00, [**Hospital Ward Name 23**] Building [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2144-11-22**]
ICD9 Codes: 2851, 4111, 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3381
} | Medical Text: Admission Date: [**2129-6-6**] Discharge Date: [**2129-6-12**]
Date of Birth: [**2078-12-5**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old
female, who was admitted on [**2129-6-6**], initially went to the
[**Hospital Unit Name 153**] after an episode of DKA. On admission, she initially
noted 7 days of nausea, vomiting with some diarrhea, urinary
frequency, and fevers and chills times 2 days. Of note, she
had a recent bilateral knee arthroscopy 11 days prior.
Initially, she had a white blood cell count 16.9, elevated
creatinine of 2.0, and an anion gap of 39 with a pH of 7.02
on ABG. Initial infectious workup was unremarkable and the
patient was placed on an insulin drip until her anion gap
closed. She subsequently was able to tolerate p.o. and was
placed on NPH regimen 40 units in the morning and 40 units at
night [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations as well as a Humalog sliding
scale. Her course in the [**Hospital Unit Name 153**] was notable for orthopedic
evaluation of the knees, who felt her knees were an unlikely
source of infection and no further imaging was needed. She
had a recent radioactive iodine ablation of her thyroid and
thyroid function tests were done, which will be checked as an
outpatient. During the hospital course, she did note some
vague abdominal discomfort, but was able to tolerate p.o.
with normal liver and pancreatic labs.
PAST MEDICAL HISTORY:
1. Type 1 diabetes mellitus diagnosed in [**2125**].
2. Hypertension.
3. [**Doctor Last Name 933**] disease.
4. Asthma.
5. Hepatitis C.
6. GERD.
7. Obesity.
8. Rheumatoid arthritis.
9. Recent bilateral knee arthroscopy in [**2129-5-26**].
10. Migraines.
11. Status post TAH and pelvic floor surgery with
bladder lift.
SOCIAL HISTORY: The patient denies tobacco or alcohol use.
Lives with a 22-year-old daughter. Currently has home VNA.
ALLERGIES: PENICILLIN CAUSES URTICARIA AND ASPIRIN CAUSES
ABDOMINAL PAIN.
MEDICATIONS AT THE TIME OF TRANSFER:
1. Losartan 100 mg once a day.
2. Vioxx 12.5 mg once a day.
3. Fluticasone inhaler b.i.d.
4. Montelukast once a day.
5. Salmeterol twice a day.
6. Albuterol inhaler p.r.n.
7. Docusate 100 mg b.i.d.
8. Hyoscyamine 0.375 mg b.i.d.
9. Methimazole 20 mg b.i.d.
10. Tylenol p.r.n.
11. Protonix 40 mg q.d.
12. NPH 40 units in the morning and 40 units in the
evening.
13. Humalog insulin sliding scale.
14. Darvocet p.r.n.
15. Senna p.r.n.
16. Bisacodyl p.r.n.
PHYSICAL EXAMINATION: Vital signs: Temperature is 98.7,
blood pressure 92/45 to 132/47, heart rate 58 to 76,
respirations 15 to 33, and saturating 99 percent on room air.
General appearance: The patient is resting comfortably in no
apparent distress. Head and neck exam: Nonicteric. Mucosa
moist. Poor dentition. Lungs are clear to auscultation
bilaterally. Cardiac exam is regular rate and rhythm. No
murmurs are noted. Abdomen: Good bowel sounds, tympanic,
and diffuse tenderness to palpation most notably over the
epigastric region. No evidence of rebound tenderness.
Extremities have trace lower extremity edema bilaterally.
Clean incision sites on knees bilaterally. No significant
swelling. Neurological exam: Grossly nonfocal.
LABORATORY DATA ON TRANSFER: White count is down to 5.4 from
16.9, hematocrit 29.8, and platelets 211. Chem-7 is with
normal BUN and creatinine of 13 and 0.6 with the glucose of
269. Normal LFTs, normal alkaline phosphatase, normal
bilirubin, and normal amylase and lipase.
HOSPITAL COURSE: Diabetes mellitus. The patient appears to
present with an episode of DKA with an unclear precipitant.
After she tolerated p.o., she was placed on a stable NPH
regimen as [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations and was transferred out
of the ICU. She had stable glucose control throughout the
rest of her hospital stay and will follow up with [**Last Name (un) **] as
an outpatient.
Abdominal pain. The patient appears to have some chronic
abdominal pain of unclear etiology. It was felt that she may
have a component of gastroparesis and was placed on Reglan.
She does have some reflux type symptoms. She was placed on a
PPI b.i.d. Ultrasound was unremarkable and labs did not
reveal any etiology for abdominal pain. She did not have
significant improvement with medication changes during her
visit and she will follow up with Gastroenterology as an
outpatient.
Musculoskeletal. She is on Vioxx and Darvocet p.r.n.
Orthopedics have evaluated her knees and felt that this was
unlikely source of an infection and unlikely to be the cause
of her DKA. She will continue to follow up with the
Orthopedics as an outpatient.
Thyroid. She was recently given reactive iodine and was
continued on methimazole. Followup with Endocrine as an
outpatient.
FEN. Her creatinine returned to [**Location 213**] after she was
initially hydrated. She did have some initial nausea and
vomiting, but was subsequently able to tolerate p.o. at the
time of discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSES:
1. Diabetic ketoacidosis.
2. Chronic abdominal pain with possible gastroparesis.
3. Severe reflux disease.
DISCHARGE MEDICATIONS:
1. Losartan 100 mg p.o. q.d.
2. Rofecoxib 12.5 mg p.o. q.d.
3. Fluticasone inhaler b.i.d.
4. Montelukast 10 mg p.o. q.d.
5. Salmeterol 50 mcg Diskus q. 12h.
6. Albuterol inhaler p.r.n.
7. Hyoscyamine 0.375 mg q. 12h.
8. Methimazole 20 mg p.o. b.i.d.
9. Tylenol p.r.n.
10. Protonix 40 mg p.o. b.i.d.
11. Reglan 10 mg p.o. q.i.d.
12. Docusate 100 mg p.o. b.i.d.
13. Senna p.r.n.
14. Bisacodyl p.r.n.
15. Darvocet p.o. q. 6h. p.r.n.
FOLLOWUP PLANS: The patient was told to follow up with her
primary care physician [**Name Initial (PRE) 176**] 1 to 2 weeks and discuss having
a gastric emptying study done at that time. Continued workup
of her chronic abdominal pain. She will also follow up with
her primary care physician to obtain an outpatient
colonoscopy. She has an appointment with Dr. [**Last Name (STitle) **] next
month and she should discuss these issues as well. She
should also follow up with her Endocrinologist Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) **] at the [**Last Name (un) **] Institute on [**2129-6-22**] to have her
insulin regimen adjusted if necessary. She also has an
appointment with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], Rheumatology unit.
She was given explicit instructions. Continue taking all
medications as prescribed and then she should seek further
medical attention if her blood sugars are consistently over
300, if she develops intractable nausea, vomiting, fevers,
chills, or has any other concerning symptoms whatsoever.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27159**], MD [**MD Number(2) 27160**]
Dictated By:[**Last Name (NamePattern1) 2366**]
MEDQUIST36
D: [**2129-12-2**] 10:46:30
T: [**2129-12-2**] 14:00:21
Job#: [**Job Number 102655**]
ICD9 Codes: 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3382
} | Medical Text: Admission Date: [**2136-10-23**] Discharge Date: [**2136-10-24**]
Date of Birth: [**2076-4-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
CC: Transfer from OSH for ? Sepsis/ARF and Hemachromatosis with
liver failure.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 60 year old female with a PMH of DM, Met Breast CA admitted
to Sturdy [**Hospital **] Hospital with cc of [**3-30**] wks of fatigue and
constipation. Workup revealed elev. WBCs and abdominal CT
ordered showed small amount of ascites and cirrhotic liver.
Initial labs were Bicarb 19, BUN 47, Creat 1.8, Alb 3, T. bili
0.3, Alk phos 178 ALT 155, AST 55, WBC 17 (80N, 3B) plt 42, INR
2.1, Ferritin 4751 with iron 168. Over her 6 day stay, pt
deteriorated and became increasingly somnolent. Lactulose was
started and greatly improved MS. Genetic screen revealed
heterozygous for hemachromatosis. Remained afebrile with WBC
[**10-23**] of 17 with 13 bands. Cx data revealed urine cx of mixed
flora and Blood cx negative to date. Levoquin and Ceftaz since
[**10-18**]. Pt also developed increased O2 requirements thought to be
from CHF/Vol overload despite a normal echo. Renally, Cr.
increased from 1.7 to 3.2. Pt was given albumin/lasix with
effect. Currently oliguric at transfer. Decreased HCT 36 -->
26.5. EGD was neg. Given 1U PRBC. Also developed Decreased SBP
on [**10-21**] and wet to MICU. Swan numbers consistent with sepsis. On
[**10-23**] (day of admission) she was hypertensive with decreased UOP
and started on levophed. Soon after arrival at [**Hospital1 18**], she had
agonal respirations with no gag and was intubated.
Past Medical History:
PMH: DM type 2; Metastatic Breast CA rx'd with [**Doctor First Name **], chemo and
rad; Elevated cholesterol; s/p CCY.
Social History:
SH/FH: Unobtainable.
Family History:
SH/FH: Unobtainable.
Physical Exam:
VS:
Pertinent Results:
[**2136-10-23**] 04:47PM PT-20.3* PTT-44.4* INR(PT)-2.9
[**2136-10-23**] 04:47PM PLT SMR-RARE PLT COUNT-17*
[**2136-10-23**] 04:47PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-1+
TEARDROP-OCCASIONAL BITE-OCCASIONAL ACANTHOCY-OCCASIONAL
[**2136-10-23**] 04:47PM NEUTS-79* BANDS-7* LYMPHS-5* MONOS-6 EOS-2
BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-13*
[**2136-10-23**] 04:47PM WBC-16.5* RBC-3.15* HGB-9.8* HCT-28.5* MCV-91
MCH-31.1 MCHC-34.2 RDW-23.3*
[**2136-10-23**] 04:47PM CALCIUM-10.5* PHOSPHATE-10.1* MAGNESIUM-2.2
[**2136-10-23**] 11:30PM HAPTOGLOB-<20*
[**2136-10-23**] 11:30PM CORTISOL-21.1*
[**2136-10-23**] 11:30PM FDP->1280*
[**2136-10-23**] 11:30PM D-DIMER-4431*
[**2136-10-23**] 09:30PM URINE HOURS-RANDOM UREA N-42 CREAT-33
SODIUM-LESS THAN
[**2136-10-23**] 07:47PM TYPE-MIX TEMP-36.7 RATES-16/4 TIDAL VOL-360
PEEP-5 O2-60 PO2-64* PCO2-48* PH-7.19* TOTAL CO2-19* BASE XS--9
-ASSIST/CON INTUBATED-INTUBATED
[**2136-10-23**] 07:47PM HGB-9.9* calcHCT-30 O2 SAT-88
[**2136-10-23**] 05:03PM TYPE-ART PO2-198* PCO2-46* PH-7.21* TOTAL
CO2-19* BASE XS--9
[**2136-10-23**] 05:03PM GLUCOSE-137* LACTATE-2.4* NA+-134* K+-5.4*
CL--106
[**2136-10-23**] 05:03PM HGB-10.0* calcHCT-30 O2 SAT-97
[**2136-10-23**] 05:03PM freeCa-1.41*
[**2136-10-23**] 04:47PM GLUCOSE-138* UREA N-99* CREAT-4.0* SODIUM-137
POTASSIUM-5.5* CHLORIDE-106 TOTAL CO2-18* ANION GAP-19
[**2136-10-23**] 04:47PM ALT(SGPT)-25 AST(SGOT)-160* LD(LDH)-8250* ALK
PHOS-201* AMYLASE-41 TOT BILI-4.4*
Brief Hospital Course:
Assessment: 60 year old female with a PMH significant for type 2
DM, h/o met. breast ca, increased chol now presents with 3-4
weeks of fatigue and constipation found to have cirrhotic liver
and heterozygous for hemachromatosis. Also developed presumed
sepsis (unclear etiology), ARF and worsening hypotension.
.
PLAN:
1) Liver failure: Heterozygous for C282Y allele. With increased
ferritin and incr. LFTs --> ReportedlyOSH CT demonstrating
cirrhosis. Hep panel and AMA neg. Planned to repeat RUQ U/S
with flow for ascites. Avoided all hepatotoxic agents. 10mg SQ
Vit K for INR elevation. Liver was consulted. Pt decompensated
overnight and family decided to make her CMO. She expired at
5am less than 10 hours after MICU admission.
.
2) ARF: DDx ATN, HRS, AIN Renally dosed all meds
.
3) Sepsis: Pt's initial WBC @ [**Hospital1 **] 18.3 with 7 bands.
Cirrhosis on CT. DDx includes Line, Ascites/SBP. CXR no clear
etiology. Awaiting cx data at time of death. Broad spectrum
Abx were administered including Vanc/Ceftaz/Flagyl. We repeated
Blood, Urine and Sputum Cx. Checked [**Last Name (un) 104**] stim. Scheduled abd
u/s to check for ascites but pt expired before this testing was
done.
.
4) Heme: Pt with increased LDH, Decr. Platelets, Decr. HCT,
Incr. INR
- Plt decr. likely [**2-29**] splenomegaly, decreased transpoeitin and
? DIC
- Checked haptoglobin, fibrinogen (DIC screen) FDP >1280, D
Dimer 4431
- Guiaic all stools
- Transfused 2 units for HCT <24 and HD unstable
.
5) Started Insulin gtt- titrated to FS 80-110 and hold
glucophage
.
6) FEN- Started D5W with 2 amps of bicarb per renal recs
@75cc/hr
- renagel
- tube feeds
- checked K frequently. No EKG signs of High K.
.
7) PPx [**Hospital1 **] PPI and Pneumoboots
.
9) Comm with daughters.
Pt expired on [**10-24**] at 5pm of complications associated with
presumed sepsis in the setting of liver failure. Her vital
signs continued to be unstable and she required pressors until
the time of death. The family was present at the time of death.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 0389, 5849, 2762, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3383
} | Medical Text: Admission Date: [**2145-1-17**] Discharge Date: [**2145-1-21**]
Date of Birth: [**2103-6-23**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Amoxicillin / Blood-Group Specific Substance
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Mental status change
Major Surgical or Invasive Procedure:
Endotracheal intubation
Placement of right subclavian line (at outside hospital)
History of Present Illness:
41yo woman with history of DM1, ESRD s/p transplant in '[**40**],
CAD s/p CABG, PVD, CHF with EF of 45%, and HTN was admitted
to [**Hospital6 33**] on ([**1-16**]) for Diabetic ketoacidosis.
She initially presented on ([**1-13**]) for evaluation of "abnormal
labs",
which revealed an anion gap of 13, sodium of 131, and glucose of
91. She was sent home with instructions to maintain hydration.
On morning of admission to [**Hospital6 **], she was found
by her mother to be suffering from nausea/vomiting, and this
persisted for many hours. She became progressively lethargic,
diaphoretic and pale.
At the outside hospital, she had significant acidosis with
initial ABG of 6.80/11/158 on FiO2 of 21%. Anion gap was 32.
Glucose was > 1000. Initial bicarb was less than 3. She had no
evidence of UTI on UA, and no evidence of any focal infiltrates
on chest xray. Urine and blood cultures were no growth to date
at time of transfer. EKG demonstrated sinus tachycardia at
121bpm with nl axis and intervals; there were increased/consider
hyperacute T waves in V1-3, and she had inverted T waves in V5-6
(seen on previous). Cardiac enzymes were negative with CK of 42,
and troponin of less than 0.01.
.
She was intubated in the emergency department ther for lethargy
and profound tachypnea. She was managed with IVF and insulin
drip. She had a right subclavian TLC placed. Her anion gap had
closed to 11 on day of transfer ([**2145-1-17**]). On transfer, her
insulin gtt was at 4units/hr, and she was on D51/2NS at
200cc/hr. She was also placed on stress dose hydrocortisone
given her history of steroid treatment. She was managed in the
ICU, and her ventilatory support was weaned down to CPAP/PS.
Last ABG done on
day of transfer was 6.92/13/141.
Past Medical History:
1. ESRD s/p living related donor transplant [**10-31**], baseline Cr
1-1.1.
2. Diabetes Mellitus type I with retinopathy, gastroparesis and
neuropathy
3. CAD s/p CABG [**5-2**] (LIMA-LAD, SVG-PDA, OMI-Diag)
4. PVD s/p R fem-[**Doctor Last Name **]
5. CHF EF = 45-50%
6. HTN
7. Chronic ulcers
8. Sarcoidosis
9. Depression
10. Blindness bilaterally [**3-4**] diabetic retinopathy. L eye
prosthesis.
Social History:
Lives with her mother in [**Name (NI) **]. Smoker: 1 ppd for 20 years.
No alcohol or IVDU. Has had care at [**Last Name (un) **] Diabetes center; her
primary doctor there is Dr. [**Last Name (STitle) 10088**]. Sees Dr. [**Last Name (STitle) 1852**] at [**Company 191**]
Family History:
no diabetes or kidney disease
Father - MI at 74
Mother with hypertension
Physical Exam:
gen: intubated; sedated on vent. Responding to commands.
heent: anicteric sclera; minimally responsive pupils
neck: supple; full range of motion
cv: RRR, 2/6 systolic murmur best at left sternal border
resp: CTA bilaterally; no focal findings
abd: soft, non-tender; nabs
extr: no c/c/e; past surgical scars; healing previous ulceration
at lle
neuro: non-focal
Pertinent Results:
CXR: Comparison made to radiographs from the previous day.
An endotracheal tube has been removed. A right subclavian line
ends at the SVC/right atrial junction. Mild cardiomegaly is
stable. CHF is slightly increased compared to the previous day.
No focal parenchymal consolidation, or pneumothorax is seen. No
large effusions or pneumothorax are seen. No osseous
abnormalities identified.
[**2145-1-20**] 07:32AM BLOOD PT-11.2* PTT-23.2 INR(PT)-0.8
[**2145-1-17**] 08:10PM BLOOD Ret Aut-2.2
[**2145-1-20**] 07:32AM BLOOD Glucose-246* UreaN-18 Creat-0.9 Na-137
K-4.7 Cl-108 HCO3-16* AnGap-18
[**2145-1-17**] 08:10PM BLOOD LD(LDH)-152 TotBili-0.1
[**2145-1-19**] 03:03AM BLOOD CK-MB-2 cTropnT-0.04*
[**2145-1-19**] 02:45PM BLOOD CK-MB-2 cTropnT-0.03*
[**2145-1-19**] 11:11PM BLOOD CK-MB-2 cTropnT-0.01
[**2145-1-20**] 10:58AM BLOOD Albumin-2.6*
[**2145-1-17**] 08:10PM BLOOD calTIBC-187* VitB12-491 Folate-7.8
Ferritn-76 TRF-144*
[**2145-1-20**] 07:32AM BLOOD FK506-4.6*
[**2145-1-20**] 07:32AM BLOOD rapmycn-2.4*
[**2145-1-18**] 05:32PM BLOOD Lactate-1.4
Brief Hospital Course:
[**Hospital Unit Name 153**] course:
Ms. [**Known lastname 19419**] was extubated on [**1-18**]. Anion gap closed with
insulin gtt. D5 1/2NS given at 200mL/hr. Complicated by episode
of flash pulmonary edema with HR 150s-160s - resolved with IV
lasix, morphine, IV lopressor. Ruled out with three negative
troponins. [**Last Name (un) **] service consulted, who suggested regimen of
lantus 20U qHS with humalog SSI. Lantus started that evening as
pt started taking PO, insulin gtt d/c'ed four hours later. On
[**1-20**], pt spiked to 101.4, CXR showing consolidation at lung
bases, probably [**3-4**] residual pulmoanry edema and atelectasis,
but can't r/o PNA. On levofloxacin 500mg PO q24h (started
[**1-17**]). ABG done: 7.4/27/96/17, lactate 1.4. has been afebrile
since. Transplant surgery consulted, recommended daily prograf
levels with goal [**6-6**], and qod rapamune levels with goal [**6-5**].
This AM, rapamune level subtherapic, increased dose to 3mg qD.
Had been giving stress dose steroids, d/c'ed and placed back on
chronic dose of 4mg qD due to no evidence of adrenal
insufficiency.
On transfer to floor, pt taking adequate PO, but somewhat
limited [**3-4**] sore throat, most likely [**3-4**] intubation. Given
cepacol lozenges, receiving tid sugar-free shakes with diabetic
diet per nutrition recommendation. on AML, AG 13, bicarb 16,
serum acetone positve, indicating and overlying element of
starvation ketosis [**3-4**] poor PO intake. She admitted eating
poorly over the past couple of weeks prior to admission.
After transfer to floor, BS remained [**Month/Day (2) **]. Glargine
increased to 28U qHS, with more aggressive sliding scale, which
resulted in much improved control. Her PO intake continued to
improve, and was taking a full consistency diet by time of d/c.
She was discharged to home on Glargine 28U qHS, and the most
recently utilized Humalog sliding scale. Transplant surgery was
satisfied with her Prograf and Rapamune regimens. She was d/c'ed
with the remainder of her levofloxacin regimen. A f/u
appointment with her PCP at [**Name9 (PRE) 191**], Dr. [**Last Name (STitle) 1852**], was made for
[**2145-2-11**]. She also has a f/u appointment with Dr. [**Last Name (STitle) **] in
renal transplant on [**2145-2-5**]. She was instructed to call [**Last Name (un) **]
to make an appointment within the next 2 weeks.
Medications on Admission:
DS bactrim three times per week
prednisone 7.5mg daily
ASA 81 daily
reglan 40mg
sirolimus 2mg daily
metoprolol 25mg [**Hospital1 **]
plavix 75mg daily
ramipril 2.5mg daily
protonix 40mg dialy
lantus 100units HS
zantac 150mg [**Hospital1 **]
remeron 15mg HS
Medications on transfer:
Insulin drip at 4units/hour
hydrocortisone 100mg IV q8h
D51/2NS at 200cc/hr
potassium, magnesium repletion
heparin 5000 units sc tid
protonix 40mg IV BID
reglan 10mg IV QID
compazine 25mg q12 prrn
lopressor 5mg IV q6h
sodium bicarbonate 100mEq once
morphine 2mg IV q10min prn
lorazepam 2mg IV once
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea.
6. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
8. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
9. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*2*
10. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed).
Disp:*50 Lozenge(s)* Refills:*0*
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days: Last dose [**2145-1-23**].
Disp:*2 Tablet(s)* Refills:*0*
12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28)
Units Subcutaneous qHS.
Disp:*1 month supply* Refills:*0*
14. Sliding scale insulin
Please take your sliding scale Humalog insulin according the
following scale.
1) Before meals:
0-50: Juice and call doctor
51-100: Nothing
101-150: 6U
151-200: 9U
201-250: 12U
251-300: 15U
301-350: 18U
351-400: 21U and call doctor
15. Sliding scale insulin
Please take your sliding scale Humalog insulin as follows:
2) Before bed:
0-50: Juice and call doctor
51-150: Nothing
151-200: 3U
201-250: 6U
251-300: 9U
301-350: 12U
351-400: 15U and call doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Urinary tract infection
Discharge Condition:
Good. Blood sugars under good control, afebrile, good oxygen
saturation, renal function at baseline
Discharge Instructions:
You have been diagnosed with diabetic ketoacidosis. You were
also followed by the [**Last Name (un) **] diabetes doctors and by the renal
transplant team. You should return to the ED with abnormal blood
sugars, fevers, chills, or for any other problems that concern
you.
You were also started on antibiotics for a urinary tract
infection. You have two remaining days of antibiotics to
complete, and you should take all of your prescribed medications
as written.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 1852**] in [**Company 191**] on [**2-12**] at
2pm. You can call [**Telephone/Fax (1) 250**] with any questions.
You have an appointment with Dr. [**Last Name (STitle) **] in renal transplant on
[**2-6**] at 9AM. You can call [**Telephone/Fax (1) 673**] with any questions.
You need to be seen at [**Hospital **] clinic. You should call ([**Telephone/Fax (1) 12171**] to make an appointment to be seen in the next 2 weeks.
In the meantime, you should keep to the insulin regimen as
written.
ICD9 Codes: 5990, 4280, 5856, 486, 4439, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3384
} | Medical Text: Admission Date: [**2144-1-17**] Discharge Date: [**2144-1-20**]
Date of Birth: [**2079-10-7**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 64 year old
male with a history of hyperlipidemia, hypertension, who
presented to [**Hospital1 69**] Emergency
Department at 01:30 a.m. with chest pain that began after
watching a movie at around 10:30 p.m. the same night. The
chest pain was associated with mild diaphoresis but no
radiation. There was associated nausea, but no vomiting.
The pain was 10 out of 10 in severity. The patient took an
antacid and called his primary care physician, [**Name10 (NameIs) 1023**] instructed
him to go straight to the Emergency Room.
In the Emergency Department, the patient's blood pressure was
initially in the 180s systolic, with oxygen saturation within
normal limits. An EKG initially was remarkable for [**Street Address(2) 100799**] elevations in V2 through V4, [**Street Address(2) 2915**]
elevations in V1, V5 through V6, lead I, AVL, and 2
millimeter downsloping depressions in lead II, III, AVF. The
patient was given aspirin, Lopressor 5 mg intravenously one
time, a heparin drip, Nitroglycerin drip and one sublingual
Nitroglycerin with significant improvement in EKG changes,
although the patient was not pain free. The patient was
therefore sent to the Cardiac Catheterization Laboratory.
Cardiac catheterization revealed an estimated left
ventricular end-diastolic pressure of about 28, mild disease
in the left main artery, total occlusion of the left anterior
descending proximally with right to left collaterals. mild
left circumflex disease, minimal right coronary artery
luminal irregularities. A stent was placed to the left
anterior descending with good result. The patient, on
examination, post-cardiac catheterization reported minimal to
no pain. The patient denied any shortness of breath.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
ALLERGIES: Severe latex allergy.
MEDICATIONS
1. Hydrochlorothiazide.
2. Lipitor.
FAMILY HISTORY: No history of coronary artery disease in
family.
SOCIAL HISTORY: The patient works as a dentist. The
patient denied any tobacco use. The patient admitted to
occasional alcohol use.
PHYSICAL EXAMINATION: On admission, blood pressure 109/68;
pulse 61; respiratory rate 20; oxygen saturation 98% on two
liters nasal cannula. In general, the patient was awake, in
no acute distress. Head and Neck examination: Extraocular
movements intact. Pupils equal; sclerae anicteric.
Oropharynx dry. Neck: Jugular venous pressure of about 4
centimeters. No bruits. Chest: Clear to auscultation
anteriorly. Cardiovascular examination: Regular rate and
rhythm. Normal S1 and S2. No murmurs, rubs or gallops.
Abdomen: Soft, nontender, nondistended. Good bowel sounds
in all four quadrants. No hepatosplenomegaly. Slow oozing
around sheaths. Extremities: Two plus dorsalis pedis pulses
bilaterally.
LABORATORY: White blood cell count 5.4, hematocrit 42.9,
platelets 194, INR 0.9, PT 28, sodium 140, potassium 3.4,
chloride 98, bicarbonate 31, BUN 23, creatinine 1.0, glucose
301.
Arterial blood gases revealed a pH of 7.37, pCO2 of 49, pO2
of 97. First set of cardiac enzymes revealed a CK of 96,
troponin 0.3.
EKG done in the Emergency Room with ten out of ten chest pain
revealed sinus rhythm at 75 beats per minute, 3 to [**Street Address(2) 100800**] elevations in lead II through V6, [**Street Address(2) 100801**] elevations in lead I and AVL. There were reciprocal
inferior changes.
EKG number two done when there was three out of ten chest
pain, revealed [**Street Address(2) 100802**] elevations. EKG
post-cardiac catheterization revealed resolution of ST
elevations with no Q waves.
BRIEF SUMMARY OF HOSPITAL COURSE: In summary, this is a 64
year old gentleman with a history of hyperlipidemia,
hypertension, who was presenting with an acute anterior wall
myocardial infarction. The patient had a totally occluded
proximal left anterior descending, which was successfully
stented.
1. Cardiovascular: Ischemia: The patient was status post
acute myocardial infarction to the anterior wall with
successful left anterior descending stent. There were no
obvious reperfusion abnormalities or Q waves immediately post
cardiac catheterization. It was suspected that the patient
had a long-standing plaque in the left anterior descending
which ruptured, with good collateral circulation. The
patient was continued on aspirin, beta blocker, Integrilin
post cardiac catheterization, and was started on Plavix 75 mg
p.o. q. day to continued a month course. Cardiac enzymes
were followed and peaked to a CK of 1,303 and a troponin of
greater than 50, and then trended downward. Daily
electrocardiograms were followed with no obvious
abnormalities.
Pump Function - the patient had an elevated left ventricular
end-diastolic pressure of 28 in the Cardiac Catheterization
laboratory. A P/A catheterization could not be done
secondary to latex allergy. The patient was diuresed gently,
as it was expected that the left ventricular ejection
fraction was depressed in the setting of an acute myocardial
infarction. Coumadin and heparin were started preemptively
in this patient in light of increased risk of thrombus
formation in the setting of a large anterior wall myocardial
infarction.
An echocardiogram was done to evaluate for the presence of a
thrombus as well as evaluate the ejection fraction which
revealed an ejection fraction of 50 to 55% with no masses or
thrombi seen in the left ventricle. There were resting
regional wall motion abnormalities including antero-apical
hypokinesis. Anti-coagulation was subsequently discontinued.
The patient reported no further episodes of chest pain during
his hospital stay.
Rhythm - the patient had no evidence for re-perfusion
phenomenon. The patient was continued on beta blocker.
2. Renal: The patient's creatinine remained stable post
cardiac catheterization.
3. Hematology: The patient's hematocrit remained stable
post cardiac catheterization.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient to be discharged home.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q. day.
2. Lipitor 20 mg p.o. q. day.
3. Atenolol 20 mg p.o. q. day.
4. Lisinopril 2.5 mg p.o. q. day.
5. Sublingual Nitroglycerin p.r.n.
6. Folate 1 mg p.o. q. day.
7. Plavix 75 mg p.o. q. day to finish a one month course.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 2692**]
MEDQUIST36
D: [**2144-4-17**] 17:08
T: [**2144-4-18**] 16:21
JOB#: [**Job Number **]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3385
} | Medical Text: Admission Date: [**2123-3-2**] Discharge Date: [**2123-3-14**]
Date of Birth: [**2069-8-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Respiratory distress.
Major Surgical or Invasive Procedure:
Intubation
s/p intubation
History of Present Illness:
54 YO F with Hx of Asthma, COPD who is admitted with Respiratory
distress that required intubation. The following history was
obtained from her [**Last Name (un) 8317**]. 2 days prior to admission, the
patient was supposed to go see a theatrical play. The patient
then developed a Fever of 102.5, Rhinorrhea, myalgias, chills.
Denies any cough or sputum. This morning, the patient developed
worsening SOB, inability to walk down stairs this morning with
[**Last Name (un) 8317**] so went to ED by ambulance.
The patient has been around sick contacts at work. Pt recently
restarted smoking. No Flu vaccine this year.
.
In ED, the pt was 102.9 and CXR did not show an infiltrate. Pt
was intubated and received Levaquin, ativan and tylenol.
Past Medical History:
1. Asthma.
2. ? COPD.
Social History:
She lives in [**Location (un) **]with [**Last Name (un) 8317**].
No EtOH, +recently restarted tobacco, no IVDU.
She works at [**Hospital1 2177**] as a Research Coordinator.
Family History:
Not contributory.
Physical Exam:
110 102/49 20 98% on Ventilator. AC 600/12 60%.
Sedated, NAD
MMM, OP-clear, PERRL, ETT in place.
RR without m
Coarse BS but no wheezes
soft, NT, ND +BS
no C/C/E, warm, 2+ DP, no Rashes
Pertinent Results:
Microbiology:
[**3-2**] Blood culture: no growth
[**3-2**] Urine culture: PROBABLE GARDNERELLA VAGINALIS.
10,000-100,000 ORGANISMS/ML.
[**3-2**] Rapid Respiratory Viral Screen & Culture:
Positive for Influenza A viral antigen.
.
Imaging:
[**3-2**] CXR:
Hyperinflated lungs. No acute cardiopulmonary process.
.
Labs:
[**2123-3-2**] 08:13AM BLOOD WBC-5.6 RBC-4.95 Hgb-14.8 Hct-42.9 MCV-87
MCH-29.8 MCHC-34.4 RDW-13.3 Plt Ct-309
[**2123-3-13**] 06:00AM BLOOD WBC-11.4* RBC-3.67* Hgb-11.0* Hct-31.9*
MCV-87 MCH-30.0 MCHC-34.5 RDW-13.6 Plt Ct-297
[**2123-3-2**] 08:13AM BLOOD Neuts-78.7* Lymphs-14.7* Monos-4.6
Eos-1.6 Baso-0.5
[**2123-3-2**] 08:13AM BLOOD Plt Ct-309
[**2123-3-4**] 05:10AM BLOOD PT-11.9 PTT-28.5 INR(PT)-1.0
[**2123-3-11**] 05:22AM BLOOD PT-12.7 PTT-29.7 INR(PT)-1.1
[**2123-3-13**] 06:00AM BLOOD Plt Ct-297
[**2123-3-2**] 08:13AM BLOOD Glucose-113* UreaN-11 Creat-0.8 Na-143
K-3.9 Cl-107 HCO3-24 AnGap-16
[**2123-3-14**] 06:00AM BLOOD Glucose-93 UreaN-15 Creat-0.7 Na-140
K-3.7 Cl-105 HCO3-26 AnGap-13
[**2123-3-3**] 04:10AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1
[**2123-3-12**] 06:50AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.0
[**2123-3-2**] 09:52AM BLOOD Type-ART pO2-95 pCO2-65* pH-7.17*
calHCO3-25 Base XS--5
[**2123-3-5**] 01:11PM BLOOD Type-[**Last Name (un) **] Temp-37.1 Rates-14/0 Tidal V-600
PEEP-5 FiO2-40 pO2-99 pCO2-42 pH-7.40 calHCO3-27 Base XS-0
Intubat-INTUBATED Vent-SPONTANEOU
[**2123-3-2**] 08:58AM BLOOD Lactate-1.9
[**2123-3-3**] 11:26AM BLOOD Glucose-136*
[**2123-3-4**] 10:27AM BLOOD O2 Sat-97
[**2123-3-4**] 01:18PM BLOOD O2 Sat-93
Brief Hospital Course:
54 yo woman with asthma who was admitted with respiratory
failure. The pt was diagnosed with influenza A and B,
parainfluenza 1,2,3 and adenovirus. She was intubated for
respiratory failure which was likely caused a severe COPD/asthma
exacerbation, compounded with severe viral infections. She
completed a course of Tamiflu. No evidence of an infectious
process was noted on CXR. She failed extubation twice, and did
well after being extubated. She was titrated down to room air
and maintained oxygen saturation in the 90s. She was started on
steroids and discharged on a tapering dose of steroids.
.
#. Respiratory Failure:
In the [**Name (NI) 153**], pt was extubated several hours after arrival.
Following extubation, pt became tachypneic with severe wheezes.
She received racemic epi and solumedrol but after no
improvement, she was reintubated. At this time, her
nasopharyngeal washes came back positive for influenza,
parainfluenza and adenovirus and she was started on Tamiflu.
Levaquin was discontinued, given low likelihood of pneumonia.
The following day, pt self extubated and was then reintubated
several hours later after she became tachypneic with diffuse
wheezes. Over the next few days, pt was transitioned from assist
control to pressure support. It was thought that she was failing
extubations secondary to laryngeal edema and she had a bedside
bronchoscopy. The bronchoscopy showed "near complete occlusion
of lingula, RLL, LLL with forced expiration due to mild
malacia." After no cuff leak was found, she was successfully
extubated on hospital day #9. Her solumedrol was slowly weaned.
She was called out to the floor on hopital day #10. Her
steroids were tapered to prednisone and the frequency of her
nebs was decreased. She was transitioned to inhalers and her
steroids were tapered. Her PFTs were obtained from her PCP and
showed an FEV1 of 70% and an FVC of 106% both of which did not
change with bronchodilators. She was discharged with combivent
inhaler, advair and a rescue albuterol inhaler. She was
recommended to see a Pulmonologist through her PCP. [**Name10 (NameIs) **] her
blood cultures came back negative.
.
# Hyperglycemia: Likely [**1-14**] steroids. She was covered with an
insulin sliding scale.
.
# UTI: The pt's urine culture showed evidence of probable
Gardnerella Vaginalis (10,000-100,000 organisms/ml).
.
COde status: Full code.
Medications on Admission:
1. Albuterol
2. Advair
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs inhaler* Refills:*0*
2. Prednisone 20 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): Take:
40mg on [**4-15**], 20mg on [**4-17**]. Stop on [**3-20**].
Disp:*8 Tablet(s)* Refills:*0*
3. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation [**Hospital1 **]-TID.
Disp:*2 inhalers* Refills:*0*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Respiratory failure s/p intubation
2. Influenza
3. Parainfluenza, adenoviruses
4. Asthma/COPD exacerbation
Secondary Diagnosis:
1. Dermatographism
Discharge Condition:
good, satting in upper 90s on room air. Ambulating and taking
POs.
Discharge Instructions:
Please take all medications as prescribed.
Please go to all follow-up appointments.
Call your physician or go to the ER if you experience chest
pain, shortness of breath that does not improve with your
inhalers, problems breathing, fever >101.4, chills or any other
concern.
Followup Instructions:
We have called Dr.[**Name (NI) 34712**] office to schedule a follow-up
appointment. They will call you on Monday to let you know whe
your appointment is.
You may want to see a pulmonologist for better control of your
asthma. If you would like this, Dr. [**Last Name (STitle) **] can set this up.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2123-3-15**]
ICD9 Codes: 5990, 3051, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3386
} | Medical Text: Admission Date: [**2131-8-21**] Discharge Date: [**2131-8-31**]
Date of Birth: [**2055-3-30**] Sex: F
Service: CCU
Dictating for: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
female with a history of non-small cell lung cancer of the
left lower lobe diagnosed in [**2131-1-26**] status post
chemotherapy and radiation therapy for locally advanced
disease, and status post radiation treatment for brain
metastases, who is admitted for pneumonia and failure to
thrive with decreased oral intake and weakness which has
worsened over the prior two to three weeks. Also, she had a
rash and urinary frequency. She was admitted and treated for
a urinary tract infection, pneumonia, and volume depletion.
On admission, she was found to have worsening hypertension
with shortness of breath that was not improved with a saline
bolus and with Lasix. An echocardiogram report showed a
pericardial effusion with tamponade and pulsus paradoxus
of 16. The patient had a pericardiocentesis with a drain
placement that removed 500 cc of fluid and an additional
200 cc to 300 cc of fluid at the bedside. The tamponade
resolved, and the patient was in stable condition.
PAST MEDICAL HISTORY: Past medical history as described
above.
ALLERGIES: Allergy to SALICYLATES to which she gets hives.
FAMILY HISTORY: Family history was noncontributory.
SOCIAL HISTORY: The patient smoked one and a half packs per
day of tobacco for 55 years and occasional alcohol use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed vital signs with a temperature of 94.7
degrees Fahrenheit, heart rate was 95 to 100, blood pressure
was 91 to 110/35 to 58, respiratory was 18, oxygen saturation
was 95% on 4 liters, and a pulse of 6 mmHg. In general, she
was awake and alert in no apparent distress. Her head, eyes,
ears, nose, and throat examination was significant for pupils
were equal, round, and reactive to light. She had dry oral
mucosa. She had jugular venous pressure at 1 cm above the
clavicle at 30 degrees. Cardiovascular examination was
significant for a regular rate and rhythm and without
murmurs, gallops or rubs. Lung examination was significant
for rales one-third of the way up bilaterally. Abdominal
examination revealed positive bowel sounds, nontender, and
nondistended. No hepatosplenomegaly. Extremities were
significant for an erythematous macular rash on the upper and
lower extremities bilaterally as well as the chest.
Pretibial edema of 1+. Neurologic examination was nonfocal.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory
examination was significant for a white blood cell count
of 13, hematocrit was 27.9, hemoglobin was 9.5, platelets
were 187. Differential showed 89 neutrophils with 3 bands
and 4 lymphocytes. Chemistry-7 showed sodium was 131,
potassium was 5.6, chloride was 101, bicarbonate was 12,
blood urea nitrogen was 48, creatinine was 2.2, and blood
glucose was 153, with an anion gap of 18. Calcium was 7.9,
phosphate was 7.2, magnesium was 1.7. PTT was 37.6 and INR
was 3. Pericardial fluid showed 2+ polymorphonuclear
leukocytes, white count of 550.
RADIOLOGY/IMAGING: A chest x-ray showed a left lower lobe
pneumonia with atelectasis and consolidation.
Electrocardiogram showed low voltage with sinus rhythm at
106, diffuse minimal ST elevations, and question of
electrical alternans.
Echocardiogram showed a left ventricular ejection fraction of
greater than 55%, with moderate-to-large pericardial
effusion, and right ventricular diastolic collapse;
consistent with impaired filling and tamponade.
The echocardiogram after pericardial drainage showed the
effusion was resolved. No residual fluid or residual
tamponade, and a thickened pericardial rim.
HOSPITAL COURSE: The patient's pericardial effusion was
initially resolved with a drain placement and reaccumulated.
It was decided to place another larger pericardial catheter
instead of a pericardial window for drainage of the
pericardial space. In addition, a drain was placed in the
pleural space to drain bilateral pleural effusions. Cytology
of the pericardial fluid showed malignant cells consistent
with non-small cell carcinoma. Drainage of the pericardial
space slowly declined, and the pericardial drain was
eventually removed without problems.
Atrial fibrillation occurred intermittently. Digoxin
0.125 mg was given for this as the patient's high liver
function tests prevented amiodarone, and the patient's
hypotension prevented the use of calcium channel blocker and
beta blockers.
The patient had pulmonary edema and bilateral pleural
effusions for which a pleural drain was placed. The patient
had episodes of oxygen desaturations to the middle 80s on
room air and was maintained on 15 liters face mask at 96% and
eventually was able to be weaned down to was 2 liters nasal
cannula with oxygen saturations in the low 90s.
At the time of this Discharge Summary, the pleural drain
continued to be in place, but the plan was to remove upon
discharge.
The acute renal failure on admission was complicated by
hyperkalemia, and hyperphosphatemia, and an increased anion
gap. All resolved with volume repletion, use of Kayexalate,
and phosphate binders.
The patient's pneumonia on admission was treated with
levofloxacin 250 mg q.d. which was increased to 500 mg q.d.
once the acute renal failure was resolved.
The hospital course was also complicated by increased liver
function tests with an AST of 5700 that eventually resolved
on its own. An ultrasound of the liver to evaluate for
metastases was negative.
The patient was found to have low platelets and a positive
screen for heparin antibody. After discontinuation of
heparin flushes, the thrombocytopenia resolved. Vitamin K,
fresh frozen plasma, and platelets were given with success to
improve coagulation.
Neurologically, the patient worsened after the placement of
the second pericardial drain and remained intermittently
lucid and disoriented.
Nutritionally, the patient was admitted with a decreased oral
intake; and this, give and take, worsened throughout the
[**Hospital 228**] hospital stay. After a discussion with the patient
and the family regarding placement of a nasogastric tube
and/or a gastrojejunostomy tube for nutritional
supplementation, it was decided that based on the patient's
poor prognosis that these options were not appropriate.
Finally, the [**Hospital 228**] hospital stay was complicated by
hypercalcemia which was treated with moderate success with
intravenous normal saline and intravenous Lasix.
MEDICATIONS ON DISCHARGE:
1. Fentanyl patch 25 mcg per hour q.72h.
2. Scopolamine patch 1.5 mg every three days as needed for
nausea.
3. Lorazepam 0.5 mg to 2 mg p.o. q.4h. as needed for anxiety
and restlessness; given sublingually and dispensed with 2 cc
of 5 mg/cc elixir.
4. Levsin 0.125 mg to 2.5 mg q.4-6h. as needed for
respiratory congestion; dispense sublingually 2 cc of
0.25mg/cc elixir.
5. Morphine concentrate 5 mg to 20 mg q.1-2h. as needed for
pain or dyspnea; dispense 2 cc of 50 mg/cc elixir.
6. Lasix 40 mg intravenously q.d.
DISCHARGE DIAGNOSES: End-stage metastatic non-small cell
lung cancer.
CONDITION AT DISCHARGE: Condition on discharge was fair.
DISCHARGE DISPOSITION: The patient was to be discharged to
the [**Hospital3 38643**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern4) 38644**]
MEDQUIST36
D: [**2131-8-30**] 15:27
T: [**2131-8-30**] 15:42
JOB#: [**Job Number 38645**]
ICD9 Codes: 5849, 486, 5990, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3387
} | Medical Text: Admission Date: [**2169-5-26**] Discharge Date: [**2169-6-5**]
Date of Birth: [**2169-5-26**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname **] is the 2970
gram product of a 38 week gestation born to a 25-year-old G3,
P0, now 1 mother.
Prenatal labs: AB positive, antibody screen negative,
hepatitis B surface antigen negative, RPR nonreactive,
rubella immune, GC/chlamydia negative, GBS unknown. Rupture
of membranes occurred at delivery with clear amniotic fluid.
[**Hospital 37544**] medical history significant for childhood leukemia
treated with chemotherapy and radiation in 87 through 90.
Hepatitis C positive, asthma, duodenitis, anxiety.
The infant was delivered by primary cesarean section for
breech presentation. Apgars were 9 and 9.
PHYSICAL EXAMINATION: A well appearing infant in mild
respiratory distress. Anterior fontanel open and flat. No
oral lesions. Palate intact. CARDIOVASCULAR: No murmurs
appreciated. RESPIRATORY: Tachypneic, 86% saturations on room
air. Breath sounds clear and equal. Intermittent flaring,
positive grunting and retractions. ABDOMEN: Soft, nontender,
nondistended. Bowel sounds active. No masses appreciated.
Pink, warm and well perfused. Moving all extremities. No hip
clicks or clunks.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname 67205**]
was admitted to the newborn intensive care unit and placed on
nasal cannula O2 with persistent O2 requirements. Chest x-ray
was obtained. Question of pneumonia versus aspiration versus
mild HMD versus retained fetal lung fluid. The infant
remained on nasal cannula O2 until [**2169-5-31**] at which time
she transitioned to room air and she remained stable in room
air since that date. The infant was noted to have apnea
bradycardia of prematurity. Last documented episode was on
[**2169-6-1**].
CARDIOVASCULAR: The infant has audible intermittent murmur
consistent with PPS in quality. An ECG was obtained which was
read as within normal limits. Chest x-ray also was within
normal limits.
FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was 2970
grams. Discharge weight is 2925g.
The infant was initially started on 60 cc per kg of D10W.
Enteral feedings were initiated on day of life 2. The infant
is currently ad lib feeding taking Enfamil 20 calories with
good volumes.
GASTROINTESTINAL: Peak bilirubin was on day of life 5 of
8.7/0.3. The infant has not required any intervention .
HEMATOLOGY: Hematocrit on admission was 50. Most recent
hematocrit on day of life 4 was 41.7. The infant has not
required any transfusions.
INFECTIOUS DISEASE: CBC and blood cultures obtained on
admission. CBC was benign. Blood cultures remained negative.
Ampicillin, gentamycin were discontinued after 3 days of
treatment as it was felt that the infant did not have
pneumonia.
NEUROLOGIC: The infant has been appropriate for gestational
age.
AUDIOLOGY: Hearing screen was performed with automated
auditory brain stem responses and the infant passed bilaterally.
OPHTHALMOLOGY:none
PSYCHOSOCIAL:Parents updated frequently and very involved in her
care.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 41215**] [**Last Name (NamePattern1) **]. Telephone
No. [**Telephone/Fax (1) 41217**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: Continue ad lib feeding Enfamil 20
calorie.
2. Medications: Not applicable.
3. Car seat position screening was not applicable.
4. State newborn screens have been sent per protocol and
have been within normal limits.
5. Immunizations received: The infant received Hepatitis B
vaccine on [**2169-6-1**].
DISCHARGE DIAGNOSES:
1. Respiratory distress, likely due to mild hyaline membrane
disease.
2. Rule out sepsis with antibiotics.
3. Apnea bradycardia of prematurity.
4. Audible PPS murmur.
[**First Name11 (Name Pattern1) 3692**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 27992**], MD [**MD Number(2) 65951**]
Dictated By:[**Last Name (NamePattern1) 58682**]
MEDQUIST36
D: [**2169-6-4**] 21:48:12
T: [**2169-6-5**] 00:04:49
Job#: [**Job Number 67206**]
ICD9 Codes: 769, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3388
} | Medical Text: Admission Date: [**2190-3-3**] Discharge Date: [**2190-3-9**]
Date of Birth: [**2108-5-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / E-Mycin / Flagyl / Pepcid
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
81F with critical AS awaiting AVR recently s/p pre-op
catheterization c/b R MCA CVA who was later discharged to rehab
[**2190-2-26**] on aspirin, now re-admitted after two episodes of
maroon-colored stools.
Pt passed two marroon stools at rehab, loose but non-malodorous
or tarry. When pressed she described intermittent episodes
similar stools over the past several weeks, last 2 weeks ago. At
rehab ahe did not have any abdominal pain, but did have some
cramping and nausea without emesis. No dizziness,
lightheadedness, CP or shortness of breath. Brought into the ED
where her initial vitals were 97.2 80 100/50 16 97% RA. Her
hematocrit was noted to be 23.4 which is down from discharge [**2-26**]
of 30.8. Of note when she presented for Cath [**2-23**] her HCT was
22.9 for which she was transfused one unit PRBCs. Two large bore
IVs were placed, she was typed and crossed for two units and
admitted to the MICU. Vitals on transfer were HR 79 BP 98/46 RR
23 O2 100%RA.
.
On arrival to the MICU, patient's VS were 74 97/52 20 100%/RA.
She feels well and the previous nausea has resolved. Of note she
has recently ([**1-3**]) had an EGD at [**Hospital **] hospital for
dysphagia. Per pts report she was treated by botox injections
for esophageal spasm. A colonoscopy was attempted but was
unsuccessful because of a hernia that resulted from her prior
cystectomy. She also reports a history of "Mediteranean Anemia."
Her father is from Sicily.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
Critical aortic stenosis [**Location (un) 109**] 0.5cm2, [**2190-2-23**]
R MCA CVA, no residula deficits
"Mediterranean Anemia"
Hypertension
Hysterectomy [**2135**]
Dyslipidemia
GERD
Bladder CA s/p cystectomy [**2165**]
Dysphagia
Neuropathy
Anemia
CCY [**2137**]
Hernia [**2175**]
Back surgery [**2183**]
Cataract removal
Social History:
Lives at home, son lives at home with her. Retired from sewing
business. Tobacco: never. ETOH: denies. Drug
use: denies.
Family History:
Mom passed away age 59 from heart problems. [**Name (NI) **] passed away age
74 from PNA. Sister passed away age 79 had a history of valve
surgery but died from leukemia. Brother passed away age 50 from
cancer. Brother alive age 84 had a valve replacement one year
ago.
Physical Exam:
ADMISSION EXAM
Vitals: 74 97/52 20 100% on RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, [**1-26**] harsh systolic
murmur loundest at RUSB with radiation to carotids, no rubs,
gallops
Lungs: Prominnet kyphosis, clear to auscultation bilaterally, no
wheezes, rales, ronchi
Abdomen: Left sided nephrostomy tube collecting clear urine and
appering clean and not infected. Large left sided distension
which is not painful. Otherwise soft, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
Rectal: large external hemmorhoids present, no obvious bleeding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
.
DISCHARGE EXAM
VS Tc 97.9 110/64 84 16 94/RA
GEN: elderly woman walking with PT in NAD, awake, AOX3
HEENT: NCAT, MMM, dentures, JVP flat, no LAD
LUNGS: kyphoscoliotic posture, lungs CTAB, no wheezes, rales,
rhonchi
CV: RRR, [**1-26**] harsh systolic murmur swallows S2, loudest RUSB
w/radiation to carotids
ABD: obese soft nontender, ventral hernia, L-sided neobladder
stoma pink and nontender, collecting clear yellow urine in
attached urine bag
EXT: WWP, +pulses, trace bilateral edema
NEURO: AOX3, CNII-XII intact, 5/5 strength upper/lower
extremities, 2+ reflexes bilaterally, gait stable w/assistance
Pertinent Results:
ADMISSION LABS
[**2190-3-3**] 03:25PM WBC-7.6 RBC-3.18* HGB-6.7*# HCT-23.4* MCV-73*
MCH-20.9* MCHC-28.5* RDW-17.1*
[**2190-3-3**] 03:25PM NEUTS-88.6* LYMPHS-7.8* MONOS-2.9 EOS-0.3
BASOS-0.4
[**2190-3-3**] 03:25PM PLT COUNT-357
[**2190-3-3**] 03:25PM PT-13.4* PTT-27.8 INR(PT)-1.2*
[**2190-3-3**] 03:25PM GLUCOSE-161* UREA N-45* CREAT-1.1 SODIUM-141
POTASSIUM-5.1 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14
[**2190-3-3**] 03:25PM ALT(SGPT)-7 AST(SGOT)-17 LD(LDH)-225 ALK
PHOS-45 TOT BILI-0.3
[**2190-3-3**] 03:25PM LIPASE-20
[**2190-3-3**] 03:25PM cTropnT-<0.01
[**2190-3-3**] 03:25PM ALBUMIN-3.0*
[**2190-3-3**] 03:38PM LACTATE-1.2
.
URINALYSIS
[**2190-3-3**] 05:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
[**2190-3-3**] 05:50PM URINE RBC-17* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
[**2190-3-3**] 05:50PM URINE WBCCLUMP-FEW MUCOUS-RARE
.
HCT TREND
[**2190-3-3**] 03:25PM BLOOD Hct-23.4*
[**2190-3-3**] 04:45PM BLOOD Hct-24.7* (+1U PRBC)
[**2190-3-4**] 12:10AM BLOOD Hct-27.4*
[**2190-3-4**] 02:25AM BLOOD Hct-25.5* (+1U PRBC)
[**2190-3-4**] 11:02AM BLOOD Hct-28.9*
[**2190-3-4**] 03:20PM BLOOD Hct-29.0*
[**2190-3-4**] 08:05PM BLOOD Hct-29.9*
[**2190-3-5**] 06:38AM BLOOD Hct-28.4*
[**2190-3-5**] 03:45PM BLOOD Hct-32.2*
[**2190-3-6**] 06:50AM BLOOD Hct-32.7*
[**2190-3-7**] 07:40AM BLOOD Hct-29.7*
[**2190-3-8**] 06:11AM BLOOD Hct-27.5*
[**2190-3-9**] 06:43AM BLOOD Hct-30.7*
.
DISCHARGE LABS
[**2190-3-9**] 06:43AM BLOOD WBC-10.3 RBC-3.87* Hgb-8.9* Hct-30.7*
MCV-79* MCH-23.1* MCHC-29.1* RDW-18.5* Plt Ct-330
[**2190-3-9**] 06:43AM BLOOD Glucose-95 UreaN-23* Creat-0.9 Na-142
K-4.6 Cl-111* HCO3-23 AnGap-13
[**2190-3-9**] 06:43AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.4
.
MICROBIOLOGY
URINE CULTURE (Final [**2190-3-4**]): NEGATIVE
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
H PYLORI SEROLOGY [**2190-3-6**] EQUIVOCAL
.
IMAGING - NONE
.
EKG [**2190-3-5**]
Sinus rhythm, HR 75. Left axis deviation. Borderline left atrial
abnormality. Non-diagnostic Q waves in the high lateral leads.
Early R wave transition. Non-specific ST segment changes in the
inferolateral leads. Compared to the previous tracing of [**2190-2-25**]
strict criteria for left ventricular hypertrophy are no longer
met and the ventricular rate is slower.
Brief Hospital Course:
81F with critical aortic stenosis with recent cardiac
catheterization complicated by right MCA stroke, on aspirin
admitted with gastrointestinal bleeding and hematocrit in the
low 20s. Hospital course was notable for stabilization of
hematocrit without significant intervention. Endoscopic
evaluation for source of bleeding has been deferred until
patient is 1 month out from her stroke given high risk within
this period and the stability of hematocrit for 4 days on
aspirin prior to discharge. Patient will have close GI follow up
after discharge for consideration of capsule endoscopy.
.
#Gastrointestinal bleeding, likely due to right sided colonic
lesion or small bowel lesion/Acute blood loss anemia:
Pt presented with two episodes of maroon-colored loose stools
preceded by crampy epigastric abdominal pain along with a drop
in hematocrit from 30 to 23 over the past few weeks suggesting
gastrointestinal bleeding of acute to sub-acute time course.
Patient was hemodynamically stable throughout hospitalization
but did require 2 units of packed red blood cells and monitoring
in the ICU initially. Patient was evaluated by GI and after
discussion with both GI and Cardiology it was felt that the
patient would be at high risk for endoscopic procedures such as
EGD and colonoscopy given the sedation needed both because of
her critical aortic stenosis, but also because of her recent
stroke within the past one month. She was monitored and had a
stable hematocrit for 4 days prior to discharge without any need
for transfusion and without any stools suggestive of recurrent
GI bleeding. Given the high risk of procedures within 1 month of
recent stroke, the plan on discharge is to have the patient
follow up in the next 4 days with GI in outpatient clinic for
consideration of capsule endoscopy to evaluate both the small
bowel and hopefully the right side of the colon as this would
not carry the risks of EGD or colonoscopy. If this is not
revealing or if bleeding recurs, further consideration will be
given to more expedited EGD and colonoscopy. At rehab, the
patient should have hematocrit checked 2x/week to determine if
bleeding has recurred. Given the high likelihood of AVM related
to critical AS, it is possible that the bleeding may recur
intermittently until her valve is fixed. Hct was 27-30 on
discharge. She was discharged on iron, but given her need for
PPI, she may require IV iron transfusions to replace her iron
losses over time.
.
#Urinary tract infection:
Pt has a chronic urinary bag into which her neobladder
w/anterior abdominal stoma drains, leaving her at increased risk
for UTIs. Admission UA grossly positive. Ciprofloxacin started
empirically for a 10-day total course (3d additional at
discharge) and continued despite contaminated urine cultures
because benefits of treating possible UTI in this pt w/low
physiologic reserve thought to outweigh risks.
.
#Acute renal failure:
On admission, creatinine elevated to 1.1 from baseline of 0.8
which was felt to be from prerenal azotemia. Creatinine improved
to baseline following blood transfusion and improved PO intake.
.
#Critical aortic stenosis:
Valve area 0.5 on last catheterization earlier this morning with
gradient >40mmHg. She had evidence of pulmonary edema and was
never hypotensive or had symptoms of exertional presyncope or
arrythmia on telemetry. Her Lasix was initially held on
admission and then restarted on discharge. She is undergoing
workup for AV repair/replacement, with outpatient cardiac
surgery evaluation scheduled at prior discharge. Cardiology and
cardiac surgery consult services were aware of admission.
.
# RECENT R MCA STROKE:
Suffered during last admission, prompted [**Hospital 3058**] rehab stay.
Family and pt very satisfied with her rehabilitation, report no
residual deficits. Neuro exam nonfocal - no speech, cognitive,
or gait disturbances but did require support to walk. Eager to
continue rehab PT. Continued home aspirin.
.
# THRUSH
Noted on exam, not bothersome. Prescribed 10 days nystatin swish
& swallow for total 14d course.
.
TRANSITIONAL ISSUES
*GI followup appt in 1 week to assess any evidence of ongoing GI
bleeding, discuss any necessary endoscopy. Needs follow-up Hct
on Thursday [**3-11**] and Sunday [**3-13**] (rehab MD to review).
*Ongoing outpatient cardiac surgery evaluation as previously
planned.
Medications on Admission:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
7. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One
(1) Tablet PO twice a day.
8. multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO once a
day.
10. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15)
ml PO once a day as needed for constipation.
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO once a
day.
10. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15)
ml PO once a day: hold for loose stools.
11. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*7 Tablet(s)* Refills:*0*
12. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 10 days.
Disp:*100 ML(s)* Refills:*0*
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*QS Capsule(s)* Refills:*0*
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*QS Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Draw blood Thursday [**3-11**] and Sunday [**3-11**].
Check Hct.
Rehab MD to review results.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY DIAGNOSES
Upper gastrointestinal bleed
Critical aortic stenosis
Recent cerebrovascular attack
.
SECONDARY DIAGNOSES
Hypertension
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname 111600**],
You were admitted to the hospital for 2 episodes of
marroon-colored stool, which suggests gastrointestinal bleeding.
You were seen by gastroenterologist who recommended increasing
your omeprazole and a follow-up gastroenterology appointment. At
that visit they will discuss possible options for further
work-up of your bleeding. Your blood counts have been stable for
the past 4 days.
We also treated you for a urinary tract infection and thrush.
We made the following changes to your medications:
CHANGED OMEPRAZOLE TO PANTOPRAZOLE 40 MG TWICE DAILY
STARTED Ciprofloxacin, TAKE ONE 250 mg TAB EVERY 12 HOURS FOR 3
ADDITIONAL DAYS
STARTED NYSTATIN SWISH AND SPIT, USE EVERY 4 HOURS FOR 10 DAYS
STARTED ADDITIONAL LAXATIVES (COLACE AND SENNA) TO KEEP YOUR
BOWELS LOOSE (STRAINING WITH DEFECATION IS DANGEROUS WITH YOUR
AORTIC STENOSIS)
We did not make any other changes to your medications.
Followup Instructions:
You need to have follow-up blood counts checked on Thursday
results.
FOLLOW-UP APPOINTMENTS:
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2190-3-16**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: NEUROLOGY
When: TUESDAY [**2190-3-23**] at 4:00 PM
With: DRS. [**Name5 (PTitle) **] & HAUSSEN [**Telephone/Fax (1) 1694**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SURGERY
When: WEDNESDAY [**2190-4-7**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
When you leave rehab, please call your primary care doctor for a
follow-up appointment within 1 week.
ICD9 Codes: 5990, 2851, 5849, 4241, 2768, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3389
} | Medical Text: Admission Date: [**2163-9-5**] Discharge Date: [**2163-9-7**]
Date of Birth: [**2144-9-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
Overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 18 year old male with past medical history
significant for depression who presents today after an
intentional overdose in the setting of recently breaking up with
his girlfriend of 1.5 years and worsening depression. He
initially presented to the [**Hospital6 **] on [**2163-8-25**]
feeling unsafe. He was able to contract for safety and was
discharged with close followup. He then presented to BU Mental
Health feeling unsafe and was section 12 and transferred to
[**Hospital1 18**] but he was felt to be safe for discharge and released to
the care of his family. He subsequently ingested unknown
quantities of ativan, motrin, nyquil, and excedrin pm
approximately 2 pm on Monday [**9-5**]. He went [**Location (un) 84770**] and wanted to jump in front of a car but couldn't bring
himself to do it. He ultimately sought medical attention about
7 yours later on Monday evening, after friends found him
lethargic and vomiting.
In the ED,vs were: T98.3 P 98 BP 126/76 R16 O2 sat 100% on RA.
Patient was slightly lethargic appearing but was conversant. He
reported taking 3 mg lorazepam, [**12-2**] ibuprofen, 1 shot [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5261**], and an unclear amount of Nyquil and excederine PM.
Initially laboratories were notable for normal chemistries and
transaminases but a serum tylenol level of 167 at approximately
7 hours after ingestion. His toxicology screen was otherwise
negative. Given that this is within the window for potential
hepatic toxicity he was started on a n-acetylcysteine drip and
transferred to the ICU.
In the ICU he was monitored on telemetry with no events. His
transaminases were monitored and showed no elevation. His INR
rose slightly to 1.5 and then trended down to 1.2. He was seen
by psychiatry who recommended 1:1 sitter and transfer to
psychiatry once medically stable for further management.
On transfer to the floor he has no complaints. Specifically he
denies fevers, chills, confusion, lightheadedness, dizziness,
chest pain, difficulty breathing, nausea, vomiting, abdominal
pain, diarrhea, constipation, dysuria, hematuria, leg pain or
swelling. All other review of systems is negative in detail.
Past Medical History:
Depression
Social History:
Born in [**State 760**]. Currently, he is a sophomore at BU in
Biomed engineering. Occasional EtOH, no tobacco or illicits.
Has used marijuana on two occassions in the past.
Family History:
Alcohol abuse in his father
Physical Exam:
Initial Physical Exam:
Vitals: T: 98.3 P: 98 BP: 126/76 R: 16 O2sat: 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Cardiac: Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Extremities: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Discharge Exam:
Unchanged
Pertinent Results:
Hematology:
[**2163-9-7**] 06:15AM BLOOD WBC-5.8 RBC-4.72 Hgb-13.9* Hct-40.5
MCV-86 MCH-29.4 MCHC-34.3 RDW-12.8 Plt Ct-224
[**2163-9-6**] 05:30AM BLOOD WBC-7.6 RBC-4.57* Hgb-13.2* Hct-39.0*
MCV-85 MCH-28.9 MCHC-33.9 RDW-12.8 Plt Ct-212
[**2163-9-5**] 09:15PM BLOOD WBC-5.7 RBC-5.41 Hgb-15.3 Hct-45.1 MCV-83
MCH-28.2 MCHC-33.9 RDW-13.3 Plt Ct-306
Coagulation Profiles:
[**2163-9-5**] 10:30PM BLOOD PT-13.9* PTT-21.4* INR(PT)-1.2*
[**2163-9-6**] 05:30AM BLOOD PT-16.8* PTT-26.8 INR(PT)-1.5*
[**2163-9-7**] 06:15AM BLOOD PT-14.1* PTT-28.6 INR(PT)-1.2*
Chemistries:
[**2163-9-5**] 09:15PM BLOOD Glucose-116* UreaN-15 Creat-1.3* Na-143
K-3.7 Cl-99 HCO3-28 AnGap-20
[**2163-9-6**] 01:05PM BLOOD Glucose-91 UreaN-9 Creat-0.9 Na-140 K-3.7
Cl-106 HCO3-24 AnGap-14
[**2163-9-7**] 06:15AM BLOOD Glucose-80 UreaN-11 Creat-0.8 Na-141
K-4.3 Cl-104 HCO3-28 AnGap-13
[**2163-9-7**] 06:15AM BLOOD Calcium-9.9 Phos-3.2 Mg-1.8
Transaminases:
[**2163-9-5**] 09:15PM BLOOD ALT-14 AST-21 LD(LDH)-190 AlkPhos-63
TotBili-0.2
[**2163-9-6**] 05:30AM BLOOD ALT-10 AST-13 LD(LDH)-134 AlkPhos-46
TotBili-0.4
[**2163-9-6**] 01:05PM BLOOD ALT-12 AST-18 LD(LDH)-170 AlkPhos-53
TotBili-0.6
[**2163-9-6**] 08:59PM BLOOD ALT-10 AST-15 AlkPhos-50 TotBili-0.3
[**2163-9-7**] 06:15AM BLOOD ALT-12 AST-18 AlkPhos-53 TotBili-0.4
Toxicology:
[**2163-9-5**] 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-167*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2163-9-6**] 08:59PM BLOOD Acetmnp-NEG
[**2163-9-6**] 05:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
This is an 18 year old male with past medical history
significant for depression who presented after an intentional
overdose in the setting of recently breaking up with
his girlfriend of 1.5 years and worsening depression.
Intentional Overdose/Tylenol Toxicity: Patient reported
ingesting significant quantities of ativan, motrin, nyquil,and
excedrin pm at approximately 2 pm on Monday [**9-5**]. Seven hours
later his tylenol level on presentation to the emergency room
was 167 which is within potential range for hepatotoxicity. He
was started on n-acetylcysteine for treatment of tylenol
toxicity and admitted to the MICU. He was monitored on
telemetry with no arrhythmias. His transaminases were monitored
and did not increase. His INR increased slightly from 1.2 to
1.5 but subsequently normalized. He showed no signs of liver
damage. He completed a 21 hour course of n-acetylcysteine. No
further medical therapy is needed for treatment of his overdose
and he is medically stable for transfer for psychiatry.
Suicide Attempt/Depression: Patient was transferred on section
12 after a serious suicide attempt. On arrival he had a
flattened affect. He was seen by social work and psychiatry who
recommended 1:1 sitter and ultimate transfer to inpatient
psychiatry facility for further management of his depression.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Depression
Overdose
Discharge Condition:
Stable. Ambulating without assistance. No evidence of hepatic
damage.
Discharge Instructions:
You were seen and evaluated for your overdose. You were found
to have an elevated tylenol level and were treated with
n-acetylcysteine for liver protection. You were monitored
initially in the ICU and then on the floor for evidence of liver
damage which you did not develop.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please do not take any tylenol products for one month
Please keep all your follow up appointments as scheduled.
Please seek immediate medical attention if you experience any
fevers, lightheadedness, chest pain, difficulty breathing,
abdominal pain, yellowing of your skin or any other concerning
symptoms.
Followup Instructions:
Please follow up with your primary care physician within one
week of discharge from psychiatry. If you do not have a primary
care physician, [**Name10 (NameIs) **] are welcome to establish primary care here
at [**Hospital3 **]. The office phone number is [**Telephone/Fax (1) 250**].
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3390
} | Medical Text: Admission Date: [**2190-12-30**] Discharge Date: [**2191-1-5**]
Date of Birth: [**2108-4-26**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
transferred with L frontal ICH
Major Surgical or Invasive Procedure:
None. Dubhoff tube placement.
History of Present Illness:
82yo RH F with no past medical history who presents after L
frontal ICH was discovered this morning at [**Hospital 1474**] Hospital.
She
was in her usual state of good health until yesterday morning,
when her husband says she awoke and was moving slowly. He noted
as well that she would only respond with yes/no to questions and
had no spontaneous speech of her own. She refused breakfast and
initially he thought she was simply mad at him. She sat at the
breakfast table and opened the paper and turned it to a puzzle
she usually does but she did not do it yesterday. He noted no
droop or decreased movement of either limb and to his
questioning
she denied all pain or headache. She then went to bed for most
of
the day. She did walk slowly and shuffling but did not fall.
In the evening, she took some water and walked upstairs
unassisted. At this point, the only change in her status was
that
her husband noticed that she seemed frustrated at her non-fluent
speech. She had no deterioration in her level of responsiveness
and they went to bed.
This morning proceeded much the same. But her son called and was
alarmed that apart from answering "hello" she could not tell him
what was the matter. He could not even tell if it were a medical
or criminal emergency and he called the police. He also felt
that
at this point her speech was slurred. At no point did they feel
she had focal weakness or other apparent abnormalities.
On EMS arrival, her bp was 166/80 but for the most part it has
remained in the 140's. On arrival to [**Hospital1 1474**], head CT revealed
L
frontal ICH and she was transferred here.
The patient denies trouble with her vision, weakness or sensory
loss and she denies headache.
Past Medical History:
none
Social History:
s/p hernia repair; several years ago, a nerve in her left
face was severed to treat facial pain (her husband points
lateral
to her left eye)
Family History:
negative for ICH
Physical Exam:
VS 99.1 79 140-160/60-70s 12 100%
Gen 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
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted
NEURO
MS Awake, alert. Unable to assess orientation even to yes/no
questions but appears to close her eyes when asked to do so if
it
is "[**2190**]". Attentive to my questions. Speech is non-fluent, to
my
exam restricted to nodding yes when appropriate. She claims to
understand what I am saying but does not follow commands. Cannot
name or repeat. Attentive to either side of space. Cannot assess
for dysarthria due to lack of verbal output. She is somewhat
abulic.
CN
CN I: not tested
CN II: Blinks to threat either side. Pupils 3->2.5 b/l. Fundi
clear
CN III, IV, VI: EOMI no nystagmus
CN V: intact to LT throughout
CN VII: slight R lower facial droop
CN VIII: hearing intact to FR b/l
CN IX, X: palate rises symmetrically
CN [**Doctor First Name 81**]: shrug [**6-5**] and symmetric
CN XII: does not stick her tongue out
Motor
Normal bulk and tone. Possible slight R pronator drift (fingers
curl). Unable to cooperate with formal power testing. At least
antigravity in her arms (understands command to hold them up) at
the deltoids. Does not hold either leg antigravity but effort is
uncertain. No difference is noted comparing her arms and legs
side-to-side. Subtle external rotation of right leg; withdraws
either purposefully.
Sensory intact to LT, PP throughout.
Reflexes
Br [**Hospital1 **] Tri Pat Ach Toes
L 2+ 2+ 2+ 2+ 1+ down
R 2+ 2+ 2+ 2+ 1+ down
Coordination unable to assess, will not perform tasks
Gait stands without assistance but when asked to step forward
her
feet appear to remain stuck on the ground
Pertinent Results:
CT head - [**2190-12-30**] - 4pm
IMPRESSION: Intracranial hemorrhage. Findings are suggestive of
amyloid angiopathy, however, underlying mass or AVM cannot be
excluded. MRI can be performed for further evaluation.
CT head - [**2190-12-30**] - 10pm
IMPRESSION: Unchanged left frontal intraparenchymal hematoma and
unchanged degree of mass effect. Findings are suggestive of
amyloid angiopathy, but an MRI can be performed to exclude
underlying mass lesion or AVM.
MR head - [**2190-12-31**]
PRELIMINARY READ:
8.3cm x 4.3cm L frontal hemmhorage. Causes focal frontal
transfalcine shift to R ~4mm and impression on the L frontal
[**Doctor Last Name 534**]. DDX: Amyloid angiopathy, AVM, bleeding tumor,
anticoagulants w/wo trauma, HTN possible but not typical
location [**Name Initial (MD) **] [**Name8 (MD) **] MD)
Brief Hospital Course:
82 year old woman with insignificant pmh presents with left
frontal hemorrhage.
NEURO:
A second CT scan 6 hours after the first revealed a stable
hemorrhage. A subsequent MRI also confirmed stable hemorrhage.
The MRI was not suggestive of amyloid. We made a plan for a
contrast study to assess for tumor when the bleeding resolved.
We repeated a head CT..
Neurosurgery was initially consulted but signed off when the
bleed proved stable and the midline shift was not clinically
significant.
The head of the bed was kept > 30degrees.
The blood pressure Goal was SBP > 100 and MAP < 130.
The patient was kept euthermic and euglycemic
We prophylactically treated for seizure with keppra 500mg IV BID
which was gradually titrated up to 1500mg [**Hospital1 **].
The patient was treated with mannitol to decreased swelling.
The patient's serum sodium and osmolality was checked serially.
She finished her mannitol taper on [**1-4**].
Both her LDL and A1c were checked and were excellent.
ID
The patient had a positive UA on admission and was treated with
three days of trimeth/sulfa.
FEN
Speech and swallow evaluationin the ICU on the second day of
admission suggested that the patient should be kept NPO. A
dobhoff tube was placed and the patient was started on tube
feeds. She had a repeat swallow eval which she failed, therefore
she had a PEG placed.
CV
She was ruled out for an MI with 3 negative sets of cardiac
enzymes. The patient was monitored on telemetry without
significant arryhtmias.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
ICH
Aphasia
Dysphagia
Discharge Condition:
Stable, persistent aphasia
Discharge Instructions:
1. Please take all medications as prescribed
2. Please re-evaluate the swallowing in [**3-6**] weeks
3. Please call your doctor or come to the closest ED if you
develop new symptoms
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2191-2-15**] 4:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3391
} | Medical Text: Admission Date: [**2167-7-15**] Discharge Date: [**2167-7-23**]
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
[**2167-7-17**]
1. Right craniotomy for evacuation of subdural hematoma and
lysis of membranes and adhesions.
2. Left bur hole through a separate incision for evacuation
of chronic left subdural hematoma
History of Present Illness:
Mr. [**Known lastname **] is an 89 year old man who had been living at home and
doing ADL's independently until he had a fall at home in [**Month (only) 116**]. A
seizure was witnessed by his girlfriend, [**Name (NI) 8214**]. EMS was called
and he was taken to [**Hospital 8641**] hospital. He
suffered a generalized convulsio for 35-45 minutes per DC
summary from [**Location (un) 8641**]. CT head and MRI brain were done. Both
revealed chronic subdural hygromas. He was seen by a
neurologist. It seems that a neurosurgeon was spoken to on the
phone and felt that there was no urgent surgery needed. His
admission was complicated by fever, confusion, gout attack, and
possible ETOH withdrawal.
He was discharged to rehab and his alertness and speech improved
somewhat. He was seen by a Dr. [**Last Name (STitle) 724**], neuropsychiatry, and
further testing was being planned. He then had issues with
rectal bleeding and had what seems like a sigmoidoscopy. This
resolved. He had a Foley placed for urinary retention.
He was seen in the ED for possible admission for further
neurological work up. He was seen by our service and we did not
feel that there was a need for urgent intervention and prior
imaging was not available for comparison. The hygromas enlarged
in size and he was admitted for surgical treatment.
Past Medical History:
gout, hypertension, and short-term memory loss observed
mostly over the past 1.5 years, vertebroplasty, hip repair
Social History:
Engineering at [**University/College 4700**]. He was in the air force
installing radar in [**Country 11150**]. As he was the primary caretaker for
his wife (who had TB), he supported himself through real estate
and investments. He has a [**Age over 90 **] year old girlfriend, [**Name (NI) 8214**]. [**Name2 (NI) **] has
a remote tobacco history. He had 1-2 drinks per day prior
to last hospitalization.
Family History:
NC
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic, normocephalic
Pupils:surgical pupils small and surgical EOMs: intact
Neuro:
Mental status: Awake and alert, HOH, cooperative with exam,
normal affect.
Orientation: Oriented to person, [**Location (un) 86**], [**Month (only) **]
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, surgical pupils.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: No pronator drift, MAE equally. Deconditioned with 4+
strength throughout.
On Discharge:Mr. [**Known lastname **] does not open his eyes. He weakly follow
commands with his right side. He withdraws his LLE. He does not
move his LUE.
Pertinent Results:
CT head [**7-9**]:
Bilateral large subdural hygromas without acute
hemorrhage. Mass effect is presumed given lack of sulcal and
ventricular prominence as would be expected at this age. No
midline shift.
CT head [**7-17**]: Interval evacuation of bilateral subdural hygromas
using a left-sided burr hole and the right craniotomy. New
hypoattenuation with intraparenchymal hemorrhage in the right
frontal lobe.
CT Head [**7-18**]: IMPRESSION: Status post bilateral subdural hygroma
evacuation with left-sided burr hole and right craniotomy with
interval worsening hypoattenuation in the right frontal lobe
with interval increase in central blood products. Interval
worsening of mass effect with 4-mm shift of midline structures
and mild subfalcine herniation.
[**2167-7-20**]
Interval progression of vasogenic edema surrounding right
frontal
intraparenchymal hemorrhage with reaccumulation of the subdural
hygromas and interval decrease in the degree of pneumocephalus.
These findings were communicated to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**], the nurse
practitioner for the neurosurgical service at 11:00 a.m. on
[**2167-7-20**].
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] from the clinic on [**7-16**]. He was
on the floor with Q4 hr neuro checks. He was on Keppra and
seizure precautions. He was on SQ Heparin for DVT prophylaxis.
PT was ordered. A pre-op work up was initiated. On [**7-17**], patient
was taken to the OR where a R mini craniotomy and L burr hole
was done to evacuate bilateral hygromas. Intraoperatively, a
membranous layer was seen and in attempts to remove layer, SAH
blood was seen and coagulated. A JP drain was placed in the
subdural space from the L burr hole which was draining
serosanguinous fluid. He was transferred to PACU for recovery.
Post op head CT revealed bilateral pneumocephalus and R frontal
venous infarct. Patient was more lethargic and found to have L
lateral gaze, he was given an extra dose of Keppra and monitored
closely. At time of post op check patient was less responsive,
but following simple commands. His L pupil was [**3-25**] and R
surgical. Later in the afternoon, patient was concerning for
seizure activity. He was given one dose of Ativan which seemed
to stop his tremors. He was loaded with dilantin and he was
transferred to ICU for further management.
On [**7-18**] he had a repeat CT scan which revealed worsening of the
right frontal infarct. He was no longer following commands but
continued to move all extremities. The HCP was updated and it
was decided that the patient should continue to be DNR/DNI. He
was eventually extubated and transferred to the step down unit.
CT head on [**7-21**] showed interval increase in edema. He followed
commands with the left side. He was left hemiplegic. He was
alert and could not tolerate a po diet. After discussions with
Palliative care and the HCP, the patient was made [**Name (NI) 3225**]. The NG
tube was removed. He was being screened for hospice. On the
morning of [**7-23**] he was discharged to home with hospice.
Medications on Admission:
Risperidone 0.25 mg PO HS Q8pm
Acetaminophen 650 mg PO/NG TID MAx 4g/24hr
Risperidone 0.25 mg PO DAILY Q2pm
Bisacodyl 10 mg PR DAILY:PRN no BM 3days
Colchicine 0.6 mg PO/NG DAILY
Sulfameth/Trimethoprim DS 2 TAB PO/NG [**Hospital1 **]
Docusate Sodium 100 mg PO BID
LeVETiracetam 500 mg PO/NG [**Hospital1 **]
Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) as needed for prn secretions for 1
doses.
2. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
3. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
2.5-5.0 mg PO Q2H (every 2 hours) as needed for pain or dyspnea.
4. lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for gen convulsion.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Bilateral subdural hygromas
Right Frontal Venous Infarct
Right Frontal Hemorrhage
Respiratory Failure
Seizure
Dysphagia
Discharge Condition:
.
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
CALL YOUR SURGEON IMMEDIATELY IF YOU HAVE ANY QUESTIONS OR
CONCERNS. STAPLES CAN BE REMOVED ON [**7-24**].
Followup Instructions:
NONE
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2167-7-23**]
ICD9 Codes: 5185, 431, 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3392
} | Medical Text: Admission Date: [**2150-8-16**] Discharge Date: [**2150-8-22**]
Date of Birth: [**2095-2-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p 20 foot fall from construction lift
Major Surgical or Invasive Procedure:
ORIF right femur fracture
History of Present Illness:
Mr. [**Known lastname 68525**] is a 55 year-old man who was transferred by [**Location (un) **]
after 20-foot fall off of a construction lift. GCS was 15 at the
scene but he was amnestic to the event. He reported back pain
on arrival to the trauma bay.
Past Medical History:
None
Social History:
Married. Self-employed
Family History:
Non-contributory
Physical Exam:
Exam on Admission:
Vitals: HR 105 BP 100/P repeat 121/78 RR 15 O2: 96% NC GCS 15
Gen: Awake, alert and oriented.
HEENT: Abrasion to left maxilla. Blood in nares.
Neck: C-collar in place
Chest: Equal bilateral breath sounds. No crepitus.
CVS: RRR.
Abd: Soft. NT/ND.
Rectal: Normal tone. No gross blood. Normal prostate.
GU: Normal scrotum. + hematuria
Musculoskeletal: Right leg splint. Thigh deformity.
Pertinent Results:
Portable Chest X-ray [**2150-8-26**]-IMPRESSION: Right seventh lateral
rib fracture, with subcutaneous emphysema better seen on CT. The
prominence of the mediastinum may be related to technique.
Please refer to the CT torso exam for details.
.
Non-Contrast Head CT [**2150-8-16**]-
1. No evidence of hemorrhage detected although study is limited
given motion artifact. 2. Lobulated mucosal thickening within
the left maxillary sinus and a small amount of fluid within it-
? inflammatory in origin. No definite fracture is detected.
.
CT Torso [**2150-8-16**]-
1. Moderate sized right traumatic pneumothorax with mild shift
of the
mediastinum suggesting a minor component of tension.
2. Multiple acute fractures including sternal, pelvic, sacral
and right
lateral rib as described above. There is no evidence of active
extravasation
from the pelvic arterial system.
3. No evidence of contrast or urine extravasation from the
bladder although
given mechanism and history of hematuria, bladder injury should
be
considered.
Right Femur 14 Views [**2150-8-16**]- 14 fluoroscopic intraoperative spot
radiographs are submitted for interpretation. An intermedullary
rod traverses a severely comminuted segmental fracture of the
proximal femoral shaft. The rod is transfixed by two proximal
screws through the femoral neck and two distal interlocking
screws through the distal metadiaphysis of the femur. The
fracture fragments are in near anatomic alignment. Please refer
to the operative note for full details.
[**2150-8-16**] 11:26PM GLUCOSE-257* UREA N-16 CREAT-1.6* SODIUM-145
POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-16* ANION GAP-24*
[**2150-8-16**] 11:26PM CALCIUM-7.4* PHOSPHATE-6.0* MAGNESIUM-1.9
[**2150-8-16**] 11:26PM WBC-11.8*# RBC-3.49*# HGB-10.9*# HCT-32.3*#
MCV-93 MCH-31.1 MCHC-33.6 RDW-14.3
[**2150-8-16**] 11:26PM PLT COUNT-181#
[**2150-8-16**] 11:13AM HGB-12.2* calcHCT-37
[**2150-8-16**] 10:40AM LACTATE-4.5*
[**2150-8-16**] 10:30AM UREA N-16 CREAT-1.7* SODIUM-140 POTASSIUM-4.2
CHLORIDE-105 TOTAL CO2-18* ANION GAP-21*
[**2150-8-16**] 10:30AM estGFR-Using this
[**2150-8-16**] 10:30AM AMYLASE-47
[**2150-8-16**] 10:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-8-16**] 10:30AM URINE HOURS-RANDOM
[**2150-8-16**] 10:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-8-16**] 10:30AM WBC-6.0 RBC-1.68* HGB-5.2* HCT-15.5* MCV-93
MCH-31.0 MCHC-33.5 RDW-13.9
[**2150-8-16**] 10:30AM PLT COUNT-108*
[**2150-8-16**] 10:30AM PT-13.1 PTT-25.5 INR(PT)-1.1
[**2150-8-16**] 10:30AM FIBRINOGE-298
[**2150-8-16**] 10:30AM URINE COLOR-[**Location (un) **] APPEAR-Cloudy SP [**Last Name (un) 155**]-1.021
[**2150-8-16**] 10:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
[**2150-8-16**] 10:30AM URINE RBC->50 WBC-[**5-24**]* BACTERIA-MANY
YEAST-NONE EPI-0-2
Brief Hospital Course:
Mr. [**Known lastname 68525**] was admitted to the trauma surgery service with the
following injuries: right-sided pneumothorax, right rib
fractures, sternal fractures, multiple pelvic fractures, right
femur fracture.
.
#) Femur Fracture- Mr. [**Known lastname 68525**] was taken to the operating room by
orthopedics for an open reduction intramedullary fixation of his
right femur fracture. He was started on Ancef postoperatively,
Lovenox and a Dilaudid PCA. He later was started on oral pain
medication. He was seen by physical and occupational therapy.
He should continue Lovenox and follow-up with Dr. [**First Name (STitle) **].
.
#) Pelvic fractures- Orthopedics was consulted regarding his
right saral fracture and left inferior pubic ramus fracture and
non-operative treatment was recommended. His activity status is
non-weight bearing of the right lower extremity, weight-bearing
as tolerated on the left lower extremity.
.
#) Urinary Tract Infection- On hospital day 5, he was noted to
have a urinary tract infection and was started on ciprofloxacin
for three days.
.
#) Disposition- Mr. [**Known lastname 68525**] was discharged to a rehabilitation
facility.
Medications on Admission:
None
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: 0.3 ML's Subcutaneous
Q12H (every 12 hours).
2. Acetaminophen 1,000 mg Packet Sig: One (1) PO Q6H (every 6
hours).
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for heartburn.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
8. Phenol-Phenolate Sodium Mouthwash Sig: One (1) Spray
Mucous membrane QID (4 times a day).
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
10. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
11. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3
hours) as needed for breakthrough pain.
12. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insominia.
13. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-16**] Sprays Nasal
TID (3 times a day) as needed for allergy symptoms.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days.
16. Loratadine 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall
Right pneumothorax
Right 3rd, 4th, and 6th rib fractures
Right pulmunary contusion
Pelvic fracture
Sternal fracture
Right femur fracture
Urinary tract infection
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital after a 20 foot fall. You were
found to have the following injuries:
Right pneumothorax
Right 3rd, 4th, and 6th rib fractures
Right pulmunary contusion
Pelvic fracture
Sternal fracture
Right femur fracture
You had a surgical repair of your femur fracture. Orthopedic
surgery also evaluated your pelvic fractures and did not
recommend further surgery. You should NOT bear any weight on
your right leg for the next eight weeks. You should continue
taking the medication Lovenox to prevent blood clots until
otherwise advised by Dr. [**First Name (STitle) **].
You were also treated for a urinary tract infection during this
hospitalization. Your scrotal swelling and bruising is likely
related to your pelvic fractures. You should continue to apply
ice as needed to your scrotum. If you have increasing pain or
swelling of your scrotum, you should call your doctor or report
to the hospital.
.
You should call your doctor or return to the hospital for:
* Chest pain, shortness of breath
* Fevers, chills, cough
* Abdominal pain, nausea or vomiting
* Worsening of your scrotal swelling
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **], Orthopedics, in 2 weeks, call
[**Telephone/Fax (1) 1228**] for an appointment.
Follow up with Dr. [**Last Name (STitle) 18191**] in 2 weks for your pelvic fractures,
call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up with Dr. [**Last Name (STitle) **] in Surgery Clinic in 2 weeks, call
[**Telephone/Fax (1) 6429**] for an appointment.
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3393
} | Medical Text: Unit No: [**Numeric Identifier 75832**]
Admission Date: [**2101-4-4**]
Discharge Date: [**2101-4-21**]
Date of Birth: [**2030-11-26**]
Sex: M
Service: VSU
HISTORY OF PRESENT ILLNESS: This is a morbidly obese man
with severe chronic obstructive pulmonary disease, who
presented on [**2101-4-4**] with bilateral common iliac and
aortic aneurysms. He had been evaluated in [**2100-11-20**] for
this with a CTA of the chest, abdomen, pelvis, and lower
extremities with contrast. That showed him to have an
infrarenal aortic aneurysm at the level of the inferior
mesenteric artery origin measuring 4.7 x 4.3 cm in maximum
dimensions, as well as having a left common iliac artery
aneurysm measuring 2.7 x 2.7 cm and a right common iliac
aneurysm measuring 4.3 x 4.2 cm. They did not extend beyond
the iliac bifurcation on either side, and at this time, the
patient had been evaluated preoperatively at length and had
undergone an angiographic evaluation as well leading up to
his presentation for endovascular repair.
PAST MEDICAL HISTORY: Hypertension; hypercholesterolemia;
diabetes mellitus, type 2; abdominal aortic aneurysm with
bilateral common iliac aneurysms; chronic obstructive
pulmonary disease - on home oxygen.
MEDICATIONS AT HOME: Albuterol; aspirin; citalopram; Lasix;
glyburide; Lantus; Levoxyl; metformin; metoprolol; NovoLog;
potassium chloride; simvastatin.
ADMISSION PHYSICAL EXAMINATION: The patient was noted to
have vital signs within normal limits and was afebrile. He
was normocephalic and atraumatic. Pupils were equally round
and reactive to light. The oropharynx was clear. He was
without lymphadenopathy or bruits. He was in a regular rate
and rhythm, without murmurs, rubs, or gallops. He was mildly
coarse bilaterally, with occasional expiratory wheezes. He
was nondistended, with normoactive bowel sounds, and he was
soft and nontender throughout, without rebound or guarding.
He had no clubbing, cyanosis, or edema, and he was noted to
be warm and well-perfused distally. His vascular exam was as
follows. He had no pulsatile abdominal mass and no abdominal
bruits. He had no neck bruits, and his pulse exam revealed 2+
brachial and radial pulses bilaterally. He had palpable
femorals bilaterally. He had palpable, but full popliteal
pulses bilaterally and palpable dorsalis pedis and posterior
tibial pulses bilaterally.
HOSPITAL COURSE: The patient was admitted on [**2101-4-4**]
and was brought to the operating room by Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) **] and underwent endovascular aortic aneurysm
repair using an Excluder endograft and an aortic cuff
extender of 26 mm along with a right external iliac artery
extender cuff of 16 x 115 mm and a left external iliac
extender cuff of 16 x 95 mm and, in addition, received a
Palmaz 40-10 stent at that time. At the end of the case,
there was a repeat angiogram performed that showed patency of
both renal arteries and good apposition of the proximal stent
graft, with no signs of leak and with good flow noted through
both iliac limbs. The device was then removed. The patient
was Perclosed and brought to the intensive care unit at this
time. He remained intubated at this time and was noted to be
stable in the initial postoperative period. With his long
history of chronic obstructive pulmonary disease, attempts
were made to carefully wean this patient. He was extubated on
postoperative day 1; however, he ended up requiring
reintubation for a desaturation episode into the 70s along
with respiratory distress. At this time, he had a CTA of his
chest to evaluate this episode of acute hypoxia and
hypercarbia to rule out pulmonary embolism. There was no
pulmonary embolism on CTA and no signs of any dissection, but
there was noted to be multifocal consolidation and bibasilar
effusions as well as scattered subcentimeter pulmonary
nodules for which follow-up in 3 months with a chest CT was
recommended. Also at this time, an echocardiogram was
performed that showed a left ventricular ejection fraction of
45% to 50%, with mild, 1+ mitral regurgitation noted. Aortic
valve leaflets were noted to be mildly thickened, but no
aortic stenosis was present. So at this time, the patient
remained intubated and attempts at diuresis were commenced
with Lasix and Diamox and these attempts were continued
throughout the postoperative period.
Tube feeds were also started in the postoperative period and
were titrated up to a goal rate of 80, which he tolerated
well. These were given through a Dobhoff tube. The patient's
abdomen was noted to be soft, and he was having bowel
movements. On postoperative day 9, due to prolonged
respiratory failure and after a brief stint on the floor, the
patient had required reintubation and a tracheostomy was
performed by the thoracic surgery service on [**2101-4-13**].
This was performed without complication, with a #8 Portex
trach placed with the diagnosis of respiratory failure at
this time. From this point forward, the patient continued to
improve, however, did have an episode of fever on [**2101-4-17**] for which full cultures were sent, of which the blood
cultures are still pending and urine cultures came back
negative. However, sputum culture revealed 4+ gram-positive
cocci in pairs and clusters and 2+ gram-negative diplococci.
The sensitivities came back as these being oxacillin-
resistant, and the patient was started on vancomycin, which
he is to continue for 2 more weeks after discharge. With the
tracheostomy in place, he did continue to improve and at the
time of discharge was noted to be on a trach collar 12 hours
a day with vent requirement at night. He also had had a
speech and swallow evaluation formerly done with a green dye
swallow evaluation as well. He also tolerated a Passy-Muir
valve well at this time, without changes in vital signs or
secretion interference, and it was noted that he can safely
wear the valve for extended periods of time. The
recommendation at this time was for a diet of thick liquids
and ground solids, with his family to bring in his dentures,
and pills were noted to be able to be given whole with thin
liquids as well. So on [**2101-4-21**], the patient was deemed
ready for discharge. He had self-discharged his Dobhoff tube,
but with the speech and swallow evaluation, he was going to
be gradually advanced on his diet. He was to be continued on
Lasix 40 mg IV t.i.d. to continue off-loading fluid. He was
to continue vancomycin as well.
FINAL DIAGNOSES:
1. Abdominal aortic aneurysm.
2. Hypertension.
3. Hypercholesterolemia.
4. Diabetes mellitus.
5. Chronic obstructive pulmonary disease - on home oxygen.
6. Status post endovascular repair of abdominal aortic
aneurysm.
7. Status post endovascular repair of bilateral common
iliac artery aneurysms.
DISCHARGE INSTRUCTIONS: The patient will be discharged to a
rehabilitation facility and to follow up with Dr.
[**Last Name (STitle) **] as directed. Please call if there is any
worsening pain, fevers, chills, nausea, vomiting, shortness
of breath, chest pain, or redness or drainage around the
wounds or if there are any questions or concerns. The patient
has passed a speech and swallow for thin liquids and pureed
solids.
RECOMMENDED FOLLOW-UP: The patient is to have a CAT scan on
[**2101-5-4**]. That is scheduled for 2 p.m., and then the
patient is to see Dr. [**Last Name (STitle) **] the same day, [**2101-5-4**], at 3 p.m. His phone number is [**Telephone/Fax (1) 1237**].
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Regular insulin sliding scale;
aspirin 81 mg p.o. q.d.; atorvastatin 20 mg p.o. q.d.; Zantac
150 mg p.o. q.d.; levothyroxine 25 mcg p.o. q.d.; citalopram
20 mg p.o. q.d.; Dulcolax 10 mg suppository p.r.n. daily;
albuterol 1 to 2 puff inhalations q.4 hours; Sarna lotion
applied topically q.i.d. as needed; Tylenol 325 mg 1 to 2
tabs p.o. q.6 hours as needed; chlorhexidine gluconate
mouthwash b.i.d.; oxycodone 5 mg p.o. q.6 hours p.r.n.;
glyburide 5 mg p.o. b.i.d.; warfarin 7.5 mg p.o. daily for
atrial fibrillation (goal INR 2 to 3) - this can be continued
for 1 month and then can be stopped if the patient continues
to be in sinus rhythm; metoprolol 25 mg p.o. t.i.d.;
Combivent inhalation q.4 hours as needed; fluticasone 110
mcg/actuation 2 puffs b.i.d.; vancomycin 1 g IV b.i.d. for 2
more weeks after discharge; Lasix 40 mg q.8 hours.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 6039**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2101-4-21**] 09:12:08
T: [**2101-4-21**] 10:28:24
Job#: [**Job Number 75833**]
ICD9 Codes: 9971, 4271, 5185, 4280, 496, 4019, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3394
} | Medical Text: Admission Date: [**2121-1-9**] Discharge Date: [**2121-1-17**]
Date of Birth: [**2056-4-16**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
[**1-9**]- Endotracheal intubation, mechanical ventilation,
subsequent extubation
[**1-11**]- Bronchoscopy
History of Present Illness:
Mr. [**Known lastname **] is a 63 year-old male smoker with a history of severe
COPD on home [**Known lastname 20358**] (4L), dCHF, and DM2 who presents from home
with dypnea and respiratory failure. He was recently discharged
on [**2120-12-19**] after being admitted for a COPD exacerbation (3 day
hospital stay) and was sent to [**Hospital3 105**] rehab. He did
well at rehab and arrived home yesterday. Since this morning,
per his wife, he began feeling increasingly dyspneic and fatigue
and had fevers; he has a chronic productive cough at baseline
which was unchanged. He then called EMS after finishing
[**Holiday 1451**] dinner with his family. Of note, his daughter has
cystic fibrosis and is "coming down with a cold." No pets at
home.
.
He was noted by EMS to be dyspneic and received nebs without
improvement. He desatted with a NRB and was intubated en route
to [**Hospital1 18**] ED.
.
In the ED, vital signs were initially: 103.4 rectal 96 109/53
99% on vent settings of cmv 550 x 16, peep 8, fio2 100%. A CXR
demonstrated a RLL infiltrate. He was given 2.5L IVF, vanc,
ceftriaxone, and levoflox and admitted to the [**Hospital Unit Name 153**].
Past Medical History:
1. Severe COPD: followed by Dr. [**Last Name (STitle) **], on prednisone and home
[**Last Name (STitle) 20358**] (4L NC) at baseline, recently he has been having monthly
admissions for COPD: [**Last Name (STitle) 1570**]'s [**7-23**]: FEV1 19%, FEV1/FVC 43%
2. Chronic Systolic CHF: TTE [**3-24**] LVEF>55%, although patient
denies this
3. Gastritis/GERD
4. h/o SBO
5. Tobacco Abuse: Previous 5PPD, now [**3-19**] cigs/day
6. Diabetes Mellitus type 2
7. Diverticulosis
8. C6-C7 HERNITATION
9. B12 Deficiency- on monthly injections
10. Obesity with possible OSA, but pt refuses sleep study or
CPAP
11. Psoriasis
12. Hypertension
13. Glaucoma
14. Recent LLE cellulitis [**2-22**]
Social History:
Home: Lives with his wife [**Name (NI) 319**] [**Name (NI) **] and his son. His
[**Name2 (NI) 8526**] has cystic fibrosis and is currently hospitalized
for respiratory infection. His wife has recently started a new
job and is under a great deal of stress.
Tobacco: previous heavy smoking history of 5 PPD, states he
recently quit smoking during [**11-22**] hospital admission
EtOH: previous history of heavy EtOH, now rarely drinks
Drugs: Denies
Family History:
Mother - died of lung cancer in 60s
Father - died of lung cancer in 60s
Sister- died of lung cancer in 50s
Physical Exam:
VS: 103.4 rectal 96 109/53 99% on AC, fio2 100%, 550 x 16, peep
10
GEN: intubated, cushingoid
SKIN: No rashes or skin changes noted
HEENT: obese neck, unable to appreciate JVD, No lymphadenopathy
in cervical, posterior, or supraclavicular chains noted.
CHEST: + b/l rhonchi, no wheezes
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: obese, no hepatosplenomegaly
EXTREMITIES: no peripheral edema
NEUROLOGIC: intubated, arousable, unable to assess strength
Pertinent Results:
Admission Labs:
ABG pH 7.27 pCO2 83 pO2 235 HCO3 40 BaseXS 7
Na:142
K:4.4
Cl:100
Glu:207
Lactate:0.6
PT: 11.8 PTT: 21.1 INR: 1.0
145 93 61
------------< 223
4.8 39 1.7
freeCa:1.08
Lactate:2.3
pH:7.22
CK: 53 MB: Notdone Trop-T: Pnd
Ca: 8.3 Mg: 2.9 P: 2.9
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
14.4 >--< 229
34.2
CBC on [**2121-1-8**]: 9.7 > 31 < 76
STUDIES:
CXR [**2121-1-9**]: Patchy opacities bilaterally which could be
consistent with
multifocal pneumonia and/or aspiration. Possible overlying
pulmonary edema. Trace right pleural effusion.
CXR [**2121-1-14**]: Relatively symmetric ground-glass opacification in
the lower lung zones is most likely pulmonary edema. Heart is
normal size. The mediastinal veins are distended. Left jugular
vein ends in the upper SVC. Lung bases are excluded from the
examination. Upper pleural margins show no abnormality, but some
pleural effusion could be present.
EKG: Artifact is present. Sinus tachycardia. Probably normal
tracing. Compared to the previous tracing there is no
significant change.
Brief Hospital Course:
Mr. [**Known lastname **] is a 63 year-old male smoker with a history of severe
COPD on home [**Known lastname 20358**] (4L), DM2, and diastolic heart failure who
presented to the ICU from home (after a brief stay at rehab
following recent hospitalization) with dyspnea and respiratory
failure. Due to worsening respiratory effort he was intubated
in the field, transported to the emergency department and
admitted to the ICU.
.
1. Hypoxic/hypercapneic respiratory failure: His respiratory
failure was felt to be secondary to pneumonia complicated by
COPD exacerbation. Mr. [**Known lastname **] has history of multiple COPD
exacerbations and pneumonia episodes in past, for which he has
been intubated, and he continues to smoke. He presented to the
ICU on [**1-9**], intubated with ABG consistent with chronic
respiratory acidosis. He was started on empiric vancomycin and
zosyn for hospital-acquired pneumonia (given recent
hospitalization and rehab stay) as well as azithromycin for
atypical coverage. His antibiotics were eventually switched to
Levaquin after a bronchoalveolar lavage culture grew
stenotrophomonas maltophilia that was sensitive to Levaquin. He
was started on tamiflu empirically, and had a flu swab that
later returned negative and his Tamiflu was discontinued. He was
extubated on [**2121-1-12**] without complication. He was initially on
high dose solumedrol IV which was transitioned to prednisone 60
mg po daily. Per Dr. [**Last Name (STitle) **] (outpatient pulmonologist), he
should continue this dose of prednisone until he his seen in
clinic. He completed a 9 day course of levaquin for his
hospital acquired Stenotrophomonas pneumonia. At time of
discharge patient is requiring albuterol nebs q3h and
ipratropium nebs q6h to prevent acute exacerbation. Patient
would also likely benefit a great deal by BiPAP. He was seen by
Respiratory Therapy on the medical floor and started on
intermittent BiPAP. Recommend continuing to offer BiPAP for
intermittent relief and throughout night. Smoking cessation
(reportedly has not smoked since [**11-22**] hospital admission) was
congratulated and abstinence encouraged. Patient is scheduled
to follow up with Dr. [**Last Name (STitle) **] in clinic on [**2121-1-29**] to address
prednisone taper.
.
2. Acute Renal insufficiency: Mr. [**Known lastname **] has a baseline
Creatinine of 0.7 which was elevated on admission to 1.7. His
creatinine trended downward (1.0) during his [**Hospital **] hospital course
in response to IV fluid. The underlying etiology for ARF on
presentation was felt to be pre-renal in the setting of
pneumonia. With later diuresis on the medicine floor for volume
overload his creatinine fell to 0.8. suggesting his diastolic
dysfunction is a considerable contributor to compromised renal
function.
.
3. Hypertension: After receiving IV fluids and high dose
steroids for his pneumonia and COPD, he became hypertensive. He
was restarted on his home amlodipine which was increased to 10mg
po daily. He was also restarted on lisinopril 40 mg po daily
and lasix 60 mg po daily (discontinued on previous admission in
setting of ARF).
.
4. Diastolic CHF: Patient appeared volume overloaded on
presentation to the medicine floor. Lasix was restarted and
patient was diuresed > 3 L. Renal function improved with
diuresis. Continue antihypertensive regimen as listed about.
Recommend compression stockings and leg elevation to reduce
lower extremity edema.
.
5. Sinus Tachycardia: Persists throughout admission. Likely
secondary to frequent albuterol nebs and respiratory distress.
If tolerated attempt to decrease frequency of albuterol nebs to
decrease tachycardia and allow greater diastolic filling.
.
6. CODE STATUS: Patient stated that he no longer would like to
be intubated on [**2121-1-17**]. However, he would not like this to
take effect until he has discussed this with his family. He
plans to meet with his family on [**2121-1-18**] to notify them of this
change. Please verify code status with patient after his family
discussion.
Medications on Admission:
MEDICATIONS AT HOME (per last d/c summary):
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) nebs q2h prn
2. Ipratropium Bromide 0.02 % nebs Q6H (every 6 hours)
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H prn
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID
6. Pantoprazole 40 mg Tablet PO Q12H
7. Simvastatin 5 mg Tablet PO DAILY (Daily)
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr PO HS
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Ferrous Sulfate 325 mg (65 mg Iron) One (1) Tablet PO DAILY
14. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
daily
15. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON
16. Calcium Carbonate 500 mg Tablet, Chewable (1) Tablet PO
TIDAC
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 1 Tablet
[**Hospital1 **]
18. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) prn
19. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) neb Q4H
21. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
22. Fluticasone-Salmeterol 500-50 mcg/Dose Disk: 1 disc [**Hospital1 **] prn
23. Insulin Lispro 100 unit/mL Solution Sig: sliding scale.
24. Triamcinolone Acetonide 0.1 % Ointment: 1 Appl [**Hospital1 **] prn
psoriasis
25. Clobetasol 0.05 % Ointment (1) Appl Topical [**Hospital1 **] prn
psoriasis
26. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
prn
27. Prednisone 20 mg PO DAILY (Daily)
28. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
29. Spiriva with HandiHaler 18 mcg Capsule: One (1) Inhalation
daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn as needed
for Constipation.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TIDAC (3 times a day (before meals)).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
DAILY (Daily).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
14. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-16**] Sprays Nasal
QID (4 times a day) as needed for congestion.
16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
17. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for psoriasis.
18. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
19. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q3H (every 3 hours).
21. Insulin
See Humalog sliding scale.
Check fsbs qachs.
Half dose while npo.
22. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day:
Hold if SBP < 100.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
COPD
Hypertension
Diastolic CHF
Diabetes Mellitus
Discharge Condition:
Patient on home [**Location (un) 20358**] requirement of 4L/min NC, ambulation is
SEVERELY limited by respiratory distress, patient requires
assistance/supervision with all ambulation, tolerates po diet
and medications.
Discharge Instructions:
You presented to the [**Hospital1 18**] Emergency Department by ambulance in
respiratory failure. You required intubation during your
transport. You were admitted to the ICU and found to have
pneumonia and an exacerbation of your severe COPD. You were
treated with antibiotics, and steroids and improved. You were
extubated and transferred to the medicine floor. There you
continued to receive antibiotics, steroids, and frequent
breathing treatments. Your lasix was restarted to remove extra
fluid and to help your breathing and your leg swelling. You
were discharged back to [**Hospital **] Rehabilitation Center where you
will continue your diuresis and respiratory therapy.
The following changes were made to your medications:
1) INCREASE amlodipine to 10 mg by mouth daily
2) RESTART furosemide (lasix) 60 mg by mouth daily
3) RESTART lisinopril 40 mg by mouth daily
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on [**1-29**] at 4 pm in the
Pulmonary Clinic located at [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) 436**].
ICD9 Codes: 0389, 5849, 2762, 4280, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3395
} | Medical Text: Unit No: [**Numeric Identifier 67446**]
Admission Date: [**2143-6-21**]
Discharge Date: [**2143-7-12**]
Date of Birth: [**2143-6-21**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 67441**], boy twin #2, was
born at 35 and 3/7 weeks by Cesarean section for concern of
growth of twin #1. Mother is a 37 year-old, Gravida I, Para
0 now II woman. Her prenatal screens are blood type B
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis surface antigen negative and group B strep unknown.
This was a pregnancy with dichorionic/diamniotic twins. The
mother received a complete course of betamethasone on [**5-11**]. Rupture of membranes occurred at delivery and there were
no sepsis risk factors. This infant emerged vigorous with
Apgars of 8 at 1 minute and 8 at 5 minutes.
His birth weight was 2,515 grams. His birth length was 47 cm
and birth head circumference was 31.5 cm.
PHYSICAL EXAMINATION: Admission physical examination
revealed an active pink infant with mild to moderate
respiratory distress with grunting and subcostal retractions.
Anterior fontanel was soft and flat. Ears normal set.
Palate intact. Neck supple. Intact clavicles. Lungs with
poor aeration. Subcostal retractions. Heart was regular rate
and rhythm, no murmur. Femoral pulses present. Abdomen
soft, positive bowel sounds, normal male genitalia. Testes
descended bilaterally. Patent anus. Stable hip exam. No
sacral anomalies. Extremities: Warm, pink and well
perfused. Normal symmetric tone, strength and moro reflex.
HOSPITAL COURSE: Respiratory status: [**Known lastname **] required
nasopharyngeal continuous positive airway pressure until day
of life #3 when he weaned to nasal cannula oxygen. He weaned
to room air on day of life #6 where he has remained. He has
had no apnea of bradycardia. On exam, his respirations are
comfortable. Lung sounds are clear and equal.
On day of life #6, he presented with a grade II over VI
systolic ejection murmur at the left lower sternal border
which persisted, prompting a cardiology evaluation. An EKG
was normal and a cardiac echo showed a structurally normal heart
and no patent ductus. No follow-up is recommended by the
cardiology service.
Fluids, electrolytes and nutrition: His weight at the time
of discharge is 2,805 grams. Enteral feeds were begun on day
of life #2 and advanced without difficulty to full volume
feedings. At the time of discharge, he is eating on an ad lib
schedule, breast feeding and supplementing with 24 calories
per ounce formula or breast milk.
Gastrointestinal: He was never treated with phototherapy.
His peak bilirubin on day of life 5 was total of 14.2, direct
of 0.3. His last bilirubin on day of life 7 was 12.7 total
and direct of 0.4.
Genitourinary: The infant was circumcised on [**2143-7-11**]. The
area is healing without complications.
Hematology: His hematocrit at the time of admission was
41.8. He has had no further hematocrit levels drawn. He has
had no blood product transfusions during his NICU stay.
Infectious disease: He was started on Ampicillin and
Gentamicin at the time of admission for sepsis risk factors.
Antibiotics were discontinued after 48 hours when the blood
cultures were negative and the infant was clinically well.
There are no further infectious disease issues.
Neurology: Audiology hearing screening was performed with
automated auditory brain stem responses and the infant passed
in both ears.
Psychosocial: The parents have been very involved throughout
the infant's NICU stay. Twin #1, his sibling, whose name is
[**Name (NI) 17976**] was discharged on [**7-8**]. The infant is discharged in
good condition.
MEDICATIONS: None.
He is discharged breast feeding and supplementing with 24
calories per ounce formula on an ad lib.
He passed the car seat position screening test.
State newborn screens were sent on [**6-24**] and [**2143-7-5**].
He has received no immunizations. The parents deferred and
prefer that to be done in the pediatrician's office.
Follow-up appointment with pediatrician is on Tuesday, [**7-16**]. Mother will need lactation.
DISCHARGE DIAGNOSES:
1. Status post prematurity at 35 and 3/7 weeks gestation.
2. Twin #2.
3. Status post hyaline membrane disease.
4. Sepsis ruled out.
5. Heart murmur without hemodynamic significance.
6. Status post mild hyperbilirubinemia.
7. Status post circumcision.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2143-7-12**] 14:05:39
T: [**2143-7-12**] 15:09:23
Job#: [**Job Number 67447**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3396
} | Medical Text: Admission Date: [**2192-1-1**] Discharge Date: [**2192-3-15**]
Date of Birth: [**2192-1-1**] Sex: M
Service: NB
HISTORY: Baby boy [**Known lastname **] is the 30-3/7 week gestation baby boy
[**Name2 (NI) **] to a 24-year-old Gravida 1, para 0, now 1 mother with
[**Name2 (NI) **] type A+, antibody screen negative, hepatitis B surface
antigen negative. Rubella immune, RPR nonreactive. GBS status
unknown secondary to preterm labor and prolonged preterm
rupture of membranes. Mom had been on Ampicillin and
Erythromycin. She received betamethasone. The infant was
delivered by vaginal delivery. He emerged vigorous with good
cry. Nuchal cord x1. Apgars were 8 at 1 minute and 9 at 5
minutes. He was admitted to the NICU for further evaluation.
Admission weight 1470 grams, head circumference 26 cm,
length 40.5 cm. Anterior fontanel was open and flat. There
was a caput present. His clavicles were intact. His palate
was intact. He had clear breath sounds with fair aeration.
Regular rate and rhythm. No murmur, good femoral pulses. His
abdomen was soft, nondistended with no masses. He was pink
and well perfused with a patent anus. He had normal external
male genitalia and he moved all extremities equally.
HOSPITAL COURSE: In the NICU is as follows.
Respiratory: He remained on room air after birth and was
started on Caffeine. He was in need of nasal cannula oxygen
around one month of life secondary to chronic lung
disease. He began chlorothiazide on day of life 43.
This was discontinued after 2 weeks with no
significant improvement in his respiratory status. He was
weaned to room air by day of life 48 and has been on room air
ever since. He had mild apnea of prematurity but his caffeine was
discontinued on day of life 23. He had desaturationss and
bradycardia's with feedings but has been without significant
bradycardia for greater than 5 days prior to his discharge.
Cardiovascular: He was stable from a cardiovascular
standpoint throughout his stay with normal [**Name2 (NI) **] pressures
and perfusion. He had soft intermittent cardiac murmur noted
throughout his stay but this did not persist and he has not
had a need for any echocardiograms throughout his stay.
Fluids, Electrolytes and Nutrition: Enteral feedings were
initiated shortly after birth and he had no difficulty
reaching full volume. He was initially fed via nasogastric
tube but as soon as he was ready he started taking p.o.
volumes and was worked up to full p.o. feeding. He has had no
significant difficulty with this. He received fortified
formula for much of his stay but has been having excellent
weight gain on Enfamil 20 K cal per ounce for the last 2
weeks. His most recent weight is 3665 grams on [**2192-3-10**]. He
has had no significant electrolyte abnormalities and has had
normal urine output throughout his stay.
GI: He had a bilirubin of 8.3 on day of life 3 and was
started on phototherapy. This was discontinued and he had a
rebound of 5.5 on the day of life 7. He was noted to be
jaundiced several days afterwards and had a bilirubin checked
and was 12.2 on day of life 11 so he was restarted on
phototherapy. He completed another 5 days of phototherapy and
his bilirubin was 5.6 with a direct component of 0.2 after
this phototherapy was discontinued. He had another bilirubin
checked around day of life 19 and this was 8.8 with a direct
component of 0.3 which was thought to be consistent with a
baby who is receiving entirely breast milk feedings.
Hematology: His [**Year (4 digits) **] type was A+, direct COOMBS negative.
His admission hematocrit was 51.2, he had a reassuring CBC at
that time. His most recent hematocrit was 35% on [**2192-2-29**] or
day of life 59. He remains on iron 25 mg per ml at a dose of
0.4 mls once daily.
Infectious Disease: He had a [**Date Range **] culture and CBC sent after
birth. His [**Date Range **] culture was negative at 48 hours. He did
receive Ampicillin and Gentamicin for 48 hours but they were
discontinued when his [**Date Range **] culture returned negative. He has
had no other significant infectious disease issues throughout
his stay.
Neurology: He had a head ultrasound on day of life 8 that was
normal and on the [**4-6**], or day of life 30 that
was normal. Audiology: He passed his hearing screening
bilaterally. Ophthalmology: He had 2 eye exams the first of
which on [**2192-2-6**] showed immature Zone 3. His follow-
up examination on [**2192-2-27**] showed mature retinas. He is
next due to have follow-up eye examination at 9 months of age
as an outpatient with Dr. [**Last Name (STitle) **].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Doctor Last Name **] [**Doctor Last Name **], [**Hospital 64547**]
Community Health Center, [**Telephone/Fax (1) 10349**].
CARE/RECOMMENDATIONS: Feeds at discharge, ad lib Enfamil 20
calorie.
MEDICATIONS: Iron concentration 25 mg per ml, dose 0.4 mls
by mouth daily
Car seat position screening: Passed.
Newborn screening status: No abnormalities noted.
IMMUNIZATIONS: Boy boy [**Known lastname **] received his 2 month
immunizations consisting of Pediarex on [**2192-3-4**].
Hemophilus influenza B on [**2192-3-1**]. Pneumococcal
vaccine on [**2192-3-1**], he also received hepatitis B
vaccination on [**2192-2-3**] for his first dose. He also
received Synergist or RSV immunoglobulin on [**2192-1-26**]
and [**2192-3-7**].
IMMUNIZATIONS RECOMMENDED: Synergist RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria.
1. [**Month (only) **] at less than 32 weeks.
2. [**Month (only) **] between 32 and 35 weeks with 2 of the following. Day
care during RSV season; a smoker in the household;
neuromuscular disease; airway abnormalities or school age
siblings.
3. With chronic lung disease.
Influenza immunization 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.
FOLLOW UP: Primary pediatrician within 2 days post
discharge. Visiting nurse has been declined by the family.
DISCHARGE DIAGNOSIS:
1. Prematurity 30-3/7 weeks.
2. Presumed sepsis.
3. Hyperbilirubinemia.
4. Apnea of prematurity.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) 56577**]
MEDQUIST36
D: [**2192-3-14**] 15:54:01
T: [**2192-3-14**] 16:50:53
Job#: [**Job Number 64548**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3397
} | Medical Text: Admission Date: [**2128-5-10**] Discharge Date: [**2128-5-15**]
Service: CCU
HISTORY OF THE PRESENT ILLNESS: The patient is an
83-year-old white male with a history of coronary artery
disease, status post CABG in [**2112**] with the following anatomy,
LIMA to LAD, SVG to diagonal, SVG to OM, SVG to RCA, who
presented for elective cardiac catheterization as a part of
preoperative evaluation for AAA of 6.2 cm by abdominal
ultrasound. The patient has been having symptoms of
exertional angina but none at rest prior to this admission.
During cardiac catheterization, the patient was found to have
right atrial pressure of 7, right ventricular pressure of
45/10, pulmonary artery pressure of 48/23, pulmonary
capillary wedge pressure (CWP) of 24, and cardiac index of
1.8. The patient was found to have a patent LIMA graft to
LAD but had an occluded SVG to PDA with 95% occlusion
stenting of which was unsuccessful and resulted in no distal
flow. The patient was noted to have collaterals from left to
right.
During the cardiac catheterization the following stenting was
done, right subclavian artery was found to have 90% stenosis
and was successfully stented with good flow to right
vertebral. Left subclavian artery was found to have 70%
stenosis at the origin of left vertebral artery. During the
stenting, left vertebral artery was lost but good flow was
maintained through the LIMA graft. The patient was chest
pain-free during the procedure and was transferred to the
Cardiac Intensive Care Unit for observation.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient
had a temperature of 97.2, pulse 64, blood pressure 143/71,
respirations 17. Oxygen saturation 98% on 2 liters by nasal
cannula. His Swan-Ganz catheter readings were right atrial
pressure of 5, right ventricular pressure 30/5, pulmonary
artery pressures 30/14, and the catheter was discontinued.
General: The patient was comfortable and lying in bed in no
apparent distress. HEENT: Pupils were equal, round, and
reactive to light and accommodation. The extraocular muscles
were intact. The oropharynx was clear. Neck: Supple.
There was no jugular venous distention. No bruits noted.
Pulmonary: The patient's breath sounds were clear to
auscultation anteriorly. Cardiovascular: Regular rate and
rhythm, normal S1, S2, distant heart sounds, no murmurs,
rubs, or gallops noted. Abdomen: Bowel sounds were present.
There were notable pulsations from the abdominal aortic
aneurysm. The abdomen was soft, nontender, nondistended,
without organomegaly. Extremities: Somewhat cold but
without clubbing, cyanosis or edema. Pulses were equal, 2+
dorsalis pedis and radial pulses bilaterally.
LABORATORY/RADIOLOGIC DATA: On admission, the patient had a
white count of 13.4, hemoglobin 14.4, hematocrit 45.9,
platelets 138,000. Sodium 140, potassium 3.4, BUN 29,
creatinine 1.5. Arterial blood gas showed a pH of 7.43, PC02
32, P02 67, phosphorus 3.3, magnesium 2.0.
The patient's EKG showed old left bundle branch block. First
set of CK was 68 on admission.
HOSPITAL COURSE: 1. CORONARY ARTERY DISEASE: The patient
was transferred to the Cardiac Intensive Care Unit for
observation following a complicated catheterization. The
catheterization was complicated by the loss of a graft
supplying PDA, although the patient was chest pain-free
during the cardiac catheterization, the patient did
experience left arm pain which was known to be his anginal
equivalent. At rest, upon transfer to the Cardiac Intensive
Care Unit, the patient was put on nitroglycerin drip for 30
minutes resulting in resolution of arm pain. The patient's
anginal equivalent at the time was attributed to a spasm of
LIMA which was essentially the only artery supplying the bulk
of his heart. The patient's enzymes were cycled and peaked
at 700. The patient was started on aspirin, Plavix,
Metoprolol, and fluvastatin. The patient remained stable and
was transferred to the regular nursing floor. ACE inhibitor
was started as well as the patient's home dose of Lasix.
Upon transfer to the regular medical floor, the day following
the transfer, the patient experienced several episodes of
rest pain as well as a short run of nonsustained ventricular
tachycardia (NSVT), eight beats. During the run of NSVT, the
patient was asymptomatic and asleep. Even though this was
still within 48 hours of myocardial infarction, the patient
was considered to be at significant risk for sudden cardiac
death given the known ejection fraction of less than 15%.
The risks of sudden cardiac death were explained to the
patient but the patient declined having an intervention done
such as risk stratification with EP study.
It was decided to optimize his medical management. His
metoprolol was increased as tolerated by his blood pressure
and the goal was to keep him symptom-free. The patient was
also put on nitroglycerin patch which helped his symptoms.
The following night, the patient had three episodes of rest
pain in both arms and became hypotensive with systolic blood
pressures around 75. The patient was given sublingual
nitroglycerin which resulted in resolution of pain.
The patient was transferred back to the Cardiac Intensive
Care Unit, was put on a nitroglycerin drip. At the same
time, it was found that the patient had a hematocrit drop
from 42 the day prior to 35 the morning of the transfer back
to the CCU in order to rule out an internal bleed in a
patient with a known AAA. Abdominal ultrasound as well as
noncontrast CTs were performed that showed no retroperitoneal
bleed and no contained bleed. The patient had an
echocardiogram to rule out cardiac tamponade that showed no
pericardial effusion but severe global hypokinesis with an
ejection fraction of less than 15%, atrial septal defect, and
3+ MR.
While the patient's cardiac enzymes were trending down after
the cardiac catheterization, there was a small bump in
cardiac enzymes at this time indicating more myocardial
damage. While in the Cardiac Intensive Care Unit, the
patient has remained chest pain-free. Both the patient and
the family were informed of different options including going
back for cardiac catheterization to find out whether the LIMA
graft was the source of the patient's symptoms; however, the
patient expressed his wishes not to proceed with cardiac
catheterization. This was in agreement with the patient's
wife and the rest of his family. Instead, the patient opted
for medical management of his coronary artery disease.
On the morning of [**2128-5-15**], the patient experienced a
pulseless ventricular tachycardia arrest, 200 joule shock was
delivered and the patient's rhythm was converted to pulseless
electrical activity. The patient was given several rounds of
epinephrine and atropine and sinus rhythm was returned but
the patient's blood pressure was kept up on a dopamine drip.
During the code, an arterial blood gas was drawn which showed
a pH of 6.99, PC02 46, and P02 of 66. The patient was
intubated and put on a ventilator. Bicarbonate drip was
started and initial laboratories showed lactate of 11
followed by lactate of 14. The patient's calcium was 6.5,
free calcium of 1.01, and the patient was given calcium
bicarbonate. The patient's arterial blood gas after several
hours on a ventilator was 7.1, pH 7.12, PC02 of 36, and P02
of 69. The patient's hematocrit and coagulation profile was
stable.
At this point, a discussion with the family was initiated.
The family was informed of the patient's clinical condition.
The prognosis as well as different options were addressed.
While the family was given time to discuss by themselves and
come up with a treatment option, the patient suffered another
cardiac arrest. The patient's systolic blood pressure while
on dopamine dropped to mean arterial pressure of 40s-50s and
the patient became severely bradycardiac. Two rounds of
epinephrine and Atropine were administered and perfusing
rhythm was returned. The patient's family was informed of
the events and it was there decision to make the patient
DNR/DNI.
Shortly afterwards, the patient suffered another pulseless
ventricular tachycardia arrest, after which the patient was
examined. There were no spontaneous respirations. There
were no breath sounds on auscultation. There were no heart
sounds on auscultation as well. There were no corneal
reflexes and no pupillary reaction to light. The patient was
pronounced dead with the time of death of 12:30 p.m. on
[**2128-5-15**]. The patient's family declined having an autopsy
done.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Name8 (MD) 4937**]
MEDQUIST36
D: [**2128-5-15**] 11:44
T: [**2128-5-21**] 11:18
JOB#: [**Job Number 47835**]
ICD9 Codes: 4111, 4275, 4280, 9971, 4240, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3398
} | Medical Text: Admission Date: [**2206-6-18**] Discharge Date: [**2206-7-3**]
Date of Birth: [**2131-1-17**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin / Levofloxacin / Fentanyl
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain/Transfer for catherization
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname **] is a 75 yo male with a history of significant
vascular disease and CAD, including CABG in [**2194**] with LIMA to
LAD and SVG to OM and SVG to PDA of RCA, s/p BMS to distal SVG
to RPDA on [**3-/2206**], LCEA in [**2202**], and LAKA in [**2200**] as well as
multiple PVD procedures who woke up the morning of presentation
with some chest pain and heart burn after having a cup of coffee
with breakfast. He states his isosorbide usually relieves
anginal symptoms, but it had not worked this morning. He tried
sublingual nitroglycerine x3 as well with no relief. His pain
was burning/sharp in nature, centrally located, without
radiation to the upper extremities. He denied nausea, vomiting,
or diaphoresis with the event. Given his symptoms, his wife
took him to [**Name (NI) **] for further evaluation. OF note, the patient
had a similary presentation in early [**Month (only) **] where ACS workup was
negative for an MI.
At [**Month (only) **], his chest pain was [**4-1**] described as "indgiestion".
VS at time of presentation were NIBP 107/56, Pulse 84,
REspratory 22, )2sat 90 % on RA. T97.4. EKG at that time
showed RBBB with new ST segment elevations in aVR, V1/V2 with
STD in V4-V6 as well as AVL,I. Ol Q waves were noted in III,
AVF. Troponin I at that time were elevated at 0.109 with CKMB
of 7.4. Heparin gtt was started. Patient was planned to have a
catherization for possible STEMI, however the [**Month/Year (2) **] lab at [**Month/Year (2) **]
was down and patient requested transfer to [**Hospital1 18**] for further
care.
At [**Hospital1 18**], patient transferred directly to the [**Hospital1 **] lab.
Received morphine prior to transfer with resolution of chest
pain. There, a right radial approach was attempted, however
total occlusion of the right subclavian artery was encountered.
The radial approach was abandoned and femoral approach was
attempted via the RFA. Angiography revealed a patent LMCA with
40% distal, 70% LAD, patent LIMA at touchdown, occluded LCX and
RCA, with Patnet SVG-RCA/SVG-LCX and LIMA-LAD. Left subclavian
was also noted to be occluded when imaged. Both carotids were
noted to be severely diseased with origin of the right SC after
spearate origin of the two carotids. Also noted were 90%
occluded left and right external iliacs at CFA level.
Hemodynamics revealed brachial NIBP to be about 80 mmHg lower
than central blood pressures, with AO BP of about 150mmHg. No
stents were placed at that time, and the patient continued to be
chest pain free. He was transferred to the CCU for further
monitroing and eventual initiation of heparin gtt.
In the CCU, the patient is in NAD. Right groin noted to have
continual oozing from recent catherization site.
REVIEW OF SYSTEMS
On review of systems, denies CP, SOB, nausea, vomiting. Has had
diarrhea for last 4 days and took loperamide the day prior to
presentation given diarrehal symptoms. No blood in bowel
movements. No dysuria or hematuria but endorses frequent
urinary hesitancy. Denies joint pains, cough, hemoptysis, black
stools or red stools.
Has chronic angina. No PND/orthopnea currently, although has
had HF exacerbations several times in the last several months.
Past Medical History:
- NSTEMI [**2206-2-20**]
- dCHF with EF 55%
- hypertension
- hyperlipidemia
- DM2 w/ neuropathy
- PVD
- presumed small-bowel AVMs with recurrent GIB and anemia
(recent bleed in [**3-/2206**] on dual antiplatelet therapy)
- h/o erosive esophagitis and AVMs of the colon
- GERD
- BPH
- anxiety
- depression
- vitamin D deficiency
- hypomagnesemia
- s/p appendectomy
- s/p bladder cystoscopy for non cancerous bladder growths
- s/p L BKA [**1-28**]
- CABG: [**2194**] @ [**Hospital1 2025**] ( LIMA to LAD and SVG to OM and SVG to PDA
of RCA, s/p BMS to distal SVG to RPDA on [**3-/2206**])
- PCI: [**2194**] prior to CABG, no stents placed
- s/p L carotid endarterectomy [**2203-5-12**]
- s/p laser eye surgery b/l ([**2204**])
Social History:
He is married and lives with his 2nd wife of 23 years. They
have 8 children between them, 7 in the area. They have 17
grandchildren all in the area.
- Tobacco history: former, 30+ pack years, quit 10+ years ago
- ETOH: denies
- Illicit drugs: denies
Uses a wheelchair at home, transfers independently.
Family History:
Mother with DM, 2x amputee, angina, died early 60s
Two brothers with DM, CAD
Physical Exam:
Admission Exam
GENERAL: Obese but NAD. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Thick neck but supple. Patient laying supine.
CARDIAC: Exteremely faint heart sounds. Barely auscultated
S1/S2. No appreciated adventitious heart sounds.
LUNGS: Auscultated anteriorly. No wheezes/rhonchi/rales or
coarse breath sounds appreciated. Large chest wall.
ABDOMEN: Distended with midline scar. NBS. Slightly tense
abdomen without tenderness to palpation. No rebound. No
organomegaly appreciated.
EXTREMITIES: S/p LBKA. Multiple surgical scars on RLE c/w prior
vascular procedures. Bilateral raidal scars consistent with
vascular procedure.
GU: Foley placed. Clear urine.
SKIN: Scars per above. Also with midline sternotomy scar c/w
CABG. Hyperpigmented macule on penis.
PULSES:
Right: Non palpaple/non dopplerable DPP, dopplerable PTP, faint
femoral pulse with oozing around access site. 1+Carotids, 1+
Radial
Left: Carotid 1+ Radial 1+ Femoral 1+ Popliteal 2+
Discharge Exam
GENERAL: Obese but NAD. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Thick neck but supple. Patient laying supine.
CARDIAC: Exteremely faint heart sounds. Barely auscultated
S1/S2. No appreciated adventitious heart sounds.
LUNGS: Auscultated anteriorly. No wheezes/rhonchi/rales or
coarse breath sounds appreciated. Large chest wall.
ABDOMEN: Distended with midline scar. NBS. Slightly tense
abdomen without tenderness to palpation. No rebound. No
organomegaly appreciated.
EXTREMITIES: S/p LBKA. Multiple surgical scars on RLE c/w prior
vascular procedures. Bilateral raidal scars consistent with
vascular procedure.
GU: Foley placed. Clear urine.
SKIN: Scars per above. Also with midline sternotomy scar c/w
CABG. Hyperpigmented macule on penis.
PULSES:
Right: Non palpaple/non dopplerable DPP, dopplerable PTP, faint
femoral pulse with oozing around access site. 1+Carotids, 1+
Radial
Left: Carotid 1+ Radial 1+ Femoral 1+ Popliteal 2+
Pertinent Results:
Admission Labs
[**2206-6-18**] 10:00PM GLUCOSE-104* UREA N-37* CREAT-1.4* SODIUM-134
POTASSIUM-6.5* CHLORIDE-98 TOTAL CO2-27 ANION GAP-16
[**2206-6-18**] 10:00PM estGFR-Using this
[**2206-6-18**] 10:00PM CK(CPK)-130
[**2206-6-18**] 10:00PM CK-MB-8 cTropnT-0.13*
[**2206-6-18**] 10:00PM CALCIUM-8.4 PHOSPHATE-5.3*# MAGNESIUM-2.3
[**2206-6-18**] 10:00PM WBC-6.8 RBC-2.98* HGB-9.5* HCT-28.7* MCV-96
MCH-32.0 MCHC-33.2 RDW-14.4
[**2206-6-18**] 10:00PM PLT COUNT-127*
[**2206-6-18**] 10:00PM PT-10.6 PTT-27.4 INR(PT)-1.0
[**2206-6-18**] 03:18PM PO2-112* PCO2-51* PH-7.39 TOTAL CO2-32* BASE
XS-5
[**2206-6-18**] 03:18PM HGB-11.1* calcHCT-33 O2 SAT-97
Studies
[**2206-6-18**] EKG: Sinus rate. RBBB morphology with LAD fasicular
block. Old qwaves in inferior leads with small Qwaves in V1-V3.
ST depressions in I, AVL, II, V4-6, with STE's in V1/V2 aVR.
TWI in I, V4-V5. Compared to prior on [**2206-5-24**] STE's are new as
well as STD's.
Cardiac [**Date Range **]
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Bilateral subclavian stenoses.
3. Bilateral carotid stenoses.
4. Bilateral common femoral stenoses.
5. Right radial artery pressure ~80 mmHg lower than central
aortic
pressure.
Discharge Labs
[**2206-7-3**] 06:05AM BLOOD WBC-9.5 RBC-3.40* Hgb-11.0* Hct-32.8*
MCV-96 MCH-32.3* MCHC-33.6 RDW-16.7* Plt Ct-165
[**2206-6-29**] 07:20AM BLOOD Neuts-77.0* Lymphs-12.0* Monos-8.2
Eos-2.6 Baso-0.2
[**2206-7-3**] 06:05AM BLOOD Plt Ct-165
[**2206-7-3**] 06:05AM BLOOD Glucose-127* UreaN-39* Creat-2.0* Na-143
K-4.1 Cl-111* HCO3-23 AnGap-13
[**2206-6-26**] 04:32AM BLOOD ALT-24 AST-26 AlkPhos-147* Amylase-46
TotBili-0.3
[**2206-6-26**] 04:32AM BLOOD Lipase-34
[**2206-6-19**] 05:29AM BLOOD CK-MB-7 cTropnT-0.24*
[**2206-7-3**] 06:05AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2
[**2206-6-23**] 06:11AM BLOOD C3-151 C4-46*
[**2206-6-18**] 03:18PM BLOOD pO2-112* pCO2-51* pH-7.39 calTCO2-32*
Base XS-5
[**2206-6-18**] 03:18PM BLOOD Hgb-11.1* calcHCT-33 O2 Sat-97
Brief Hospital Course:
75 yo male with a history of significant vascular disease and
CAD as well as DM, HTN, HLD, presenting with NSTEMI vs STEMI
from OSH now status post catherization without further stenting.
Acute
#TIA's/Sub-acute PCA Infarct-
Patient is s/p L CEA in [**2202**].
Carotid series done [**6-20**] on this admission revealed:
1. Complete occlusion of the right CCA. Flow is noted within
the right ICA,
though absence of diastolic flow is concerning for distal
stenosis.
2. Findings consistent with a 70-79% stenosis of the left ICA,
with reversed
flow within the left vertebral artery into the left subclavian
artery,
consistent with subclavian steal.
On the AM of [**6-25**], the patient developed new onset slurring of
speech and L sided weakness. This resolved over approximately 1
hour. Neurology was urgently called and a STAT CT scan was done
which revealed new hypodense area in the right PCA
territory consistent with acute to sub-acute infarct. At this
time, the patient was placed on a heparin gtt. This was d/c'ed
evening of [**6-26**] after patient had melenotic stools and a drop in
Hct. He experienced a second TIA in house on [**6-27**] during which he
temporarily had a slurring of speech. An MRA of the neck was
obtained which revealed stenosis of multiple arteries in the
neck. After an interdisciplinary meeting btw Cardiology,
Neurology, and Vascular Surgery, it was decided that the risks
outweighed the harms to intervene regarding his arterial disease
given his other comorbidities.
A family meeting took place on [**2206-7-2**] discussing the [**Hospital 228**]
medical condition and disposition. It was agreed upon with the
patient, family, and healthcare personnel that he go to a high
skill rehab facility to strengthen the patient enough so he can
transfer him self around his home. His status was made "Do Not
Hospitalize" while at the rehab facility. DNR and DNI orders
were also agreed upon.
#Contrast-Induced Nephropathy
After receiving 300 cc contrast during cardiac [**Hospital **] [**6-18**],
patient had rise in creatinine from 1.4 to 6.5 (peaked [**6-23**]) and
then normalized by [**6-30**]??. Renal was consulted. They recommended
PRN lasix boluses for decreased urine output. The patient never
required dialysis and his hyperkalemia and hyperphosphatemia
were managed medically.
#CAD/STEMI:
Coronary angiography [**6-18**] showed no significant changes from his
recent catherization in 4/[**2205**]. No culprit lesion could be
identified. Cardiac enzymes were cycled and troponin rose from
.13 to .24. The patient was continued on his home dose of plavix
and asa in the setting of his recent BMS placement. His home
dose of isosorbide nitrate (90mg qAM) was changed to 60mg qHS to
due to multiple hypotensive episodes encountered during the
hospital stay. Rosuvastatin was changed to atorvastatin 80 and
his metoprolol succ 100mg qd was changed to metropolol tartrate
50 mg [**Hospital1 **].
#PVD/Subclavian stenosis: No intervention done during this
hospital stay. As was mentioned above, the patient has severe
PVD affecting the subclavian, vertebral, and carotid system. As
he is not an appropriate candidate for surgery the
recommendation made to the patient was medical management.
#Upper GI Bleed
The patient has a history of GI bleeds and AVM's with known
gastric AVM's. After being placed on a heparin gtt for a TIA on
[**6-25**], the patient had melenotic stools and a 5 pt drop in Hct (30
to 25) the evening of [**6-26**]. The heparin gtt was d/c'ed and due to
patient's hx of angina and vascular disease, he was transfused
slowly with 1UPRBC with an appropriate response. After heparin
gtt d/c'ed, no more melena detected and Q6hr CBC's were stable.
However, upon transfer back to the CCU on [**7-1**] the patient had 1
more episode of melena. Hcts remained stable and no invasive
intervention was performed. The patient's Aspirin and
clopidogrel were d/ced and dypiradimole/aspirin (Aggronox) was
started in consult with neurology- the thought was to
anticoagulate the patient to treat his TIAs and PVD affectively
while reducing his chance for continuing GI bleed.
Chronic
#HTN: Discrepancy between peripheral reads and central reads by
about 100 mmHg. On cardiac catheterization, it was noted that
central BP was about 150 mmHg. Target BP should be about
70-80s/40s (equivalent to 170s/140s centrally). For this reason,
urine output and mental status were used as a surrogate for
patient's tru BP. Lisinopril was d/c'ed [**1-23**] contrast-induced
nephropathy. Metoprolol was changed to 50 mg [**Hospital1 **] as above.
#T2DM. Insulin-dependent, with complications of nephropathy and
retinopathy.
SSI was continued in house
#BPH: Home finasteride and tamsulosin were continued in house.
# Anxiety and depression: Patient has long history of anxiety
and depression.
citalopram 40 mg was continued in house and later increased to
60 mg daily. Alprazolam dose was decreased from 0.5mg to .25mg
TID to allow for more reliable neuro exam as patient appeared to
be having recurrent TIA's.
Transitional Issues:IMPORTANT
- The patient is being discharged to a high level rehab facility
with the intent as described above. He has multiple ACTIVE
medical conditions that you should know about. His status is
"Do NOT HOSPITALIZE"- these will apply to chief complaints for
chest pain, and any neurologic events.
1. Ongoing TIAs. The patient may experience slurred speech or
eye deviation or weakness daily. These are not new. He is
being optimized medically with Aggronox for transient neurologic
ischemia. He has been evaluated by neurology, cardiology, and
vascular surgery for this and the recommendation was made to not
intervene. Please be aware that this is his baseline.
2. Chest pain- the patient has severe coronary artery disease
that is chronic and will not benefit from intervention. He
should be medically managed if chest pain should occur. Please
go up on his isosorbide mononitrate as blood pressure tolerates.
Sublingual nitroglycerin is also an option.
3. GI bleeds- Patient has chronic small bowel AVMs. In the
event that he has a massive GI bleed, he [**Month (only) **] be considered for
hospitalization because blood transfusions may help him
symptomatically. However, he should only be hospitalized if he
has MAJOR bleeding and if he symptomatic.
Diabetes- Please follow up on blood sugars and adjust diabetes
medications as necessary. Regimen has been changed multiple
times since admission.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR
Transfer handwritten Rx list.
1. Levemir 18 Units Breakfast
2. ALPRAZolam 0.5 mg PO TID:PRN anxiety / nausea
3. Finasteride 5 mg PO DAILY
4. esomeprazole magnesium *NF* 40 mg Oral once daily
5. Gabapentin 300 mg PO Q 12H
6. Rosuvastatin Calcium 10 mg PO DAILY
7. Aspirin 325 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
11. Furosemide 40 mg PO DAILY
12. Citalopram 40 mg PO DAILY
13. Sucralfate 1 gm PO BID
14. Cyanocobalamin 50 mcg PO DAILY
15. Vitamin D [**2193**] UNIT PO DAILY
16. Ferrous Sulfate 325 mg PO DAILY
17. Magnesium Oxide 400 mg PO ONCE Duration: 1 Doses
18. Repaglinide 2 mg PO BIDWM
19. Multivitamins 1 TAB PO DAILY
20. Ascorbic Acid 500 mg PO BID
21. Fish Oil (Omega 3) 1000 mg PO BID
22. Ocuvite *NF* (vit A,C & E-lutein-minerals;<br>vit C-vit
E-lutein-min-om-3) 1,000-60-2 unit-unit-mg Oral once daily
23. Nitroglycerin SL 0.3 mg SL PRN chest pain
24. HydrALAzine 50 mg PO Q8H
25. Docusate Sodium 100 mg PO BID
26. Senna 1 TAB PO BID:PRN constipation
27. Polyethylene Glycol 17 g PO DAILY
28. Prochlorperazine 10 mg PO Q6H:PRN nausea
29. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. ALPRAZolam 0.25 mg PO TID:PRN anxiety / nausea
2. Ascorbic Acid 500 mg PO BID
3. Citalopram 60 mg PO DAILY
4. Cyanocobalamin 50 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO BID
9. Gabapentin 300 mg PO BID
10. Levemir 18 Units Breakfast
11. Isosorbide Mononitrate (Extended Release) 120 mg PO QHS
12. Multivitamins 1 TAB PO DAILY
13. Nitroglycerin SL 0.3 mg SL PRN chest pain
14. Senna 1 TAB PO BID:PRN constipation
15. Sucralfate 1 gm PO BID
16. Tamsulosin 0.4 mg PO HS
17. Vitamin D [**2193**] UNIT PO DAILY
18. Metoprolol Tartrate 50 mg PO BID
hold for heart rate <60 or extreme lethargy
19. Esomeprazole Magnesium *NF* 40 mg ORAL ONCE DAILY
20. Prochlorperazine 10 mg PO Q6H:PRN nausea
21. Sulfameth/Trimethoprim DS 1 TAB PO BID
22. Simethicone 40-80 mg PO QID:PRN bloating
23. Dipyridamole-Aspirin 1 CAP PO BID
24. Atorvastatin 80 mg PO DAILY
25. Acetaminophen 650 mg PO Q6H:PRN pain
Do not exceed 4gm /day
26. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Primary- Unstable Angina
Transient Ischemic Attacks
GI bleed
Secondary- Contrast-Induced Nephropathy
Peripheral Vascular Disease
Type II Diabetes
Discharge Condition:
Level of Consciousness: Mentating ok (conversant, answering
questions) but with active neurological impairment
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted to the hospital for chest pain and were taken
to the cardiac catheterization lab. The doctors in the [**Name5 (PTitle) **] lab
found no new blockages in your arteries. The vessels from your
open heart surgery looked healthy. However, they did find you
have other arteries around your body with significant disease,
including your subclavian arteries. Dr [**Last Name (STitle) **] recommends you have
a procedure to explore and possibly treat this disease.
Unfortunately, the contrast used during your cardiac
catheterization caused you to have kidney damage during your
hospital stay. This improved over several days with fluids and
IV water pills.
You were found to have severe peripheral vascular disease in the
arteries of your neck, which has been resulting in "transient
ischemic attacks", or TIAs. This has been complicated by your
GI bleeding. The vascular surgeons, neurologists, and
cardiologists all agreed that any surgical intervention would
only cause more harm than good to your medical condition. We
had a family meeting and decided to discharge you from the
hospital to a high level rehab facility to increase your
strength before going home. We discussed possibly getting
hospice care involved once you are home.
Please see your medication list to review changes made to your
medications.
It was a pleasure taking care of you, Mr [**Known lastname 63255**].
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2206-7-24**] at 4:00 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
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 5849, 5990, 412, 2767, 4019, 4280, 2724, 3572, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 3399
} | Medical Text: Admission Date: [**2131-10-10**] Discharge Date: [**2131-11-4**]
Date of Birth: [**2093-4-27**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 32912**]
Chief Complaint:
2cm cyst in body of pancreas with history of recurrent
pancreatitis
Major Surgical or Invasive Procedure:
1. Robotic-assisted minimally invasive distal pancreatectomy and
splenectomy with intraoperative ultrasound.
2. Urgent exploratory laparotomy, oversewing and repair of
splenic artery, and placement of intra-abdominal drain.
3. Exploratory laparotomy, lysis of adhesions, and drainage of
left upper quadrant intra-abdominal fluid collection.
History of Present Illness:
38 y/o female with a history of multiple episodes
of pancreatitis and a cystic mass in the body of the pancreas
who
comes to the office for surgical evaluation. In short, her first
episode of pancreatitis was in [**2130-2-28**], when she presented
with epigastric pain radiating to the back. She was
hospitalized,
and CT of the abdomen showed a ~2 cm cystic mass in the body of
the pancreas, and evidence of pancreatitis in the pancreatic
tail. She was discharged and was doing well until [**2131-7-29**],
when
she again presented with epigastric pain radiating to the back.
Work-up during her second hospitization was notable for
triglyceride of 830, lipase of 782, and normal LFTs; MRCP showed
no significant interval change in the pancreatic cystic mass,
atrophy of the pancreatic tail, no biliary dilatation, no
gallstones, no choledocholithiasis. Her pancreatitis was
attributed to elevated triglycerides, and she was put on
gemfibrazil. On [**2131-9-7**], she was seen outpatient in the
HPB Surgery Clinic. It was recommended that she undergo fine
needle aspiration of the cystic mass with endoscopic ultrasound.
Since then, she's had another episode of pancreatitis, and GI
performed FNA of the cyst, which was acellular with CEA of
43ng/Ml and amylase of 109,200. After being seen in surgery
clinic twice by Dr. [**Last Name (STitle) **] for further evaluation, it was felt
that she likely had a mucinous cystic neoplasm and that it was
likely the cause of her recurrent pancreatitis. The patient was
advised on her options, including imaging surveillance, no
surgery, repeat endoscopic ultrasound to test the cyst fluid
CEA, and surgical
excision. The patient desired to proceed with surgical
management, and the plan was made with the patient to perform a
robotic assisted distal pancreatectomy and splenectomy.
Past Medical History:
Past medical history:
HIV, Hepatitis B, hypertriglyceridemia, hypertension, anxiety,
depression, genital herpes
Past surgical history:
c-section x3
Social History:
She lives with her fiance and 3 children in [**Location (un) 5503**]. She
smokes 1ppd x 10 years. Occasional social alcohol use, no
history of drug use.
Family History:
No family history of pancreatic cancer or pancreatitis.
Physical Exam:
GENERAL: NAD, AOx3
CARDIOVASCULAR: RRR, no m/g/r
LUNGS: CTAB
ABDOMEN: soft, non-distended, mild peri-incisional tenderness to
palpation, incisions healing well with no erythema or drainage,
JP drain in place with minimal [**Doctor Last Name 352**] serous fluid in bulb and no
surrounding erythema or drainage at insertion site.
EXTREMITIES: warm and well perfused, no edema
Brief Hospital Course:
Ms. [**Known lastname **] is a 38 y/o female with a history of multiple episodes
of pancreatitis and a cystic mass in the body of the pancreas
who, after being seen in clinic by Dr. [**Last Name (STitle) **], decided to go
forward with surgical management of her pancreatic cyst. On
[**2131-10-10**] the patient underwent a robotic-assisted minimally
invasive distal pancreatectomy and splenectomy with
intraoperative ultrasound with no intraoperative complications.
After a brief stay in the PACU, the patient arrived on the floor
NPO, on IV fluids with a foley catheter, and a dilaudid PCA for
pain control. During the first night after surgery, she became
tachycardic, for which she received two 500cc LR boluses, and
then a 1L LR bolus, and a hematocrit was checked that came back
at 27.6, with a repeat hematocrit 4 hours later being 24.3.
Given her persistent tachycardia and falling hematocrit, she was
transfused one unit of blood and received a CT scan of the
abdomen and pelvis on the morning of [**2131-10-11**] that showed the
presence of hematoma adjacent to the divided pancreas without
evidence of retroperitoneal hematoma related to the inferior
epigastric artery. After discussion of the risks and benefits
of surgery with the patient, and 2 telephone attempts to contact
her significant other, she was taken to the operating room for
urgent exploratory laparotomy. On operation, she was found to
be bleeding from the edge of her intact splenic artery staple
line, and underwent oversewing and repair of the splenic artery
with placement of an intra-abdominal drain. On the evening
following her re-operation, she acutely desaturated in to the
85% range and became tachycardic into the 140's, prompting a CTA
of the chest that revealed no evidence of pulmonary embolism but
did show a multifocal pneumonia. She was transferred to the ICU
and started on Vancomycin and Zosyn, where she remained for 2
days receiving antibiotics another one unit of packed RBC's. She
was transferred back to the floor, where she continued
antibiotics and was started on a clear liquid diet while
awaiting return of bowel function. On [**10-18**] her creatinine bumped
to 1.4 from a baseline of 0.4, so her Vanc and Zosyn were
stopped given she had received a 7 day course of antibiotics and
was now experiencing acute kidney injury. She also became
increasingly distended and had 3 episodes of bilious emesis, so
an NG tube was placed to suction with an immediate return of 1.5
liters of bilious gastric fluid. It was felt that her renal
failure was likely pre-renal azotemia and not a manifestation of
bowel ischemia, and she was aggressively rehydrated and a renal
consult was placed, who agreed that she was likely dehydrated
and pre-renal due to rapid fluid shifts and fluid losses in the
setting of a small bowel obstruction. A CT abdomen/pelvis was
performed that showed a high grade small bowel obstruction in
the LUQ in the area of the surgical bed, but given that she was
only one week post-op it was felt that conservative management
with NG tube and IV fluids would be the best course for the time
being, and she was also started on TPN for nutrition.
Unfortunately, after 3 days of NG tube suction she developed
coffee-ground output with intermittent episodes of bright red
bloody output from her NG tube despite being on a PPI twice
daily, became tachycardic, and her hematocrit began to fall
despite receiving 1 unit of packed RBC's, with a nadir of 18.0
on [**10-24**]. At this point she was again transferred to the ICU,
where she was transfused a total of 3 more units of packed
RBC's. Ms. [**Known lastname **] also failed to resume bowel function with
consistently high NG tube outputs, and in combination with her
new upper GI bleed it was now felt that she would need to be
taken back to the OR for an EGD and exploratory laparotomy in
the setting of a background concern for bowel ischemia. On
operation and EGD she was found to have a non-bleeding ulcer, a
retroperitoneal abscess in the left upper quadrant over which
the proximal jejunum was densely
adherent causing the proximal small-bowel obstruction, and
viable non-ischemic bowel. After surgery she returned to the
ICU, where she developed an anemia post-operatively on [**2131-10-26**]
and was transfused with two units of ABO compatible pRBCS. Her
pre-transfusion vital signs were: T=98 F, RR=30 on 2 L O2,
HR=123, and BP=148/88. Without premedication, she was transfused
with two complete units of pRBCs between 10:05 and 12:05AM on
[**2131-10-26**]. At 15:35, her O2 sat dropped to 91% on 2L O2 and her
oxygen was increased to 4L. A chest x-ray showed worsened
interval pulmonary edema with bilateral pulmonary infiltrates.
At about 20:00, her O2 sat dropped to 92% and her O2 was
increased to 6L with duoneb treatment. Suspecting possible fluid
overload, 20mg of IV lasix was also administered. Her O2 sat
dropped
transiently to 60% at 7AM the following morning and she was
placed on a face mask for better oxygenation. Her O2 sat was
stabilized and her interval chest x-rays showed no change.
Echocardiogram showed normal ventricular function without signs
of volume overload. Over the next two days, she weaned off
oxygen support, and never had any other symptoms such as hives,
jaundice, or hematuria. By [**10-29**] her pulmonary infiltrates were
resolving on her chest xray, her creatinine was trending down,
and her hemodynamics were overall stable with some tachycardia
and episodes of hypertension that were treated with and
responsive to lopressor and IV hydralazine, and she was
ultimately deemed stable for transfer back to the floor. Her NG
tube output was significantly decreased at the time of transfer,
and the decision was made to remove it. Her platelet count
continued to be in the 1000-1400 range and her GI bleed was
resolved, so she was started on aspirin 325mg daily for
anticoagulation in addition to her subcutaneous heparin. She
continued on TPN for nutrition, and on [**11-1**] began passing flatus
with a non-distended abdomen. Her diet was advanced to clears,
which she tolerated, and was then advanced to full liquids the
following day without issue. Her JP drain amylase was checked
after she took in a full liquid diet and was found to be [**Numeric Identifier 15614**],
but her JP drain output was consistently less than 10cc per day
and it was felt that she was ready for a regular diet. She
tolerated her regular diet and began having bowel movements. She
remained stable hemodynamically, was ambulating and voiding
without assistance, and her pain was well controlled on PO
oxycodone. On [**2131-11-4**] she was deemed stable for discharge home,
and the patient felt comfortable managing her JP drain at home
given its low output and her experience with having JP drains at
home in the past for her prior mastectomy, so she did not desire
home services. She had already received her post-splenectomy
vaccines pre-operatively in clinic, and her laparotomy staples
and PICC line were removed just prior to discharge. She was
given prescriptions for her new medicines, notably her
oxycodone, PPI, and stool softeners, and was instructed to
follow up in clinic with Dr. [**Last Name (STitle) **] in 2 weeks and to follow up
with her primary care doctor as soon as possible, and was
advised to call Dr. [**Last Name (STitle) **] with any questions or concerns.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pancreatic mucinous cystic neoplasm (2.0 cm) with
ovarian-type stroma and minimal epithelial atypia.
2. Post-operative splenic artery bleed
3. Multifocal pneumonia
4. acute kidney injury
5. small bowel obstruction
6. upper gastrointestinal bleed
7. gastric ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Stable.
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 [**6-7**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Please do not drive until you have seen Dr. [**Last Name (STitle) **] in follow up
clinic. In particular, avoid driving or operating heavy
machinery while taking your pain medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised. We have added an additional blood pressure
medicine to your home regimen, and you should see your primary
care provider as soon as possible to follow up on your blood
pressure control regimen.
Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
Avoid swimming and baths until your follow-up appointment.
You may shower, and wash surgical incisions with a mild soap and
warm water. Gently pat the area dry.
JP Drain Care:
Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever greater than 101 degrees).
Please maintain suction of the bulb. Please note the color,
consistency, and amount of fluid in the drain. Specifically,
please keep records of how much fluid came out during each day
(there are CC markers on the bulb that you can use to estimate
the daily drainage before you empty the bulb for the day). Call
Dr.[**Name (NI) 111777**] office if the amount increases significantly or
changes in character. You may shower; wash the area gently with
warm, soapy water, but otherwise please keep the insertion site
clean and dry otherwise. Avoid swimming, baths, hot tubs; do
not submerge yourself in water. Make sure to keep the drain is
attached securely to your body to prevent pulling or
dislocation.
Followup Instructions:
Dr. [**Last Name (STitle) **] would like to see you in clinic 2 weeks from when you
were discharged from the hospital. Please call [**Telephone/Fax (1) 274**] to
make this appointment.
Please also follow up with your Primary Care Doctor as soon as
possible, ideally within one week from discharge, for a wellness
check and to go over your recent hospitalization and medication
changes.
ICD9 Codes: 486, 5845, 5070, 2851, 2760, 5789, 2767, 2768, 4019, 311, 3051 |
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